You are here

Provider: West Hertfordshire Hospitals NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 February 2019

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.

Of the six core services we inspected on this occasion, we rated one as inadequate, two as requires improvement, and three as good.

In rating the trust overall, we took into account the current ratings of the core services not inspected this time. Of the 14 core services across all three sites that have been inspected to date, one was rated inadequate, three were rated requires improvement, and nine were rated as good. One was not rated as we had insufficient evidence to rate end of life care services at St Albans City Hospital.

We rated well-led for the trust overall as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 28 February 2019

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

  • Mandatory training compliance did not meet the trust target of 90%.
  • Safeguarding adults and children training compliance was below the trust target for medical staff.
  • The environment in which services were provided were not always designed and managed to ensure the safety of patients using them. Not all areas were secure, for example in the emergency department (ED) at Watford General Hospital. Some premises were not fit for purpose.
  • Appropriate records of patients’ care and treatment were not always kept. Records were not always up-to-date, some had missing signatures and were observed being completed retrospectively. Some documentation of care was unclear. Records were not stored appropriately in the UCC at Hemel Hempstead Hospital.
  • The management of medicines, including prescribing and administering was not always in line with best practice. For example, not all patients in the ED had been weighed prior to being prescribed weight-dependent anticoagulant medicine. Nursing staff at the MIU used patient group directions despite them not being duly authorised in line with trust policies. When antibiotics were prescribed, there was not always a review date or rationale for continuing the medicines in the medicines administration record.
  • Some risks to patients were not assessed and responded to appropriately. In maternity, not all staff knew how to best manage and care for women with reduced fetal movements. There remained no formalised process for clinically assessing patients presenting to the minor injuries unit. Patients with mental health concerns in ED were not always monitored. Staff did not always escalate or refer patients when their risk score (NEWS) indicated a deterioration in their condition.
  • Infection prevention and control measures were not robust in the UCC and MIU. Patients at risk of infection were not always isolated in a timely manner and some areas of the department were visibly unclean.

However:

  • With the exception of the MIU and UCC, infection risks were controlled well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Hand hygiene was good.
  • There was enough medical and nursing staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment across ED, maternity, and surgery.
  • Most staff recognised incidents and reported them appropriately. Managers investigated incidents and generally provided feedback to staff. Lessons were learnt as a result of incidents and actions monitored in most areas. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff who had received training on how to recognise and report abuse, knew how to apply it.

Effective

Requires improvement

Updated 28 February 2019

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

  • The trust was not meeting the target of 90% for staff receiving appraisals, with one area at 54.6%.
  • There remained a lack of monitoring of patient outcomes and compliance with evidence-based protocols in the UCC and MIU. This had previously been identified by the Care Quality Commission as an area which required improvement.
  • A range of printed policies and procedures which reflected clinical guidance that had been superseded was available across the department at the MIU and UCC.
  • Mental capacity assessments and best interest decisions were not always documented as required within medical care.
  • There was a clear theme amongst maternity complaints of delays in administering pain relief for women.

However:

  • Most services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural, and other preferences.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They were able to explain how they acted in patient’s best interests when they were unable to make decisions for themselves.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

Caring

Good

Updated 28 February 2019

Our rating of caring stayed the same. We rated it as good because:

  • Staff cared for patients with compassion, kindness and respect. Feedback from patients and those close to them was positive about the way staff treated them. Patients felt supported and cared for by staff.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Bereavement policies and pathways were in place to support the relatives of patients who passed away in the children’s ED. Staff were especially caring and responsive to parents who suffered the loss of a child or young person. They were committed to continually improving the care and services they provided for bereaved parents.

Responsive

Requires improvement

Updated 28 February 2019

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

  • Not all patients could access services when required. In ED, waiting times to be seen for treatment were generally higher (worse) than the England average. In surgery, waiting times from referral to treatment and arrangements to admit treat and discharge patients were not in line with good practice. In maternity, delays were reported in antenatal clinic waiting times (ANC) and Triage waiting times which had continued to be a theme from complaints.
  • Complaints were not dealt with in a timely manner across the urgent and emergency care services, nor were lessons learned and shared at the MIU.
  • Not all surge areas had agreed criteria when being used as an inpatient area in times of capacity issues.
  • Adaptations to the environment on care of the elderly wards were not consistently or fully implemented, to improve the experience of patients living with dementia.

However:

  • The number of patients who left the department without being seen was lower (better) than the England average. Performance in the children’s ED was consistently close to and at times, did meet the national four-hour standard.
  • Patients’ individual needs were taken into account. The service had a person-centred care approach to meeting the needs of patients living with a dementia.

Well-led

Requires improvement

Updated 28 February 2019

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

  • Some of the issues identified in our 2017 inspection had not been resolved. For example, inpatient areas had patient names displayed on white boards in areas visible to visitors walking onto the ward. Service enhancements and improvements had not been sustained at the MIU and UCC.
  • The ED did not have effective arrangements in place to ensure information used to monitor, manage and report on performance was accurate. Information was of a poor quality with a reliance on manual processes to extract data at the MIU and UCC; this was labour intensive and did not allow for real-time reporting.
  • The trust information technology systems were slow and access to computers was an issue for staff in some areas. There were connectivity issues for maternity staff working in the community.
  • Whilst leaders generally understood the challenges to quality and sustainability, actions had not always been implemented to address all the issues.
  • There lacked a systematic and robust approach to governance and the management of risk within the MIU and UCC. There was a lack of divisional oversight and there was no active improvement strategy for the MIU and UCC at the time of the inspection.

However:

  • The trust had managers at all levels with the right skills and abilities to lead services.
  • Managers across services generally promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were committed to improving the quality of care and patient experience and worked together to do so. We saw an improvement in culture within the ED.
  • Services had a vision for what they wished to achieve and most had workable plans to turn it into action, developed with involvement from staff, patients and key groups representing the local community.
  • Most services had effective systems for identifying risks, planning to eliminate or reduce them, coping with both the expected and unexpected. Divisional risk registers identified key risks and all risks were recorded on risk registers.
  • The arrangements for governance were operated effectively across most services.