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Provider: North Middlesex University Hospital NHS Trust Requires improvement

Reports


Inspection carried out on 02 July to 15 August 2019

During a routine inspection

  • 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 


CQC inspections of services

Inspection carried out on 22 May 2018

During an inspection to make sure that the improvements required had been made

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 three of the trust’s eight services as good and five as requires improvement.
  • We rated well-led for the trust overall as 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.

Inspection carried out on 20 - 23 September 2016

During a routine inspection

This was the second comprehensive inspection of The North Middlesex University Hospital NHS Trust under the Care Quality Commission (CQC) methodology for inspecting hospitals.

We carried out an announced inspection between 20 and 23 September 2016. We also undertook unannounced visits during the following two weeks.

We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, End of life Care, Services for Children and Outpatients and diagnostic services.

We have rated the hospital trust as Requires Improvement overall.

Our key findings were as follows:

Safe

  • There was improved clinical governance and leadership of Urgent and Emergency care and oversight of the ED at a trust level.
  • There was an increase in consultant and middle grade doctors in the ED and an increase in night time medical cover, since our last inspection.
  • We found full utilisation of the Royal College of Paediatrics and Child Health (RCPCH) Situation awareness for everyone (SAFE) programme and the use of the MIDSEY huddles optimised patient safety and the early detection of deteriorating patients.
  • Actions from a previous never event in surgery actions had not been fully implemented.
  • There was an inconsistent approach to the sharing of learning from incidents.
  • Safeguarding training level 2 adults and children was below target level for both nurses and doctors.
  • None of the nursing staff working on the surgical assessment unit completed advanced life support training.

Effective

  • Patients were offered pain relief in a timely manner.
  • Patients had access to an immediately available, fully staffed emergency theatre and a consultant on site at any time of the day or night.
  • Unplanned readmission rates for critical care within 48 hours of discharge were better than the national average.
  • The unplanned re-attendance rate to ED within seven days was consistently worse than the national average.
  • Multi-disciplinary work between the ED and other specialisms was not yet fully embedded
  • The hospital did not comply with the national guidance which recommends that the ratio of recovery beds to operating theatres should not be less than two.
  • There was no out of hours cover for the Specialist Palliative Care Team (SPCT). This was not compliant with NICE guidelines.
  • Unplanned readmission rates for critical care within 48 hours of discharge were better than the national average.

Caring

  • In most areas of the trust we observed staff treating patients and their relatives with compassion and kindness.
  • Staff demonstrated a good understanding of the importance of privacy and dignity and maintained this for patients and their relatives.
  • Bereavement officers were very caring and helpful towards bereaved families and went the extra mile to assist with making appointments for the relatives with the authorities to register the death of a loved one.
  • In maternity services we observed that privacy and dignity were not always protected and staff did not always address patients in the appropriate manner.
  • The results for the NMUH CQCs Maternity Survey of Women’s Experience of Maternity Services 2015 were worse than other trusts for all indicators for the labour and birth and staff during labour, and birth section of the report. Results were about the same as other trusts for care in hospital after birth.
  • Once the initial holistic assessment had taken place by the Specialist Palliative Care Team, there was no counselling support offered to patients. If they required this service, they had to request referral and wait to be accepted and seen by the psychologist.

Responsive

  • The rate of cancelled operations from April 2014 to March 2016 was consistently lower than the England average. If cancelations occurred patients were treated within the subsequent 28 days.
  • Changes implemented to the surgical assessment unit and introduction of the ‘hospital at home’ team helped to manage the flow within the hospital and ensure patients were treated in an optimal environment.
  • There were effective systems to ensure patients’ individual needs were identified and met by staff. This included an electronic ‘flagging’ system to identify patients with additional support needs and personalised ’10 things about me’ assessments.
  • The trust was meeting national waiting times for diagnostic imaging within six weeks and outpatient appointments within 18 weeks for incomplete pathways.
  • The ED was not meeting the target time to admit, transfer or discharge 95% of patients within 4 hours of their arrival in the ED.
  • The ED was not meeting the ambulance handover target time of 15 minutes, however performance against this was being actively monitored.
  • Staff did not have specialist knowledge of the needs of patients who lived with dementia or patients with a learning disability.​ 

    There was no children’s learning disabilities nurse and patients were not identified or flagged on admission.

  • Patients told us it was often very difficult to get through on the appointments telephone helpline to either change an appointment or seek advice.

Well Led

  • Staff felt positive about the changes in the trust’s senior management team and said communication and organisational culture was improving.
  • A new management team had been introduced to the ED since our last inspection. Staff reported that they felt supported in their roles by the new departmental management team. There was clear nursing and medical leadership visibility with the department and staff felt able to highlight issues to them.
  • Staff expressed some uncertainty about the implications for them in relation to the newly developed relationship with another trust.
  • Clinical service risk registers did not fully indicate how risks were mitigated and who was responsible for implementing actions.
  • In maternity several members of staff described a culture of bullying and discrimination.
  • There was no clear End of Life Care (EoLC) strategy. At the time of our inspection there was no identified non-executive director appointed for oversight of EoLC within the trust despite this having been brought to their attention during our last inspection in 2014. We have since been informed that a non-executive director had filled this position in June 2016.

We saw several areas of outstanding practice including:

  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • Outpatient and diagnostic services had strong leadership. Staff were inspired to provide an excellent service with the patient at the centre.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.

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

Importantly, the trust must:

  • The trust must code their complaints correctly to reflect palliative and end of life care complaints.
  • The trust must send out bereavement surveys to the relatives of patients who have died within the hospital.
  • The trust must produce and ratify an end of life care strategy.

Importantly, the trust should:

  • Ensure learning from incidents is more robust and shared with all staff.

  • Ensure that all medicines and instruments associated with a resuscitation are disposed of safely afterwards.
  • Ensure the renewal of advanced paediatric life support (APLS) certificates of those doctors and consultants whose certificates had expired
  • Improve mandatory training levels for medical and nursing staff.
  • Improve safeguarding adults level 2 training for medical and nursing staff.
  • Improve safeguarding children level 2 training for medical and nursing staff.
  • Improve hand hygiene levels to ensure consistency especially amongst medical staff.
  • Ensure medical and nursing staff are fully trained and able to identify and support the needs of patients living with dementia.
  • Ensure medical and nursing staff are fully trained and able to identify and support the needs of patients with learning disabilities.
  • Improve appraisal rates of nurses.
  • Ensure all actions in response to the never event are fully implemented.
  • To analyse causes for higher than the national average mortality rate as suggested by the bowel cancer and the national hip fracture audit data.
  • Carry out an audit of the stillbirth rate for the period Jan – Dec 2016 and develop an action plan to address themes.
  • Provide one to one care in labour to all women.
  • Replace all damaged equipment in Emergency Gyanecology Unit and triage.
  • Monitor and report VTE compliance
  • Monitor the temperature of medicines storage
  • Carry out a review of culture within maternity and use tools such as ‘walk in my shoes’.
  • Review waiting times in triage and develop an action plan to address themes.
  • Ensure mandatory training and multidisciplinary intrapartum care training targets are met.
  • Display cleaning schedules or checklists all clinical areas.
  • Ensure all staff observe the ‘bare below the elbows’ policy.
  • Ensure patients have a named midwife.
  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • Ensure there are appropriate processes and monitoring arrangements in place to improve the 32 and 61 day cancer targets in line with national targets.
  • Ensure there is improved access for beds to clinical areas in diagnostic imaging.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3-6 June 2014 and 23 June 2014

During a routine inspection

We carried out this comprehensive inspection of the North Middlesex University Hospital NHS Trust as part of the Care Quality Commission's (CQC) new approach to hospital inspections. The trust had been identified as lower risk (band 5) on the Care Quality Commission’s (CQC) Intelligent Monitoring system. We carried out an announced inspection of North Middlesex University Hospital between 3 and 6 June 2014 and returned to the trust to areas where we had concerns on 23 June 2014. These areas of concern included outpatients and, in particular, the ambulatory care and day hospital service and the access to medical records department.

The North Middlesex University Hospital NHS Trust serves the boroughs of Enfield, Haringey, Barnet, and surrounding areas, with a local population of more than 350,000. The trust has a multidisciplinary accident and emergency (A&E) department and urgent care centre (UCC) in a recently built £123 million hospital building that opened to patients in June 2010. The trust provides a full range of adult, older people’s and children's services across medical and surgical disciplines. The trust’s specialist services include stroke, HIV/AIDS, cardiology (including heart failure care), haematology, diabetes, sleep studies, fertility and orthopaedics.

The trust had recently taken over services from the accident and emergency (A&E) department at nearby Chase Farm Hospital, and this has had significant impact on all the services at the trust. The BEH (Barnet, Enfield and Haringey) strategy outlines the health reconfiguration of services, including the transfer of services from Chase Farm Hospital (Enfield) and Barnet Hospital (Barnet) to North Middlesex University Hospital (Haringey), and other potential moves that do not affect this trust. All staff spoke about the Barnet Enfield and Haringey strategy and how it had affected the services they provide by increasing the workload and adding pressures to care for patients. We saw significant increases in patient numbers across the board from the A&E department through the wards and to outpatients and within the end of life pathway, including the mortuary.

The trust has two locations registered with CQC – North Middlesex University Hospital located in the Enfield local authority area and St Ann’s Hospital in the Haringey local authority area. We did not inspect St Ann’s Hospital on this occasion as it did not have inpatient beds and the vast majority of activity undertaken by the trust is at the North Middlesex University Hospital site.

We inspected all the main departments of North Middlesex University Hospital: accident and emergency, including the urgent care centre; medical wards, including care of the elderly; surgical wards and theatres; critical care; maternity and family planning; services for children and young people; end of life care and outpatient departments.

Overall, this hospital requires improvement.

We rated it good overall in the following departments: surgery, critical care, maternity and family planning, and services for children and young people. However, we rated accident and emergency, medical wards, end of life care and outpatients as requiring improvement.

While we rated the hospital good overall in caring and effectiveness, it requires improvement overall in providing safe care, being responsive to patients’ needs and being well-led. The trust had commissioned a report into its governance systems by KPMG in December 2013 and we found that the recommendations made in the report required further embedding for the trust to assure itself that patients are receiving safe, effective and responsive care.

Our key findings were as follows:

  • Most feedback from patients, carers and relatives was positive in relation to the care being provided by the hospital.
  • The hospital staff had fully embraced the increased workload brought about by the reconfiguration of hospital services under the Barnet, Enfield and Haringey (BEH) strategy and the closure of Chase Farm Hospital accident and emergency department. However, services were struggling with this additional workload and further work is required to ensure that the quality of service does not suffer as a result of the number of patients now being treated.
  • While the hospital had achieved much in absorbing increased numbers of patients, its infrastructure of staffing levels, training provision, complaints handling and governance had been stretched, and there had been an underestimate of the resources needed to maintain services at the current level. The trust had failed to respond adequately to these issues.
  • The improved environment with the extensive rebuilding programme had undoubtedly enhanced patient experience.
  • We saw examples of good practice in most areas and of dedicated care in the maternity department (despite overstretched resources), surgery, critical care and services for children and young people.
  • We saw many examples in every area of the hospital of staff giving treatment in a caring and compassionate way.
  • In surgery, the clinical teams coped well with the pressures of high demand by working with commitment and flexibility while maintaining a calm and professional atmosphere.
  • We saw examples of good multidisciplinary working contributing to areas of good practice (for example, the use of the ‘five steps to safer surgery’ procedure and enhanced treatment and recovery pathways).

We saw several areas of outstanding practice, including:

  • The trust had developed partnership working with local primary care providers to address the poor use of primary care services by the local population. This included regular teleconferences with local authorities and other services to tackle frequent inappropriate visits to the trust by the same patients, and delayed transfers of care.
  • The trust had recently launched a health bus to inform the local community about the availability of, and access to, primary care services, and to offer basic health checks to people in its catchment area.
  • The trust had developed an in-house database to improve the quality of care to patients with HIV; it was marketing this database to other providers.
  • The department had an innovative pathway for patients with sickle cell conditions. Staff displayed a high level of knowledge in diagnosing and treating this specialism.

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

Importantly, the trust must:

  • Take action to ensure that the outpatients department is responsive to the needs of patients in that appointments are made in a timely manner, those with urgent care needs are seen within the target times, cancellations are minimised and complaints are responded to.
  • Take action to improve its training – both mandatory and non-mandatory – and its recording and administration of training records and training renewal requirements.
  • Ensure that the provision of ambulatory care maintains people’s privacy and dignity.

In addition the trust should:

  • Review the needs of people living with dementia across the hospital to ensure that they are being met.
  • Review the use of the decontamination room in A&E, which poses a contamination risk to the rest of the hospital. This was closed during our inspection following highlighting our concerns.
  • Ensure that medicines are stored safely in A&E and that systems for recording take home medication are consistent throughout the hospital.
  • Ensure that A&E staff undertake risk assessments for those patients at risk of falls or pressure sores.
  • Review the risk assessments for the ligature points noted in the psychiatric assessment room in A&E.
  • Ensure that there is adequate provision of food and drink for patients in A&E who are waiting for long periods including at night.
  • Improve patient discharge arrangements at weekends.
  • Improve investigation and response times to complaints particularly in A&E and outpatients.
  • Ensure that the lines of responsibility between A&E and children’s services over the responsibility for the paediatric A&E are clear to staff during a period of change.
  • Review arrangements for the consistent capture of learning from incidents and audits and ensure that learning and audit data is always conveyed to staff.
  • Improve medical recording to remove anomalies and inconsistencies in records, paying particular attention to elderly care wards and take steps to improve the security of records in surgery.
  • Review the provision of specialist pain nurse support across the whole hospital.
  • Ensure consistent ownership and knowledge of the risk register across all nursing and medical staff.
  • Review decisions made at a senior non-clinical level being unchallenged and having a potential clinical impact on patient welfare.
  • Review development and promotional prospects and progress for staff such as healthcare assistants.
  • Review and implement a system for updating national guidelines in maternity and palliative care.
  • Improve documentation around assessment of mental capacity in end of life care.
  • Improve consistency of use of early warning scores for deteriorating patients.
  • Improve documented guidance for staff around referral of patients to palliative care.
  • Increase mortuary capacity beyond current temporary arrangements.
  • Appoint a non-executive director with responsibility for end of life care.
  • Review clinic cancellation processes to avoid clinic appointments being cancelled at short notice.
  • Review appointment arrangements to ensure that appointments are not booked at unsuitable times or clinics overbooked in error.
  • Review the waiting areas in outpatient clinics, particularly the eye, fracture and urology clinics at busy times to prevent people having to stand while waiting.
  • Review follow-up outpatient appointment arrangements to increase capacity to organise follow-up appointments in some of the outpatient clinics. This includes dietician, nephrology, paediatric urology and hepatology clinics where no appointments were available within 5 weeks.
  • Improve communication with outpatient staff and their involvement in the development of the service to ensure service vision and values are understood and fully supported by staff. Allow staff increased opportunity to express their concerns related to developments within the trust and how this affects their day-to-day work.
  • Accelerate plans to move to 7-day working across all core services. The support for patients recovering from surgery is limited at weekends with no access to occupational therapists, physiotherapists or clinical nurse specialists.
  • Improve the recording of care on the labour ward.
  • Improve access to records for community midwives.
  • Review the impact of the Barnet, Enfield and Haringey strategy, its impact on staff and its potential impact on quality of care.
  • Review the heavy reliance on agency staff due to a 20% shortage of paediatric nurses in the neonatal unit.
  • Review inconsistency around documentation of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms.
  • Improve training for junior doctors on palliative care.
  • Improve the privacy and dignity of patients during the reception process and waiting times to see a clinician within the Urgent Care Centre during the reception process.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.