St Albans City Hospital

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 third comprehensive inspection of the trust. In September 2015 the trust was rated as inadequate overall and went into special measures. A further inspection took place in September 2016.and was rated requires improvement overall, as was St Albans City Hospital. The trust remained in special measures

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.

At St Albans City Hospital we inspected and rated the core services of:

• Minor injuries unit
• Surgery
• Outpatients and diagnostic imaging.

We rated St Albans City Hospital as requires improvement overall.

We rated the Minor Injuries Unit (MIU) as requires improvement. We rated surgery and outpatients and diagnostics services as good.

For the five key questions that we inspect and rate, we rated safe effective and well led as requiring improvement. Caring, and responsive were rated as good overall.

• During our last inspection, we found 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.

• 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 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 support provided out of hours from Watford General Hospital site.
• Those who had surgery cancelled were not always treated within the following 28 days in line with guidance.

However:

• During this inspection, we 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.

• 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 patient’s 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 (shorter stay) 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.
• Cross site working occurred to improve risk and quality management within the service.
• The service demonstrated a drive to improve clinical services and supported innovations.
• 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.
• Referral to treatment times had improved since our last inspection and were similar to the England average.
• 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.
• 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 to a patient had happened because of waiting over 30 weeks.

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

Importantly, the trust must:

• To ensure that there are effective triage/ streaming systems in place in the unit and all staff have had appropriate training to carry out this process.
• Ensure that systems and processes are in place to monitor and review all key aspects of performance to identify areas for improvement.
• Develop a clinical audit process in the MIU to monitor compliance with clinical guidelines and protocols in line with other areas of the unscheduled care division.
• Implement arrangements for identifying, recording and managing risks, issues and mitigating actions.
• Ensure that all staff caring for patients under 18 years of age complete safeguarding children level 3 training.

• Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
• Monitor compliance with hand hygiene and environmental infection control in the phlebotomy department.
• Ensure staff within the radiology department are up-to-date on fire and evacuation training.
• Ensure that all risks relating to outpatient services are identified, recorded and managed on the departmental risk register.

In addition the trust should:

• Undertake a safety review of the medicines cupboard located in the reception area.

• Consider a process to avoid waste and dirty linen to be removed from the vanguard theatres without travelling outside or through a clean area.
• Patients who have had surgery cancelled should be treated within 28 days of the cancellation.
• Improve the availability of patient records during pre-operative assessment clinics.
• Consider decontaminating reusable naso-endoscopes in a washer-disinfector at the end of each clinic, to meet Department of Health Technical Memorandum (HTM) 01-06 best practice.
• Risk assess the multiple uses of the treatment room in the main outpatient department at that is used for the treatment of leg ulcers and consider using a separate room.
• Ensure damaged chairs in the main outpatient department are replaced.
• Consider providing outpatient services during evenings and weekends.
• Ensure staff are up to date with Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DOLS) training.
• Ensure patients in radiology have their privacy and dignity maintained at all times.
• Ensure patients across all specialties are seen within 18 weeks of referral.
• Consider using electronic systems to flag patients with mobility issues, dementia or a learning disability so that arrangements can be made in advance to meet their needs.
• Improve communication between divisions within outpatient services.

Professor Edward Baker

Chief Inspector of Hospitals

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 Watford Hospital, St Albans Hospital and Hemel Hempstead Hospital were all inspected. Unannounced inspections were undertaken of Watford Hospital and Hemel Hempstead Hospital on the 19 September 2016 but we did not visit St Albans at this time.

We inspected and rated the core services of urgent and emergency care, surgery and outpatients and diagnostic imaging.

We rated St Albans City Hospital as requires improvement overall. We rated the Minor Injuries Unit (MIU) and surgery as requires improvement. We rated outpatients and diagnostics services as good. For the five key questions that we inspect and rate, we rated three (safe, effective and responsive) as requires improvement and caring was rated as good. Well-led was rated as inadequate overall.

• During the last inspection, we found that there was no clear streaming or triage process in place in the MIU. This had not improved at this inspection. We escalated this as an urgent concern to the trust, who took a range of actions to address this risk to patient safety.
• There was no clear process in place to ensure that patients who were waiting to see a clinician were assessed as safe to wait in the MIU.
• There was no clear operational policy or standard operating procedure to support non-clinical staff with streaming decisions in the MIU.
• There was no clear eligibility criteria set out and agreed to define which patients would be suitable for urgent ambulance transfers.
• There was no process in place in the MIU to monitor and review arrival time to initial assessment.
• Nurse staffing met patients’ needs at the time of the inspection for adult patients, but not for children as there was not always a nurse present in the MIU with the full range of competencies to assess children’s needs.
• Learning from incidents was not effectively shared and communicated to all relevant staff in the MIU to minimise the risk to patient safety.
• Staff in MIU had minimal understanding of the duty of candour regulation and its requirements.
• Not all staff had had the mandatory training relevant to their roles. Not all staff had had the required safeguarding adults training.
• In the MIU, only 43% of nursing staff and 0% of administrative and clerical staff had received an appraisal from April 2015 to March 2016, which was significantly below the trust’s target of 90%. There were not robust appraisal and clinical supervision systems in place to support staff.
• Staff in the MIU were not aware of the trust’s strategies related to patients with complex needs, such as patients living with dementia.
• There were no clear escalation processes in place in the MIU to manage the service during periods of high demand or excessive waiting times.
• During the last inspection, it was reported that here was no local clinical audit programme for the MIU. During this inspection we founds there was still no local clinical audit programme in place.
• Whilst local leadership in the MIU was effective, there was inconsistency in leadership and visibility from senior departmental leaders.
• There was no clear strategy for the service. Staff were not always given the opportunity to have their views reflected when changes to the service were being made.
• There was a lack of effective governance measures in place to support the delivery of good quality care in the MIU. Risks to patient safety in the service had not been identified.
• In surgery, sufficient improvements to the governance and risk management systems, to demonstrate full compliance with the requirement notice that was issued after the last inspection, had not been made.
• Theatre teams were not consistently using the five steps to safer surgery checklist.
• Operations were carried out on high risk patients and there were no critical care beds on site. Critically ill patients were transferred to Watford General Hospital.
• Staff did not always observe infection control guidelines in surgery.
• Medicines were not being stored safely as they were stored above the recommended temperatures in surgery.
• Referral to treatment times were consistently below the England average in surgery.
• Venous thromboembolism (VTE) assessments were initially completed but not consistently repeated in line with best practice.
• Staff were unaware of the trust mission, vision, and strategic objectives.
• One of the junior doctors had not received a trust induction and had been working in the service for eight months in surgery.
• Not all staff received feedback after reporting incidents and some staff said they did not report all incidents.
• 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 87% of patients met this target from May 2016 to September 2016. This meant performance had declined over the past six months.
• Data for July to 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 87% of patients were seen within this timeframe. This meant performance had declined over the past six months.
• The Royal College of Paediatrics and Child Health (RCPCH) Intercollegiate Document 2014 state that clinical staff assessing and treating children and young people should have level three safeguarding children training. Not all medical staff in outpatients had received this training but the trust took actions to address this once we raised it as a concern.
• Patient records were not always available for their appointments.
• We saw that patients were treated with kindness and respect. We saw staff taking the time to interact with patients and those accompanying them.
• The MIU was consistently performing above the national target of 95% for four hour admission to discharge.
• There were good processes in place for medicines management at the MIU.
• The environment was visibly clean in surgery.
• Patient notes had documented risk assessments undertaken in surgery.
• There were competency frameworks for staff in all surgical areas.
• Ward sisters had access to leadership programmes in surgery.
• Patients told us staff requested their consent prior to any procedure and records seen demonstrated clear evidence of informed consent.
• The hospital had a nurse led pre-assessment clinic, which provided choice to patients regarding their appointments.
• Following their last inspection, many improvements had been made in outpatients and their performance data improved. We have seen evidence of clear action plans as a result of the last inspection. This could partly be contributed to the new leadership appointments made, including the lead nurse and service lead for outpatients. Both services recognised that since the last inspection they needed to improve their systems and process and provide a greater leadership for the nursing team.

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

Importantly, the trust must:

• To ensure that there are effective streaming systems in place in the unit and all staff have had appropriate training to carry out this process.
• Ensure there are processes in place to monitor arrival time to initial clinical assessment for all patients.
• To establish a process so that all children are seen by a clinician within 15 minutes of arrival in the MIU.
• To ensure that there are effective processes in place in the MIU to provide clinical oversight for patients waiting to be seen.
• To ensure non-clinical staff in the MIU receive sufficient support or training to provide oversight to recognise a deteriorating patient.
• To ensure the MIU has direct access to a registered children’s nurse at all items and that paediatric competencies for emergency nurse practitioners are recorded as a part of their continuous professional development (CPD) in line with national recommendations.
• To ensure that effective governance frameworks, standard operating procedures and policies are in place to support service delivery.
• To ensure that systems and processes are in place to monitor and review all key aspects of performance to identify areas for improvement and all potential risks in the MIU and surgery.
• To ensure that staff in the MIU are given training and support to understand the duty of candour statutory requirements.
• To ensure all staff in the MIU, surgery and outpatients have had the mandatory training relevant to their roles and that all staff receive an annual appraisal.
• To ensure medicines are stored at correct temperatures in all areas and ensure appropriate action is taken if temperatures are outside the recommended range in surgery.
• To ensure the surgery service is compliant with recommendations for the safe management of controlled drugs.
• Plans must be put into place to ensure referral to treatment (RTT) and cancer treatment times to continue to improve so that they are similar to or better than the England average.
• To ensure all resident medical officers (RMOs) staff receive a trust induction.
• To ensure all staff received feedback after reporting incidents.
• To ensure all staff in surgery report any issues, concerns and incidents using the trust’s electronic incident reporting mechanism.
• Actions on fire risk assessments in surgery are should be completed urgently and areas are regularly monitored for future compliance.

In addition the trust should:

• To consider ways to make the MIU environment more child-friendly in line with national recommendations.
• To consider ways of developing an audit process in MIU to monitor key areas of performance and compliance to protocols/pathways in line with other areas of the unscheduled care division.
• To monitor how learning from incidents is effectively shared and communicated to all relevant staff to minimise the risks to patient safety.
• To review the environment and facilities to enhance privacy and dignity in the MIU reception area.
• To consider ways to ensure that staff are aware of the strategy for the MIU and continue to develop ways for their views to be heard.
• To establish clear escalation processes to manage the service during periods of high demand or excessive waiting times.
• To monitor how pain assessments and management systems being used in the service.
• To review processes for monitoring those patients transferred from the MIU to other services in an emergency.
• All patients should have a venous thrombus embolism (VTE) assessment within 24 hours of admission and follow the National Institute of Health and Clinical Excellence (NICE) guidelines on VTE assessment and treatment.
• Action should be taken reduce the number of cancelled surgery operations and benchmarking should be undertaken against other similar hospitals.
• Pre-assessment documentation should include an assessment for patients living with dementia or a learning disability.
• The five steps to safer surgery checklists should be incorporated into all services and the three step checklist should be removed from use.
• All patients transferred, because of complications; from St Albans hospital should be fully reviewed. This should include an audit of any delay in this transfer.
• To review delays for patients receiving take home medicines and a plan put into place to minimise these delays.
• All complaints should be responded to within the agreed timescales.
• To review ways in which all staff are made aware of the trust’s mission, vision, and strategic objectives.
• To improve the availability of medical records for clinic appointments more than 96% of
• To provide safeguarding children level three training to all required clinical staff in outpatients.

Professor Sir Mike Richards

​Chief Inspector of Hospitals