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Archived: Northwick Park Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 August 2014

We carried out this comprehensive inspection because North West London Hospitals NHS Trust had been identified as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. We carried out an announced inspection of Northwick Park Hospital between 20 and 23 May 2014. Northwick Park is the main location of the trust and accommodates the senior management team.

North West London Hospitals NHS Trust is located in the London Boroughs of Brent and Harrow, and cares for more than half a million people living across the two boroughs, as well as patients from all over the country and internationally. The North West London Hospitals NHS Trust manages three main sites registered with the Care Quality Commission: Northwick Park Hospital and St Mark’s Hospitals in Harrow, and Central Middlesex Hospital in Park Royal. St Mark’s Hospital as an internationally-renowned centre for specialist care for bowel diseases. The trust has a sustainable clinical strategy with Ealing Hospital to improve patient pathways, and is underpinned by combined ICT and estate strategies, and a vision to establish Northwick Park Hospital as the major acute hospital of choice for outer North West London.

The hospital has had some issues in the past, particularly around its maternity services. However, the management team has worked hard to address these. We saw a number of areas where improvements had been made to the maternity services, but it still requires further improvements in order to provide a safe, effective, caring and responsive service.

Overwhelmingly across the trust, staff were found to be caring and compassionate towards patients, their family and friends. The management of areas at a local level required some improvement for services to develop and provide good care.

Our key findings were as follows:

  • The patient flow through the hospital impacted on patients waiting in the A&E department, in that patients were often 'bedded down' in A&E until a bed became available. 
  • Middle grade doctors did not always receive the training and supervision they required.
  • Policies and protocols, particularly in surgery and critical care, were not always up to date and reflective of national guidance.
  • Pressures on the critical care units were such that some patients were discharged too early and had to be re-admitted on some occasions.
  • The pace of change in maternity was slow, leading to potential risks for women using the service.
  • In most areas the hospital, while clean, was in need of refurbishment.

We saw an area of outstanding practice:

  • The stroke unit was providing a ‘gold standard service’ with seven-day working. It had been the recipient of the prize for the 2013 Clinical Leadership Team at the British Medical Journal awards.

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

Importantly, the trust must:

  • Ensure that there are appropriate numbers of staff to meet the needs of patients in the A&E department, surgical areas and critical care.
  • Ensure that there are systems in place to assess and monitor the quality of the service provided in A&E, critical care, surgery and maternity, to ensure that services are safe and benchmarked against national standards.
  • Ensure that the environment is safe and suitable in paediatric services.
  • Ensure that equipment is available, safe and suitable within the paediatric service.

In addition the trust should:

  • Review the coping strategies within A&E during periods of excessive demand for services.
  • Empower senior staff to make changes to ensure that patients are safe in A&E and maternity.
  • Ensure that planned changes are undertaken in a timely manner in surgery and in maternity.
  • Review discharge arrangements in A&E and critical care to avoid re-admission to these areas.
  • Encourage a proactive midwifery department.
  • Encourage increased multidisciplinary working in areas such as maternity.
  • Review the confidentiality of medical records within the outpatients department.
  • Review the effectiveness of clinics to prevent overbooking, late running and cancellations.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 August 2014

Effective

Requires improvement

Updated 20 August 2014

Caring

Requires improvement

Updated 20 August 2014

Responsive

Requires improvement

Updated 20 August 2014

Well-led

Requires improvement

Updated 20 August 2014

Checks on specific services

Medical care (including older people’s care)

Good

Updated 20 August 2014

Care and treatment in the medical services were based on published guidance, and there was evidence that outcomes for patients were good. Safe staffing levels had been set and were maintained by the use of bank and agency staff. Patients we spoke with told us they had been treated with dignity, shown respect and had been well cared for by staff. We found that there was strong and enthusiastic leadership shown by directorate management teams, including matrons and ward managers. The environment and equipment were visibly clean, and infection control practices were good.

Care was organised to meet the needs of the patient, and translation services were available. There was a multidisciplinary approach involving patients and relatives to ensure the safe and effective discharge of patients from hospital.

Services for children & young people

Requires improvement

Updated 20 August 2014

Services for children and young people at Northwick Park Hospital require improvement. Children received effective care from staff trained to work with children. Staff engaged well with children of different ages. The facilities were generally good, particularly in the day care/children’s outpatient area. Staffing and skill mix on the ward, the neonatal unit and the day care/outpatient service were sufficient.

However, there was insufficient space for storage of equipment on the children’s ward, and some areas were cluttered.

Parents had confidence in the care their children received, and spoke positively about staff’s compassion and communication. We observed staff showing care and responsiveness to individual children. However, we found some areas where safety needed to be strengthened, such as ensuring clinical equipment was not accessible to children on the inpatient ward, and that medical equipment was serviced annually. 

There were arrangements to meet the diverse language needs of the population served by the hospital. However, there was a lack of joined up working across the medical team and between doctors and nurses. We also found that the service itself was distant from the trust board. There were no processes to obtain the views of the service from families and friends, although we were told that some ideas were being considered.

Critical care

Inadequate

Updated 20 August 2014

The critical care unit (CCU) at Northwick Park Hospital is inadequate as there was insufficient data recording of activities and outcomes to ensure that the services provided a good practice. The service cannot benchmark itself against national data as it had chosen to undertake a local auditing system. However data was not robustly and consistently being collected. Nursing staff were supported through good policies and protocols, however despite the large numbers of locum medical staff used there were no guidance or protocols for them to treat patients in line with. This could potentially lead to inconsistent care being provided.  

Whilst there was only limited information to indicate that instances of harm had occurred in the past, there were insufficient measures in place to ensure that patients were safe and received high quality care. Pressure on the department meant that some patients were discharged too early and had to be readmitted on some occasions. There was a lack of departmental senior staff to take action on these issues, and senior staff at the trust had not acted on the concerns. Despite the pressure staff were under, they were seen to be caring and supportive of relatives.

End of life care

Good

Updated 20 August 2014

We found that the end of life care to patients was good overall. The hospital had good links with the specialist palliative care team (SPCT) and community services, in order to support patients and their families. The SPCT and other services involved in end of life care were passionate, caring and maintained patients’ dignity throughout their care. There was clear multidisciplinary involvement in patient care. Patients were involved in advance care planning and their preferences were observed and followed through when possible and appropriate. People’s cultural and religious needs were taken into account.

End of life care training was not mandatory within the trust and this meant that healthcare professionals at the hospital found it difficult to attend the courses provided by the SPCT.

Maternity and gynaecology

Requires improvement

Updated 20 August 2014

The maternity service was not meeting some of its performance targets. Although risks to the service had been identified and were being monitored, there was a lack of pace in taking action to minimise risks to women using the service.

We saw that there were efforts being made to introduce changes that would deploy the midwife workforce more flexibly, but further effort was needed to win staff support and embed these changes for the benefit of women and their babies. The maternity service did not respond to complaints in a timely manner, nor did it actively seek women’s feedback on the maternity pathway. Women reported to us and through a number of surveys that the care they received fell below expectations.

Outpatients and diagnostic imaging

Requires improvement

Updated 20 August 2014

Patients received compassionate care and were treated with dignity and respect by staff. The outpatients environment was clean, reasonably comfortable, well maintained and safe. Staff were professional and polite, and promoted a caring ethos.

Patient notes for the individual clinics were kept in open trolleys and we saw that on occasions, these were left unsupervised. The lack of secure storage meant there was the possibility of confidentiality being breached.

Clinicians took sufficient time in consultations, and patients said that they felt involved in their care. The demand for some of the clinics was greater than the capacity. This meant that some clinics ran late and also had long waiting times for appointments. There were initiatives in place to consider moving some services to improve their efficiency.

Surgery

Requires improvement

Updated 20 August 2014

The surgical service at Northwick Park Hospital requires improvement. Whilst the day-to-day running of the department generally provided safe care, the service faced notable risks. The low number of middle grade doctors and the low number of general surgical lists meant that there were delays in emergency surgery taking place. Nursing staff received appropriate training and support, and multidisciplinary working was good. However, there was a lack of up-to-date protocols and guidelines for staff to work from. Patients said that they were well looked after and supported, and we observed this taking place.

While the concerns highlighted had been raised internally, and plans to improve the department had been drawn up, these changes had not occurred. It was not clear if there was a specific plan for when these planned adjustments would be made.

Urgent and emergency services

Requires improvement

Updated 20 August 2014

The A&E department at Northwick Park Hospital required improvement in order to protect people from avoidable harm. There were inadequate staffing levels to provide safe care to patients within the majors treatment area. The escalation protocol was inadequate and did not provide a sufficient or measurably safe response.

Northwick Park Hospital was consistently not meeting the four-hour A&E waiting time target. The leadership within the A&E department did not ensure that patient experience and flow through the department was assured. The staff we spoke with demonstrated an attitude of commitment, but their morale was low. However, staff took the time to listen to patients and explain to them what was wrong and any treatment required. Patients told us that they had all their questions answered and felt involved in making decisions about their care.