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Archived: West Middlesex University Hospital NHS Trust Requires improvement

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Reports


Inspection carried out on 25–28 November 2014

During a routine inspection

West Middlesex University Hospital is the main acute hospital for the West Middlesex University Hospital NHS Trust, which provides acute medical services to a population of around 400,000 people across the London Boroughs of Hounslow and Richmond on Thames and surrounding areas.

Following the board's decision that this trust would not meet the requirements for Foundation Trust status, it has been in negotiations to merge with another NHS trust. Following our inspection, it was announced on 19 December 2014 that the merger with Chelsea and Westminster NHS Foundation Trust had been approved by the Competition and Markets Authority.

The trust is planning for an increase in emergency and maternity attendances that will result from The London North West Strategy, "Shaping a Healthier Future".

We carried out this comprehensive inspection as part of our overall inspection programme of NHS acute trusts. We undertook an announced inspection of the trust between 25 and 29 November and unannounced inspections on 9 and 13 December.

We inspected all the main departments of the hospital: Urgent and emergency services (A&E),medical care,surgery,critical care,maternity and gynaecology,services for children and young people,end of life care, and outpatient and diagnostic imagery.

Overall this hospital requires improvement.

We rated the hospital good overall in the following departments: medical care,critical care and maternity and gynaecology. However, our inspection results rated the following services as requiring improvement: urgent and emergency services,surgery,services for children and young people,end of life care, and outpatients and diagnostic imaging.

While we rated the hospital as good overall in caring,it requires improvement overall in providing safe care,being responsive to patients' needs and being well-led. We rated the hospital overall as inadequate in providing effective care.

Our key findings were as follows:

  • Most patient, carer and patient relative feedback was positive in relation to the care being provided by the hospital.
  • We saw many examples in most areas of the hospital of staff giving treatment in a caring and compassionate way.
  • We found care being delivered in a supportive atmosphere.
  • Critical care wards were consistently good in relation to safe and effective treatment which was responsive to patient needs, delivered with compassion and in a well-led culture.
  • The physical environment in the hospital was well maintained as well as clean and hygienic.
  • The urgent and emergency care department had a calm and well managed response to heavy emergency demand on the Wednesday evening during our inspection visit.
  • Uncertainty around the merger with another trust had resulted in a number of interim appointments in clincal and managerial areas. The trust had recently started to appoint to permanent posts notably Director of Nursing.
  • There was widespread access to the Datix incident reporting system to allow staff to report incidents. However, feedback and learning to staff arising from those incidents was mixed in effectiveness.
  • There was insufficient consultant support in palliative care and the trust overall had not given sufficient focus on end of life care.There were mixed levels of understanding of the compassionate care pathway.
  • There were concerns about the leadership in the Special Care Baby Unit (SBCU) and this had an adverse effect on the performance overall of services to children and young people.
  • The hospital has a limited acute oncology service.
  • The trust did not have a robust document and policy management process. We found several examples of out of date policies in use on the wards.
  • Ultrasound capacity in the early pregnancy unit was insufficient to meet demand.

We saw several areas of outstanding practice including:

We saw several areas of outstanding practice including:

  • The A&E department had a calm and well-managed response to very heavy emergency demand on the Wednesday evening of our inspection visit. Management support was also well considered, calm and effective.
  • We found the care and support given by the mortuary staff and patient affairs office to relatives after the death of their family member was exemplary.
  • The innovative ‘heads-up’ structured approach to handover in medicine

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Address the midwife/mother ratio both in terms of immediate levels of care and the strategic planning for expansion of obstetric services.

  • Review and act upon consultant and nursing staffing levels in Emergency Services
  • Review the processes for the management of policies and procedures to ensure that staff has access to the most up to date versions.
  • Review its provision of End of Life services; its palliative care staffing levels and support of end of life care on the wards.
  • Ensure full completion of DNACPR forms
  • In medicine, address the lack of an acute oncology service
  • In surgery, improve the frequency of consultant ward rounds.
  • Ensure full completion of WHO Checklists for surgery
  • Remove the practice of unverified consultant patient discharge letters
  • Improve leadership and effectiveness in the SBCU
  • Address the issue of late availability of TTA medicines leading to late discharge or patients returning to collect them.

In addition the trust should:

  • Further develop it’s strategies for ensuring that the organisation is learning from incidents and issues.
  • Continue to clarify its strategic intent, stabilise leadership and continue to engage its workforce in planning for change.
  • Review its pharmacy services to be more responsive to the needs of patients
  • The trust should ensure that the room in the A&E department designated for the interview of patients presenting with mental ill health has a suitable design and layout to minimise the risk of avoidable harm and promote the safety of people using it.
  • The trust should review the arrangements for monitoring patients in the A&E department to ensure clear protocols are consistently used so that changes in patients’ condition are detected in a timely way to promote their health.
  • The trust should review the number and skill mix of nurses on duty in the A&E department to reflect Royal College of Nursing Baseline Emergency Staffing Tool (BEST) recommendations to ensure patients’ welfare and safety are promoted and their individual needs are met.
  • The trust should review the number of consultant EM doctors employed in the A&E to reflect the College of Emergency Medicine (CEM) recommendations.
  • The trust should respond to the outcome of their CEM audits to improve outcomes for patients using the service.
  • The trust should review the arrangements for monitoring pain experienced by patients in the A&E to make sure people have effective pain relief.
  • The trust should review the arrangements for providing people with food and drink and assessing their risk of poor nutrition so people’s nutrition and hydration needs are met.
  • The trust should review their arrangements for assessing and recording the mental capacity of patients in the A&E to demonstrate that care and treatment is delivered in patients’ best interests.
  • The trust should make arrangements to ensure contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.
  • The trust should review some areas of the environment in A&E with regard to the lack of visibility of patients in the waiting area and arrangements for supporting people’s privacy at the reception, the observation ward and the resuscitation area.
  • The trust should review the provision of written information to other languages and formats to that it is accessible to people with language or other communication difficulties.
  • The trust should review the way it considers the needs of people living with dementia when they are in the A&E department.
  • The trust should review their management of patient flow in the A&E department so patients are discharged in a timely way or transferred to areas treating their specialty.
  • The trust should review the risk register in the A&E to make sure all identified risks are included and action is taken to mitigate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21, 22 November 2013

During a routine inspection

The visits to West Middlesex University Hospital took place over two days. During the inspection we visited eleven wards including children’s and elderly care wards, the maternity unit, accident and emergency services and some of the outpatients departments. We asked staff who worked in and people who used the outpatient departments to complete comment cards, and we received 11 of these from people who use the service and eight from staff. We also met with senior management staff, including the director of nursing, the director of quality, discharge co-ordinator and education and training lead. During our visit we were also accompanied by a specialist advisor for maternity services.

Throughout our two day visit we spoke with at least 90 people who use the service and/or their relatives/representatives. We also spoke with approximately 67 staff of different disciplines, including doctors, nurses, health care assistants, dieticians, physiotherapists and occupational therapy staff.

Prior to the inspection we also contacted and received information from some social work teams within the main local authorities that are served by the hospital.

The majority of feedback we received from people who use the service and their representatives was positive. Some comments we received from people were: "I feel that I am respected", “the care I had has been very good. The staff have been great”, “my experiences at West Mid were OK. Information was given clearly and I was satisfied with this”, “sometimes waiting is long but the care provided and the doctors, nurses and other professionals are excellent.”

However, other people told us that they felt that the discharge planning could be improved for people leaving hospital, such as in relation to waiting for transport and ensuring that appropriate arrangements were in place when people returned home. A number of people also commented about long waiting times in the clinics and outpatients they attended, despite them having an appointment.

People received care and support through a multi-disciplinary approach to ensure their needs were met appropriately. Although staff received training to enhance their skills, they did not feel they were always supported in their work and did not regularly receive clinical supervision.

We found that the hospital was clean and there were systems for infection prevention and control. However, we also observed some shortfalls in regards to cleanliness and infection control which could be putting people at risk from the spread of infection.

The trust had systems in place to regularly assess and monitor the quality of service that people received. They took action in response to incidents to minimise risks to people who use the service.

Inspection carried out on 21 March and 31 May and 13 August 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 26 April 2012

During a routine inspection

We spoke with patients on four wards: Osterley 1, Osterley 2, Syon 2 and Richmond.

Everyone we spoke with felt that their privacy and dignity was respected by staff. Patients told us that they were “well cared for” and that they had confidence in the staff. Most people we spoke with felt that their individual needs were met through the treatment and care they received.

Patients we spoke with about discharge from the hospital told us that they had received the appropriate discharge documentation to ensure that their care and treatment would be continued by their community healthcare provider.

Patients and their relatives told us that they were satisfied with the care and treatment they received from staff. One patient told us, “From porter to consultant, everyone has been excellent”.

Inspection carried out on 28 April 2011 and 18 September 2012

During a themed inspection looking at Dignity and Nutrition

All of the patients we spoke with told us that they found the ward staff polite and respectful towards them and always willing to help. They all felt that their dignity was protected by staff and that their privacy was respected.

The majority of patients we spoke with felt that they were involved in their care and that staff listened to them when they expressed their preferences. Most patients and relatives reported no concerns with the care and treatment but said they would feel comfortable speaking to the senior ward staff if they did have any.

The majority of the people we spoke with felt that they had not received enough information about their care and treatment and the facilities available during their stay in the hospital. However, they did confirm that staff were always willing and available to answer questions.

Most patients said they enjoyed the food and were happy with the range offered. One person said ‘meals are very good’. Most people who needed special diets felt their needs had been met. Almost everyone said they had the opportunity to wash their hands before and after eating and that staff ensured they were in a comfortable position before eating. All felt that they received enough support with eating. People reported they had drinks whenever they wanted them and water was always available.

Inspection carried out on 18 September 2012

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.