Hemel Hempstead General 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. 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.

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

At Hemel Hempstead Hospital, we inspected and rated the core services of the urgent care centre, outpatients and diagnostic imaging. At the previous inspection in September 2016, the hospital was rated inadequate overall. However, since then the one service that had heavily contributed to this rating had been taken over by another trust and therefore was not inspected on this occasion.

At this latest inspection, we rated Hemel Hempstead General Hospital as requires improvement overall. We rated the urgent care centre (UCC) as requires improvement 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 requires improvement. Caring and responsive was rated as good overall. This was an improvement.

There were areas of practice where the trust needs to make improvements:

• We found risks that we had identified at previous inspections did not feature on the risk register both in the urgent care centre and outpatient and diagnostics services.
• Not all staff working in clinics that saw children had the appropriate level of safeguarding training. This was raised as an issue during the inspection in September 2016.
• 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.
• 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.

However, there were areas of good practice:

• There had been several improvements in assessing and responding to patient risk. All patients were now assessed by a triage nurse, usually within 20 minutes of arrival. This compared well to our last inspection when patients were waiting up to two hours for an initial clinical assessment.
• We observed staff maintaining patients’ privacy, dignity and confidentiality. They demonstrated empathy towards patients who were in pain or distressed and were skilled in providing reassurance and comfort.
• Almost all patients (99%) were treated, discharged or transferred within four hours, with an average time to treatment of 27 minutes.

Importantly, the trust must:

• Ensure that systems and processes are in place to monitor and review key aspects of performance (for example patient waiting times) to identify areas for improvement.
• Ensure there are processes in place to monitor arrival time to initial clinical assessment for all patients.
• Develop an audit process in the UCC to monitor compliance to protocols/pathways 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:

• Consider the roles and responsibilities of the rotational leadership role with regards to defined responsibilities and consider devising a job description.
• Consider the UCC, as part of the unscheduled care division, featuring in the current strategy document.
• 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.
• Consider providing outpatient services at evenings and weekends.
• Ensure staff are up to date with Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DOLS) training.
• To consider 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.
• Consider using hearing loop systems across the department.
• Consider ways of improving communication between divisions within outpatient services.
• Consider how effective clinical leadership is at UCC in circumstances where the matron was also responsible for a neighbouring emergency department and a minor injuries unit that was several miles away.

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 General Hospital and Hemel Hempstead Hospital on the 19 September 2016.

We inspected and rated the core services of the urgent care centre, medicine and outpatients and diagnostic imaging. We also inspected the mortuary as part of the end of life core service but did not rate this.

We rated Hemel Hempstead Hospital as inadequate overall. We rated medical care as inadequate. We rated Urgent Care Centre (UCC) as requires improvement. We rated outpatients and diagnostic imaging as good. For the five key questions that we inspect and rate, we rated three (safe, responsive and well-led) as inadequate and caring and effective were requires improvement.

• Whilst most staff were kind and caring in the hospital, we found concerns regarding staff attitude to patients and visitors on Simpson ward.
• During the last inspection, we found that there was no clear streaming or triage process in place in the UCC. 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 process in place in the UCC to monitor and review arrival time to initial assessment. The UCC did not have an effective process in place to ensure that all children under the age of 16 received an initial assessment within 15 minutes in line with The Intercollegiate document ‘Standards for Children and Young People in Emergency Care Settings, 2012’.
• 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 UCC.
• The premises did not always meet the needs of patients. The designated children’s waiting area was not child-friendly and had no appropriate distraction items for children.
• Staff in the UCC had not received all required mandatory training. Staff had received no specific training in sepsis management. Not all staff had had the required safeguarding adults training.
• Staff in UCC had minimal understanding of the duty of candour regulation and its requirements.
• 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 UCC with the full range of competencies to assess children’s needs.
• Staffing levels did not meet patient need and acuity at all times of day at the time of inspection on Simpson ward. Non-clinical staff were used to provide one to one care for patients requiring supervision.
• Learning from incidents was not effectively shared and communicated to all relevant staff to minimise the risk to patient safety in the hospital.
• There was not an effective process in place to monitor and review patient outcomes in the UCC and on Simpson ward.
• There were not robust appraisal and clinical supervision systems in place to support staff in the hospital.
• There were not robust processes in place to manage demand and patient flow in the UCC and on Simpson ward.
• There was no clear strategy for the UCC and Simpson ward. Staff were not always given the opportunity to have their views reflected when changes to the service were being made.
• Medicines were not always managed safely.
• There was a lack of effective governance measures in place to support the delivery of good quality care. Risks to patient safety in the service had not been identified in the UCC and on Simpson ward.
• 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 on Simpson ward.
• Fire safety was not sufficient on Simpson ward to ensure patients and staff would be kept safe in the event of a fire.
• There were no activities to engage patients, including those with complex needs and living with dementia on Simpson ward. We did not observe staff engaging patients living with dementia who appeared anxious or distressed.
• There were no formal admission criteria to Simpson 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.
• 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 states 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.
• The UCC was consistently meeting the national target of 95% for four-hour admission to discharge.
• Effective induction and orientation processes were in place for new staff and agency/bank staff on Simpson ward. 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.
• Staff felt that their local leaders were visible and approachable.
• Standards of cleanliness and hygiene were well maintained in the mortuary. 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. Equipment was generally well maintained and fit for purpose.
• The recently appointed senior and junior sisters had improved morale and processes in the outpatient department.
• 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:

• Ensure that there are effective streaming systems in place in the Urgent Care Centre (UCC) 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.
• Establish a process so that all children are seen by a clinician within 15 minutes of arrival to the UCC.
• Ensure that there are effective processes in place in the UCC to provide clinical oversight for patients waiting to be seen.
• Ensure non-clinical staff receive sufficient support or training to provide oversight to recognise a deteriorating patient in the UCC.
• Ensure the UCC has direct access to a registered children’s nurse at all times and that paediatric competencies for emergency nurse practitioners are recorded as a part of their continuous professional development (CPD), in line with national recommendations.
• Ensure that effective governance frameworks, standard operating procedures and policies are in place to support service delivery in the UCC.
• 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 UCC and on Simpson ward.
• Ensure that staff are given training and support to understand the duty of candour statutory requirements.
• Ensure all staff have had the mandatory training relevant to their roles and that all staff receive an annual appraisal in the UCC and on Simpson ward.
• Ensure that all outpatients administrative staff receive appraisals.
• Maintain medicines at correct temperatures in all areas and ensure appropriate action is taken if outside recommended range on Simpson ward.
• Ensure that all medicines are suitable for use and have not expired on Simpson ward.
• Ensure safe storage and management of controlled drugs on Simpson ward.
• Ensure staffing levels and competency of staff meets patient need at all times on Simpson ward.
• Ensure appropriate assessments and authorisations are in place for Deprivation of Liberty Safeguards on Simpson ward.
• Ensure that the Simpson ward can meet the needs of patients with vulnerabilities, including those living with a dementia and those displaying difficult behaviours and to ensure the provision of activities to engage patients in meaningful stimulation.
• Ensure learning from incidents and feedback is embedded to drive improvements on Simpson ward.
• Review the admission and exclusion criteria for Simpson ward to ensure all referred patients have their needs met.
• 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.
• Ensure all staff understand the duty of candour regulation and its requirements.

In addition the trust should:

• Consider ways to make the UCC environment more child-friendly in line with national recommendations.
• Consider ways of developing an audit process in UCC to monitor key areas of performance and compliance to protocols/pathways in line with other areas of the unscheduled care division.
• Monitor how learning from incidents is effectively shared and communicated to all relevant staff to minimise the risks to patient safety.
• Consider ways to ensure that staff are aware of the strategy for the UCC and continue to develop ways for their views to be heard.
• Establish clear escalation processes to manage the service in the UCC during periods of high demand or excessive waiting times.
• Monitor how pain assessments and management systems are being used in the UCC.
• Review processes for monitoring those patients transferred from the UCC to other services in an emergency.
• Review how staff can be supported via a clinical supervision process.
• Monitor how staff demonstrate compassionate care towards patients at all times on Simpson ward.
• Review discharge pathways to ensure access and flow are improved for Simpson ward.
• Review the process for having medical records available for all clinic appointments.
• Review the provision of advice leaflets in a variety of other languages in outpatients.
• Provide safeguarding children level three training to all required clinical staff in outpatients.

Professor Sir Mike Richards

Chief Inspector of Hospitals