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Watford General Hospital Requires improvement

All reports

Inspection report

Date of Inspection: 17 December 2013
Date of Publication: 21 January 2014
Inspection Report published 21 January 2014 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 17 December 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider, reviewed information sent to us by other regulators or the Department of Health and talked with other regulators or the Department of Health. We were accompanied by a specialist advisor.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People’s care and treatment on the stroke unit and on the fractured neck of femur pathway reflected relevant research and guidance. However care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare. The arrangements in place to deal with foreseeable emergencies did not ensure that equipment had been checked as safe to use.

Reasons for our judgement

For part of this inspection we focused on the fracture neck of femur (NOF) pathway. The fractured neck of femur pathway is a system used within a trust to provide and monitor a specific course of treatment and surgery for a person admitted with a fractured femur. Prior to our inspection we were aware that the trust had a higher than expected mortality rate for patients who had received surgery to repair their injury. We were also informed that the Medical Director for the trust had implemented changes to improve care and reduce mortality in this area.

We were supported by a specialist advisor for our inspection who was an experienced registered nurse with understanding of orthopaedics. We found that by December 2013 the Trust had decreased mortality from 12% to 6%. This is now below the national average of 8% and is a positive improvement. We examined the records of 41 patients during this inspection. We identified 17 patients that had been admitted in the previous week with a fractured neck of femur, of which four had recently received surgery. In all cases the care received was clearly documented and it had been fully assessed that the patients were safe to return to the ward after surgery. This demonstrated that the trust had responded to the concerns with the pathway by implementing measures to reduce the risk of harm to people.

We spoke with four nurses, the orthopaedic nurse responsible for fractured neck of femur care, the modern matron, consultant in orthopaedics and the Medical Director about the pathway. We found that changes implemented included the employment of a nurse specialist in fractured neck of femur, patients remaining in recovery for a longer period after surgery and that the outreach team from intensive care were also consulted in the patients post-surgery care. We also found that the service had changed its operating policy. This meant that surgery for fractured neck of femur would only be performed by a consultant surgeon with the anaesthetic provided by a consultant anaesthetist.

We found that the pathway tool used in orthopaedics was not a standard tool for use in patient care. This meant that orthopaedic patients, who had been admitted for example to a medical ward, may be placed at risk of harm. This was because staff on non-orthopaedic wards did not use the fracture neck of femur pathway; five staff we spoke to in a non-orthopaedic ward were unaware of the pathway. Overall the risk to patients with a fractured neck of femur had reduced but sustained improvements were needed and sharing of knowledge on non-orthopaedic wards was required to ensure that patient care on the pathway is safe.

We visited the stroke unit during this inspection to ask about the stroke pathway for new admissions. The Stroke Unit is a specialist unit which accepted direct referrals through the emergency department and ensured people were rapidly assessed and treated according to their particular needs on the stroke unit. Overall we found that people were treated in line with national guidelines and best practice. All patients were placed on a ‘stroke pathway’ to maximise opportunities to reach the best outcome for their condition.

We spoke with three staff on the AAU unit. The staff told us that patient transfer time from the emergency department must be completed within 30minutes. We were told that this can result in the need to stop a medication round in order to move the patient within the time due to pressure of bed availability within the hospital. We were told by one member of staff that tests can be delayed until the person is on the ward because the bed in AAU needs to vacated for the next admission. This meant that the pressures of bed management may place people at risk of unsafe care or treatment by delaying them in receiving the tests and treatment required.

On AAU we found that the care had been assessed, planned and delivered appropriately. Risk assessments had been undertaken where required. For