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Provider: The Hillingdon Hospitals NHS Foundation Trust Requires improvement

On 24th July 2018, we published a report on how well The Hillingdon Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

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

Read more about use of resources ratings

Reports


Inspection carried out on 6 March 2018

During a routine inspection

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

  • We rated safe and well-led at Hillingdon Hospital as inadequate; effective and responsive as requires improvement, and caring as good. We rated three of the trust’s 12 core services as good, three as requires improvement and two service as inadequate. In rating the trust, we took into account the current ratings of the four services at Mount Vernon Hospital not inspected this time.
  • We rated well-led for the trust overall as requires improvement.


CQC inspections of services

Inspection carried out on 5 and 7 May 2015

During an inspection looking at part of the service

When we inspected in October 2014, we told that the trust that it must make improvements, which included:

  • Make sure it complies with infection prevention and control standards and monitors cleanliness against national standards.
  • Assure itself that the ventilation of all theatres meets required standards.
  • Make sure that staff are appropriately trained in safeguarding both adults and children, and that the trust regularly monitors and assesses the completion of actions agreed at weekly ‘safety net’ meetings.
  • Make sure that all staff understand their responsibilities in relation to the trust’s systems and processes that exist to safeguard children.
  • Make sure patients and visitors are protected against the risks associated with unsafe or unsuitable premises.
  • Make sure that there equipment is properly maintained and suitable for its purpose.
  • Make sure that equipment is available in sufficient quantities in order to ensure the safety of patients and to meet their assessed needs.
  • Make sure that all staff receive the full suite of mandatory training that is required to minimise risks to patient safety.
  • Make sure patients are protected against the risks associated with the unsafe use and management of medicines.
  • Make sure that early warning system documentation is appropriately maintained and that all staff react appropriately to triggers and prompts.

Our key findings from this inspection were as follows:

  • The inspection took place approximately three months after we published our comprehensive inspection report in February 2015. We found that the trust had responded appropriately to many of the key issues we highlighted at that time. In some areas however, custom and practice had not changed, despite systems and processes being implemented to deliver changes in practice.
  • We observed improved practice in some areas in relation to hand hygiene and the use of personal protective equipment, however, some staff in A&E and on medical wards were not following best practice.
  • We observed improved practice in the management of medicines in most departments. Where there were known issues plans were in place and steps had been taken to begin to address these issues and mitigate the risks. However, we found best practice was not always followed by all staff, with daily checks occasionally not happening as necessary and some areas left unsecured.
  • It was evident that the trust had taken significant action to address estates deficiencies highlighted by the previous inspection. The trust had restructured its estates function, provided the capital works to the operating theatres and had moved to a less reactive, more planned maintenance service.
  • The comprehensive work programme for theatres was on going at the time of our visit. The works to the operating theatres, both to date and planned, and the commitment to annual maintenance were in line with the Health Technical Memorandum (HTM) 03-01.
  • The trust had implemented a new estates compliance reporting process to provide the organisation with a collective understanding of its risks and level of compliance against best practice and legal requirements.
  • The trust was cleaning and auditing in line with the National Specifications for Cleanliness in the NHS.
  • Children presenting to the trust's A&E were appropriately safeguarded as effective systems and processes were in place. Staff received appropriate training which had increased their awareness and key staff were deployed to oversee practice and promote good practice.
  • Equipment was clean and staff had enough equipment to meet patient needs. Further supplies could be accessed in a timely way when required.
  • Mandatory training figures had improved, the divisions we reviewed having made sure the targeted number of staff received mandatory training, including for infection prevention and control and safeguarding.
  • Early warning score documentation was completed accurately and staff responded correctly to triggers and prompts as required.

Areas for improvement:

The provider must continue to review progress and performance against each of the musts listed in the February 2015 provider report.

It must also provide the commission with an action plan detailing how it will address the failures detailed in the requirement notice at the end of this report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 1, 2, 3,15 and 16 October 2014

During a routine inspection

We carried out this inspection as part of our comprehensive inspection programme of all NHS acute providers and we inspected both of the trust’s locations of Hillingdon and Mount Vernon Hospitals.

Overall, this trust was rated as requires improvement with an inadequate rating for providing safe care and a good rating for caring. We rated it requires improvement for providing effective care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

  • There were many concerns identified which present risks to patient safety.

  • The trust was not complying with infection prevention and control standards.

  • Staff records regarding training showed poor performance in key areas such as infection prevention and control, safeguarding and moving and handling.

  • The trust is failing to effectively assess and monitor the quality of care it provides.

  • The trust was delivering the key national performance indicators, such as ED waiting times with 95.2% of patients attending being treated, transferred or discharged across the A&E (87%) at Hillingdon Hospital and the Minor Injuries Unit (99%) at Mount Vernon Hospital.

  • The trust had a very committed workforce, but there was a significant shortage of nursing staff which was compounded by additional wards being open.

  • The trust performed better than expected in the number of patients acquiring clostridium difficile, however, they performed worse than expected for patients acquiring MRSA bacteraemia.

  • There were many areas where the trust was aware of the challenges and risks and had logged these risks on local and corporate risk registers, however, there were often no plans or measures for implementation for when the risks were going to be addressed or when changes had been made, including:

  • The risk that child protection issues could be missed due to a failure to follow agreed processes had been identified, but not addressed;
  • The risk of admitting children with high dependencies to wards that aren’t appropriately staffed to meet their needs, has been on a risk register for over a year without being appropriately managed; and
  • There were risks identified with the management of the storage of anaesthetic drugs where changes had been implemented, but were not sufficient to manage the risks.

We saw several areas of good practice including:

  • The nurse practitioners in the Minor Injuries Unit made direct referrals to specialities both internally and externally to the hospital; this included tertiary referrals to specialists such as plastic surgery.
  • The effective management of 18 week referral to treatment times for patients.
  • The specialist care for children with diabetes, specifically the outreach work into schools.
  • A maternity triage care bundle to promote consistency of care provided for women.
  • Announced and unannounced “skills drills” training to rehearse obstetric emergencies.
  • Good access to physiotherapy and occupational therapy and good multidisciplinary team working for surgical patients at Mount Vernon Hospital.
  • Good multidisciplinary team working to support one stop outpatient clinics.
  • Trainee doctors commented very positively on the support and mentorship they received while working at the trust.
  • The critical care unit had physiotherapy presence seven days a week, and undertook ward rounds each day, as well as being available on call.
  • The trust had a proactive specialist nurse for organ donation.

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

The trust MUST

  • Make sure it complies with infection prevention and control standards and that it monitors cleanliness against national standards.
  • Assure itself that the ventilation of all theatres meets required standards.
  • Address the risks associated with the numerous staffing establishment shortages across the trust.
  • Make sure that staff are appropriately trained in safeguarding both adults and children, and that the trust regularly monitors and assesses the completion of actions agreed at weekly ‘safety net’ meetings.
  • Make sure that all staff understand their responsibilities in relation to the trust’s systems and processes that exist to safeguard children.
  • Make sure staff are trained and understand their responsibilities in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Make sure that the use of keypads on wards does not unlawfully restrict patients’ liberty.
  • Make sure that all staff receive the full suite of mandatory training that is required to minimise risks to patient safety.
  • Make sure agency staff receive an appropriate local induction on to wards.
  • Make sure that there are adequate numbers of paediatric staff trained in Advanced Paediatric Life Support as per the Royal College of Nursing’s recommended standard.
  • Make sure of the effective operation of systems to enable the trust to identify, assess and manage risks relating to the health, welfare and safety of patients.
  • Make sure that local leaders are held accountable if they do not routinely and accurately complete required audits.
  • Make sure that trust premises are secure and that maternity and children’s areas and wards cannot be accessed by the public without staff knowledge and appropriate challenge when necessary.
  • Make sure patients are protected against the risks associated with the unsafe use and management of medicines.
  • Make sure patients and visitors are protected against the risks associated with unsafe or unsuitable premises.
  • Make sure that there equipment is properly maintained and suitable for its purpose and that out of single use equipment is disposed of appropriately.
  • Make sure that equipment is available in sufficient quantities in order to ensure the safety of patients and to meet their assessed needs.
  • Make sure that records are accurately and appropriately maintained, are kept securely and can be located promptly when required.
  • Make sure that early warning system documentation is appropriately maintained and that all staff react appropriately to triggers and prompts.
  • Complete venous thromboembolism assessments as appropriate.
  • Log the date of receipt of a complaint as the date the trust are first made aware of the complaint.

The trust should:

  • Review the process for admitting patients to wards from the accident and emergency to make sure the process is effectively managed and that unnecessary delays in transferring patients are not occurring.
  • Ensure there is a fixed rota for consultant cover out-of-hours for the critical care unit.
  • Consider providing support from a Practice Nurse Educator for critical care nursing staff.
  • Consider contributing to ICNARC data collection.
  • Confirm the trust’s permanent bed capacity and an accurate base staffing establishment figure the trust projects it needs to deliver safe and effective care for this number of beds.
  • Engage with local end of life care leadership to establish the trust’s strategy for the service.
  • Make sure that appropriate translation services are available and are being utilised to meet patient need.
  • Review the resourcing of medical secretaries to make sure they can meet patient need and the trust’s own targets for sending GP letters.
  • Consider implementing the Friends and Family Test for all wards at the trust.
  • Consider whether patient outcomes could be improved through dedicated consultant cover and / or consultant oversight for the Minor Injuries Unit.
  • Consider auditing pre-operative starvation to make sure patients are not starved for significantly longer than required.

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.