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The Hillingdon Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 August 2015

When we inspected in October 2014, we told that the trust that it must make improvements, which included:

  • Make sure it complies with infection prevention and control standards and monitors cleanliness against national standards.
  • Assure itself that the ventilation of all theatres meets required standards.
  • Make sure that staff are appropriately trained in safeguarding both adults and children, and that the trust regularly monitors and assesses the completion of actions agreed at weekly ‘safety net’ meetings.
  • Make sure that all staff understand their responsibilities in relation to the trust’s systems and processes that exist to safeguard children.
  • Make sure patients and visitors are protected against the risks associated with unsafe or unsuitable premises.
  • Make sure that there equipment is properly maintained and suitable for its purpose.
  • Make sure that equipment is available in sufficient quantities in order to ensure the safety of patients and to meet their assessed needs.
  • Make sure that all staff receive the full suite of mandatory training that is required to minimise risks to patient safety.
  • Make sure patients are protected against the risks associated with the unsafe use and management of medicines.
  • Make sure that early warning system documentation is appropriately maintained and that all staff react appropriately to triggers and prompts.

Our key findings from this inspection were as follows:

  • The inspection took place approximately three months after we published our comprehensive inspection report in February 2015. We found that the trust had responded appropriately to many of the key issues we highlighted at that time. In some areas however, custom and practice had not changed, despite systems and processes being implemented to deliver changes in practice.
  • We observed improved practice in some areas in relation to hand hygiene and the use of personal protective equipment, however, some staff in A&E and on medical wards were not following best practice.
  • We observed improved practice in the management of medicines in most departments. Where there were known issues plans were in place and steps had been taken to begin to address these issues and mitigate the risks. However, we found best practice was not always followed by all staff, with daily checks occasionally not happening as necessary and some areas left unsecured.
  • It was evident that the trust had taken significant action to address estates deficiencies highlighted by the previous inspection. The trust had restructured its estates function, provided the capital works to the operating theatres and had moved to a less reactive, more planned maintenance service.
  • The comprehensive work programme for theatres was on going at the time of our visit. The works to the operating theatres, both to date and planned, and the commitment to annual maintenance were in line with the Health Technical Memorandum (HTM) 03-01.
  • The trust had implemented a new estates compliance reporting process to provide the organisation with a collective understanding of its risks and level of compliance against best practice and legal requirements.
  • The trust was cleaning and auditing in line with the National Specifications for Cleanliness in the NHS.
  • Children presenting to the trust's A&E were appropriately safeguarded as effective systems and processes were in place. Staff received appropriate training which had increased their awareness and key staff were deployed to oversee practice and promote good practice.
  • Equipment was clean and staff had enough equipment to meet patient needs. Further supplies could be accessed in a timely way when required.
  • Mandatory training figures had improved, the divisions we reviewed having made sure the targeted number of staff received mandatory training, including for infection prevention and control and safeguarding.
  • Early warning score documentation was completed accurately and staff responded correctly to triggers and prompts as required.

Areas for improvement:

The provider should consider the concerns of the staff on children's wards about whether locks could hamper access in an emergency.

Professor Sir Mike Richards

Chief Inspector of Hospitals

 

Inspection areas

Safe

Requires improvement

Updated 7 August 2015

Effective

Requires improvement

Updated 7 August 2015

Caring

Good

Updated 7 August 2015

Responsive

Requires improvement

Updated 7 August 2015

Well-led

Requires improvement

Updated 7 August 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 11 February 2015

The trust had recognised the risk to safe and responsive care because of inadequate midwifery staffing. The staffing establishment had been increased and newly appointed midwives were expected to join the trust before the end of the year. At times of high activity current risk was mitigated by the use of the escalation policy to prioritise the needs of women in labour. This meant that other areas were sometimes short staffed.

Women were able to access antenatal and postnatal services near their home and high risk women were seen at antenatal clinics at the hospital. These clinics were sometimes crowded and women had to wait for appointments. There had been no evaluation of the reconfiguration of the community midwifery service to assess its effectiveness and staff told us they were under pressure. The business case to increase staffing had been agreed; the appointments had not been made at the time of our inspection.

The wards were kept clean, but infection-control procedures were not always followed. The storage of medicines did not comply with nationally recognised good practice.

There had been improvements to the effective use of the World Health Organization (WHO) surgical safety checklist in obstetric procedures. There was a high level of awareness about the importance of safeguarding women and babies.

Trainee doctors said the teaching and support from consultants was of a high standard. Midwifery staff took part in a well-established appraisal process and had opportunities for training and development. Staff were confident about the quality of care they provided, and this was reflected in the positive comments of women who used the service. Bereaved parents were well supported.

There was a systematic approach to clinical governance, which included a process for reviewing and investigating incidents, an audit programme and clear allocation of responsibility for reviewing guidelines.

Medical care

Requires improvement

Updated 7 August 2015

Medical care (including older people’s care)

Updated 7 August 2015

The safety domain rating was reviewed as a result of our follow-up inspection in May 2015. This review did not alter the overall rating for this service, however, the safe rating was changed from Inadequate to Requires Improvement.

We found the medical wards were clean.

Records on medical wards were stored in lockable trolleys in the doctors’ office located on the wards. Most of the doctors’ offices were lockable on the wards although two were waiting for the maintenance department to fit locks.

We reviewed more than ten medical administration records (MAR) across medical wards and found they were fully completed.

Across medical wards we observed several patients receiving oxygen therapy. We did not find an oxygen prescription on the MAR for any of these patients.

Early warning score documentation was completed accurately and staff responded to triggers and prompts as required.

Urgent and emergency services (A&E)

Requires improvement

Updated 7 August 2015

The safety domain rating was reviewed as a result of our follow-up inspection in May 2015. This review did not alter the overall rating for this service, however, the safe rating was changed from Inadequate to Requires Improvement.

We found practice had improved in the management of medicines. Risks had been identified through audit and steps had been taken to mitigate risks. However, we found best practice was not always followed by all staff, with daily checks occasionally not happening as necessary and some areas where medicines were stored were left unsecured.

Housekeeping staff had been allocated to A&E at all times of day. Senior nursing staff told us that domestic support had increased in direct response to the previous inspection and that it had made a big difference in the cleanliness of the department.

The vast majority of staff had received mandatory training, including safeguarding training and training on infection prevention and control.

Surgery

Requires improvement

Updated 7 August 2015

The safety domain rating was reviewed as a result of our follow-up inspection in May 2015. This review did not alter the overall rating for this service, however, the safe rating was changed from Inadequate to Requires Improvement.

We found that the trust had taken action to address the estates deficiencies highlighted by the previous inspection.

The changes to operating theatres were work in progress at the time of our inspection. The works to date, the planned works and the commitment to annual maintenance were in line with the Health Technical Memorandum (HTM) 03-01 to provide assurance that the environment protected patients from the risk of infection.

Medicines were stored and managed in line with best practice and relevant guidance.

Intensive/critical care

Requires improvement

Updated 11 February 2015

Experienced and dedicated staff worked hard to ensure the unit was safe.  Nursing and medical staffing levels were appropriate, although the rota for full specialist consultant cover was not complete out of hours.  The unit had a high retention rate of experienced staff.  Some of the routine safety checks were not being done, and there was a lack of local examination and display of patient harm data.

Care and treatment was delivered by trained and experienced staff, and patients, relatives and trainee doctors spoke highly of the unit.  There was input into patient care from many disciplines.  Essential inputs into patient care such as pain relief and good nutrition and hydration were managed well.

The unit did not conform to modern building standards and had a shortage of space.  The facilities for patients and relatives were poor. 

Senior staff were committed to their patients, their staff and their unit.  However, there was not enough reliable data or audit work to base decisions upon and drive the service forward. A lack of participation in a national audit programme meant data was not adjusted for patients’ inherent risks, and the unit did not benchmark itself against other similar units to judge performance.  There was, however, a strong culture of teamwork and commitment.

Services for children & young people

Requires improvement

Updated 7 August 2015

The safety domain rating was reviewed as a result of our follow-up inspection in May 2015. This review did not alter the overall rating for this service, however, the safe rating was changed from Inadequate to Requires Improvement.

We found that children presenting to the trust's A&E were appropriately safeguarded as effective systems and processes were in place.

Keypad locks had been installed on the main doors to the ward to improve security.

Equipment was clean and staff had enough equipment to meet patient needs and could access further supplies in a timely way when they required them.

Mandatory training figures had improved with the divisions we reviewed having made sure that the targeted number of staff received mandatory training, including for infection prevention control and safeguarding.

End of life care

Requires improvement

Updated 11 February 2015

The SPCT hoped that the newly appointed committee and the recent appointment of a board director lead would increase the visibility of end of life care (EOLC) in the hospital. They said this would ensure that appropriate and consistent EOLC was provided to patients by all staff across the hospital and not be seen as the sole responsibility of the SPCT.

The SPCT talked passionately about future aspirations to bring patient’s EOLC to the forefront of staff minds and to develop integrated care pathways that involved community services such as nursing, palliative care, GPs, ambulance, hospices and care homes, to frail and older patients, and those dying through complex health issues. It was hoped that this would decrease the number of unnecessary admissions to the hospital.

We saw that there were regular ward and SPCT MDT meetings to discuss patients who had been recognised as dying. The trust had developed, but not implemented end of life guidance to replace the Liverpool Care Pathway. The completion of ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) forms was variable and the documentation of mental capacity assessments was inconsistent.

All the staff involved in end of life care were passionate, caring and maintained patients’ dignity throughout their care. Relatives told us they were supported and felt informed at all times. One relative described the care as “outstanding”.

The SPCT did not have the resources to provide support to patients seven days a week, however there was an out of hours on-call system. Hospital staff reported they felt able to request support from the SPCT whenever it was required. The SPCT usually responded within 24 hours. 60% of the patients supported by the SPCT were non-cancer patients. This showed a good balance between cancer and non-cancer patients being provided with the specialist services from the palliative care team.

There were no dedicated palliative care beds at the hospital and it was not always possible to care for people at the end of their life in a side room. There were very few rooms in the hospital for private conversations to be held. The SPCT were able to arrange rapid discharge for people who wished to die in a different location. They also had access to dedicated palliative care beds in a local nursing home.

There was no trust EOLC policy or strategy. Staff reported there had been very little senior management engagement until the very recent appointment of a board director. There were limited governance systems although some audits had taken place. Action plans had been developed but there was no evidence of changes being implemented. We did find some examples of good leadership, especially within the SPCT. Ward based staff were committed to providing high quality care for patients at the end of life.

Outpatients

Requires improvement

Updated 11 February 2015

We found that letters to general practitioners (GPs) were not being sent within the five-day period in line with trust policy. On the day of our inspection, the majority of medical secretaries were not typing letters within this timeframe.

The renal outpatients department (OPD) was unable to provide patients with follow-up appointments in a timely manner.

The ophthalmology clinic was not an ideal environment, as it was too small to meet with the demands of the service. Although the trust had attempted to mitigate the issue by running extra clinics within the community, this issue was still evident at the Hillingdon Hospital site.

The trust was very responsive when planning the service to meet the needs of local people. Effective consultation allowed the service design to meet the needs of local communities and staff groups. We saw good ownership of the care and treatment they delivered by staff of all grades.

A proactive stance was taken in addressing issues that impacted on care delivery, such as developing a policy to monitor and reduce non-attendance at hospital appointments. In general, resources and facilities were good and met the needs of people attending the department.

We found that the OPD was accurately monitoring patient pathways. The central booking service was consistently able to give patient appointments within the NHS England and Clinical Commissioning Groups 2012 regulations about 18-week referral-to-treatment targets. We were able to see evidence of clear strategies to monitor and maintain systems to ensure that the trust met with these targets. The trust was consistently meeting with the two-week wait timescale for patients with urgent conditions, such as cancer and heart disease. We were able to see evidence of clear strategies to monitor and maintain systems to ensure that the trust met with these targets.

We found good local leadership within the OPD departments. The OPD matron was praised highly by staff who felt that they were proactive and supportive.