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Inspection Summary


Overall summary & rating

Inadequate

Updated 28 February 2019

At this inspection, we inspected urgent and emergency care. We did not inspect surgery or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

Our rating of services went down. We rated it them as inadequate because:

  • Our rating for safe went down to inadequate overall. There remained no formalised process for clinically assessing patients presenting to the minor injuries unit, outstanding from previous inspections. Patients could wait for period of up to three hours before being seen by a healthcare professional.
  • Our rating for effective remained requires improvement overall. There remained a lack of monitoring of patient outcomes and compliance with evidence-based protocols. This had previously been identified by the Care Quality Commission as an area which required improvement.
  • Our rating for caring remained good overall. Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Our rating for responsive went down to requires improvement overall. Supporting services including diagnostic imaging were not commissioned to mirror the opening times of the minor injuries unit. This meant patients were either required to reattend the service between 9am and 5pm Monday to Friday for an x-ray, or patients were directed to the emergency department at Watford General Hospital, or the urgent treatment centre at Hemel Hempstead.
  • Our rating for well led went down to inadequate overall. Whilst there had been changes to the leadership team with the addition of a senior emergency nurse practitioner to oversee and manage the minor injuries service, there remained little oversight of the service at divisional level.
Inspection areas

Safe

Inadequate

Updated 28 February 2019

Effective

Requires improvement

Updated 28 February 2019

Caring

Good

Updated 28 February 2019

Responsive

Requires improvement

Updated 28 February 2019

Well-led

Inadequate

Updated 28 February 2019

Checks on specific services

Minor injuries unit

Requires improvement

Updated 10 January 2018

Overall, we rated the Minor Injuries Unit (MIU) as requires improvement because;

  • There was no initial clinical assessment of adult patients. This had not improved since our last inspection and meant that patients’ condition was at risk of deteriorating while they waited for treatment.
  • Although children were assessed quickly during our inspection, the trust could not provide assurance that this took place consistently.
  • Staff did not use an early warning scoring system in order to identify deteriorating patients.
  • There remained a lack of monitoring of patient outcomes, performance measures and compliance with evidence-based protocols.
  • X-ray services were not always available when patients needed them.

  • There was no job description for the lead nurse role meaning that their responsibilities were unclear. The matron of the unit also managed a neighbouring emergency department and an urgent care centre that was several miles away. This left little time for direct clinical leadership of the MIU.
  • There was a lack of understanding of the risks that could affect the delivery of good quality care. We raised this with the trust at our last inspection. There had been some improvements but not all risks had been added to the risk register.

However, we also found:

  • Nurse practitioners had undertaken further training in the assessment and treatment of sick children and there was always access to a specialist children’s nurse if necessary.
  • Children were clinically assessed on arrival and pain relief administered if necessary.
  • We observed staff taking trouble to maintain patient’s privacy, dignity and confidentiality. They demonstrated empathy towards people who were in pain or distress and were skilled in providing reassurance and comfort.
  • Almost all patients (99.9%) were treated, discharged or transferred within four hours.
  • An escalation plan had been introduced that provided support to the unit if patients were waiting more than two hours for treatment.
  • Staff engagement had improved and clinical staff were encouraged to attend monthly clinical governance meetings.

Outpatients and diagnostic imaging

Good

Updated 10 January 2018

Overall, we rated the outpatients and diagnostic imaging service as good because:

  • Since our previous inspection in September 2016, an outpatient quality improvement plan (QIP) had been implemented for issues raised. Performance data had improved and the service was performing in line with their planned trajectory.
  • There was a positive incident reporting and learning culture across the services provided. Duty of candour was evident in incident investigations we reviewed.
  • Radiation protection in the diagnostic imaging department was robust. Medical physics experts and radiation protection supervisors actively worked with staff to provide advice and ensure compliance with safety standards.
  • Medical records were comprehensive, legible, accurate and up-to-date. They were stored safely in a locked office or in lockable trolleys when being used in clinics.
  • Medicines and prescription pads were stored securely in all areas we visited.
  • The main outpatient department was due to have a full nursing establishment by the end of 2017.
  • Waiting lists for outpatient appointments were reviewed weekly and risk assessments were completed for patients who waited 30 weeks or more. At the time of our inspection, no clinical harm had occurred because of waiting over 30 weeks.
  • Care and treatment was delivered in line with evidence-based guidance, standards and best practice. Pathways were in place for the management and treatment of specific medical conditions that followed national guidance.
  • A local audit programme included monitoring compliance with best practice. The outpatient department regularly achieved the trust target.
  • The diagnostic imaging department was working towards the Imaging Services Accreditation Scheme (ISAS).
  • There was a comprehensive clinical audit programme in the radiology department to monitor compliance with trust policy and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). Results showed consistent compliance and actions taken to improve.
  • During our previous inspection, the service was found to be in breach of Regulation 18 of the Health and Social Care Act Regulations 2014: Staffing due to low appraisal rates. At this inspection in August/September 2017, we found that appraisal rates had improved to meet the trust target of 90%.
  • Clinics were run by specialists in their field and staff were supported to develop based on their professional and clinical interests. Multidisciplinary meetings were held to assess, plan and deliver co-ordinated care.
  • The service communicated regularly with patients’ GPs and had worked with the trust’s GP liaison manager to share information with local doctors.
  • Staff understood their responsibilities for obtaining consent and making decisions in line with legislation, including the Mental Capacity Act (MCA) 2005. Patient records we reviewed contained evidence of appropriate consent, where required.
  • Patients were treated with kindness, dignity, respect and compassion. Staff understood people’s personal, cultural, and religious needs and provided care in a considerate manner.
  • Chaperones were available throughout the outpatient and diagnostic imaging services. All patients we spoke with had been offered a chaperone or to have a friend or relative accompany them.
  • Staff communicated with people so that they understood their care, treatment and condition. Patients we spoke with felt well-informed about their treatment and could explain what would happen next.
  • Patients we spoke with described being offered emotional and social support.
  • Outpatient and diagnostic imaging services were planned and delivered to meet people’s needs.
  • The facilities at were generally suitable for the services provided.
  • During our last inspection, we were not assured that patients had timely access to outpatient treatment. The service was found to be in breach of Regulation 12 of the Health and Social Care Act Regulations 2014: Safe care and treatment, due to being worse than national standards for waiting times. During this inspection, we found that most waiting times had improved to meet national standards.
  • The trust had improved its performance for cancer waiting times and was meeting the national standard in four out of five measures.
  • Patients had timely access to diagnostic imaging services and the percentage of patients waiting more than six weeks was lower than the England average.
  • Services were planned and delivered to take into account different people’s needs. This had improved since our previous inspection with the introduction of hearing loops and written information in languages other than English.
  • The departments tailored care to meet the needs of patients with a learning disability and the main outpatient department was working towards gaining a Purple Star accreditation for this.
  • The phlebotomy service engaged with people in vulnerable circumstances and took actions to overcome barriers when people found it difficult to access services.
  • Leaders and staff across outpatient and diagnostic imaging services were continuously striving for improvement. In addition to the QIP, local leaders had further plans to improve services.
  • All staff we spoke with felt respected and valued. The culture across outpatient and diagnostic imaging services encouraged openness, candour and honesty.
  • Patients, relatives and visitors were actively engaged and involved when planning services. Clinical leads led an outpatient user group to gather information on patient experience.
  • Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients. Radiology governance and risk management processes were robust and effective.

However:

  • We saw evidence that learning within the clinical divisions was shared across Watford General, Hemel Hempstead General and St Albans City Hospitals. However, this was not always communicated to the outpatient services in other divisions.
  • During our previous inspection, we found that not all staff working in clinics that saw children had the appropriate level of safeguarding training. This was still the case at the inspection in August 2017.
  • We could not be assured that the service was fulfilling its mandatory duty to report cases of female genital mutilation (FGM) as all staff we spoke with were unaware of the trust policy on identifying and assessing the risk of FGM.
  • There was an infection control concern regarding the use of one treatment room in the main outpatient department. The room was used for leg ulcer care in the morning and by the ear nose and throat team to suction patients’ ears in the afternoon. This posed an infection control risk as leg ulcers are open wounds that could have been infected by bacteria.
  • Hand hygiene and environmental infection control audits were not carried out in the phlebotomy department.
  • Some clinic rooms did not have non-slip finish flooring to minimise falls and infection control risk, which was not in line with Department of Health guidance. This had been recognised as an issue and floors were scheduled to be replaced by October 2017.
  • Although naso-endoscopes were cleaned manually, the service did not follow best practice guidelines for scope decontamination.
  • Compliance with fire safety training in the radiology department was worse than the trust target of 90%.
  • Staff compliance with Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) training was below the trust target.
  • There were no seven-day outpatient services provided at the time of inspection. Some ad-hoc Saturday clinics had been provided, but this had not taken place since March 2017.
  • Friends and Family Test scores for outpatient services across the trust were worse than the England average from January to June 2017. This had improved in July 2017.
  • Changing facilities for patients in the ultrasound department were not in a discreet location to maintain privacy and dignity.
  • Staff were not always informed in advance if a new patient had mobility issues, a learning disability or dementia. This meant adjustments could not be made prior to their attendance.
  • In the main outpatient department, we could not be assured that there was robust local risk assessment or management, as staff could not provide us with evidence.
  • At the time of inspection, there was only one risk on the department risk register. However, during our inspection we identified other risks that should have been recognised.

Surgery

Good

Updated 10 January 2018

We rated this service as good because:

  • There were clear processes in place for reporting incidents and providing feedback. Learning from incidents was shared across all areas.
  • ‘Test your care’ nursing care indicators were consistently high and meeting trust targets.
  • Written records were consistent across areas, clearly maintained with risk assessments and nursing/medical records easy to locate. Records were stored securely throughout our inspection.
  • Improvements had been made in relation to standardisation of World Health Organisation safer surgery checklists and compliance with these met the trust target.
  • Infection control practices had improved since the previous CQC inspection and audits demonstrated good levels of compliance.
  • There was a dedicated orthopaedic ward and a dedicated general surgical ward to manage patients’ specific needs.
  • Policies were up to date in line with guidance from the National Institute for Health and Care Excellence (NICE) and other professional associations.
  • Care bundles were embedded in patient care to improve patient outcomes.
  • Significant work was being carried out in relation to enhanced recovery. Enhanced recovery pathways were used to improve outcomes for patients in general surgery, breast, urology, orthopaedics and ear nose and throat (ENT). Outcomes for enhanced recovery were collected and monitored within the service.
  • The average length of stay for patients was better than the England average.
  • The re-admission rate for elective patients were slightly better than the England average overall. However, the re-admission rate for elective orthopaedic patients was slightly worse than the England average.
  • The service continuously reviewed and improved patient outcomes through participation in national audits including the elective surgery Patient Reported Outcome Measures (PROM) programme, the National Joint Registry and surgical site infection audits.
  • Staff told us they had opportunities for personal development and to enhance their skills. Practice development support was available to all staff.
  • All staff provided a caring, kind, and compassionate service, which involved patients and their relatives in their care. All the feedback from patients and their relatives was positive.
  • Staff provided emotional support to patients and staff directed patients to clinical nurse specialists for support where required.
  • Patients’ and relative feedback was sought on the care they received to ensure they were happy with the care provided.
  • Changes in senior leadership had led to positive operational and cultural changes within surgical service.
  • Senior managers had a clear understanding of risks to the service and how these were being mitigated and monitored.
  • All staff spoke positively about working within the service and felt local and senior managers were approachable.
  • Staff understood the trust's vision and values and portrayed these in their day to day role.
  • There was cross site working in place to improve risk and quality management within the service.
  • The service demonstrated a drive to improve clinical services and supported innovations.

However:

  • The vanguard theatre did not allow for waste and dirty linen to be removed without travelling outside or through a clean area.
  • Imaging, diagnostics and dietetics and speech and language therapy services were available Monday to Friday from 9am to 5pm. If support was required outside of these hours it would be undertaken at the Watford Hospital site. If a patient required diagnostic imaging, for example an x-ray or scan, outside of these hours they would have to be transferred to the Watford site via non-emergency ambulance transport.
  • Pharmacy support was available on site Monday-Friday with out of hours and weekend support from Watford General Hospital site.
  • The trust was failing to meet referral to treatment targets for all specialties. The trust performance was also worse than the England average.
  • Those who had surgery cancelled were not always treated within the following 28 days in line with guidance.

Urgent and emergency services

Inadequate

Updated 28 February 2019

Our rating of this service went down. We rated it as inadequate because:

  • There remained no formalised process for clinically assessing patients presenting to the Minor Injuries Unit. Patients could wait for period of up to three hours before being seen by a healthcare professional.
  • There remained a lack of monitoring of patient outcomes and compliance with evidence-based protocols. This had previously been identified by the Care Quality Commission as an area which required improvement.
  • Staff had access to guidelines and policies via the trust intranet which were up-to-date and relevant. However, a range of printed policies and procedures which reflected clinical guidance that had been superseded was available across the department. This included guidance relating to the management of children requiring life support therapy.
  • Whilst there had been changes to the leadership team with the addition of a senior emergency nurse practitioner to oversee and manage the minor injuries service, there remained little oversight of the service at divisional level.
  • There lacked a systematic and robust approach to governance and the management of risk. Despite our previous inspection findings, we found that service enhancements and improvements had not been sustained. There was no effective process for identifying risks or plans to eliminate or reduce such risks.
  • Commissioners were seeking to extend clinical services at St Albans City Hospital however there had been no planning or review of staffing establishments and staff skill-sets to determine whether such an extension of services was feasible in the time-scale given. In part, this was because commissioners had not finalised a service specification to enable the trust to consider the full impact on staffing.
  • Information was of a poor quality with a reliance on manual processes to extract data; this was labour intensive and did not allow for real-time reporting. Information was not considered holistically to enable the divisional management team to assess the safety and effectiveness of the service.
  • There was no active quality improvement strategy for the service at the time of the inspection.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had a good knowledge of their responsibilities to report safeguarding concerns and make referrals. They were supported by the trust safeguarding team to do this.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. We observed excellent multi-disciplinary working. Therapies staff were based on some wards and staff communicated well with each other.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They were able to explain how they acted in patient’s best interests when they were unable to make decisions for themselves.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment. Most patients were aware of plans for their care and treatment and said they had been provided with the information they needed to help them make decisions about their care.
  • Staff took account of most patients’ individual needs. Interpretation and translation services were available for people who were unable to speak English. Most staff showed a good awareness of the needs of patients with some complex needs such as those with a learning disability or autism.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.