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Watford General Hospital Requires improvement

We are carrying out checks at Watford General Hospital. We will publish a report when our check is complete.

Reports


Inspection carried out on 30 August – 1 September 2017 and 12 September 2017

During a routine inspection

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

Part of the inspection was announced taking place from 30 August 2017 to 1 September 2017 during which time Watford Hospital, St Alban’s Hospital and Hemel Hempstead Hospital were all inspected. We carried out the unannounced inspection on the 12 September 2017.

This was the third comprehensive inspection of the trust. The trust was rated as inadequate overall and was placed into special measures in September 2015. The last inspection took place in September 2016, where the trust and was rated requires improvement overall. It remained in special measures.

Urgent and emergency care services was rated inadequate during our last inspection in September 2016. Medical care, surgery, services for children and young people and outpatients and diagnostics were rated as requires improvement in 2016.Critical care, maternity and gynaecology and end of life care were rated as good.

At this inspection we rated Watford General Hospital as requires improvement overall.

During this inspection, medical care and surgery were rated as requires improvement. Critical care, maternity and gynaecology, services for children and young people, end of life care and outpatients and diagnostics have been rated as good. This means all these services, except medical care and surgery, have improved and provide a better service to their patients. However, emergency services were rated inadequate.

We saw several areas of outstanding practice throughout Watford General Hospital. For example:

  • There were a number of outstanding innovations in the children’s emergency department to support the needs of parents, children and younger people. This included support from voluntary groups charities and volunteers to tackle important issues such as mental health and suicide awareness.
  • The set up and design of the children’s emergency department as an environment to children was outstanding as it enabled the service to undertake interventions on children quickly. The design and space for a district general hospital was unique and was modelled on the set up of the tertiary children’s units.
  • We observed outstanding care interactions provided by staff to children in the emergency department and in the children’s observation bay.
  • The pathways of care in the children’s emergency department, their effective use within the department on patients was outstanding.
  • Staff kept patients at risk of harming themselves safe without depriving them of their liberty. There was an effective process for prompt senior nurse assessment and the provision of enhanced care for patients at risk. An enhanced care team was receiving training to make sure they provided patient centred care.
  • The “iSeeU” initiative provided women who were separated from their babies at birth the opportunity to use face-time technology to see their baby receiving care and treatment on the neonatal care unit.
  • The pilot Phoenix team provided a case loading service for women with uncomplicated pregnancies who wanted to give birth at home or at the birth centre. The team sent a congratulations card to every mother who was part of their team once they had delivered their baby.
  • An electronic referral pathway had improved the care for infants with prolonged neonatal jaundice. The pathway had been developed in partnership with GPs, health visitors, community midwives and local commissioners. This had resulted in a reduction in the referral to appointment time (under 48 hours) and the overall time for parents to receive their child’s results was two weeks from referral.
  • The diagnostic imaging service monitored its compliance by auditing best practice relating to patients receiving chest radiography. Guidance from the Royal College of Radiologists (RCR) states that it is best practice to undertake chest radiographs on patients in the poster anterior (AP) upright position, apart from when this is not appropriate due to immobility or ill health. Following an audit performed within the diagnostic imaging department, staff embraced the importance of change in practice especially in difficult casualty situations.

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

Importantly, the trust MUST:

  • The trust must ensure governance quality systems in ED, including the reporting of incidents, identification of risk and management of risk registers provide assurances that the service runs safely and effectively.
  • The trust must ensure that the staffing levels on duty are based on acuity, and ensuring the numbers on duty for nursing, medical and support staff are sufficient to ensure safe care.
  • The trust must ensure that appropriate action is taken to improve the culture within the emergency department.
  • Ensure that there are processes in place to complete patients’ venous thromboembolism risk assessments on admission and repeated assessments 24 hours after admission in line with national guidance.
  • Ensure that patient risk assessments are detailed with information to allow an accurate assessment of the patients’ clinical condition.
  • Ensure that there are processes in place to manage and report mixed sex accommodation as incidents and where possible prevent patients of the opposite sex being cared for in the same clinical area.
  • Ensure that patient personal identifiable information is not displayed or discussed openly within earshot of unauthorised persons.
  • Ensure that staff working within the DVT clinic are competent at the identification of medicines and contraindications.
  • The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. A formal decision specific mental capacity assessment must be undertaken of the patient’s ability to understand this decision and to participate in any discussions.
  • Ensure that all staff caring for patients under 18 years of age complete safeguarding children level three training.
  • Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
  • Ensure that World Health Organisation (WHO) five steps to safer surgery checklists are completed in their entirety.
  • Ensure that infection prevention and control standards are maintained in treatment rooms where minor operations are performed.
  • Ensure that all risks within the outpatient department are included in the departmental risk register.
  • Ensure clinical staff within the radiology department are up-to-date on fire and evacuation training.

The trust SHOULD:

  • Review the arrangements for the collection of blood samples from the emergency department.
  • Review ambulance offload and handover times in the emergency department.
  • Consider how to effectively learning from complaints is fully implemented to improve patient experience.
  • Develop an integrated governance system for the children’s emergency department, ensuring there are effective reporting system, and management of risk processes.
  • Ensure that all staff maintain all infection control and prevention practices.
  • Patients’ nutrition and fluids should be accurately recorded and totalled daily.
  • Ensure theatres are compliant with national standards, including the ventilation in the theatre preparation rooms.
  • Take steps to ensure the facilities for day surgery patients are appropriate.
  • Patients should not be nursed in recovery or ESAU overnight.
  • Ensure patients whose surgery is cancelled are treated within 28 days of the cancellation.
  • Ensure all surgical patients have access to timely treatment after referral.
  • All relevant staff, including junior doctors, should be trained to recognise and respond to signs of sepsis.
  • All patient records should be available at pre-operative assessment clinics.
  • The route in which the painkiller Paracetamol is to be administered should always be clearly documented in patients’ prescription charts.
  • Audits of the WHO Surgical Safety Checklist and five steps to safer surgery are improved to assess how well teams are participating in the checks.
  • Surgery services should fully participate fully in implementing the National Local Safety Standards for Invasive Procedures.
  • The audit programme should be managed effectively and that actions identified are completed and re-audited. This should include an audit of the recognition of sepsis and the treatment provided to patients with signs of sepsis.
  • All staff should comply with the trust’s hand hygiene policy.
  • Standards of cleanliness and hygiene continue to be monitored on Starfish ward.
  • Patients should be discharged from the critical care unit within four hours of the decision to discharge, to improve the access and flow of patients within the critical care unit (CCU).
  • Patients requiring admission to CCU should be received in four hours of the decision to admit.
  • A microbiologist should have daily input to the ward rounds on CCU to review patients care in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
  • Take actions to reduce the incidence of mixed sex breaches in the critical care unit.
  • Local mortality and morbidity review meeting minutes should include clear delegated actions and monitoring of these.
  • The risk register contains all current risks identified to the provision of the critical care service.
  • Ensure the service reviews its processes to provide at least 50% of nursing staff with a post registration critical care qualification in line with GPICS standard (2015) and mitigate for any gaps.
  • Medicines should be stored within the recommended temperature range.
  • All medicines given are documented in line with national guidance.
  • All equipment is safety tested annually.
  • Resuscitaires should be checked daily.
  • Symphysis-fundal height measurements (maternity) are clearly plotted on growth charts.
  • Actions should continue to be taken to reduce the caesarean section rate.
  • Actions should be taken to improve the perinatal mortality rate and reduce the number of full term babies admitted to the neonatal care unit.
  • All complaints are investigated and closed in a timely manner.
  • Reduce the number of medical outliers to the gynaecology ward.
  • Take action to reduce staffing vacancies and turnover of staff.
  • Consider reconfiguring the neonatal unit as its current configuration meant there was insufficient space, which did not reflect current guidelines.
  • Continue to monitor the movement of children from the inpatients’ wards to the operating theatre along a corridor that was not fit for that purpose.
  • Consider ways of improving the environment for children in the operating and recovery areas of the trust.
  • Access to emergency equipment should not be impeded.
  • Dietary supplements should be stored securely.
  • All staff should receive training in a major incident exercise or undergo major incident training.
  • The information system for the diabetes service should meet the needs of the service.
  • Consider ways to improve the response to the Friends and Family Test in children’s services.
  • Continue to monitor the level of cancelled outpatient appointments over six weeks in children’s services.
  • Consider how to improve the results of the next Picker survey in children’s services.
  • Review the risk register process to ensure the trust was aware of the risks for the end of life care and mortuary services.
  • The main outpatient department should have a dedicated area suitable to care for patients on a stretcher, bed or wheelchair.
  • Decontaminate reusable naso-endoscopes in a washer-disinfector at the end of each clinic to meet best practice, as outlined in the Department of Health Technical Memorandum (HTM) 01-06 Decontamination of flexible endoscopes.
  • Ensure staff are up-to-date on the mental capacity act and deprivation of liberty safeguards training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 6-9 and 27 September 2016

During a routine inspection

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

This was the second comprehensive inspection of the trust the first taking place in April and May 2015. It was rated as inadequate overall and went into special measures in September 2015.

Part of the inspection was announced taking place between 6 and 9 September 2016 during which time the hospitals that make up the trust, Watford General Hospital, St Albans Hospital and Hemel Hempstead Hospital were all inspected. Unannounced inspections were undertaken of Watford Hospital and Hemel Hempstead on the 19 September 2016.

We have rated Watford General Hospital as requires improvement overall. Medicine, emergency services, critical care, maternity and gynaecology and end of life care were all rated inadequate in September 2015. Emergency services remain inadequate, however, all, except critical care, maternity and gynaecology services and end of life care, which have now been rated good, have been rated as requires improvement. This means all these services, except emergency services and services for children and young people, have improved and provide a better service to their patients. There was one outstanding rating, caring within children and young people’s services.

Our key findings were as follows:

  • Most staff were aware of their roles and responsibilities in the management and reporting of incidents, however this was not consistent in all areas of the hospital. The hospital had a lower rate of incidents compared to the national average. This can be an indicator that not all incidents are being reported. In addition, feedback from incidents and evidence of learning from them was inconsistent throughout the hospital.
  • Duty of candour was poorly known amongst most trust staff and there was limited evidence that it had been applied routinely.
  • There had been one never event which occurred in the maternity service. A root cause analysis had been undertaken and there was evidence of learning from this event and actions taken to mitigate future risk.
  • There were effective safeguarding procedures in place for both adults and children. Staff had received appropriate training, in most departments. However, not all who dealt with children and young people were trained to level three, which is the expected standard.
  • Patients did not have their mental capacity assessed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice. There was no trust database relating to the total number of patients, the expiry of initial authorisation or the date of external assessment. This meant that patients were potentially being deprived of their liberty without appropriate authorisation made. Locally, some wards had understanding of those patients who were being cared for under a deprivation of liberty safeguard (DoLS). In addition, the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form did not prompt staff to complete a capacity assessment as part of the decision making process.
  • Provision for patients who had a mental health problem was poor in the emergency department.
  • The trust was making improvements to the organisation of outpatient clinics. However, clinics still frequently over-ran and some patients told us they had experienced long delays. The length of time patients waited to be seen was not monitored. The trust’s patient administration system had no facility for recording when patients were seen and the information was not collected manually.
  • There was a notable culture of acceptance regarding the waiting time breaches in the emergency department with many relating to time to see a clinical decision maker or receive treatment from a doctor. This had improved at the unannounced inspection.
  • The percentage of patients discharged, admitted or transferred within four hours was consistently around 83%, against a target if 95%.
  • The number of ambulance handover delays over 30 minutes totalled 2,535, putting the trust in the top quartile of all trusts in England. Between November 2015 and August 2016, the trust has had 2107 black breaches.
  • The percentage of patients leaving the department before being seen was higher, at 6.5%, than the England average of 3%.
  • The percentage of emergency admissions via A&E waiting from four to 12 hours from the decision to be admitted ranged from 12% to 44% against the England average of 8%.
  • Referral to treatment performance had been improving since the last inspection, and exceeding the target for some clinics. However, due to poor performance in certain clinics only 86% of patients met this target from May 2016 to September 2016.
  • Data for September 2016 showed that the trust had fallen below the national 93% target that all suspected cancers should be referred to a consultant and seen within two weeks; only 89.4% of patients were seen within this time period. For breast cancer, for the year to date only 76% patients had been seen within two weeks.
  • The Five Steps to Safer Surgery checklist were not consistently used; there was a mixture of five and three step processes in operation.
  • The management and storage of medications was not always safe. There was varied practice regarding the safe management and storage of patients own controlled drugs. Treatment room temperatures consistently exceeded recommended temperatures.
  • Staffing levels were below the trust targets. Mandatory training compliance did not meet the trust target of 90% in all subjects, including basic life support. Not all staff had received an annual performance appraisal. This was a concern we raised in our previous report.
  • Although we saw that all departments appeared to be clean, Patient-led assessments of the care environment (PLACE) audits for cleanliness and privacy and dignity were below the England average. We found that there was some poor practice around privacy and dignity in outpatients.
  • The Intensive Care National Audit and Research Centre (ICNARC) results 2016 showed the critical care unit had a higher than national average for delayed discharges of 14% compared to the national average of 5%. The trust was in the worst 5% of units for this element. On occasions the unit was unable to admit or discharge patients due to the unavailability of beds. This resulted in single sex breaches. Patients could be nursed in theatre recovery for over 10 hours whilst waiting for a bed either in the critical care unit (CCU) or on the ward. We found that patients experienced multiple moves within admission areas, and were frequently transferred between areas overnight.
  • Patients told us that the care they received was good and that they felt safe and in most departments. We saw patients were treated with dignity, respect. During our inspection the weather was hot; we saw that in most departments there was no provision for ensuring patients received extra fluids during this time.
  • Staff had undergone sepsis training and were able to recognise and treat sepsis according to national guidelines.
  • The numbers of MRSA, Methicillin Sensitive Staphylococcus Aureus (MSSA), and Clostridium difficile, reported between June 2015 and May 2016 were lower than the England average. Between June 2015 and June 2016 there were low numbers and prevalence rates of pressure ulcers, falls with harm and catheter acquired urinary tract infections reported.
  • The children’s emergency department was outstanding in terms of environment. Children and young people had a dedicated resuscitation area away from the adult department, which was set up with equipment and medicines for children. The medicines storage and management of medicines in the children’s emergency department was exemplary.
  • Relationships between staff, patients and relatives were strong, caring and supportive. Staff regularly went above and beyond for the children and young people who used their services and valued their emotional wellbeing
  • Staff treated all patients with kindness, dignity and respect. All patients and their carers that we spoke with told us that staff were kind, caring and included them in the planning of care and treatment.
  • Patients moving from children’s services to adult services were prepared in advance for the transition by individual specialist consultants and nurses.
  • Nursing staff completed local induction training when they joined the outpatient department. We saw the training programme which included training on the use of equipment within the department and a medicines competency assessment. Induction programmes were developed to meet the needs of different staff groups for example for trained nurses and healthcare assistants.

We saw an area of outstanding practice in the children’s emergency department where children were seen promptly.

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

Importantly, the trust MUST:

  • Ensure that care for patients with mental health issues in the emergency department is safe by ensuring that they are cared for in a safe environment, that their safety is risk assessed, and that staff are suitably trained to meet their needs, as well as keep staff safe from harm.
  • Ensure governance quality systems, including the reporting of incidents, duty of candour, completion of local audits, learning from incidents and complaints and ensuring the risk register is up to date.
  • Ensure that observations of patients who could be acutely unwell are undertaken in a timely way and escalated as required.
  • Ensure the timely completion of patient records.
  • Ensure that patients who have been in the emergency department for more than six hours are reviewed by a senior clinician and are risk assessed.
  • Ensure that there is a provision for the offering of regular drinks to patients during their time in the emergency department.
  • Ensure that there are appropriate systems in place to track the patients and the expiry of those being treated under a deprivation of liberty safeguards.
  • Ensure that staff completing ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms where a person lacks capacity to make an informed decision or give consent act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • Ensure that all staff caring for patients less than 18 years of age has completed safeguarding level 3 training.
  • Ensure the safe management of medicines at the hospital complies with Home Office 2016 guidelines on the security of controlled medicines. This includes patients’ own medication.
  • Ensure that there are procedures in place for the safe management of temperatures within treatment rooms and areas where temperature sensitive medications are stored.
  • Prescriptions for syringe pumps must comply with the trust’s prescribing standards.
  • Ensure that mandatory training compliance meets trust targets of 90%, including blood transfusion training.
  • Devise an action plan to address the shortfall between appraisal rates and the trust target and make sure that the trust target is reached.
  • Ensure staff in outpatients comply with the trust’s hand hygiene policies.
  • Ensure treatment rooms where invasive procedures take place are clean.
  • To improve the percentage of patients to be seen within 18 weeks of referral from a GP for an outpatient appointment.

  • To improve the percentage of patients waiting to see a consultant with a suspected cancer to meet the national target of 93%.

Action the hospital SHOULD take to improve

  • Review the arrangements for the collection of blood samples from the emergency department.
  • Provide training to staff in dementia awareness, learning disabilities and complex needs.
  • Review the escalation plan for the emergency department and make this effective in practice.
  • Review staff training and knowledge on the Mental Capacity Act and DoLS.
  • Review ambulance offload and handover times in the emergency department.
  • Limited numbers of staff in the emergency department had been trained in safe breakaway. No staff members had received training in ethical control and restraint. Consider increasing the number of staff in the emergency department who have been trained in safe breakaway, and in ethical control and restraint.
  • Consider learning and outcomes from complaints.
  • Consider developing a vision and strategy for the future of the emergency department.
  • Consider lack of staff engagement across the emergency department and work towards improving this.
  • Reduce the number of patient moves out of hours within admissions and ward areas.
  • Consider undertaking a risk assessment in relation to the lack of a dirty utility area in the emergency surgical admissions unit.
  • Review processes and practice so that venous thromboembolism risk assessments are consistently completed and repeated according to trust policy and that the proforma used to complete assessments is fit for purpose.
  • Consider further training for staff around Deprivation of Liberty safeguards to ensure that all staff are aware of when it is appropriate to consider an application to meet patients’ needs and protect their rights when necessary.
  • Review processes so that patients are discharged from the critical care unit (CCU) within four hours of the decision to discharge to improve the access and flow of patients within CCU.
  • Consider how to meet the needs of patient requiring admission to CCU at all times.
  • Review the microbiologist input to the ward rounds on CCU to review patients care daily, in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
  • Take actions to reduce the incidence of single sex breaches in CCU.
  • Review procedures and practice so that all medicines are administered and documented in accordance with trust policy and national standards.
  • Review the process for obtaining tablets for patients to take home to reduce high volumes being received in pharmacy during the afternoon which they are unable to action in a timely manner.
  • Review procedures and practice so that modified obstetric early warning score observation charts are completed and acted on in accordance with trust policy.
  • Take the required actions to meet the 62 day referral to treatment time for patients with suspected gynaecological cancers.
  • Review the consultant cover in palliative care staffing levels. The consultant cover in palliative care staffing levels were below the National Institute of Health and Care Excellence (NICE) guidelines, commissioning guidance for palliative care published collaboratively with the association for palliative medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK.
  • Within end of life care, the service should collect effective information on the percentage of patients who were discharged to their preferred place within 24 hours.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14 to 17 April, 1 and 17 May 2015.

During a routine inspection

West Hertfordshire NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in West Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

West Hertfordshire NHS Trust provides services from 3 sites Watford Hospital, St Albans Hospital and Hemel Hempstead Hospital

We carried out this inspection as part of our comprehensive inspection programme. We undertook an announced inspection of Watford Hospital St Albans Hospital and Hemel Hempstead Hospital between 14 and 17 April 2015.

We also undertook an unannounced inspection on 1 and 17 May at Watford General Hospital

Overall, we rated Watford General hospital as inadequate with 2 of the 5 key questions which we always rate being inadequate (safe and well led).

The main concerns were particularly where five of the eight core services we inspected were rated as inadequate. Only one service was rated as good – the children’s and young people’s service. This service was rated as outstanding for caring.

Overall we have judged the services at the hospital as good for caring. Patients were treated with dignity and respect and were provided with appropriate emotional support. We found caring in children’s and young people’s services to be outstanding. However caring required improvement in two areas - maternity and outpatient services where patients were not always treated with dignity and respect.

Improvements were needed to ensure that services were safe, effective, responsive to people’s needs and well-led.

We saw several areas of outstanding practice including:

  • The children’s and young people’s service was rated as outstanding for caring.
  • For world sepsis day, the sepsis team launched a ‘sing-along’ video called ‘Stamp Out Sepsis’ (SOS), sung in time to a well-known song. This was an innovative method that aimed to raise awareness of sepsis and encouraged staff to remember six actions that could improve patient outcome.
  • The dementia care team had implemented a delirium recovery programme which aimed to reduce length of stay, readmissions, antipsychotic prescribing and promoted cognitive and physical functioning by cognitive enablement and health and wellbeing for patients. This allowed patient’s the opportunity to return home with up to three weeks of 24 hour live in care. The outcomes clearly demonstrated that the majority of patients with delirium went home with the programme in place when usual care would have predicted placement from hospital directly. Most patients recovered to a sufficient level to stay at home.
  • Starfish ward staff had supported a parent whose child was frequently admitted to the ward to obtain funding to set up a carers support team. The team was subject to the same governance and recruitment checks as the ward’s staff. The carers support team offered sitting services, information and signposting, and befriending services for parents whose children were in-patients at Starfish ward. However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must ensure medicines are always administered in accordance with trust policy.
  • The trust must review the governance structure for Emergency Department (ED) to have systems in place to report, monitor and investigate incidents and to share learning from incidents as well as complaints.
  • The trust must ensure there is an effective clinical audit plan in place in ED and End of life care (EoLC).
  • The trust must ensure that major incident arrangements are suitable to ensure patients, staff and the public are adequately protected and that patients were cared for appropriately in the event that a major incident occurred.
  • The trust must ensure that all premises are secure
  • The trust must ensure that all equipment is maintained and for safe use.
  • The trust must ensure all surgical areas are fit for purpose and present no patient or staff safety risks.
  • The trust must ensure that all equipment has safety and service checks in accordance with policy and that the identified frequency is adhered to in respect of emergency equipment requiring daily checks.
  • The trust must review the provision of the continuous piped oxygen and suction issue on Letchmore Ward.
  • Action must be taken to ensure difficult airway management equipment is adequate and checked to ensure it is fit for purpose.
  • The trust must ensure staff are able to attend and carry out mandatory training, to care for and treat patients effectively, particularly regarding annual resuscitation training.
  • The trust must ensure that staffing levels within adult ED meet patient demand.
  • Action must be taken to ensure medical staff are suitably trained to manage the safe transfer of patients from critical care to other hospitals and services.
  • The trust must ensure that all staff are effectively supported with formal supervision and appraisals systems.
  • The trust must ensure that staff delivering information to bereaved people receive training in communication and bereavement.
  • The trust must ensure that all records are accurate and reflective of patients’ assessed needs. The trust must ensure that all patient records are accurate to ensure a full chronology of their care has been recorded.
  • The trust must ensure that all confidential computerised patient records in the Emergency Surgical Assessment Unit and outpatients are securely stored to minimise the risk of unauthorised access.
  • The trust must ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.
  • The trust must ensure that at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff to ensure people who use the service are safe and their health and welfare needs are met.
  • The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • The trust must ensure all patients have appropriate care plans to meet their assessed needs.
  • The trust must review the elective surgery cancellation rates and review the elective surgery service demand.
  • The trust must review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • The trust must review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.
  • The trust must review the environment within ED to meet patient demand effectively
  • The trust must have systems to robustly manage risk and governance.
  • The trust must ensure that there are robust governance and risk management systems in place that reflect level of risks and are fully understood by all staff
  • The trust must ensure that all incidents are investigated in a timely manner and lessons learning cased to all staff
  • The trust must review the elective surgery cancellation rates and review the elective surgery service demand.
  • The trust must review the cancellation of outpatient appointments and take the necessary steps to ensure that issues identified are addressed and cancellations are kept to a minimum.
  • The trust must review waiting times in outpatients’ clinics and take the necessary steps to ensure that issues identified are addressed.
  • The trust must ensure that all patients’ records are kept up to date and appropriately maintained to ensure that patients receive appropriate and timely treatment.

The trust should also:

  • The trust should review the hospital bed capacity process to ensure appropriate flow through the ED.
  • The trust should review clinical pathways to ensure they are consistently followed
  • The trust should ensure that staff understand their responsibilities to report all incidents.
  • The trust should ensure suitable arrangements are in place to ensure staff receive appropriate clinical supervision to enable them to deliver care and treatment to people who use the services.
  • The trust should ensure that all clinical single use equipment is stored safely and appropriately; and disposed of when it has expired.
  • The trust should ensure that all medication is stored safely and appropriately.
  • The trust should ensure that all food products are disposed of when they have expired used by dates.
  • The trust should review the risk register to identify all risks across medical inpatient services.
  • The trust should ensure they take the required actions to meet the 18 week refer to treatment national target in surgery
  • The trust should take actions to ensure patients are discharged from the unit within four hours of the decision to discharge to improve the access and flow of patients within the critical care unit.
  • The critical care service should take actions to reduce the incidence of re admission of patients to critical care within 48 hours.
  • The trust should take action to review staffing arrangements to ensure it is able to provide a seven day 24 hour critical care outreach service.
  • The trust should take action to ensure referrals of critical care patients are managed in accordance with the trust’s operational critical care policy.
  • The trust should take action to ensure there is sufficient medical cover for weekends and out of hours for the critical care service
  • The trust should ensure that mandatory training for staff in children and young people’s services is updated.
  • Patients should receive individual risk assessments for the journey to the theatre from children and young people’s wards.
  • The trust should ensure patients’ names are not visible to people visiting the ward to ensure patient confidentiality is not compromised.
  • The trust should ensure records of actions taken to address risks on the risk register are completed in a timely way.
  • The trust should ensure an effective, personalised care planning process is in place to meet the needs of all patients receiving end of life care.
  • The trust should provide education for all staff on care of dying patients.
  • Ensure that information on how to complain is accessible to patients in all patient areas within the hospital.
  • Put in place a clear strategy for leadership development at all levels.
  • Review issues identified and associated with transport problems when accessing outpatient appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 20, 21 November 2014

During a routine inspection

We spoke to 29 patients who used the service, 40 members of staff and members of the executive team. We looked at the personal care and treatment records of 21 people who used the service. We observed how people were being cared for and talked with patients using the service. We talked with staff, and reviewed information given to us by the provider. We were accompanied by two specialist advisors. Following the visit, we asked the trust to provide further information in order that a judgement could be made: this information was received at the end of December 2014.

Safety

We found that learning from incidents was not always shared and that safeguarding procedures were not robust. Nurse staffing levels were affected by the high level of staff vacancies, despite on-going recruitment significant pressures on staff were evident in the maternity service. Mandatory training for staff was below the trust’s targets. Infection control procedures were effective at the time of our inspection. Record keeping within the hospital had improved since our last inspection.

Effective

Overall mortality rates for the trust had improved and there was some evidence of review of care pathways to give improved outcomes for patients. We found poor nursing care planning in some instances and the care and treatment given to patients was not always meeting their needs. The trust was behind trajectory for staff appraisals at the time of the inspection and most staff did not receive formal supervision on a regular basis. We saw good multi-disciplinary working between different professionals. We found variable levels of staff understanding and recording of patients’ mental capacity to make decisions. There were concerns about the hospital’s application of the Deprivation of Liberty safeguards (DoLS).

Caring

Overall, staff were very kind and compassionate in their approach to patient care and the hospital was seeking meaningful feedback from patients and their advocates. Patients’ dignity was respected.

Responsive

This domain was not assessed as part of this inspection.

Well led

Whilst the trust had made significant improvements in its governance and risk management processes, we found it was not yet fully embedded throughout the staff team at the hospital. A series of patient safety initiatives had been implemented to address the concerns we had found at our last inspection, these initiatives were in use at the time of the inspection.

Inspection carried out on 17 December 2013

During a routine inspection

We visited the emergency department, acute admissions unit (AAU,) a surgical ward, a medical ward, the stroke ward, a dementia ward, an orthopaedic ward and reviewed the governance services. We spoke to 29 patients who used service, 40 members of staff and members of the executive team.

People were mostly satisfied with the care they received. In most cases people were complimentary about the attitude of staff. We found that the trust had responded to concerns around mortality at the trust. Overall mortality rates at the trust had improved.

We found concerns with cleanliness and infection control across four departments visited. We found blood stains on the floor in one area that has not been cleaned. We noted it had dried to the floor at the time of being seen, therefore had been there for some time.

On the AAU we found areas of concern around staffing that were not consistent with our findings in the other areas visited. We were told by the executive team that the day of our visit was one of the busiest days for admissions.

We found that the governance and quality monitoring services were not effective. Concerns were identified about whether appropriate action in relation to risk management had been taken by the trust.

We found that the organisation was well led. The Executive team had responded well to areas of concern. Whilst reactive improvements were noted, long term sustainability will be monitored by the Commission.

Inspection carried out on 29 January 2013

During a routine inspection

The people we spoke to were happy with the care and treatment they had received at Watford General Hospital. They told us that their treatment had been explained to them and that their care had been delivered in a manner that promoted their dignity and independence. We were told that the staff were ‘wonderful’ and that they were ‘kind and caring and would do anything to ensure you were as comfortable as possible’. Some people told us that they were concerned about the patients who had a memory loss or a dementia and they told us ‘that they found their crying in the night sad and disturbing’.

We saw that staff were aware of infection control and that the hospital had systems in place that ensured that staff and visitors were aware of the risks of cross infection. Staff were aware of their duty of care to vulnerable adults and to children.

All the wards had protected meal times and there were systems in place to monitor, the food and fluid intake of the people.

All the people had care plans and risk assessments as appropriate.

We found that there were systems in place to assess and monitor all aspects of the running of the hospital.

Staff consistently told us that they found if increasingly difficult to meet the needs of the patients and that they worried about how they deliver care to people now and how they would cope in the future if the staffing levels were not reviewed.

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

As this review did not involve a visit, we did not speak to anyone who used the service to assess the improvements implemented. We did however, review evidence provided by the trust and the report following the recent deanery visit.

Inspection carried out on 21 March 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 1 December 2011

During an inspection in response to concerns

The parents of the children who use the service told us that they are very happy with the service. We were told that the staff are wonderful and that they are competent, calm, confident. We were told by the family of one child that the staff calm us in a very stressful situtation. We were told that the family felt the the staff were on the journey of caring for the sick child with them.

Inspection carried out on 27 October 2011

During an inspection in response to concerns

We did not receive any information from people who use the service during this review, and did not actively seek their views in this instance as this was not seen as an appropriate method of seeking evidence in the specific issues that had been raised about the service.

Inspection carried out on 7 January and 22 April 2011

During an inspection in response to concerns

People told us that they were confident that they would receive the care they needed from appropriately trained staff. They told us that they were happy with the numbers of staff on duty and that they were seen within, what they regarded as a reasonable timescale. They told us that they were treated in a manner that promoted their dignity and that at all times their confidentiality was protected.

Most people told us that they were happy with the environment but there were occasions when the department was not appropriately cleaned following specific incidents.

They told us that they were not happy that the vending machines in the reception area were not working.