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Provider: London North West University Healthcare NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 November 2019

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

  • We rated safe, effective, responsive and well led as requires improvement and caring as good.
  • We rated well-led at the trust level as requires improvement.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
Inspection areas

Safe

Requires improvement

Updated 6 November 2019

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

  • The trust provided mandatory training in key skills however there was some confusion among midwifery staff as to the correct length of mandatory training and its content. Compliance rates for mandatory training and safeguarding training were below trust targets in the surgical services at Northwick Park Hospital and Central Middlesex Hospital. Not all clinical staff in children and young people services at Central Middlesex Hospital caring for children were trained to safeguarding level three however, plans were in place to ensure all staff received this training.
  • In medical care at Central Middlesex Hospital, some staff did not always report incidents and, in particular, near misses.
  • The trust did not always control infection risk well. Hand hygiene was not consistently being undertaken in maternity services. In children and young people services, the Rainbow Unit at Central Middlesex Hospital was found to be untidy and we could not be assured that children’s toys were regularly cleaned.
  • Due to capacity issues in the emergency department at Northwick Park Hospital, patients were still being cared for on trolleys in the corridor which meant private conversations could be overheard.
  • At our last inspection we found that the clinical decisions unit (CDU) was being used inappropriately to treat level two patients. Whilst the service assured us that this was no longer the case we did find that the area was being used as overflow for patients requiring inpatient beds and patients within the CDU could be there for over four hours and sometimes up to three days. In children and young people services at Central Middlesex Hospital, staff we spoke with in Recovery Stage One told us that children were cared for in a mixed four bedded recovery bay with adults.
  • Staff at Central Middlesex Hospital did not use a nationally recognised tool to identify deteriorating patients, such as Paediatric Early Warning Signs (PEWS) or a validated acuity score system to assess patients. We were told that not all medical staff had European Paediatric Life Support (EPLS) or Advanced Paediatric Life Support (APLS) training. There was no paediatrician available on-site at Central Middlesex Hospital. Staff had to refer to the consultant of the day or week, who was based at a different hospital in the trust. Some staff were not aware of this arrangement.
  • Some medicine storage areas did not meet national guidance for security for controlled drugs in the Northwick Park surgical service.

However:

  • Mandatory training compliance rates at Northwick Park and Ealing emergency departments had improved. Staff monitored patients who were at risk of deteriorating appropriately.
  • At Ealing Hospital emergency department, at our last inspection we found that the service was still treating children instead of stabilising and transferring. At this inspection, we found that the service had overhauled its approach to paediatric patients presenting at the emergency department (ED). The service now had posters up both outside the service and within the waiting room letting patients know that they did not treat acutely unwell paediatric patients. If an acutely unwell paediatric patient presented at the service, they would stabilise and transfer to a neighbouring ED.
  • In maternity, the issue we found at the last inspection with the third lift (designated for theatres) being able to be accessed by members of the public had been addressed. The service had now ensured that direct access from the delivery suite to the theatres could now only be achieved with swipe card access.

Effective

Requires improvement

Updated 6 November 2019

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

  • Training compliance rates for deprivation of liberty safeguards was poor among medical staff. Some staff had a variable understanding of the mental capacity act (MCA) and deprivation of liberty safeguards (DoLS).
  • We found that the emergency departments still performed poorly in most of the Royal College of Emergency Medicine (RCEM) audits.
  • In children and young people services at Central Middlesex Hospital, staff did not monitor the effectiveness of care and treatment and the service did not participate in relevant national clinical audits. They therefore did not have a baseline upon which to generate improvements to the service.
  • We found that some trust policies were out of date.
  • There was no health promotion directed to children and young people in either the Rainbow Unit, pre-assessment area or in recovery areas.
  • Managers did not always effectively appraise all staff’s work performance in surgical services.

However:

  • There was a positive multidisciplinary working culture within services.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Recording of pain scoring had improved.
  • In children and young people services at Central Middlesex Hospital, theatre lists were prioritised and carefully ordered taking into account age, procedure and special needs. This information was shared with parents via the parents’ information booklet.

Caring

Good

Updated 6 November 2019

Our rating of caring stayed the same. We rated it as good because:

  • Patients, families and carers were positive about the care across the service and we observed compassionate and courteous interactions between staff and patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients and relatives we spoke with consistently told us about the kindness of the staff.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Responsive

Requires improvement

Updated 6 November 2019

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

  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations relating to national standards
  • The emergency departments’ performance for Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival was poor. However, significant improvements had been made and performance was no longer consistently below the England average. The trust were continuously working with NHS Improvement to improve their performance. The trust had been above the England average for six months.
  • There were limited facilities available for parents and relatives, such as a quiet area for parents waiting while their child was in surgery. There were no separate toilet facilities in the children’s surgical unit for children, parents or carers who required the use of a wheelchair. There were also no baby changing facilities or areas where mothers could breastfeed with privacy.
  • Signage at Central Middlesex Hospital to show members of the public where the paediatric surgical department was poor.

  • In medical care, ward spaces were not dementia friendly and there was limited interaction or stimulation for patients with dementia or cognitive impairment.
  • Flow out of the medical care service at Central Middlesex Hospital was poor. There was a significant population of medically fit patients who could not be discharged due to difficulties in arranging care and support in the community.

However:

  • At the last inspection, we saw the surgical service at Northwick Park Hospital had received instruction from Health Education England that the surgical senior house officers (SHO) could not take referral calls from urgent care centres on weekends and that a surgical registrar must lead this. At this inspection we saw the senior team had put in place suitable strategies to meet the staffing requirement.
  • The surgical service at Northwick Park Hospital took account of patients’ individual needs. Each ward had adapted equipment for patients to use during mealtimes, including menus printed in Braille and in a choice of 11 languages.
  • In the maternity department there were facilities for partners to stay and a new built bereavement room situated on the delivery suite but away from all the delivery rooms.

Well-led

Requires improvement

Updated 6 November 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • There were systemic issues around culture within the maternity service. We were told that staff morale had deteriorated because of staffing pressures and that some staff were going off sick due to the culture of the organisation. Staff were not able to raise concerns without fear of reprisal.
  • There were concerns about the lack of visibility and lack of regular daily contact with the senior leadership team of the maternity department.
  • Not all services had a clear vision for what they wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
  • We found a lack of clarity over where the overall responsibility and accountability of children and young people services lies within Central Middlesex Hospital. We also found a lack of clarity for how and where this service feeds into the trust.
  • Governance in children and young people services at Central Middlesex Hospital was weak. The risk register for the recovery ward was out of date. There was a lack of up to date policies and associated audits demonstrating that the care being delivered was compliant national standards and best practice. We were not assured that the service was guided or supported via a paediatric surgical network.
  • There was no clear evidence that areas from the last inspection for children and young people services had been addressed or necessary improvements made.
  • In medical care, risks were mitigated and managed but there had been limited action to address risks directly.
  • The senior leadership team for medical care at Central Middlesex Hospital recognised the sometimes poor relationship between its staff and local authority staff, but there had been no action to address this.

However:

  • At Northwick Park Hospital emergency department, we found clinical governance arrangements were departmentally focused. There was a new a clinical governance team leading on urgent and emergency care services.
  • At Ealing Hospital emergency department, it was reported at our last inspection that staff felt as though there was a lack of divisional and senior trust leadership presence. This was not the case whilst on inspection as staff spoke highly of management and knew members of the executive team by name.
  • In the surgical service, leaders and staff actively and openly engaged with patients, staff, the public and local organisation to plan and manage services.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 6 November 2019

Our rating stayed the same. We rated it as requires improvement. NHS London conducted a use of resources inspection in June 2019. NHS London rated use of resources as requires improvement because the trust did not consistently manage its resources to allow it to meet its financial obligations on a sustainable basis and to deliver high quality care. NHS London also conducted a financial governance assessment at the same time as our CQC inspection.

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

End of life care

Good

Updated 21 June 2016

Overall, the services provided by London North West Hospitals NHS Trust for community health End of Life care was rated as good because;

We found the community palliative care team (CPCT) for the London boroughs of Brent and Harrow and Ealing and Hounslow to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. However there were some concerns expressed by the CPCT’S whether all community generalist nurses who supported patients on a day-to-day basis had the skills and expertise to recognise when a patient who had reached the last 12 months or less of their life was deteriorating.

Some generalist community nurses were reported to be “task based” when caring for patients and did not always consider a patient in a whole or holistic way. We were given examples where generalist nurses had not spotted deterioration in a patient they were regularly caring for. However there was no evidence of harm to patients. We did observe some generalist nurses who were good at identifying changes and indications of deterioration in patients’ condition, such as end stage dementia. Others had specialist interest and skills in relation to specific patient groups such as learning difficulties.

Staff were aware of their responsibility in raising concerns and reporting incidents. However we found some incidents and concerns staff shared with us had not been reported through the electronic reporting system as would have been expected. This included missed appointments, telephone messages not being received, and delayed hospital discharges. There was a mixed response as to how often staff received feedback from reported incidents. Some staff told us they only received feedback relating to their own location, while other staff told us they also knew of incidents that happened in other areas of the trust; therefore we found an inconsistency in shared learning and improvement measures.

The community staff reported that local leadership was visible, accessible and responsive. Local managers had appropriate knowledge and experience to lead services and they were well aware of issues and challenges their teams faced. Staff felt empowered by their local team leaders and managers. However this was not reflected at trust level. Staff were unclear of the trust vision and reported feeling they would not be able to instigate or effect any change. The service level leads told us although there was trust board representation they did not feel that EOLC received the level of support it required to effect the change required to provide an integrated strategy which provided seamless, safe and high quality care for all patients across the trust’s locality.

At a local level the community palliative care team strove to educate, support and provide advice to community nurses, primary care providers and nursing/care homes. A recent education audit in Ealing and Hounslow identified that many community healthcare staff wanted EOLC training. The audit had secured funds and training was hoping to go ahead early in 2016.

The patients and relatives spoke positively about their interactions with the teams involved in their care. They described the staff as “kind” and that “nothing was too much trouble for them”. They told us they felt understood and able to raise any concerns they had. Patients records and care plans were regularly updated, matched the needs of the patient and were relevant to EOLC. Holistic assessments looked at the whole picture; the patient’s physical, emotional, spiritual, psychological and social needs were assessed and their carers’ views were taken into consideration. Pain relief, symptom management and nutrition and hydration needs were monitored, recorded and any changes were responded to.

Staff were able to explain their understanding of the Mental Capacity Act (MCA) 2005 and Deprivations of Liberty Safeguards (DoLS). They told us they would act in the best interests of the patient should they lack mental capacity to make decisions for themselves. They understood the patient’s carer should be consulted in gaining an understanding of what the patient would want when making best interest decisions and people could not consent on behalf of the patient unless they had a relevant legal directive to do so. All staff understood their role and responsibility to raise any safeguarding concerns.

The palliative care teams were committed to making end of life care a priority for the trust. However we found each team across the acute and community sites was approaching support for community patients in different ways and therefore care for patients was not equitable across all the London boroughs the trust supported. For example Ealing patients had overnight nursing support through Marie Curie, while patients in Harrow and Brent did not have access to this support; and Harrow patients with long term chronic conditions and identified at end of life were supported in their homes through a ‘virtual ward’ scheme which prevented unnecessary admissions to hospital, this was not provided to Ealing and Brent patients.

The acute and community palliative care teams were aware that although they had the expertise the push for improving and providing a seamless service should not fall on their shoulder alone as ”death and dying was everyone’s business” and therefore should be a trust-wide responsibility. To address this the end of life strategy committee included people such as those who had experienced the service, chaplaincy, GPs, community services, clinical nurse specialists, consultants, and other organisations such as Marie Curie.

Community health inpatient services

Good

Updated 31 August 2018

Our rating of this service improved. We rated it as good because:

  • Patient risk was effectively monitored through a multidisciplinary team approach. There was a clear process for identifying and responding to deteriorating patients, who were transferred to the acute hospital if necessary. Incidents were consistently and properly investigated and the outcomes fed back to staff.
  • The community hospitals were clean. Cleaning schedules were followed and staff observed infection prevention protocols.
  • Clinical staff were following NICE and other clinical guidance. Therapy teams effectively monitored patient outcomes.
  • There was good and effective multidisciplinary team working, who provided one joined up service and provided patients with good outcomes.
  • Health promotion was seen as an important part of preparing people to go home and to meeting patient need.
  • Relatives and patients all told us that staff were compassionate. We were given clear examples of this, which included for patients who were more vulnerable or who had extra need.
  • Senior staff told us of the professional expectation they had of staff and we witnessed staff working compassionately against the backdrop of staffing pressures.
  • Community hospitals were aware of their integral role in trust pathways and worked well with both acute and community teams. Multidisciplinary staffing teams were meeting patient need, many of whom were in vulnerable circumstances.
  • There was a service wide admissions criteria and the assessment process was reasonably proficient in identifying inappropriate referrals. The services worked towards discharge from day one.
  • There were a low number of formal complaints. The service promoted swift resolution of any issues brought to them by patients and relatives.
  • At the last inspection the trust, community leadership team and inpatient hospitals all worked in isolation. At this inspection community hospitals were working as one team, with unified protocols and a shared culture.
  • At the last inspection there was no single clear process of management and clinical governance across the community hospitals. At this inspection there was one community hospital leadership group and the meetings structure was a shared one, across community hospital services.
  • Meetings were taking place within community inpatient settings to assure themselves of quality monitoring. Audits were routinely occurring within community inpatient services.

However

  • We found pockets of large vacancy rates for nurses and a reliance on a low number of bank staff. In some instances, healthcare assistants were being used to fill nurse shifts.
  • The use of a safer staffing model for acute settings was being used. It did not adequately measure staffing need in rehabilitation settings and placed further pressure on staff to provide a quality service.
  • There was a lack of psychiatry input for neurological patients, which was on the risk register. It meant that assessment of deteriorating mental health conditions, receiving advice on treatment and which medications worked best alongside neurological treatments was lacking.
  • There was a lack of on-site security where the Willesden Community Rehabilitation Hospital was located. This raised a number of potential risks and was on the trust risk register. There were measures in place to keep wards secure. However, incidents that involved neurological patients becoming agitated or self harming had to be supported by ward staff only and remained a risk.
  • There was a lack of supervision for lower grade doctors and out of hours medical support to the wards.
  • The average length of stay on Robertson ward was stated as six to eight weeks, but many were going beyond this due to unmet social needs such as appropriate housing options.
  • Community hospital staff experienced poor, time consuming access to essential online information systems.
  • The divisional performance reports did not provide a complete picture of how community hospitals were performing. It was therefore not clear how the board were assured on how community hospitals were performing.
  • A new trust medical director had reviewed medical cover and agreed that the current level of input would remain and the duty of care remained consultant led. However, there were gaps in supervision of junior grade doctors and out of hours support to the wards.

Community dental services

Good

Updated 31 August 2018

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

  • Staff reported incidents appropriately and they were investigated.
  • Staff understood their safeguarding responsibilities and were aware of the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
  • Medicines were stored, handled and administered safely.
  • Risk assessments such as Legionella and fire safety had been completed and there were action plans in place.
  • Appropriate systems were in place to respond to medical emergencies.
  • Equipment was well maintained and fit for purpose.
  • Staffing levels were appropriate and met patients’ needs at the time of inspection.
  • Patients’ individual care records were comprehensively written in a way that kept people safe. Relevant information was recorded appropriately and staff had access to relevant details before providing care.
  • Standards of cleanliness and hygiene were generally well maintained. Systems were in place to prevent and protect people from a healthcare associated infection.
  • Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.
  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
  • The service followed effective evidence based care and treatment policies which were based on national guidance.
  • There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
  • During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.
  • People were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.
  • Staff involved patients in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.
  • There was an effective system to record concerns and complaints about the service.
  • Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
  • There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

However, we found that:

  • Mandatory training was provided for staff. The service did not meet the trust’s target of 85% completion for mandatory training in manual handling - level 2 (face to face), information governance and Resuscitation (basic life support).
  • The service had not completed X-ray audits in the last 12 months.
  • The service did not have a comprehensive risk register. The risk register did not include the need to update the information technology including the software for the electronic dental care records. The service had not considered the risk of the clinical director managing the service on one day per week employment. The waiting list for endodontic treatment was 14 months at the Heart of Hounslow Centre for Health and there were 360 patients on the waiting list.

Community health services for children, young people and families

Good

Updated 21 June 2016

  • We gave an overall rating for the Community health services for children, young people and families of Good because:

  • Children and young people’s services were effective. Care and treatment was evidence based and staff were competent. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently.
  • Services delivered by the trust were caring. Staff were dedicated and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Emotional support was available to patients and their families who were dealing with difficult circumstances.
  • Children and young people’s services were responsive to the needs of the people who used them. Generally, services were delivered to the right people at the right time within the commissioning framework of the trust. There were services in place to help protect vulnerable young people and children.
  • The service was well led at the local level. We had varying feedback from staff regarding their view of their place within organisation and the level of staff engagement. Most staff we spoke with felt the acute service did not understand community services. They felt the focus of the organisation was on acute services and community services tended to get lost within the larger organisation.
  • Staff were committed to providing a good service to their patients. However staff shortages and large caseloads placed too much pressure on staff resulting in them working extra hours. It was only due to the commitment of staff and the support of local managers’ services were being sustained.
  • Staff generally reported good supportive leadership at local level and we met some very committed and enthusiastic managers who were working hard to develop and improve their services. With the exception of one team all staff were positive about the support they received.

However;

  • The safety of children and young people’s services required improvement. This was because there were significant staff vacancies within the service in both nursing and therapy roles. The trust had developed the health visitor clinical academic hub, which had significantly helped to raise the profile of health visiting within the trust through publication of papers and nominations for national awards. With the work of the hub and streamlined recruitment processes there had been some success in recruitment but significant vacancies remained.
  • The impact of vacancies was that many staff were trying to manage caseloads well above best practice guidance of 300 families per health visitor. Health visitors working in Brent and Ealing did not know how they would meet the requirement for all parents to have a visit at 28 weeks of pregnancy. This is a national target to be implemented from October 2015.

Community health services for adults

Good

Updated 21 June 2016

The trust provides variety of services within the community including community nursing services provided by district nurses, community matrons and specialist nursing services. This includes long-term condition management and coordination of care for people with complex needs or multiple conditions, wound care, medicines management and acute care provided at home. Furthermore rehabilitation and reablement following illness or injury, community outpatients and diagnostic services and prevention and health promotion services. The community health service for adults provides services to a population of 828,000 people in areas of North West London. Community teams were based in 50 locally based sites, including health centres, GP practices and community hospitals, which span across London Boroughs of Brent, Ealing, and Harrow. The trust provided overall 1,350,700 community appointments in 2014/2015. It included over 447,000 of home visits made by district nursing teams and nurses working at night, 90,000 of musculoskeletal and physiotherapy team interventions, 75,500 podiatry appointments, 20,500 interventions by nutrition and dietetics team and 7,000 provided by the continence and bladder and bowel management teams. The trust employed about 1,950 community healthcare professionals providing out-of-hospital, community-based healthcare services.

On the week of the inspection we visited nine locations across the three boroughs where community teams were based. We accompanied community teams on home visits and spoke with 34 patients and some of their relatives and carers. We also spoke to 91 members of staff which included managers, doctors, nurses, healthcare assistants, allied health professionals such as physiotherapist, podiatrists, and dieticians among others.