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We are carrying out checks at The Whittington Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 28 February 2018

Critical Care:

We rated safe, effective and caring as good and responsive and well-led as requires improvement. The rating of safe improved since our last inspection. Our overall rating of this service

stayed the same

. We rated it as

requires improvement

because:

  • There was a lack of local oversight of equipment maintenance and safety testing.
  • The service was not meeting the trust’s target for staff completing mandatory.
  • Although the incident reporting culture on the unit had improved, not all delayed discharges and mixed sex accommodation breaches were reported as incidents.
  • The service did not meet all best practice recommendations set out within The Faculty of Intensive Care Medicine (FICM) Core Standards for Intensive Care Units.
  • Speech and language therapy (SALT) was not available at weekends.
  • There was no dedicated psychological support service for the unit and staff told us that many patients would benefit from this.
  • Some relatives felt engagement and communication from staff could be improved. They did not always felt fully informed.
  • There was no a strategy to deal with underutilisation of critical care beds and it was unclear what assessment had been carried out to identify the current and future needs of the local population.
  • There were ongoing issues with patient flow. The majority of patients were delayed over the recommended four hours before being discharged to a different ward.
  • Not all patients who were ventilated on the unit were offered a follow-up clinic due to lack of no administrative support. This did not meet best practice recommendations set out within FICM Core Standards for Intensive Care Units
  • There was very little information visibly available to support relatives and visitors.
  • There was no internal referral system to refer patients to a psychological support service. Instead, the patient’s GP was contacted and ask to make a referral.
  • Opportunities to learn from complaints were missed. We did not observe any leaflets about how to make a complaint visibly displayed on the unit or within the designated relatives’ rooms.
  • It was unclear what the long-term plans were for the future of the service. The uncertainty over the future of the unit had a negative effect on staff morale.
  • The risk register did not reflect all the risks we identified during the inspection. We were not assured that there were effective systems for identifying, monitoring and mitigating risks.
  • There was limited evidence that staff and patients’ views were gathered to improve and plan the service.

However:

  • Staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse
  • Staff adhered to the hospital policy of being ‘bare below the elbows’ to reduce the risk of infection.
  • There was a clear escalation policy for any suspected cases of sepsis.
  • Patient records were clear, up-to-date and available to all staff providing care.
  • Learning and feedback from incidents was shared with staff via email, at handovers and team meetings. Staff were able to give us examples of learning from incidents.
  • Staff used appropriate risk assessments and care bundles to reduce the risk of patient harm.
  • Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients.
  • Patient outcomes were mainly in-line with, or better than, the national average for comparable units.
  • We saw evidence of good multidisciplinary working between staff on unit and different specialities.
  • Consultant-led ward rounds took place twice daily, seven days a week.
  • Patients and relatives were treated with compassion and kindness. They offered emotional support and reassured patients.
  • Patients’ family members and carers were provided with on-site accommodation within the nearby ‘relatives’ room’ to allow them to stay at the hospital overnight.
  • There was a positive and friendly culture on the unit. Staff supported each other and valued input from their colleagues. Staff told us they felt confident to raise concerns or ask questions.
  • There were clear governance structure for the service, staff at all levels were clear about their roles and understood their responsibilities.

Outpatient Department:

We rated safe, responsive, caring and well-led as good. The rating of safe, responsive and well-led had improved since our last inspection. Our overall rating of this service

improved

. We rated it as

good

because:

  • There were clear procedures in place for the care of patients who became unwell or patients who deteriorated whilst waiting at the clinic.
  • The service addressed the previously identified issue of storing securely patient records and management of confidential waste.
  • The service improved the availability of patient records in clinics.
  • The service significantly reduced staff sickness.
  • Evidence-based guidelines, recommendations, best practice and legislation were applied to patients’ treatment and care.
  • Staff were competent for their roles.
  • Good multidisciplinary team working helped staff understand and meet the range and complexity of patients’ needs. Each service specialty had its own multi-disciplinary team meeting.
  • Staff understood the relevant consent and decision making requirements of legislation and guidance.
  • Staff demonstrated compassion and kindness as they put patients and their relatives at ease.
  • The service took account of patients’ individual needs and was designed to meet the needs of the local population, including specialist clinics.
  • There was a ‘one stop’ breast cancer clinic and a separate ‘one stop’ clinic for patients with a suspected skin cancer.
  • The trust is performing consistently better than the England average for cancer waiting times.
  • Divisional leaders were visible and were proactive in engaging with patients and staff.
  • The departmental nursing staff won the trust annual ‘acute team of the year’ award.
  • Risks were generally understood and shared by all staff across the department.

However:

  • Incidents were not consistently reported and we were not assured that staff fully understood what constituted an incident.
  • Information about patient outcomes was not routinely collected and monitored by the department.
  • The department’s ‘did not attend’ rate was higher than the England average.

There were continuing capacity issues in certain clinics due to overbooking. In some cases, patient appointments were cancelled on the day.

Inspection areas

Safe

Requires improvement

Updated 28 February 2018

Effective

Good

Updated 28 February 2018

Caring

Good

Updated 28 February 2018

Responsive

Good

Updated 28 February 2018

Well-led

Good

Updated 28 February 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 28 February 2018

  • We were not assured that staff fully understood what constituted an incident or that there was an embedded culture of recording of incidents. We had mixed responses from staff about what they reported and some told us they did not believe it would result in change.
  • We observed inconsistent adherence to good hand hygiene practice.
  • The senior leadership team had not managed to improve the volume of reported incidents on the electronic reporting system. Whilst this was recognised as an area of improvement, there was no current plan in place to manage it.
  • There were continuing capacity issues in certain clinics and the fracture, ophthalmology and urology clinics in particular, similar to the time of the last inspection. This meant patients experiencing long waits and staff told us they experienced anger from some patients who became frustrated with the wait.
  • There were recurrent problems with sampling where blood and urine samples were submitted without the proper labelling or patient identification. This meant that some patients had to be recalled in order to repeat the test.

Maternity and gynaecology

Good

Updated 8 July 2016

We rated the service a Good because our main concerns were limited to safety issues within the service. 

Patient risk assessments were undertaken in a timely and comprehensive manner. Across both services medical, midwifery and nursing staff provided safe care; staffing levels were in line with national averages and were regularly reviewed.

Staff delivered evidence-based care and treatment and followed NHS England and the National Institute for Health and Care Excellence (NICE) national guidelines and policies and procedures were accessible to staff. Staff were competent and understood the guidelines they were required to follow

There was multidisciplinary working that promoted integrated care. The audit programme monitored whether staff followed guidelines and good practice standards.

Staff were caring and thoughtful, and treated women with respect. Patients’ confidentiality and privacy were protected. All the patients and relatives we spoke with gave positive feedback about their care and how staff treated them. Women and their partners felt involved with their care and appropriate explanations were given to them.

Referral to Treatment Times (RTT) for gynaecology patients were routinely above 90%. Appropriate arrangements were in place for patients who could not make informed decisions about their care. Systems were in place to support patients who had a learning disability. Complaints were dealt with effectively and improvements made, where necessary

Whilst there were established local governance and risk management arrangements, safety risks we identified in our inspection had not been addressed. The leadership team was not yet fully established and the vision and strategy of the service was not formal and plans to expand the service had not been fully communicated to staff.

There was limited assurance about safety of women undergoing elective procedures in the second obstetric theatre. Safety information, including staffing levels, was not displayed in any public area. Incidents were reviewed and learnt from, though there were some gaps in ensuring all actions listed on serious incident investigations were completed. Equipment was not readily available in the community and resuscitation equipment was not always checked. Mandatory training rates were, in some areas, well below the trust’s levels of expected compliance.

Medical care (including older people’s care)

Good

Updated 8 July 2016

We rated Medical care (including older people's care) as good overall because most patients were kept safe while they are being cared for at The Whittington Hospital. Patients who are at risk of deteriorating were monitored and systems were in place to ensure that a doctor or specialist nurse was called to provide the patient and ward staff with additional support. The trust had an open culture and had systems that allowed them to learn from clinical incidents. The medical wards had enough doctors and nurses to keep people safe.

We found that care on medical wards was provided in line with national and local best practice guidelines. Audits were being undertaken and there was good participation in national and local audits that demonstrated good outcomes for patients. Patient morbidity and mortality outcomes were well within what would be expected for a hospital of this size and complexity and no mortality outliers had been identified. Although there was a good knowledge of the issues around capacity and consent, the levels of staff training in these areas was low.

Patients received compassionate care and were treated with dignity and respect. Most of the patients and relatives we spoke with said they felt involved in their care and were complimentary about the staff looking after them. One person told us: “It’s great, they look after me well here. They are so nice and take an interest in how I am getting on”. The medical division had good results in patient surveys and results indicated an improvement in the views of patients over the last 12 months.

The medical division is effective at responding to the needs of its patients from all parts of its community. The hospital operational management team had a good understanding of status of the hospital at any given time. Bed availability was well managed. Elderly care pathways had been well designed to ensure that elderly patients were assessed and supported with all their medical and social needs. The hospital had designed pathways that if possible kept patients out of the emergency department (ED). The Ambulatory Care Unit and Hospital at Home provided effective alternate pathways for GPs and other referrers.

The Medicine, Frailty & Networked Service Integrated Care Service Unit (ICSU)is well led. Divisional senior managers had a clear understanding of the key risks and issues in their area. The division had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis. Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. They described the hospital as a good place to work and as having an open culture. The most consistent comment we received was that the hospital was a friendly place to work and people enjoyed working with their teams.

Urgent and emergency services (A&E)

Good

Updated 8 July 2016

We gave an overall rating for the urgent and emergency services of good because:

Some aspects of these services were outstanding. The multi-disciplinary working within the services, with other departments within the hospital and with external organisations put the patient at the centre of care and treatment. The Ambulatory Care Centre for adults provided an innovative service to patients, with access to diagnostic, therapeutic and specialist medical and surgical services in one place.

The emergency department (ED) performed better than the average ED in England in the speed of initial assessment, the timeliness of ambulance handover, and the percentage of people staying for more four hours in the department. However, there were times when there were no in-patient beds available and patients remained in ED for a long time.

The timeliness and quality of medical review was sometimes compromised because of the low number of consultant posts and the difficulty recruiting middle-grade doctors. Consultants worked hard to maintain standards in the ED, to review patients with complex needs, and to provide supervision and training to junior and middle grade doctors in training. This was not sustainable with the current consultant numbers. The nursing numbers and skill mix on ED were suitable. Nurses of all grades received excellent training and development opportunities.

ED and ambulatory care took part in national and local clinical audits to monitor the effectiveness of care and treatment. The analysis of incidents, complaints and staff feedback contributed to initiatives to make services safer and more responsive. There was action to improve services, and the action monitored to assess their impact.

There was outstanding work in the ED to protect people from abuse. Staff were well-trained and aware of their responsibilities. The lead consultant and nurse for safeguarding coordinated weekly meetings attended by relevant trust wide staff to discuss people at risk and to make plans to keep them safe.

The Ambulatory Care Centre environment was bright and welcoming and there had been other improvements in the ED, but some areas required further renovation. There were some shortcomings in cleanliness and waste disposal on ED.

The leadership of the newly formed ICSU were clear about their purpose and were confident in achieving this. There was an exceptionally positive culture in ambulatory care, reflected in the views of staff and patients.

Surgery

Good

Updated 8 July 2016

We rated the surgical services as good overall because:

We found that the surgery service at Whittington Hospital was effective and caring. However, improvements were needed to ensure that the service was safe, well-led and responsive to patients’ needs.

The surgery service had a good overall safety performance with low rates of serious incidents and few surgical site infections. We found good processes for reporting and escalation of incidents and good sharing of learning from incidents. All of the clinical areas we visited were clean and there were good infection control systems in place. However, there were significant staffing pressures across the service, particularly around recruitment and retention of nursing staff.

The surgery service at Whittington Hospital was effective. There were good patient outcomes across surgical specialties. The trust performed well in national clinical audits. There were short length of stay and low readmission rates. There was good multidisciplinary team (MDT) working. There were enhanced recovery processes for different patient groups. Good learning and development opportunities were available to staff.

Staff across the surgery service were friendly, caring and professional. Patients told us that nurses and doctors had a caring approach and they were treated with dignity. There was good family involvement and we found a very good approach to partnership care and keeping family members engaged at all stages of the surgery process.

There was good provision and systems in place to support patient’s individual needs, including those with complex needs. Flow within the surgery system was well managed, particularly at the front end of the patient experience, from admissions through theatres and into recovery. However, flow was impacted by significant bed pressures on surgery wards. Surgery wards were used as overflow wards for medical patients.

We found a cohesive and supportive leadership team and there was a clearly defined strategic plan for the service. Leadership of the service was clinically led. Matrons were very visible on the ward and consultants provided clear clinical direction.

The escalation of risks was not robust. A number of identified risks were not addressed adequately or in a timely way. The service required investment by the trust to alleviate pressure and build capacity. There were some challenges with the organisation culture within the service, which impacted on staff morale.

Intensive/critical care

Requires improvement

Updated 28 February 2018

  • There was no long-term strategy for the critical care unit. The service did not have plans in place to address the reduced bed occupancy on the unit in a way that met the needs of local people. Senior staff we spoke with were unable to confirm what the plans for the future of the service were.
  • Patient flow through critical care was still a significant issue. There had been some limited improvement in the proportion of patients experiencing a delay in being discharged from the unit. However, 68% of patients were delayed, for more than the recommended four hours, before being discharged to the ward. Many patients waited so long that they were discharged directly home from critical care.
  • Not all incidents of delayed discharge and mixed sex accommodation breaches were being recorded and investigated appropriately.
  • The unit’s risk register did not reflect all the risks we identified during our inspection. For example, we found that there was a lack of local oversight of equipment maintenance and safety checks. Not all staff had completed their mandatory resuscitation training. These, and other risks, were not reflected on the unit’s risk register.
  • Not all patients received the standards of care recommended by The Faculty of Intensive Care Medicine (FICM) Core Standards for Intensive Care Units. Patients requiring total parenteral nutrition sometimes had to wait 48 hours to start receiving nutritional support. Not all patients were screened for delirium on admission. Many patients were not offered the support of a specialised critical care follow-up clinic once they had been discharged from the unit.
  • There was limited evidence that peoples’ views and experiences were gathered and acted on to shape and improve the service. Opportunities to learn from complaints and feedback from patients, their relatives, and staff were missed.

However:

  • Overall patient safety on the unit had improved. The service had improved how it managed patient safety incidents and controlled infection risk. The number of incidents and near misses being reported by staff had improved. Managers shared learning from incidents with staff and staff had an opportunity to reflect on how they could improve.
  • Staff understanding of deprivation of liberty safeguards (DoLS) had improved. Staff we spoke were familiar with DoLS and demonstrated a good understanding of consent and mental capacity.
  • There was a positive and friendly culture on the unit. We observed good team working amongst staff of all levels. Staff told us that they were proud to work for the hospital and were well supported by their colleagues.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Patient outcomes were in line with, or better than, other similar critical care units and use of evidence-based practice was embedded throughout the unit.
  • Staff treated patients with kindness and compassion. Feedback from patients was consistently positive about the care they had received on the unit.

Services for children & young people

Good

Updated 8 July 2016

We rated services for children and young people as good overall because;

We saw that there were systems in place to ensure good governance and monitoring of standards for children, young people and infants who required acute medical care and surgical intervention and investigations.

Staff were proud to work for the trust and it was clear from speaking to parents that the public perception of the Whittington trust was very good. Inter-professional working was exemplary throughout children’s services.

Staff were aligned to, and supported the trust wide mission and vision. Leadership of individual aspects of children’s services was good with staff speaking positively about their immediate team leaders. The aspirations of the chief executive and his management team were fully supported by the staff.

End of life care

Good

Updated 8 July 2016

We rated End of Life Care as good overall because;

We found that staff providing end of life services were caring, the service was effective and well led. However, the safety of end of life services provided at Whittington Hospital required improvement. The end of life services also required improvement across the responsive domain.

Patients told us staff were caring and compassionate and that they were involved in planning their care and making decisions. We observed staff being respectful and maintaining patients’ dignity, there was a strong person centred culture. Patients in their last days were suitably assessed and their nutritional and hydration needs were met. Care and treatment was delivered in line with current evidence-based standards. Patients had appropriate access to pain relief. The trust had scored much better than the national average for clinical indicators in the national care of the dying audit. Palliative care and end of life team members were competent and knowledgeable.

There were no serious incidents relating to end of life care in the hospital. Staff received appropriate end of life training. They knew how to report concerns.

There was good end of life care awareness across the hospital. The trust appointed both, a non-executive lead, and an executive director to take lead and provide representation of end of life care at board level. Specialist palliative care team members felt supported in their work and worked well as a team. Staff were clear about their roles and their involvement in decision making and demonstrated a positive and proactive attitude towards caring for dying people.

However, not all staff had received adequate training including training in operating syringe pumps, Mental Capacity Act or training related to patients' deprivation of liberty. Patients DNR CPR forms were not always completed accurately. The trust did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital and provision of seven day services. They did not monitor discharge times and if there were any obstacles to patient’s discharge. There was no formal rapid discharge pathway to ensure speedy discharge of patients who wished to die at home or another location. Staff did not always record and analyse if patients were cared for at their ‘preferred place of care’. The trust did not gather and analyse patients and relatives views in relation to end of life care to inform service delivery and planning.

Other CQC inspections of services

Community & mental health inspection reports for The Whittington Hospital can be found at Whittington Health NHS Trust.