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Provider: West Hertfordshire Hospitals NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 June 2020

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

We rated effective, caring and well led as good and safe and responsive as requires improvement. This was an improvement from our last inspection when we found caring as good and safe, effective, responsive and well led as requires improvement.

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

In rating the overall trust, we took into account the current ratings of the core services not inspected this time. Of the 18 core services across all three sites that have been inspected to date. None were rated as inadequate, two were rated as requires improvement and the remaining services were rated as good. We rated the trust ‘effective’ as good overall even though one of the location (St Albans City Hospital) was ‘requires improvement’. This was because it would be disproportionate due to the size and nature of the services at St Albans minor injuries unit. Although our inspection methodology has changed, we have not inspected diagnostic imaging or outpatient services as individual core services and their combined ratings remain good as of the January 2018 inspection.

We rated well led for the trust overall as good.

Inspection areas

Safe

Requires improvement

Updated 17 June 2020

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

  • Mandatory training compliance had improved although there were some area where compliance was not in line with the trust target, particularly medical staff compliance.

  • Safeguarding training varied across services, with some areas not achieving the trust target.

  • Clinical environments were not always suitable to needs. Theatre recovery was not suitable as there was no separate children’s recovery area. Clinical areas were not always visibly clean.

  • Patient records were not always detailed or of a high quality. There were some gaps in recording of care and treatment, and staff signatures and dates were missing. Some patients notes were untidy with some surgical speciality records difficult to locate. Patient weights were not always recorded which could impact on patients safety with regards to medicine prescribing. Some patients risk assessments were not routinely repeated, although patients were escalated appropriately if they showed any signs of deterioration.

  • Some prescriptions for antibiotics did not record review dates as per best practice. This concern was raised at our last inspection. Antibiotics were also not always administered in a timely manner when managing patients with suspected sepsis.

  • Staff did not always complete daily checks of equipment, such as resuscitation equipment to ensure it was safe to use.

  • Cleaning materials were not stored securely and could be accessed by unauthorised people. Some cleaning schedules were not signed or dated, and some were outdated.

However:

  • The design, maintenance and use of faculties, premises and equipment kept people safe. Staff were trained to use equipment and staff managed clinical waste well.

  • Staff completed risk assessments for each patient and used recognised assessment tools to assess and monitor for changes in patients clinical conditions.

  • Infection prevention and control was manged well. Staff kept themselves and equipment clean. They used control measures to prevent the risk of spreading infections. Hand hygiene was generally good.

  • There was enough medical and nursing staff with the right skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment across all services.

  • Staff generally 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 and shared across the trust. 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

Good

Updated 17 June 2020

Our rating of effective improved. We rated it as good because:

  • 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. Services made adjustments for patients’ religious, cultural, and other preferences.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.

  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

  • Services were available seven days per week to support timely patient care.

  • Staff gave patients practical support and advice to lead healthier lives.

  • 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.

However:

  • Pain scores were not always recorded.

  • Performance in national audits was variable.

  • Not all staff had completed Mental Capacity Act and Deprivation of Liberty Safeguards training. There was also some gaps in the recording of patients capacity and details of best interest discussions.

Caring

Good

Updated 17 June 2020

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.

Responsive

Requires improvement

Updated 17 June 2020

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

  • Not all patients could access treatment when they wanted it. Performance data was varied and showed delays in patient assessments times in emergency departments and prolonged referral to treatment times across some specialities.
  • Complaint response times were sometimes longer than guidance within the trust policy.

However:

  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.

Well-led

Good

Updated 17 June 2020

Our rating of well-led improved. We rated it as good because:

  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.

  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.

  • 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.

  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.

  • The trust mostly collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. Data or notifications were consistently submitted to external organisations as required.

However:

  • Information systems were not fully integrated. Whilst there was a plan in place to improve, staff told us IT systems were not always user friendly and could cause delays in accessing information.

  • There was some lack of clarity around Simpson ward at Hemel Hempstead General Hospital and their role the future

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 17 June 2020

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

NHS Improvement are assessing 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 17 June 2020

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