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Hemel Hempstead General Hospital Requires improvement

The rating for 'Medical care (including older people's care)' shown on this page does not reflect our latest judgement of services at Hemel Hempstead General Hospital.

The medical care at this hospital is now provided by Hertfordshire Community NHS Trust. We'll update this page to reflect this change soon.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 February 2019

At this inspection, we inspected urgent and emergency care. We did not inspect end of life care (mortuary only) or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Our rating for safe remained requires improvement overall. Mandatory training rates remained low and below the trust target.
  • 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 remained good overall. In most cases, patients could access the service when they needed it.

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 urgent care centre, there remained little oversight of the service at divisional level.
Inspection areas

Safe

Requires improvement

Updated 28 February 2019

Effective

Requires improvement

Updated 28 February 2019

Caring

Good

Updated 28 February 2019

Responsive

Good

Updated 28 February 2019

Well-led

Inadequate

Updated 28 February 2019

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 1 March 2017

Overall, we rated the service as inadequate because:

  • There were not appropriate systems in place to identify and monitor risk, and learning from incidents was not shared across multidisciplinary teams. There were not always policies or procedures in place to support staff.
  • Staffing levels did not meet patient need and acuity at all times of day at the time of inspection. Non-clinical staff were used to provide one-to-one care for patients requiring supervision.
  • Appropriate Deprivation of Liberty Safeguards authorisations were not in place for patients on the ward, and staff did not always understand the impact of this.
  • Patients received weekly consultant reviews; however, these were not conducted in conjunction with medical staff caring for patients on a daily basis.
  • Medicines were not always managed safely.
  • Visiting staff did not always discuss patients in a respectful way and this went unchallenged by ward staff. There were concerns expressed by patients and family members regarding staff attitude and care. Staff did not always communicate and involve family members in the progress of discharges.
  • There were no activities to engage patients, including those with complex needs and living with dementia. We did not observe staff engaging patients living with dementia who appeared anxious or distressed.
  • Patients were not always positioned well or comfortably during meal times.
  • There were no formal admission criteria to the ward, which meant that staff could not be assured that appropriate patients were being placed under their care. The ward lacked identity and all staff gave different descriptions of the service provided. There was no clear vision, identity or strategy in place for the ward, resulting in the ward admitting patients from a variety of specialities and with complex conditions.
  • There were significant problems with flow out of the ward, due to a lack of ownership of the discharge process.
  • Senior staff were not aware of the significant risks to patient safety that we found and raised during our inspection.
  • Staff were concerned about the future of the ward and this impacted morale and culture. Staff did not feel engaged in developments and changes relating to the future of the ward. Staff felt there was a significant disconnect between the ward and the rest of their trust, which was affecting the care they could provide.

However, we also found that:

  • Evidence-based care was provided to patients on the ward, reflective of national guidance. Patient nursing risk assessments and observation records were thoroughly completed for all patients. Medical and nursing records were easily accessible and up to date.
  • Infection control procedures were in line with trust policy and audits showed good compliance rates for hand hygiene.
  • Mental capacity assessments were carried out appropriately and this was documented clearly in patient records. Staff understood safeguarding vulnerable adults and how to report any concerns. Safeguarding training rates met the trust target.
  • Effective induction and orientation processes were in place for new staff and agency/bank staff. Staff felt that whilst there was uncertainty about the ward, they tried to maintain the ‘family’ feel of the ward and work together as a team.
  • Data collected through patient satisfaction audits was generally positive and regularly shared with the team. Patients generally were positive about the care they received whilst on the ward and dignity being maintained during interactions with patients.
  • Staff felt well supported by the ward sister and spoke highly of them.

End of life care

Not sufficient evidence to rate

Updated 1 March 2017

We inspected, but did not rate, elements of the safe key question. We did not inspect the effective, caring, responsive, or well-led key questions on this inspection. Significant improvements had been made since the April 2015 inspection. We found that:

  • Staff knew how to report incidents appropriately and incidents were investigated, shared, and lessons learned. Risks in the environment and in the service had been recognised and addressed and the service had a robust risk register in place.
  • Standards of cleanliness and hygiene were well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
  • Facilities were in a good state of repair in the mortuary. The air-change system in the mortuary was being monitored to ensure there were no risks to staff.
  • Appropriate checking systems were in place to monitor the temperatures of the body fridges. Equipment was generally well maintained and fit for purpose. Chemicals hazardous to health were generally appropriately stored.
  • Appropriate systems were in place to respond to major incidents and emergencies.

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. Performance data had improved and the service was performing in line with their planned trajectory.
  • There was a positive incident reporting culture across the hospital. All staff we spoke with knew how to report an incident and were aware of details of recent incidents and learning.
  • Radiation protection in the diagnostic imaging department was robust.
  • The main outpatient department had no nursing vacancies at the time of our inspection.
  • Since our previous inspection in September 2016, the availability of patient notes had improved.
  • 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.
  • Waiting lists for outpatient appointments were reviewed weekly. Risk assessments and individual treatment plans were completed for patients who waited 30 weeks or more. At the time of our inspection, no clinical harm had occurred to patients 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.
  • There was a local audit programme in the outpatient department that included monitoring compliance with best practice.
  • 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).
  • 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 patient care.
  • The service communicated regularly with patients’ GPs and worked with the trust’s GP liaison manager to share information.
  • Staff understood their responsibilities for obtaining consent and making decisions in line with legislation, including the Mental Capacity Act (MCA) 2005.
  • Patients were treated with kindness, dignity, respect and compassion. In addition, staff were considerate of people’s personal, cultural, and religious needs.
  • Chaperones were offered and available throughout the outpatient and diagnostic imaging services.
  • 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.
  • Staff recognised when people needed additional support to help them understand and took action to meet their needs.
  • Patients we spoke with described being offered emotional and social support.
  • 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 written information in languages other than English.
  • The main outpatient department was working towards gaining a Purple Star accreditation for the care and treatment they provided to patients with a learning disability.
  • 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.
  • The culture in across outpatient and diagnostic imaging services encouraged openness, candour and honesty. All staff we spoke with felt supported, respected and valued.
  • Patients, relatives and visitors were actively engaged and involved when planning services. People were encouraged to provide feedback and we saw their comments used to improve services.
  • Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients.

However:

  • 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.
  • Hand hygiene and environmental infection control audits were not carried out in the phlebotomy department.
  • 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. There were no plans to introduce evening or weekend clinics.
  • 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.
  • Five out of 16 specialties were not meeting the England overall performance for patients being seen within 18 weeks of referral.
  • During the previous inspection, it was raised that hearing loops were not in use to aid people with hearing impairment. This was still the case at the most recent inspection.
  • 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 to facilitate their journey through the department.
  • At the time of inspection, there was only one risk on the outpatient department risk register. This was related to clinics being overbooked. However, during our inspection we identified other risks that should have been recognised and mitigated.

Urgent and emergency services

Requires improvement

Updated 28 February 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • 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 through the trust’s 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.
  • Whilst there had been changes to the leadership team with the addition of a senior emergency nurse practitioner to oversee and manage the urgent care centre, 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 findings from 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.
  • 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.
  • 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.