The Hillingdon Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safeguarding practices were strong, with high compliance rates in training. There were well-established processes for reporting safeguarding concerns, and joint safeguarding committee meetings provided comprehensive oversight of safeguarding issues. Additionally, patients generally felt well-informed about their care and the risks associated with their treatment. They were given adequate time to discuss their care with clinical teams, and appropriate consent processes were in place, ensuring that patients could make informed decisions about their treatment.

Staffing levels, particularly among medical staff, remained a significant concern. While the Trust reported that vacant shifts were covered through bank or agency staff, staff told us that medical vacancies had led to increased pressure on existing teams, with extended working hours for resident doctors. These conditions raised concerns about fatigue and its potential impact on patient care. However, following the inspection the service informed us that there had been no cancellations of operations

Infection prevention and control protocols were not consistently adhered to, with hand hygiene compliance rates falling below the trust target. Although there had been some improvements in MRSA screening, compliance still did not meet the required standards, indicating a need for enhanced infection control practices.

Medicines management remained an area of concern, with ongoing risks such as frequent drug administration errors, missed medications, and incorrect documentation. In response to these concerns, the trust implemented targeted actions to strengthen medicines management processes. These included stricter protocols, enhanced staff training, and the introduction of regular audits to monitor compliance and identify areas for improvement.

The service’s use of the Surgical Assessment Unit (SAU) for stays exceeding the time prescribed by the operational protocol due to bed shortages was noted. This inappropriate use led to a lack of essential facilities, such as communal bathrooms and hot food, for extended patient stays. The service’s physical environment also raised concerns, with overcrowding and the use of inappropriate spaces for inpatient care compromising patient safety and dignity.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service demonstrated a strong commitment to managing patient safety incidents, fostering a culture of openness and transparency. Staff were proactive in recognising and reporting concerns, including near misses, and consistently adhered to trust protocols using the electronic reporting system. This indicated that safety procedures were embedded in practice. Serious incidents were reported clearly and in accordance with trust guidelines, with evidence showing that staff understood and upheld their duty of candour. Patients and families received honest explanations and appropriate support when incidents occurred, aligning with trust policies.

Managers conducted investigations into safety incidents, sharing lessons learned with both the immediate team and the wider service. These efforts promoted a learning culture and reinforced staff confidence in raising concerns without fear of blame. Staff reported feeling well-supported in this process, contributing to a positive and transparent safety culture across the organisation.

Feedback mechanisms were robust, with staff receiving information on the outcomes of both internal and external incident investigations. Regular meetings facilitated the discussion of feedback and identification of opportunities for improving patient care. For example, during handovers on the Jersey ward and the theatre huddle, risks and incidents were communicated openly, with safety updates and lessons from previous events being shared.

Changes were made because of feedback, demonstrating a commitment to improvement. Safety information boards displayed a 'You said, we did' section, showing how complaints had led to service enhancements. Lessons learned from incidents were circulated monthly; however, the issues identified were mostly isolated and related to medical devices and consumables, with no dominant recurring themes.

Despite these positive practices, the service had a backlog of 139 open incidents at the time of assessment, with 111 overdue for investigation. This indicated a need for improvement in the timeliness of incident investigations to ensure that safety lessons were integrated swiftly. Managers reported prioritising high-risk cases and allocating additional resources to address delays and reduce the backlog.

Despite the backlog, managers maintained thoroughness in their investigations, involving patients and families when appropriate. They also provided support and debriefing for staff after serious incidents, reinforcing a supportive and learning-focused environment.

The service showed a strong commitment to safety, with staff feeling encouraged and supported to raise concerns. Staff consistently reported safety events using the electronic system and received feedback, demonstrating a transparent approach to incident management. Data from the Learning from Patient Safety Events (LFPSE) system, filtered to the surgical specialty, highlighted themes such as delays in doctor reviews, issues in the surgical assessment unit, admissions from the daycare unit, drug errors, and falls. These themes identified areas for the service to focus on in future safety and improvement initiatives.

The assessment revealed significant issues related to the safe management of patient care systems and pathways, particularly within the Surgical Assessment Unit (SAU). The SAU was designated for short-term stays of up to 24 hours; however, it was frequently used for housing patients beyond this period due to shortages of beds in the main surgical wards. This practice persisted despite prior recommendations, made at the time of the last inspection, advising against the extended use of the SAU for inpatient care.

Three patients were observed to have exceeded the 24-hour stay limit in the SAU. One patient had stayed for 48 hours, another for 40 hours, and a third for 30 hours. These findings mirrored those from the previous inspection, where similar issues were noted.

The SAU lacked several essential facilities necessary for longer-term patient care, such as a communal bathroom, inpatient beds, and immediate access to hot food—facilities typically available in other inpatient wards. This inadequate environment, combined with delays in transitioning patients to appropriate wards, compromised continuity and quality of care. For example, on the day of the assessment, 3 patients remained in the SAU for over 24 hours, exceeding the trust’s protocol of transferring patients within 6 hours of a decision to admit. These delays were primarily due to the unavailability of beds in the surgical wards, highlighting systemic challenges in maintaining safe care systems and ensuring timely transitions for patients.

In addition, delays were observed across the service. One patient, initially admitted to the surgical daycare unit for a scheduled surgery, was informed on the day that their procedure was cancelled and rescheduled for a later date in September. The patient expressed disappointment, highlighting the impact of such delays on patient experience.

Staff working in the SAU acknowledged the regular breaches of the 24-hour limit, primarily attributing this to the ongoing shortage of surgical beds. Although the service had an escalation process in place, involving a surgical bed manager available Monday to Friday and a hospital bed manager providing 24/7 coverage for out-of-hours situations, the system struggled to cope due to the overall capacity issues within the service.

While there was a structured escalation process, it was evident it did not fully mitigate the delays caused by bed shortages, leading to repeated breaches of the established protocols. This finding indicated that despite efforts to plan and organise patient care, the service faced ongoing challenges in maintaining safe and effective systems of care, especially during transitions between units and wards.

Safeguarding practices within the service were generally robust, with compliance rates for safeguarding training in both nursing (99%) and medical staff (93%) exceeding the trust’s target of 90%. Nursing and medical staff had received training specific to their roles on how to recognise and report abuse, and they demonstrated an understanding of how to protect patients from various forms of abuse, including those with protected characteristics under the Equality Act.

The service had established clear processes for identifying and reporting safeguarding concerns, supported by accessible policies available to all staff via the intranet. Joint safeguarding committee meetings were well-attended and provided comprehensive oversight of safeguarding issues, demonstrating a collaborative approach with other agencies to protect patients at risk of harm.

Posters displaying the safeguarding team’s contact information were visible across the unit; however, not all staff were aware of the safeguarding lead, highlighting the need for improved visibility and communication regarding safeguarding leads. Staff interviewed had a good understanding of safeguarding procedures and knew how to make a safeguarding referral. They were able to explain what constituted a safeguarding concern and described the correct process for raising issues, including who to contact within the safeguarding team.

The service had introduced a resource folder containing information on safeguarding, female genital mutilation, modern slavery, and the Mental Capacity Act since the last inspection. While this was a positive development, senior staff needed to become more familiar with its contents to better support their teams in addressing safeguarding issues effectively.

Staff were observed discussing safeguarding concerns during handovers, including cases under the Deprivation of Liberty Safeguards (DoLS). A patient’s notes reviewed included a completed DoLS form, demonstrating that procedures were being followed appropriately.

The service worked with patients to understand risks and enabled them to engage in activities important to them; however, it did not always manage these risks holistically to ensure care was consistently safe and supportive. Patients reported feeling well-informed about their care and the associated risks, noting that they were given adequate time to discuss their treatment options with the clinical team. Information was provided through verbal discussions and supplementary leaflets, ensuring patients could make informed decisions. Consent forms were completed appropriately, with key risks clearly identified.

However, risk assessments, such as those for Venous Thromboembolism (VTE), were not consistently completed or reviewed. VTE assessments were crucial for identifying patients at risk of developing blood clots, and while the service's monthly VTE audits indicated compliance rates above the trust target of 95% for April, May, and June 2024, this was not always reflected in practice. On the day of the assessment, some VTE assessments were either incomplete or not followed up when a patient declined prescribed medication, increasing the risk of complications such as blood clots.

Staff were knowledgeable about managing patient risks and identifying deterioration using a nationally recognised tool. However, the inconsistency observed in completing certain clinical risk assessments, including falls and pressure ulcer assessments, indicated a gap in adherence to best practice. The service had measures to monitor risk compliance, such as monthly audits, but these alone were insufficient in ensuring that risk management practices were consistent in daily operations.

Shift changes and handovers included key information necessary to keep patients safe, and staff shared important information when transitioning patient care.

The service had not made improvement since the last inspection. The service’s physical environment did not always meet the needs of its patient population, leading to some overcrowding and delays that could compromise patient safety and care quality. At the time of the inspection, areas such as the Surgical Assessment Unit (SAU) were used for over 24 hours inpatient care despite not being fully designed or equipped for prolonged stays. While mitigations were in place to support patient hygiene needs, the unit lacked some dedicated washing facilities, and the use of chairs in curtained areas raised concerns about comfort, privacy, and dignity. Recovery areas were not in use for inpatient stays during the inspection; however, staff told us that these areas were occasionally used for this purpose when surgical bed capacity was exceeded, despite not being designated or equipped for inpatient care.

There was inadequate storage in theatre corridors, which had been noted in the report of 2018 and persisted. It continued to hinder the safe movement of staff and equipment, posing potential safety risks.

Plans for a new hospital and the relocation of elective surgeries to Mount Vernon Hospital had been discussed by the senior leadership team, but these plans were not imminent. Consequently, the existing space constraints remained a significant challenge, impacting the quality of care provided. Overcrowding and delays were observed in several areas, including the surgical daycare unit, recovery areas, and surgical wards. The service required interim measures to manage current capacity issues effectively until more permanent solutions were implemented.

Staff reported that the surgical building lacked the capacity to support the current patient volume, resulting in delays and the admission of patients to inappropriate areas. This was also reflected in staff incident reports reviewed. Staff from the SAU indicated that they sometimes had to accept patients who did not meet the unit’s criteria due to capacity constraints. Overcrowding was also observed in the surgical daycare unit, with staff confirming insufficient space to safely manage patient care. Additionally, the female side of the surgical daycare unit did not have in-wall oxygen and suction at every bed space, resulting in the use of portable oxygen cylinders at the bedside, which was not in line with best practice standards. This was recognised on the trust’s risk register, with mitigations in place at the time of inspection.

The assessment found that the lighting in 2 theatres was dim, and 2 lights were completely static, impacting visibility during surgeries. Furthermore, the recovery area did not meet national guidance from the Association of Anaesthetists of Great Britain and Ireland (AAGBI). The trust operated 7 theatres but had only 7 recovery beds instead of the recommended 14, failing to comply with the recommended bed-to-theatre ratio. However, the trust informed us that processes were in place to mitigate this risk. When the recovery area was full, a ‘traffic light’ system was used to alert theatres, and the theatre floor co-ordinator and recovery nurse in charge worked together to prioritise patient transfers from theatre to recovery. The bays in the recovery area were also smaller than required at approximately 2 meters by 2 meters, compared to the recommended 3.5 meters by 2.5 meters. Additionally, there were insufficient plug sockets in each bay; professional guidelines suggest 6 sockets on either side of the trolley, but the service only had 4, plus 1 additional socket permanently used for the cardiac monitor. These issues had not seen improvement since the last inspection.

Not all electrical equipment had undergone portable appliance testing (PAT), indicating a need for improved safety checks on electrical devices. Equipment used to deliver care and treatment was suitable for its intended purpose, securely stored, and properly utilised.

The overall environment still failed to fully meet national guidelines, with the recovery area and surgical wards requiring further updates to ensure a safe and functional patient care environment. Security protocols were in place, requiring swipe cards for entry and exit, with patients using an intercom system. Emergency trolleys across the unit were checked daily, with all necessary items present and in date.

Staff managed clinical waste appropriately, and the use of equipment was aligned with maintaining safety standards where space and resources allowed.

Staffing levels remained a concern, particularly among medical staff. Despite efforts to address these issues, such as revising job descriptions and recruiting from overseas, the service continued to experience fluctuating vacancy rates. These challenges directly impacted patient care, with staff reporting that the availability of doctors at times limited the ability to proceed with planned procedures, disrupting service delivery. While nursing staffing levels were appropriate on the days of assessment, the service needed to address the high vacancy rates among medical staff and the pressure on resident doctors to work extended hours. Sustainable staffing solutions were necessary to ensure safe and consistent staffing levels, ultimately supporting the delivery of high-quality, patient-centred care.

Nursing staffing levels were stable, with the service having enough nursing and support staff with the right qualifications, skills, and experience to provide safe care. On the days of assessment, the nursing establishment was met, with the Surgical Assessment Unit (SAU) and Jersey Ward being fully staffed. Nursing staff vacancy rates were consistently low, recorded at 5.5% in April, 6.5% in May, and 5.3% in June 2024, all of which were below the trust’s target of 11%.

Managers regularly reviewed and adjusted staffing levels and skill mix to ensure adequate coverage, and bank and agency staff received a full induction. However, the assessment found that despite stable nursing numbers, the overall staff sickness rate remained at 5% from April to June 2024.

Medical staffing levels were, on occasions, insufficient, and this continued to impact patient safety and care quality. The trust’s data showed medical staff vacancy rates of 3% in April, 13.5% in May, and 8.1% in June 2024, with a trust target of 11%. On the day of the assessment, staff reported that some surgeries were deferred due to medical staff availability. Resident doctors reported feeling pressured to work extended hours, sometimes 7 to 9 days consecutively, which they felt contributed to fatigue and could impact patient care.

The service did not always have enough medical staff available to match the planned numbers, and managers struggled with recruitment despite proactive measures, such as updating job descriptions and targeting overseas recruitment. Locum staff were used to fill gaps where possible, and managers ensured they received a full induction before beginning work. However, the high turnover and sickness rates among medical staff remained a concern that needed sustainable solutions to maintain safe staffing levels.

The vacancy rate for administrative and clerical staff was 11% in June 2024, which met the trust’s target. However, administrative staff reported needing to work additional shifts to compensate for these vacancies, indicating that staffing levels could still be improved to reduce the burden on existing staff. Staff reported receiving appropriate support, including annual appraisals with managers.

Healthcare assistants (HCAs) on the Kennedy Ward reported ongoing staffing issues, and patients on this ward expressed that more staff were needed to provide adequate care. Despite these challenges, the service demonstrated positive recruitment and training practices for volunteers, who played an active role in improving patient experience. One volunteer developed a colour-coded hospital map to assist patients navigating the first and second floors, demonstrating an engaged and proactive approach to supporting the service.

The service had robust recruitment practices in place to ensure that all staff, including agency and volunteers, were suitably experienced, competent, and able to fulfil their roles. All staff interviewed, including medical personnel, agency nurses, and volunteers, confirmed that they received an induction and appropriate training for their roles. The service also ensured competency documentation for medical and anaesthetic staff, supporting safer recruitment and staff development.

While some positive practices were noted, overall adherence to Infection Prevention and Control (IPC) protocols required improvement. The service needed to increase compliance with hand hygiene standards and ensure that MRSA screening was consistently performed for all eligible patients. The trust reported that work was underway with the IPC team and management to address these concerns specifically on surgical wards. Hand hygiene compliance rates were below the trust target of 90%, with recorded rates of 75% in May, 70% in June, and 85% in July 2024. These figures indicated a need for improvement in ensuring that all staff adhered to hand hygiene practices to minimise the risk of infections., staff on Dorica Ward were observed not washing their hands between patient contact, which further supported the trust’s hand hygiene audit findings. This lack of compliance heightened the risk of infection for patients and staff.

The service carried out methicillin-resistant staphylococcus aureus (MRSA) screening for patients meeting the criteria set out in the MRSA screening policy. However, compliance was recorded at only 83%, indicating that not all patients were adequately protected from potential infection risks. Although this was an improvement from the last inspection, where there was no assurance of MRSA screening for high-risk groups, it still highlighted the need for enhanced monitoring, education, and adherence to IPC protocols to minimise infection risks and ensure patient safety.

The premises and equipment were generally kept clean and hygienic. Clinical areas were observed to be clean and clutter-free, with staff utilising green 'I am clean' stickers to indicate which equipment had been cleaned that day. Staff were seen cleaning equipment after patient use, demonstrating adherence to some infection control principles.

Staff used personal protective equipment (PPE) appropriately. The service had systems in place to prevent surgical site infections, and staff worked to identify and manage these infections effectively when they occurred.

Medicines management remained a significant risk to patient safety within the surgical unit. The assessment found that drug administration errors, missed doses, and incorrect documentation persisted, echoing the issues highlighted in the previous inspection. Although improvements were noted in the secure storage of medicines and controlled drugs, serious lapses in the safe handling and optimisation of medicines continued.

Pharmacy staff completed medicines reconciliation for only 50-60% of patients within 24 hours of admission, and these issues persisted. Patients on the Surgical Assessment Unit (SAU) and the surgical daycare unit did not routinely receive clinical pharmacy support, and although medicines reconciliation is expected within 24 hours of admission, delays were identified for those whose stay unexpectedly exceeded this timeframe. The trust informed us that pharmacy support is requested if a patient remains beyond 24 hours; however, this was not always evident in practice at the time of the inspection.

The service had systems and processes in place to prescribe, administer, record, and store medicines; however, these were not always followed effectively. Staff stored medicines securely in line with national guidance, using best practice procedures. Emergency medicines were accessible on the wards, and staff conducted daily checks to ensure the availability and safety of these medicines. The surgical daycare unit used prepared medicines packs to facilitate timely discharge and reduce delays.

Staff were observed preparing medicines using aseptic techniques and had adequate space for preparing intravenous (IV) antibiotics. However, issues persisted with the electronic prescribing system (ePMA). The system lacked alerts for duplicate prescriptions or when doses exceeded the prescribed limits. For instance, 1 patient was administered 4 doses of Metronidazole within 24 hours, although the prescribed regimen was 3 doses. This increased the risk of adverse effects and patient harm.

Patients were allowed to self-administer medicines when appropriate; however, risk assessments for self-administration were often incomplete and not documented according to trust policy. On several occasions, ePMA records inaccurately indicated self-administration when this was not the case. Additionally, the required support and documentation for patients self-administering medicines were not always present, creating inconsistencies in practice.

Staff had access to pharmacy support, including an out-of-hours service, and medicines incidents were discussed regularly within departmental meetings. The Medication Safety Committee met quarterly to review incidents and implement improvement initiatives. Learning was shared trust-wide through a monthly prescribing tips newsletter. However, due to staffing shortages, some education and training sessions were not available, affecting staff knowledge and confidence in medicines management.

Patients reported that they received information about their medicines during discharge, and their allergy statuses were documented clearly in patient records. Red colour-coded wristbands were used to alert staff of allergies. Some patients on the Surgical Assessment Unit (SAU) stated that they remained on trolleys for 2 days, which was outside the recommended time limit for this unit. These patients faced delays in medicines reconciliation, particularly as pharmacy support was not extended to the SAU.

While some aspects of medicines optimisation, such as antimicrobial prescribing, adhered to local guidelines and emergency medication checks were consistent, the overall compliance with medicines management protocols was insufficient. There were instances where missed doses were not documented or followed up properly. For example, 1 patient prescribed a treatment dose of anticoagulant injections for a thrombus did not receive their medication on 2 occasions, and no explanation or action was recorded in the notes, placing the patient at risk.