You are here

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

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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

The provider did not have an effective system in place to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

We were aware prior to our inspection that at a risk summit held, concerns were raised about the governance processes within the trust. For this inspection we spoke with members of the executive team and the new associate director for governance. We found that the governance department was significantly understaffed to be able to effectively monitor and report on the risks within the organisation. We were informed that there was a recruitment process in place to increase support to the governance department.

The trust is required to report incidents through the ‘National Reporting and Learning Scheme’ (NRLS) on a regular basis. They are also required to report serious incidents through the Strategic Executive Information System (STEIS) when the incident is identified. We were aware, prior to our inspection, that some concerns relating to the identification and reporting of serious incidents had been raised about the trust.

We found that there was a policy in place for reporting serious incidents which included responsibility for decision making. We found that the trust had trained incident investigators however serious incident investigations were not always completed by trained investigators. We viewed one investigation and found that the root cause had not been assessed; the lessons learnt did not include sharing information outside of the department or division. We discussed this with the governance lead who told us that there was no system in place to regularly share learning from incidents, complaints, PALS and surveys etc. across the divisions, but that this will be implemented in the new governance arrangements. Therefore we were not assured of the quality of serious incident investigations nor that learning from incidents was implemented.

Because we were aware of concerns related to reporting we looked at the trust’s records of incidents reported from 01 April 2013 to 31 October 2013. We found that there was no monitoring system in place to ensure all incidents that were classified as ‘serious’ were identified and responded to correctly. This is because the governance structure and support system in place did not support the auditing of incidents to identify any potential serious incidents. This meant that we could not rely on the accuracy of the reports from the trust around serious incidents submitted prior to December 2013, or see how the trust had assessed whether or not specific incidents had affected the quality of the service provided to people.

The governance lead informed us that they had implemented, within the two weeks prior to our visit, that a new process had been drafted for deciding whether incidents reported were serious incidents and to ensure appropriate action had been taken.. This meant that when implemented the trust will be responding appropriately to serious incidents however incidents that occurred over the past 12 months may not have been identified, reported or learnt from.

We viewed a governance action plan which identified how compliance with essential standards would be achieved. We found that the current incident system computer server was at maximum capacity and was at risk of failing to provide the service required to report incidents. We also found that that the trust risk register had not been updated for an extensive period of time and was out of date. We examined the risk register and found items which had been added from 2005 that had not been resolved. We were not fully assured that the current organisational risks were prioritised effectively to reduce the risks to the service and people who used the service.

There were a number of other national reporting agencies that the trust had to submit their data to. There was information available to show that the trust was working to understand and analyse reasons for higher than expected deaths. We viewed a report into the mortality levels within the trust completed by the medical director. We saw that the trust had improved