You are here

Provider: London North West University Healthcare NHS Trust Requires improvement

On 31 August 2018, we published a report on how well London North West Healthcare NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 August 2018

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

  • We rated safe, effective, caring and well-led as requires improvement, and caring as good. We rated three of the trust’s services as requires improvement, one service as good and two of the services as inadequate. In rating the trust, we took into account the current ratings of the other services not inspected this time.
  • We rated well-led at the trust as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 31 August 2018

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

  • Mandatory training completion rates for nursing and medical staff were not meeting the trust target. There had been insufficient improvement since the previous inspection.
  • Processes and systems were not reliably in place to protect children from abuse and harm. Children on the child protection register were not always identified, and arrangements for vulnerable patients between 16 and 18 years were not robust.
  • Nutrition and hydration assessments were not always completed. We found gaps in feeding charts and the frequency of patient assessment reviews.
  • The trust did not always provide a smooth and timely transition for patients moving between children and adult services. The trust did not have a transition policy and staff felt that guidelines required clarity.
  • The last inspection report included a requirement for the trust to ensure Control of Substances Hazardous to Health (COSHH) assessments were up to date and maintained. We found COSHH assessments on medical wards which were significantly out of date, and ward managers unaware if the assessment had been completed or not.
  • Incidents of mixed sex accommodation breaches in critical care were only recently recorded and investigated appropriately.
  • The service continued to face significant issues with ambulance turnaround which led to high numbers of black breaches.
  • There was a lack of supervision for lower grade doctors and out of hours medical support to the wards in community services.

Effective

Requires improvement

Updated 31 August 2018

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

  • The unplanned readmission to critical care within 48 hours of discharge was worse when compared with results for similar units and nationally.
  • From March 2017 to February 2018, the trust’s unplanned re-attendance rate to accident and emergency within seven days was worse than the national standard of 5% and also consistently worse than the England average.
  • The trust did not comply with the principles outlined in the National Enquiry into Patient Outcome and Death (NCEPOD) classifications around access to emergency theatres.
  • The National Hip Fracture Database audit showed the crude proportion of patients having surgery on the day of or day after an admission was in the worst of 25% of hospitals. The crude overall hospital length of stay fell in the worst 25% of hospitals
  • The trust completion rate for appraisals was 62%, significantly below the trust target of 85%.
  • Staff understanding of patients need for Mental Capacity Act (MCA) and deprivation of liberty(DoL) assessments was variable. Some staff were not able to demonstrate awareness of when MCA and DoL’s assessments would be necessary.

Caring

Good

Updated 31 August 2018

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

  • Results from the Friends and Family Test responses exceeded the trust standard and 100% of respondents reported they would recommend the service in critical care.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients and relatives and could signpost them to services within the organisation as well as external organisations for additional support.
  • Patients and relatives told us staff were respectful and helpful and gave them regular updates.
  • Observations of care showed staff maintained patients’ privacy and dignity on most wards visited, and patients and their families were involved in their care.

Responsive

Requires improvement

Updated 31 August 2018

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

  • Bed occupancy between March 2017 and February 2018 averaged 80% which was not in line with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendation of 70% critical care occupancy.
  • Similar to what we found at the previous inspection, there were issues with patient flow in the urgent and emergency care department. Patients were waiting for long periods of time in the department and experienced delays accessing beds within the hospital.
  • There were six patients at the emergency department who waited more than 12 hours from decision to admit until being admitted
  • Referral to treatment times were not being met for some surgical specialities such as general surgery, colorectal surgery, oral surgery and ear nose and throat.
  • The trust performance for cancelled operations was worse than the England average.
  • Patient records we viewed for people living with dementia did not have the care pathway document completed, or only partially completed. This meant that the individual needs of patients were not being adequately recorded, which may have impacted on the availability of enhanced care.
  • Medical wards at Ealing Hospital followed the trust “+1” escalation policy. This stated that at times of high activity, an additional patient could be cared for in the corridor of the ward. Most staff we spoke with stated that this policy did not provide patients with sufficient privacy or dignity. We reached the same conclusion. Patients were spending long periods in corridors before being provided with a bed in a bay or being discharged.

Well-led

Requires improvement

Updated 31 August 2018

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

  • Patient flow out of critical care was still a significant issue and the unit was an outlier for delayed discharges.
  • Some staff raised concerns about the culture in the urgent and emergency care department. Some staff felt they were not listened to by the trust, especially when it came to decisions about service development.
  • Staff and managers were clear about the challenges their department faced. They explain the risks to the department and the plans to deal with them. However, the risk register did not contain all risks we found within a department.
  • There were no joint governance meetings between the emergency department and the urgent care centre. This meant learning from serious incidents was not shared with the urgent care centre.
  • Staff we spoke on medical wards stated there were not opportunities for engagement at Ealing Hospital, and they did not feel represented or consulted on the future direction of the hospital. Staff from medical wards consistently stated that the lack of engagement was impacting on morale for staff.
  • Staff we spoke with across medical wards were unsure of the future development plans or the vision for the division at Ealing Hospital. Staff stated that the communication from the trust regarding future plans was somewhat unclear, and that this created some anxiety for the staff. Staff we spoke wit also stated they did not feel they had been consulted on the direction of the clinical strategy.
  • Medical staff stated that patient pathways and the delivery of services were redesigned without consulting the medical workforce, which meant that changes did not always include local knowledge on what worked well and what could be improved.
Checks on specific services

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 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.

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 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.