Chief Inspector of Hospitals recommends West Hertfordshire Hospitals NHS Trust should be placed into special measures following inspection

England's Chief Inspector of Hospitals has recommended West Hertfordshire Hospitals NHS Trust should be placed into special measures after a Care Quality Commission inspection resulted in it receiving an overall rating of Inadequate.

Following inspections undertaken in April and May, CQC inspectors found the trust, which provides acute healthcare services to approximately half a million people living in West Hertfordshire, needed to make a number of improvements to ensure it was consistently delivering care which was safe, effective, caring, and responsive to people’s needs in services that are well-led.

In the emergency department at Watford General Hospital, patients arriving were not always seen by a clinician in a timely way, with untrained staff being used to assess and direct patients. CQC raised this urgently with the trust during the inspection.

Facilities in some areas across the trust were in a poor state of repair and caused a potential risk to staff and visitors and equipment such as resuscitation equipment was not always appropriately checked.

Nursing staff numbers were acknowledged as a major risk. The Royal College of Nursing told CQC that problems with recruitment and staff turnover were a long standing issue for the trust. Frequent staff shortages and poor management of agency staff in the maternity unit increased risks to patients. The trust had a rolling recruitment programme and plans were also in place to widen the recruitment drive internationally.

CQC’s Chief Inspector of Hospitals, Professor Sir Mike Richards, said:

“We found a number of serious problems when we inspected the services run by West Hertfordshire Hospitals NHS Trust and I have made a recommendation to the Trust Development Authority that the trust should be placed into special measures.

“We made the TDA aware of our concerns following the inspection and it has begun to work with the trust to make sure these are appropriately addressed and that progress is monitored.

“We were concerned about the safety and quality of care provided by some of the trust’s services and there was little evidence of trust-wide learning, with limited actions to improve patient safety. There had been lack of response to external reports where actions had been recommended and not acted upon and the quality and accuracy of some of the data provided by the trust was poor, for example the trust could not provide information on the number of formal complaints received.

“While the majority of staff were caring, compassionate and kind, we found that the approach of some staff within the maternity unit and OPD required improvement. We were struck by the low morale of many of the staff that we interviewed. Staffing was a challenge and recommended standards were not always being followed. Many of the staff inspectors spoke with expressed low levels of satisfaction, high levels of stress and work overload. Some senior staff told us they did not feel empowered to make decisions.

“One of the reasons we rated the trust as Inadequate for being well-led was because there was little information to show that it was clear about where risks to patients were greatest. The incoming interim Chief Executive, however, demonstrated a good understanding of the challenges the trust faced, along with the commitment to address them. She took decisive action in some areas immediately following the inspections.

“The trust managers have told us they have listened to our inspectors’ findings and have begun to take action where it is required. We have maintained close contact with the trust since the inspection and will undertake further inspections, including unannounced visits to check that the necessary improvements have been made.”

The inspection highlighted a number of concerns and areas where the trust must improve, including:

• The trust must review the environment within the Emergency Department to meet patient demand effectively.
• Effective arrangements must be in place for the management of risk at all levels within the organisation.
• The trust must ensure that when a person lacks capacity to make an informed decision or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005.
• Staff must be 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 all areas are fit for purpose and present no safety risks to patients or staff.
• 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.
• Action must be taken to ensure difficult airway management equipment is adequate and checked to ensure it is fit for purpose.
• There must be a robust incident and accident reporting system in place and lessons learnt from investigations of reports are shared with staff to improve patient safety and experience.

Despite the overall rating of Inadequate, inspectors identified a number of areas of Outstanding practice across the trust, including:

• The children and young people’s service at Watford Hospital was rated as Good overall and rated as Outstanding for being caring.
• The trust had delivered a significant reduction in mortality over the past two years, dropping from higher than expected rates to lower than expected rates.
• The dementia care team had implemented a delirium recovery programme which aimed to reduce the length of stay and readmission to hospital. This allowed patients the opportunity to return home with up to three weeks of 24 hour live-in care.
• The trust had introduced a pilot pre-operative reminder telephone call service. Patients were called three days prior to their surgery for reminders and checks. Staff said the service would become permanent if successful.
• The trust had undertaken a significant amount of work to understand and improve its mortality rates over the previous 18 months.

An inspection team, including doctors, nurses, midwives, hospital managers, trained members of the public, a variety of specialists, CQC inspectors and analysts spent four days at the trust in April and two days in May. The trust was judged as Inadequate with regard to whether services were safe and well-led and rated as ‘Requires Improvement’ for whether services were effective, caring and responsive.

West Hertfordshire NHS Trust provides services from three hospital sites: Watford Hospital, St Albans City Hospital and Hemel Hempstead Hospital. Both Watford Hospital and St Albans City Hospital were rated as Inadequate overall and Hemel Hempstead Hospital was rated as Requires Improvement.

Full reports including ratings of all core services have been published on the CQC website.

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