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

The service lacked a proactive and positive safety culture grounded in openness and honesty. Staff did not respond to safety concerns, investigate or report safety incidents, or implement learning to continually identify and embed good practice. Continuity of care was not ensured, particularly during transitions between different services. The service did not work effectively with individuals to understand and manage risks.

There were insufficient numbers of staff with the appropriate skills, qualifications, and experience. The service did not consistently identify or mitigate potential risks within the care environment. Equipment, facilities, and technology were not always suitable to support the delivery of safe care. The service failed to adequately assess or manage the risk of infection, and staff did not effectively identify or control its spread, nor did they escalate concerns to appropriate agencies in a timely manner.

Medicines and treatments were not consistently safe or aligned with people’s needs. At our previous assessment, this key question was rated as inadequate. At this assessment, the rating remains inadequate. This meant people were not safe and were not protected from avoidable harm.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff had systems in place to raise concerns. The trust had several initiatives to cascade learning from incidents and complaints to front-line staff. We saw that whilst events were investigated, learning was not embedded into practice and repeated errors occurred. This included poor management of sharp bins, cleanliness, and uniform adherence.   

Despite the presence of governance structures and processes for monitoring risks and performance, some key challenges, such as those related to capacity, access, and flow, persisted. The service leadership was aware of these ongoing issues, but support for and actions to address them had not been implemented in a timely manner, and plans for improvements were still in development without imminent changes.

Internal systems generally supported patient flow through the emergency department (ED), however external factors impacted on some patient pathways. A dedicated transition nurse managed the transfer of care, including the transition from children to adult services. The service electronically tracked patient journeys, recording times of arrival, triage, tests, and discharge.

Staff spoke of a significant and sustained increase in the number of patients with mental health (MH) issues presenting at the ED. Since January 2024, 91 MH patients absconded from ED. Long waits for MH patients were often due to bed shortages or social care delays. The average length of stay (LOS) for MH patients was 9-14 hours for adults and 7-14 hours for young people over the past six months. The longest LOS was 24-72 hours for young people and 51-69 hours for adults. Monthly the number of MH patients presenting to the ED ranged from 178-227, with a daily attendance of between 1-15 people. A staff member expressed concern about the lack of alcohol withdrawal support for patients, which can result in death if not managed appropriately. The trust did not provide any indication of plans to address this.  Patients were able to see approved mental health nurses for assessment under the Mental Health Act 1983, including at night.

Staff reported insufficient security presence in the ED, particularly since reduced police presence post ‘Right Care Right Place’ implementation. They suggested that increased on-site security was needed.  Staff noted that they had regular contact with 3 different police forces, British transport police, the Metropolitan Police and Heathrow Security Services. 

An average of 1,780 people accessed the ED and the UTC monthly. In June 2024, 1,785 people were seen, with 250 receiving same day emergency care (SDEC). The service reported low mortality rates. Increased ED acuity calls, and use of the Manchester Triage tool improved the detection of deteriorating patients.

At the time of our inspection only admitting speciality teams could make a ‘decision to admit patients’. Staff informed us this often led to delays as some specialty teams were reluctant to accept patients from the ED.  

The electronic patient’s medication administration (ePMA) system alerted staff to check for sepsis, based on the National Early Warning Scores (NEWS2) – which can identify acute deterioration. However, we found that this alert was not always triggered if the NEWS2 was not fully completed. We looked at records for one patient where this was the case. The patient had not been prescribed antibiotics, despite a high NEWS score and clinical records indicating sepsis. We highlighted this to a member of staff who took immediate action.

Sepsis audit showed that between 49 to 71% of patients were administered antibiotics within 60minutes of sepsis trigger since April 2024 (the trust target was above 90%). The trust told us that there was ongoing work to improve these figures.  

There were systems to support frequent emergency department attendees, enabling staff to treat them more consistently. 

Patients had direct access to clinical teams and were able to bypass ED when already triaged by their GP and given a referral letter. 

There was an understanding of safeguarding and how to take appropriate action. People were cared for by qualified staff who knew how to identify and escalate people at risk of harm. Clinicians were suitably trained at level 3 or level 4 safeguarding for adults and children depending on their role.  Staff knew how to report safeguarding concerns and who the safeguarding leads were. Safeguarding training was mandatory for clinical and non-clinical staff. There was a weekly multi agency safeguarding meeting where referrals were reviewed. Safeguarding training compliance exceeded the 90% target in ED, paediatric ED and the UTC.  

There was a commitment to taking action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. The service could also refer patients to third-party services for domestic violence support.   

Risk assessments about care were not person-centred or proportionate and were not regularly reviewed with the person. We did not observe the service keeping people informed about any risks and how to keep themselves safe.  

The waiting room was used as a “fit to sit” area and during our inspection there was no consistent observation of the area. The waiting area often had unwell patients, and we found examples of patients with chest pains, trauma and kidney infection having stayed in the waiting area for significant amounts of time. We spoke to patients in the waiting area who did not know what was happening or what they were waiting for. We saw no evidence assessments were made to determine a patient’s suitability for the area.  

There was no clear guideline for staffing the main ED waiting area to ensure oversight of deteriorating patients. Patients were in the ED for significant lengths of time, and this had an impact on timely care and treatment, including for MH patients. Staff could follow a protocol for people who were at risk of absconding. If a patient left before treatment and posed a risk of harm, the service contacted the police. 

There were delays in between prescriptions and administration of medicines in the waiting area. Medication and analgesia were sometimes administered up to an hour late. In one case, a patient was prescribed medication at 11:05 hours but given at 12:15 hours. In another case, analgesia was prescribed at 10:59 hours but given at 12:00 hours. 

Paediatric patients underwent multiple triage assessments (UTC and paediatric ED), potentially delaying care. Staff informed us that children brought in via the UTC were not always properly triaged. They provided an example involving two children with suspected sepsis that had their treatment delayed because of incorrect triage.  

Staff expressed concerns about medical staff capability to manage acutely ill patients, especially children, and about inadequate support for 16-18-year-olds. Adults and young people could wait up to 3 days for a bed, once assessed as requiring admission under the MHA. Paediatric patients with MH needs were frequently admitted to a paediatric ward.  

Premises and facilities did not always support the delivery of safe care. The service had 4 resuscitation cubicles which was insufficient for the number and acuity of patients seen. 

People using the service told us that the AECU was not conveniently located in proximity to the ED it was difficult to locate. The service had limited dedicated isolation cubicles. This posed an infection risk to patients, putting them at risk of cross-contamination. 

Leaders and staff had not considered how environments can keep people safe from psychological harm as well as physical harm, for example, facilities were inadequate for the care of patients with mental health difficulties. The service had only one mental health review room which was ligature-free in the main ED. However, there were up to 5 or 6 mental health patients during our inspection. In addition, there was no ligature-free room or cubicle in the paediatric ED. 

Facilities, equipment and technology were not well organised or maintained to consistently support staff to deliver safe and effective care. Patients were frequently cared for on a narrow corridor, which compromised their privacy and dignity. The ED corridor was used to care for patients throughout our inspection including during ambulance handovers.  

Data showed a lack of consistent arrangements in place to monitor the safety and upkeep of the premises. Despite multiple completions or risk assessments, a fire safety inspection from July 2024 showed fans and heaters in the department had expired PAT test (an inspection of electrical equipment to ensure it's safe to use) labels or had none at all. The risk register identified non-compliant ventilation arrangements across the ED.

We observed there was no air conditioning system in the red zone and the fans provided could put patients and staff at risk of microbes. However, after our inspection the trust took immediate action to address this.

The service did not have appropriate staffing levels and skill mix to make sure people received safe care. There was no paediatric emergency medicine (PEM) consultant in line with the Royal College of Paediatric and Child Health (RCPCH) standard which recommends that a paediatric ED should have at least one PEM consultant. However, the service had access to general paediatric consultants.   

Staff did not always receive the support they needed to deliver safe care. There was no administrative support for medical staff. Staff indicated they could not provide teaching records for medical staff due to the lack of administrative staff. We observed that nurses in charge were not able to focus on their role as they were occupied with other nursing tasks such as IV treatments and cannulation, due to no phlebotomist presence. 

Staff informed us they often struggled with pressures associated with staffing in the ED. They said the department was very busy and did not have the required number of staff used for winter pressures. Some nursing staff expressed concerns that they often had no HCA available. They explained that this impacted their ability to focus on core nursing tasks as they have to prepare the cannula, commode and do other tasks HCAs do.  

Senior staff informed us they were fully established for qualified adult nurse staffing except for 0.61 whole time equivalent (WTE) vacancy for Band 7 nurse. There was also 7.34 WTE vacancy for Band 2 staff. There were some gaps in paediatric ED nurse staffing. These included 1.08 WTE band 7, 1.17 WTE band 6, 2 WTE band 5 and 0.71 WTE band 2 vacancies.  

Mental health nurses were recruited from agencies to support the care of patients with mental health disorders.  

The number of patients seen, and the poor layout of the facility meant that the service needed more consultants to cover all the different areas of the ED, to supervise and train junior doctors adequately.  

Nurses received training appropriate to their role.  Mandatory training rates were above 90%

People were not protected as much as possible from the risk of infection because premises and equipment were not always kept clean and hygienic. Most of the facilities for mental health patients were clean and well-maintained. However, the family rooms in a separate corridor were not clean at the time of the inspection. 

Staff did not always adopt measures to prevent the control and spread of infections. We observed poor infection prevention and control practices in the ED. We observed the male and female toilets in the ED corridor looked unsanitary and had long-term stains on the floor. We observed cleaning staff handling clinical waste without using appropriate personal protective equipment (PPE) such as gloves.  

There was not an effective approach to assess and manage the risks of infection, that was in line with current relevant national guidance. Clinical staff were not always changing their gloves, washing their hands or cleaning equipment between patient care. We observed some clinical staff had long painted nails contrary to national guidance.

The department did not have a dedicated pharmacist or pharmacy technician which was not in line with national guidance. However, staff we spoke with understood the process of accessing medicines, advice and out of hours support from pharmacy. 

Patients were not always prescribed their regular medicines and did not always receive their medicines on time. Patients did not receive pain relief in a timely manner. 

Patients were not always prescribed their regular medicines, which meant they were at risk of adverse events due to missed medicines. For example, we looked at records for 1 patient who was taking an antihypertensive at home. This medicine had not been prescribed and there was no documentation in the records for why this had been missed.  

Staff told us that they felt unsupported by senior leaders when concerns were raised about shortages in pharmacy staffing. We were told that there were difficulties and delays in receiving support by specialty teams when patients were waiting in the emergency department for an inpatient bed. This often resulted in delays in prescribing medicines including antibiotics. There was no process to ensure that patients on critical medicines were prioritised. This meant that there was a risk of deterioration in the patient’s condition due to missed medicines.

There was no clinical pharmacy provision for the service, so we were told that apart from controlled drug audits, no other audits in relation to medicines optimisation were taking place. Therefore, the trust could not be assured that medicines were being used safely in the ED. 

Staff told us that due to staffing shortages, education and training was not always available to upskill their knowledge of medicines optimisation. 

Staff had access to emergency medicines. Medicines including controlled drugs (medicines requiring additional security measures due to their potential for misuse) were stored securely. However, we found some out-of-date medicines in one area, which we highlighted to the ED manager. There were improvements required in the security of prescription forms to reduce the risk of misuse or diversion.  

We found some discrepancies in the recording of controlled drugs in the register, which were highlighted to staff immediately.  

An electronic prescribing and medicines administration system was in place, but we found that there were no alerts when duplicate medicines were prescribed, placing patients at risk of harm due to overdose. Staff had access to resources to enable them to obtain medicine history from patients, but this was not always fully documented or prescribed. Allergies were not always recorded, placing patients at risk of receiving medicines they were allergic to.  

The service had a process for the supply of medicines under patient group directions (PGD`s) where staff had been trained specifically for this and prepared medicines To Take Away (TTA) to avoid delays in discharge.