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Provider: North Middlesex University Hospital NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 October 2019

  • We rated safe, effective and responsive as requires improvement.
  • We rated caring and well led at trust level as good.
  • Four of the eight core services were rated as requires improvement and four as good overall.
  • We inspected urgent and emergency services and found that they had improved to good in responsive and well led which gave the service an overall rating of good.
  • We inspected medical care and found that they had maintained the rating from the previous inspection. The ratings for responsive and well led went up to good, caring remained good and ratings for safe and effective remained requires improvement.
  • We inspected services for children and young people and found that they had maintained the rating from the previous inspection. The ratings for effective, caring and responsive remained good and ratings for safe and well led remained requires improvement.

Our full Inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website - www.cqc.org.uk/provider/RAP 

Inspection areas

Safe

Requires improvement

Updated 25 October 2019

  • Urgent and emergency services, medical care and services for children and young people services, that we inspected, were rated requires improvement for safe.
  • Surgical services, which we did not inspect, maintained a good rating for safe.
  • Critical care, maternity, end of life and outpatients, which we did not inspect, maintained a requires improvement rating for safe.
  • We found inconsistencies in stock management of medicines across the services we inspected. We found a significant amount of expired medicines including on the resuscitation trolley and grab bag despite regular checks being completed by staff. Therefore, we were not assured there were comprehensive governance processes in place at ward level.
  • Staff did not always complete all risk assessments for each patient swiftly and updated the assessments to minimise patients’ risk.
  • Staff were not consistently aware of incidents or learning from incidents. Staff did not consistently know what serious incidents, never events, near misses or other incidents had occurred trust-wide.
  • In ED the completion rates for adult immediate life support level 3 for nursing staff and paediatric and adult intermediate and basic life support for medical staff was worse than trust target of 90%.
  • Staff did not complete the necessary post-dose physical health checks after patients received medication for their mental state by rapid tranquilisation.
  • In ED staff managed clinical waste well however we found inconsistency in the management of confidential waste.
  • The medical care service did not always have enough nursing staff of all grades. Some wards carried many nurse vacancies. This meant that bank and agency staff were often used to fill shifts and these staff did not always have the right skill mix for specific medical specialties. Staff told us night shifts were especially challenging as sometimes there were more agency nurses than permanent nurses.
  • We reviewed 24 records across all the CYP areas inspected and found inconsistencies with the quality of documentation.
  • The trust continued to use weekly ‘harm free panels’ to reduce pressure ulcers and improve overall safety awareness amongst staff. Staff found the panels to be educational and helpful.
  • Staff understood how to protect children and young people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Effective

Requires improvement

Updated 25 October 2019

  • Urgent and emergency services and services for children and young people services, that we inspected, were rated good for effective.
  • Medical care services, that we inspected, were rated requires improvement for effective.
  • Surgery, critical care and maternity, which we did not inspect, maintained a good rating for effective.
  • End of life, which we did not inspect, maintained a requires improvement rating for effective.
  • We do not rate effective in outpatients.
  • We found inconsistencies with the quality of documentation. Also, mental capacity assessments were not always completed for patients with deprivation of liberty safeguards.
  • Large number of complaints were not investigated and closed with the complaints policy, which stated complaints should be resolved within 30 days.
  • Although the service had dedicated staff member in place to monitor paediatric and neonatal guidelines, we found many of the paediatric policies were out of date.
  • The refurbished ED had a new facility Horizon unit for patients in ED who need mental health support.
  • During the last inspection we advised the trust to ensure that staff had adequate mental health training including the Mental Health Act. On this inspection, we found the trust had made improvements to address this. Staff in paediatrics were receiving training in Mental Capacity Act (MCA) at the time of the inspection and the trust had started a ‘We can talk’ programme which provided mental health training for all staff.
  • The trust addressed issues since the last inspection with the gastrointestinal bleeding rota. The rota was complete which was available seven days a week, 24 hours a day.

Caring

Good

Updated 25 October 2019

  • Urgent and emergency services, medical care and services for children and young people services, that we inspected, were rated good for caring.
  • Surgery, critical care, maternity, end of life and outpatients, which we did not inspect, maintained a good rating for caring.
  • Patients told us they felt involved in their care plans most of the time.
  • Patients we spoke with felt like their individual needs were understood and respected. Staff respected patients personal, religious, social and culture needs and how they related to patients’ care needs.

Responsive

Requires improvement

Updated 25 October 2019

  • Urgent and emergency services, medical care and services for children and young people services, that we inspected, were rated good for responsive.
  • Critical care, maternity, and outpatients, which we did not inspect, maintained a good rating for responsive.
  • Surgery and end of life, which we did not inspect, maintained a requires improvement rating for responsive.
  • The service planned care to meet the needs of local people and took account of patients’ individual needs.
  • In medical care services the trust took an average of 46.7 days to investigate and close complaints; In ED the trust took an average of 57.4 days to investigate and close complaints; this was not in line with their complaints policy, which states complaints should be resolved within 30 days. 
  • The trust did not meet the Royal College of Emergency Medicine recommendation that patients should not wait more than one hour from time of arrival to receiving treatment.
  • From January to December 2018, the average length of stay for medical non-elective patients was 7.8 days which was higher than the England average of 6.2 days.
  • There were clear pathways to navigate patients through the ED. Based on staff assessment at streaming and triage,patients could be directed to different areas such as the fit zone, sit to treat and the UCC.
  • From April 2018 to March 2019, no patients waited more than 12 hours from the decision to admit until being admitted, which was in line with the Royal College of Emergency Medicine recommendation.
  • The average length of stay for medical elective patients from January to December 2018 was 5.4 day which was lower than the England average of 6.0 days. This was an improvement from our last inspection when it was 7.7 days.
  • There was timely access to children and young people services and most specialities were meeting referral to treatment targets (RTT).
  • Psychological support was available for patients with mental health support needs as staff could refer patients to the mental health liaison team easily.
  • The hospital play therapist provided a comprehensive programme of play support to children across all paediatric areas.
  • The hospital provided a wide variety of child friendly food and snacks and there were specific menus for children and young people. The menus included options for specific cultures, tastes and specific needs.

Well-led

Good

Updated 25 October 2019

  • Leadership at trust level, that we inspected, was rated good.
  • Urgent and emergency services and medical care, that we inspected, were rated good for well led.
  • Services for children and young people services, that we inspected, were rated requires improvement for well led.
  • Surgery, critical care, maternity, which we did not inspect, maintained a good rating for well led.
  • End of life and outpatients, which we did not inspect, maintained a requires improvement rating for well led.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service  promoted equality and diversity in daily work, and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • The service had engaged with the patients, staff and stakeholders in the re-design of the refurbished adult emergency department (ED) and implementation of the ED action plan.
  • Staff in the care of elderly wards developed a three-year strategy for dementia awareness which was launched in 2018. It included re-invigorating use of the dementia care bundle, training all new clinical staff to tier two level in dementia awareness, continue to participate in the national audit for dementia and to learn from its outcomes.

  • There was a new governance team within the division which has resulted in fewer out-of-date actions for serious incidents. Outstanding actions for serious incidents were monitored at a divisional level through regular meetings with the governance manager and at the governance sign-off panel.

  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • During the last inspection, the service had recently introduced a CYP board but regular meetings were not taking place. On this inspection, we found this had improved as meetings were taking place quarterly and the minutes reviewed showed actions were being completed.

  • Although the divisional leaders had good oversight on most risks in the division, not all risks identified at the time of inspection were noted on the risk register. For example, there was limited oversight of medications management on the ward.
  • During this inspection we were told about the backlog for discharge summaries of which the oldest dated back to October 2018. Although the trust submitted information after the inspection to confirm the backlog had been cleared,we were not assured at the time of the inspection that appropriate risk assessments had taken place as only a 10%sample was reviewed with no target date set to clear the back log.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 25 October 2019

Our rating of stayed the same. We rated it 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. The approach to identifying and realising efficiency opportunities was not yet embedded across the organisation.

NHS Improvement are currently planning to assess all non-specialist acute NHS trusts and foundation trusts for their Use of Resources assessments.

The aim of the assessment is to improve understanding of how productively trusts are using their resources to provide high quality and sustainable care for patients. The assessment includes an analysis of trust performance against a selection of initial metrics, using local intelligence, and other evidence. This analysis is followed by a qualitative assessment by a team from NHS Improvement during a one-day site visit to the trust.

Combined rating

Combined rating summary

Requires improvement

Updated 25 October 2019

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

Our combined rating for Quality and Use of Resources is awarded by combining our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating, using the ratings principles included in our guidance for NHS trusts.

This is the second time that we have awarded a combined rating for Quality and Use of Resources at this trust. The combined rating for Quality and Use of Resources for this trust was requires improvement, because:

  • We rated safe, effective, responsive, and as requires improvement; well led and caring as good.
  • We took into account the current ratings of the five core services not inspected at this time. Hence, four services across the trust are rated overall as requires improvement, and four services are rated good.
  • The overall ratings for the hospital remained the same.
  • The trust was rated requires improvement for Use of Resources.