The Hillingdon Hospital

Updated 14 February 2024

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

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

The Hillingdon Hospital provides maternity services to the population of Hillingdon, Uxbridge, and surrounding areas.

Maternity services include an early pregnancy unit, maternal and fetal medicine, antenatal clinic, maternity day assessment unit, outpatient department, maternity assessment unit, antenatal ward (Katherine Ward), labour ward, midwifery led birthing centre (closed during our inspection), 2 maternity theatres, 2 postnatal wards (Alexandra Ward and Marina Ward), and an ultrasound department. Between April 2021 and March 2022 4,085 babies were born at The Hillingdon Hospital.

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

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

Our rating for this hospital stayed the same. We rated it as inadequate.

Our rating of Requires Improvement for maternity services did not change ratings for the hospital overall. We rated safe as Requires Improvement and well-led as Requires Improvement.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the maternity labour ward, triage service, the bereavement suite, theatres, and the antenatal and postnatal wards. We visited the 4-bedded midwifery led unit (MLU), but this was closed for births during the inspection.

We spoke with 12 midwives, 2 maternity support workers, 2 housekeepers, 4 women and birthing people and 2 birthing partners. We received 6 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 8 patient care records including observation and escalation charts and 8 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

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

Updated 18 January 2023

Updated 24 July 2018

• There was an open and constructive culture of sharing and learning from incidents.
• Safeguarding knowledge and processes had improved. Staff understood their responsibilities and how to keep patients safe.
• Medicines were stored and managed appropriately; patients received the correct doses at the right times.
• The effectiveness of care and treatment was monitored and improvements were made as a result.
• Nutrition and hydration needs were met as a result of effective monitoring.
• Patients’ pain was managed and monitored well.
• There was a multidisciplinary approach to patient care and staff worked well together to deliver an effective service.
• Staff cared for patients with compassion and ensured that dignity and privacy were respected.
• There was good emotional support for patients and their families and carers.
• Patients and those close to them were supported to understand their care and treatment and were involved in making decisions.
• The department delivered a broad range of services including speciality and one-stop clinics.
• There was timely access to services and good flow through the department.
• There was a positive, ‘can do’ culture in the department and staff were proud to work there.
• There had been an improvement since the previous report in staff feeling listened to and supported by their managers.
• There were processes for engaging staff in news and developments in the department including newsletters and meetings.

However:

• The department had not implemented a seven day service.
• There were limited examples of the department supporting patients to manage their own health.
• Staff did not receive formal training provision for learning disabilities and the service relied on support from external partners or the trust’s learning disability link nurse.
• Some areas where children were seen in adult outpatients were not child friendly.
• Parents reported delays in seeing the dietitian.
• There was limited engagement with patients and those close to them to gather their input in improving the service.

Updated 24 July 2018

• We rated safe, responsive and well-led as requires improvement, and effective and caring as good.

• The rating for effective improved since the last inspection; the rating for each of the other key questions remained the same.

• The senior management team had not taken note of all of the concerns raised at the previous inspection and only made improvements in the areas of 24 hours consultant cover, healthcare assistant recruitment, partial improvement of the ventilation system and submission of the Intensive Care National Audit and Research Centre (ICNARC) data.

• There were no formal morbidity and mortality meetings. Learning from any clinical case presentations was not shared with the wider directorate, or fed back to the board through any identifiable governance structure.

• At the time of inspection, the unit was unable to provide optimal care for patients requiring isolation facilities such as positive and negative air pressure management. There was increased risk of cross infection, as at the time of our inspection; the ITU environment was not compliant with recommended building (HBN04-02) standards and heating and ventilation for health sector building (HTM 03-01) standards. We found inconsistencies in hand hygiene practice amongst staff, in particular during ward rounds. There was dust on some equipment and high surfaces. This remained an area of concern from the time of the last inspection.

• We found inconsistencies in the daily checks of the difficult airway/ intubation trolley in the located in the unit. Nursing staff equipment competencies for some key pieces of equipment had not been rechecked since 2015 and were now overdue.

• In the ITU, oxygen was not prescribed on the patient prescription chart as per the trust policy on the prescribing and administration of oxygen in adults.

• In February 2018, the nursing vacancy rate was 16%. Staff informed us that due to increased bed pressures recently, there had been many occasions when the supernumerary nurse would cover the short staffed/unfilled shifts. There was no 24-hour cover provided by the critical care outreach team (CCOT). This was an area of concern at the last inspection.

• The unit did not use any sepsis screening tool and there was no separate policy for sepsis management in place. Although the outreach team told us that sepsis was part of the deteriorating patient policy. All junior staff we spoke with were not aware where to find information on sepsis management and if there was trust lead for sepsis.

• The unit was not meeting the Core Standards for Intensive Care Units recommendation of having a practice nurse educator, who dedicated two-thirds of their time to this role. This was an area of concern at the last inspection and we found no improvement in regards to this provision.

• The unit had made no progress in relation to the facilities for patients and relatives. There was only one patient toilet in the unit and no bath or shower facilities. Since the last inspection, there had been limited improvement in the facilities on the unit for relatives and visitors.

• Capacity and flow was one of the key areas of concerns for the unit. According to ICNARC data covering April 2016 to March 2017, the percentage of bed days occupied by patients with discharge delayed more than 8 hours and 24 hour was higher compared to other similar unit.

• We found that divisional and executive team were not visible and rarely visited the unit. The staff told us that there was little support for the critical care unit within the trust; they felt isolated and disjointed from the division. At the time of the last inspection, we found that there was no evidence of strong critical care leadership to challenge or influence the future direction of the service. At this inspection, we found there was still lack of any consensus regarding cohesive future direction of the service.

• There was a lack of an effective governance structure driven by the unit leadership team. Not all the junior staff we spoke with could articulate the department governance arrangements and how it fed into the divisional governance structure. Not all risks identified by us during the inspection were reflected on the risk register. In addition to this, many risks identified at the last inspection were still outstanding.

• Staff struggled to locate clinical guidelines quickly as the trust intranet search engine was not user friendly.

However:

• Staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk, or had been exposed to abuse. There was a clear and effective process to ensure that potential safeguarding concerns were escalated.
• The service used safety monitoring results well. The unit now monitored incidents of falls, pressure ulcers, venous thromboembolism (VTE), central venous catheter infections and catheter associated urinary tract infections (UTIs). This information was displayed in both the staff room and on noticeboards within the unit. This had improved since the last inspection.

• The unit had made progress with regard to consultant cover and now had a separate on-call rota.

• Since the last inspection, the unit had made improvement and was now contributing data to the Intensive Care National Audit and Research Centre (ICNARC).

• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

• At a local level, there was clear leadership for both medical and nursing staff. The lead consultant and unit manager worked closely together. They were both visible in the department and junior clinical staff described them as approachable and supportive.

• We saw collaborative working between clinicians. Junior doctors and nurses felt supported, with regular supervision. We saw that the medical team worked well together, with consultants being available for junior doctors to discuss patients and to give advice where needed.

Updated 24 July 2018

• We rated safe, effective, caring, responsive and well-led as good.
• The ratings of safe, effective, responsive and well-led improved since the last inspection. The rating for caring remained the same.
• Since our last inspection there had been a focus on the trust wide understanding and development of end of life acre. There was now a strategy and governance programme in end of life care with a clear structure of leadership and accountability.
• Appropriate measures were in place to keep patients safe from avoidable harm. Record keeping had improved.
• There were specialised end of life care advanced care plans in place and risk assessments had been adapted for patients at the end of their lives.
• Team working was strong and the development of staff within the specialist palliative care team had strengthened governance structures. There was a non-executive director in place that sat on the board and had end of life care oversight.
• Patients were provided with compassionate and person-centred care, which took account of their individual differences and needs. There was multi-disciplinary input to ensure that patients received a holistic and individualised care plan.
• The specialist palliative care team had developed end of end training within the trust and worked well with external agencies in order to coordinate care for each patient.

However:

• There was not always evidence that the appropriate mental capacity assessments had been carried out where this was noted in the patients DNACPR form.
• There was no end of life champion on each ward and the SPCT team did not take oversight for the training of staff in syringe pumps.
• The bereavement service had limited opening hours and inappropriate waiting areas for bereaved family members.

Updated 14 February 2024

Updated 24 July 2018

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

• We rated safe and well-led as requires improvement, and responsive and caring as good. We do not rate effective for this core service.

• The rating for responsive improved since the last inspection; the rating for safe went down and the rating for each of the other key questions remained the same.
• We were not assured that the laser service met the Medicines and Healthcare Products Regulatory Agency safety standards
• The laser service did not have a laser protection advisor in place since the start of the laser service in 2012, although the trust was making suitable arrangements at the time of the inspection there still was no one officially in post.
• We were not assured the department had adequate governance procedures for the laser service as set by the Medicines and Healthcare Products Regulatory Agency safety standards. Risks associated with laser practice were not present on any trust risk register.
• Staff did not always maintain appropriate records of patients’ care and treatment. Records were not always clear, up-to-date and available to all staff providing care.
• The service did not have suitable premises and there was a large backlog of estates maintenance.
• The service provided mandatory training in key skills to all staff.
• The service did not actively monitor the effectiveness of care and treatment and use this information to improve the service.
• The department had managers with the right skills to run the service; however senior nurses felt that their managerial duties were at times excessive of their role.
• The service had a vision for what it wanted to achieve, however we were not assured it had workable plans to turn it into action.
• The service had limited engagement with patients and staff to plan and manage appropriate services.
• The service had systems for identifying risks and planning to eliminate them, however the services active risks were of an excessive age.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so; however some compliance with some training failed to meet trust targets.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people.
• People could access the service when they needed it. Waiting times from referral to treatment were in line with good practice.
• The service took account of patients’ individual needs.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

Updated 24 July 2018

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

• Safeguarding Children (level 2) failed to meet the trust target.
• The surgical assessment unit (SAU) was dividing singular bed spaces into two patient bed spaces, with the use of screens. This meant that only one patient had access to oxygen, call bells and suction.
• Staff we spoke with were not aware of the sepsis six (bundle of medical therapies) and we could not locate a screening tool for sepsis.
• We were not assured that high-risk patient groups were screened for MRSA at pre-admission.
• The hospital did not audit the World Health Organisation (WHO) five steps to safer surgery in 2017.
• Similarly to the last inspection we found five of the 13 mandatory training modules failed to meet the trust target, including manual handling which we observed to be very poor.
• There were no pre-operative fasting audits for patients fasting before surgery.
• DoLs (Deprivation of liberty) had been put in place for three patients without a DoL’s assessment.
• The hospital provided a range of information leaflets including support groups. However, similarly to the last inspection we did not see any information printed in any other language.
• Similarly to the last inspection many spaces within the surgery division were being used to house inpatients, this included the female day care unit, recovery and the day room in Kennedy. These facilities were not suitable for inpatients due to the lack of essential equipment, and washing facilities.
• Staff in recovery were not trained to discharge patients, for example providing patients with ‘to take away’ medications which caused delays.
• The trust took an average of 51 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be completed in 30 days.
• Executive staff told us that issues that arose out of hours were not always addressed with appropriately. Problems were dealt with in the moment with little forward planning.
• Staff reported that staff retention was low and that this was linked to poor relationships with management.
• Staff reported that they were often left without senior management and “no one in charge”.

Updated 24 July 2018

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

• There was deterioration in infection prevention and control since the time of the last inspection.
• Medicines were not always appropriately stored or checked.
• The mental health interview room was not safe.
• Regular observations of patients were not carried out.
• There was poor recognition of sepsis.
• There was low participation in clinical audits and the trust performed poorly in some.
• There was poor assessment of patients’ pain.
• The appraisal rate for doctors was 13%, which was below the trust standard of 90%.
• We observed some negative staff behaviour towards patients.
• There was poor communication with patients.
• The department did not meet the target to admit, discharge, or transfer 95% of patients within four hours between February 2017 and February 2018.
• The service did not meet the standard that patients should wait no more than one hour for initial treatment during this same time period.
• The waiting area for patients who attended by their own means was very crowded with insufficient seating.
• We found that staff had poor awareness of the needs of people with learning disabilities.
• Translation services were not always offered to patients.
• There were differences between the recorded risks on the risk register and what staff expressed was on their ‘worry list’.
• There had been no significant improvement in the storage and checking of medicines since the last inspection.
• Junior doctors told us there were differences in consultant leadership and some were more supportive than others.
• Many staff told us they did not feel able to escalate their concerns about pressures of work and how this impacted on poor patient safety and experience.

However:

• The environment in paediatric ED was well maintained.
• Staff were confident about how to record incidents.
• Multidisciplinary working was evident in most areas of the department.
• Patients and carers in the paediatric ED and the CDU spoke very positively of their experiences.
• The department had a frailty pathway, supported by specialists, to safely reduce admissions and length of stay for elderly patients and ambulatory care pathways.
• There was a mental health matron seconded from a local trust who supported staff to offer a better patient experience to those with mental health issues.
• The trust was working alongside the NHS Improvement Emergency Care Improvement Programme Team (ECIP) to drive up standards and improve patient experience.
• Many staff told us that members of the operational team were visible and they could tell us who they were.
• Staff told us they enjoyed good local teamwork.