The Care Quality Commission
  • Organisation
  • SERVICE PROVIDER

London North West University Healthcare NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

9, 10 and 11 February 2022 and 8 and 9 March 2022

During a routine inspection

London North West University Healthcare NHS Trust runs Northwick Park Hospital, Ealing Hospital, Central Middlesex Hospital, St. Mark’s Hospital, and a range of community services across its local boroughs.

The trust employs more than 9,000 clinical and support staff and serves a diverse population of approximately one million people. The trust was last inspected in 2019 and was rated requires improvement overall.

The trust provides, urgent and emergency care, medical care, surgery, critical care, maternity, gynaecology, children and young people services, end of life care and outpatient services. The trust provides a range of community services including: dental services, sexual health services, paediatric audiology, musculoskeletal specialist and end of life care.

We inspected medical care and surgery core services at Northwick Park Hospital and Ealing Hospital on 9, 10 and 11 February 2022. Our inspection was unannounced to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received.

We also carried out an announced well led inspection of the trust on 8 and 9 March 2022. We rated the trust overall requires improvement for well led.

We issued requirement notices to the trust for medical care at Ealing Hospital. Details of these can be found under the Musts in the Areas for Improvement section.

We rated medical care at Ealing Hospital requires improvement overall because:

  • The service did not always have enough nursing and support staff to keep patients safe. The service was mitigating the staffing risks during twice daily safety huddles. However, there was a 22% vacancy rate for band 5 nurses.
  • We found a drawer in the catheterization labs with a range of out of date equipment and a monitor in the catheterization labs which did not have a servicing date. We also found out of date equipment on a resuscitation trolley in the acute medical unit (AMU). There was a risk that staff could inadvertently use out of date equipment.
  • On Ward 6 South, we found discrepancies in the use of Waterlow scoring. This is a tool used for pressure area risk assessment. This meant that patients’ level of risk of developing pressure ulcers may not be accurately assessed and timely actions taken.
  • Medical staff mandatory training in resuscitation was 72.2%. This was less than the 80% standard. This meant some staff may not have up to date skills in resuscitation.
  • There was a lack of seamless services between the trust and other NHS providers of mental health care for patients temporarily on an acute ward waiting for transfer to a mental health facility. There was a risk of delays in patients care and treatment as a result of a lack of clarity about the responsibility for clinical decision making whilst the patient was an inpatient in the acute hospital.
  • Due to a shortage of registered mental health nurses, the service had a policy of cohorting patients assessed as requiring enhanced observations or one to one care in a bay. However, we saw cohorted bays were not always observed by staff. There was a risk to patients if they were assessed as requiring enhanced observations or one to one care and this was not provided in accordance with their assessed needs at all times.
  • The patient electronic record could only display a maximum of two patient needs on screen. This had led to staff not placing a magnetic identifier for the confusion care pathway above a patient’s bed. The lack of a visual prompt for staff led to a patient not receiving a scheduled review after 72 hours. There was a risk that without a visual prompt, staff working on the bay may not be aware of patients’ needs, unless they fully consulted patients’ electronic records.
  • Records were not always stored securely. We found a patient’s ‘adult inpatient care needs assessment’ booklet next to the reception area in the acute medical unit (AMU). We saw a computer in the endoscopy reception which was unattended and not locked. There was a risk that unauthorised people could have accessed confidential patient information.
  • Staff told us the trust’s senior executive team and some ward leaders were not visible at Ealing Hospital, as they were based off-site at Northwick Park Hospital.
  • The signage enabling patients and visitors to navigate around the hospital was confusing for patients and visitors.
  • Staff on the Older Persons Short Stay Unit (OPSSU) were using a printed copy of the infection prevention and control policy. There was a risk that staff may use an out of date policy instead of using the most up to date policies on the trust’s intranet.
  • We saw a cracked shower chair and shower chairs with chipped enamel on the OPPSSU. This could pose a patient safety and infection control risk as microorganisms can thrive in cracked surfaces.
  • Domestic staff on the acute medical unit (AMU) was not aware of control of substances hazardous to health regulations (COSHH), including the trust’s policies and guidance on COSHH.
  • The trust was a large provider of cancer services but staff told us they did not have a local cancer strategy. This meant there was a potential risk that cancer services were not aligned to local commissioning and provision of services to support people during and after their cancer treatment.

However:

  • The service managed safety incidents well and lessons were learnt from them.
  • Staff gave patients enough to eat and drink and gave them pain relief when they needed it.
  • Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to information.
  • Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to raise complaints.
  • Staff understood the service’s vision and values, and how to apply them in their work and all staff were committed to improving services continually.

We rated surgery at Ealing Hospital good overall because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service was not fully compliant with DHSC Health Technical Memorandum 07/01 and the Health and Safety Executive Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 in relation to sharps waste.
  • The service had persistently high vacancy rates. At the time of our inspection the service had vacancies for 36 whole time equivalent (WTE) nurses (12%). However, the number of nurses and healthcare assistants matched the planned numbers and vacancies were filled with bank and agency staff.

We rated medical care at Northwick Park Hospital requires improvement overall because:

  • Indications of patients having venous thromboembolism (VTE) prophylaxis were not always specified on the prescription charts we viewed. This meant staff reading the prescription may not have information on patients VTE status.
  • Records were not always stored securely. We saw records cupboards were not locked when not in use on Darwin ward. This meant unauthorised people may have been able to access patients’ confidential information.
  • All staff did not consistently receive feedback from incidents. One member of staff on Darwin ward told us they were not aware of an incident that had happened on the ward.
  • We saw a ‘do not attempt cardiovascular resuscitation’ (DNAR) form on Herrick ward where it was unclear whether the patient’s DNAR had been cancelled. Staff were unable to tell us the reasons for the cancellation.
  • We saw a sharps bin in the discharge lounge stacked on top of another sharps bin. The sharps bin was open and had not been signed or dated. There was a risk of the sharps bin being knocked over and potentially causing harm to patients or staff.
  • We saw a wheelchair with broken foot straps on the discharge lounge. There was a risk that staff may have used the wheelchair, even though staff had reported the wheelchair to the medical engineering department.
  • The hospital was not meeting national standards in some areas of the myocardial ischaemia audit.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risks well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

We rated surgery at Northwick Park Hospital good overall because :

  • The service managed staffing well and maintained consistent levels of training and appraisals despite pressures on the service caused by COVID-19.
  • Services were demonstrably multidisciplinary, and staff had established a wide range of new working opportunities to support patient outcomes.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Pharmacy cover on wards was limited due to short staffing. This meant pharmacists could not always join ward rounds and could not always review prescriptions daily.
  • The service did not have a coherent, overarching vision for what it wanted to achieve. Individual departments and divisions developed their own strategies in the absence of a trust-level approach.

We carried out a well led inspection of the trust on 8 and 9 March 2022.

We rated well led for the trust as requires improvement overall because:

  • We found that issues such as lack of adequate mental health provision for patients in crisis were a regular feature although the trust recognised the need to urgently address this issue.
  • The trust Board was not representative of the population it served. However, we noted the trust had developed equality, diversity and inclusion strategies.
  • The current trust strategy was in need of refreshing and updating to demonstrate more clearly its purpose within the integrated care system. The new chief executive recognised the need to renew the strategy linking clinical, finance, workforce, community and estates strategies.
  • Despite a strengthened governance structure, the trust governance team was under-resourced, leading to late and incomplete information both externally and internally to the board.
  • Further work was needed on the trust board assurance framework to ensure that actions were specific, measurable, actionable, relevant and timely (SMART).

However:

  • The executive board and non-executives had developed in cohesiveness and visibility with a strong emphasis on improvements in performance and embeddedness.
  • We noted improved clinical leadership and a greater involvement of the medical workforce in the ongoing work of the trust.

02 July to 15 August 2019

During a routine inspection

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.

5th June to 7th June 2018

During a routine inspection

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.

5th June to 7th June 2018

During an inspection of Community dental services

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.

5th June to 7th June 2018

During an inspection of Community health inpatient services

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.

19 - 23 October 2015; unnanounced visits 3 - 7 November 2015

During a routine inspection

London North West Healthcare NHS Trust is one of the largest integrated care trusts in the country, bringing together hospital and community services across Brent, Ealing and Harrow. Established on 1 October 2014 from the merger of North West London NHS Trust and Ealing Hospitals NHS Trust, and employing more than 8,000 staff it serves a diverse population of approximately 850,000.

The trust runs Northwick Park Hospital, St Mark’s Hospital, Harrow; Central Middlesex Hospital in Park Royal and Ealing Hospital in Southall. It also runs 4 community hospitals – Clayponds Rehabilitation Hospital, Meadow House Hospital, Denham unit and Willesden Centre - in addition to providing community health services in the London Boroughs of Brent, Ealing and Harrow.

At the end of the financial year 2014-15 the trust had a deficit of £55.9 million.

We carried out this inspection as part of our comprehensive acute hospital inspection programme for combined acute hospital and community health based trusts. We inspected Northwick Park Hospital, Ealing Hospital and the following community health services: community services for adults; community services for children, young people and families; community inpatient services; community services for end of life care and community dental services.

The announced part of the inspection took place between 19-23 October 2015 and there were further unannounced inspections which took place between 3-7 November 2015.

Overall we rated this trust as requires improvement. We rated acute end of life services as good. We rated the following acute services provided by the trust as requires improvement: Urgent and emergency care, medical care including care of the elderly, surgery, critical care, maternity and gynaecology, acute services for children and outpatients and diagnostic imaging.

We rated the following community services as good: services for children, young people and families, services for adults, and end of life care. We rated the following community services as requires improvement: community inpatient services and community dental services.

We rated caring at the trust as good, but safety, effective, responsive and well-led as requires improvement.

Our key findings were as follows:

  •     The merger of the trust had been protracted and subject to delay. This had had a negative effect on performance and leadership.
  • We saw overall disappointing progress in merging systems and processes at the trust. To most intents and purposes Ealing and Northwick Park appeared to be operating as separate entities and community health services appeared disengaged from the rest of the trust.
  • There appeared to be substantial duplication of support functions at both main sites. There appeared to have been lack of control over spend of administrative, non-staff, and nursing staffing budgets with little rationale over nursing numbers on wards.
  • A new chief executive had recently been appointed earlier in 2015. She was in the process of building a new executive team and by the time of our inspection only one member of the previous substantive executive team was in post. This meant that the new executive team were in the process of getting to grips with their respective functions.

  • All staff working at the hospital were dedicated, caring and supportive of each other within their ward and locality. There was a high degree of anxiety and uncertainty borne out of the merger and also fears of service removal and potential job losses particularly at Ealing Hospital.

    • There appeared to be a lack of firm information provided to staff about the effects of Shaping a Healthier Future - to reconfigure services in north west London - despite the chief executive holding regular briefing session. This added to staff anxieties.

  • We saw several areas of good practice or progress including:

  •     a newly opened emergency department at Northwick Park

  • a good service overall for end of life care particularly at Ealing and in the community health service.
  • a refurbished and child friendly ward for children's care called Jack's Place.
  • caring attitudes, dedication and good multi-disciplinary teamwork of clinical staff.
  • good partnership working between urgent and emergency care  staff and London Ambulance staff.
  • good induction training for junior doctors.
  • research projects into falls bundles, stroke trials and good cross site working in research.
  • Staff told us there were good opportunities for training and career development.
  • We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.
  • The play specialists in services for children demonstrated how they could make a difference to the service and its environment in meeting the needs of the children and young people. This included an outstanding diversional therapy approach for children and young people, which was led by the play specialist and school tutor.
  • evidence of good antibiotic stewardship, particularly at Ealing pharmacy, with regular reviews of need; and the roll out of drug cabinets across certain parts of the trust with secure finger print access. 
  • patient satisfaction data collected by iPAD in one pharmacy location
  • an increase in pharmacy cover at one community unit (Denham) enabling  reduced medicines related risks.
  • The availability and input of dedicated psychologists as part of the multidisciplinary team at the Willesden Centre for Health and Care provided patients with improved long term outcomes.
  • The virtual ward operating in the Harrow community, with input from clinicians based at Northwick Park Hospital, supported patients who have long term chronic conditions to stay in their own homes and reduce hospital admissions.

However, there were also areas of poor practice where the trust needs to make improvements:

  • There was limited sparse medical cover on eHDU out of hours and at weekends, which meant there was frequently no doctor immediately available on the unit. Consultants responsible for eHDU and Dryden HDU were not intensivists and processes for escalating surgical patients were unclear. Additionally, less than the recommended proportion of eHDU nurses had critical care qualifications.
  • There was a lack of expert support from consultant radiologists at weekends, which impacted on the accuracy of clinical diagnosis being achieved. Risks related to patient safety and service delivery had not always been identified and agreed timelines for resolution had not always been identified. This led to scans being reported by specialist registrars (SpR’s) and amended by consultants on Mondays. They reported an apparent 25% amendment rate, with missed pathologies.
  • Surgical staff were not always reporting incidents. Consultants and other surgical staff told us they did not routinely complete incident reports for issues or concerns as the forms were said to be “too laborious” and nothing was done to change the problems highlighted.
  • Access to services and patient flow through the ED at Northwick Park to wards in the hospital was poor and patients experienced long waits in the HDU and assessment unit areas.
  • The performance dashboards for ED showed that compliance with achieving the mandatory targets, including the 4 hour treatment target, had been poor over the previous 12 months.
  • The emergency department participated and performed poorly in the College of Emergency Medicine audits on pain relief, renal colic, fractured neck of femur and consultant sign-off; and there were no clear action plans drawn up by the department indicating what actions were taken as a result of the audits.
  • Compliance with safeguarding training was poor particularly among medical and dental staff.
  • The trust target was to have 95% of staff having completed mandatory training. Trust data, as of March 2014 – July 2015, showed compliance with the target was poor in many areas.
  • We saw examples of poor infection control practice such as linen left on a bin when a nurse was putting gloves on, staff wearing nose rings and hooped earrings that were not covered and name badges that were made of paper.
  • There was a poor environment on the stroke wards at Northwick Park Hospital.
  • There were poor handovers between ED and the wards at Northwick Park with MRSA screening and medicines management not always clear or complete in the handovers.
  • Nutrition and hydration was poorly managed on Northwick Park medical wards with poor assessments, choice of food and support for those that needed it.
  • In surgery, several groups of patients had no formally defined pathway, which impacted on their safety.
  • The National Bowel Cancer Audit for 2014 indicated that data completeness for patients having major surgery was poor at 30%, compared with an England average of 87%.
  • There was a lack of formal escalation process for surgical patients who deteriorated on eHDU aside from the support provided by the outreach team.
  • Handovers to the consultant taking over care of eHDU patients on a Monday morning was completed by the weekend on call anaesthetic registrar rather than a consultant to consultant handover. Staff highlighted this as a concern as there was a risk important information could be missed.
  • In maternity and gynaecology, there were safety concerns  related to midwife shortages, not having safety thermometers on display and some staff reporting that they did not get feedback after reporting incidents. Staff raised concerns about one midwife covering the triage and observation areas at same time during times of pressure.
  • We were concerned that some of the risks we identified were not on the risk register, such as the room used for bereaved women on the delivery suite at Northwick Park Hospital with a lack of sound proofing from the ward.
  • Staff on wards outside of the end of life team had a poor understanding of end of life care and the trust LDLCA - Last days of life care agreement. Concern was raised that doctors and nurses on the wards did not recognise deteriorating and dying patients.
  • Signage for outpatient clinics was in some cases poor and or stopped short of providing clear directions for patients.
  • In outpatients and diagnostic imaging, poor patient experience was due to overbooking clinics, lack of capacity in outpatients and lack of availability of medical records in time for clinics.
  • In OPD, we were concerned incidents were not always appropriately recognised, escalated or investigated and lessons learned were not widely shared.

  • The pre-inspection information identified some concerns around consultant cover in haematology. Some of the facilities were not suitable to meet the needs of patients, for example, the haematology day care service.

  • At Ealing ED we had some concerns around the care and treatment of children. There were insufficient children’s nurses employed to ensure they were consistently available at all times. Not all adult-trained staff had been trained in paediatric life support.

  • There were some aspects of poor morale of staff on the medical wards at Ealing.

  • There were some concerns with cleanliness and the state of repair or servicing of equipment and fixtures on medical wards at Ealing.

  • Audits showed hand hygiene was a concern with some wards either not submitting audits or scoring less than 90%.

  • All types of therapy visits on wards were unscheduled meaning patients could miss their therapy if they were away from their bed or in pain.
  • We were concerned at the lack of provision for dementia care and inconsistent assessment of patients failing to direct them to a dementia friendly wards at Ealing. However, patients living with dementia were not specifically triaged to be admitted to this ward and some aspects of the ward were not dementia friendly.
  • In surgery at Ealing there was inadequate stock of some “bread and butter” items of equipment, such as endoscopic gastro-intestinal cartridges.Sets came back from the decontamination unit incomplete.
  • At Ealing OPD, the outpatients risk register identified five issues of concern including lack of capacity, temperature in the women’s clinic environment, lack of availability of complete medical records, overbooking clinics and absence of a dedicated plaster sink in the plaster room.
  • Trust wide there were temperature control issues across sites in rooms where medicines are stored.
  • The trust was not compliant with Fit and Proper Persons regulations requirements.
  • The above list is not exhaustive and the trust should address these and the rest of the issues outlined in our reports in its action plan.

Importantly, the trust must:

  • provide expert support from consultant radiologists at weekends.
  • ensure effective processes for reporting, investigating and learning from incidents, and ensure all staff always report incidents.
  • provide sufficient trained and experienced medical and nursing cover on eHDU at all times including out of hours and at weekends to ensure  immediate availability on the unit.
  • We issued the trust with a Section 29 (A) warning notice in relation to the three " must do" items listed immediately above requiring substantial improvements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

19 - 23 October 2015; unannounced inspections between 3 - 7 November 2015

During an inspection of Community health services for adults

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.

19/10/2015

During an inspection of Community end of life care

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.

19/10/2016

During an inspection of Community health services for children, young people and families

  • 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.

19 - 23 October 2015; unannounced inspections between 3 - 7 November 2015

During an inspection of Community health inpatient services

Overall, the service provided by London North West Hospitals NHS Trust for community health inpatient services requires improvement because;

  • The Denham unit did not have enough nursing staff to keep people safe all the time. There were not enough full time registered nurses which meant too many agency nurses were being used.

  • The community hospitals were not always ensuring that patients with memory needs were being identified and their care was not being adapted to meet their individual needs.

  • Services, processes and standards were variable across the three community hospitals. There was no single clear process of management and clinical governance. There was no clear trust plan for developing the service.

  • The trust had good systems and processes in place for keeping patients safe. They ensure that patients are well enough to be cared for in the unit and that if patients deteriorate this is identified and the patients were transferred to an acute hospital if needed.

  • Community health inpatient 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.

  • Multidisciplinary teams worked well together to provide patients with good outcomes. In particular, physiotherapists and occupational therapists were well integrated and showed leadership in ensuring patients achieved their recovery goals.

  • All the patients and families we spoke with were very positive about the care they had received in the community hospitals. One person told us, “ They have been great. I have got all the care I needed”. Another said, “ The nurses are nice and they have been trying to get me well enough to go home”.

  • Community services 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 who were dealing with difficult circumstances.

  • Staff generally reported good supportive leadership at local level and we met some committed and enthusiastic managers who were working hard to develop and improve their own specific services.

19 - 23 October 2015; unannounced inspections between 3 - 7 November 2015

During an inspection of Community dental services

We gave an overall rating for the community dental service of requires improvement because:

  • The service did not consistently identify or address potential safety issues. This included risks to patient safety and the secure storage of confidential patient records. The monitoring of safety systems required improvement, as illustrated by our finding of nitrous oxide cylinders that were past their expiry date. There was limited use of systems to report and share learning from incidents and near misses.
  • Systems to manage patient records required improvement. There was inconsistent use and availability of software and IT equipment. There were gaps in visible management and support arrangements for staff as managers were based at a different location to the services and had to spread their time across five locations.
  • There was a long waiting time to access specialist endodontic and periodontic services. The service did not take into account the needs of the local population when planning services, as there were no leaflets available in languages other than English, despite there being a sizable section of the local population with English as a second language.
  • Trust-level management was not visible. Staff were not aware of the trust’s vision and strategy.
  • Risks were not always managed appropriately or in a timely way. For example, staff raised an issue with a door as a risk to patient safety, but action was only taken after a child sustained an injury. Management presence at the locations was limited. Staff did not always feel actively engaged or empowered and felt remote from the trust.

However,

  • We found staff to be caring and passionate about their work. They were hard working, committed and were proud of the service they provided. Staff spent time listening to and talking with patients, or those close to them. They treated people with respect and kindness. Staff communicated with patients in a way they could understand and enabled them to manage their own oral health and care when they could.
  • We observed good practice and procedures in place for cleanliness, hygiene and infection control.
  • We found that staff had the knowledge, skills and competence to carry out their roles and responsibilities effectively.
  • The service was responsive to the needs of patients with physical disabilities, for example hoists were available and staff visited patients who were unable to get to the clinic.
  • Most staff we spoke to felt well supported by their line managers within the service.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.