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Archived provider: Heatherwood and Wexham Park Hospitals NHS Foundation Trust Inadequate

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  • We have recommended Heatherwood and Wexham Park Hospitals NHS Foundation Trust should be placed into special measures. Find out more.

Inspection Summary


Overall summary & rating

Inadequate

Updated 1 May 2014

Heatherwood and Wexham Park Hospitals NHS Foundation Trust has six sites. The two main sites are Wexham Park Hospital and Heatherwood Hospital. They also provide outpatient services at King Edward VII Hospital in Windsor, St Mark’s Hospital in Maidenhead, Chalfont’s and Gerrards Cross Hospital and Fitzwilliam House in Bracknell.

The trust provides services to a large and diverse population of more than 465,000. The area it covers includes Ascot, Bracknell, Maidenhead, Slough, South Buckinghamshire and Windsor. The trust has approximately 3,600 staff and a total number of 650 beds. The trust has recently increased the bed capacity at Wexham Park to meet increased demand following an increase in their catchment area for A&E, paediatrics and wards, and had plans to open more capacity later in 2014.

The trust’s catchment area population includes a significant proportion of ethnic minority groups and 30 languages are spoken in the area covered by the trust. The most common (excluding English) include Hindi, Polish, Urdu, Somali, Romanian and Punjabi.

The trust became a foundation trust in 2007. At the time of the inspection, the executive team (based at Wexham Park Hospital) comprised members who were either interim appointments or relatively new in post, with only one member of the executive team in post for over three years. The chief executive had been in post for two years and four months (but had formally resigned, with a leaving date in March 2014).

We inspected this trust as part of our in-depth hospital inspection programme because it represented a variation in hospital care according to our new intelligent monitoring model. This looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations. Using this model, Heatherwood and Wexham Park Hospitals NHS Foundation Trust was considered to be a high-risk service.

At the time of the inspection, Wexham Park Hospital was in breach of a number of regulations and, in many instances, it has been providing care below the essential standards, as found during two previous CQC inspections in May and October 2013. In May 2013, there were particular concerns about the care provided to patients in Accident & Emergency (A&E) and the impact this had on the ability of inpatient wards to provide the essential standards of care. At the inspection in October 2013, improvements in A&E were noted to have been made. However, we found that Wexham park Hospital was in breach of eight regulations. As a result we served compliance actions for breaches of two of the regulations (15 and 16) and warning notices for breaches of six regulations (9, 10, 12, 17, 20, and 22).

We gained views from partner organisations who expressed their concerns about the care provided at Wexham Park Hospital and the future sustainability of the trust.

Heatherwood and Wexham Park Hospitals NHS Foundation Trust provides the following regulated activities, which formed part of our inspection; diagnostic and screening procedures, management and supply of blood and blood derived products, maternity and midwifery services, surgical procedures, termination of pregnancies and treatment of disease, disorder or injury.

We carried out an announced inspection visit on 12 and 13 February. We held focus groups and drop-in sessions for staff. We talked with patients and staff from many areas of the hospital. We observed how people were being cared for, talked with carers and/or family members, and reviewed patients’ records of personal care and treatment. We held two listening events when patients and members of the public shared their views and experiences of Heatherwood and Wexham Park Hospitals NHS Foundation Trust. Patients who were unable to attend the listening events shared their experiences via email or telephone. We carried out three unannounced visits, when we looked at how the hospital ran at night, the levels and type of staff available, how patients were cared for, and patient flow through the hospital.

The trust had a long history of problems. Financial shortfall and high turnover of senior leadership had resulted in poor outcomes in recent CQC inspections and expressions of increasing concern from multiple stakeholders. The trust we found was one that had a significant legacy from a history of financial challenges and the hospital had a culture which was not open with learning at its heart. Trust wide improvements were commencing with support from external agencies, however these were at very early stages and the trust remained challenged. The future sustainability of the trust was clearly a concern. Although efforts had recently been made in response to these concerns they were still very much in their infancy.

The culture was one of learned helplessness and accusations of bullying and harassment were heard throughout the organisation. Although the chief executive was reported to have high visibility and communicated regularly with the frontline, she had recently resigned and was due to leave in March 2014.

The trust was clean and wards that were heavily criticised in previous CQC reports showed evidence of improvement. However, staffing levels were still low in many areas and there was heavy reliance on agency staff to sustain both the medical and nursing workforce.

Inspection areas

Safe

Inadequate

Updated 1 May 2014

The hospital had recently undergone a deep clean and all areas inspected were visibly free from dirt. Most staff were seen to wash their hands appropriately.

Unsafe staffing levels were a consistent theme throughout the trust and were noted in almost all clinical disciplines including medical, nursing, and allied health professionals.

Escalation beds had been opened at short notice, which were staffed largely by agency. Many of these staff had not worked in the trust previously and there was evidence that induction to wards was not systematic.

Notes were found to be inconsistently completed in many departments throughout the trust. This was particularly notable for of falls assessments. At Heatherwood there had been four falls in the previous seven days, one of which had resulted in a fractured hip.

There was a lack of a genuine safety culture, with the exception of the critical care unit and the children’s and young person’s department. The culture in the trust did not encourage staff to report incidents as they perceived there was little subsequent change. This was consistently a lost opportunity to improve practice and outcomes. Although there were individuals and groups of staff who took the time to progress initiatives, there was no evidence that this was embedded practice.

Governance processes were not seen to be robust enough to allow the trust board to gain assurance that they were providing safe care.

Effective

Requires improvement

Updated 1 May 2014

Although many staff told us that they followed national and local guidelines, during the unannounced inspection we found that a significant number of the policies and guidelines were out of date. In addition, the trust provided evidence confirming that 27% of the policies were out of date.

We were provided with a table of audit activity currently being undertaken, but with the exception of critical care and children and young people’s care, we were not provided with evidence of the results for these audits or how practice had changed as a result. Although the trust provided evidence that it is good at undertaking audits, in some areas there was no evidence that this resulted in patient care being more effective or safe. We found the trust was not acting on the results of audits by identifying improvements, implementing or appropriately monitoring change. We found examples where performance was getting worse when repeat audits were undertaken.

There was a shortage of equipment on some wards and some of the ward areas were in need of repair.

While we found good multidisciplinary working in many areas, there was a lack of consistency in multidisciplinary working trust-wide. Some groups of consultants were not working collaboratively.

Caring

Requires improvement

Updated 1 May 2014

The trust scored below the national average for the Friends and Family test. In the CQC inpatient survey, the trust performed worse than other trusts for eight of the areas of questioning.

Members of the public expressed their concern to us at the listening event regarding poor care and the loss of dignity that they and their relatives experienced during treatment at the trust. They were also concerned with the lack of communication they received from the trust.

We witnessed staff in some areas (children’s and young people, critical care and end of life care) deliver kind and compassionate care. Heatherwood Hospital consistently received good feedback from patients.

Due to the pressures placed upon them, staff were not always able to provide the amount of emotional support that patients wanted and deserved.

Responsive

Inadequate

Updated 1 May 2014

The trust was very busy and failed to consistently meet national targets to admit, transfer or discharge patients from the A&E department within four hours. The trust has been predominantly performing much worse than the England average, with patients waiting between four and 12 hours following the decision that they should be admitted.

In order to increase capacity, extra beds had been opened, but there was little evidence of initiatives to try to reduce unnecessary admissions. Patient discharges were being delayed in many cases due to a shortage of radiology, physiotherapy, and occupational therapy assessments being completed in a timely manner.

The lack of capacity and delayed discharges resulted in medical patients being placed on surgical wards. Some patients were moved numerous times, which resulted in delayed care or lack of continuity of care. The use of surgical beds by medical patients resulted in a significant number of patients having their operations cancelled on the day.

Discharges were not planned from admission, and there were significant delays due to lack of resources within the radiology department.

Vulnerable patients were not always a priority for the trust and translation services, though available, were not always used.

Complaints were not answered promptly and we were unable to find evidence that previous concerns had been learned from. Patient stories or complaints were not regularly reviewed by the board.

Well-led

Inadequate

Updated 1 May 2014

The trust lacked a clear vision for staff to align or aspire to. The lack of clarity about the hospital’s future left many staff feeling disempowered.

There had been a high turnover of executive team members and the chief executive had recently resigned. Staff referred to the trust as ‘rudderless’

The governance arrangements and risk management structures throughout the trust were neither standardised nor consistent throughout departments or divisions. This resulted in the board receiving assurances which were not always robust. In addition, risks throughout the trust were not being progressed or actioned in a timely manner, with many missing their set target date for completion. Information governance needed further investigation to establish its accuracy. The trust had taken steps to source external support to review and improve these aspects.

Sickness levels were found to be under-reported and therefore not a true reflection of staff sickness figures. The trust performed poorly in both the staff survey and the GMC National Training survey. There was a widespread reference to culture of bullying and harassment.

The workforce was disempowered and disengaged. Nursing turnover was high with recruitment and retention being a fundamental concern. This resulted in high use of agency staff. The trust was taking steps to improve retention by schemes within HR, but these were not started at the time of the inspection.

While there were groups who were engaged with the holistic patient experience, some consultants were seen to prioritise their individual working practices and displayed dysfunctional behaviours to the detriment of patient experience in the trust.

Patient experience was not at the heart of everything that was done at the trust. We witnessed a mixture of ‘firefighting’ and learned helplessness from frontline staff and an executive team that had focused on financial improvement. As a consequence, innovation was not encouraged or rewarded.

Members of the executive team were unanimously concerned about the perceived instability in the future of the hospital and recognised the need for long term significant support in order to achieve a sustained and improved future for the trust.

Some of the executive directors did not have confidence that, as a board, they could make the required significant improvements within an acceptable period. We did not feel that there was the required skill and capability within the trust to make the complex and necessary changes trust-wide.