Archived: Wexham Park Hospital

Our inspection in October 2013, to which this report relates, was a follow up inspection to determine whether the trust had addressed the concerns we raised during our previous inspection. We inspected the hospital's accident and emergency department (A&E), emergency department decision unit (EDDU), acute medical unit (AMU), medical intervention day unit (MIDU), and wards 1, 3, 4, 5, 7, 9, 17, and 18. We also inspected in-patient paediatrics, the neonatal unit, diagnostic imaging, and rehabilitation. We also inspected the hospital's maternity service in response to concerns which were raised with us. This included triage and assessment, labour ward, post natal ward, and birthing centre. We tracked care pathways for 12 patients, looked at 24 sets of patient records and 45 drug charts, interviewed 137 members of staff and 3 paramedics, and spoke with 56 patients and/or their relatives.

We found the trust had made significant improvements in some areas, particularly in managing capacity issues in A&E and ensuring the movement of patients from A&E and onto in-patient wards. At the time of our inspection, the A&E department was undergoing an expansion and refurbishment programme. Dedicated facilities for assessing and treating patients were newly in place. There were improved systems for assessment and triage, reduced waiting times, and improved arrangements for protecting patients' privacy and dignity. Standards of care and clinical assessment in the EDDU were improved. Two new wards had been developed to provide additional hospital beds and reduce the hospital's need to use escalation areas. New systems were in place for setting up and opening areas which were not normally used to accommodate in-patients, called escalation areas. We found the storage of medicines was better managed.

A number of wards we inspected were well led and well managed. These included wards 1, 3, and 5 as well as MIDU and the neonatal unit. Patients on these wards were pleased with the care they received and spoke highly of the staff. We observed staff worked well together as a team; patient records were up to date; the wards were clean; and patient care was of a high standard.

We re-visited the medical wards we had previously inspected and found marked improvement in the standard of care provided on some but not all of them. We had particular concerns about the leadership and management of AMU / ward 7 and ward 4. On these wards, we observed many instances of poor practice where the quality of care fell significantly below essential standards. Patients' privacy and dignity was not always respected; medical and nursing notes were not complete or up to date; there were poor arrangements for ensuring the confidentiality of patient records; and standards of hygiene and cleanliness were not maintained. These wards were also found to be consistently short staffed. The care some patients received was below essential standards and put them at risk of harm. We raised our concerns with trust managers during our inspection so that safety issues could be addressed immediately.

We found many areas of the hospital were in need of refurbishment and redecoration. Signage was poor and many people told us they found it difficult to find the area of the hospital which they needed. There were inadequate arrangements for ensuring hospital facilities and equipment were appropriately maintained. With limited exception, we found patient areas across the trust to be dirty and dusty. In some instances, the poor condition of the premises prevented the proper cleaning and disinfection. Equipment was not always cleaned or replaced when needed.

There were systems in place to identify risks to patient safety and maintain the quality of services. As we found in our previous inspection, however, these were often ineffective. There were examples of breaches in care that were not picked up through the trust's quality monitoring arrangements. We found staff did not always comply with trust policies and procedures. Specific examples of this which we found were not identified by the trust. Staff did not always report incidents of harm to patients. There were systems in place for implementing National Institute for Health and Clinical Excellence (NICE) guidelines but the use of the guidelines was not robustly audited. Where audits raised concerns, the concerns were not always addressed. The use of national guidelines other than those published by NICE were not systematically implemented, monitored or audited.

While lessons from incidents and complaints were identified by managers and clinical leads at governance meetings, they did not always translate into changes on wards or in clinical practice. Lessons learned were not always communicated to staff on ward level. On the labour ward, midwives and doctors told us lessons learned from a series of serious patient safety incidents were not communicated to them. They felt this contributed to tensions between labour ward staff and to the development of a culture of blame and suspicion.

There was a lack of engagement between trust managers and ward level staff. Staff did not feel they were encouraged or empowered to raise concerns and make suggestions for improvement. A number of staff across the hospital expressed concerns about bullying and harassment from managers. In some instances staff raised concerns with us but told us they were reluctant to speak with us for fear of reprisal from their managers and asked not to be named.

We visited the hospital's Accident and Emergency Department (A&E), Emergency Department Decision Unit (EDDU), acute medical unit (AMU), medical interventions day unit (MIDU), acute stroke unit as well as wards 4, 6, 7, 9, and 18. We also visited the paediatrics unit and a number of the hospital's escalation areas. We tracked care pathways for 12 patients, interviewed 56 members of staff and four paramedics, and spoke with 42 patients and relatives.

We found that the A&E department was overwhelmed by a combination of high A&E attendances and a shortage of in-patient beds in the rest of the hospital. The department was very crowded and busy. Our observations showed staff struggling to cope with high numbers of A&E attendances and patients waiting up to eleven hours to be admitted onto a ward. There was a clear focus on managing the demand for in-patient beds, sometimes at the expense of providing basic care.

Across the hospital, we saw many instances where the care given to patients was good; however, we also saw a number of instances where the quality of care given to patients was below essential standards. The majority of patients we spoke with were satisfied with the quality of care provided. However, we received a number of complaints from patients about the quality of nursing care and poor communication.

We observed a number of instances where peoples' privacy and dignity were not respected. This was particularly the case in A&E and EDDU. We found poor standards of cleanliness and inadequate infection control arrangements in some areas of the hospital. Storage of medicines on wards was poor, with patients and visitors on some wards easily able to access drugs which should have been kept in a locked area. We identified a number of concerns around staffing including high vacancy rates in some areas and an over reliance on bank and agency staff. In all of the patient records we checked, we found evidence of poor record keeping, poor communication, and an absence of care plans.

There were systems in place for identifying risks to patient safety and maintaining the quality of services. However, in many instances, these were ineffective. Where concerns were identified, they were not always addressed and reviewed to ensure standards were maintained. There was a clear emphasis on responding to national and local clinical targets but little emphasis on ensuring that overall patient experiences were positive.