London North West University Healthcare NHS Trust

20190416 900885 Post-inspection Evidence appendix template v4

London North West University Healthcare

NHS Trust

Evidence appendix Watford Rd

Harrow

HA1 3UJ

Tel: 020 8864 3232

Date of inspection visit:

2 July to 15 August 2019

Date of publication:

6 November 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Facts and data about this trust

London North West University Healthcare NHS Trust is one of the largest integrated care trusts in

the country, bringing together hospitals and community services across Brent, Ealing and Harrow.

London North West University Healthcare operates hospital services from three main hospital

sites:

• Northwick Park Hospital

• Ealing Hospital

• Central Middlesex hospital.

The trust was established on 1 October 2014 from the merger of Northwick Park Hospital, Ealing

Hospital NHS Trust and Central Middlesex Hospital. The trust employs more than 9,000 clinical

and support staff and serves a diverse population of approximately one million people.

The trust also provides a range of community services in the London Boroughs of Brent, Ealing

and Harrow. The trust provides inpatient/outpatient hospice services at Meadow House Hospice

and community services at Willesden Community Rehabilitation Hospital.

In December 2017 the trust was officially named a university teaching hospital.

The trust was last inspected in 2018 and was rated requires improvement.

The trust runs services at Northwick Park Hospital, Ealing Hospital and Central Middlesex

Hospital.

The trust provides, urgent and emergency care, medical care, surgery, critical care, maternity,

gynaecology, children and young people services, end of life care and outpatient services. The


trust also provides a range of community services including: diabetic eye screening, district

nursing, falls services, family dental, musculoskeletal specialist and physiotherapy services and

many more.

We inspected Northwick Park Hospital, Ealing Hospital and Central Middlesex Hospital.

A list of the sites at the trust is below:

Name of acute hospital site

Address Details of any specialist services provided at the site

Geographical area served

Northwick Park Hospital

Watford Road, Harrow, Middlesex, HA1 3UJ

• Critical care

• Diagnostics

• End of life care

• Gynaecology

• Maternity

• Medical care

• Outpatients

• Surgery

• Services for children and young people

• Urgent and emergency care

Brent, Ealing and Harrow

Ealing Hospital

Uxbridge Road, Southall, Middlesex, UB1 3HW

• Critical care

• Diagnostics


• Gynaecology

• Maternity

• Medical care

• Outpatients

• Surgery


• Urgent and emergency care


Central Middlesex Hospital

Acton Lane, London, NW10 7NS

• Surgery

• Medical care

• Outpatients




St Mark’s Hospital (co-located with Northwick Park)

Watford Road, Harrow, Middlesex, HA1 3UJ

• Medical care (centre for colorectal disease)


(Source: Routine Provider Information Request (RPIR) P2 - Sites) London North West University Healthcare NHS Trust has approximately 1,382 inpatient beds and 132 day case beds located across four acute locations: Northwick Park Hospital, Ealing Hospital, Central Middlesex Hospital and St Mark’s Hospital (which is co-located with Northwick Park Hospital). These four hospitals serve a combined population of approximately one million people in Harrow, Brent, Ealing and surrounding areas.


The number of staff employed by the trust as of January 2018 was 8,753. The trust’s services are commissioned mainly by Brent, Ealing and Harrow Clinical Commissioning Groups. (Sources: Routine Provider Information Request (RPIR) – Beds and Total staffing; trust website)

Is this organisation well-led?

Leadership

The trust had a senior team with an appropriate range of skills, knowledge and experience to

perform its role. The trust board members brought with them extensive experience from NHS

organisations, other public sectors and the private sector. Their collective skills and experience

included senior management, commercial and legal positions, clinical and senior management

positions, senior Department of Health roles, senior finance and human resources experience,

senior medical and medical research appointments, and senior voluntary sector and educational

positions. The trust chair took an active role in ensuring that the board comprised of individuals,

both executive and non-executive, who were able to bring the right mix of experience and

expertise to the board leadership of the trust.

The board comprised of the chairman, six non-executive directors, the chief executive and eight executive directors. Three new executive board members had joined the trust in recent months: director of corporate affairs, director of estates and facilities, and chief nurse. Their appointments had filled some significant gaps although posts had been covered on an interim basis. At the time of our inspection the chief financial officer was about to leave and, pending a replacement, his post was being filled by the assistant director of finance. In the previous year two non-executive directors had stood down and had been replaced by two new appointments. The board had overall responsibility for setting strategy, and monitoring performance, quality and

finance including maximising the efficiency of the trust’s services.

The trust board met nine times in the previous twelve months. The board had also undertaken a number of development sessions in place of a formal board development programme which, we were told, was in the process of being developed. We noted last year that no formal board development programme had been in place and the trust gave the reason for further delay this year to be pending the appointments above. However, as a board development programme was intended to be ongoing there was a need to progress this despite board turnover now apparent from the departure of the director of finance. The trust subsequently told us that the it was in the procurement and selection process for a board development supplier. Below board level the trust had continued with its effective leadership programme led by a local

university. This five-month long programme had now been running for some years and up to the

date of our inspection some 300 staff had completed the programme in the previous 18 months. It

was aimed at staff with leadership potential in clinical, nursing and operational as well as

administrative areas.

We found that succession planning had developed further since our last inspection, extending

down the trust structure and now included staff just below the level of divisional general manager

and divisional clinical director. In addition, the trust had applied to be a pilot for a leadership

academy talent management programme which involved diagnostics upon which to devise a

development programme.


The chief nurse was the lead for children’s’ services and adolescent mental health, learning

disability and autism. There was also a non-executive director with direct responsibility for

safeguarding.

There was evidence from our conversations and interviews with senior members of staff, including

non-executive directors, of constructive challenge among the leadership team. Throughout our

engagement with the trust we noted their openness and honesty from the chair and chief

executive and at all levels.

The trust leadership team had a comprehensive knowledge of current priorities and were realistic

in their assessment of challenges. Throughout our interviews with executive and non-executive

board members and other senior staff, they demonstrated that they knew their successes as well

as being open and honest about their challenges. The knowledge of the board was enhanced not

only by regular board meetings but by their programme of visits to frontline and administrative

areas of the trust which we noted had increased since our previous inspection.

There were clear lines of accountability for medicines within the Trust. The Chief Pharmacist

reported to the Medical Director who had board level responsibility for medicines management.

Within the pharmacy department there was a clear leadership structure.

Fit and Proper person (FPPR) checks were in place. However, we felt that there was more work to

be done to bring all the FPPR records and arrangements we saw up to an acceptable standard. A

Fit and Proper Person’s Policy was ratified in the Appointments and Remuneration Committee of

18 December 2017. The review date was set at 18 December 2021. However, the policy should

have been reviewed on 1 January 2019. The trust subsequently told us that the review had taken

place on 19 January 2019 but this updated review date had not been entered on to the policy

document that we saw. The trust should satisfy itself that all relevant FPPR are in place by sight

and possession of the documents and not rely on third party assurances. At the time of

appointment, the trust had not assured itself that DBS checks were in place by having physical

copies. This is how errors of omission occur by one organisation relying on another by trust alone

for vital checks.

The more recent appointment files were more complete than for some of the older appointments.

The FPPR reviews improved in quality and comprehensiveness over the years with the more

recent years being better but evidence of not completely going thoroughly through the whole file

was evidenced by two NEDS having records of passports that expired. There was some missing

evidence of appraisals carried out. Two NEDs had out of date DBS checks and assurance

documentation was listed as held by NHSE/I in many cases. This meant that the trust did not have

documentary evidence of its own assurance in these cases. The director of workforce and

organisational development said that requests for copies of these documents had been made and

it is a recommendation that the trust reviews its FPPR processes and documentation to ensure

that it has documentary proof of compliance in all cases.

The trust comprised of three former trusts (Central Middlesex, Ealing and Northwick Park) including

a community health arm. Following the publication of Shaping a Healthier Future (SaHF) designed

to reshape health services in North West London there had been some difficulties in its

implementation leading to uncertainty particularly at Ealing Hospital. Changing demographics had

overtaken the SaHF plans which had been shelved by the Government in March 2019. This meant

that the planned closure of Ealing Emergency Department (ED) did not go ahead, and had led to a

feeling of greater security about the future there.


We saw evidence from board papers of challenge from the NEDs, including the new appointees, to

the trust board on matters affecting the trust. As the NEDs were from many backgrounds, challenge

took place on many levels with evidence their views were listened to.

The trust chief executive was highly visible in ward areas and the new chief nurse had set herself

the task of visiting all ward areas possible in the short time she had been appointed. Board

visibility as a whole was improved from our previous inspection. There was a programme of board

visits to services and staff fed back that leaders were more visible and approachable. Service

leads held meetings more frequently at different sites in the trust and there was evidence of more

cross site working from both clinicians, managers and administrative staff.

Of the executive board members at the trust, 11% were Black and minority ethnic (BME) and 44% were female. Of the non-executive board members 14% were BME and 29% were female.

Staff group BME % Female %

Executive directors 11.0% 44.0%

Non-executive directors

14.0% 29.0%

All board members 13.0% 38.0%

(Source: Routine Provider Information Request (RPIR) – Board diversity)

Vision and strategy

In recent years the overall trust vision and strategy had been geared to the delivery of Shaping a

Healthier Future (SaHF). Now that SaHF had been withdrawn the trust found itself without an

overall strategy and needing to develop one. Upon delivery of such a strategy rested revised

clinical, financial and estates and facilities strategies which likewise needed development to take

account of these changing circumstances. At the time of our inspection these strategies starting

with the overall strategy had not yet been developed. The trust leadership and board recognised

this need.

However, the trust’s stated vision, in the absence of an overall strategy on how this might be

achieved, was to provide excellent care in the right setting by being compassionate, responsive

and innovative. This was underpinned by six corporate objectives: improving focus on safety and

quality; improving patient satisfaction and engagement; creating a sustainable workforce; ensuring

financial sustainability, and becoming an excellent integrated care organisation.

In January 2018 the trust published its then new clinical strategy which was based around three

priorities: emergency and ambulatory care; end to end integrated care, and specialist services.

Underpinning these were the aims of improving outcomes and experiences for frail older people;

to integrate cancer care, and to play a greater role in prevention and well-being. Contained in the

overall strategy were short term priority projects (year one) to significantly improve A & E

performance; to expand ambulatory care pathways; implement the north west London frailty model

across all sites; help develop the Brent and Harrow integrated care system, and to expand the use

of digital technology in care.

The trust had a Medicines Optimisation Strategy and Pharmacy business plan in place, in

accordance with a national Hospital Pharmacy Transformation Plan. A key priority of this plan was

to increase the number of pharmacist independent prescribers in various areas. In conjunction with


this, the department were planning to direct more clinical staff towards ward-based teams (in line

with Carter recommendations). Staff knew about the medicines optimisation strategy as it was

shared in team meetings and in 1:1 discussions, (for example, during appraisals). Elements of the

Carter review action plan were evident, such as the need to improve procurement and implement

an electronic prescribing and medicines administration system (EPMA) across the trust in the future.

The department worked collaboratively with the local STP partnership on agenda items such as

antimicrobial stewardship, discharge to pharmacy programme and biosimilar medicines

implementation.

The chief pharmacist told us that the medicines optimisation strategy and vision were shared widely

through the trust divisional governance meetings with the emphasis that this is cascaded across

other sub-groups. The pharmacy team were also involved in education and training of healthcare

professionals including nurses and junior doctors.

The trust had a transformation programme which aimed to change its culture to one of continuous

improvement and to put the experiences of staff and patients foremost in these changes. The trust

had engaged with staff and patients to develop its Quality Improvement Plan (QIP). The trust was

a member of the North West London Sustainability and Transformation Partnership (STP) on

system wide transformation and financial recovery. This aimed to set out plans for the health and

social care system within North West London over the next five years while increasing local

accountability.

The trust had also worked with several different patient interest groups focussing on individual

services within the trust, for example Ealing Heartlink and Pulmonary fibrosis support group. The

trust had also worked with Healthwatch teams from Ealing, Brent and Harrow.

The trust had set up a fellowship programme for staff interested in becoming improvement

champions. The first training cohort had been completed with applications for the second cohort

under way. Monthly improvement “labs” had been set up for staff who had improvement ideas but

who needed guidance on how to develop them. The trust had also launched the new national

productive ward scheme for improving ward processes.

The trust has stated that collaboration over the next twelve months would centre on supporting

borough based integrated care partnerships (ICP) to include improvements to outpatients, same

day care, and digitisation of health records. The trust has also worked with the North West London

Sustainability and Transformation Partnership (STP) on system wide recovery and transformation.

The trust launched its five-year people strategy in 2016 and reviewed it in 2018 to check that it

remained aligned to “Developing Workforce Safeguards” recommendations. Workforce information

was reported regularly to the trust board and relevant sub-committees.

One key project was the proposed implementation of a new electronic patient records system, to

replace the current paper records in place throughout the trust. Financial approval was still

awaited but the trust had determined its preferred supplier in a joint project with a neighbouring

NHS trust.

The trust stated that plans were in place to work with patients, families and voluntary organisations

on the implementation of a revised Patient Experience Improvement Strategy. This was to focus

on patient and carer engagement, involvement and co-design of service delivery.

The trust demonstrated work it had done in improving care for patients living with mental health

conditions. It worked with a mental health partnership organisation to train emergency department

staff in the Mental Health Act, Mental Capacity Act and London’s Section 136 care pathway. In


addition, it continued to work with neighbouring NHS mental health trusts to exchange skills

between mental health trust nurses and staff in the trust’s emergency departments.

The trust continued to align its services to local plans and requirements in the local health and

social care economy. This included active involvement in sustainability and transformation plans.

The trust continued to plan services to meet the needs of the local population. Following the

withdrawal of SaHF, the decision was taken not to close the emergency department at Ealing

Hospital.

The leadership team continued to monitor and review progress on delivering local service plans.

The board met regularly to consider strategic, operational and quality matters and to review

assurance via its operational leads and via reports of committees reporting to the board.

We noted at this inspection a renewed energy on the part of operational managers and divisional

leaders and staff in addressing operational issues within their divisions and examples of this were

found across the five divisions of the trust. We noted that this was beginning to improve the

operational performance of the trust. For example, the ED departments while still not achieving all

ED targets was identified as the most improved in London.

The trust continued to work with staff, patients and local stakeholders emphasising its values

based on HEART – honesty, equality, accountability, respect and teamwork.

The trust’s estimated financial deficit for the forthcoming year was approximately £90 million. The

trust had made progress in understanding the drivers of its financial deficit but there appeared to

be no medium-term financial strategy underpinned by financial delivery plans to address the

deficit. It was encouraging that operational performance was improving and this needed to

continue while meeting its planned financial plan when apparent. There was a risk in this to the

organisation in that the well-regarded director of finance was about to leave the trust. Similarly, the

Estates and Facilities Strategy could only be formulated and addressed piecemeal until an overall

set of strategies was in place.

Culture

The trust provided the following breakdowns of medical and dental and nursing and midwifery staff by ethnic group.

Ethnic group Medical and dental staff

Clinical workforce (including medical staff)

Non-clinical workforce

White 36% 30% 39%

Black and minority ethnic 40% 65% 56%

Unknown / Not stated 24% 5% 5%

(Source: Routine Provider Information Request (RPIR) – Diversity) The ethnic representation in the trust’s workforce broadly mirrored the ethnicity of different groups within the local population.


We spoke with representatives of the trust BAME and LGBTQ support groups and they were

positive about the support the trust had given to them over the previous year. However, we found

the understanding of best practice in engaging with BAME groups and developing the culture of

the organisation was, to some extent, limited. The BAME group was longer established with about

400 members. The BAME representative told us that the trust had instigated support sessions to

facilitate BAME staff developing into senior roles. This was to help break the barriers to promotion

that BAME staff had previously complained about. The Director of HR and OD told us that the trust

had increased the number of BAME staff at nurse band 8A and above. She felt that the next steps

included communicating more with staff that the chances of BAME staff being disproportionately

disciplined had gone down.

The trust LGBTQ group had been reconstituted since our previous inspection with support from the trust. They had received identity badges and had been supported by the trust to attend London Pride 2019 and received other support as required. They had a sponsor on the board who was the chief nurse. The trust told us that their next step was to encourage other minority support groups including a disability support group within the trust. We detected a more positive culture within the trust although this perhaps had not yet been reflected in the latest NHS Staff Survey results. The Director of HR and OD was disappointed in the equality and bullying and harassment results and acknowledged there was more work to be done. The trust had launched a bullying and harassment questionnaire to understand better what staff saw as bullying and harassment. Once that was complete an analysis would be undertaken to be taken to focus groups and leading to more staff training in the area. The trust continued to recognise staff success by staff awards at the trust annual awards

ceremony. Recent examples of external awards included a staff member and colorectal cancer

team shortlisted for a national publication’s value award; administrator of the year and volunteer of

the year, an award for a disability lead nurse and team; HR team finalists in an engagement

award; long service awards for staff; a staff member shortlisted for nurse of the year; an

appointment to a professional British society organisation for a trust consultant; an award for

educational excellence and a London Lifetime parliamentary award.

There still appeared to be a gap of perception in relation to trade union trust relationships.

Relationships were on the whole positive with the BMA Local Negotiating Committee (LNC)

representative whose negotiations with the trust centred primarily on job and job plan related

issues. The wider trade union group remained less positive. The Director of HR and OD told us

that there were regular meetings held and the trust remained committed to consultation when staff

were affected by changes to the way services were run. However, the trade unions continued to

claim that while they were quorate in meetings with the trust, management were often not quorate

at meetings. They had complained to trust leadership about this and matters had improved only to

slip back again.

Managers continued to address poor staff performance where needed and a number of staff were

currently being performance managed. The performance management framework was supported

by HR policies in place at the time of inspection.

The trust had a full-time equivalent Guardian of Safe Working Hours. This role was designed to

reassure junior doctors and employers that rotas and working conditions are safe for doctors and

patients. We did receive one comment in relation to long serving doctors who had had to work

unduly long hours in the past of lukewarm support for this ethos. However, the Guardian reported

that they had the full support of the board and could take problems direct to either divisional

leaders or direct to the executive team.


There were now two Freedom to Speak up Guardians in the trust who worked together

collaboratively across the trust without having separate areas of specialty or separate location

areas. They similarly reported full support from the trust and were engaged in numerous meetings

of different occupational groups as and when they occurred to publicise the Guardian role. They

were satisfied with the facilities and equipment the trust had provided for them on request. From

June 2018 until March 2019 there had been 48 contacts from staff members across all grades

including nurses, doctors and consultants. Main themes that emerged related to potential patient

safety, quality, bullying and harassment and grievance. The Guardians saw the role as continuing

to develop as they publicised it more via notices and meetings in the trust and aimed for the trust

leadership to view them as “eyes and ears” while remaining impartial and person focused. They

had a nominated NED as board sponsor and reported to the trust board quarterly. The trust

encouraged them to make best use of the Freedom to Speak up Guardian network by attending a

network meeting every two months, an annual conference, taking a fortnightly bulletin,

communicating with other guardians and being part of a buddying system.

We saw more evidence of cross site working since our last inspection to help break down previous

barriers between the different locations of the trust. More meetings were being held at different

locations with divisions being cross-site, and the medical director was instigating and encouraging

doctors to work on rotation at the different sites where possible and applicable. Increased cross

site working as well as the removal of some threats to, for example ED at Ealing was leading to a

more harmonious environment and managers reported to us that there was more identification

with the trust as a whole as opposed to strict identification with one or another location where

people had traditionally worked.

We continued to be concerned about relationships within the maternity department at the trust.

There had been allegations of a leadership unwilling to engage on a day to day basis with

midwives. Following our last inspection of maternity, the trust had undertaken an assessment

programme of its midwife workforce to assess individual capability. This resulted in a number of

staff being assigned to a job role at a lower band, whilst on pay protection. Staff voiced that they

felt this assessment had been completed unfairly. Following an upheld grievance around how this

assessment had been conducted, the chief nurse decided to conduct the assessment again with

an independent assessment panel to demonstrate impartiality and fairness to all concerned.

NHS Staff Survey 2018 results – Summary scores: The following illustration shows how this provider compares with other similar providers on ten key themes from the survey. Possible scores range from one to ten – a higher score indicates a better result.


There were no themes for which the trust’s 2018 scores were significantly higher (better) when compared to the 2017 survey. The trust’s 2018 scores for the following themes were significantly lower (worse) when compared to the 2017 survey:

• Safe environment – bullying and harassment

(Source: NHS Staff Survey 2018) The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April 2015. Trusts have to show progress against nine measures of equality in the workforce. The scores presented below are indicators relating to the comparative experiences of white and black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard. The data for indicators 1 to 4 and indicator 9 is supplied to CQC by NHS England, based on data from the Electronic Staff Record (ESR) or supplied by trusts to the NHS England WRES team, while indicators 5 to 8 are included in the NHS Staff Survey. Notes relating to the scores:

• These scores are un-weighted, or not adjusted.

• There are nine WRES metrics which we display as 10 indicators. However, not all indicators are available for all trusts; for example, if the trust has less than 11 responses for a staff


survey question, then the score would not be published.

• Note that the questions are not all oriented the same way: for 1a, 1b, 2, 4 and 7, a higher percentage is better while for indicators 3, 5, 6 and 8 a higher percentage is worse.

• The presence of a statistically significant difference between the experiences of BME and White staff may be caused by a variety of factors. Whether such differences are of regulatory significance will depend on individual trusts' circumstances.

As of May 2019, each of the ESR staffing indicators assessed above (indicators 1a to 3) showed a statistically significant difference in score between White and BME staff:

• 1a. In 2018, BME candidates were significantly less likely than White candidates to hold senior (band 8+) clinical roles (4.8% of BME staff compared to 12.8% of White staff). This remained similar to the previous year, 2017.

• 1b. In 2018, BME candidates were significantly less likely than White candidates to hold senior (band 8+) non-clinical roles (6.0% of BME staff compared to 16.1% of White staff). This remained similar to the previous year, 2017.

• 2. In 2018, BME candidates were significantly more likely than White candidates to get jobs for which they had been shortlisted (16.0% of BME staff compared to 19.5% of White staff). This has increased by 9.0% compared to the previous year, 2017.

• 3. In 2018, BME staff were significantly more likely than White staff to be disciplined (0.7% of BME staff compared to 0.3% of White staff) when compared to White staff. This remained


similar to the previous year, 2017. This indicator looks at the relative likelihood of staff entering the formal disciplinary process, as measured by the start of a formal disciplinary investigation.

Of the four indicators from the NHS staff survey 2018 shown above (indicator 5 to 8), the following indicators showed a statistically significant difference in score between White and BME staff:

• 7. 65.2% of BME staff believed that the trust provided equal opportunities for career progression and promotion (2018 NHS staff survey) which was significantly lower when compared to 80.9% of White staff. The score had remained similar when compared to the previous year, 2017.

• 8. 16.3% of BME staff experienced discrimination from a colleague or manager in the past year (2018 NHS staff survey which was significantly higher when compared to 10.7% of White staff. The score had remained similar when compared to the previous year, 2017.

There were three BME Voting Board Members at the trust, which was significantly different to the number expected, based on the overall percentage of BME staff. (Source: NHS Staff Survey 2018; NHS England)

We noted that WRES KPI data showed an improvement in terms of an increased likelihood of BAME staff being appointed from being shortlisted.

The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment.

The trust scored between 91.1% (December 2017) and 96.3% (June 2017) between June 2017 and May 2019.

From June 2017 to June 2018 recommendation rates fluctuated and throughout this period there were several points outside of the control limits. However, since then recommendation rates have been consistent.


The response rate chart below is included to give context, given that there were five data points in the Friends and Family test scores data above that were outside of the control limits. London North West Healthcare NHS Trust Friends and Family test response rate:

(Source: Friends and Family Test)

Sickness absence rates:

The trust’s sickness absence levels from March 2018 to February 2019 were lower than the England average.

(Source: NHS Digital)


In the 2018 General Medical Council Survey the trust performed the same as expected for all of the indicators. (Source: General Medical Council National Training Scheme Survey)

Governance

The trust governance framework was built around the trust board and the trust board committee

structure. We noted at our last inspection that the previous structure of governance committees

which had been in place since 2015 had become unwieldy with the risk of duplication of

responsibilities between the various committees. In November 2018, the structure was slimmed

down, with three board sub-committees – clinical excellence, integrated governance and patient

and staff committees being subsumed into an overall Quality and Safety Committee. In addition to

this latter committee, there still existed the appointments and remuneration committee, audit

committee, finance and performance committee, charitable funds management committee and

workforce and equality committee. Although the pillars of a new committee structure were now in

place it had yet to mature and it was too early to comment on the structure’s overall effectiveness.

We were concerned that the chair was also the chair of the audit committee albeit on an interim

basis until new the audit committee chair was appointed. In our opinion this was a conflict of

interest.

The trust non-executive directors had responsibilities for challenging and supporting the executive

directors in decision making and on the trust’s strategy. They also held collective accountability

with the executive directors for the exercise of their powers and for the performance of the trust.

Papers for board meetings and other committees were of a reasonable standard and contained

appropriate information. There were some board and committee papers which were data rich but

less clear about progress or improvements being made and actions being closed off as completed

from board meeting to board meeting.

Two recent governance external reviews had between them highlighted the following areas of

development, namely increasing the governance links for example between the clinical

governance team, divisions and the chief nurse and between other functions such as legal,

complaints and end of life care. It was noted that the new chief nurse had already started to make

a difference in supporting and raising the profile of the trust’s safety culture.

It was acknowledged by trust representatives of the 22 strong governance team that divisional

knowledge and practice of governance was varied and that there was a need to have a systematic

approach to give assurances across the divisions in respect of roles and achievement of common

high standards of governance. The team were proud of good working relationships between

clinical governance and the divisions to achieve those common standards and good collaborative

working between trust sites and in multi-disciplinary meetings (MDTs). The team commented that

despite receiving two external governance reviews they were unclear as to board plans in this

area.

Non-executive and executive directors were largely clear about their areas of responsibility. A

clear framework set out the structure of ward, team, division and senior trust meetings. Managers

used meetings to share essential information such as learning from incidents and complaints and

to take action as needed. However, we have noted elsewhere that sometimes in trust

documentation, confirmation that actions had been completed were sometimes missing. The trust

divisions had established governance groups which were responsible to ensuring standards were


achieved within their services. The divisional governance groups met monthly and received

monthly reports to enable them to monitor performance and review progress. Each division

produced monthly reports to the clinical quality and risk group.

In our 2018 report we criticised the Board Assurance Framework (BAF) as needing further

development. We found that little had been done to develop this further. While the structure was

reasonable and logical, the content remained light in detail. There was no information detailing

external assurance which might be included. The Chair of the Audit Committee acknowledged that

more work was still needed on the BAF. Most of the information was in summary form with little

evidence of clear links to the risk register. We were not assured that the board would have

sufficiently clear oversight of risk in the BAF document. The Director of Corporate Affairs who had

joined the trust recently in April 2019, stated that there was a forward plan to redraw the BAF and

bring it back to the board but could not be specific about timescales. We felt that little so far had

been done to address the issues relating to the BAF that had been raised a year earlier.

The Board Assurance Framework detailed six strategic objectives and accompanying risks from

divisional and local risk registers that were rated as 15 or above.

There were currently just five strategic risks identified, whereas it would be reasonable to have

between three to five per objective/ goal (i.e. around a total of 15 strategic risks).

The BAF had an overarching ‘heat map’ which was good practice and showed at a glance the risk

scores for all objectives.

Two of the five risks had been given an assurance strength of reasonable assurance with three

risks assigned partial assurance. The BAF had been reviewed by the following committees:

Quality & Assurance Committee - last reviewed 08/05/2019; Workforce & Development Committee

and the Finance & Performance Committee – last reviewed May 2019; Finance & Performance

Committee – last reviewed 28/01/2019, and trust board - last reviewed 07/03/2019.

There were plans in place for emergencies. For example, adverse weather, a flu outbreak, natural

disaster, terrorist incident or a disruption to business continuity. The trust stated that it had in place

plans that were compliant with the requirements of the NHS England Emergency Planning

Resilience and Response Framework 2015 and associated guidance. The trust emergency

preparedness team continued to work with partner agencies across three local boroughs to plan

for all types of foreseen incidents. At the same time, the trust participated in a number of multi-

agency major incident exercises and associated business continuity preparations and

arrangements. The team had placed the trust on standby during the Grenfell Tower fire disaster to

offer and provide support even though this was out of area.

Where cost improvements were taking place, there were arrangements to consider the impact on

patient care. Managers monitored changes for potential impact on quality and sustainability. The

trust stated in its latest report and accounts that it would deliver a financial strategy that supported

the sustainability of the trust which would not impact on the quality of patient care. The trust was

signed up to the Sustainability and Transformation Plan (STP) for North West London which aimed

to set out the plans for more integrated healthcare while increasing local accountability.

The trust had a cost improvement plan of £29 million. The bulk of this plan was phased into the

last six months of the financial year. There were £11 million savings still unidentified. Some

managers complained that individual CIP targets had been set at the same level across the board

and were doubtful of meeting their target placing into doubt the contribution to the cost efficiencies

and financial performance of the trust.


The trust provided their Board Assurance Framework, which details six strategic objectives within

each and accompanying risks. A summary of these is below:

1. Improving focus on quality and safety

2. Improving patient experience, satisfaction and engagement

3. Creating a sustainable workforce that is lead and engaged in developing and improving

services

4. Ensuring financial stability

5. Planning for the future

6. Continuing the journey to becoming an excellent integrated care organisation

(Source: Trust Board Assurance Framework – March 2019)

Management of risk, issues and performance

In terms of financial governance, despite making significant gains in operational performance over

the previous 12 months and having sound financial governance processes in place, these

improvements were not mirrored in financial performance. In financial year 2018/19 the trust met

its Control Total (before Provider Sustainability Funding), but this was largely due to non-recurrent

profit on land disposals. Improvements made in financial year 2017/18 to the underlying deficit

position had not been sustained in financial year 2018/19. The underlying deficit position has

worsened from £82.9m in financial year 2017/18 to £88.9m in financial year 2018/19 driven by

failure to deliver recurrently the efficiency plan.

For the current financial year 2019/20 the Trust was set a control total of £35.7 million deficit which

included £32.2 million of provider sustainability funding (PSF), financial recovery funding (FRF)

and marginal rate emergency tariff (MRET) allocation. The trust was alone in London for not

accepting this control total although the board were satisfied with the reasons for that decision.

In view of its challenging financial position the trust was in need to produce a plan to improve that

position, improve its productivity and minimise its external funding requirements.

Financial metrics Historical data Projections

Previous Financial Year (2016/17)

Last Financial Year (2017/18)

This Financial Year (2018/19)

Next Financial Year (2019/20)

Income £681.1m £701.4m £751.4m £659.8m

Surplus (deficit) (£84.1m) (£45.9m) (£27.7m)

Full Costs £765.2m £747.5m £779.1m £757.4m

Budget (or budget deficit)

(£61.5m) (£49.5m) (£31.4m) (£97.0m)

The deficit reported in 2017/18 was lower than the previous year. Projections for 2018/19 indicated that the deficit will decrease, however the planned budget deficit for 2019/20 was more than three times the deficit in 2018/19. (Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

The trust provided a document detailing their 28 highest profile risks. Each of these have a current risk score of 16 or higher out of 25. Details of the risks with the highest score of 20 are


shown below:

Date risk opened

ID Description Risk score (current)

Risk level (target)

Last review date

13/12/2016 61 Water infrastructure and operating practices at Ealing hospital site.

20 10 12/02/2019

13/12/2016 88 Risk of harm to children and young people requiring critical care level 2

20 6 12/03/2019

25/01/2017 382 Equipment replacement programme for aging equipment in Radiology

20 4 26/02/2019

30/11/2017 668 Estates development for sexual health - Hillingdon sector.

20 4 21/03/2019

30/01/2018 697 Risk of digital infrastructure failure

20 12 12/02/2019

27/03/2018 762 Lack of capital investment in priority business cases and/or backlog.

20 10 31/01/2019

06/08/2018 838 NWP site bed capacity constraints

20 6 08/03/2019

06/08/2018 839 Ealing Hospital and acute services future sustainability

20 8 08/03/2019

06/02/2019 917

Support for maintaining equipment in Ealing Hospital cardiac catheterisation laboratory

20 4 21/03/2019

07/02/2019 923 Inconsistent completion of documentation

20 6 21/03/2019

(Source: Trust Corporate Risk Register)

The Audit Committee reviewed the establishment and maintenance of integrated governance, risk

management and internal control across clinical and non-clinical activities of the trust and reported

on these to the board. The chair of this committee had a realistic approach and good insight into

the risks of the organisation. There was a recognition that more work needed to be done to align

the organisation’s risks with the Board Assurance Framework and there was good insight into the

relationship with finance. There was a proactive approach and internal auditors were being

commissioned to look at specific areas of concern. The Committee did not work in isolation and

there were good links with other committees of the trust and with external auditors.

Day to day operational risks were being managed well, exemplified by improved operational

performance driven by newly energised Divisional General Managers, Divisional Clinical Directors

and senior nursing staff, coordinated by the chief operating officer (COO). This was with the

exception of patient flow, affecting overall performance and caused in part by delayed discharges,

as well as difficulty meeting referral to treatment (RTT) targets.

Overall risk management functions needed time to mature and senior managers recognised this.

The trust risk register lacked detail and there was insufficient direct link to the Board Assurance

Framework (BAF). Evidence of completing actions to show that risks had been mitigated was also

lacking. The trust relied on external parties and consultant organisations to identify risks before the


trust started to address them and there was less evidence of risks identified through internal

processes first before being acted upon. One senior leader of the trust commented that the trust

risk register did not contain sufficient detail for the board to be assured that risks were being

effectively managed. The trust governance team were also of the opinion that more work needed

to be done within divisions to monitor and close off actions on the risk register.

The trust had a system for the management of safety alerts. This process was overseen by the

trust Patient Safety Committee. Action plans were produced, and copies of the trust medicines

incident policy were available to staff via the intranet. Staff across the trust knew how to use the

Datix® system to report medicines incidents. All medicines incident reports were sent to the

pharmacy department to review. Outcomes were discussed with team members, including

prescribers and ward pharmacists, along with shared learning sent out to wards in the form of

newsletters and emails. This ensured that learning was accessible to all staff across the trust.

The trust had a pharmacy risk register and concerns voiced included the restriction in dispensary

space at the pharmacy department, the aseptic unit and shortage of some medicines. Currently, a

business case proposal had been done to increase the resources in these areas to mitigate the

risk, and the department were awaiting further news on funding for the electronic prescribing and

medicines administration IT system (EPMA).

Our review of trust safeguarding of children and adults indicated that there was still some progress

to be made. We found a lack of outcomes recorded for many of the safeguarding incidents

referred to local authorities (LA). If there was no feedback from the LA there was no escalation

from the trust. Out of the three local authorities, the trust had recently begun a feedback meeting

with one of them. There appeared to be a lack of evidence of action points completed arising out

of assurance visits by the local authority. Record keeping contained inconsistencies although the

trust had recently gained acceptance for a common safeguarding referral form across its three

local authorities. An annual safeguarding report was produced for the board but we found no

evidence of a safeguarding strategy attached to it. We saw a one-page safeguarding action plan

but little evidence of documented completed actions.

We reviewed ten serious incidents. The investigation process and reports were of good quality

with learning and action points identified. Most were over the timeframe for completion with some

having significant delays although we noted that the length of delay had reduced over the previous

six months. We noted however that there were a number of outstanding actions, inconsistent sign-

off processes and it was not always clear who was ultimately responsible for ensuring all actions

had been completed. We noted that the STEIS template did not include a safeguarding trigger

question. It was apparent that more dedicated time was needed for staff to complete the SI

process particularly to meet timeframes and also to ensure actions had been completed and

learning disseminated as well as more overall control and oversight over the SI process.

Information management

The Senior Information Risk Owner (SIRO) for the trust was the Director of Strategy/Deputy Chief

Executive.

The trust reported four data security incidents, which met the Information Governor’s Office (ICO)

reporting threshold from April 2018 to March 2019. Two involved loss of inadequately protected

electronic equipment from NHS and non-NHS premises respectively. One was unauthorised

disclosure of information and one other undefined. Two of these incidents were reported as

Section 170 Offences under the Data Protection Act. The ICO subsequently concluded that the

trust had taken appropriate responsive action in both cases.


The national Data and Security and Protection (DSP) toolkit measures Data Protection

compliance. The trust failed to meet the mandatory requirements of the DSP but had developed

an action plan with the aim of meeting the standard required. It failed on training compliance, its

information asset transfer register, publication of data protection impact assessments and

confirmation of security clauses in third party contracts and supply.

Data security incidents were monitored through the trust’s information governance and cyber

security group which met bi-monthly and reported to the Risk and Quality Committee. Incidents

referred to the trust’s Caldicott Guardian. which was the Medical Director, were reported via the

DSP toolkit if they met the ICO reporting threshold. All other incidents below this threshold were

investigate d internally.

At its regular board meetings, the board received approved minutes from the committees, chaired

respectively by non-executive directors, sent to the board plus reports from its executive directors

providing updates and assurance in all areas of the trust ‘s activity as well as its monthly quality

report.

Leaders used meeting agendas to address quality and sustainability sufficiently at all levels across

the trust. Staff said they had access to all necessary information and were encouraged to

challenge its reliability. The trust was aware of its performance using KPIs and other metrics.

Team managers had access to a range of information to support them with their management role.

This included information on the performance of the service, staffing and patient care. Divisional

performance review documents included updates on finance, people, quality and safety as well as

performance. Financial performance information included trend analysis, financial forecasting,

financial risks and mitigations. Information was in an accessible format, timely, accurate and

identified areas for improvement. There were issues with capacity within the business intelligence

team and a tension between providing information externally and internally.

Systems were in place to collect data from wards and teams and this was not over burdensome

for front line staff. There were issues with capacity within the business intelligence team to provide

timely and accurate information and a tension between providing information externally and

internally.

Board minutes we reviewed indicated that the Board Integrated Performance Report was

discussed at every trust board meeting and that non-executive directors offered robust challenge

in these discussions.

IT systems and telephones were working well and they helped to improve the quality of care. Staff

had access to the IT equipment and systems needed to do their work, with the exception of

access to electronic patient records. However, one of the risks listed in the board assurance

framework was the trust potentially not having sufficient technology available to support its clinical

strategy.

Leaders and the trust submitted notifications to external bodies as required. These included

serious incidents, never events, unexpected deaths and information governance incidents and

breaches.

The trust had completed the Information Governance Toolkit assessment. An independent team

had audited it and the trust took action where needed. The trust information governance group met

quarterly. Internal auditors had monitored the information governance toolkit including information

security, records management and data quality.


Information governance systems were in place including confidentiality of patient records.

However, in our core service inspection despite these systems being in place, patient records

were left unsecured in different locations around the trust.

The trust still relied on paper patient records and it was noted that this was a hindrance to speedy

information to individual as well as a hindrance to data collection. The trust had put in a capital bid

in conjunction with a neighbouring NHS trust for an electronic patient record system. Although

capital authorisation was still awaited, both trusts had determined their preferred supplier in

anticipation of capital authorisation.

Engagement

The responsibility for engagement had passed from the Patient and Staff Committee to the Quality

and Safety Committee in November 2018. It was chaired by a non-executive director and its

executive sponsors were the chief nurse and medical director. Patient feedback was collected in

various ways including Friends and Family Test (FFT); websites; social media and letters. A total

of 87840 patients had completed the Friends and Family Test in 2017 with 94.8% of respondents

saying they would recommend the trust’s services to their friends and family. The board used

patient stories at board meetings to enable board members to better understand issues from the

patient’s perspective.

The ward, team and division had access to feedback from patients, carers and staff and were

using this to make improvements. Communication systems such as the intranet and newsletters

were in place to ensure staff, patients and carers had access to up to date information about the

work of the trust and the services they used.

Videoed patient stories were being used throughout the trust. Learning from these stories and

connecting with patient experience was being used to drive service improvement and more patient

centred care. Staff involved in these patient stories were given the opportunity to present any

changes and improvements made as a result. The trust Patient Advice and Liaison Service

(PALS) provided a drop-in service for patients, carers and families to provide positive or negative

feedback about services. The trust was also seeing an increase in feedback being received via

social media. We noted also that executive and non-executive board members were now more

visible in the trust.

The trust board meetings were held in public allowing public to access and give feedback. The

trust also held its first public open day in 2016 as a forum to meet the public that it served and this

was now an annual event.

In order to develop relationships further with external stakeholders, the medical director led the

trust transformation programme to accelerate change and improvement across the organisation.

The trust was engaged in collaborative work with external partners, such as involvement with

sustainability and transformation plans. The trust kept stakeholders informed about progress

against trust targets and standards and about progress against action plans for example arising

out of previous CQC inspections.

Improving patient experience, satisfaction and engagement was one of six objectives within the

trust’s vision.

The trust stated that plans were in place to work with patients, families and voluntary organisations

on the implementation of a revised Patient Experience Improvement Strategy. This was to focus

on patient and carer engagement, involvement and co-design of service delivery.


Much of these initiatives were in the planning stage. When we spoke with patient groups we were

informed of some dissatisfaction as they felt there were some improvements which could be made

to the switchboard and patient appointment letters at no or low cost. For example, patient groups

described that the administrative function around receiving letters and accessing the trust via

telephone was slow and often resulted in errors. The patient groups felt that having direct

telephone access to individual clinics and departments would be an improvement. Likewise,

patient groups informed us that there were often errors and inconsistency in appointment letters

across the trust, resulting in patients being sent the wrong hospital site or location and as a result

missing their appointment. There were complaints from patient groups about a general lack of

communication on the part of the trust. The patient group representatives from maternity and St

Marks Hospital which were more clearly defined units described a more positive situation than

found in the others generally around the trust.

Recognising themes based on communication and staff behaviour which arose from various

patient experience feedback channels, the trust introduced a HEART based element into its

annual appraisal for staff to identify and begin to address these issues on an individual basis. We

saw further examples whereby patient feedback influenced service design. For example, a new

fleet of patient transport ambulances offering greater comfort, enhanced mobility and patient

safety had been introduced following patient consultation and feedback.

In relation to staff engagement the trust explained that it was launching a “Conversation for Action”

initiative providing staff with a further forum of engagement with senior leaders across the

organisation.

Another aspect of engagement with staff was through the practical avenue of encouraging

behavioural change in staff in the area of waste management, recycling and environmental

sustainability.

The stakeholders of the trust included Brent CCG which was the sponsor CCG accompanied by

Harrow and Ealing CCGs. Other stakeholders included the local authorities of Ealing, Brent and

Harrow, local Healthwatch, voluntary organisations, NHSi, and Health Education England (HEE).

All the stakeholders attended a quality summit following the previous CQC inspection when the

trust’s action plan was adopted and supported. Key themes arising from the previous CQC

inspection at the Quality Summit included leadership, culture, patient experience and engagement,

maternity, Ealing Hospital, continuous quality improvement and patient flow. At a subsequent

public meeting held with Brent Health and Wellbeing Board the trust pledged to renew its

engagement activities with its local authority and CCG stakeholders.

The chief nurse and medical director were determined to make engagement with external

stakeholders a more collaborative relationship. An example of where more collaborative work was

needed was the issue of patient flow, particularly delayed discharges for difficult to place patients.

This was having an adverse effect on operational performance and greater collaboration was

needed between the trust and local authorities on a network basis to improve this situation.

The trust consulted with stakeholders to gain broad input in its annual Quality Account. This

described the priorities the trust intended to meet in the coming financial year. It was submitted to

the board for comment and approval and was also reviewed by external auditors.

Learning, continuous improvement and innovation

The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.


Question In days Current

performance

What is your internal target for responding to complaints? 3 100%

What is your target for completing a complaint? 40 80%

If you have a slightly longer target for complex complaints please indicate what that is here

N/A N/A

April 2018 to March 2019

Number of complaints resolved without formal process in the last 12 months?

4,192

(Source: Routine Provider Information Request (RPIR) – Complaints process overview tab) From April 2018 to March 2019, the trust received a total of 1,105 complaints. The highest number of complaints were for medical care, with 24.0% of total complaints, followed by outpatients (20.6%) and surgery (18.3%).

Core Service Number of complaints Percentage of total

Medical care 265 24.0%

Outpatients 228 20.6%

Surgery 202 18.3%

Urgent and emergency services 133 12.0%

Other 98 8.9%

Maternity 45 4.1%

Adults community 41 3.7%

Services for children and young people 30 2.7%

Diagnostics 21 1.9%

Gynaecology 13 1.2%

Critical care 7 0.6%

End of life care 7 0.6%

Community inpatients 7 0.6%

Provider wide 7 0.6%

Community children, young people and

families 1 0.1%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

From April 2018 to March 2019, the trust received a total of 189 compliments. The highest number of compliments were for medical care, with 38.1% of total compliments, followed by surgery (33.9%) followed by urgent and emergency care (10.1%). A breakdown by core service can be seen in the table below:

Core service Number of

compliments Percentage of

total

Medical care 72 38.1%

Surgery 64 33.9%

Urgent and Emergency Services 19 10.1%

Community Inpatients 15 7.9%

Outpatients 10 5.3%


Maternity 4 2.1%

Services for children and young people 2 1.1%

Other 2 1.1%

Diagnostics 1 0.5%

(Source: Routine Provider Information Request (RPIR) – Compliments) We reviewed ten complaint files. We found good quality response letters in most of them. The

majority were within the trust timescale of 40 days. There appeared to be a good monitoring of

timescales. Less effective was capturing learning. There was openness and honesty in

acknowledgement of complaints upheld and there was evidence of support to staff where

complaints had not been upheld. One complaint letter was however particularly thorough in

describing the lessons learnt and how learning was to be shared with staff. Duty of Candour was

evident with clear levels of apology and support.

In examining the trust review of deaths, we noted that they followed national guidance. The trust

reviewed all patient deaths whether expected or unexpected. The reported 75% compliance with

level one reviews and approximately 55% compliance with level two reviews. Paper as opposed to

electronic patient notes was a hamper to efficiency and it was hoped to have electronic notes in

about 18 months’ time. Deaths that met national triggers had a more in-depth review.

There were forty specialties across the trust to review inpatient deaths and each specialty had at

least one mortality lead. The mortality leads could review deaths themselves of assign them to a

reviewer. Mortality leads were present at mortality meetings (M&M) and the frequency of these

depended on the specialty.

Learning from deaths was disseminated from the learning from patient deaths group which met

monthly and information fed into the quality and safety committee. A quarterly report was

published for the board and for the public to see on the trust website. Learning was disseminated

to front line staff through divisional and ward meetings. Medical and nursing students learned via

the teaching hospital sessions; via trust induction processes and post graduate programmes. The

trust gave us several examples of improvements to care and treatment which had resulted directly

from learning from deaths.

The trust was 100% compliant in completing all national clinical audits on the national register for

acute trusts for the previous two years. The trust published results of its national clinical audits and

NICE recommendations in the same way via the trust intranet. The trust had a key performance

indicator (KPI) of implementing learning from national audit results although the resultant action

plans may take longer to complete. For local audits there was a control mechanism within the

central governance team to check on validity before a local audit was authorised. This is done in

conjunction with the trust’s quality improvement plan.

The trust had a strong focus on continuous learning and improvement at all levels of the

organisation, including participation in research and the development of clinical and strategic

partnerships. The trust had a strong research and development programme which placed it in the

top ten per cent of research-active NHS organisations. This was aimed at improving patient care

through innovation and new treatments. Over 50% of the 154 Caldecott Guardian requests in the

year to April 2019 were for research projects. The majority of the remainder were for local audit.


NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The table below shows which of the trust’s services have been awarded an accreditation.

Accreditation scheme name Service accredited

Joint Advisory Group on Endoscopy (JAG)

St Marks Hospital Endoscopy (October 2018 – Deferred until August 2019) Central Middlesex Hospital Endoscopy (April 2018) Ealing Hospital Endoscopy (engaged but not yet accredited)

Clinical Pathology Accreditation and its successor Medical Laboratories ISO 15189

Bowel cancer screening Hub (10/7/18) TDL Laboratories (27/2/18)

MacMillan Quality Environment Award (MQEM)

Macmillan Cancer Information Centre Northwick Park

(Source: Routine Provider Information Request (RPIR) – Accreditations tab)


Acute services

Ealing Hospital

Uxbridge Rd

Southall

UB1 3HW

Tel: 020 8967 5000

https://lnwh.nhs.uk/ealing-hospital/

Urgent and emergency care

Facts and data about this service The emergency department at Ealing Hospital provides care for the local adult population 24 hours a day, seven days a week.

The emergency department at Ealing hospital is located alongside an Urgent Care Centre (UCC). The UCC at Ealing hospital is not managed or staffed by staff from London North West Healthcare Trust and was not inspected as part of this inspection. However, we looked at how the Ealing Hospital emergency department and the UCC worked together in determining whether patients would be seen in the emergency department or in the UCC. The role of the UCC is to manage people with minor illnesses to avoid inappropriate pressure on the emergency department. Patients presented to the department either by walking into the reception area or by ambulance. Those requiring immediate treatment were taken to the resuscitation area. Patients who walked into the ED registered at reception and then saw a triage nurse for an initial assessment. This initial assessment was carried out by the urgent care centre which was registered by a different provider. Patients were prioritised to be seen depending on their acuity and would be streamed to be seen in majors. The department has different clinical areas where a patient can be treated depending on their needs, including: resuscitation, majors, clinical decisions unit (CDU) and ambulatory care. If a child (under 18) presented at the service acutely unwell, the service would stabilise and then immediately transfer to Northwick Park. Additionally, the trust provides an integrated intermediate care service known as STARRS (short term assessment rehabilitation reablement service) which aims to reduce hospital admissions and reduce the length of stay of patients in hospital by continuing their care at home. This is a multi-disciplinary team of nurses, physiotherapists, occupational therapists, therapy technicians, social workers, consultant physician, dietitians, health care support workers, paramedics, administration team and a man with a van. There is also a rapid response team, which is commissioned by a local CCG. The service aims to avoid emergency department attendances and hospital admissions. Patients are assessed in their own home within two hours of a telephone referral. The team is led by an elderly care consultant


and provides clinical, rehabilitation and social support. Referrals are accepted from GPs, ambulance services and the complex patient management group (CPMG). The team is also present in the emergency department at Northwick Park Hospital, assessing patients to prevent hospital admissions. The ambulatory care services provide patient care, aimed at preventing hospital admissions. There are pathways in place for direct GP referrals, outpatient diagnostics, working with the urgent care centre and direct access to inpatient services. The assessment units provide support with the flow through the emergency department to the ward areas and facilitate the patient’s acute admission from the emergency departments. The trust commented that both sites experienced on going recruitment issues where national and international recruitment campaigns continued within the department for both nursing and medical staff to reduce reliance on temporary staffing. However, pressure had reduced at Ealing Hospital following the announcement from the government regarding Shaping a Healthier Future which confirmed there would be no changes to the emergency department provision at this site. The urgent care centres are run by a primary care provider as a GP-led minor injury and illness centre. We inspected the ED over two days during an announced inspection. We looked at all areas of the department. We spoke with 35 members of staff, looked at 21 medical records and spoke with six patients and two relatives. Activity and patient throughput Total number of urgent and emergency care attendances at London North West University Healthcare NHS Trust compared to all acute trusts in England, February 2018 to January 2019:

From February 2018 to January 2019 there were 144,549 attendances at the trust’s urgent and emergency care services as indicated in the chart above. (Source: Hospital Episode Statistics) Urgent and emergency care attendances resulting in an admission:


The percentage of A&E attendances at this trust that resulted in an admission in 2018/19 was higher than the previous year. In 2017/18 the proportion was the same as the England average, however, for 2018/19, it was higher. (Source: NHS England) Urgent and emergency care attendances by disposal method, from February 2018 to January 2019:

* Discharged includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment

(Source: Hospital Episode Statistics)


Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training

The service provided mandatory training in key skills including the highest level of life support training to all staff and made sure everyone completed it. The emergency department provided training in key skills to all staff, the mandatory training requirements for nursing and midwifery staff and medical staff is detailed in the tables below. Training was provided via e-learning modules or face-to-face sessions. Staff we spoke with confirmed they had undertaken mandatory training and no concerns with accessing additional training. The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in the urgent and emergency care department at Ealing Hospital is shown below:

Training module name


Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

Manual handling - level 2 (online) 1 1 100.0% 85.0% Yes

Health & safety 96 97 99.0% 85.0% Yes

Equality diversity and human rights 94 97 96.9% 85.0% Yes

Infection control clinical 94 97 96.9% 85.0% Yes

Resuscitation (BLS) 93 97 95.9% 85.0% Yes

Conflict resolution 93 97 95.9% 85.0% Yes

Information governance 93 97 95.9% 85.0% Yes

Fire safety acute clinical 84 97 86.6% 85.0% Yes

Manual handling - level 2 (face to face) 81 96 84.4% 85.0% No

At Ealing Hospital urgent and emergency care department the target was met for eight of the nine mandatory training modules for which qualified nursing staff were eligible, with the remaining module having a compliance rate just below the target. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for medical staff in the urgent and emergency care department at Ealing Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

Information governance 51 65 78.5% 85.0% No

Infection control clinical 43 60 71.7% 85.0% No

Fire safety acute clinical 41 60 68.3% 85.0% No

Health & safety 42 65 64.6% 85.0% No


Equality diversity and human rights 41 65 63.1% 85.0% No

Conflict resolution 14 24 58.3% 85.0% No

Manual handling - level 2 (online) 30 60 50.0% 85.0% No

Resuscitation (BLS) 27 65 41.5% 85.0% No

At Ealing Hospital urgent and emergency care department the target was met for none of the eight mandatory training modules for which medical staff were eligible. During the inspection we discussed mandatory training with the service leadership and were provided with updated mandatory training compliance figures. The department was meeting the trust target of 85% in all but three mandatory training sessions: Fire Safety (83%), PREVENT (83%) and Safeguarding children level 3 (18.75%). When we questioned medical staff on the low training rates they informed us that where rates were low, doctors were being placed on courses. We were provided with evidence that the staff who were not up to date were booked on courses to bring them up to date by the end of the year. The service had also made changes to the training programme to ensure that staff could catch up with e-learning at home. We were assured that where training figures were low for Basic Life Support training, it was because medical staff received advanced life support training instead.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 85% for completion of safeguarding training. Staff demonstrated a thorough awareness of safeguarding procedures and described how they had involved safeguarding teams when they had concerns. Staff confirmed they had received training in safeguarding adults and children (level 2 and 3). Safeguarding training also covered female genital mutilation (FGM) and child sexual exploitation (CSE). Where women were identified as having suffered FGM or were at risk of FGM, cases were referred to the safeguarding team and the local authority. If a patient with FGM was under 18, the case would be reported to the police as well as the local authority. In the year a prior to our inspection there were two patients with FGM who presented at the ED. The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for qualified nursing staff in the urgent and emergency care department at Ealing Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

PREVENT 97 97 100.0% 85.0% Yes

Safeguarding children level 2 30 30 100.0% 85.0% Yes

Safeguarding adults level 2 90 93 96.8% 85.0% Yes


Safeguarding children level 3 12 14 83.5% 85.0% No


At Ealing Hospital urgent and emergency care department the target was met for three of the five safeguarding training modules for which qualified nursing staff were eligible. Neither of the level 3 modules met the target. It should be noted there were low numbers of eligible staff for some of the modules which may have impacted on the rates. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in the urgent and emergency care department at Ealing Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)


Safeguarding adults level 2 41 60 68.3% 85.0% No

PREVENT 29 65 44.6% 85.0% No

At Ealing Hospital urgent and emergency care department the target was met for none of the three safeguarding training modules for which medical staff were eligible. The service informed us that where staff were behind on training, they had been placed on an upcoming course. As well as a central safeguarding team being in place, there was a safeguarding lead present in the department. Every Thursday morning there were safety net meetings that discussed all safeguarding queries and referrals. Present at the meetings were liaison health visitors, named nurses, doctors, substance misuse team and social services. Senior staff from the ED were also present. Staff received weekly reports on all safeguarding queries. To ensure that all safeguarding concerns were picked up by staff on the shop floor, it was a mandatory question on the online system. Staff had to ensure that issues with domestic violence and safeguarding queries were picked up before they could advance to the next stage of the records. The service had preventative measures for ensuring that at risk children were not being forgotten. For example, the service used the Child Protection Information System (CPIS) when a referral for a child had to be made. This system enabled the service to see if the child had ever been booked in anywhere else. If this were the case, it would flag on the electronic system. The service had bedrails policy in place. This policy outlined the guidance around the proper use of restraints. Any individual requiring restraint would first have to have a detailed risk assessment in place. The service audited the use of IV tranquilisation. There had been no such uses in the 12 months prior to our inspection.

Cleanliness, infection control and hygiene

The service-controlled infection risk well. Staff used equipment and control measures to

protect patients, themselves and others from infection. They kept equipment and the

premises visibly clean.

The emergency department was visibly clean and tidy. Hand sanitiser dispensers were available

and located at appropriate places throughout the clinical areas to encourage frequent use by staff

and visitors.


All the staff we saw adhered to the national policy of bare below the elbows. Hand wash basins

and personal protective equipment including gloves and aprons were available throughout the

emergency department. We observed staff washing their hands before attending to patients. Staff

put on fresh aprons and gloves before giving personal care to patients and these were changed in

between patients. We saw staff disposed of clinical waste safely.

The service carried out weekly hand hygiene audits. We observed three such audits carried out

over June 2019. The service received 100% in two of these audits. In the audit carried out week

commencing 18 June 2019, the service received 60% compliance in hand hygiene. The top failure

in this audit was staff members not using soap and water to wash their hands between patients.

Poor audit results were shared with staff and staff were encouraged to improve.

Environment and equipment

The design, maintenance and use of facilities, premises, vehicles and equipment kept

people safe. Staff were trained to use them. Staff managed clinical waste well.

The emergency department at Ealing Hospital was located on the ground floor of the main site and

comprised of the following clinical areas:

- Urgent Care Centre (which was provided by a different service)

- Resuscitation area – with three adult trolleys and one paediatric trolley.

- A majors area – with nine trolleys and two side rooms.

- Accident and emergency clinical decisions unit (CDU) with eight bays and two side rooms.

- Ambulatory care unit with three chairs and two side rooms.

The resuscitation unit could be accessed by two means. Firstly, by patients who came in to the

service on foot. Secondly, there was a corridor linking the area where the ambulances came in.

This helped ambulance staff safely transfer patients from the ambulance to the resuscitation area.

The bays in the resuscitation area were adequately sized with enough room for a full resuscitation

team as well as emergency equipment. Curtains separated bays from one another, which enabled

dignity and privacy for patients. The paediatric bay was opposite the adult bay. It could be

separated by a curtain and was colourful and friendly. We checked the resuscitation equipment for

paediatric patients and found that all sizes of equipment were present and regularly reviewed. If

there was more than one child at a time, they would occupy the adult bay opposite, but we were

assured this rarely happened.

The majors area was designed with the doctors and nurses station close to the centre, so

clinicians and nurses could see most of the patients at any given time.

The emergency department (ED) was close to x-ray, CT and MRI facilities, which allowed for

diagnostic procedures to be completed quickly.

We saw that the maintenance and use of equipment kept people safe. We looked at all the

resuscitation trolleys and resuscitation grab bags in the ED. Each trolley was sealed with a

numbered tag and we found that the contents were present, in date and checklists were

completed daily by appropriate staff in most cases. In one case, we found some outdated single

use equipment, but once we informed staff they removed and replaced it.


We looked at various pieces of equipment and saw that they had a sticker indicating when they

had last been serviced and when the next service was due. The estates team assisted staff with

broken equipment.

Assessing and responding to patient risk

Staff completed risk assessments for each patient swiftly. They removed or minimised

risks and updated the assessments. Staff identified and quickly acted upon patients at risk

of deterioration.

Patients presented to the department either by walking into the reception area or by ambulance. Those requiring immediate treatment were taken to the resuscitation area. Patients who walked into the ED registered at reception and then saw a triage nurse for an initial assessment. Triage is the process of determining the priority of patients’ treatments based on the severity of their condition. This initial assessment was carried out by the urgent care centre which was registered by a different provider. Patients were prioritised to be seen depending on their acuity and would be streamed to be seen in majors. This meant that patients had to wait twice, firstly to be triaged at UCC then again once they had been streamed. This process meant that patients could be waiting in the department for a needlessly long time. Prior to arriving at the department, the ambulance service telephoned the department to alert them of the arrival of a patient. This would ensure a team was waiting for them on arrival. Ambulance staff would be met by a multidisciplinary team including medical staff, nursing staff and a band 3 phlebotomist. A senior doctor (ST4 or higher) would always be present in the rapid assessment treatment area. If a patient was critically unwell they would be taken directly to the resuscitation (resus) area. Here there were three adult bays and one paediatric bay. All staff that worked in the resus area were Immediate Life Support (ILS) trained. The urgent care centre (UCC) within the ED did see and treat patients of all ages as a 24-hour service but children under the age of 16 who required specialist input would be referred to one of the local dedicated paediatric EDs in the area. At our previous inspection, it was clear that there was a risk of acutely unwell children entering the department for urgent treatment. The service made the local community aware that they only stabilised and transferred unwell children. Since our last inspection, the service had put up posters at the entrance of the ED and at the UCC. These posters stated that they did not treat acutely unwell children. If an unwell child did present at ED, the service would stabilise in the resuscitation bay meant for children and transfer to Northwick Park within an hour of arrival. There were no registered paediatric nurses employed at Ealing hospital. On each shift there was at least one Paediatric Immediate Life Support (PILS) trained nurse. Overall, 85% of the nurses were trained in PILS, the remaining eight members of staff were new starters at the time of our inspection. The service maintained one bay in the resuscitation room designed for the management of paediatric patients. Within the bay they equipment especially for paediatric patients, this included paediatric resuscitation equipment, guidelines displayed at bedside and a transfer bag. We checked all the equipment in this bay and found that it was regularly checked as per policy and maintained adequately. The service completed an online incident form each time they had a paediatric patient admission at the ED. We saw the last three incidents and found them to be thorough with adequate information pertaining to the steps taken. The service also had a transfer policy for this process. We found that improvements could still be made in relation to severe sepsis and shock


management. The service audit revealed that with regards to 2019 compliance, only 54% of patients had their observations measured, this was down from 2017 compliance where 98% of patients had their observations measured. The service were aware that improvements could be made with regards to initial assessment, senior review and fluid balance. The trust scored worse than other trusts for one of the five Emergency Department Survey questions relevant to safety. The trust scored “about the same” as other trusts for the remaining four questions.

Question Score RAG

Q5. Once you arrived at the hospital, how long did you wait with the ambulance crew before your care was handed over to the emergency department staff?

7.8 About the same as other trusts

Q8. How long did you wait before you first spoke to a nurse or doctor?


Q9. Sometimes, people will first talk to a nurse or doctor and be examined later. From the time you arrived, how long did you wait before being examined by a doctor or nurse?


Q33. In your opinion, how clean was the emergency department? 8.3 About the same as other trusts

Q34. While you were in the emergency department, did you feel threatened by other patients or visitors?

9.2 Worse than other

trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) The median time from arrival to initial assessment was better than the overall England median for the 12-month period from April 2018 to March 2019. Trust performance followed a similar trend to the England average. Ambulance – Time to initial assessment from April 2018 to March 2019 at London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators) A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. From April 2018 to March 2019 the trust reported 760 “black breaches”, with low numbers in summer and early autumn and high numbers in the winter period.


The trust commented that demand and capacity issues led to the majority of the breaches and for 21 weeks the trust’s full capacity protocol/escalation process was in place. (Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

Nurse staffing

The service had enough nursing and support staff with the right qualifications, skills,

training and experience to keep patients safe from avoidable harm and to provide the right

care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix,

and gave bank and agency staff a full induction.

The trust planned and reviewed staffing levels and skill mix so that people received safe care and

treatment. The trust used Royal College of Nursing, National Quality Board and NICE Guidelines

as tools to plan staffing requirements in ED. The trust

The trust had a sickness leave target of 4% for qualified nursing staff. Monthly sickness rates


from April 2018 to March 2019 for nursing assistants in urgent and emergency care at Ealing Hospital showed an upward trend from April 2018 to August 2018. This was due to a staff member being on long term sickness leave. On average the annual sickness rate was 7.2%. Senior staff were aware of the sickness rate and used regular bank staff to mitigate against this.

Monthly bank hours from April 2018 to March 2019 for nursing assistants in urgent and emergency care at Ealing Hospital showed an upward trend from October 2018 to March 2019 due to staff sickness.

Medical staffing

The service had enough medical staff with the right qualifications, skills, training and

experience to keep patients safe from avoidable harm and to provide the right care and

treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave

locum staff a full induction.

We always saw staffing levels and skill mix planned and reviewed so that people received safe

care and treatment. We saw a minimum of a consultant presence, with a consultant on call out of

hours, and a minimum of an ST4 in the department 24/7, in line with Royal College of Emergency

Medicine (RCEM) guidelines.

From April 2018 to March 2019, the breakdown of WTE staff in post in urgent and emergency care at Ealing Hospital is shown in the chart below.


Urgent and emergency care annual staffing metrics

(April 2018 to March 2019)

Staff group Annual average establishment

Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)

Annual agency/ locum hours (% of

available hours)

Annual unfilled hours (% of

available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 294.4 24.7% 13.0% 5.2%

Qualified nurses

170.3 35.9%** 15.0% 7.2% 35,092 (13.5%)

59,542 (23.0%)

11,854 (4.6%)

Nursing assistants

38.9 4.7% 21.6% 6.2% 21,967 (29.2%)

0 (0.0%)

0 (0.0%)

Medical staff 51.0 15.0% 2.7% 0.7% 17,664 (22.2%)

10,946 (13.8%)

1,458 (1.8%)

* All staff includes other staff groups not specifically shown in the above table. ** Whilst on inspection the service confirmed the new figures for nursing staff vacancy. This figure was 10%, therefore below the trust target.

Monthly vacancy rates from April 2018 to March 2019 for all staff in urgent and emergency care at Ealing Hospital showed a shift from October 2018 to March 2019. The service was very proud of their recruitment drive and at the time of our inspection were able to get their vacancy rate for registered nurses down to 10%. This was below the trust target of 11%.


Monthly vacancy rates over the last 12 months for medical staff in urgent and emergency care at Ealing Hospital showed a shift from October 2018 to March 2019. Monthly turnover rates from April 2018 to March 2019 for all staff in urgent and emergency care at Ealing Hospital appeared to be stable with only random variation over the whole period.

Monthly bank hours from April 2018 to March 2019 for all staff in urgent and emergency care at Ealing Hospital showed an upward trend from October 2018 to March 2019 due to staff sickness. The service provided evidence that they used regular bank staff who were oriented with the department.


Monthly locum hours from April 2018 to March 2019 for medical staff in urgent and emergency care at Ealing Hospital showed an upward trend from April to November 20181. Locums were in use to cover medical staff shortages. The service informed us that locums had a full induction and if they were required they would be used on a day shift so that they could shadow a consultant. All locums would be provided with their own login details and would have to discuss every case with a senior member of the medical team. To this end, only regular locum staff were used at the service.

Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date,

stored securely and easily available to all staff providing care.

Information governance training was part of the annual mandatory training requirement for all staff

working at the hospital, and 95% of nursing staff and 97% of medical staff in the ED had

completed this within the last year.

The service used paper-based records to store patient information and observations. Records

were stored in the staff area not accessible by the public.

Over the course of the inspection we reviewed 21 sets of medical records and found that most of

these complied with the General Medical Council (GMC) standards for documentation. In eight of

the records, the grade of the clinician was not clear on the notes. Two of the notes were not

signed and dated. All the notes we reviewed were compliant with Nursing & Midwifery Council

(NMC) standards for documentation.

Where applicable (for example in majors) all patients had their National Early Warning Score

calculated accurately and recorded. NEWS is a tool developed by the Royal College of Physicians

which improves the detection and response to clinical deterioration in adult patients and is a key

element of patient safety and improving patient outcomes.

We saw a three-month snapshot of documentation audits performed by the service. Results of

documentation audits were between 80%-100% compliance. This was not the case in June 2019

where the service scored itself 67% for the SKINN bundle completion.

1 (Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Bank agency and locum tabs)


Medicines

The service used systems and processes to safely prescribe, record and store medicines.

Medicines were stored appropriately in locked cupboards and treatment rooms. Lockable fridges

were available for those drugs needing refrigeration. Fridge temperatures were recorded daily to

ensure medicines were stored within the correct temperature range. Record logs we checked

confirmed that fridge temperatures were within range.

In clinical areas, staff kept medicines and intravenous (IV) fluids in locked cupboards with

restricted access to ensure security. All medicines that we checked were within date. Some

prescription medicines are controlled under the Misuse of Drugs legislation (and subsequent

amendments). These medicines are called controlled medicines or controlled drugs (CDs) and

their storage and dispensing are regulated by legislation. CDs were stored in locked cupboards,

which a registered nurse held the keys for and which were checked twice a day. Two qualified

nurses checked drug stock daily. We checked the CD register and found that all entries were

completed in line with best practice. We saw that the CD keys were kept with the nurse in charge,

separate from other keys in line with best practice.

Over the course of our inspection we checked 21 prescription records. We found that in three

cases, the allergy status of the patient had not been clearly documented. We also found that

appropriate analgesia was prescribed in all relevant cases within a timely manner. Where

indicated, we found that antibiotics were prescribed and administered in a timely way.

We reviewed the prescribing of antibiotics and found that all clear indications for use and duration

of treatment documented. We saw clear protocols in place for the administration and prescribing of

antibiotics.

The service had access to an on-site pharmacist and to take out (TTO) medication could be

prepped and delivered by the pharmacy team.

Prior to our inspection we requested any audit results relating to medicines. This information was

not provided.

Incidents

The service managed patient safety incidents well. Staff recognised and reported incidents

and near misses. Managers investigated incidents and shared lessons learned with the

whole team and the wider service. When things went wrong, staff apologised and gave

patients honest information and suitable support.

Trust level In accordance with the Serious Incident Framework 2015, the trust reported 15 serious incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS England from May 2018 to April 2019. A breakdown of incidents by incident type are below.

Incident type Number of incidents

Percentage of total

Treatment delay 6 40.0%

Diagnostic incident including delay (including failure to act on test results)

2 13.3%

Sub-optimal care of the deteriorating patient 1 6.7%

Pending review* 1 6.7%


Slips/trips/falls 1 6.7%

Surgical/invasive procedure incident 1 6.7%

Maternity/Obstetric incident: mother and baby (this include foetus, neonate and infant)

1 6.7%

Abuse/alleged abuse of child patient by third party 1 6.7%

Maternity/Obstetric incident: mother only 1 6.7%

Total 15 100.0%

* this is the never event described above A breakdown of incidents within urgent and emergency care at Ealing is in the table below.


Percentage of total


2 40.0%



Total 5 100.0%

The remaining incident took place at the patient’s home.2 Between July 2018 and July 2019, the ED reported 1228 incidents. Of these, 224 (18.3%) were

near miss, 865 (70.6%) were no harm, 105 (8.6%) were low harm, 28 (2.3%) were moderate harm

and three (0.2%) were severe/major harm.

An incident reporting procedure was in place and staff reported incidents via an electronic

reporting system. Staff knew how to report an incident and informed us that they received

immediate feedback from any incidents reported because they were a small team. This

information was also fed into staff meetings where action plans were also discussed.

Feedback and learning points from incidents were shared with staff via team meetings and the

service intranet. Staff nurses informed us the clinical practice facilitator provided additional training

in areas where there had been incidents.

The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of certain

‘notifiable safety incidents’ and provide reasonable support to that person. Staff at all levels were

aware of the expectation of openness when care and treatment did not go according to plan.

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

From May 2018 to April 2019, the trust reported one never event for urgent and emergency care.

The incident occurred in January 2019 at Northwick Park Hospital and related to the unintentional

connection of a patient requiring oxygen to an air flowmeter.3

The service conducted Mortality & Morbidity (M&M’s) every month. This formed part of the clinical

governance structure and nurses attended to ensure collective learning.

2 (Source: Strategic Executive Information System (STEIS))

3 (Source: Strategic Executive Information System (STEIS))


Safety thermometer

The service used monitoring results well to improve safety. Staff collected safety

information and made it publicly available.

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month. A suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of the suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and one new urinary tract infections in patients with a catheter from March 2018 to March 2019 within urgent and emergency care.4

Is the service effective?

Evidence-based care and treatment

The service provided care and treatment based on national guidance and evidence-based

practice. Managers checked to make sure staff followed guidance. Staff protected the

rights of patients subject to the Mental Health Act 1983.

We saw staff access the hospital intranet to source professional policies and trust standard

operating procedures. Where relevant, these referred to the Royal College of Emergency Medicine

(RCEM), National Institute for Health and Care (NICE) guidelines.

We saw that the ED had an extensive audit programme that included national and local audits in

line with NICE guidelines. Both clinical and nursing staff led on different audits and the service

maintained an audit calendar.

We saw that the rights of people subject to the mental Health Act 1983 (MHA) were protected and

staff had regard to the MHA Code of Practice. Staff of all levels demonstrated a good

understanding of the MHA.

Nutrition and hydration

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 needs.

We saw that people’s nutrition and hydration needs were assessed and met. Depending on how

long a patient remained in the ED, they could be offered food up to three times. If a patient was on

4 (Source: NHS Digital - Safety Thermometer)


the clinical decision unit (CDU) they could even be offered a hot meal. This was because a patient

could stay in the CDU for up to 24 hours in accordance with policy.

In the CQC Emergency Department Survey, the trust scored 6.0 for the question “Were you able

to get suitable food or drinks when you were in the emergency department?” This was about the

same as other trusts.5

Water was available in all areas if the department and we observed patients with drinks at their bedside.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain, and gave pain

relief in a timely way. They supported those unable to communicate using suitable

assessment tools and gave additional pain relief to ease pain.

We saw that patients pain levels were assessed and managed adequately. In the 21 records we

reviewed, all patients had pain assessment scores completed at the same time as their

observations. The service implemented the Faculty of Pain Medicine’s Core Standards for Pain

Management (2015). We reviewed 21 records and found that in all of them the service

implemented standard 2 of the guidance which states that all patients with acute pain must have

an individualised analgesic plan appropriate to their clinical condition that is effective, safe and

flexible. All analgesia was prescribed and administered in a timely manner. Patients were asked

about pain at initial triage and we found that this was adequately followed up throughout the

patients stay in the department.

Where a patient was non-verbal due to learning disability, dementia, alcohol abuse or any other

reason, the service could make use of a range of pain scoring tools. Tools used in the department

included rating pain from one to ten (one being no pain and ten being a lot of pain). The trust also

made use of the Face, Legs, Activity, Cry and Consolability (FLACC) pain score.

At our last inspection we found that patients did not always have their pain reassessed. At this

inspection, we saw that all patients had their pain reassessed at least every hour in line with

RCEM guidelines. Patients we spoke with told us that pain relief had been offered to them and

they did not have to ask for it.

In the CQC Emergency Department Survey, the trust scored 5.0 for the question “How many

minutes after you requested pain relief medication did it take before you got it?” This was about

the same as other trusts. The trust scored 7.0 for the question “Do you think the hospital staff did

everything they could to help control your pain?” This was about the same as other trusts.6

Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make

improvements and achieved good outcomes for patients but were still below national

standards in several outcomes.

In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe

asthma audit, Ealing Hospital emergency department failed to meet any of the national

5 (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) 6 (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)


standards of 100%. The department was in the upper UK quartile for six standards: - Standard 2a (fundamental): As per RCEM standards, vital signs should be measured and

recorded on arrival at the emergency department. This department: 58.0%; UK: 26%. - Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given

within 10 minutes of arrival at the emergency department. This department: 42.0%; UK: 25%. - Standard 4 (fundamental): Add nebulised Ipratropium Bromide if there is a poor response to

nebulised β2 agonist bronchodilator therapy. This department: 87.2%; UK: 77%. - Standard 5a (fundamental): within 60 minutes of arrival (acute severe). This department:

50.0%; UK: 19%. - Standard 5b (fundamental): within 4 hours (moderate). This department: 57.7%; UK: 28%. (Source: Royal College of Emergency Medicine)

In the 2016/17 Consultant sign-off audit, Ealing Hospital emergency department failed to meet any of the national standards. The department was in the lower UK quartile for two standards, the applicable one being:

• Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years and over. This department: 0.0%; UK: 10%.

The department’s results for the remaining two standards were all within the middle 50% of results. (Source: Royal College of Emergency Medicine) In the 2016/17 Severe sepsis and septic shock audit, Ealing Hospital’s emergency department failed to meet any of the national standards. The department was in the upper UK quartile for three standards:

• Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement, temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary blood glucose recorded on arrival. This department: 98.0%; UK: 69.1%.

• Standard 4: Serum lactate measured within one hour of arrival. This department: 79.0%; UK: 60.0%.

• Standard 6: Fluids – first intravenous crystalloid fluid bolus (up to 30 mL/Kg) given within one hour of arrival. This department: 60.0%; UK: 43.2%.

The department was in the lower UK quartile for three standards:

• Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or involvement of critical care medic (including the outreach team or equivalent) before leaving the emergency department. This department: 24.0%; UK: 64.6%.

• Standard 3: O2 was initiated to maintain SaO2>94% (unless there is a documented reason not to) within one hour of arrival. This department: 8.0%; UK: 30.4%.

• Standard 5: Blood cultures obtained within one hour of arrival. This department: 0.0%; UK:


44.9%. The department’s results for the remaining two standards were all within the middle 50% of results. (Source: Royal College of Emergency Medicine) The table below summarises Ealing Hospitals performance in the 2018 Trauma Audit and Research Network audit. The TARN audit captures any patient who is admitted to a nonmedical ward or transferred out to another hospital (e.g. for specialist care) whose initial complaint was trauma (including shootings, stabbings, falls, vehicle or sporting accidents, fires or assaults).

Metrics (Audit measures)

Hospital performance

Audit Rating Meets national

standard?

Case Ascertainment (Proportion of eligible cases reported to TARN compared against Hospital Episode Statistics data)

92.3 - 100+% Good ✓

Crude median time from arrival to CT scan of the head for patients with traumatic brain injury (Prompt diagnosis of the severity of traumatic brain injury from a CT scan is critical to allowing appropriate treatment which minimises further brain injury.)

103 mins Takes longer than TARN aggregate

Crude proportion of eligible patients receiving Tranexamic Acid within 3 hours of injury (Prompt administration of tranexamic acid has been shown to significantly reduce the risk of death when given to trauma patients who are bleeding)

33.3% Lower than

TARN aggregate

N/A

Crude proportion of patients with severe open lower limb fracture receiving appropriately timed urgent and emergency care (Outcomes for this serious type of injury are optimised when urgent and emergency care is carried out in a timely fashion by appropriately trained specialists.)

Not eligible - N/A

Risk-adjusted in-hospital survival rate following injury (This metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.)

4.4 additional survivors

Positive outlier ✓

(Source: TARN)

From April 2018 to March 2019, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and worse than the England average.


Unplanned re-attendance rate within seven days - London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators)

Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s

work performance and held supervision meetings with them to provide support and

development.

To keep up paediatric competencies, staff took part in ED simulation training once a month. Both

agency and bank staff would take part too.

We saw a structured teaching and clinical supervision programme in place for all medical staff.

Junior doctors attended bi-monthly training sessions, and middle grade staff attended training

throughout the month. Staff told us this time was protected to allow them to attend. Training for

medical staff included: rheumatology, Deprivation of Liberty (DoLs) and dermatology.

Junior doctors informed us that they received a two-day induction with access to additional

learning throughout the year. They did however inform us that teaching took place every other

week and that they would benefit from weekly sessions.

All new doctors and locums were provided with an induction handbook prior to starting to work in the department. The handbook provided them with a range of information including rotas, information about working in the department and several common protocols. From April 2018 to March 2019 87.0% of staff within urgent and emergency care at Ealing Hospital received an appraisal compared to a trust target of 85.0%.

Staff group


Staff who received an

appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Estates and ancillary 1 1 100.0% 85.0% Yes

Medical and dental 12 13 92.3% 85.0% Yes

Administrative and clerical 28 31 90.3% 85.0% Yes

Additional clinical services 30 35 85.7% 85.0% Yes


Nursing and midwifery registered 83 97 85.6% 85.0% Yes

All staff groups 154 177 87.0% 85.0% Yes

At Ealing Hospital, all five staff groups met the trust target, including medical and dental and nursing staff. (Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Multidisciplinary working

Doctors, nurses and other healthcare professionals worked together as a team to benefit

patients. They supported each other to provide good care.

We saw effective multidisciplinary working in the ED. Both nursing staff and medical staff told us

that there was good multidisciplinary working across the department. Interactions we observed

between all members of staff seemed cooperative and positive.

Specialities such as maxillofacial, eye and ear nose and throat were not available at Ealing, but

staff could contact staff within the trust if they required specialist input.

We saw that staff could access specialist support either via clinical nurse specialist or consultant

with the use of the trust directory.

The trust agreed a service level agreement with the neighbouring mental health trust to undertake all Mental Health Act administration and ensure that detained patients had their Section 132 rights read. Copies of detention papers were kept on the patient record. The local mental health trust also ensured that patients had Mental Health Act tribunals arranged if necessary. The Short Term Assessment, Rehabilitation and Reablement service (STARRS) provided support for patients in the emergency department and community to prevent admission. They had close working relationships with General Practitioners (GPs) for patients with dementia around admission avoidance. The team worked well with the ED staff.

Seven-day services

Key services were available seven days a week to support timely patient care.

Diagnostic imaging services were available 24 hours a day, seven days a week, co-located on the

same floor as the ED. This included access to x-ray, magnetic resonance imaging (MRI) and

computerised tomography (CT) scans. During our inspection, the service did not have access to

ultrasound services as the machine was being repaired.

There was a consultant and ST4 available seven days a week, twenty-four hours a day, in line

with Royal College of Emergency Medicine (RCEM) guidelines.

Health promotion

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

The service had a substance abuse team that was available on a weekday. If staff had any

concerns about a patient in this area they could refer them to the alcohol nurse specialist.


We saw a range on information about smoking cessation, alcohol abuse cessation and other

health and social welfare issues throughout the department. Information was available via poster

and leaflet.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff supported patients to make informed decisions about their care and treatment. They

followed national guidance to gain patients’ consent. They knew how to support patients

who lacked capacity to make their own decisions or were experiencing mental ill health.

They used agreed personalised measures that limit patients' liberty.

The service maintained a presumption of capacity for all patients. We observed staff asking patients initial questions in triage and if patients could follow instructions, then capacity was presumed. They had a standard operating procedure in place for assessing capacity for patients who self-discharged. If a patient absconded, the police would be informed as well as the patients next of kin. In the case of a patient absconding where the service was worried about mental capacity they would also fill out a DATIX form. In the three months prior to our inspection there had been one patient absconding – all local protocol was followed in this instance. Where the service had concerns about a patient’s mental health, they would begin enhanced observation policy where the patient would be provided with 1:1 care. If one of these patients managed to abscond from the service, the psychiatric liaison team would call the police. The chances of this were limited as patients would be placed in bays were always visible to staff. Healthcare assistants would provide 1:1 care for patients and 80% of them had received safe restraint training from an external organisation. If the service had concerns about a paediatric patient’s mental health they would het the mental health team involved. If the patient required an inpatient stay they would be placed on the CDU where they would receive 1:1 care. If the patient was safe to be discharged they would be followed up by child and adolescent mental health services (CAMHS). The service had regular interfacing with the mental health team as they would meet monthly. The trust set a target of 85% for completion of Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training.

A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 for qualified nursing staff in urgent and emergency care at Ealing Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

Deprivation of Liberty Safeguards (DoLS)

85 90 94.4% 85.0% Yes

Mental Capacity Act level 2 90 97 92.8% 85.0% Yes

In urgent and emergency care the target was met for both of the MCA and DoLS training modules for which qualified nursing staff were eligible.

A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in urgent and emergency care at Ealing Hospital is shown below:




Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

Mental Capacity Act level 2 43 60 71.7% 85.0% No


32 60 53.3% 85.0% No

In urgent and emergency care the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible.7 During the inspection we discussed mandatory training with the service leadership team and were provided with updated mandatory training compliance figures. Most clinicians (96%) were trained in Mental Capacity Act level 2. This was above the trust target of 85%.

Is the service caring?

Compassionate care

Staff treated patients with compassion and kindness, respected their privacy and dignity,

and took account of their individual needs.

We saw both medical and nursing staff taking the time to listen to patients and relatives. We saw

nursing staff delivering care in a compassionate and thoughtful way, ensuring that consent was

gained before any interventions.

The Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment.

The trust scored between 87.9% and 94% from March 2017 to February 2019.

The data show three data points outside of the control limits (in May 2018, June 2018 and February 2019). These unusual data points may be a sign of something out of the ordinary happening and merit further investigation to understand what happened in those months and what can be learnt from this.

7 (Source: Routine Provider Information Request (RPIR) – Training tab)


Response rates for the A&E friends and family test can often be low, the table below shows the response rate for this metric. Over the two-year period there was an average of 1,913 responses per month for this trust. London North West Healthcare NHS Trust – response rate March 2017 to February 2019

(Source: Friends and Family Test – NHS England)

Emotional support

Staff provided emotional support to patients, families and carers to minimise their distress.

They understood patients’ personal, cultural and religious needs.

We saw staff providing emotional support to patients and their relatives. Staff took the time to

answer questions and to explain what was going to happen next to provide reassurance. We saw

this was done in a kind and considerate manner. Patients and their relatives we spoke with told us

they had been kept well informed and up to date at all times.

Understanding and involvement of patients and those close to them

Staff supported and involved patients, families and carers to understand their condition

and make decisions about their care and treatment.

We saw staff treat patients as partners in their care. Staff took the time to ensure patients and their

families understood treatment plans and we observed medical staff speaking to patients and

relatives both respectfully and professionally.

All staff wore name badges and introduced themselves by name. Staff routinely asked patients how they would like to be addressed. Staff wore different coloured uniforms, which made identifying different disciplines and grades of staff easier. There was a poster that identified what discipline and grade of staff each colour uniform related to. The trust scored worse than other trusts for five questions (relating to doctors and nurses talking to the patient as if they weren’t there, involving patients in decisions about care, explaining results of and reasons for tests in a way patients can understand and communication of danger signals to look out for after the patient goes home) and about the same as other trusts for the remaining 21 questions.

Question Trust 2016 2016 RAG

Q10. Were you told how long you would have to wait to be examined?


Q12. Did you have enough time to discuss your health or 8.2 About the same



medical problem with the doctor or nurse? as other trusts

Q13. While you were in the emergency department, did a doctor or nurse explain your condition and treatment in a way you could understand?


Q14. Did the doctors and nurses listen to what you had to say? 8.8 About the same as other trusts

Q16. Did you have confidence and trust in the doctors and nurses examining and treating you?


Q17. Did doctors or nurses talk to each other about you as if you weren't there?

8.3 Worse than other trusts

Q18. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?


Q19. While you were in the emergency department, how much information about your condition or treatment was given to you?


Q21. If you needed attention, were you able to get a member of medical or nursing staff to help you?


Q22. Sometimes in a hospital, a member of staff will say one thing and another will say something quite different. Did this happen to you in the emergency department?


Q23. Were you involved as much as you wanted to be in decisions about your care and treatment?


Q44. Overall, did you feel you were treated with respect and dignity while you were in the emergency department?


Q15. If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you?


Q24. If you were feeling distressed while you were in the emergency department, did a member of staff help to reassure you?


Q26. Did a member of staff explain why you needed these test(s) in a way you could understand?


Q27. Before you left the emergency department, did you get the results of your tests?


Q28. Did a member of staff explain the results of the tests in a way you could understand?


Q38. Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand?


Q39. Did a member of staff tell you about medication side effects to watch out for?


Q40. Did a member of staff tell you when you could resume your usual activities, such as when to go back to work or drive a car?


Q41. Did hospital staff take your family or home situation into account when you were leaving the emergency department?


Q42. Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home?


Q43. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left the emergency department?


Q45. Overall 7.5 About the same as other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)


Is the service responsive?

Service delivery to meet the needs of local people

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.

Throughout the service we observed enough seating for patients and their relatives. This

included the waiting area.

Services were planned with the clinical commissioning groups, external providers and the local

authority. The department used ambulatory care services to alleviate patient flow pressures.

Ambulatory care services allowed admission of patients for rapid treatment, diagnostic testing

and discharge.

Ealing hospital did not operate a paediatric emergency department. The urgent care centre

(UCC) within the Emergency Department (ED) did see and treat patients of all ages as a 24-hour

service but children under the age of 16 who required specialist input would be referred to one of

the local dedicated paediatric EDs in the area. The service had put up posters in the ED stating

that it only stabilised children under 16 and had also reached out to the local authority and the

community to ensure they were aware that the service did not treat acutely unwell under 16-year

olds.

The Short Term Assessment, Rehabilitation and Reablement team (STARRs) provided

intermediate care services for patients in Brent. The service provided a multi-disciplinary, holistic

assessment of patients. This service supported early discharge by providing hospital services in

the community. The rapid response team was community based and focused on admission

prevention. This service was provided seven days a week between 8:00am and 10:30pm.

Patients in the emergency department were either referred here by nursing staff or picked up via

STARRS reviewing the electronic patient system to identify patients presenting with things such

as falls and mobility issues.

Meeting people’s individual needs

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.

The service did what it could to meet the needs of the local population. The service had a high Punjabi, Polish and Romanian patient base. They made use of a speakerphone app that interpreted the clinical decisions into whichever language they needed. The emergency department had access to a dementia lead nurse. There were a number of initiatives in place or planned to improve care for patients with dementia. This included dementia training for healthcare assistants and implementing the ‘important things to me’ within the department. We saw that frailty was identified and recorded as soon as patients arrived.


The local mental health hospital worked with the trust to provide a psychiatric liaison team. This team managed all the s.136 notices if they took place at the service. Usually such cases would take place at Northwick Park. Psychiatric support was available twenty-four hours a day, seven days a week. The service was part of a monthly, collaborative frequent attenders meeting. This meeting contained representatives from the ED in the area, the clinical commissioning group, the mental health trust, the local authority and the police. The objective of this meeting was to have systematic oversight of all frequent attenders in the area and deliver an effective approach to the management of frequent users of services. The trust scored about the same as other trusts for all three Emergency Department Survey questions relevant to the responsive domain.

Question – Responsive Score RAG

Q7. Were you given enough privacy when discussing your condition with the receptionist?

7.0 About the same as

other trusts

Q11. Overall, how long did your visit to the emergency department last?


trusts

Q20. Were you given enough privacy when being examined or treated?


other trusts


Access and flow

People could access the service when they needed it and received the right care promptly.

Waiting times from referral to treatment and arrangements to admit, treat and discharge

patients were in line with national standards.

The ED was operational twenty-four hours a day, seven days a week and patients could self-refer,

be referred by their GP or the 111 service or arrive via ambulance. Most walk-in patients were

streamed depending on their acuity to be seen in the urgent treatment centre, or majors. The

majority (63%) of patients who attended the ED were self-referrals.

The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The median time from arrival to treatment at the trust did not meet the standard in any months over the 12-month period from April 2018 to March 2019. From April 2018 to March 2019 performance was much worse than the standard and the England average. Median time from arrival to treatment from April 2018 to March 2019 at London North West University Healthcare NHS Trust:



The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From April 2018 to March 2019 the trust failed to meet the standard each month. Performance fluctuated around the England average. Four-hour target performance - London North West University Healthcare NHS Trust:

(Source: NHS England - A&E Waiting times) From April 2018 to March 2019 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted fluctuated around the England average, following a similar trend. Percentage of patients waiting more than four hours from the decision to admit until being admitted - London North West University Healthcare NHS Trust:

(Source: NHS England - A&E SitReps).


Over the 12 months from April 2018 to March 2019, four patients waited more than 12 hours from the decision to admit until being admitted. This occurred in April 2018 (one patient), December 2018 (one patient) and March 2019 (two patients). (Source: NHS England - A&E Waiting times) From April 2018 to August 2018 the monthly percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment fluctuated around the England average. From August 2018 onwards, performance was stable, at a slightly higher rate compared to the England average until March 2019 when the England average increased. Percentage of patient that left the trust’s urgent and emergency care services without being seen - London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators) From April 2018 to March 2019 the trust’s monthly median total time in A&E for all patients was much higher than the England average. Over the 12 months performance by the trust did not improve or worsen. Median total time in A&E per patient - London North West University Healthcare NHS Trust:



Learning from complaints and concerns

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.

During inspection we saw information displayed about Patient Advice and Liaison Service (PALS) and how patients and relatives could make complaints. We saw that lessons were learnt from concerns and complaints and shared with staff of all levels. Staff told us that complaints were discussed in handover and included on wider team agendas. Trust level: From April 2018 to March 2019 the trust received 133 complaints in relation to urgent and emergency care at the trust (12.0% of total complaints received by the trust). The trust took an average of 41.1 working days to investigate and close complaints, this was not in line with their complaints policy, which stated complaints should be answered within 40 days. At the time of reporting 18 complaints were still open. These had been open for an average 47.0 working days. A breakdown of complaints by type is shown below:

Type of complaint Number of complaints

Percentage of total

Clinical treatment 73 54.9%

Attitude of staff (values & behaviour) 16 12.0%

Communication/information to patients (written and oral) 12 9.0%

Patients' privacy, dignity and wellbeing (including compassion,

respect, diversity, property and expenses) 7 5.3%

Admissions, discharge and transfer arrangements (excluding delay

due to absence of care package) 7 5.3%

Waiting times 4 3.0%

Access to treatment or drugs 4 3.0%

Patient care including nutrition/hydration 3 2.3%

Others 3 2.3%

Facilities (including food, cleanliness, maintenance, parking, portering) 2 1.5%

Appointments, delay/cancellation 1 0.8%

Transport (ambulances only) 1 0.8%

Total 133 100.0%

Ealing Hospital: From April 2018 to March 2019 there were 22 complaints about urgent and emergency care at Ealing Hospital. The trust took an average of 45.0 working days to investigate and close complaints, this was not in line with their complaints policy, which stated complaints should be answered within 40 days.


At the time of reporting six complaints were will open. These had been open for an average of 61.7 working days. The service informed us that there were no specific trends and all complaints were investigated in accordance with the trust policy. The lessons learned from complaints were shared at weekly team meetings and were discussed at clinical governance meetings. From April 2018 to March 2019 there were 19 compliments about urgent and emergency care at the trust (10.1% of all received trust wide). A breakdown of compliments by site is below:

Site Number of

compliments Percentage

of total

Northwick Park Hospital 18 94.7%

Ealing Hospital 1 5.3%

Total 19 100.0%

The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led?

Leadership

Leaders had the integrity, 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.

At our last inspection we found that the emergency department had a clear management structure at both divisional and departmental level. The managers knew about the quality issues, priorities and challenges. We found that this had remained the case at this inspection. The emergency department (ED) was part of the emergency and ambulatory division within the trust. The clinical director role and clinical lead role were split across both Northwick Park and Ealing Hospital. These two departments worked closely together, and the role split maintained integration across both sites. Ealing Hospital ED had its own lead nurse, matron and service manager leading the department.

There was a clear clinical and nursing leadership presence in the department and it was easy for

staff to access and locate the consultant and nurse in charge of the shift. Staff of all levels

informed us that they felt well supported, well led and that senior staff were approachable and

present.

Vision and strategy

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.


The trust aimed to put patients at the HEART of everything they do. HEART stood for Honesty, Equality, Accountability, Respect and Teamwork. All staff we spoke with knew these values and said they were embedded in practice. The departments vision was ‘to provide high quality medical care whilst meeting the four-hour

performance target and quality indicators as determined by the Royal College of Emergency

Medicine’.

Staff we spoke with knew and understood the vision and strategy for the service. Staff

understanding reflected what senior leaders told us about the vision and strategy. Staff told us

they felt they were included in discussions about changes to the service.

Culture

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.

At our previous inspection we found that some staff highlighted issues with the culture of the department. Issues with bullying was mentioned by some staff and a lack of support from band 7 nurses. At this inspection we did not find this to be the case. Staff we spoke with felt respected and valued and spoke highly of their jobs and colleagues. Staff told us that their managers looked after their well-being, and there was a ‘family feel’ to working in the department. Both senior and junior staff, nurses and consultants spoke of putting patients at the centre of what they do. They were aware of their challenges regarding the population that they served and were confident that they could provide patients with quality care. The service had an employee assistance programme which contained a 24-hour confidential helpline. On inspection, we observed posters raising awareness for the programme.

Governance

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.

There were weekly safety net meetings that discussed all safeguarding queries and referrals.

These meetings were attended by liaison health visitors, named nurses, doctors, substance

misuse team, CAMHS, social services and ED staff.

There were monthly forums for clinical staff titled the annual integrated medical clinical

governance forums. Sessions were different each month and included learning on: serious

incidents, dermatology, cardiology, sexual health, neurology, infectious diseases and pharmacy.

We saw the minutes of an Ealing liaison psychiatry services interface meeting. This meeting took

place once a month and was attended by a variety of staff groups. At this meeting, the

collaborative nature of services outside of the trust was also discussed. For example, the service

relationship with CAMHS, UCC and primary care was discussed.



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.

At our previous inspection we found that effective risk management arrangements for mental

health patients were not in place and this placed patients at risk of unsafe care and treatment. The

process for ensuring emergency department staff completed one to one observations of patients

was not robust. At this inspection we found that this risk had been mitigated. The service had

strong links with the psychiatric liaison team. All staff had access to further learning in this area

and all staff were confident that mental health patients would be cared for well.

The department maintained a risk register. We reviewed the risk register and found that it

contained four active risks. These risks matched the risks we found whilst on inspection. However,

we also found risks with how clinical areas were being utilised in the ED. For example, the Clinical

Decisions Unit (CDU) was not always used in accordance with its policy. We were informed that

patients could stay on the CDU for much longer than four hours and often patients were placed on

CDU as overflow whilst waiting for inpatient beds.


Staff could find the data they needed, in easily accessible formats, to understand

performance, make decisions and improvements. The information systems were integrated

and secure. Data or notifications were consistently submitted to external organisations as

required.

There were clear and robust performance measures which were reported and monitored. The

department could monitor performance of the ED against the four-hour target daily through an

electronic patient board.

Staff had secure access to the trust intranet which gave them access to trust news, policies and

procedures. They could access their training and personal development records as well as ED

specific standard operating procedures.

Staff we spoke with told us they were able to access the information they needed to provide safe

and effective care. There were systems to manage and monitor care records and we saw this in

practice with electronic patient care records. Clinical staff did inform us that one of their risks was

that there were too many systems in the department and not all of them communicated well. The

service was aware of this as a risk and had plans to merge systems once they went paperless.

Engagement

Leaders and staff actively and openly engaged with patients, staff, equality groups, the

public and local organisations to plan and manage services. They collaborated with partner

organisations to help improve services for patients.

We saw a copy of the weekly Emergency department newsletter – Edit. This newsletter was

circulated to all ED staff online and contained news on complaints or compliments received as well

as helpful reminders. This newsletter was published every Thursday.


The service carried out staff recognition awards every year and employee of the month every

month. The ED at Ealing had won several staff recognition awards.

The department had launched ‘WOW boards’ campaign. The boards were decorated by staff and comments were left on the boards by staff to say what achievements they were proud of whilst working in the department. The aim was to highlight good practice to improve morale. The service had ‘you said. We did’ posters throughout the department. This showed how the service made reasonable adjustments after receiving patient feedback. For example, in June 2019 the service received feedback that there were ‘long delays in seeing a doctor’. In response to this, the service now provides regular updates to patients to better manage expectations.


All staff were committed to continually learning and improving services. They had a good

understanding of quality improvement methods and the skills to use them.

The department had developed a patient sepsis video for parents whose children attend the paediatric emergency department with a fever or suspected infection. The video was a four minute video aiming to educate parents about the warning signs to look out for sepsis. ED had piloted a mobile phone app in which they could book porters via the app. The purpose of the application was to reduce staff burden of filling out a two page referral form when a porter was needed. The app allowed staff to provide special instructions for the porters, such as the need to carry patient records or oxygen. The department had done a rotational shift with the local mental health trust. The purpose of this was for staff to get an ides how the other service was run, learn and share knowledge and understanding to improve the way they worked together. Following the rotation the staff came together to discuss how they could improve joint working and communication between the two trusts. This had been recognised as good practice in the Nursing Times News.


Northwick Park Hospital

Watford Rd

Harrow

HA1 3UJ

Tel: 020 8864 3232

https://lnwh.nhs.uk/northwick-park-hospital/

Urgent and emergency care

Facts and data about this service The emergency department at Northwick Park Hospital provides care for the local population 24 hours a day, seven days a week. Patients present to the department either by walking into the reception area or arrive by ambulance via a dedicated ambulance-only entrance. Patients transporting themselves to the department are seen initially by a triage nurse (triage is the process of determining the priority of patients’ treatments based on the severity of their condition). The department has different areas where patients are treated depending on their needs, including an Urgent Care Centre (UCC), majors (here called the High Dependency Unit (HDU)), minors (here called the Assessment Unit), resuscitation (resus), Clinical Decision Unit (CDU), and the Paediatric Emergency Department (PED) with its own waiting area and bays is within the department. Additionally, the trust provided an integrated intermediate care service known as STARRS (short term assessment rehabilitation reablement service) which aimed to reduce hospital admissions and reduce the length of stay of patients in hospital by continuing their care at home. This was a multi-disciplinary team of nurses, physiotherapists, occupational therapists, therapy technicians, social workers, consultant physician, dietitians, health care support workers, paramedics, administration team and a man with a van. There was also a rapid response team, which is commissioned by a local CCG. The service aimed to avoid emergency department attendances and hospital admissions. Patients were assessed in their own home within two hours of a telephone referral. The team was led by an elderly care consultant and provided clinical, rehabilitation and social support. Referrals were accepted from GPs, ambulance services and the complex patient management group (CPMG). The team was also present in the emergency department at Northwick Park Hospital, assessing patients to prevent hospital admissions. The ambulatory care services provided patient care, aimed at preventing hospital admissions. There are pathways in place for direct GP referrals, outpatient diagnostics, working with the urgent care centre and direct access to inpatient services. The assessment units provided support with the flow through the emergency department to the ward areas and facilitated the patient’s acute admission from the emergency departments. The trust commented that both sites experienced on going recruitment issues where national and


international recruitment campaigns continued within the department for both nursing and medical staff to reduce reliance on temporary staffing. However, pressure had reduced at Ealing Hospital following the announcement from the government regarding Shaping a Healthier Future which confirmed there would be no changes to the emergency department provision at that site. The urgent care centres were run by a primary care provider as a GP-led minor injury and illness centre. We visited the ED over three days during our announced inspection. We looked at all areas of the department and we observed care and treatment. We looked at 41 sets of patient records. We spoke with 40 members of staff, including nurses, doctors, allied health professionals, managers and support staff. We also spoke with 18 patients and their relatives who were using the service at the time of our inspection. We reviewed and used information provided by the organisation in making our decisions about the service.

Total number of urgent and emergency care attendances at London North West University Healthcare NHS Trust compared to all acute trusts in England, February 2018 to January 2019:

From February 2018 to January 2019 there were 144,549 attendances at the trust’s urgent and emergency care services as indicated in the chart above. (Source: Hospital Episode Statistics) Urgent and emergency care attendances resulting in an admission:


The percentage of A&E attendances at this trust that resulted in an admission in 2018/19 was higher than the previous year. In 2017/18 the proportion was the same as the England average, however, for 2018/19, it was higher. (Source: NHS England) Urgent and emergency care attendances by disposal method, from February 2018 to January 2019:

* Discharged includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment (Source: Hospital Episode Statistics)

Is the service safe? e service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.


Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone completed it. Key aspects of mandatory training such as information governance and fire safety were undertaken as part of the induction process for new starters. Ongoing mandatory training was undertaken as e-learning modules and further classroom based sessions. The trust set a target of 85% for completion of mandatory training. During the last inspection mandatory training compliance was poor for medical staff and there was no lead for education within the department. The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for qualified nursing staff in urgent and emergency care is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)









Manual handling - level 2 (face to face)

217 257 84.4% 85.0% No

In urgent and emergency care the target was met for eight of the nine mandatory training modules for which qualified nursing staff were eligible, with the remaining module having a compliance rate just below the target. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for medical staff in urgent and emergency care is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



Health & safety 94 123 76.4% 85.0% No






In urgent and emergency care the target was met for none of the eight mandatory training


modules for which medical staff were eligible, however the compliance rate for the information governance module was just below the target. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in the urgent and emergency care department at Northwick Park Hospital is shown below:



Staff

trained

Eligible

staff

Completio

n rate

Trust

target

Met

(Yes/No)







Manual handling - level 2 (face to face)

101 121 83.5% 85.0% No



At Northwick Park Hospital urgent and emergency care department the target was met for six of the nine mandatory training modules for which qualified nursing staff were eligible. The compliance rate for the manual handling – level 2 (face to face) module was just below the target. During the inspection we discussed mandatory training with the trust leadership team and were provided with updated mandatory training compliance figures. The department was meeting the trust target of 85% in all mandatory training except manual handling level two (70.9%). However, the leadership team showed us staff were booked onto this training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for medical staff in the urgent and emergency care department at Northwick Park Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)








At Northwick Park Hospital urgent and emergency care department the target was met for five of the seven mandatory training modules for which medical staff were eligible. The manual handling – level 2 (online) module compliance rate was close to the target.


During the inspection we discussed mandatory training with the trust leadership team and were provided with updated mandatory training compliance figures. The department was meeting the trust target of 85% in all mandatory training except PREVENT (74%) and fire safety (77.6%). Medical staff were booked onto these two trainings following our inspection in order to improve compliance.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff had access to the trust’s safeguarding policy and knew how to access the safeguarding team for advice and guidance when required. Staff told us the team were supportive in giving advice and guidance where required. Safeguarding information, including contact numbers and the trust lead were kept on wards and staff were aware of how to access this. There was also a safeguarding liaison health visitor based within the hospital whose role was to support safeguarding activity. The liaison health visitor visited the emergency department and paediatric emergency department each day to collect any safeguarding referrals. Staff we spoke with were aware of their responsibilities in relation to safeguarding vulnerable adults and children and were able to define triggers that would prompt them to obtain a safeguarding assessment for patients. Staff we spoke with in the paediatric ED (PED) were aware of their responsibilities to protect vulnerable children. They were knowledgeable about safeguarding procedures. The PED had a safeguarding flag system in place. Patients were checked against the Child Protection Register. Any safeguarding concerns were escalated to the safeguarding liaison health visitor who visited the department on a daily basis to collect the referral forms. There was a weekly safety net meeting to review referrals and outcomes to share learning. We reviewed 20 records in the PED and saw safeguarding assessments were completed and patients were appropriately referred to the health visitor. The trust had a domestic abuse service and staff could access an Independent Domestic Violence Advocate (IDVA) for patients if required. The Emergency Departments had a policy in place for the management, referral and treatment of Female Genital Mutilation (FGM). If FGM was highlighted as a risk then a multi-agency referral was completed to ensure the correct support packages can be put in place for women and their families At the last inspection, compliance with safeguarding training was poor for medical staffing. The trust set a target of 85% for completion of safeguarding training. The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for qualified nursing staff in urgent and emergency care is shown below:

Training module name April 2018 to March 2019


Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)


PREVENT 257 267 96.3% 85.0% Yes




In urgent and emergency care the target was met for three of the five safeguarding training modules for which qualified nursing staff were eligible. Neither of the level 3 modules met the target. It should be noted there was a low number of eligible staff for the safeguarding adults level 3 module which may have impacted on the rate.

A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in urgent and emergency care is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



PREVENT 70 123 56.9% 85.0% No

In urgent and emergency care the target was met for none of the three safeguarding training modules for which medical staff were eligible. The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for qualified nursing staff in the urgent and emergency care department at Northwick Park Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)


PREVENT 119 128 93.0% 85.0% Yes



At Northwick Park Hospital urgent and emergency care department the target was met for three of the four safeguarding training modules for which qualified nursing staff were eligible. During the inspection we were provided with updated figures. As in the above table the department was meeting the target for all safeguarding training except safeguarding children level three (77.6%). However, the senior leadership team provided us with information which showed staff who did not have this training were booked on the course following our inspection. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in the urgent and emergency care department at Northwick Park Hospital is shown


below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)

PREVENT 41 56 73.2% 85.0% No



At Northwick Park Hospital urgent and emergency care department the target was met for none of the three safeguarding training modules for which medical staff were eligible. It should be noted there were low numbers of eligible staff for some of the modules which may have skew the percentages. However, the senior leadership team provided us with updated training compliance figures during the inspection. For medical staffing the trust was meeting the 85% trust target for all safeguarding training except safeguarding children level three (51.2%). We were again shown plans which showed staff had been booked onto this course following the inspection to improve compliance.


The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. The service had established systems in place for infection prevention and control, which were accessible to staff. These were based on the Department of Health’s code of practice on the prevention and control of infections, and included guidance on hand hygiene, use of personal protective equipment such as gloves and aprons, and management of the spillage of body fluids. All the infection prevention and control standard operating procedures we reviewed were up to date and accessible by staff on the hospital intranet. There were housekeeping staff for cleaning all areas of the emergency department including the PED, High Dependency Unit (majors), Assessment unit (minors), resuscitation, clinical decision unit (CDU) and the waiting areas. We saw cleaning staff frequently over the course of the inspection. Throughout our visit we found all areas of the emergency department to be maintained to a high standard of cleanliness. Areas were clean, tidy and free from dust.

We reviewed patient areas across the department. All areas were visibly clean. Patients and relatives were satisfied with the level of cleanliness throughout the department.

We saw the use of green ‘I am clean’ stickers in the utility rooms which were used to identify which equipment had been cleaned by staff and were ready to be reused. We saw stickers were marked with the date the item was cleaned and observed staff replacing stickers once they returned the clean. There was easy access to personal protective equipment (PPE) such as aprons and gloves in all areas we inspected and saw all staff used PPE as required. There was also sufficient access to


handwashing and drying facilities. Services displayed signage prompting people to wash their hands.

Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our inspection, such as hand washing and using hand sanitisers when entering and exiting the unit and bed spaces, and wearing PPE when caring for patients. Where patients had a known or suspected infection, they were nursed in single rooms. There were signs displaying presence of infection, which meant staff, and visitors were aware of the precautions to take prior to entering the patient area. We observed staff adhering to these protocols and doors remained closed. We reviewed hand hygiene data for the department which was displayed in the waiting area. Between July 2018 and May 2019 hand hygiene compliance varied between 50% and 100%. Compliance on the environmental cleaning audit was between 98% and 99% for the same time period. The department also audited Methicillin-resistant Staphylococcus aureus (MRSA) screening. Between July 2018 and May 2019 compliance varied between 90% and 97%. MRSA is a type of bacteria that is resistant to several widely used antibiotics. Compliance with this audit had improved since the last inspection. Waste management, including those for contaminated and hazardous waste, was in line with national standards.


The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well. In the emergency department (ED) there was a waiting area for patients waiting to see the triage nurse. This area was visible from the ED reception desk so patients in the ED could be observed as they waited. The adult triage cubicles were behind a closed door but triage staff told us they were able to view patients every time they came to the door to get the next patient.

The triage area had five cubicles and a small waiting area for patients to sit and wait if they required further assessment. The high dependency unit (majors) had 14 cubicles of which two were used for ambulance assessments. The HDU area was where patients were accommodated within the ED who required a bed whilst having monitoring, assessments or investigations. The assessment area (minors) had 13 cubicles five of which were used for patients who would have a quick turn around and seven for patient requiring further assessments. The bays were not all visible from the nursing station but nurses were assigned to particular cubicles to mitigate this.

The department had a separate paediatric ED (PED) and waiting area. The department had nine bays and a dedicated triage room. Within resuscitation there was one bed dedicated for use by the PED which had access to equipment for children and young people. The resuscitation area had seven bays, one of which contained equipment suitable for acutely unwell children. All seven bays were used for adults with one bay set up for trauma. The clinical decision unit (CDU) had 10 cubicles and two rooms with seats for up to four patients. This meant the CDU could accommodate up to 18 patients. This was near the HDU and staffed by ED staff. This provided a short stay ward facility for patients awaiting test results or requiring


overnight observation.

Similar to the last inspection we found the CDU was being used inappropriately for patients who required transfer to a hospital bed. This was against the CDU admission criteria. CDU was used for patients who require additional observation before being discharged home. Staff reported often CDU was being used for patients who required a hospital admission to other departments such as medical wards and surgical wards. During the inspection we saw numerous patients were inappropriately placed on CDU whilst waiting for a bed within the hospital.

Staff told us they were able to access equipment required to care for patients and access to computer terminals to allow access to pathology and imaging results for example as well as policies and guidelines.

We checked various pieces of equipment throughout our inspection including electrocardiogram (ECG) and weighing scales and saw they had all been safety checked. Scales had stickers on to say when they had last been calibrated.

Staff reported the ‘Pit Stop’ area could often get very busy due to the volume of ambulances that attended the ED. Patients attending the ED via ambulance were assessed in two of the bays within the department. Since the last inspection the service allocated areas within the corridor for pit stop patients. There were 10 areas allocated in the corridors for patients. Senior leaders recognised that this meant patient privacy and dignity could not always be maintained. Private conversations and investigations such as blood tests were being carried out in the corridors. Resuscitation trolleys were available in the emergency department. Resuscitation trolleys were meant to be checked on a daily basis. The department checked the number of times a resuscitation trolley was not checked on a daily basis. Each month the total number of missing days was calculated and displayed in the patient waiting room. Between July 2018 and May 2019 the number of missed days varied between zero and three occasions. We checked a number of trolleys during the inspection and found there were some days the trolleys weren’t checked which supported the audit results. The emergency department had one dedicated mental health assessment room. The assessment room and ensuite bathroom were visibly clean. An adjacent observation room was available. We noted that the room was bare and windowless and did not provide a therapeutic environment for patients who were waiting a long time in the ED. The assessment room had CCTV. Doors had viewing panels for observation. Staff had access to an alarm system in the event of an emergency. The assessment room and ensuite were anti-ligature and minimally furnished with weighted furniture. At the last inspection staff raised concerns about the mental health place of safety room being in the middle of the clinical decisions unit (CDU). Senior leaders told us the room was going be to moved into a different area of the department. There were plans for this to be rebuilt following our inspection.

Children or young people identified with mental health needs were seen within the PED. A dedicated room was available and any equipment or ligature risks were removed. The patient would be placed on one-to-one observations to minimise risks. If required, the patient would be moved to the paediatric department within the hospital wards.



Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

Patients presented to the department either by walking into the reception area or arrive by ambulance via a dedicated ambulance-only entrance. Patients transporting themselves to the department were seen by a triage nurse (Triage is the process of determining the priority of patients’ treatments based on the severity of their condition).

In line with NHS Improvement good practice guide on improving patient flow (2017) the department was streaming patients attending at the front door by a trained member of UCC staff to the most appropriate area. Streaming involved taking a brief history and performing basic observations including calculation of early warning scores. However patients had to queue twice before being streamed. On arrival patients first went to the reception desk to register and then had to queue at a second desk to be streamed. When the department was busy this could cause delays.

We observed triage of a number of patients and saw patients were triaged within 15 minutes of arriving at the emergency department. We reviewed 21 adult patient records and saw 21 of these were triaged within 15 minutes. Patients were streamed to the appropriate areas of the department and observations were taken. Within triage there was a doctor who was there to assist and support triage nurses if required. For example, to assess patients with more risk, offer guidance and support and prescribe any medications if required. There was a ‘blue light system’ which operated as an active way of alerting senior staff to any acute patient problems in the triage area. This ensured patients at risk were identified and rapidly moved to the acute area in a timely way.

We reviewed audit data for triage times between June 2018 and June 2019. Compliance varied between 10 and 21 minutes in the adult emergency department. The department met the target of 15 minutes for every month except November (16 minutes), January (21 minutes) and February (18 minutes). This had improved since the last inspection, In PED, the department met the 15 minute target for every month of the same dates. Ambulance patients were taken into a separate entrance called ‘Pit Stop’ which had access to resuscitation if required. The ambulance service telephoned the department to alert them of the arrival of a patient needing immediate treatment, so a team was waiting for them on arrival. The pitstop area had made a number of changes since the last inspection to improve patient safety. All patients who arrived by ambulance were now assessed by a streaming nurse and doctor upon arrival. The ambulance streaming nurse completed patient observations and streamed the patient to different areas of the department based on risk. There were five areas patients could be streamed to which were: resus: high dependency bay: cubicle within the main emergency department: emergency department waiting room; and Urgent Care Centre (UCC). Children who did not attend by ambulance were seen for an initial assessment by the UCC and if they required ED treatment directed to the children’s ED where triage was undertaken by a nurse. The trust scored worse than other trusts for one of the five Emergency Department Survey questions relevant to safety. The trust scored “about the same” as other trusts for the remaining four questions.

Question Score RAG


Q5. Once you arrived at the hospital, how long did you wait with the ambulance crew before your care was handed over to the emergency department staff?


Q8. How long did you wait before you first spoke to a nurse or doctor?


Q9. Sometimes, people will first talk to a nurse or doctor and be examined later. From the time you arrived, how long did you wait before being examined by a doctor or nurse?


Q33. In your opinion, how clean was the emergency department? 8.3 About the same as other trusts

Q34. While you were in the emergency department, did you feel threatened by other patients or visitors?


trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) The median time from arrival to initial assessment was better than the overall England median for the 12-month period from April 2018 to March 2019. Trust performance followed a similar trend to the England average. Ambulance – Time to initial assessment from April 2018 to March 2019 at London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators) From April 2018 to March 2019 there was a fluctuating trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Northwick Park, with percentages ranging from 50.4% in November 2018 to 69.4% in October 2018. Ambulance: Number of journeys with turnaround times over 30 minutes - Northwick Park


Ambulance: Percentage of journeys with turnaround times over 30 minutes - Northwick Park

(Source: National Ambulance Information Group) The trust provided us with site specific data for ambulance turn around within 15 minutes and turnaround within 30 minutes. Between July 2018 and June 2019, Northwick Park Hospital ambulance turn around within 15 minutes was between 51% and 75%. For the same dates, ambulance turn around within 30 minutes was between 16% and 27%. A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. From April 2018 to March 2019 the trust reported 760 “black breaches”, with low numbers in summer and early autumn and high numbers in the winter period.

The trust commented that demand and capacity issues led to the majority of the breaches and for 21 weeks the trust’s full capacity protocol/escalation process was in place. The trust provided site specific data around black breaches for Northwick Park Hospital. Between


July 2018 and June 2019 there were 859 black breaches. The highest number occurred in January 2019 (202). The department faced significant delays with ambulances due to the high volume of ambulances that attended the department. The leaders told us the trust received high numbers of ambulances on a daily basis compared to other local NHS trusts. When the department had introduced their new streaming nurse this had led to a further increase. We received data from the trust which showed that between March 2019 to August 2019 the department had received an average of 3951 ambulances per month. The departments leadership team highlighted ambulance turn around as one of the departments biggest risks. Since the last inspection the department had been working to reduce the number of breaches within the department. Whilst the department had seen a reduction this was still a serious issue for the team. To improve patient safety the department had introduced a streaming nurse and doctor at the ambulance entrance. This meant patents were seen by the streaming team and moved from the ambulance faster. All patients had their observations done and were streamed to different areas of the department depending on risk. For example, if a patient required immediate life saving interventions they were sent to resuscitation. Feedback from staff regarding the new procedure was positive. It meant the emergency department had better oversight of patients arriving by ambulance. The department used the national early warning scoring system (NEWS)and the modified versions for children, neonates. The department conducted monthly audits looking at compliance with NEWS scores. Between July 2018 and May 2019 compliance varied between 97% and 99%. The department displayed results from the audit in the patient waiting room. We reviewed 41 records during the inspection and saw early warning scores had been completed for all patients. The children’s department used an age appropriate paediatric early warning score to assess deterioration and all 20 records we viewed had this completed. Within the PED there was a traffic light coding in use which determined how quickly a patient was seen by a doctor. For example, patients rated as ‘Green’ should be seen within 120 minutes and patients rated as ‘Red’ should be moved immediately to resus. The department used a sepsis six care bundle which was designed to offer basic interventions within first hour. During the inspection we observed good practice for two patients who were at risk of sepsis. In both cases, patients were seen by medical staff and reviewed, appropriate investigations took place and antibiotics were prescribed within one hour. Staff told us there was a sepsis lead within the trust. There was also access to a sepsis squad if staff required support. The trust was aiming to continue to progress the implementation of the sepsis programme and sustain and embed processes to ensure sepsis was identified. The trust had achieved 90% for screening and initiating treatment for sepsis. The trust had also introduced NEWS 2. At the last inspection we found effective risk management arrangements were not in place and this placed mental health patients. The process for ensuring emergency department staff completed one to one observations of patients was not robust. Senior leaders told us they had embedded this process since the last inspection. The department had taken a number of steps to improve management of mental health patient observations. This included, a two hour workshop on enhanced observations at team days,


Practice Development Nurses (PDNs) completed training on enhanced observations policy and the policy was also disseminated across all staffing groups. At the last inspection staff did not document risks and actions needed to keep mental health patients safe during their time in the ED in sufficient detail in the patient record. During this inspection we found one instance where a patient had left the department without the staff being aware. We reviewed the missing person policy. This document provided a step by step guide on what to do if a patient left the department. This included a search, contacting the patient, contacting the police for support if required and completing an incident form. The staff had followed these steps, however the staff did not complete an incident reporting form.

The PED had good links with the children and adolescent’s mental health services (CAMHS)

outreach team including out of hours. Escalation procedures were in place for out of hours

CAMHS liaison where there were long delays in a young person being seen.

We reviewed training figures for intermediate life support (ILS) and paediatric intermediate life support (PILS). For nursing staff 89.4% of staff had ILS training and 88% had PILS training. The trust provided us with data which showed that 100% of medical staff were compliant for advanced life support (ALS).

Nurse staffing

The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.

From April 2018 to March 2019, the breakdown of WTE staff in post in urgent and emergency care at Northwick Park Hospital is shown in the chart below.





Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 337.8 19.3% 10.2% 3.8%

Qualified nurses

155.0 24.4% 10.1% 5.2% 43,153 (11.3%)

41,884 (11.0%)

13,652 (3.6%)

Nursing assistants

40.6 20.6% 20.1% 3.8% 19,470 (21.1%)

0 (0.0%)

1,240 (1.3%)

Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in urgent and emergency care at Northwick Park Hospital were not stable and may be subject to ongoing change.

Monthly agency hours from April 2018 to March 2019 for qualified nurses, health visitors and

midwives in urgent and emergency care at Northwick Park Hospital were not stable and may be

subject to ongoing change.

We requested the most recent nursing vacancy rates during the inspection. The vacancy rate for

band five nurses was 37.9%, band six nurses 4.2% and band seven nurses was 4.1%. Overall,

this meant there was an vacancy rate of 21.1%. The trust had recruited into some of the vacant

positions which improved the vacancy rate to 11.29% once those staff started their posts.

The department leaders had been working on recruitment in order to improve this vacancy rate. This included recruiting from overseas. Whilst staffing had improved since the last inspection, some staff still said staffing levels were an issue when the department was busy. Staff in the PED said staff would be taken from PED and moved to the main ED which left the team short.

During the inspection we found there were appropriate numbers of nursing staff in the department, based on number of staff and skill mix and the types of patients seen in the department. However, some staff said there were times the department did not feel safe due to staffing issues.

The trust assessed staffing levels and skill mix based on the Royal College of Nursing (RCN), Emergency Care Association (ECA), and the Faculty of Emergency Nursing (FEN) recommendations. RCN guidance recommend two registered nurses to one patient in cases of major trauma or cardiac arrest and one registered nurse to four cubicles in major or minor trauma. Staffing levels were discussed each day the safety huddle.


The Royal College of Paediatrics and Child Health (RCPCH) guidelines say services should have trained children’s nurses on duty 24 hours, seven days a week. The trust reported in the 12 months preceding our inspection there had been children’s nurse on all shifts. The trust reported there was a nurse trained in paediatric intermediate life support (PILS) on every shift. There were Advanced Clinical Practitioner (ACP) trainees within the department providing support to team. These were eight ACPs in the department who worked supernumerary. Within CDU, there were two rooms which seated four patients each. Staff told us these eight chairs were staffed by one nurse only. Within Pitstop, there was now a streaming nurse on duty every day. There were also two pit stop nurses allocated to monitor patients who were offloaded into pitstop bays. Nursing handovers were planned at the beginning of each shift. We observed one handover on the day of our inspection. All nurses attended for the initial allocation session and key information or announcements were made.

Medical staffing

The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave locum staff a full induction. Trust Level: From April 2018 to March 2019, the breakdown of WTE staff in post in urgent and emergency care is shown in the chart below.




Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 725.8 21.6% 10.4% 4.3%


Qualified nurses

364.6 28.2% 10.8% 6.0% 84,155 (12.5%)

101,512 (15.1%)

25,775 (3.8%)

Nursing assistants

88.7 13.1% 20.9% 4.7% 41,437 (24.8%)

0 (0.0%)

1,240 (0.7%)

Medical staff 132.3 18.3% 1.1% 0.9% 55,493 (27.0%)

26,006 (12.6%)

5,300 (2.6%)

Allied health professionals

40.7 29.9% 3.9% 3.1%

* All staff includes other staff groups not specifically shown in the above table. ** The trust has confirmed that the medical staffing turnover figures include planned rotation, which inflates the rate. Vacancy rates:

Monthly vacancy rates from April 2018 to March 2019 for all staff in urgent and emergency care showed a shift from October 2018 to March 2019.

Monthly vacancy rates from April 2018 to March 2019 for medical staff in urgent and emergency care showed a shift from October 2018 to March 2019. Monthly turnover rates from April 2018 to March 2019 for all staff groups in urgent and


emergency care appeared to be stable with only random variation over the whole period.

Monthly sickness rates from April 2018 to March 2019 for allied health professionals in urgent and emergency care showed a downward trend from November 2018 to March 2019. Bank, locum and agency staff usage:

Monthly bank hours from April 2018 to March 2019 for medical staff in urgent and emergency care showed an upward trend from April to August 2018. This was due to vacancy cover within the department. From April 2018 to March 2019, the breakdown of WTE staff in post in urgent and emergency care at Northwick Park Hospital is shown in the chart below.


Urgent and emergency care annual staffing metrics (April 2018 to March 2019)


Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 337.8 19.3% 10.2% 3.8%

Medical staff 76.1 18.7% 0.0% 0.7% 37,829 (30.0%)

15,060 (11.9%)

3,842 (3.0%)


10.0 26.7% 0.0% 0.1%

* All staff includes other staff groups not specifically shown in the above table. ** The trust has confirmed that the medical staffing turnover figures include planned rotation, which inflates the rate.


Monthly vacancy rates from April 2018 to March 2019 for medical staff in urgent and emergency care at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Monthly vacancy rates from April 2018 to March 2019 for allied health professionals in urgent and emergency care at Northwick Park Hospital showed a shift from October 2018 to March 2019. Turnover rates

Monthly turnover rates from April 2018 to March 2019 for all staff in urgent and emergency care at Northwick Park Hospital showed a downward trend from June 2018 to October 2018. Monthly sickness rates from April 2018 to March 2019 for all staff groups in urgent and emergency care at Northwick Park Hospital appeared to be stable with only random variation over the whole period.


Monthly agency and locum hours from April 2018 to March 2019 for all staff in urgent and emergency care at Northwick Park Hospital were not stable and may be subject to ongoing change. The trust leaders informed us that the percentage of locum doctors used per week for the 12 months preceding our inspection was 27.5%.

Monthly bank hours from April 2018 to March 2019 for medical staff in urgent and emergency care at Northwick Park Hospital showed an upward trend from April 2018 to August 2018. In January 2019, the proportion of consultant staff reported to be working at the trust were lower than the England average and the proportion of junior (foundation year 1-2) staff was higher. Staffing skill mix for the 82 whole time equivalent staff working in urgent and emergency care at London North West University Healthcare NHS Trust: This

Trust England average

Consultant 27% 30%


Middle career^ 10% 15%

Registrar group~ 35% 34%

Junior* 28% 21%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Consultant cover was from 8am to 10pm seven days a week which was in line with the recommended 16 hours per day cover recommend for A&E departments by the College of Emergency Medicine (CEM). The department had a budget for 22 WTE consultants of which 17.8 WTE were in post, this had increased from the last inspection. The department met the 10 consultant minimum per department as recommended by CEM at the time of our inspection. Locum doctors were used to fill some of these posts. We spoke to various staff during the inspection about consultant cover. All staff we spoke with told us they felt there was enough consultant and medical cover in the emergency department. The department had 32 WTE posts for Middlegrade doctors and reported a deficit of five WTE. There were also 25 Senior House Officer (SHO) posts with a reported deficit of two WTE. The service adhered to the CEM recommendation of having a standard 4 grade doctor. The department had senior doctor presence 24 hour a day seven-days a week. The PED had a paediatric consultant based between 10am and 10pm Monday to Friday. Over the weekend there was cover between 2pm and 10pm. Outside of those hours there was an on-call paediatric consultant. Medical handovers took place at the start and end of each shift where all key information was handed over efficiently and effectively.

Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care. We reviewed 20 patient records in the adult emergency department and found completion was good. Recording of early warning scores were completed and recorded in all patient notes. Pain scores were completed in all of the records. The national early warning score (NEWS) is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. We reviewed 21 paediatric patient records and all were completed to a good standard. We saw consistent recording of paediatric early warning scores (PEWS) which included repeat


observations and times. PEWS is a specialised tool that measures the infant/ child’s clinical status and recommends an appropriate response. At the last inspection, we found inconsistent recording of pain scores for patients presenting with painful conditions. At this inspection, we found this had improved and pain scores were recorded in all the records we checked. We found all 41 records had documented information about allergies. We saw risk assessments were appropriately completed in patient records, such as risk of falls and Glasgow Coma Scale (GCS) scores for patients with head injuries or confusion.

Medicines

The service used systems and processes to safely prescribe, administer, record and store

medicines.

The department used a computerised medication administration system, which was accessed by

staff using their fingerprint.

Some prescription medicines are controlled under the Misuse of Drugs legislation (and

subsequent amendments). These medicines are called controlled medicines or controlled drugs

and their storage and dispensing are regulated by legislation. Controlled drugs were stored and

administered safely by two qualified nurses.

Staff followed systems and processes when safely prescribing, administering, recording and

storing medicines. Medicines were stored securely in locked trolleys and doors were locked to

treatment rooms with access restricted to appropriate staff. Controlled drugs were stored securely

and managed appropriately.

Staff reviewed patient’s medicines regularly and provided specific advice to patients and carers

about their medicines. We saw that nursing staff introduced themselves to patients before

offering them medicines, they explained what they were giving, and observed the patient take

them.

A designated pharmacist visited patients who needed to stay overnight Monday to Friday to

review their prescriptions and advise medical staff when doses needed to be revised.

Staff stored and managed all medicines and prescribing documents in line with the provider’s

policy.

The temperature of the medicines fridge in the department was monitored electronically through

the computerised administration system and we did not find any evidence that the fridge

temperatures were outside the recommended range.

Records showed that daily checks of medicines stock on the resuscitation trolleys had been

performed to ensure that they were fit for use in accordance with trust policy. Medicines were

stored at appropriate temperature range including medicines which needed to be stored in

refrigerators

The Nursing staff used Patient Group Directions (PGDs) to give medicines. There was a

procedure in place to review them. PGDs are written instructions which allow specified healthcare


professionals to supply or administer particular medicines in the absence of a written prescription.

We checked PGD’s being used by the nursing team and saw this was being used effectively to

support patient access to medicines for pain relief and diarrhoea in a timely way.

The service had systems to ensure staff knew about safety alerts and incidents, so patients

received their medicines safely.

Decision making processes were in place to ensure people’s behaviour was not controlled by

excessive and inappropriate use of medicines.


followed national guidance to gain patients’ consent before administering medicines.

The department completed monthly medicines management audits and the results were displayed

within the department. Between July 2018 and May 2019 performance varied between 88% and

100%.

FP10s (prescription pads)were stored in the Controlled Drugs (CD) cupboard. The CD key is

stored in the Omnicell medicines unit that logs details of who access the keys. FP10s were

signed out by two members of staff in pharmacy and signed into the ward by nurse and

pharmacy staff member. When CD balance check was done a count was done with the FP10s.

There was also a logbook kept to track serial numbers.

The Omnicell sent daily reports to pharmacy on which antibiotics have been administered. There

was a stewardship ward round Monday to Friday with a consultant microbiologist. There was also

an antibiotic stewardship group (clinicians and nursing staff) quarterly to discuss

audits/guidelines.

Incidents

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2018 to April 2019, the trust reported one never event for urgent and emergency care. The incident occurred in January 2019 at Northwick Park Hospital and related to the unintentional connection of a patient requiring oxygen to an air flowmeter. We reviewed the serious incident investigation for the never event. The incident was appropriately investigated and recommendations for changes to practice were identified. Staff were aware of the lessons learned. In accordance with the Serious Incident Framework 2015, the trust reported 15 serious incidents


(SIs) in urgent and emergency care which met the reporting criteria set by NHS England from May 2018 to April 2019. A breakdown of incidents by incident type are below.


Percentage of total



2 13.3%





Maternity/Obstetric incident: mother and baby (this include foetus, neonate and infant)

1 6.7%


Maternity/Obstetric incident: mother only 1 6.7%

Total 15 100.0%

* this is the never event described above A breakdown of incidents within urgent and emergency care broken down by site are in the tables below.

Northwick Park Hospital:


Percentage of total





Maternity/obstetric incident: mother only 1 11.1%


Total 9 100.0%

* this is the never event described above Between July 2018 and July 2019 the ED reported 1225 incidents. Of these, 224 (18.3%) were near miss, 865 (70.6%) were no harm, 105 (8.6%) were low harm, 28 (2.3%) were moderate harm and three (0.2%) were severe/major harm. Staff reported incidents using the Datix incident reporting system. The majority of staff told us they were encouraged to report incidents and the incident reporting culture was still good within the hospital. Staff were able to identify how to report incidents and the types of situations that should trigger incident-reporting completion, including near miss situations. However, we found an incident where a patient waiting for a mental health assessment had left the department and an incident had not been reported.

There was mixed feedback from staff regarding feedback and learning from incidents. Some staff told us they received feedback from incidents. For example, previous never events that had occurred in the department had resulted in a number changes. Information about actions from these never events was shared with staff in a number of ways. This included emails, newsletters and via department meetings and handovers. Information was also shared via screensavers on the department’s computer terminals. We saw learning and recommendations from the never events had been posted in the seminar room which was shared by nursing and medical staff.


However, some medical staff said they did not receive feedback or learning from incidents.

Mortality and Morbidity (M&M) meetings occurred within the department on a monthly basis at clinical governance meetings. We reviewed minutes from these meeting and saw cases were appropriately discussed and minutes were disseminated electronically to staff. The duty of candour (DoC) is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Most staff we spoke with had a good knowledge of duty of candour and, senior staff were very clear about their responsibilities in relation to DoC. However, there were some staff who did not know what we meant by DoC.

Safety thermometer

The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month. A suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of the suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and one new urinary tract infections in patients with a catheter from March 2018 to March 2019 within urgent and emergency care. (Source: NHS Digital - Safety Thermometer)






We looked at various clinical policies and guidelines during the inspection within the emergency department (ED) and on the trusts internet. We saw policies were based on NICE and best practice guidelines. Staff showed us how they would access the local guidelines on the trust intranet. Junior doctors told us that clinical guidelines were easily accessible. At the last inspection we saw there were out of date guidelines available on the trust intranet. On this inspection, we checked 17 guidelines and all of them were in date.


Staff used a variety of information technology within the department to enhance speed and access to patient care and treatment. This included internal electronic systems and systems used for digital imaging. The department used care bundles which were put into action as soon as the patient entered the department, for example, the sepsis six care bundle. This ensured patients were seen and treated effectively by staff and appropriate tests were carried out. The department undertook regular audits. These included national audits requested by the Royal College of Emergency Medicine (RCEM); others were based on the National Institute for Health and Care Excellence (NICE) guidance such as early warning scores and hand hygiene. We saw examples of care pathways completed for patients who had presented with specific conditions such as fractured neck of femur and sepsis. These pathways followed evidence based guidance for management of treatment and conditions. Staff displayed good knowledge of the treatment of patients presenting with sepsis. We saw staff appropriately following the sepsis six protocol. Patients who were receiving intravenous fluid (IV) were cared for by healthcare professionals competent in assessing patient fluid and electrolyte needs in line with NICE guidance. IV therapy delivers liquid substances into the vein and can be used for injections or infusions. In some patient records we saw they were assessed for venous thromboembolism (VTE) and those at risk of VTE were offered appropriate prophylaxis in accordance with NICE guidance. VTE is a condition where a blood clot forms in the vein. At the last inspection we did not see information of consistent use of VTE assessment. Where patients were over the age of 75 the frailty service used the Rookward score as part of their assessment of patients. Rockwood is a clinical frailty scale that is used to measure severity of frailty as part of a comprehensive geriatric assessment and is recommended by the British Geriatric Society silverbook.

‘Pit Stop’ had developed its own sepsis assessment and early intervention pathway


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 needs. In the CQC Emergency Department Survey, the trust scored 6.0 for the question “Were you able to get suitable food or drinks when you were in the emergency department?” This was about the same as other trusts. Water was available in all areas if the department and we observed patients with drinks at their bedside. Patients were offered food and drink where appropriate and staff met patient’s nutritional needs. Patients were asked if they had any special dietary needs and this was recorded by the nursing

staff. There was choice of food suitable for children.

Intravenous fluids were given where indicated and was noted in the patient’s records.


Pain relief

Staff assessed and monitored patients regularly to see if they were in pain, and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. In the CQC Emergency Department Survey, the trust scored 5.0 for the question “How many minutes after you requested pain relief medication did it take before you got it?” This was about the same as other trusts. The trust scored 7.0 for the question “Do you think the hospital staff did everything they could to help control your pain?” This was about the same as other trusts. The department used a range of pain scoring tools including scales (where patients rated their pain on a scale of 1-10), the use of faces and pictorial pain guides and the use of the Face, Legs, Activity, Cry and Consolability (FLACC) pain scale. Patients were asked about pain when booking in at the main reception and at triage to ensure analgesia could be provided in a timely way. Most patients we asked told us they had their pain relief adequately met. Patients we spoke with told us they had been asked about pain and offered pain relief if required. We observed staff asking patients if they were in any pain. At the last inspection we found pain scores were not always recorded for children with painful conditions. We reviewed 21 patient records in paediatric emergency department (PED) and found pain scores were recorded for all patients.

Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma audit, Northwick Park Hospital’s emergency department failed to meet any of the national standards of 100%. The department was in the lower UK quartile for five standards:

• Standard 2a (fundamental): As per RCEM standards, vital signs should be measured and recorded on arrival at the emergency department. This department: 0.0%; UK: 26%.

• Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given within 10 minutes of arrival at the emergency department. This department: 9.9%; UK: 25%.

• Standard 5: If not already given before arrival to the emergency department, steroids should be given as soon as possible as follows: - Adults 16 years and over: 40-50mg prednisolone PO or 100mg hydrocortisone IV - Children 6-15 years: 30-40mg prednisolone PO or 4mg/kg hydrocortisone IV - Children 2-5 years: 20mg prednisolone PO or 4mg/kg hydrocortisone IV

- Standard 5a (fundamental): within 60 minutes of arrival (acute severe). This department:

0.0%; UK: 19%.


- Standard 5b (fundamental): within 4 hours (moderate). This department: 0.0%; UK: 28%.

• Standard 9 (fundamental): Discharged patients should have oral prednisolone prescribed as follows: - Adults 16 years and over: 40-50mg prednisolone for 5 days - Children 6-15 years: 30-40mg prednisolone for 3 days - Children 2-5 years: 20mg prednisolone for 3 days

This department: 37.8%; UK: 52%.

The department’s results for the remaining two standards were all within the middle 50% of results. The department had conducted a re-audit of performance in 2019 and told us performance had improved but there was still further work to do. Recording of vital signs being measured had improved from 0% to 100%. High dose nebulised β2 agonist bronchodilator should be given within 10 minutes of arrival at the emergency department had improved from 10% to 36%. However, the department were still not meeting the standard around discharged patients. The department was planning to introduce proforma, with a step by step guide to support staff. In the 2016/17 Consultant sign-off audit, Northwick Park Hospital emergency department failed to meet any of the national standards of 100%. The department was in the lower UK quartile for two standards:

• Standard 1 (developmental): Consultant reviewed: atraumatic chest pain in patients aged 30 years and over. This department: 0.0%; UK: 11%.

• Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years and over. This department: 0.0%; UK: 10.0%.

The department’s results for the remaining standard was within the middle 50% of results. (Please note the following standard was not reported - Standard 2 (developmental): Consultant reviewed: fever in children under 1 year of age). The department had conducted a re-audit in 2019 and found atraumatic chest pain had improved to 50% from 0%, abdominal pain in patients over 70 had improved to 50% from 0%. Senior leaders told us the increased number of consultants had improved performance and better communication between junior and senior medical staff. In the 2016/17 Severe sepsis and septic shock audit, Northwick Park Hospital’s emergency department failed to meet any of the national standards of 100%. The department was in the upper UK quartile for two standards:

• Standard 7: Antibiotics administered: Within one hour of arrival. This department: 61.2%; UK: 44.4%.

• Standard 8: Urine output measurement/fluid balance chart instituted within four hours of arrival. This department: 62.1%; UK: 18.4%.

The department’s results for the remaining six standards were all within the middle 50% of results.


When we last inspected the department had conducted re-audit of performance against sepsis standards. Performance had improved in terms of patients receiving serum lactate, blood cultures, IV fluids and IV antibiotics within one hour of arriving at the ED. However, recording of urine output had declined as only 16.1% of patients had a documented urine output/fluid balance chart within four hours, compared to 61.6% in the previous audit. The recording of the patient’s GCS/ CBG on arrival with a majority of patients having neither recorded. These recordings were classified as a fundamental standard by the RCEM guidelines. As a result of the audit the department had put a number of recommendations in place. This included staff education around the RCM guidelines, discussion with sepsis leads around practice, encourage wide spread use of the sepsis six care bundle and better recording of when these take place. The department also planned to increase access of fluid balance charts and improve recording of senior clinician review. The department had recently conducted a re-audit in 2019 which identified the two major areas for improvement were recording of a full set of clinical observations and prescribing oxygen to maintain saturation. However, the recording of urine output was still an ongoing issue and performance had dropped from 62% in 2017 to 18% in 2019. The table below summarises Northwick Park Hospitals performance in the 2018 Trauma Audit and

Research Network audit. The TARN audit captures any patient who is admitted to a nonmedical

ward or transferred out to another hospital (e.g. for specialist care) whose initial complaint was

trauma (including shootings, stabbings, falls, vehicle or sporting accidents, fires or assaults).



Audit Rating Meets national

standard?

Case Ascertainment (Proportion of eligible cases reported to TARN compared against Hospital Episode Statistics data)

62.2% - 70% -

Crude median time from arrival to CT scan of the head for patients with traumatic brain injury (Prompt diagnosis of the severity of traumatic brain injury from a CT scan is critical to allowing appropriate treatment which minimises further brain injury.)

74 mins Takes longer than TARN aggregate

Crude proportion of eligible patients receiving Tranexamic Acid within 3 hours of injury (Prompt administration of tranexamic acid has been shown to significantly reduce the risk of death when given to trauma patients who are bleeding)

33.3% Lower than

TARN aggregate

N/A

Crude proportion of patients with severe open lower limb fracture receiving appropriately timed urgent and emergency care (Outcomes for this serious type of injury are optimised when urgent and emergency care is carried out in a timely fashion by appropriately trained specialists.)

0.0% Lower than

TARN aggregate


Risk-adjusted in-hospital survival rate following injury (This metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.)

1.4 additional survivors

As expected ✓

From April 2018 to March 2019, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and worse than the England average. Unplanned re-attendance rate within seven days - London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators) Following the inspection the trust provided updated unplanned readmission data. The data showed that where first attendance and reattendance were at Northwick Park Hospital the unplanned readmission rate between April 2018 and March 2019 was 3%. The department had also conducted a re-audit of the Fractured Neck of Femur national audit. The audit whilst not directly comparable showed improvements

Competent staff

At the last inspection the department did not have a Practice Development Nurse (PDN). We

found the department now had a PDN in place who took the role of supporting education within the

department.

For new nurses competencies were required to be completed and signed off by one of the band 7 nurses. For example, new staff would need to be signed off as competent before working in the resuscitation area.


Student nurses said there was good exposure and support within the department for their development. All new doctors were provided with an induction handbook prior to starting working in the department. The handbook provided them with a range of information including rotas, information about working in the department and a number of common protocols. There was an induction process in place for agency nurses who were new to the department. On arrival they were given a tour of the department and completed a local induction document before starting the shift.

All doctors we spoke with told us they had access to regular training within the department. This took place on a weekly basis. However, some doctors said they were unable to attend the training due to how busy the department was and workload pressures. Nursing staff told us there was training within the department. Staff were separated into teams and every quarter each team had a team day where training needs were covered. Some staff had been accepted onto the Advanced Clinical Practitioner training and reported good support and development. From April 2018 to March 2019 82.9% of staff within urgent and emergency care at the trust received an appraisal compared to a trust target of 85.0%. Trust level:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Additional professional scientific and technical

6 6 100.0% 85.0% Yes


Allied health professionals 21 25 84.0% 85.0% No

Administrative and clerical 78 93 83.9% 85.0% No

Nursing and midwifery registered 216 267 80.9% 85.0% No

Additional clinical services 64 82 78.0% 85.0% No

Estates and ancillary 3 4 75.0% 85.0% No

All staff groups 440 531 82.9% 85.0% No

In urgent and emergency care, two of the seven staff groups, including medical staff, met the trust target. Three further staff groups, including nursing staff, had compliance rates close to the target. From April 2018 to March 2019 78.8% of staff within urgent and emergency care at Northwick Park Hospital received an appraisal compared to a trust target of 85.0%.

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)



5 5 100.0% 85.0% Yes








At Northwick Park Hospital, two of the seven staff groups, including medical staff, met the trust target. However, the compliance rate for nursing staff did not meet the target. During the inspection the senior leadership provided us with up to date appraisal rates for staff. For nursing staff the appraisal rate was 86.1% which met the trust target of 85%. This had improved since the last inspection. For medical staff the appraisal rate was 98.1% which also met the trust target.


Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. The department held two hourly board rounds which included a multi-disciplinary board round every morning. Board rounds are a summary discussion of the patient journey and what is required that day for it to progress. Any waits or delays for the patient are identified which enhances their experience and should minimise the risk factors associated with a prolonged stay in the emergency department (ED). The hospital had regular bed management meetings; these were attended by the A&E matron and senior staff from specialties. The bed meetings had the objective of establishing and continuously updating discharge plans and forecasts that would create capacity to meet both the scheduled and the anticipated unscheduled demand on the hospital for the day. We observed positive teamwork between nursing and medical staff in the clinical decision unit. The interactions between administrative staff and ambulance crew were positive, friendly and task-focussed. The department still demonstrated good partnership working with local ambulance services. There were regular meetings held to discuss issues around ambulance turn over time and ambulance surges. A psychiatric liaison team consisting of psychiatric liaison nurses and medical staff attended the department when requested if patients needed a mental health assessment or support. Staff reported good links with the psychiatric liaison team provided by the neighbouring mental health trust. The liaison team office was located within the mental health centre close to the ED. The service operated over 24 hours. In order to strengthen links with the mental health trust the department had some cross over work with the mental health team. Nurses from the department and mental health nurses from the trust spent a day within each other’s department. This helped educate them about how each service operated. The leadership team told us the aim of this rotation was to create a degree of shared knowledge and development.


Regular meetings were held between both departments and included the trust health and safety lead, police liaison officer and head of security. Meetings included the review of frequent attenders to the ED department and how best to support them. Plans for frequent attenders were shared on team days. The trust agreed a service level agreement with the neighbouring mental health trust to undertake all Mental Health Act administration and ensure that detained patients had their Section 132 rights read. Copies of detention papers were kept on the patient record. The local mental health trust also ensured that patients had Mental Health Act tribunals arranged if necessary. The Short Term Assessment, Rehabilitation and Reablement service (STARRS) provided support for patients in the emergency department and community to prevent admission. They had close working relationships with General Practitioners (GPs) for patients with dementia around admission avoidance. The team worked well with the ED staff. There was effective multidisciplinary working between the frailty team and the ED team which enabled appropriate assessment of frail elderly patients and where necessary, onward referral to the rapid assessment and discharge team.

Seven-day services

Key services were available seven days a week to support timely patient care. The A&E provided a twenty-four hour, service seven days a week. There was support provided from other hospital services in the provision of specialist care. The hospital provided a dedicated 24 hours a day, seven days a week children’s A&E. There was an ST4 doctor available 24 hour a day seven days a week. Consultants were available seven days a week in the department and available on-call if required. The department had access to a pharmacist seven days a week. During the week this service was available 8am till 5pm and on-call during the night. At the last inspection staff on CDU highlighted concerns regarding a lack of pharmacy support, which caused delays in administration of key medications. Senior leaders told us pharmacy provision had improved in CDU and they were hoping the post would become substantive.

The diagnostic imaging department provided a seven day, 24 hour on call service. This was in accordance with the NHS services, seven days a week, priority clinical standard 5, 2016. This requires hospital inpatients to have seven-day access to diagnostic services such as x-ray and computerised tomography (CT). There was also access to magnetic resonance imaging (MRI) 24

hours a day seven days a week.

Health promotion

Staff gave patients practical support and advice to lead healthier lives. The hospital had an alcohol liaison team (ALT). Staff could refer patients to the ALT for support and advice on external agencies that could provide information and support for both alcohol and drugs. The contact details for the service were also available on the Trust’s website. There was a range of information leaflets available for patients in the paediatric emergency department for parents and carers around common childhood conditions including asthma and


head injuries. We did not see any other health promotion information throughout the emergency department.


Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limit patients' liberty. The trust set a target of 85% for completion of Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training.

A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 at trust level for qualified nursing staff in urgent and emergency care is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



162 225 72.0% 85.0% No

In urgent and emergency care the target was not met for either of the MCA and DoLS training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in urgent and emergency care is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



32 60 53.3% 85.0% No

In urgent and emergency care the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible. Northwick Park Hospital:

A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 for qualified nursing staff in urgent and emergency care at Northwick Park Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



66 121 54.5% 85.0% No


In urgent and emergency care the target was not met for either of the MCA and DoLS training modules for which qualified nursing staff were eligible.

A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in urgent and emergency care at Northwick Park Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)


During the inspection we were provided with updated compliance figures for Mental Health Capacity Act level two training for medical staffing. The department was achieving 93% which met the trust target of 85%. Staff were aware of the trusts Mental Capacity Act (MCA) policy and how this could be accessed. Nursing and medical staff undertook training in the MCA and Deprivation of Liberty Safeguards (DoLS). The psychiatric liaison team offered advice and support in relation to best interest decisions for patients with mental health problems. They also provided training for ED staff in mental health awareness and the Mental Health Act. Most staff demonstrated a good knowledge of the principles of informed and implied consent as well as the Mental Capacity Act (2005) in relation to patients with dementia. Staff could explain about deprivation of liberty safeguards (DoLS) of patients. They did say that DoLS was usually completed on the ward and was not common practice in the ED. Staff recorded capacity assessments and best interests decisions in patient’s clinical records. However, we were unable to review examples of capacity assessments during our inspection. We saw the trust policy and consent form included reference to “Gillick competence”. This is when it is appropriate for consent to be obtained from a child under the age of 16 without the knowledge or authority of the parent.


Compassionate care



We observed staff in the resuscitation area providing friendly, supportive and comforting care. We

observed several patients within this area being spoken to with dignity and respect and staff could

dedicate time to understanding the needs of each individual patient.

Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

Most patients were complimentary about the care they received. For example; “The staff have

been kind.”; “The staff have treated me good, they are very nice”; and “The staff have been

excellent, they couldn’t do enough for you”;


The interactions we observed between staff and patients were professional and compassionate. Patients were triaged by a nurse in the main A&E waiting area. This was in a screened off corridor

separate from the main A&E and at a far enough distance that conversations with the nurse could

not be overheard.

We observed staff maintaining patients’ privacy and dignity by keeping them covered and drawing curtains during examinations and procedures. We observed all nurses asking for permission to enter patient bed areas when the curtains were closed. However, patients in the pit stop were cared for on trolleys in the corridor which meant privacy was not maintained. We observed several interactions between patients and staff and saw staff speaking to patients In a kind and reassuring manner. Staff spent time to listen to what patients had to say. All staff treated patients in a compassionate and courteous manner. The majority of patients had their call bells and could access staff via this if they needed help.

In paediatric emergency department we observed staff taking extra time to engage with children and young people during procedures. Staff used methods to distract patients during painful procedures such as taking bloods. The Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment.

The trust scored between 87.9% and 94.0% from March 2017 to February 2019.

The data show three data points outside of the control limits (in May 2018, June 2018 and February 2019). These unusual data points may be a sign of something out of the ordinary happening and merit further investigation to understand what happened in those months and what can be learnt from this.

Response rates for the A&E friends and family test can often be low, the table below shows the response rate for this metric. Over the two-year period there was an average of 1,913 responses per month for this trust. London North West Healthcare NHS Trust – response rate March 2017 to February 2019


(Source: Friends and Family Test – NHS England)

Emotional support

Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.

We saw staff providing emotional support to patients, as well as their friends and families. This included reassurance from nursing, ancillary, and medical staff. We observed paediatric staff allaying the anxieties of a parent in regards to their child having tests.

Staff were supportive of the parent and explained why the tests were required and what would

happen during the tests.

Staff told us they could access clinical nurse specialists and specialist teams in the hospital that could provide emotional support for patients and their relatives. This included but was not limited to end of life care and mental health. Patients could access support from the Trust’s multi-faith chaplaincy service. The service offered spiritual, religious and pastoral support, as well as signposting to local bereavement services and services to meet the spiritual and religious needs of patients, families and carers. Staff told us there was good access to debriefs and emotional support following any difficult cases within the department.


Staff supported and involved patients, families and carers to understand their condition

and make decisions about their care and treatment.

Most patients told us that staff kept them informed about their treatment and care. We observed

doctors and nurses offering patients and relatives the opportunity to ask questions and to clarify

anything they were unsure of. All patients felt able to ask questions of those caring for them and

felt listened to by their doctors and nurses.

Staff involved patients and those close to them in decisions about their care and treatment. Most patients’ we spoke with told us they were provided with enough information and access to clinicians to ensure they were able to make informed choices about their care and treatment.


However, some patients felt they were left waiting a long time without any updates on what was happening. We found one occasion where an elderly patient had become incontinent because staff had not had time to take them to the toilet. The urgent and emergency care (A&E) had a relatives’ room where relatives and carers could wait while their relatives were being cared for or the room could be used for breaking bad news to relatives and carers. There was a separate viewing room where people could spend time with a member of their family that had passed away in the A&E.

All staff wore name badges and introduced themselves by name. Staff routinely asked patients how they would like to be addressed. Staff wore different coloured uniforms, which made identifying different disciplines and grades of

staff easier. There was a poster that identified what discipline and grade of staff each colour

uniform related to.

Patients were given information in a language they could understand without complicated medical

terminology.

Patients from ‘Pit Stop’ sometimes were left waiting for cubicles in the corridor. We spoke to

some of these patients who told us staff had explained why they were waiting there. There were

also two nurses dedicated to these patients whilst they waited.

There were no dedicated play specialists but staff told us they might be able to access them

through the paediatrics department if urgent.

In the Emergency Department Survey 2016 the trust scored worse than other trusts for five questions (relating to doctors and nurses talking to the patient as if they weren’t there, involving patients in decisions about care, explaining results of and reasons for tests in a way patients can understand and communication of danger signals to look out for after the patient goes home) and about the same as other trusts for the remaining 21 questions.


Q10. Were you told how long you would have to wait to be examined?


Q12. Did you have enough time to discuss your health or medical problem with the doctor or nurse?


Q13. While you were in the emergency department, did a doctor or nurse explain your condition and treatment in a way you could understand?


Q14. Did the doctors and nurses listen to what you had to say? 8.8 About the same as other trusts

Q16. Did you have confidence and trust in the doctors and nurses examining and treating you?


Q17. Did doctors or nurses talk to each other about you as if you weren't there?


Q18. If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so?


Q19. While you were in the emergency department, how much information about your condition or treatment was given to you?


Q21. If you needed attention, were you able to get a member of medical or nursing staff to help you?


Q22. Sometimes in a hospital, a member of staff will say one 8.5 About the same



thing and another will say something quite different. Did this happen to you in the emergency department?

as other trusts

Q23. Were you involved as much as you wanted to be in decisions about your care and treatment?


Q44. Overall, did you feel you were treated with respect and dignity while you were in the emergency department?


Q15. If you had any anxieties or fears about your condition or treatment, did a doctor or nurse discuss them with you?


Q24. If you were feeling distressed while you were in the emergency department, did a member of staff help to reassure you?


Q26. Did a member of staff explain why you needed these test(s) in a way you could understand?


Q27. Before you left the emergency department, did you get the results of your tests?


Q28. Did a member of staff explain the results of the tests in a way you could understand?


Q38. Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand?


Q39. Did a member of staff tell you about medication side effects to watch out for?


Q40. Did a member of staff tell you when you could resume your usual activities, such as when to go back to work or drive a car?


Q41. Did hospital staff take your family or home situation into account when you were leaving the emergency department?


Q42. Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home?


Q43. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left the emergency department?


Q45. Overall 7.5 About the same as other trusts






to plan care.

The emergency department (ED) management monitored bed capacity on a daily basis in bed management meetings. These meetings were made more regular as and when required. The department regular had to activate the full capacity protocol. The department used ambulatory care services to alleviate patient flow pressures. Ambulatory


care services allowed admission of patients for rapid treatment, diagnostic testing and discharge. The service held meetings to discuss frequent attenders which enabled them to out a care management plan in place. This meant when a frequent attender visited the emergency department staff could access a care plan on the patients records and ensure they were treated appropriately. The frequent attenders meeting was included London Ambulance Service (LAS), the ED, social services and the local mental health team. The emergency department served a local population of homeless people. We spoke with nursing staff about provisions in place when homeless people attended the department. Security linked in with local organisations to provide support when they attending the emergency department (ED). Patients were offered food and drink and offered clean and dry clothing. The psychiatric liaison team provided an alcohol liaison specialist and an older adult’s specialist. The alcohol liaison nurse had developed a care bundle for patients attending the ED department for alcohol related reasons, this included support for patients who were intoxicated and suffering from alcohol withdrawal. The department saw a large demographic of elderly patients with complex medical diagnosis. The Short Term Assessment, Rehabilitation and Reablement team (STARRs) provided intermediate care services for patients in Brent. The service provided a multi-disciplinary, holistic assessment of patients. This service supported early discharge by providing hospital services in the community. The rapid response team was community based and focused on admission prevention. This service was provided seven days a week between 8:00am and 10:30pm. Patients in the emergency department were either referred here by nursing staff or picked up via STARRS reviewing the electronic patient system to identify patients presenting with things such as falls and mobility issues. Patients handed over at ‘Pit Stop’ (ambulance receiving area) were now streamed at the door by a streaming nurse and doctor. However, some patients were streamed to the pit stop trolleys area in the corridor and meant confidential conversations could still be overheard if someone walked past. The trust had a designated paediatric ED (PED), which was separated from the main ED department. This area contained all relevant equipment required for treating children and was segregated from the main department. The waiting area was designed with children in mind, with appropriate toys and games available for a range of age groups. There was also information regarding sepsis recognition and information about breastfeeding support. The department had linked in with a local school in order to improve the wall art within the paediatric waiting area. In discussions with carers and children the department had decided to have a circus theme within the waiting area. The departments waiting room was large and had enough seating for patients. There were also drinks and food available in vending machines.


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.

At the last inspection there was a frailty service who worked within the department. The service worked Monday to Friday 8:00am to 5:00pm and comprised of a locum doctor, junior doctor and nursing and therapies staff. We were told be senior leaders that this service had been temporarily


stopped due to financial pressure. The emergency department had access to a dementia lead nurse. There were a number of initiatives in place or planned to improve care for patients with dementia. This included dementia training for healthcare assistants and implementing the ‘important things to me’ within the department. The department had access to a drug and alcohol liaison nurse 9am to 5pm Monday to Friday. We saw information leaflets displayed throughout the ED providing information on who to access for support for domestic violence. There was information in the staff seminar room directing staff how to make a referral for victims of abuse. The department had access to interpreting and translation services for those who did not speak English. This included face-to-face, British Sign Language (BSL), telephone interpreting and translation services. The ED waiting area had a low desk area for disabled patients to be able to register on arrival. There were drinks and vending machines available in the waiting areas for patients and relatives. There was a relative’s room available near the resuscitation area where confidential conversations could take place. This was linked with a separate viewing for when patients passed away. The room was equipped with a sink, sofa, hand washing and kitchen facilities. Staff reported that patients who required a mental health assessment by an approved mental health professionals (AMHPs) in and out of hours had to wait a long time before they were assessed. This led to increased waiting times and delays to discharge or transfer to other services for patients with mental health concerns in the emergency department. The psychiatric liaison team supported the trust to assess patients suffering from mental illness. They aimed to see patients in the emergency department within one hour and patients in all other wards within 24 hours. The table below shows the waiting times for mental health patients within the department once the decision had been made to admit them between January 2019 and June 2019.


As can be seen in the table above there were a number of mental halt patients waiting for long times in the emergency department whilst waiting for beds. Senior leaders were aware of this issue due to the bed crisis in mental health services across the country. Staff told us there was access to a learning disability nurse within the trust if they required support. Patients with learning disabilities were flagged on the computer system. The trust had introduced an electronic identification system for patients with Learning Disabilities in 2017. All learning Disability patients known to the organisation were added to the system so that upon admission they were identifiable by trust staff. Any new patients were added to the flagging system once their condition was known.

The department had noted an increased number of ruptured spleens due to accidents involving

patients hitting themselves on the handlebars of mopeds. As a result, there was a new ruptured

spleen protocol in place which ensured quicker access to scans within ultrasound and

Computerised Tomography (CT) scanning.

The trust scored about the same as other trusts for all three Emergency Department Survey questions relevant to the responsive domain.

Question – Responsive Score RAG

Q7. Were you given enough privacy when discussing your condition with the receptionist?


other trusts

Q11. Overall, how long did your visit to the emergency department last?


trusts

Q20. Were you given enough privacy when being examined or treated?


other trusts



Access and flow

Access to beds in the hospital still presented a significant challenge for the ED and this contributed to significant breaches against the departments key performance indicators. Most medical and nursing staff in the A&E identified concerns with patient access and flow in the department. Staff told us both the adults A&E and paediatric A&E often struggled to meet the demands placed upon it, because of a lack of capacity elsewhere in the hospital. Staff told us ED being blocked due to unplaced patients was a daily occurrence. At ‘Pit Stop’ this resulted in the A&E using inappropriate areas such as corridors. During the inspection we attended the site meeting. During this both hospital sites discussed

staffing levels, any emergency department breaches and bed capacity. This allowed the trust as

a whole to identify any capacity issues and plan to ensure flow. These meetings were held four

times a day.

At the last inspection there was a significant problem with black breaches within the department

due to the significant number of ambulances that the trust received. The department had

introduced a streaming nurse and doctor at the ambulance door. All patients arriving by

ambulance patients were now offloaded and streamed to different areas of the department based

on risk. This new process had been put in place to improve ambulance flow through the

department.

The Department of Health clinical indicators suggest that patients arriving by ambulance or self-

presentation should be triaged within 15 minutes of arrival at A&E and given analgesia within 20

minutes if required. The ambulance streamers was helping the department better achieve this

standard. However, there were still a significant number of black breaches within the department.

The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The median time from arrival to treatment at the trust did not meet the standard in any months over the 12-month period from April 2018 to March 2019. From April 2018 to March 2019 performance was much worse than the standard and the England average. Median time from arrival to treatment from April 2018 to March 2019 at London North West University Healthcare NHS Trust:



We were provided with sit specific data following the inspection. Between July 2018 and June 2019 the median time spent in the department varied between three hours and 35 minutes and three hours and 52 minutes.

The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From April 2018 to March 2019 the trust failed to meet the standard each month. Performance fluctuated around the England average. At the last inspection the trust was consistently below the England average. We found the trust had significantly improved their performance and were above the England average between October 2018 and March 2019. Four-hour target performance - London North West University Healthcare NHS Trust:

We requested the four hour wait target data at a site specific level. For Northwick Park, between July 2018 and June 2019, performance varied between 80.9% and 88.4%. From April 2018 to March 2019 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted fluctuated around the England average, following a similar trend. Percentage of patients waiting more than four hours from the decision to admit until being admitted - London North West University Healthcare NHS Trust:


(Source: NHS England - A&E SitReps). Over the 12 months from April 2018 to March 2019, four patients waited more than 12 hours from the decision to admit until being admitted. This occurred in April 2018 (one patient), December 2018 (one patient) and March 2019 (two patients). For Northwick Park hospital ED between July 2018 and June 2019 the number of patients waiting more than 12 hours was five. The trust provided site specific data for Northwick Park Hospital. Between July 2018 and June 2019, the number of patients who waited between four hours and 12 hours varied between 858 and 1546 with the worst performing month being January 2019. From April 2018 to August 2018 the monthly percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment fluctuated around the England average. From August 2018 onwards, performance was stable, at a slightly higher rate compared to the England average until March 2019 when the England average increased. Percentage of patient that left the trust’s urgent and emergency care services without being seen - London North West University Healthcare NHS Trust:

(Source: NHS Digital - A&E quality indicators) The trust provided us with site specific information following the inspection. Between July 2019 and June 2019, the number of patients who left the department without being seen varied between 53 (0.7%) and 113 (1.2%). The total number of patients who left within this same time period was 957 (0.9%). From April 2018 to March 2019 the trust’s monthly median total time in A&E for all patients was much higher than the England average. Over the 12 months performance by the trust did not improve or worsen. Median total time in A&E per patient - London North West University Healthcare NHS Trust:


(Source: NHS Digital - A&E quality indicators) We found patients were still being placed in CDU to avoid breaching the departments KPIs. During the inspection, we saw patients on CDU who were waiting to be admitted to medical beds within the hospital. Where patients required admission to a mental health hospital staff reported that there were delays in accessing beds and approved mental health professionals. Escalation procedures were in place for adult and CAMHS referrals which were delayed. The trust had an escalation policy for overcrowding in ED with processes to be followed at times of severe pressure. The policy described the escalation level criteria and risks which reflected the capacity of the ED and the process in the event of there being more patients than can be safely cared for. The patients we spoke to within the department were very positive about the staff. However, a number of patients highlighted waiting times as their key concern.


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. Trust level: From April 2018 to March 2019 the trust received 133 complaints in relation to urgent and emergency care at the trust (12.0% of total complaints received by the trust). The trust took an average of 41.1 working days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting 18 complaints were still open. These had been open for an average 47.0 working days A breakdown of complaints by type is shown below:


Percentage of total





Patients' privacy, dignity and wellbeing (including compassion,

respect, diversity, property and expenses) 7 5.3%

Admissions, discharge and transfer arrangements (excluding delay

due to absence of care package) 7 5.3%




Others 3 2.3%




Total 133 100.0%

From April 2018 to March 2019 there were 100 complaints about urgent and emergency care at Northwick Park Hospital. The trust took an average of 40.0 working days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting 12 complaints were still open. These had been open for an average of 39.7 working days. A breakdown of complaints by type is below


Percentage of total




Patients' privacy, dignity and wellbeing (including compassion, respect, diversity, property and expenses)

6 6.0%




Admissions, discharge and transfer arrangements (excluding delay due to absence of care package)

3 3.0%


Others 2 2.0%



Total 100 100.0%

From April 2018 to March 2019 there were 19 compliments about urgent and emergency care at the trust (10.1% of all received trust wide). A breakdown of compliments by site is below:

Site Number of

compliments Percentage

of total




Total 19 100.0%

Complaints could be made in a number of ways including through the Patient Liaison Service (PALS), via a formal written process through the Chief Executive (CEO) and directly to staff. When complaints were made directly to staff the team tried to resolve this issues so a formal complaint was not required. We saw PALS leaflets throughout the department informing patients how to make a complaint if

required.

Any key learnings from complaints was shared with staff via the clinical governance newsletter.

For example, in the June 2019 newsletter one of the main concerns raised was communication

and doctors attitudes. The newsletter reminded staff about appropriately professional attitudes.

The department also displayed the number of complaints they received each month on information

boards throughout the department.


Leadership

Leaders had the integrity, 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 emergency department was part of the emergency and ambulatory division within the trust. The division had a clinical director and clinical lead who were split across Northwick Park Hospital and Ealing Hospital. The purpose of these splits posts was to ensure integration of the two emergency departments (EDs). Northwick Park Hospital ED had its own lead nurse and matrons leading the department. The Urgent Care Centre (UCC) was managed by an alternative provider and not by the trust. They were rated as requires improvement by the CQC. We saw consultants and other senior staff members to have a visible presence within the department. The trust had a strong focus on integration of the two departments. The majority of staff reported feeling valued and felt the management team cared for their well-being. We observed nursing shift coordinators to be capable and efficient, multi- tasking while allocating tasks to the nursing team in order to maximise their impact on patient care. Most nursing staff reported that their matron was visible and supportive. Clinical leadership from the consultant body was good. Junior medical staff told us consultants were approachable and present within the department.

Monthly meetings between senior A&E clinicians and senior staff from the local mental health

Trust’s psychiatric liaison team supported partnership working. This ensured that patients’ physical

and mental health needs were assessed in an integrated way.


Vision and strategy




Leaders and staff understood and knew how to apply them and monitor progress.

Senior leaders told us the departments strategy was similar to when we last inspected. The main

focus of the strategy was to improve the departments structure performance against the national

emergency department targets.

The trust aimed to put patients at the HEART of everything they do. HEART stood for Honesty, Equality, Accountability, Respect and Teamwork. All staff we spoke with knew these values and said they were embedded in practice. The departments vision was ‘to provide high quality medical care whilst meeting the four hour performance target and quality indicators as determined by the Royal College of Emergency Medicine’. This vision was displayed in the central control area of the adult emergency department. To achieve this vision the department had what they called the ‘pillars of strategy’. This included focusing on the integration of the two departments, improving staffing and working on recruitment, education and training, clinical governance and mortality and morbidity, learning from mistakes, and clinical audit and quality improvement.

Senior leaders told us one of the visions they had for the department was to improve provision for

mental health patients within the department. Due to the high number of mental health patients

requiring one to one observations the department were thinking about ways to reduce costs

around this. Senior leaders told us one of their visions was to have a mental health nurse based

within the emergency department at each site who could track mental health patients journeys

throughout the hospital. The department, was also aiming to have Healthcare Assistants (HCA)

trained in mental health to provide additional support for these patients during their journey within

the hospital. The aim of this was to improve the mental health patient experience and care.

Culture

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. Managers in A&E promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with told us that even though there were demand and capacity pressures on the

urgent and emergency care (A&E) there was high staff morale. Most staff we spoke with told us

they felt supported by managers and matrons. Staff told us there was a culture of ‘team working’ in

the A&E.

At the last inspection some staff raised concerns about the culture within the department. We were

told there were examples of bullying in the department and a lack of support from band 7 nurses.

This had improved since the last inspection. However, there was still some negative feedback

regarding some of the band seven nurses.


Learning from incidents was better embedded into the culture of the department. However, some medical staff said they did not get regular feedback regarding learning from incidents. Senior leaders told us sharing from serious incidents was shared via the departments newsletter. We reviewed one the newsletters and saw learning from the two most recent serious incidents was shared. Staff we spoke with were aware of the trust whistleblowing policy and were aware of the trust ‘freedom to speak up’ guardian.

Governance

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. The A&E used a systematic approach to improving the quality of its services and safeguarding standards of care. The emergency department sat within the division of emergency and ambulatory care. Executive

level accountability for ED performance was the responsibility of the chief operating officer. The

medical director and head of nursing were responsible for patient safety and quality. Since the last

inspection the department now had its own governance lead.

The department now had its own clinical governance team called ‘Emergency and Ambulatory

Care Divisional Governance Team’. At the last inspection, governance fell under the medicines

team.

We found the department had a clinical governance meeting each month which included mortality

and morbidity. We reviewed minutes from these meeting and saw items such as incidents, risks

and complaints were not standing agenda items. There were also monthly divisional meeting and

quality and performance review. These meetings discussed incidents, complaints and

performance and fed into the trusts clinical and quality committee, which then fed into the trust

board meeting.

Reviews of the service level agreement between the acute trust and mental health trust took place

regularly at the quarterly psychiatric liaison meeting. There was also a mental health work stream

was in place which both trusts contributed to.


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. There was the emergency pathway improvement committee (EPIC). This group met on a weekly basis to discuss the risk in the ED with speciality teams. The group also looked at patient pathways, flow and bed management. The department continued to have regular meetings with NHS Improvement to improve the departments performance against its Key Performance Indicators (KPIs). The trusts performance against the four hour target was still below the target of 95%. However, the department


performance overall had improved. In April 2019, the trust had achieved 91% which was higher than the England average of 85.1%. In this month the trust were ranked 21 out of 129 trusts. Overall, the trust was performing better against the England average compared to when we last inspected them. The senior leaders recognised the improvement process to meeting the departments targets was

not going to be a quick fix. The department was working closely with the trust to improve patient

flow in and out of the hospital. We were told the hospital was often operating at over 100% bed

occupancy and often the full capacity protocol was in use. Any patient who was in the ED for more

than four hours was escalated to site management. There were regular bed management

meetings to discuss patient flow within the hospital and to work together to think about patients

who could be sent to the discharge lounge and prevent bed blockages.

The department aimed to identify any social needs and make referrals to the STARRS team for

any care packages to be started early. They had also introduced a STARRS team virtual ward

rounds with an elderly care consultant. The aim of this was to prevent patients coming to the

department if their needs could be addressed in the community.

During our meeting with the ED leadership team we asked them what were the three biggest risks to the department. The leadership told us the biggest concerns were patient flow out of the ED, ambulance turnaround and staffing. The departments risks were shared with staff in the clinical governance newsletter. The June, 2019 newsletter informed staff that the biggest risks with the ED were lack of capacity, inappropriate location of the mental health suite and lack of pharmacy support. The band five vacancy rate and improved since the last inspection. Senior leaders continued to see this as one of the biggest risks in the department. The department had taken a number of steps to improve staffing including overseas recruitment, job fairs and universities and offering staff the opportunity to be part of the rotation programme. The trust were also thinking about approaching secondary schools. The department had been working with human resources around retention. There had been sessions ran called ‘conversations for actions’ with staff to get feedback and better understand how the department can make staff feel more valued. We reviewed the risk register and saw there were six risks on the risk register relating to the emergency department. These were staffing levels, lack of capacity in the ED, lack of pharmacy support, inappropriate location of the mental health assessment room, high vacancy rates for medical and nursing staffing, mental health patient observations and insufficient security presence. We found some risks in the department which were not on the risk register. For example, similar to the last inspection black breaches and ambulance turnaround were a significant risk for the ED. However, this was not entered as its own risk on the risk register. One of the risks identified by senior leaders was the high number of black breaches and ambulance turnaround. The department previously had introduced a risk assessment tool in the ‘Pit Stop’ area which was used by staff used during times of high demand. The risk assessment helped staff come to a decision regarding the number of ambulances to offload at a time. Since the last inspection the department and taken further steps to try improve patient safety and offload times. There was now a streaming nurse and doctor available to stream patients arriving by ambulance. All patients would have their observations taken and would be streamed to different areas of the department based on risk. This included being streamed to resuscitation, the main emergency department, ‘Pit Stop’, the urgent care centre (UCC) and to the main waiting room. Senior leaders told us this meant the department had better oversight of these patients as they were then on the departments electronic record system. This had been started around six weeks before our inspection and was led by one of the Advanced Clinical Practitioners (ACP). The


department were very proud of this new process. There were also two dedicated nurses allocated to ‘Pit Stop’ patients who could start the patients interventions as required. Senior leaders told us the changes to ‘Pit Stop’ was the first stage of the improvement process. The aim was to ‘get it right at the front door’ first and ensure patients are safe. We were told there were plans to audit ambulance pick ups and post codes with London Ambulance Service. The aim of this was to help see what postcodes patients were coming from to help inform any action planning around improvement work. Trust leaders told us the department got a lot of out of area patients via ambulance which impacted on discharge planning. At the last inspection we identified risks with mental health patient not being appropriately observed following recommendations by the mental health team. The department informed us they had taken a number of steps to improve this and had trained staff around enhanced observations. In addition, at the last inspection concerns were raised regarding the mental health room being in the middle of the Clinical Decisions Unit (CDU). Senior leaders told us the department would be moving this room to a different area within the main emergency department. At the time of the last inspection the EDs performance against national targets such as ambulance turn around and the four hour wait time target was poor. Whilst performance was still poor the trust had made improvements. Performance against the national four hour wait target was no longer consistently below the England average. The department had also recently introduced a streaming process at ‘Pit Stop’ to improve the safe management of patients arriving via ambulances.

The Clinical Decisions Unit (CDU) was still not being used appropriately. We reviewed the quick

guide for admitting to CDU and the exclusion criteria says patients should not be admitted to CDU

if they are confused, have abnormal CT scan, awaiting speciality review or have a news score of

more than two. Our concerns were that a number of patients on CDU were awaiting transfer to

either medical beds or surgical beds within the hospital.

There were still no joint governance meetings between the two services to discuss risk and learning from incidents.

The directorate had an audit programme, which was used to monitor services and compliance against national and local standards. Results of some audits were displayed in the ED waiting room including MRSA screening, medicines management, hand hygiene and national early warning scores compliance. The trust had action plans in place to address poor performance in some of the national audits.

The department also had information around quality improvement initiatives within the department.

Information leaflets highlighted what the issue was, what the department hoped to achieve and

what interventions they were implementing. For example, for paediatric suspected appendicitis

one of the issues was patients being seen out of hours and there being no clear agreement

between the ED, radiology and surgeons. The department had implemented a new patient

pathway and parent information leaflets. Another example, was work being done around dealing

with agitated patients within the ED. The department was going to be providing training on

behavioural disturbance and breakaway training. There were plans to review cases where rapid

tranquilisation was used to identify any areas for improvement.



The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required. Staff we spoke with told us they were able to access the information they needed to provide safe and effective care. There were systems to manage and monitor care records and we saw this in practice with electronic patient care records The ED used a computer system which displayed all information about patients within the ED. This included information about time in the department. Within the central control area in the assessment and high dependency there was a screen which displayed the current waiting time for assessment, current performance against the four hour target and how many patients had breached. The ED used multiple patient record systems online. When the ED needed to refer patients to medical wards they were required to duplicate all the information from one electronic system to another. The intranet was available to all staff and contained links to current guidelines, policies and procedures. This meant staff could access advice and guidance easily. All staff we spoke with knew how to access the intranet and the information contained within. All staff had access to their work email and we were shown that they received organisational information on a regular basis including updates and changes to policy and procedures.

Engagement

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. There were newsletters produced on a monthly basis, which gave details of things such as never events and serious incidents. These were posted in staffing areas and included information about the main risks to the department, learning from incidents and complaints. It also included some positive feedback from patients. At this inspection we saw various signs prompting patients to leave feedback on how the department were doing. There was also a section for ‘you said, we did’ where the department gave feedback on what changes were being made as a result of any complaints raised. The department had launched ‘WOW boards’ campaign. The boards were decorated by staff and comments were left on the boards by staff to say what achievements they were proud of whilst working in the department. The aim was to highlight good practice to improve morale. The ED still held nursing team days every four months for nursing staff. This gave staff the opportunity to discuss concerns within the department.


The trust had engaged with staff grade doctors to discuss the rota and how rota patterns could be improved to suit the needs to the doctors. For example, minimalizing the number of shifts that ended at times when it was difficult to use public transport to get home. The trust had recognition awards for staff called the ‘Staff Excellence Awards’. The trust had linked in with Wembley Stadium who provided free tickets for staff to attend events at the stadium. The aim of this was to improve staff morale.


All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research. The department had introduced the emergency pathway improvement committee (EPIC) committee in order to regularly discuss patient flow and bed management. There were also two hourly board rounds to discuss issues within the departments. The departments focus was to continue to improve performance against national targets and key performance indicators. Priorities for the department included consideration of how ambulance handovers could be more efficient and improve patient flow. The department had a streaming nurse and doctor at the ambulance door. This meant the department had better oversight of all patients arriving by ambulance. Each patients’ observations were taken and patients were streamed to the most appropriate part of the department based on risk. The department had done a rotational shift with the local mental health trust. The purpose of this was for staff to get an ides how the other service was run, learn and share knowledge and understanding to improve the way they worked together. Following the rotation the staff came together to discuss how they could improve joint working and communication between the two trusts. This had been recognised as good practice in the Nursing Times News. The department had developed a patient sepsis video for parents whose children attend the paediatric emergency department with a fever or suspected infection. The video was a four minute video aiming to educate parents about the warning signs to look out for sepsis. ED had piloted a mobile phone app in which they could book porters via the app. The purpose of the application was to reduce staff burden of filling out a two page referral form when a porter was needed. The app allowed staff to provide special instructions for the porters, such as the need to carry patient records or oxygen. The department was liaising with a local youth foundation to introduce youth worker volunteers into department to improve patient experience.

Surgery

Facts and data about this service

The surgical department at the trust comprises 21 wards/departments across four sites. A list of the wards and the specialties they cover are in the table below: Northwick Park Hospital:

Ward/department name Specialty


Dowland Ward Urology

Edison Ward Surgery, surgical assessment unit (SAU),

gynaecology

Eliot Ward General surgery and vascular

Evelyn Ward Trauma & orthopaedics

Fletcher Ward Gastroenterology

Gray Ward Maxillo-facial surgery

Sainsbury Private patients

Theatres admissions unit (TAU) All surgery

Theatres Theatres

Central Middlesex Hospital:


Abbey Ward Surgery

Ambulatory care and diagnostics (ACAD) pre-

assessment Surgery

ACAD recovery Surgery

ACAD theatres admissions unit Surgery

ACAD theatre Surgery

Brent emergency care and diagnostics

(BECAD) theatre Surgery

Ealing Hospital:


Ward 3 North Surgical admissions unit

Ward 7 North General surgery

Ward 7 South Trauma & orthopaedics

Theatres Theatres

St Marks Hospital:

Ward name Specialty

Frederick Salmon Ward Colorectal Surgery

Jonson Ward Intestinal rehabilitation unit

(Source: Routine Provider Information Request (RPIR) – Sites tab) The trust had 40,000 surgical admissions from January 2018 to December 2018. Emergency admissions accounted for 14,277 (35.7%), 20,096 (50.2%) were day case, and the remaining 5,627 (14.1%) were elective. (Source: Hospital Episode Statistics)


Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training

The service provided mandatory training in key skills to all staff, however, there were no

assurances everyone completed it.

The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)










In surgery the target was met for eight of the nine mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




Health & safety 317 453 70.0% 85.0% No






In surgery the target was met for none of the nine mandatory training modules for which medical staff were eligible. None of the 12 eligible medical staff completed the manual handling – level 2 (face to face) training module.


Northwick Park Hospital surgery department: A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in surgery at Northwick Park Hospital surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)










In surgery the target was met for six of the nine mandatory training modules for which qualified nursing staff at Northwick Park Hospital were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for medical staff in surgery at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)





Health & safety 76 112 67.9% 85.0% No




In surgery the target was met for none of the eight mandatory training modules for which medical staff at Northwick Park Hospital were eligible. Staff demonstrated awareness of the trust’s sepsis standards and of national guidelines relating to the Sepsis 6 pathway. Sepsis management was not part of the trust’s mandatory training package although a dedicated ‘sepsis squad’ worked across all wards and clinical areas to provide guidance and direction. The mandatory training was comprehensive and met the needs of patients and staff. We saw no evidence that clinical staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism and dementia. (AMSAT) Senior team were aware of the levels of low completion for medical staff, however this was not cited on the divisional risk register. We were told it was difficult to gain assurance however, there were no safety concerns. We were told that in August 2019 a passport system for doctors would be introduced whereby in date mandatory training completed at previous Trusts could be


transferred to LNWH.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse, and they knew

how to apply it.

Safeguarding policies and procedures were in place across the trust. These were available

electronically for staff to refer to and staff demonstrated how to access them. Staff knew how to

obtain advice and support from the safeguarding team and could describe the process they would

use to escalate a safeguarding concern.

The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)





PREVENT 485 508 95.5% 85.0% Yes


In surgery the target was met for five of the six safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)





PREVENT 201 453 44.4% 85.0% No

In surgery the target was met for one of the five safeguarding training modules for which medical staff were eligible. Northwick Park Hospital surgery department:


Nursing staff received training specific for their role on how to recognise and report abuse. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 qualified nursing staff in surgery at Northwick Park Hospital is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




PREVENT 235 245 95.9% 85.0% Yes

The target was met for all the four safeguarding training modules for which qualified nursing staff in surgery at Northwick Park Hospital were eligible. Medical staff received training specific for their role on how to recognise and report abuse. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in surgery at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



PREVENT 57 112 50.9% 85.0% No

The target was met for none of the three safeguarding training modules for which medical staff in surgery at Northwick Park Hospital were eligible.

Staff could give examples of how to protect patients from harassment and discrimination, including

those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked

with other agencies to protect them

Staff knew how to make a safeguarding referral and who to inform if they had concerns.

Staff followed safe procedures for children visiting the ward.


The service controlled infection risk well. The service used systems to identify and prevent

surgical site infections. Staff used equipment and control measures to protect patients,

themselves and others from infection. They kept equipment and the premises visibly clean.


Nurses demonstrated good knowledge and practice in infection control, including in the use of the

aseptic non-touch technique (ANTT). Staff adhered to enhanced infection control processes to

provide safe care for patients at increased risk of infection.

During our observations in wards and theatres we observed that all staff adhered to good hand

hygiene practices. We saw staff confidently challenge colleagues who did not adhere to the bare

below elbow policy.

Throughout the surgical department we saw there were sufficient hand washing facilities and wall

mounted hand sanitiser dispensers in corridors. Attention was drawn to these with hand hygiene

notice boards. Staff in all areas had access to personal protective equipment (PPE) such as gloves

and aprons. We observed theatre staff wore the appropriate PPE during surgical procedures.

Waste management practices were observed and complied with the hospital policy and good

practice guidelines for segregation of waste. The areas where disposed waste was kept were locked

as per policy. Sharps bins were labelled and dated, and bed linen was bagged appropriately. Sluices

in wards were clean, tidy and well organised.

Arrangements were in place to isolate patients awaiting elective surgery pre-operatively from

patients requiring emergency surgery.

We saw staff consistently used bright green ‘I am clean’ stickers to indicate when an item of

equipment was clean and ready for use.

Hand hygiene audits were conducted weekly on each surgical ward and measured staff practice in

line with 10 hospital standards. The audits were also audited independently by the IPC team. Audits

made available to us on inspection demonstrated 99% compliance in May and 98% in June.

Cleanliness standards were monitored and regular audits were completed jointly with a domestic

supervisor, theatre band 7 and matron. Ward managers used weekly cleaning checklists for infection

control duties that were the responsibility of permanent ward staff and not the cleaning contractor, such

as the weekly cleaning of medicine trolleys.

We saw evidence of a rolling deep cleaning programme in place for theatres, staff told us contractors

for cleaning were responsive to the ward’s needs.

Staff maintained documentation of the cleaning and had completed these in the months leading to our

inspection.

Nurses carried out tests for Methicillin-resistant Staphylococcus aureus (MRSA) for each patient on

admission in addition to a check of past medical history for previous infection. They also

implemented care bundles, such as the vomiting care bundle, where patients were admitted with

existing infections. Each ward had side rooms that could be used as isolation rooms in the event an

infectious patient was admitted.

Staff worked effectively to prevent, identify and treat surgical site infections (SSIs). There were no

incidents of SSIs where root cause analysis had identified any responsibility of theatre for the

infection. The trust monitored orthopaedic patients infection via weekly MDT meeting at the

Northwick Park site.


The design, maintenance and use of facilities, premises and equipment kept people safe.

Staff were trained to use them. Staff managed clinical waste well.

Documents seen on inspection confirmed an annual ventilation inspection had taken place in all

theatres. Hospital redevelopment and estates were recorded as a risk on the trust corporate risk


register. Senior staff told us capital for equipment was in place which would lead to infrastructure

improvements within the surgical division.

Emergency resuscitation equipment was in place, trolleys we reviewed were visibly clean and daily

and weekly checklists were completed. We saw that tamper proof seals were present on all

resuscitation trolleys as required by trust policy.

Safety testing was in place for equipment, all the equipment we observed had stickers with dates

confirming that maintenance checks had been completed.

Although compliance for fire safety mandatory training was below the trust target, all staff we spoke

with had a good understanding of fire safety and emergency procedures.

Patients could reach call bells and staff responded quickly when called.

On inspection we saw a two bed paediatric area created within recovery, as per national guidance.

Although privacy screens were in place, there was a risk of paediatric patients being able to see

adults recovering from surgery. On inspection we observed the paediatric area in use and although

side screens were drawn the front screen was open and the patient was able to observe the mixed

adult ward. Staff we spoke with were aware of the risks associated with the paediatric area within a

mixed adult recovery ward. The paediatric beds were located directly opposite the nurse’s station

and staff told us the beds were observed at all times.

The surgical assessment unit (SAU) was currently located on Edison ward. Edison ward

encompassed general surgery, emergency gynae and other surgical specialities.

On inspection we noted the ward as very busy and two of the allocated rooms for SAU were occupied

by inpatients. Staff told us SAU operated with three rooms for patient assessment or treatment and

one room which was used as a waiting area. The service ran 24 hours a day, 7 days per week.

Patients were referred to SAU via the trusts emergency departments and directly from general

practitioners. Staff told us 16 to 18 year olds were seen in SAU three to four times per week and

when seen an incident form was completed.

We observed the SAU waiting area was small and cramped, the seating was mostly of hard seating

and low backed chairs. All chairs were very close together and provided little privacy. Although there

were several key concerns in relation to the SAU provision staff told us there were plans for the unit

to relocate to the Lister unit from 11 July 2019. The new location was closer to the emergency

department, contained three rapid assessment spaces, had two consulting rooms, eight short stay

beds and a phlebotomy room.

On inspection we saw there was an equipment cleaning programme and protocols in place and

responsible staff were identified. Equipment checked on inspection was visibly clean with labels

identifying the date equipment had last been cleaned.

The theatre procurement team managed and maintained the asset inventory for the whole trust, this

allowed for standardised practice across all three sites. The team kept a maintenance schedule and

were responsible for ordering, monitoring and reporting faults with equipment.

All equipment in theatres were assigned a category to identify the lifespan of the product

and when it would need to be replaced.

There was a risk register for increased capital requirements and all requests went through a central capital programme. For example, staff told us some cameras which were in use were no longer supported by the original equipment manufacturer and therefore needed replacing. Lease


and loan options were explored in the interim whilst awaiting capital allocation. There had not been any incidents in relation to cancellation of surgery due to equipment not being replaced. Senior staff told us stores and stock issues were related to the NHS supply chain. We identified a

good network for stock availability which involved borrowing and sharing to ensure supplies. An

incident report was completed if surgery was cancelled due to lack of stock availability.

We were assured of the protocols and processes in place to manage equipment defects or failures.

The protocol stated all equipment would be quarantined until investigation and outcomes were

completed.


Staff completed and updated risk assessments for each patient and removed or minimised

risks. Staff identified and quickly acted upon patients at risk of deterioration.

Routine patients attended a pre-assessment visit prior to their operation date. During this

appointment, clinical specialist nurses discussed risk factors and referred patients into services if

appropriate, for example diabetes specialist services.

All surgical procedures were consultant-led. Patients were reviewed by a consultant surgeon or

consultant anaesthetist irrespective of pre-operative mortality risk.

There were processes in place to reduce the risks to patients undergoing surgery. These included

the use of the World Health Organisation (WHO) surgical safety checklist.

During our inspection, we saw that the WHO checklist was embedded in practice. We witnessed

two cases in theatres where the WHO surgical safety checklist was completed correctly.

The five steps to safer surgery audit results provided by the trust showed 100% implementation rate

for July 2018 to June 2019. Compliance rates for the completed steps of the checklist were 100%,

except for brief/debrief, which showed a 97% compliance during the same period.

As part of the annual trust improvement plan the trust had trained staff on the use of NEWS2. The

National Early Warning Score 2 (NEWS2) is a scoring system that identifies patients at risk of

deterioration or needing urgent review. Observations were recorded on paper charts in patients’

records together with the calculated level of risk. The service undertook monthly NEWS2 snapshot

reviews. Results showed a compliance rate of 100% in July 2018 to June 2019 for the surgical ward.

We looked at NEWS2 charts in six patient records and found them to be completed correctly. This

was initiated in all areas where patient observation took place. We saw compliance measured

through review as part of the safety huddle.

The NEWS2 assessment enabled staff to carry out holistic assessments of each patient’s condition

and staff used other escalation systems for more urgent or specific escalation, such as the major

haemorrhage protocol. The major haemorrhage protocol was in place in case of major blood loss

and for an urgent need of a blood transfusion.

The trust used national guidelines for sepsis to underpin the management of sepsis, staff used the

national Sepsis 6 care bundle to manage patients at risk of, or with confirmed, sepsis. An escalation

plan was in place for patients who needed an urgent review. The sepsis pathway was part of the

NEWS2 patient observation chart.


We looked at completed risk assessments in eight patient records. In each case staff had completed

these for venous thromboembolism, MRSA, pressure sores, falls and psychological risks.

There was a safety brief held on Evelyn ward daily including weekends. Information was shared

about all surgical wards such as staffing, discharges, empty beds, risks, 1:1 care needs, patients

with additional needs such as learning difficulties or dementia etc, infection control risks, NEWS2

escalating and patients moved during the night. This was attended by surgical speciality leads and

ward matrons.

A team safety huddle was held daily in theatres. On inspection we observed the huddle and saw

that safe staffing and a safety checklist was discussed.

Surgical services were managed in accordance with National Confidential Enquiry into Patient

Outcome and Death (NCEPOD) recommendations, for example, all elective high-risk patients were

seen by anaesthetist and fully investigated in pre-assessment clinics.

There was a comprehensive handover of CEPOD patients from the anaesthetic team. The

CEPOD list is a permanently staffed operating theatre that can run on a 24-hour basis. This resource

is shared amongst surgical specialities that may need to conduct urgent or emergency operations.

Nurse staffing

The service had enough nursing staff, with the right mix of qualification and skills, to keep

patients safe and provide the right care and treatment. Managers regularly reviewed and

adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.

From April 2018 to March 2019, the breakdown of WTE staff in post in surgery at Northwick Park Hospital is shown in the chart below.

Surgery annual staffing metrics (April 2018 to March 2019)


Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available


available hours)


hours)

Trust target 11.0% 13.0% 4.0% All staff* 709.3 16.5% 17.3% 5.1%

Qualified nurses

384.6 18.9% 9.2% 5.7% 87,134 (11.4%)

48,599 (6.3%)

26,920 (3.5%)

Nursing assistants

128.0 17.6% 12.7% 6.9% 64,627 (24.9%)

0 (0.0%)

8,924 (3.4%)

Medical staff 120.3 11.1% 43.1% 1.2% 24,874 (11.4%)

3,526 (1.6%)

18,590 (8.5%)


2.5 30.6% - -

* All staff includes other staff groups not specifically shown in the above table ** The trust has confirmed that the medical staffing turnover figures include planned rotation, which inflates the rate.

Vacancy rates:

Monthly vacancy rates from April 2018 to March 2019 for all staff in surgery at Northwick Park Hospital showed a downward trend from October 2018 to March 2019.


Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Northwick Park Hospital showed a downward trend from October 2018 to March 2019.

Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in surgery at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Sickness rates:


Monthly sickness rates from April 2018 to March 2019 for all staff in surgery at Northwick Park Hospital showed a downward trend from May 2018 to September 2018.

Monthly sickness rates from April 2018 to March 2019 for nursing assistants in surgery at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Monthly turnover rates from April 2018 to March 2019 for nursing assistants in surgery at Northwick Park Hospital showed a shift from October 2018 to March 2019. Bank, locum and agency staff usage:


Monthly bank hours from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Northwick Park Hospital showed a downward trend from May 2018 to September 2018. From September 2018, they were not stable and may be subject to ongoing change.

Monthly bank hours from April 2018 to March 2019 for all staff in surgery at Northwick Park Hospital showed a downward trend from August 2018 to December 2018.

Monthly bank hours from April 2018 to March 2019 for nursing assistants in surgery at Northwick Park Hospital showed a downward trend from October 2018 to March 2019.

The trust used the NHS London Procurement Partnership (LPP) and Crown Commercial Service (CCS) framework agencies for the supply of all clinical locums. As a condition of being on framework, agencies ensured the locums supplied were subject to the same pre-employment checks as NHS staff. Agencies completed a placement checklist for each locum they supplied providing details of professional registrations, disclosure and barring service (DBS), right to work, fitness to practice, assurance that two current references were on file and all statutory and mandatory training was up to date. Agencies were regularly audited for compliance against their frameworks. Any that failed the audit were suspended from framework and removed from the trusts suppliers list until they successfully passed audit. On inspection we saw an induction and orientation process for bank and agency staff. Agency and bank staff we spoke with told us they received a good induction and orientation and allocated


a buddy to work with for first two weeks. There was an overseas nurse recruitment programme to help reduce vacancies. We spoke with international nurses on the surgical ward who commended the support and training they had experienced. One overseas nurse told us that they had recently received their PIN. They said they had a lot of help and support in achieving this and had been allocated a buddy for two weeks which made the process and transition easier. The nursing team on all wards monitored staffing levels every day. This information was updated daily on a quality board, which was displayed at the ward entrances. Staffing levels were discussed daily in a safety brief on Evelyn Ward. If there were staff shortages, managers would take action, such as requesting temporary staff or moving staff from other areas. We saw evidence of this during observation of the safety brief. This ensured flexible working and allowed staff allocation in the right place at the right time to meet patient needs and make best use of available resources. Theatre duty rotas seen on inspection showed staffing levels during surgical procedures was compliant with recommendations from the Association for Perioperative Practice (AFPP). The trust reviewed its nursing workforce using the Safer Nursing Care Tool (SNCT) and case load. In 2018 the trust acquired a licence to use the SNCT from an external company. Results from using these workforce planning tools were cross-checked with professional judgement, benchmarking with peers and triangulated with quality indicators and outcomes such as incidents, staff and patient experiences. In November 2018 NHSI undertook a safer staffing review of nursing, providing assurance to the trust board. A monthly nursing, midwifery and allied health professional safer staffing report was presented by the chief nurse to the workforce development committee, workforce and equality committee and to the trust board. A safer staffing and escalation policy was in place.

Medical staffing

The service had enough medical staff, with the right mix of qualification and skills, to keep

patients safe and provide the right care and treatment. Managers regularly reviewed and

adjusted staffing levels and skill mix, and gave locum staff a full induction

Surgery annual staffing metrics


Staff group

Annual

average

establishment

Annual

vacancy

rate

Annual

turnover

rate**

Annual

sickness

rate

Annual

bank

hours (%

of

available

hours)

Annual

agency/

locum

hours

(% of

available

hours)

Annual

unfilled

hours

(% of

available

hours)

Trust target 11.0% 13.0% 4.0%

Medical staff 12.3 9.4% 47.8% 4.3% 0 0 2,574

(18.8%)


(0.0%) (0.0%)

** The trust confirmed that the medical staffing turnover figures included planned rotation, which

inflated the rate.

Vacancy rates:

The service had low and reducing vacancy rates for medical staff.

Monthly vacancy rates from April 2018 to March 2019 for medical staff in surgery at Northwick Park Hospital showed a shift from October 2018 to March 2019. Sickness rates:

Sickness rates for medical staff were low and reducing.

Monthly sickness rates from April 2018 to March 2019 for medical staff in surgery showed a downward trend from November 2018 to March 2019. Bank and locum staff usage:

Managers could access locums when they needed additional medical staff.

Managers made sure locums had a full induction to the service before they started work.


Monthly bank hours from April 2018 to March 2019 for medical staff in surgery at Northwick Park

Hospital showed an upward trend from November 2018 to March 2019.

(Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Nursing bank agency and Medical locum tabs) The service had a good skill mix of medical staff on each shift and reviewed this regularly. In January 2019, the proportion of consultant staff reported to be working at the trust was lower than the England average and the proportion of junior (foundation year 1-2) staff was the same.

Staffing skill mix for the whole time equivalent staff working at London North West University Healthcare NHS Trust:

This Trust

England average

Consultant 42% 49%


Registrar Group~ 34% 29%

Junior* 11% 11%


(Source: NHS Digital Workforce Statistics) Medical staffing levels in theatres complied with the standards of the AFPP.


Junior doctors at various levels covered the ward 24-hours, seven days a week. Consultants led ward rounds on the inpatient wards. There was 24-hour, seven day a week on-call rota for consultant surgical cover on site. Staff on the wards felt supported by doctors and told us there was senior medical support available when needed.

At the last inspection, we saw the service had received instruction from Health Education England

(HEE) that the surgical senior house officer (SHO) could not take referral calls from urgent care

centres on weekends and that a surgical registrar must lead this. At this inspection we saw the

senior team had put in place suitable strategies to meet the staffing requirement.

Records



Staff prepared and maintained patient records in line with trust guidelines, which were based on

standards from the Royal College of Physicians, the Nursing and Midwifery Council and the

Chartered Society of Physiotherapists. This included ten standards for each entry and 13 standards

for prescription charts.

The hospital used a combination of electronic and paper records. Admission notes, risk

assessments, care plans, observations, nursing or medical documentation, consent forms and

anaesthetic protocols were kept in the paper record. Imaging and blood test results were stored

electronically. Paper records were stored appropriately in lockable trolleys or cupboards and

electronic records were not left displayed on unattended computer screens. Access to the

computers and patient confidential information was password protected, with staff having access

via personal logins and passwords.

Staff recorded progress notes and observations for each patient and care plans were individualised

and based on a surgical pathway. We reviewed eight patient records and found documentation

completed to a good standard. Fluid balance charts were all totalled and balanced.

We saw there was a process within patient records to manage patient ward moves. An assessment

booklet also contained an escalation process for patient moves so they were clearly documented.

Staff told us if a patient moved more than twice an incident report was completed.

A confusion pathway was contained in all notes reviewed, however, was not applicable to the

patients reviewed.

All patient records we looked at complied with the General Medical Council (GMC) guidelines on

legibility and completion. This included the date, time and designation of the clinician completing the

record.

Care summaries were sent out to the patient’s general practitioner (GP) on discharge to ensure

continuity of care within the community. Patients also received a copy of their discharge letter with

their latest medication prescription to share with the GP.

In theatres, there was a standard operating procedure, which outlined the process for documenting

and tracing surgical implants. The implant details including the unique serial number were recorded

in the patient record.


Medicines

The service used systems and processes to safely prescribe, administer and record

medicines. Medicines were not stored at recommended temperature.

Staff followed systems and processes when safely prescribing, administering, recording and storing

medicines.

Staff managed medicines and prescribing documents in line with the provider’s policy. However,

some medicine storage areas did not meet national guidance for security. The controlled drug

cabinet on Evelyn ward was made from wood, this did not meet the minimum standards. We also

saw there were exposed wires within the cabinet which could pose as a health and safety risk.

Staff reviewed patient’s medicines regularly and provided specific advice to patients and carers

about their medicines.

We saw that nursing staff introduced themselves to patients before offering them medicines, they

explained what they were giving, and observed the patient take them. A designated pharmacist

visited the surgical wards Monday to Friday to review prescriptions and advise medical staff when

doses needed to be revised. The pharmacist reviewed medicines and information provided to

discharged patients.


performed to ensure that they were fit for use in accordance with trust policy. However, records

showed that temperatures had fallen outside of the recommended range for storing medicines and

action had not always been taken by staff. Temperature recordings on Evelyn ward showed in May

2019 the treatment room temperature had been above 30 degrees for 16 days and in June 2019

the room temperature had been above 30 degrees throughout the month. No action had been taken.

Intravenous fluids were stored in a separate room and on inspection we noted it was very warm,

however, the temperature was not monitored. Storing medicines outside of the recommended

temperature range may reduce their effectiveness.

Staff followed current national practice to check patients had the correct medicines. We reviewed

eight drug charts and saw antibiotics were reviewed every 48 hours.

The trust had an antibiotic stewardship team which is comprised of consultant microbiologists and

lead pharmacists who monitored the usage of antibiotics within the trust, this involved completion of

stewardship rounds to review antibiotic prescribing and ensure advice was available seven days a

week to discuss microbiology results and treatment.

The trust was an early implementer of the Antibiotic Review Kit (ARK) as part of the antimicrobial

stewardship programme to reduce unnecessary antibiotic use. This was currently being piloted

across several wards on the Northwick Park site. This acted as a decision aid for prescribers,

prompting review of all new antibiotic prescriptions within 72 hours. A new prescription chart had

been launched to prevent antibiotic prescribing for longer than 72 hours without a review. Other

initiatives included:

• Consultant microbiology attendance on multi-disciplinary ward rounds in ‘hot spot areas’ e.g.

augmented care, infectious disease.

• Twice yearly audits of indication and duration documentation on prescription charts.

• Targeted antibiotic rounds which involved reviewing the use of a particular antibiotic.

• Microbiology advice on antibiotics requested by referral for all medical staff.


• Twice weekly review of positive blood cultures and antibiotic prescribing.

• Empirical guidelines available to medical staff via phone app.

Policies and procedures were available and accessible to staff via the trust intranet. Policies we

viewed as part of our inspection were in date and in line with best practice and national guidelines.

Clinical guidance was also available on the trust intranet.

The service had systems to ensure staff knew about safety alerts and incidents, so patients received

their medicines safely.



Staff supported patients to make informed decisions about their care and treatment. They followed

national guidance to gain patients’ consent before administering medicines.

Senior management told us to adhere with medicine management standards, specific training had

been implemented on another trust site. We were told this would be rolled out to the Northwick Park

Hospital at the end of the year through a task and finish group. Medicines management champions

would be appointed to improve accountability for standards.

Incidents

Incidents


and near misses. Managers investigated incidents and shared lessons learned with the

whole team and the wider service. When things went wrong, staff apologised and gave

patients honest information and suitable support. Managers ensured that actions from

patient safety alerts were implemented and monitored.

Staff we spoke with described an open and fair culture with a learning and sharing approach to

incidents. Senior management did not advocate a blame culture and all staff stated they felt

comfortable raising any concerns.

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2018 to April 2019, the trust reported four never events for surgery, with two occurring at the Northwick Park Hospital site. Details of which are below:

Date of incident

Site Never Event type

May 2018 Central Middlesex Hospital

Wrong implant/prothesis


Retained foreign object

May 2018 Northwick Park Hospital

Wrong site surgery

June 2018 Northwick Park Hospital

Wrong site surgery

(Source: Strategic Executive Information System (STEIS))


In accordance with the Serious Incident Framework 2015, the trust reported 23 serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from May 2018 to April 2019. A breakdown of the incident types reported is in the table below:


Percentage of total



Diagnostic incident including delay (including failure to act on

test results) 2 8.7%

Medical equipment/devices/disposables incident 2 8.7%

Pressure ulcer 2 8.7%


Total 23 100.0%

A breakdown of incidents within surgery broken down by site are in the tables below. Northwick Park Hospital:


Percentage of total



Diagnostic incident including delay (including failure to act on

test results) 2 13.3%

Medical equipment/devices/disposables incident 1 6.7%


Total 15 100.0%

(Source: Strategic Executive Information System (STEIS)) There were several routes that learning from incidents was shared. Feedback was automatically supplied via an incident reporting system to the reporter of an incident. Actions were developed to manage incidents and required multi-disciplinary team (MDT) and joint working input. This promoted shared learning and working. Incident feedback was shared in monthly team meetings for the wards and theatres and were attended by allied health professionals, nursing and medical staff. New incidents and shared learning from previous incidents were shared with staff through emails, newsletters, at safety huddles and departmental meetings. Learning from incidents was shared trust wide, for example theatre staff were aware of details of a never event that had occurred at the other site. Incidents reports were presented to specialty-based groups where appropriate. Learning from incidents was presented at the relevant monitoring groups such as falls and tissue viability steering groups and other divisional clinical governance groups. Serious incident (SI) investigations with learning to be shared were presented by the divisions at the serious incident review group and the patient safety committee. The trust monthly team briefings covered key incident reporting and learning themes from serious incidents and never events investigations for wider dissemination of learning.


On our inspection we saw a “Learning from Incidents Webpage”, where SI reports were published for learning. In May 2018 the trust developed a centralised system of tracking the outcomes from incident investigations by utilising the actions module on the incident reporting risk management system. the system allowed monitoring of the progress of implementation of each action in real time. Reports could be generated for divisional and individual monitoring and updates. The process was monitored at the weekly serious incident review group and the patient safety committee. The previous inspection identified healthcare assistants (HCAs) did not have access to the incident reporting system. On inspection, all staff we spoke with including HCAs knew how to report incidents on the incident reporting system and had a good knowledge on action plans developed following serious incidents and never events Following the last CQC inspection the service had produced a learning from serious incidents handbook for all staff. Senior staff told us this handbook was designed to share the themes of various serious incidents and never events that had occurred within the surgical division, St Mark’s, critical care and outpatients. Staff told us the aim of the handbook was to share lessons learnt from incidents to all staff members to improve staff awareness on patient safety. The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of ‘certain

notifiable safety incidents’ and provide reasonable support to that person. Staff we spoke with were

aware of the requirements and we found that it was embedded into practice in the service.

Mortality and morbidity (M&M) meetings took place regularly to discuss cases when patients had deceased. Deaths were reviewed, lessons learned, and actions were documented and shared. We saw minutes of M&M meetings of different surgical specialities, which we found well attended and comprehensive.

Safety thermometer

The service used safety monitoring results well.

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection took place one day each month. Data from the Patient Safety Thermometer showed that the trust reported 34 new pressure ulcers, five falls with harm and five new catheter urinary tract infections from March 2018 to March 2019 for surgery. Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter acquired urinary tract infections at London North West University Healthcare NHS Trust:

1

Total Pressure ulcers (34)


2

Total Falls (5)

3

Total CUTIs (5)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only





practice. Managers checked to make sure staff followed guidance. Staff protected the rights

of patients subject to the Mental Health Act 1983.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and

national guidance. On inspection we saw all staff had access to up to date hospital and trust

guidance and policies. Staff were able to show us a range of policies on request. All policies viewed

were in date.

Medical staff followed local guidelines and policies, based on National Institute for Health and Care

Excellence (NICE), Association of Anaesthetist of Great Britain and Ireland (AAGBI) and Royal

College guidelines. The policies we reviewed confirmed this and were within date.

Staff managed services in line with the standards of the National Confidential Enquiry into Patient

Outcomes and Death (NCEPOD) and the Royal College of Surgeons in relation to access to

emergency surgery and unscheduled care.

Clinicians used the American Society of Anaesthesiologists (ASA) physical fitness classification

system to assess patient suitability prior to surgery. This ensured staff adhered to an established

evidence base and consultants in each specialty identified the minimum ASA score for effective

surgery.

We observed staff following local policies and procedures with respect to swab counts, as well as

surgical instrumentation in theatre. We observed the patient journey throughout including into the

operating theatre and saw how staff complied with WHO safety checks at each stage.

Within theatre areas, we observed staff adhered to the national institute for health and care

excellence CG74 (NICE) guidelines related to surgical site infection prevention and treatment.


Nursing staff followed recommended practice with respect to minimising the risk of surgical site

infections

There was a sepsis pathway to follow, where patient’s needs indicated that this was required.

At handover meetings, staff routinely referred to the psychological and emotional needs of patients,

their relatives and carers.

The previous inspection detailed the general surgery review in November 2017 as part of the

national ‘getting it right first time’ (GIRFT) programme. The review aimed to identify if care was

delivered in line with best practice and evidence-based guidance. The programme lead rated the

service overall as ‘requires improvement’ and found six key areas for improvement action. The

divisional general manager for surgery and clinical director prepared a 10-point action plan to

address these areas. We were told on inspection that all actions had now been completed.


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 adjusted for

patients’ religious, cultural and other needs. Staff did not always follow national guidelines

for patients fasting before surgery

Nutritional needs of patients were assessed by nursing staff as part of the admission process in the

initial assessment and when patients’ circumstances changed. The wards used a nutrition screening

tool to assess patients for the risks of dehydration or malnutrition. We saw completed malnutrition

screening in electronic patient records. This meant patients were not without food for long periods.

Patients we spoke with were satisfied with the quality and variety of food. Staff adhered to protected

mealtimes on the ward for patients to encourage eating and aided where needed.

Staff had access to a nil by mouth policy with guidance for pre-operative fasting, providing

information regarding intake of fluid and food before elective surgery.

The service had scheduled to undertake a three month audit of fasting times for July 2019

We saw that fluid balance charts were in use where patients had to have their fluid intake and output

measured and monitored.

We saw that patients in SAU and Dowland ward had to wait for some time before going to theatre,

in some cases since 7am until after midday. This meant that these patients were starved longer than

would be recommended and it was not clear whether patients could have liquids.

At the time of inspection, we noted the temperature within wards were raised due to the summer

forecast. We saw the trust had placed extra cooling fans in patient areas and bays. To mitigate

against the warm temperature the ward manager on Eliot ward told us a champion for the day was

allocated to give out extra water to patients. This was either a HCA or a nurse.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain and gave pain



Pre-operative assessment included information about the patient with respect to existing pain

management, such as the medicines they took. Pain relief was noted to be prescribed for patients.


Patients we spoke with confirmed that they had been asked about their pain and had been given

pain relief in a timely manner.

Staff used a pain scoring tool to assess each patient in addition to regular rounding checks to identify

changes in need. Nurse practitioners were also prescribers and could administer pain medicine and

issue instructions for as-needed (PRN) pain relief. Staff carried out a pain review and pain site

assessment for each patient on admission. We saw this was consistently completed in all records

we looked at. Care records observed demonstrated there was a pain score assessment in use, and

this was completed to a good standard.

Patients on patient-controlled analgesia (PCA), which is a method of allowing the patient in pain to

control their infusion pump, for example morphine, would be reviewed by the pain team.

A dedicated pain team was based in the hospital and provided on-demand reviews and coordinated

care. Nurses referred patients to this team when they requested frequent additional pain relief in

addition to prescribed pain relief. This team joined ward rounds as needed and provided guidance

for nurses and clinicians out of hours for patients with complex needs. Staff confirmed there was

good access to the local pain management team. Nursing or medical staff could make referrals.

Each ward had a pain link nurse who attended extended training and meetings with the pain team.

They acted as a point of reference for ward colleagues and helped to prepare pain management

plans for patients.

We observed staff included patients in discussions of pain relief, such as side effects they may

experience and unfamiliar sensations with anaesthesia.

Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. Trust level: From January 2018 to December 2018, all patients at the trust had a similar to expected risk of readmission for elective admissions when compared to the England average. Urology patients at the trust had a similar to expected risk of readmission for elective admissions when compared to the England average. Colorectal surgery patients at the trust had a higher than expected risk of readmission for elective admissions when compared to the England average. General surgery patients at the trust had a lower than expected risk of readmission for elective admissions when compared to the England average. Elective Admissions – Trust Level:


Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity

All patients at the trust had a similar to expected risk of readmission for non-elective admissions when compared to the England average. General surgery patients at the trust had a similar to expected risk of readmission for non-elective admissions when compared to the England average. Trauma and orthopaedics and ear, nose and throat (ENT) patients at the trust had higher than expected risks of readmission for non-elective admissions when compared to the England averages. Non-Elective Admissions – Trust Level:


(Source: Hospital Episode Statistics - HES - Readmissions (01/01/2018 - 31/12/2018)) Non-Elective Admissions - Northwick Park Hospital:

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity

Northwick Park Hospital: The table below summarises Northwick Park Hospitals performance in the 2018 National Hip Fracture Database. For five measures, the audit reports performance in quartiles. In this context, ‘similar’ means that the trust’s performance fell within the middle 50% of results nationally.


Metrics (Audit indicators) Hospital

performance

Comparison to other Trusts

Meets national

standard?

Case ascertainment (Proportion of eligible cases included in the audit)

112.3% Better ✓

Crude proportion of patients having surgery on the day or day after admission (It is important to avoid any unnecessary delays for people who are assessed as fit for surgery as delays in surgery are associated with negative outcomes for mortality and return to mobility)

69.6% Similar

Crude peri-operative medical assessment rate (NICE guidance specifically recommends the involvement and assessment by a Care of the Elderly doctor around the time of the operation to ensure the best outcome)

89.7% Similar

Crude proportion of patients documented as not developing a pressure ulcer (Careful assessment, documentation and preventative measures should be taken to reduce the risk of hospital-acquired pressure damage (grade 2 or above) during a patient’s admission); this measures an organisation’s ability to report ‘documented as no pressure ulcer’ for a patient

91.3% Worse

Crude overall hospital length of stay (A longer overall length of stay may indicate that patients are not discharged or transferred sufficiently quickly; a too short length of stay may be indicative of a premature discharge and a risk of readmission)

23.2 days

Worse No current standard

Risk-adjusted 30-day mortality rate (Adjusted scores take into account the differences in the case-mix of patients treated)

4.4% Within

expected range

No current standard

The table below summarises the trusts performance in the 2018 National Bowel Cancer Audit.


Trust performance


Meets national

standard?


88.9% Good Good is over

80%

Risk-adjusted post-operative length of stay >5 days after major resection (A prolonged length of stay can pose risks to patients)

77.9% Worse than

national aggregate

No current standard


Risk-adjusted 90-day post-operative mortality rate (Proportion of patients who died within 90 days of surgery; post-operative mortality for bowel cancer surgery varies according to whether surgery occurs as an emergency or as an elective procedure)

2.3% Within

expected range

No current standard

Risk-adjusted 2-year post-operative mortality rate (Variation in two-year mortality may reflect, at least in part, differences in surgical care, patient characteristics and provision of chemotherapy and radiotherapy)

20.9% Within

expected range

No current standard

Risk-adjusted 30-day unplanned readmission rate (A potential risk for early/inappropriate discharge is the need for unplanned readmission)

16.2% Worse than expected

No current standard

Risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection (After the diseased section of the bowel/rectum has been removed, the bowel/rectum may be reconnected. In some cases, it will not and a temporary stoma would be created. For some procedures this can be reversed at a later date)

48.5% Within

expected range

No current standard

(Source: National Bowel Cancer Audit) The table below summarises the trust’s performance in the 2018 National Vascular Registry.


Trust performance


Meets national

standard?

Abdominal Aortic Aneurysm Surgery (Surgical procedure performed on an enlarged major blood vessel in the abdomen)


115.0% Not applicable ✓

Risk-adjusted post-operative in-hospital mortality rate (Proportion of patients who die in hospital after having had an operation)

4.3% Within the expected

range

No current standard

Carotid endarterectomy (Surgical procedure performed to reduce the risk of stroke; by correcting a narrowing in the main artery in the neck that supplies blood to the brain)



Crude median time from symptom to surgery (Average amount of time patients wait to have surgery after the onset of their

5 days Not applicable ✓


symptoms)

Risk adjusted 30 day mortality and stroke rate (Proportion of patients who die or have a stroke within 30 days of their operation)


range

No current standard

(Source: National Vascular Registry) The table below summarises the trust’s performance in the 2018 National Oesophago-gastric Cancer Audit.


Trust performance


Meets national

standard?

Trust-level metrics (Measures of hospital performance in the treatment of oesophago-gastric (food pipe and stomach) cancer)


>90% Better No current standard

Age and sex adjusted proportion of patients diagnosed after an emergency admission (Being diagnosed with cancer in an emergency department is not a good sign. It is used as a proxy for late stage cancer and therefore poor rates of survival. The audit recommends that overall rates over 15% could warrant investigation)

1.0% Better No current standard

Risk adjusted 90-day post-operative mortality rate (Proportion of patients who die within 90 days of their operation)

Not eligible Not

applicable No current standard

Cancer Alliance level metrics (Measures of performance of the wider group of organisations involved in the delivery of care for patients with oesophago-gastric (food pipe and stomach) cancer; can be a marker of the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results. Contextual measure only.

Crude proportion of patients treated with curative intent in the Cancer Alliance (Proportion of patients receiving treatment intended to cure their cancer)

41.5% Similar No current standard

(Source: National Oesophago-Gastric Cancer Audit) The table below summarises London North West University Healthcare NHS Trust performance in the 2018 National Ophthalmology Database Audit. (Audit of patients undergoing cataract surgery)


Trust performance


Meets national

standard?

Trust-level metrics


(Measures of hospital performance in the treatment of cataracts


92.2% Not available No current standard

Risk-adjusted posterior capsule rupture rate (Posterior capsule rupture (PCR) is the index of complication of cataract surgery. PCR is the only potentially modifiable predictor of visual harm from surgery and is widely accepted by surgeons as a marker of surgical skill.

0.6% Within

expected range

No current standard

Risk adjusted visual acuity loss (The most important outcome following cataract surgery is the clarity of vision)

0.3% Within

expected range

No current standard

(Source: National Ophthalmology Database Audit) The service participated in the National Joint Registry. (Audit of hip, knee, ankle, elbow and shoulder joint replacements) Data for April 2017 to March 2018 showed that Central Middlesex Hospital performed 450 primary total knee replacements. This was higher than national average (228). In the same period, there had been 223 primary hip replacements. This was similar to national average (226). Primary knee and hip surgeries accounted for 93% of all surgical procedures in that period. Data showed that the 90-day mortality and revision rate were within expected range for primary knee and hip operations carried out at Central Middlesex Hospital between August 2013 and August 2018. (Source: National Joint Registry) In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations:

• Groin Hernias

• Varicose Veins

• Hip Replacements

• Knee replacements Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left. These changes are measured in a number of different ways, descriptions of some of the indicators presented are below. The visual analogue scale (EQ VAS) is asking to mark health status on the day of the interview on a vertical scale. The bottom rate (0) corresponds to "the worst health you can imagine", and the highest rate (100) corresponds to "the best health you can imagine". The EQ-5D-5L questionnaire has two parts. Five domain questions ask about specific Issues namely mobility self-care usual activities pain or discomfort anxiety or depression. The EQ-5D-5L uses 5 levels of responsiveness to measure problems. The range is; no problem - disabling/extreme.


The Oxford Hip Score (OHS) is a patient self-completion report on outcomes of hip operations containing 12 questions about activities of daily living, a simple scoring and summing system provides an overall scale for assessing outcome of hip interventions.

In 2016/17 performance on groin hernias was worse than the England average for both indicators. For hip replacements, performance was better than the England average for the EQ VAS score, worse than the England average for the EQ-5D index and similar to the England average for the Oxford Hip Score. For knee replacements performance was better than the England average for the EQ VAS score and worse than the England average for the EQ-5D and Oxford Knee Score. For varicose veins, performance was worse than the England average for the Aberdeen Varicose Vein Questionnaire and EQ VAS score and about the same as the England average for the EQ-5D index. (Source: NHS Digital)

Competent staff



development.

Trust level: From April 2018 to March 2018, 87.1% of required staff in surgery received an appraisal compared to the trust target of 85.0%. The breakdown by staff group can be seen in the table below:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)




Additional professional scientific and

technical 48 56 85.7% 85.0% Yes





All staff groups 1,045 1,200 87.1% 85.0% Yes

In surgery four of the seven staff groups met the trust target, including nursing and medical staff. Northwick Park Hospital: From April 2018 to March 2018, 85.1% of required staff in surgery at Northwick Park Hospital received an appraisal compared to the trust target of 85.0%. The breakdown by staff group can be seen in the table below:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)






technical 9 11 81.8% 85.0% No



At Northwick Park Hospital two of the six staff groups including medical staff met the trust target, with nursing staff achieving just below 85.0%. (Source: Routine Provider Information Request (RPIR) – Appraisal tab) All new staff, including agency staff underwent a local induction and orientation before starting their roles. We were shown evidence of induction documentation for staff during our inspection. Staff were supernumerary and did not work out of hours during the first three weeks. They were given competency books and were assigned a mentor and a buddy for additional support for two weeks. Nurses we spoke with described good support in attaining competencies and meeting requirements for registration. The trust had a good pass rate. Practice development nurses were available for staff to support them in achieving competencies or training goals. Staff we spoke with said they had good access to their practice development nurses and felt supported. There were clinical education training courses for registered nurses and healthcare support workers. Leadership programmes were offered for experienced nurses. There were opportunities


to undertake post registration courses such as mentorship, orthopaedic nursing, master level degrees or attendance at conferences.




Nurse practitioners in this service coordinated care between teams. There was also an allocated

registrar for confidential enquiry into perioperative deaths (CEPOD) elective procedures, which

meant patient care and treatment planning was reviewed efficiently by the most appropriate

specialist. We also saw evidence of MDT working in patient notes, including consistently detailed

and clear reviews from physiotherapists, the respiratory team and dietitians.

Dietitians provided specialist reviews for patients, including the head and neck dietetics team who

reviewed all patients being treated for cancer. This team met weekly with the oncology team in an

MDT meeting as well as weekly with other allied health professionals and joined ward rounds every

two days.

Consultants and the MDT coordinated care for older people who needed a package of care prior to

being discharged to a community bed or home. This included liaison with social workers and senior

staff in care homes or with district nurses.

Multi-disciplinary ‘huddle’ meetings took place in theatres daily, during which performance was

discussed, as well as bed availability and cancellations.

A multi-professional therapy team provided input to patients within the department and consisted of

physiotherapists, occupational therapists, dietitians and complex discharge co-ordinators. A

multidisciplinary meeting took place every morning on the ward to discuss patients. It was held by

the nurse in charge, together with the physiotherapist and the occupational therapist.

Staff involved social care workers and community healthcare services when planning discharge of

patients with complex needs. Discharge planning was initiated after admission for all patients, staff

referred to a dedicated discharge team if required. All patients were discharged with a letter

containing clinical information about their hospital stay, which could be shared with their GP. The

letter contained telephone numbers to contact in case of any further questions or queries.

Seven-day services

Key services were available seven days a week to support timely patient care.

Emergency surgery was provided 24-hours, seven days a week with consultant cover available at

all times.

An on-call consultant was available for each surgical speciality seven days a week.

Vascular nurse practitioners provided a seven-day service on Eliot ward and vascular medicines

reviews took place daily, seven days a week.

There was 24-hour, seven day a week on-call rota for consultant surgical and anaesthetic cover on

site. Junior doctors at different levels of training were on site 24 hours a day and seven days a week.

An anaesthetic registrar provided cover on site 24 hours, seven days a week. For theatre cases out

of hours an anaesthetic consultant was available on call.


Physiotherapy, occupational health, dietitian and speech and language therapy services were

available Monday to Friday from 8.30am to 4.45pm. Physiotherapists also covered the wards on

weekends on site and on-call out of hours. An occupational therapist was available on site on

Saturday mornings.

The pharmacy service was available Monday to Friday from 8.30am to 5pm and Saturdays from

9am to 3pm. Outside of these times, there were two on-call pharmacists available for advice and

support.

There was 24 hours, seven days a week access to diagnostic imaging.

Health promotion


Staff supported patients to manage their own health, care and well-being and to maximise their

independence following surgery and according to individual needs.

Nurses in the pre-assessment clinic provided patients with information on how they could promote

their fitness before their surgical procedure. For example, eating a healthy diet, moderating alcohol

intake, increasing physical activity and giving up smoking.

Weekly smoking cessation clinics were available for patients and staff by appointment.

Health promotion information was readily available for patients, and their families and members of

the public visiting the hospital. For example, flu vaccination, and recognising signs of sepsis.

The last inspection identified a targeted exercise programme developed by a senior vascular

physiotherapist on Eliot ward to help patients with their recovery and support good health outcomes.

We saw this exercise programme was still active and well received.



followed national guidance to gain patients’ consent. They knew how to support patients

who lacked capacity to make their own decisions or were experiencing mental ill health. They

used agreed personalised measures that limit patients' liberty.

The trust set a target of 85% for completion of Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training.

A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


303 321 94.4% 85.0% Yes


In surgery the target was met for both MCA and DoLS training modules for which qualified nursing staff were eligible.


A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



162 329 49.2% 85.0% No

In surgery the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible.

A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for qualified nursing staff in surgery at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


130 137 94.9% 85.0% Yes


In surgery the target was met for both of the MCA and DoLS training modules for which qualified nursing staff at Northwick Park Hospital were eligible. A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for medical staff in surgery at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



26 59 44.1% 85.0% No

In surgery the target was not met for either of the MCA and DoLS training modules for which medical staff at Northwick Park Hospital were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)

Staff we spoke with understood their roles and responsibilities under, the Mental Capacity Act (MCA)

2005 and Deprivation of Liberty Safeguards (DoLS). They knew how to support patients

experiencing mental ill health and those who lacked the capacity to make decisions about their care.

Consent to care and treatment was obtained in line with legislation and guidance, including the

MCA. Staff understood their responsibilities and the procedures in place to obtain consent from

patients prior to undertaking surgical procedures. This was in line with the consent for examination

and treatment policy which gave clear guidance for staff. We saw completed and signed (authorised)

forms for treatment and exploratory investigation during the inspection.


Medical and nursing staff we spoke with explained the consent procedures and what to do if a

person lacked capacity to consent to care and treatment. They were able to outline the principles

of the MCA and the implications for their practice.

Patients we spoke with told us they were given all the information they needed to make a decision

about the treatment being provided. They felt medical and nursing staff had fully explained the

procedure at their initial appointment, they were given further information at their pre-operative

assessment and when they were admitted for surgery it was explained again. This meant that when

a patient was due to sign their consent form they had been provided with clear, concise information

about the procedure and the associated risks and benefits.

A standard operating procedure was in place that meant staff always asked if a patient was happy

to proceed with surgery at the latest point they could withdraw. During our observations in theatres

we saw staff required patients to confirm their name and date of birth and the procedure they were

due to have as part of the consent process.

The Deprivation of Liberty Safeguards (DoLS) protect people who are not able to make decisions

and who are being cared for in hospital or in care homes. People can only be deprived of their liberty

so that they can receive care and treatment when this is in their best interests and legally authorised

under the MCA. The authorisation procedures for this in care homes and hospitals are called the

Deprivation of Liberty Safeguards (DoLS).

Staff said that elective patients with a learning disability or those living with dementia would be

involved in a pre-operative meeting with the carer or family member to ensure there was a plan in

place for their admission. Staff said that carers or family members were encouraged to stay with the

patient and operating lists would be adjusted to suit patient needs. Specialist teams, such as the

palliative care team, had extended training and experience in providing care to patients with reduced

mental capacity or a DoLS authorisation in place. Each ward had named staff trained to complete

DoLS referrals.


Compassionate care

The Friends and Family Test response rate for surgery at London North West University Healthcare NHS Trust was 32% which was better than the England average of 26% from February 2019 to February 2019.

Site name Friends and family test response rate

Northwick Park Hospital 30%

Central Middlesex Hospital 30%

Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

Theatre admissions

unit1,943 27% 94% 93% 97% 95% 99% 100% 100% 97% 97% 93% 97% 98% 96%

Eliot 826 62% 98% 95% 98% 100% 98% 96% 95% 99% 99% 98% 99% 100% 98%

Edison 758 22% 91% 94% 89% 91% 84% 93% 95% 93% 92% 91% 83% 91% 91%

Gray 565 33% 93% 97% 98% 96% 93% 94% 96% 92% 98% 96% 97% 90% 95%

Evelyn 369 49% 84% 81% 96% 85% 91% 94% 95% 100% 88% 88% 95% 91%

Fletcher Ward 235 21% 88% 88% 85% 100% 97% 100% 100% 92% 97% 91%

Dowland 216 23% 98% 87% 98% 95% 83% 100% 94% 95%

Jonson 122 51% 89% 100% 93% 94% 100% 100% 80% 86% 82% 100% 100% 94%

Ward nameTotal

Resp1,2

Resp.

Rate

Percentage recommended3 Annual

perf1


1. The total responses exclude all responses in months where there were less than five responses at a particular ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12 month period.

2. Sorted by total response. 3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in

seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard. (Source: NHS England Friends and Family Test)

We spoke with ten patients and five relatives during our inspection and found most people had

experienced positive care. One patient said she was “Happy with the service.” Another patient

commended friendly theatre staff.

Patients said staff respected their privacy and dignity but that the busy environment made this

difficult. For example, on Edison ward and Evelyn ward patients told us staff gave them time to

discuss their treatment but that it was difficult to do this privately because of how busy the wards

were.

During our observations we saw staff treated patients and their relatives with kindness and

compassion and maintained their dignity and privacy. For example, staff were discreet when

supporting patients with personal care and ensured curtains and doors were closed during

examinations. We saw staff always asked patients for consent before providing care or treatment

and were always polite when interrupting conversations between patients and relatives to deliver

care.

All patients received a patient experience questionnaire during their stay and were encouraged to

complete them. We observed staff encouraging patients to fill out the forms.

Part of the survey was the friends and family test (FFT), which asked patients how likely they were

to recommend the hospital to friends and family if they needed similar care or treatment. The

answers showed an average of 94% across the surgical wards at Northwick Park Hospital.

Following feedback from patients and their families a freezer was installed within the surgical division

to offer surgical patients ice cream all year round.

Staff on each ward displayed letters and cards of thanks received from patients and their relatives.

Compassionate care was part of the trust’s vision and staff said this was included in their

supervisions, appraisals and team meetings.

Emotional support

Staff provided emotional support to patients to minimise their distress.

All the patients and relatives we spoke with told us they felt supported throughout their journey.

Patients said the support provided by staff from consultation, pre-assessment and surgical

intervention was good. Patients told us that this included both the clinical and non-clinical staff. A

patient told us that staff helped him feel relaxed.

Patients said that when they needed psychological support staff had organised for them to see the

mental health team or a psychologist.

The palliative specialist care team provided emotional support as part of the end of life care pathway

and ensured this continued as part of patient’s care plan if they were discharged to a hospice or

home.


Staff knew how to access multi-faith spiritual support through the chaplaincy and spiritual service

on site, available for patients and relatives. Chaplains visited patients and their families on request

and there was a quiet room in the hospital.


Staff involved patients and those close to them in decisions about their care and treatment.

We saw staff explaining to patients and their relatives the care and treatment that was being

provided. Patients informed us that they were given enough information both pre and post

procedure. Patients and their relatives told us that they could ask staff about their care and

treatment. The patients we spoke with felt well informed. One patient said, “The surgeon explained

everything, and communication has been good.”

A patient on the ward told us that he was seen daily by his doctors who took time to explain his

treatment and answer questions.

Each bed space had wipeable boards with the names of staff looking after the patient written up. We saw consultants’ names on boards near patients’ beds and patients we spoke with knew who their named consultant was.

During our observations of ward rounds we saw doctors introduced themselves to patients and explained what they were doing and why. Similarly, nurses introduced themselves when meeting patients for the first time and explained the care they were about to provide. During our observations of care in theatres we saw staff consistently reassured patients to put them at ease and encouraged them to ask questions about their planned procedure.

During inspection we saw a patient approach the nurse’s station on Dowland ward in the afternoon. The patient was a trauma patient who was placed on the urology ward and was conveying frustration about not being given adequate instruction. The patient had been starved from midnight and was still unaware of when his operation would be. We observed staff being attentive and responsive. Staff listened attentively to the patient’s concerns and then sought advice from the consultant and relayed the necessary information back to the patient.





to plan care.

There were clear guidelines for admission to the day surgery and surgical wards. Patients were

admitted to the unit via referral from GPs and via the emergency department. Patients admitted for

elective surgery were screened for MRSA prior to admission. There was access to pre-assessment

clinics, which facilitated preparation and planning for surgery based on patient need and any

identified risks.


The service took account of patients’ individual needs

A large team of clinical nurse specialists supported other clinical staff and, in many cases, provided

treatment themselves.


There were systems in place to aid the delivery of care to patients in need of additional support. For

example, patient needs associated with dementia or a learning disability were included in the nursing

assessment and care record and referred to specialist services within or outside of the trust where

appropriate.

Staff we spoke with knew which patients were living with dementia and identified their needs and

planned their care accordingly.

When a patient with a learning disability used the service, they would be routinely offered a ‘hospital

passport’. This was designed to help hospital staff understand each patient’s needs, likes, dislikes

and interests. During our inspection we did not see any people with a learning disability using the

service. We were therefore not able to fully assess the impact of this.

Staff on Fletcher ward told us cardiac monitors were imminently being placed in two bays to monitor

patients who may deteriorate with an acute bleed.

Staff in Sainsbury Ward had prepared an inpatient admission and assessment printed booklet for

patients. This helped patients to understand a range of common treatments and provided

information on logistics of being cared for on the ward.

Each ward had adapted equipment for patients to use during mealtimes, including menus printed in

Braille and in a choice of 11 different languages. Staff provided colour-contrasting blue mugs and

plates to help patients living with dementia who experienced reduced visual perception. Large-

handled cutlery and cups with lids were always also available on wards for patients with reduced

dexterity.

Information leaflets about a wide range of topics were available and could be provided in other

languages upon request. Interpreter services were available and accessible.

Nurses in some surgical wards felt they did not have the training or resources to meet the needs of

medical patients cared for as outliers. However, senior management told us outliers were discussed

in the daily safety briefing and resources and trained staff would be looked at to meet the patients’

needs.

Mixed sex breaches are defined as a breach of same sex accommodation, as defined by the NHS

confederation. There is a need to provide gender sensitive care for patients, which promoted privacy

and dignity, applicable to all ages. Data provided by the trust reported there had been 60 mixed sex

adult overnight accommodation breaches within the reporting period.

Access and flow

People could not always access the service when they needed it. Waiting times from referral

to treatment were not in line with national standards. However, the average length of stay for

elective surgery was shorter than the England average.

From February 2018 to January 2019 the average length of stay for patients having elective surgery at the trust was 4.1 days. The average for England was 3.9 days. The average length of stay for patients having elective trauma and orthopaedics surgery at the trust was 3.2 days. The average for England was 3.7 days. The average length of stay for patients having elective colorectal surgery at the trust was 8.9 days. The average for England was 7.0 days. The average length of stay for patients having elective urology surgery at the trust was 2.1 days.


The average for England was 2.5 days.

Note: Top three specialties for specific trust based on count of activity.

The average length of stay for patients having non-elective surgery at the trust was 3.9 days. The average for England was 4.7 days.

The average length of stay for patients having non-elective general surgery at the trust was 3.0 days. The average for England was 3.7 days. The average length of stay for patients having non-elective maxillo-facial surgery at the trust was 1.0 days. The average for England was 1.6 days. The average length of stay for patients having non-elective trauma and orthopaedics surgery at the trust was 11.0 days. The average for England was 8.4 days.


From February 2018 to January 2019 the average length of stay for patients having elective surgery at Northwick Park Hospital was 3.8 days. The average for England was 3.9 days.

From February 2018 to January 2019 the average length of stay for patients having elective urology at Northwick Park Hospital was 2.3 days. The average for England was 2.5 days. From February 2018 to January 2019 the average length of stay for patients having elective maxillo-facial surgery at Northwick Park Hospital was 4.3 days. The average for England was 3.2 days.

From February 2018 to January 2019 the average length of stay for patients having elective colorectal surgery at Northwick Park Hospital was 6.7 days. The average for England was 7.0 days.


Note: Top three specialties for specific site based on count of activity.

The average length of stay for patients having non-elective surgery at Northwick Park Hospital was 3.5 days. The average for England was 4.7 days.

The average length of stay for patients having non-elective general surgery at Northwick Park Hospital was 2.7 days. The average for England was 3.7 days. The average length of stay for patients having non-elective maxillo-Facial surgery at Northwick Park Hospital was 1.0 days. The average for England was 1.6 days.

The average length of stay for patients having non-elective ear, nose and throat (ENT) surgery at Northwick Park Hospital was 2.2 days. The average for England was 2.1 days.


(Source: Hospital Episode Statistics)

The Sainsbury Wing provided care and treatment to private patients referred mainly from St Mark’s

Hospital and some NHS patients during times of high demand. The unit provided a range of surgical

specialist care including colorectal, maxillo-facial, ear, nose and throat and orthopaedics. Staff

provided care based on clinical need. This meant staff provided care to meet each patient’s needs,

such as one-to-one nursing, regardless of whether their insurance plan covered it.

Senior staff told us patients often had a delayed discharge on Sainsbury ward due to delays in take

home medications (TTAs). We were told the ward would start dispensing ten basic medications as

TTAs to reduce the delay in discharge.

The emergency surgery team provided a 24-hour, seven-day dedicated service led by nurse

practitioners and a medical team.

Eliot ward was a designated vascular hub for the surrounding boroughs and patients from other

hospitals were transferred there for specialist treatment. Two vascular nurse clinical practitioners


carried out pre-assessments and coordinated admissions, which ensured the service was planned

in line with the greatest patient need.

The theatre assessment unit provided nurse-led pre-operative care and assessment for patients for

up to 23 hours. Nurses assessed patient health and medication and provided information on what

to expect after their procedure.

From March 2018 to February 2019 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was worse than the England average.

(Source: NHS England) Over these 12 months there was a gradual deterioration in the trust’s performance, both in absolute terms and relative to the England average. Two specialties were above the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.

Specialty grouping Result England average

Urology 81.9% 75.9%

Trauma & orthopaedics 70.8% 58.7%

Four specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.


General surgery 48.3% 71.9%

Oral surgery 46.8% 56.8%

Ophthalmology 45.4% 64.9%

Ear, nose & throat (ENT) 28.9% 60.6%

Senior management told us there had been no 52 week breaches. We were told a harm review had been conducted which concluded no harm caused due to RTT delays. A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice. Over the two years, the trust reported no cancelled operations where the patient was not treated with 28 days. Percentage of patients whose operation was cancelled and were not treated within 28 days - London North West University Healthcare NHS Trust:


Over the two years, the percentage of cancelled operations at the trust was higher than the England average, following a similar trend to England over the four quarters. Cancelled operations as a percentage of elective admissions only includes short notice cancellations. (Source: NHS England) The trust reported that although they monitor patient moves including multiple ward moves and step downs, data does not identify ward moves due to non-clinical reasons therefore figures for this section have not been provided. (Source: Routine Provider Information Request (RPIR) – Ward moves tab) The trust stated there had been 80 incidents reported related to bed moves in the 12 months preceding inspection of these, three incidents had been graded as catastrophic or moderate harm. From April 2018 to March 2019, there were 851 patients moving wards at night within surgery. A breakdown of numbers of moves by site and ward is in the table below.

Site name Number of moves Percentage of total (%)



St Marks Hospital 101 11.9%


Central Middlesex Hospital 2 0.2%

Total 851 100.0%

Ward name Number of moves Percentage of total (%)

Eliot Ward 248 37.1%

Evelyn Ward 233 34.8%

Gray Ward 80 12.0%

Edison Ward 77 11.5%

Fletcher Ward 24 3.6%

Dowland Ward 7 1.0%

Total 669 100.0%

(Source: Routine Provider Information Request (RPIR) – Moves at night tab) Access to surgical services was via GP referral or via the emergency department. The service

prioritised care and treatment for people with the most urgent needs and there was access to

emergency theatre.

We observed several medical outliers on the surgical wards during our inspection. On Evelyn ward

we saw two medical outliers. Staff informed us this impacted on the access and flow of patients into

the wards.

Patients referred from the urgent care centre for surgery were transferred to SAU. Staff told us they

only received the patient if they were ambulatory and if the patient had a stable blood pressure. Staff

told us if there were no SAU spaces available the patients would have to wait in the emergency

department. The service had two CEPOD lists which excluded trauma and orthopaedic patients.

The day before surgery all lists were reviewed to identify which recovery area patients would go to.

The anaesthetist would revise plans if needed. Lists with recovery area identified were seen on

inspection.

There was a standard operating procedure for theatre recovery which included escalation process, recovery milestones and overnight stays. On the completion of surgery, the theatre staff would contact the identified recovery to ensure space was available and check if recovery staff were ready to receive the patient. There were two recovery areas. Theatre 9, which had four spaces. Patients recovered in this area would be one of four categories, fast track, day surgery, short stay or elective surgical procedures. The second area was main recovery and had 13 spaces and accommodated all types of patients. We noted an improvement from the last inspection to the theatre recovery capacity. Staff told us patients were never recovered in theatres and access to ITU beds was not usually an issue.



The service treated concerns and complaints seriously, investigated them and learned

lessons from the results, and shared these with all staff. However, not all were responded to

within the timeframe set by the trust.

From April 2018 to March 2019 the trust received 202 complaints in relation to surgery at the trust (18.3% of total complaints received by the trust). The trust took an average of 64.1 working days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting 36 complaints were still open. These had been open for an average of 60.6 working days. A breakdown of complaints by type is shown below:


Percentage of total



29 14.4%






6 3.0%


Integrated care including delayed discharge due to absence of care package

2 1.0%

Facilities services (including food, cleanliness, maintenance, parking, portering)

2 1.0%


Trust administration 1 0.5%

Others 1 0.5%

Consent to treatment 1 0.5%

Total 202 100.0%

From April 2018 to March 2019 the trust received 119 complaints in relation to surgery at Northwick Park Hospital. The trust took an average of 70.2 working days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting 18 complaints were still open. These had been open for an average of 62.7 working days. A breakdown of complaints by type is shown below:


Percentage of total



21 17.6%







2 1.7%


2 1.7%


Others 1 0.8%


Total 119 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab) Senior leadership told us that the number of open complaints had reduced over a few months prior to inspection. We viewed a sample of investigations and outcomes of five complaints from different surgical areas. We found these to be comprehensive, detailed and completed to a high standard. From April 2018 to March 2019 there were 64 compliments received for surgery at the trust (33.9% of all received trust wide). Of these, 34 were at Northwick Park Hospital, two were at Central Middlesex Hospital and the remaining 28 were at other sites. The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab)

Complaints and learning were on the agenda of divisional quality and safety meetings and the

outcome of each investigation was shared with the staff involved. Case studies were presented by

investigating managers at the quarterly complaints working group, where peer support and learning

about the investigation process as well as the outcome could be identified. Complaints and learning

were also discussed at monthly team meetings.

Matrons and service managers investigated complaints and used learning from each to discuss

improved practice with staff. All staff we spoke with demonstrated good knowledge about themes of

complaints in their usual area of work and said they felt feedback from the senior team helped them

to improve care.

Staff told us that, where possible, they would resolve any issues locally with patients informally, prior

to a formal complaint being made. Any concerns raised by patients on the wards would be

addressed immediately by the member of staff or escalated to the nurse in charge. If possible, issues

were resolved immediately to patients’ satisfaction.

Patient advice and liaison services leaflets and posters were visible in-patient areas and, on the

wards, informing patients how to raise a concern or make a complaint. The trust provided this

information electronically and in large print on request.


Leadership


Leaders had the integrity, 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.

Two divisional heads of nursing, a clinical director and a divisional general manager led surgery at

divisional level. Each specialty and service had a dedicated clinical lead, a clinical nurse manager

and a matron.

Staff reported that management at all levels were visible and spoke positively about management

at local level and directorate level.

All staff we spoke with said the senior trust and divisional teams were visible and easy to contact.

This included the divisional heads of nursing, the clinical lead for surgery, the medical director and

the chief executive officer.

One staff member stated, “I feel very supported and empowered, I can ask for help at any time and

I feel listened to in this trust more than my previous job at another trust.”

Senior management were very complimentary about the staff within the division and quoted all staff

as “Dedicated”, “Hardworking” and “Fantastic”. Senior management stressed the importance of staff

maintaining a good work/life balance and stated they stressed to staff three things, “first you, then

family and then work”.

Safety huddles were conducted at the beginning of each shift which allowed information to be shared

with staff.

Staff received a weekly email which contained updates on relevant trust information.

Vision and strategy



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.

The trust core values were displayed on each ward and all staff we spoke with demonstrated an

awareness of these. They told us the trust placed value on their understanding of the vision and

strategy and these areas were always discussed during appraisals and frequently in staff meetings.

The surgical service vision was aligned to the need to support a growing emergency pathway, to

support an aging population and to maintain and grow specialist services. The service opted to

create a single specialty elective surgical centre focused on orthopaedics and to create a multi-

specialty elective surgery hub, including sub-specialties in day surgery, minimally invasive and/or

robotically assisted procedures.

Staff we spoke with were aware of the values of the trust and how they applied them in practice.

However, staff had varying understanding of the surgery division’s vision and strategy with senior

staff being in general more aware of it.

Culture

Managers were successfully promoting a positive culture that supported and valued staff.


Staff and managers told us morale was variable dependant on workload and acuity of patients

however, all described a good team working culture. At the time of our inspection we were told there

were some cases of alleged bullying and harassment. Senior management stated that local

resolution was in progress.

Theatre staff from different areas told us that management had implemented positive changes and

that things had improved over the last two years. Nurses and doctors reported approachable and

supportive colleagues and described good teamwork and supportive managers. Consultants we

spoke with praised the supportive and close working relationship with their colleagues.

The trust had a whistleblowing policy in place and all staff we spoke with knew how to access the

freedom to speak up guardians. Staff felt confident and able to raise concerns if they needed to.

All staff we spoke with told us the culture and morale in the surgery service were much improved

since our previous inspection. They felt positive about the direction taken, and described the current

culture as inclusive, safe, open to challenges and conducive to change.

Several staff we spoke with had worked at the trust for many years, and had achieved career

progression in clinical, nursing or management roles through education and support provided by the

trust. Newer members of staff spoke positively about the welcome they had been shown and

described their induction as individually tailored, welcoming, well organised and relevant and felt the

service was keen for new ideas and willing to listen.

Results of the 2018 NHS Staff Survey from the surgical division showed 54% of staff said they were

supported by their manager to receive training. 63% of staff said feedback from patients was used

to make informed decisions compared to the trust average of 51%. However, 31% of staff within the

surgical division said they had experienced harassment, bullying or abuse from colleagues

compared to the trust average of 26%.

Results of the 2018 NHS Staff Survey from across the trust showed 55% of staff would recommend

the organisation as a place to work compared to 58% staff recommendation in 2017.

Non-executive directors from the workforce and equality committee held three drop in sessions for

staff, split into doctors, nurses and admin and clerical staff. They were one hour sessions where a

summary of the staff survey was presented. Staff were encouraged to share their thoughts without

fear of reprisal.

The trust had recently conducted a safety attitude questionnaire to evaluate safety climate within

the organisation. The survey had a focus on exploring various element of safety within the

organisation including impact of teamwork, working environment, job satisfaction, organisational

commitment to safety as well as perception of management and support. The survey results were

being analysed at the time of inspection by an external healthcare partner and de-brief sessions

were planned to disseminate the results and formulate an improvement plan for improvement in

patient safety.

Governance

The trust used a systematic approach to continually improving the quality of its services and

safeguarding high standards of care by creating an environment in which excellence in

clinical care would flourish.

There was a solid governance framework in place to support the delivery of the strategy and good

quality care.


Clinical and leadership teams used a series of scheduled meetings to maintain appropriate

governance. This included a monthly morbidity and mortality meeting between anaesthetists and

emergency department consultants, weekly x-ray department meetings and monthly directorate-

level clinical governance meetings. Directorate-level meetings include all specialties and were

followed by a specific meeting for emergency surgery.

The clinical lead for each specialty provided information for staff on new or updated policies by e-

mail and during team and governance meetings. This included cross-specialty information. For

example all staff in the directorate were issued with the new standard operating procedure SAU and

summary of service following the recent restructure. This practice enabled each team to remain up

to date with services and practice in the rest of the directorate.

Oncology and palliative care teams met every six weeks to discuss patient case reviews and

incidents, including serious incidents and never events. This reflected a multidisciplinary approach

to governance.

The pre-operative assessment team joined a multidisciplinary clinical governance meeting monthly

and held a meeting for the speciality on a quarterly basis.

The trust shared feedback from serious incidents to all staff in a newsletter, which included shared

learning and any resulting changes to policies and procedures.


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 surgical risk register was reviewed regularly and contained description of the risk, ratings,

controls in place, assurances, actions, progress and updates. Managers and senior staff were aware

of the risks in their service areas. Minutes of meetings at various levels evidenced risk registers

were reviewed, discussed and updated.

Each specialty held multidisciplinary morbidity and mortality (M&M) meetings at least monthly. We

looked at the minutes for a meeting with the emergency surgery team and saw M&M case reviews

were detailed and were based on the principles of a root cause analysis. This included a human,

system and patient factors review as well as a discussion of unknown factors in each case that

contributed to the outcome. The meeting team identified positive elements of decision-making in

each case as well as areas for learning.

The Trust had a business continuity plan in place, as well as winter plan, which included discharge

support actions, promoting flu vaccination and collaboration with colleagues.

The Trust had an audit programme to improve performance and support safety. Audits were

reviewed in board and governance meetings as well as at local and divisional levels.

Staff told us the main risks in theatres were:

- Recovery capacity, whereby an escalation process was in place. - Overnight stays within recovery, where an incident report was completed. Staff did their best

to minimise impact of what patients might see in recovery area utilising screening. This was relevant to the paediatric recovery area also.


- Patients discharged from the recovery area, a risk assessment was completed if this was to occur.

- Mixed sex breaches – usually due to overnight stays and hospital bed capacity. Breaches were recorded and presented to trust board.


The trust collected, analysed, managed and used information well to support all its activities,

using secure electronic systems with security safeguards.

Administration systems were embedded in each ward or department and helped each team to

provide timely care for elective and emergency patients. For example, a dedicated administration

team in the theatre admissions unit prepared patient notes for elective admissions 24 hours

beforehand and stored them securely ready for the patient’s arrival.

We saw consistent standards of information and data management in all the wards we visited. This

included secure, access-controlled storage of patient records when staff were not using them.

Physiotherapists worked across large areas of the hospital and multiple surgical areas and had

developed secure communication methods using social media channels to ensure they could rapidly

share important patient information. Communication channels had restricted access and

Confidential waste bins were available in each clinical and administrative area and information

security and governance was a part of the trust’s mandatory training. Staff followed

recommendations to prevent against data loss or breaches of confidentiality. For example, we

observed staff logging off computers before leaving the station.

Paper records contained patients’ clinical updates, reviews, theatre documentation and clinic letters.

The electronic patient record system contained clinical data about patients, including laboratory test

results, microbiology results, imaging reports and images.

Engagement

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public

and local organisations to plan and manage services. They collaborated with partner

organisations to help improve services for patients.

The trust had evolved following the merger from two organisations to one with strong leadership,

diverse workforce and a vision of transformation for the benefit of patients. Over the last five years

the organisation has engaged its workforce in the co-creating of the HEART values, which was now

recognised by 97% of the workforce and embedded in every aspect of the trust business.

In 2019, the trust launched an organisational development and engagement plan supported by the

‘Listening for Action’ initiative. This was an executive led initiative to mobilise the workforce to co –

produce a positive future for change.

Staff described the team and ward meeting schedules as a positive aspect of their engagement with

colleagues and each senior team. They also said this helped to establishment communication with

patients as each clinical nurse manager or lead nurse passed on feedback that indicated an area

for improvement. Some staff told us they did not routinely receive positive patient feedback during

team meetings and that senior staff used the quality assurance boards for this instead.


The multidisciplinary emergency surgery team incorporated feedback and qualitative outcomes from

patients and their relatives in monthly meetings. This included a discussion of positive impacts on

patient’s lives.

Each ward displayed a ‘You said, we did’ board to demonstrate how the team responded to feedback

from patients and visitors.

The LNWH trust had recently undertaken a Medical Engagement Scale (MES) Survey. The survey

was a valid tool consisting of 30 items and provided an overall index of medical engagement together

with an engagement score on three reliable meta-scales. At the time of inspection, the results were

being analysed by an external company. The findings would include overall index of medical

engagement together with an engagement score for ten primary scales of engagement. This would

be utilised to compare engagement profiles of the trust medical staff groups with similar trusts and

build a trust wide improvement plan for medical engagement for improving staff engagement and

for patient benefits.


All staff were committed to continually learning and improving services. They had a good

understanding of quality improvement methods and the skills to use them. Leaders

encouraged innovation and participation in research.

The service was committed to improving services by learning from when things go well and when

they go wrong: promoting learning and development, and research and innovation. Staff were

positive about the support they received to challenge existing practice and try out new ideas.

All departments we visited had worked collaboratively to reduce delays and improve patient flow.

The trust identified they struggled with continuing operational pressures and used escalation

scheduled care beds when demand necessitated. Staff within specialities understood the

importance of ensuring all patients waiting had their risk of harm reviewed.

The surgical division was in the process of developing a gold standard pathway for general surgery

which was based on current best practice. Data provided after inspection detailed the introduction

of a gold standard hernia surgery pathway. This was developed to offer a financially stable high

quality day surgery experience for patients.

Maternity


The trust provides maternity services across three acute sites with community midwifery services in various locations including children’s centres and GP clinics. A breakdown by site is below: Northwick Park Hospital

Ward/department Beds

Delivery suite 19


Florence Ward 31

Midwifery led unit - birth centre 19

Obstetric observation bay -

Recovery -

Antenatal -

Postnatal -

Additionally, there are obstetric outpatients (general and specialist), a fetal medicine unit, day assessment unit, maternity theatres, a bereavement service with close operational links to the neonatal service. Central Middlesex Hospital At Central Middlesex Hospital there are both consultant and midwifery led clinics available for antenatal and postnatal care. Ealing Hospital Midwifery led clinics are available at Ealing Hospital for antenatal and postnatal care. (Source: Routine Provider Information Request (RPIR) – Sites tab, Routine Provider Information Request (RPIR) – Acute context) From January to December 2018 there were 4,468 deliveries at the trust. A comparison from the number of deliveries at the trust and the national totals during this period is shown below. Number of deliveries at London North West University Healthcare NHS Trust – Comparison with other trusts in England:

(Source: Hospital Episodes Statistics (HES)


A profile of all deliveries and gestation periods from January to December 2018 can be seen in the tables below.

Profile of all deliveries (January 2018 to December 2018)

LONDON NORTH WEST

UNIVERSITY HEALTHCARE NHS TRUST

England

Deliveries (n) Deliveries (%) Deliveries (%)

Single or multiple births

Single 4,403 98.6% 98.6%

Multiple 61 1.4% 1.4%

Mother’s age

Under 20 99 2.2% 3.0%

20-34 3,370 75.5% 74.6%

35-39 800 17.9% 18.5%

40+ 195 4.4% 4.0%

Total number of deliveries

Total 4,464 581,697

Notes: A single birth includes any delivery where there is no indication of a multiple birth. This table does not include deliveries where delivery method is 'other' or 'unrecorded'.

Gestation periods (January 2018 to December 2018)

LONDON NORTH WEST UNIVERSITY

HEALTHCARE NHS TRUST

England

Deliveries

(n) Deliveries

(%) Deliveries

(%)

Gestation period

Under 24 weeks * * 0.6%

Pre-term 24-36 weeks * * 7.9%

Term 37-42 weeks 3,427 95.8% 91.4%

Post Term >42 weeks * * 0.1%

Total number of deliveries with a valid gestation period recorded

Total 3,576 472,862

Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'.

Gestation periods were unrecorded for 19.9% of deliveries at this trust compared to 18.7% nationally.

To protect patient confidentiality, figures between 1 and 5 have been suppressed and replaced with “*” (an asterisk). Where it was possible to identify numbers from the total due to a single suppressed number in a row or column, additional numbers (generally the next smallest) have also been suppressed.

(Source: Hospital Episodes Statistics (HES))



Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it however there was some confusion among midwifery staff as to the correct

length of mandatory training and its content.

The trust set a target of 85.0% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for qualified nursing staff in maternity is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)









Manual handling - level 2 (face to

face) 170 224 75.9% 85.0% No

In maternity the target was met for eight of the nine mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for medical staff in maternity is shown below:



Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)





Health & safety 50 61 82.0% 85.0% No



In maternity the target was met for three of the seven mandatory training modules for which medical staff were eligible, with three further modules having compliance rates close to the


target. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in maternity at Northwick Park Hospital is shown below:



Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)










face) 135 179 75.4% 85.0% No

In maternity the target was met for six of the nine mandatory training modules for which qualified nursing staff at Northwick Park Hospital were eligible, with two further modules having compliance rates just below the target. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for medical staff in maternity at Northwick Park Hospital is shown below:



Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)






Health & safety 42 51 82.4% 85.0% No


In maternity the target was met for four of the seven mandatory training modules for which medical staff at Northwick Park Hospital were eligible, with two further modules having compliance rates close to the target. (Source: Routine Provider Information Request (RPIR) – Training tab)

We spoke to four midwives all of whom said that mandatory training days were allocated via the off-duty rota. All four were up to date with their training. There was some confusion amongst midwifery staff as to the correct length of mandatory training and its content. Staff told us that mandatory training had to be completed in their own time, and they were not given additional time to complete this. However, after the inspection, we were told


by the trust that substantive staff did not undertake mandatory training in their own time. We were shown rosters to evidence this. One midwife told us that she had worked in the organisation for four years and when she had started, mandatory training was covered over five days but had now been reduced to two days. She also told us that some of the sessions had been significantly reduced in the time allocated – e.g. shoulder dystocia training. We spoke with another two midwives, with one saying that mandatory training was over three days and the other midwife saying that training was over two days, and that antenatal and new-born screening updates had been removed from the mandatory day programme. The midwife was unable to say what the expectation was for midwives to keep updated in this area of their practice. After the inspection, the trust told us they had condensed mandatory training from four days to two days to reduce inefficiency and ensure staff were available on wards. Mandatory training had been reviewed and condensed into two days and covered subjects such as the use of simulation for obstetric emergencies and cardiotocography (CTG) assessment, neonatal life support, learning from serious incidents, risk management and safeguarding. Trust wide training requirements were completed outside of the two day programme. We were told that manual handling training was a one-and-a-half to two-hour face-to-face course, and this was not included in the three-day protected mandatory training time. Fire safety, which was also face-to-face, we were told also had to be completed in staff’s own time, which was not given back. Basic life support training was also not included in the three-day mandatory training. Training on sepsis was provided through the mandatory training programme, and since March 2019 included obstetricians. It was expected that compliance for all staff groups would be over 90% from February 2020. The sepsis training compliance for staff working in the maternity service was as follows: midwives – 95%, Nurses - 50%, maternity support workers – 53.10%, obstetric consultants – 33.3%, and junior doctors – 32.5%.

Safeguarding

Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

We spoke with four midwives who demonstrated a good knowledge of safeguarding and were able to explain how to access a drive where previously identified issues were recorded. One midwife talked about how to encourage disclosure, documentation and referral to other relevant services. We spoke with two maternity support workers (MSWs) who also said that they were kept up to date regarding any women for whom safeguarding issues had been identified when they became an inpatient on the ward area (Florence ward). We were told that there are two staff members who are the identified safeguarding leads for maternity and that there was another member of staff who had a specialist interest. We spoke with one of the named midwives for female genital mutilation (FGM), who informed us that there were FGM clinics being held once a week at Northwick Park Hospital and Central Middlesex Hospital, with the service having just been expanded to the community. We were informed that clinics would not just be made available to pregnant women, but also to non-pregnant women.


The service had just received funding for two full-time midwives to run a deinfibulation service (a surgical procedure which is carried out for women living with FGM, to allow intercourse or facilitate childbirth). We were told that there was a consultant lead who was supportive of the work that the FGM team were doing and that there would be consultant input for higher risk patients, such as those with diabetes or a high body mass index (BMI). A band 7 community midwife told us that a datix referral would be made to the safeguarding team if at a woman’s booking, they had concerns. We were informed that this referral would be sent to all of the correct agencies such as the mental health team, who would do a complete assessment of the woman and determine how often she would need to be seen. However, if a woman with mental health concerns was picked up outside of a woman’s initial booking, the community midwife would assess that situation by liaising with the woman’s GP or contacting the hospital where the woman delivered (if she didn’t deliver at Northwick Park). The community midwife told us that her experience of liaising with other hospitals to obtain information about a woman who had delivered had been very good, but on the occasions where it hadn’t, then her first point of contact would be to the woman’s GP. The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for qualified nursing staff in maternity is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


PREVENT 218 225 96.9% 85.0% Yes




In maternity the target was met for all of the five safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in maternity is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


PREVENT 47 61 77.0% 85.0% No



In maternity the target was met for one of the four safeguarding training modules for which medical staff were eligible. It should be noted that the numbers of eligible staff for the safeguarding children modules were low. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for


qualified nursing staff in maternity at Northwick Park Hospital is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



PREVENT 173 180 96.1% 85.0% Yes



The target was met for all of the five safeguarding training modules for which qualified nursing staff in maternity at Northwick Park Hospital were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in maternity at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


PREVENT 38 51 74.5% 85.0% No


The target was met for one of the three safeguarding training modules for which medical staff in maternity at Northwick Park Hospital were eligible. It should be noted that the number of eligible staff for the safeguarding children level 3 module was low. (Source: Routine Provider Information Request (RPIR) – Training tab)


The service did not always control infection risk well. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and the premises visibly clean. We observed that there were areas where the hand hygiene points were not obvious when entering clinical areas, for example, in the antenatal clinic. We observed staff not always undertaking hand hygiene when entering and leaving patient areas. However, we spoke to three women who told us that they had observed staff adhering to hand washing when delivering clinical care and we were asked to wash our hands when we were on the delivery suite. On an observation of whether midwives were using alcohol gel to decontaminate hands, results showed that they were not but on the second observation, they were seen to be. This indicates that hand hygiene was not consistently being undertaken. One woman told us that she had spent a few days on the delivery suite and that it was her observation that cleaning was sporadic. Patients were screened as set out in the guidance for Methicillin-resistant Staphylococcus Aureus (MRSA) Screening and Control Policy and Infection Prevention and Control Policy. Patients were


tested as per clinical need for clostridium difficile (C. difficile) and gram-negative bloodstream infections (GNBSIs), i.e. when symptomatic and/or if there was a clinical suspicion. A report provided to us on behalf of the director of infection prevention and control, showed that between April 2018 and March 2019, there were no cases of c. difficile on any of the women’s wards. In the same period, there were no cases of MRSA on any of the women’s wards. However, there had been four cases of e-coli blood stream infections. This occurred twice in the birth centre and three times on the delivery suite. There had been no incidences of blood stream infections in the same period on any of the women’s wards. There were posters on delivery suite showing results of 98% compliance with infection prevention and control, with monthly audits on infection prevention and control being carried out. We looked at the hand hygiene audit results for the month of April 2019, and it showed that despite our observations, medical staff and nurses were 100% compliant in hands being de-contaminated with soap and water and wearing gloves. Cleanliness and hygiene in community clinics such as children’s centres was maintained by cleaners in those centres who cleaned the rooms and dustbins. The midwives and maternity support workers were supplied with hand gel, aprons and gloves from the trust. Equipment was cleaned after use, using disinfectant wipes also supplied by the trust. We were told by the senior midwifery manager that in women’s homes, paper towels were supplied to midwives.


The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well. In relation to security access to the maternity unit, there were three lifts in the maternity building. One of the lifts was a theatre lift and could only be called by staff with a swipe card. There were now clear signs on the lift doors to state that they could only be used by staff and there were tailgating signs at ward entrances and in the public lifts which said, “Never let anyone follow you in without authorisation and showing proper I.D.”. We were told by the consultant midwife that if the lift for the theatres did not work, then the public lifts could be configured to reroute to the theatres but there would be a security guard stationed on the theatres to prevent unauthorised access to the area by the public. There was a door from theatres that provided direct access to the delivery suite. However, only authorised staff with swipe access could now gain entry. Staff reported that they had good access to equipment when they needed it. However, a midwifery support worker told us that there was a shortage of blood pressure machines, cardiotocography (CTG) machines and baby cots. We saw that cardiotocography CTG belts were changed between patients. We checked two adult resuscitation trolleys, one on Edith ward and the other on Florence ward antenatal and postnatal ward respectively. The resuscitation trolley on Edith ward was stored in the corridor of the ward, was locked and was clean. Daily check records reviewed for 15 April 2019 to 2 July 2019 showed that there was a total of 77 opportunities for checking of the trolley. Checks recorded as completed were carried out for 75 opportunities, with checks being missed on 26 and 27 May 2019. The resuscitation trolley on Florence ward was stored in the corridor of the ward and was locked and clean. Daily checks were reviewed for the period 1 April to 2 July 2019. This was a total of 93 opportunities for checking, with checks recorded as completed on 90 occasions. The three missed occasions were on the 12, 15 and 26 June 2019.


Daily check records were reviewed for five separate neonatal resuscitation trolleys on Edith ward for the period 1 April 2019 to 31 May 2019. This was a combined total of 305 opportunities for checks on the trolley, with only one missed opportunity out of 305 for one of the trolleys. We looked at a postpartum haemorrhage (PPH) trolley, that was stored in the corridor of Edith ward. It was locked and clean. Daily check records were reviewed for the period 1 April to 31 May 2019. This was a total of 61 opportunities for checking with checks recorded as completed on 60 occasions, with one missed check on the 27 May 2019. Records for June 2019 could not be located by staff and the checking records for the PPH trolley on Florence ward could not be located by staff. We looked at a glucose meter (a medical device for determining the approximate concentration of glucose in the blood) on Edith ward. Daily check records were reviewed for the period 1 April to 31 May 2019. This was a total of 61 opportunities for checking, with checks recorded as completed on 60 occasions. There was one missed check on 15 May 2019. We also looked at a hypoglycaemia box on Edith ward. Daily checks were reviewed for 1 April to 31 April 2019. This was total of 61 opportunities for checking with checks recorded as completed on all 61 occasions. Equipment that we looked at on the wards had received safety testing and servicing. However, we did see an oxygen saturation machine in the room designated for community midwifery, that hadn’t been checked since January 2018. In one of the home birth bags for women, we observed that a forceps delivery pack had expired on 3 March 2019. We highlighted this to a member of staff who removed the delivery pack and put aside the oxygen saturation machine for it to be serviced. The breastfeeding room in the antenatal department looked out onto a stairwell that led to another part of the hospital but also onto the local bus stand. However, privacy was maintained using roller blinds. The room was furnished with a sofa like chair, three red infant chairs, a portable fan and a call bell. We tested the call bell to ensure that it worked. We spoke with a band 7 community midwife who told us what equipment community midwives would carry when visiting postnatal women. This included: a blood pressure machine, thermometers, stethoscopes, sonicaid (a device used to listen to a fetal heart), delivery packs in the event of unforeseen deliveries, heal prick test equipment including heal prick cards, gloves and lancets, as well as equipment to remove sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) such as stitch cutters and clip removers. Home birth bags for women having a home birth were delivered to women at 37 weeks of their pregnancy. The single use contents of these bags included: absorbent pads, gloves, aprons, forceps delivery packs, suture packs, urinary in-and-out catheter, sterile gloves (used for the delivery of a baby and vaginal examinations). Measuring jugs for measuring urine output were also used, as we were told that previously the service found that women were having urine retention after delivery, consequently leading to women having damaged bladders; we were told that a bladder care policy was in place. Other contents also included, three types of disposable bags – one for contaminated waste, one for general disposal and the other for the woman’s placenta, a cardboard kidney dish, baby labels and baby name tags. Home birth equipment, which staff would take at the time of a delivery, included suction, medical gases which were oxygen and nitrous oxide (an inhaled gas used as a pain medication), pulsometer (device used to measure baby’s oxygen levels after delivery, blood pressure machines. Emergency equipment was also available if it was needed, including a laryngoscope. Resuscitation was also kept in the home equipment bag. Bags were checked once a week, but previously they had been checked daily.


We were told that the electrical and biomedical engineering (EBME) department were responsible for servicing equipment.


Staff completed and updated risk assessments for each women and took action to remove or minimise risks. Staff identified and quickly acted upon women at risk of deterioration In responding to the risk of a woman arriving in labour without having previously booked, and subsequent care, we were provided with an ‘Asylum seekers, refugees and women whose first language is not English’ guideline. This guideline set out that during labour and delivery: care in labour should be the same as for any other labouring woman. A face to face interpreter should be available during intrapartum care; and partners and family members including children must not be used to interpret. Postnatally, the guideline set out that: staff should ensure that women understood the postnatal process especially immunisation for the baby, any investigations, and follow up treatment, for example Anti D for rhesus negative women; staff should explain to the women and her family the role of the community midwives and Health Visitor when they and baby were discharged from the hospital; women and baby should not be discharged from the post-natal ward if their accommodation is defined as roofless (sleeping outdoors). Instructions in the guideline stated that staff should contact the social care team as soon as soon as a woman’s homelessness had been identified. The head of security and general manager for maternity told us that there has been one incident of the doors been prised open to gain unauthorised access to the maternity reception at night. This happened in September 2018. Following this incident, a security guard was placed in the maternity reception until the doors were replaced in October 2018. We were told that since the doors had been replaced, there had been no further incidents of the doors being prised open, and the security team continued to carry out at least four patrols over a 24-hour period. Of the five sets of notes that we looked at on the post-natal ward (Florence Ward), four out of five women had a medical risk assessment completed. All five women had received a flu and pertussis (whooping cough) vaccine. However, just three out of the five women had received a mental health risk assessment and an antenatal VTE risk assessment. We saw no evidence in any of the five records that these women had received CO (carbon monoxide) monitoring. In a briefing guide set out by Public Health England for midwifery staff, it states that, “smoking in pregnancy poses significant health risks to the mother and to the baby. For the mother, smoking in pregnancy carries with it all the health risks associated with smoking but with some additional pregnancy related health risks, including ectopic pregnancy, placenta praevia and pre-eclampsia; pregnant women are also at increased risk of deep vein thrombosis”. The briefing guide also states that all records on smoking (or not) should be consistent in the woman’s handheld and hospital notes, and on computerised records (if available), to allow everybody involved in antenatal care to monitor progress and to track their success. The guide further sets out the simple steps that staff can take to intervene with women who smoke, which is to record smoking status, and then advise women that carbon monoxide screening is routinely carried out on all pregnant women. The trust’s antenatal care guideline also stated that it would offer CO monitoring to all women and would refer to the smoking cessation service and would document advice given where appropriate. The service used an algorithm and risk assessment tool for the screening and surveillance of fetal growth in singleton pregnancy. Women with one or more risk factors such as being diabetic, having hypertension, a raised BMI (body mass index) or having a maternal age of more than 40 years that result in a serial assessment of fetal weight and umbilical doppler from 26-28 weeks until delivery. We asked, if concerns were identified around the environment the woman was living in, either because of an abusive partner or family member(s) how this would be managed. A deputy matron


told us that options included referring to guidelines that supported decision making and discussing matters with the matron were ways in which this was managed and escalating to the senior midwifery team if further input was required. Other options considered were that staff could see a patient in a hospital setting as opposed to a home visit or having contact in a children’s centre. If a decision was made to see a client at home, two midwives were to undertake the visit and the visit was to be performed early in the working day. Staff were aware of the lone working policy. We were told that there were twice daily bleep test calls for emergencies and that switchboard kept a log. We asked to see a copy of the log and was told that test results were recorded on paper forms and not always transcribed onto spreadsheets for general managers to review. To address this, the trust told us they were in the process of looking at alternative methods for recording the twice daily bleep test calls. The admission of patients to the obstetric complex care bay was a multidisciplinary decision involving the obstetrician, anaesthetist and senior midwife. The criteria included: sepsis, diabetic stabilisation, obstetric haemorrhage, moderate to severe eclampsia, or if being stepped down from the intensive treatment unit (ITU). The ‘Recovery and Complex Care’ guideline described the type of patient requiring level 3 care (patients requiring advanced respiratory support, together with support of at least two organ systems. This level included all complex patients requiring support for multi-organ failure) should be transferred to the hospital’s general ITU. The transfer of obstetric patients to the general ITU followed the same principles as admission of any patient to the ITU. The decision to transfer women onto the wards who no longer fulfilled the criteria for being in obstetric complex care, would be made by the senior midwife, obstetrician and anaesthetist. The discharge and transfer criteria included: being fully conscious, maintaining a clear airway, having a stable pulse and blood pressure, pain control that was adequate, not exhibiting excess vomiting, and having a temperature that was within acceptable limits. We spoke with a theatre nurse who informed us that there was 100% compliance with World Health Organisation (WHO) five steps to safer surgery safety check lists in obstetric theatres. She was able to tell us about the safety briefing, sign in, time out and sign out, and components of the WHO safety check list. We looked at the WHO checklist audit results from June 2018 to June 2019 and saw that compliance ranged between 92% and 100%. For the months May and June 2019, results were 100%. The reasons listed for the occasions where compliance was not at 100%, was because of the time out not being recorded due to fetal distress. We observed an electronic board that was being used on Florence ward which displayed situation, background, assessment and recommendation (SBAR) assessments for all the women who were currently inpatients. SBAR is a structured form of communication that enables information to be transferred accurately between individuals. SBAR consisted of standardised prompt questions in four sections to ensure that staff were sharing concise and focused information. It allowed staff to communicate assertively and effectively, reducing the need for repetition and the likelihood for errors. The assessments were colour coded, which enabled staff to recognise at a glance whether women had green, amber or red assessments. There was an escalation bay with two beds on the delivery suite, which received patients directly from triage or via ambulance if needed. The service provided medical terminations of pregnancy for women who presented beyond 12 completed weeks, or who required abortion for urgent medical reasons. The hospital had a close working relationship with a neighbouring NHS hospital who carried out a service of surgical terminations if required. Staff had access to a consultant gynaecologist and a consultant obstetrician 24/7 for advice and to assist with decision-making, which ensured that women received care promptly to minimise further risk to health.


In the previous inspection of the maternity service, we had asked for a copy of the child abduction policy for maternity, but we were not provided with one. On this inspection, we had been provided with the policy, which clearly set out how staff would respond in the event of a baby or infant being abducted. The service also participated in baby snatch drills.

Midwifery, nurse and staffing

The service had maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction. We spoke with two maternity support workers (MSWs), three junior grade doctors, two consultants, a band six midwife, matron, a ward manager on the labour ward, two labour ward coordinators. All staff complained of a shortage of midwifery staff. A specialist trainee doctor told us that, “There is a shortage of midwives and I do not feel the unit is safe.” Another specialist trainee told us that they had concerns about the safety of the unit. A MSW told us that the unit felt unsafe due to the shortage of midwives, with staff allegedly not wanting to work on the unit and put their professional registration on the line. The matron on the labour ward was described as fantastic and helping on the labour ward when the unit got busy but other matrons did not. The labour ward coordinators told us that they were short staffed 50% of the time, with morale at its lowest as a result. We were told that the ward manager for the labour ward had been working clinically for more than 50% of her working week for the last four weeks due to a shortage of midwives. She told us that her job plan was totally managerial, which meant that she had been unable to do her ward manager job. The trust subsequently advised us that the ward manager was transitioning into her role and that there was no set percentage attributed to the role of ward manager in terms of clinical shifts. There was at the same time a full time matron in post to whom the ward manager reported in a supportive role. Staff told us they felt that the labour ward was short staffed and that did not have much support from the senior managers above. We were shown examples whereby an email was sent at 4.20pm to senior midwifery staff for approval of a shift in two days’ and a response was received the following day which said, “Do not email me after 4pm, I do not work after 4pm.” We were told this had happened on two occasions. We were told by the head of midwifery that the service was in the process of completing a comprehensive staffing review and consultation and that all vacancies have been frozen during this period. The 8% reduction in birth numbers had also supported the temporary drop in staffing numbers and any gaps in numbers had been supported by bank staff. Ward managers completed a daily staffing acuity tool to manage staffing and acuity of the ward. A monthly report was then produced and submitted to the trust safer staffing manager. To mitigate staffing shortages the service used agency staff or community midwives and specialist midwives. We were told that recruitment had resumed, and the department had offered seven positions to band 5 and 6 midwives. Ongoing proactive recruitment was to continue, and the outcome of the consultation will see an additional 9 WTE band 7 midwives move down to band 6. The labour ward had 104 hours consultant presence, which includes 8am to 8pm seven days a week and 8pm to 8am two nights per week. We were told by the deputy clinical director for obstetrics that consultants who were on-call, could attend the hospital within 30 minutes. There


was obstetric SHO cover from 8am to 8pm and obstetric and gynaecological cover from 8pm to 8am. There was registrar cover from 8am to 8pm and 8pm to 8am. From January 2018 to December 2018 the trust had a ratio of one midwife to every 30.1 births. This was worse than the England average of one midwife to every 24.6 births. (Source: Electronic Staff Records – EST Data Warehouse)

From April 2018 to March 2019, the breakdown of staff in post WTE in core service is shown in the chart below.

Maternity annual staffing metrics



Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 347.9 11.8% 24.7% 5.1%

Qualified nurses

182.0 11.2% 21.6% 5.6% 36,317 (10.3%)

21,139 (6.0%)

8,469 (2.4%)

Nursing assistants

52.5 5.0% 15.3% 8.3% 12,745 (12.4%)

720

(0.7%)

Medical staff 71.6 8.4% 40.2% 1.9% 7,098 (7.5%)

0 (0.0%)

7,233 (7.6%)

* All staff includes other staff groups not specifically shown in the above table ** The trust has confirmed that the medical staffing turnover figures include planned rotation, which inflates the rate. We received up to date data for vacancies and sickness rates for midwives from March 2019 to August 2019. Data showed that there was a 13.5% average vacancy rate and 6.6% average sickness rate which were both higher than the trust target of 11% and 4% respectively.


Monthly vacancy rates from April 2018 to March 2019 for all staff in maternity showed a downward trend from September 2018 to January 2019.

Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in maternity showed a downward trend from September 2018 to January 2019.

Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in maternity showed a shift from October 2018 to March 2019. Monthly turnover rates from April 2018 to March 2019 for all staff groups in maternity appear to be stable with only random variation over the whole period.


Sickness rates

Monthly sickness rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in maternity showed a shift from October 2018 to March 2019.

Monthly bank hours from April 2018 to March 2019 for nursing assistants in maternity showed a shift from October 2018 to March 2019. From April 2018 to March 2019, the breakdown of WTE staff in post in maternity at Northwick Park Hospital is shown in the chart below.


Maternity annual staffing metrics



Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 241.5 10.5% 27.6% 4.6%

Qualified nurses

140.9 13.3% 22.2% 4.5% 36,317 (10.3%)

21,139 (6.0%)

8,469 (2.4%)

Nursing assistants

42.2 7.3% 18.9% 8.2% 12,745 (12.4%)

0 (0.0%)

720 (0.7%)

Medical staff 57.4 5.8% 46.7% 2.4% 1,331 (1.6%)

0 (0.0%)

7,233 (8.9%)



Monthly vacancy rates from April 2018 to March 2019 for all staff in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in maternity at Northwick Park Hospital showed a downward trend from September 2018 to January 2019.

Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019. Monthly turnover rates from April 2018 to March 2019 for all staff in maternity at Northwick Park Hospital appear to be stable with only random variation over the whole period.


Monthly sickness rates from April 2018 to March 2019 for all staff in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Monthly sickness rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019.

Monthly sickness rates from April 2018 to March 2019 for nursing assistants in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019.


Monthly bank hours from April 2018 to March 2019 for all staff in maternity at Northwick Park Hospital showed a downward trend from August 2018 to January 2019.

Monthly bank hours from April 2018 to March 2019 for nursing assistants in maternity at Northwick Park Hospital showed a shift from October 2018 to March 2019.


Monthly bank hours from April 2018 to March 2019 for medical staff in maternity at Northwick Park Hospital showed a downward trend from August 2018 to December 2018. (Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Nursing bank agency and Medical locum tabs) In January 2019, the proportion of consultant staff reported to be working at the trust was the same as the England average and the proportion of junior (foundation year 1-2) staff was lower, with no junior staff reported to be working in maternity. Staffing skill mix for the 63.3 whole time equivalent staff working in maternity at London North West University Healthcare NHS Trust: This


Consultant 42% 42%



Junior* 0% 6%



Records

Staff kept detailed records of women’s care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care. The storage of records on both Edith ward (the Birth Centre) and Florence ward (antenatal and postnatal ward) were in trolleys kept within the area designated as a work station for staff. These trolleys were unlocked; however, during our period of observation on both areas, we did not see these areas left unattended. In addition to reviewing five sets of records, with regards to risk assessments, we looked at six other sets of records using the following criteria: legibility of patient records; whether entries were dated and signed; evidence of care planning; inclusion of and the correct scoring of MEOWS charts; and documentation of venous thromboembolism (VTE) assessments. In three sets of notes, all entries were legible, however in the other three they were not always legible. In all six set of records, entries had been dated and signed. CTG recording were included within all records that we looked at. We saw evidence of care planning in all six set of records; however there was no documentation to indicate that women had proactively been involved in planning care. VTE assessments had been documented in 4 of the 6 sets of records and MEOWS (maternity early obstetric warning scoring) charts were seen in 5 of the 6 sets of records. All five had been


correctly totalled with appropriate actions recorded. We saw evidence of monthly audits regarding the correct completion of MEOWS charts. Compliance from the audits seen was good. In addition, five sets of prescription sheets were reviewed for four of the five seen allergies and maternal weight had been documented. Midwives sent discharge summaries to community midwives and general practitioners (GPs) when a woman and baby went home from hospital.

Medicines

The service used systems and processes to safely prescribe, administer, record and store medicines. With the exception of the midwifery led unit (MLU), the other inpatient maternity wards had recently had an automated medicine dispensing system installed, which provided safe storage and dispensing of medicines. The system required staff fingerprints to dispense medicines. Stock checking was automatic, and withdrawal of controlled drugs required two different staff fingerprints to be recorded. One midwife told us that whist this had removed the need to locate the key holder when medicines were required, there was the potential for delay in an emergency for e.g. in the event of a postpartum haemorrhage (PPH) occurring on the ward two fingerprints are required to open the fridge and access the emergency drugs. She was unable to recall an episode when such a delay had been recorded. A community midwife told us that they did not any carry medicines, other than syntometrine, syntocinon, ergometrine for home births, which are medicines used to stimulate the smooth muscle of the uterus (womb) in the third stages of delivery. Vitamin K was also carried for the babies. These medicines were stored in the fridge on the MLU and midwives would collect them when they went to collect the homebirth equipment, which was also stored on the MLU. For home births, medical gases (oxygen and nitrous oxide) were transported from the hospital in midwives’ cars. We were told that staff would carry a special card and place on the dashboard of their cars when carrying these medical gases, and there was also a COSHH (control of substance hazardous to health) policy that could be referred to. We visited the room at the hospital where equipment for community midwives was stored. We looked at an oxygen cylinder and nitrous oxide cylinder, both of which has expiry dates of 14 February 2022 and 26 August 2021 respectively. We saw monthly medicines audits carried out by the ward manager on the labour ward since April 2019, and they showed 100% compliance with medicines management.

Incidents

The service managed safety incidents well. Staff recognised and reported incidents and

near misses. Managers investigated incidents and shared lessons learned with the whole

team and the wider service. When things went wrong, staff apologised and gave patients

honest information and suitable support. Managers ensured that actions from patient

safety alerts were implemented and monitored.

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a


never event. From May 2018 to April 2019, the trust reported no never events for maternity. (Source: Strategic Executive Information System (STEIS)) In accordance with the Serious Incident Framework 2015, the trust reported 17 serious incidents (SIs) in maternity which met the reporting criteria set by NHS England from May 2018 to April 2019. A breakdown of the incident types reported is in the table below:


Percentage of total

Maternity/obstetric incident: baby only (this include foetus,

neonate and infant) 13 76.5%

Maternity/obstetric incident: mother and baby (this include

foetus, neonate and infant) 3 17.6%

Medication incident 1 5.9%

Total 17 100.0%

A breakdown of incidents at Northwick Park Hospital is below.


Percentage of total

Maternity/obstetric incident: baby only (this include foetus,

neonate and infant) 12 80.0%

Maternity/obstetric incident: mother and baby (this include

foetus, neonate and infant) 2 13.3%


Total 15 100.0%


All four midwives who we interviewed, demonstrated a good knowledge of how to report incidents. They all said that there was a positive culture with regard to incident reporting. One midwife said that she believed there was a good culture of reporting main incidents for example, PPH (primary postpartum haemorrhage), shoulder dystocia, but that other incidents such as lack of resources, or staff were not necessarily reported. Staff were all aware of the existence of the weekly meetings at which incidents for the preceding week were discussed. They all said that feedback with regard to learning from incidents was well disseminated via email, newsletters and at hand-over. They also said that they received individual feedback if they had been involved in an incident or if they had been the reporter. The antenatal and new-born screening coordinator told us that the trust incident management policy referred to the Public Health England guidance on reporting incidents related to screening.


Both maternity support workers interviewed understood incident reporting and were able to recall instances when they had received feedback with regard to lessons learnt. In information provided to us by the risk manager about the various ways in which learning of incidents were disseminated to staff, we were told of the following: that a monthly newsletter was emailed to all clinical staff including obstetricians; incidents were discussed at mandatory training, which all clinical staff had to attend; a ‘message of the week’ initiative had begun in January 2019; posters were emailed out to staff and messages were printed and laminated and put on noticeboards, in addition to the ‘message of the week’ being discussed at safety huddles. In the risk newsletter that we saw for January 2019, it detailed all of the previous month’s incidents, which included 13 unexpected admissions to the neonatal unit, 8 3rd and 4th degree tears, nine shoulder dystocias, seven postnatal readmissions and nine major obstetric haemorrhages. We saw that uterine rupture (tearing of the uterus) was the theme for the latest month’s risk newsletter. The newsletter gave a narrative of what uterine rupture was, and detailed what the risk factors, symptoms and management were associated with this type of tearing.

Safety thermometer

The service did not use the correct monitoring results well to improve safety. Staff did not collect safety information to share with staff, women and visitors. We did not see evidence of use or knowledge of the Maternity Safety Thermometer. The Maternity Safety Thermometer is a measurement tool for improvement that focuses on: perineal and abdominal trauma, post-partum haemorrhage, infection, separation from baby and psychological safety. The tool allows teams to take a temperature check on harm and records the number of harms associated with maternity care, but also records the proportion of mothers who have experienced ‘harm free’ care. It supports improvements in patient care and patient experience, prompts immediate actions by healthcare staff and integrates measurement for improvement into daily routines. The key performance indicators displayed on ward areas showed maternity performance against the general safety thermometer data but was not specific to maternity. We spoke to four midwives and two MSWs, none of whom were aware of the Maternity Safety Thermometer.



The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of women subject to the Mental Health Act 1983. There were 105 guidelines on the trust intranet. We checked several guidelines, of which the majority had been updated. These included: ‘Perinatal Mental Health Guideline’, ‘Obesity in Pregnancy’, ‘Epilepsy in Pregnancy’, ‘Chicken Pox in Pregnancy’, ‘Fetal Medicines’ Antenatal Care’, ‘Teenage Pregnancy’, ‘Prematurity’, ‘Obstetric Cholestasis’, ‘VBAC’ (vaginal birth after caesarean), and ‘Group B Streptococcus’. These guidelines were referenced in line with recent Royal College of Obstetricians and Gynaecologist (RCOG) green top and National Institute for


Health and Care Excellence (NICE) guidelines. The RCOG produces guidelines as an aid to good clinical practice and NICE provides national guidance and advice to improve health and social care. The guidelines that we saw during our inspection that were out of date and had review dates ranging from October 2018 included: ‘Multiple Pregnancy’, ‘Substance Misuse in Pregnancy’, ‘Asylum Seekers, Refugees and Women Whose First Language is not English’, and ‘Disability in Pregnancy’. Following on from our inspection and in data requested from the trust, we saw that some of those listed guidelines had notes on them to say that they “under review for completion July 2019”. A trainee doctor was able to show us how to access guidelines on the trust intranet. We checked the ‘Shoulder Dystocia’ guideline which was updated on 12 September 2018. Shoulder dystocia can be defined as a condition requiring special manoeuvres to deliver the shoulders following an unsuccessful attempt to apply downward traction. This happens when the anterior shoulder impacts against the symphysis pubis after the fetal head has delivered. The algorithm within the guideline was in line with Practical Obstetric Multi-Professional Training (PROMPT) Manual 3 (2017), which specified that a midwife coordinator, experienced obstetrician, additional midwifery help, and the neonatal team were to be called urgently at the declaration of an emergency. The service had a guidelines and audit lead and they showed us a list of audits which were presented in 2018/2019. These were: ‘Perineal Repair’, ‘Bladder Care’, ‘VBAC’, ‘Still Birth’, ‘Theatre Utilisation’, ‘Diabetes in Pregnancy’, ‘Failed IOL’ (induction of labour), and ‘Multiple Pregnancy’. Various audits such as ‘Still Births’, ‘Diabetes in Pregnancy’ and ‘Theatre Utilisation’ were re-audited. The clinical director and head of midwifery told us that the service had ensured that the objectives of the Academy of Medical Royal College – ‘Taking Responsibility Accountable Clinicians & Informed Patients’ had been implemented. For midwifery staff, the divisional lead told us that every woman knew who her named midwife was, and that the shift co-ordinator would allocate the named midwife at the onset of the shift. The named midwife would introduce herself to the women at the start of the shift and they would put their names above the woman’s bed to identify that they were providing care following a 1:1 introduction. For obstetric staff, the clinical director told us that there were named consultants for high risk antenatal inpatients. In addition, there was a consultant on the delivery suite (labour ward) for all other patients, who would liaise with the named consultant to discuss the management of their care. We were told by the deputy matron for antenatal care that the measuring and recording of symphysis fundal height ((SFH) - the distance from the pubic bone to the top of the uterus measured in centimetres) was achieved by using the international SFH standard chart. We were told that guidance for measuring SFH was “clear” and “precise”. We saw recommendations for how SFH measurements should be taken in the ‘Antenatal Care’ guideline. We were told that the pathway for referral and escalation were included in the ‘Intrauterine Growth Restriction’ guideline and that there was a risk assessment form that also had clear instructions on escalation of abnormal findings.


Staff gave women 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 women’s religious, cultural and other needs.


Patients had fluids in labour and a very light diet in early labour. We spoke to three women all of whom told us that they had received adequate nutrition and hydration. One woman also said that meal times were too early with lunch being served at 12:00 and dinner at 17:00. In the maternity day unit, we observed that meals were ordered for women who would be in the unit at meal times and that in addition staff were able to order sandwiches, tea, coffee, biscuits, cake, and fruit for women to have at times outside of the set meal times. All three women whom we spoke with, said that they had received support with breastfeeding and one woman commented that the support she had received on this occasion was much better than when she had her previous child 15 months ago.

Pain relief

Staff assessed and monitored women regularly to see if they were in pain, and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. We spoke to nine women who all told us that they had received adequate pain relief and that this had always been given to them without having to wait long. Two out of the nine women to whom we spoke with had requested an epidural for labour. They both reported that they didn’t have to wait and one of the women told us that she had agreed timescales for an epidural, but when she requested it sooner, she didn’t have to wait. The remaining other seven patients reported that pain management had been timely and that options included: paracetamol, gas and air, and analgesia. We spoke with an anaesthetist, who told us that the response times for women receiving an epidural were good, with the service undertaking a monthly audit of the response times. Staff on the labour ward told us that patients got timely epidurals as requested. However, we spoke with a maternity support worker (MSW), who told us that she was concerned that due to a lack of anaesthetists, women often had to wait for longer than 30 minutes to get an epidural 8 out of 10 times. We were provided with the average epidural response time in minutes for the months January, March and June 2019. The data showed results of 20 minutes, 15 minutes and 15 minutes respectively.

Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for women. The table below summarises Northwick Park Hospital’s performance in the 2018 National Neonatal Audit Programme against measures related to maternity care.



Comparison to other

hospitals

Meets national

standard?

Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any dose of antenatal steroids? (Antenatal steroids reliably reduce the

92.3% Better than expected ✓


chance of babies developing respiratory distress syndrome and other complications of prematurity)

Are mothers who deliver babies below 30 weeks gestation given magnesium sulphate in the 24 hours prior to delivery? (Administering intravenous magnesium to women who are at risk of delivering a preterm baby reduces the chance that the baby will later develop cerebral palsy)

63.1% Within

expected range

No current standard

(Source: National Neonatal Audit Programme) The trust participated in the National Maternity and Perinatal Audit programme however we were not provided with any results for this audit. (Source: National Maternity and Perinatal Audit Programme) From January 2018 to December 2018 the total number of caesarean sections was as expected. The standardised rates for elective and emergency caesarean sections were also as expected.

Standardised caesarean section rate (January 2018 to December 2018)

Type of caesarean

England LONDON NORTH WEST UNIVERSITY HEALTHCARE

NHS TRUST

Caesarean rate

Caesareans (n)

Caesarean rate

Standardised Ratio

National comparison

Elective caesareans 12.8% 513 11.5% 90.4 Similar to expected

Emergency caesareans

16.5% 878 19.7% 119.6 Similar to expected

Total caesareans 29.3% 1,391 31.2% 106.8 Similar to expected

Notes: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries. Delivery methods are derived from the primary procedure code within a delivery episode. This table includes all deliveries, including where the delivery method is 'other' or 'unrecorded'.

In relation to other modes of delivery from January 2018 to December 2018 the table below shows the proportions of deliveries recorded by method in comparison to the England average:

Proportions of deliveries by recorded delivery method (January 2018 to December 2018)

Delivery method

LONDON NORTH WEST UNIVERSITY HEALTHCARE NHS

TRUST England

Deliveries (n) Deliveries (%) Deliveries (%)

Total caesarean sections1 1,391 31.2% 29.3%

Instrumental deliveries2 567 12.7% 12.3%


Non-interventional deliveries3 2,506 56.1% 58.4%

Total deliveries 4,464 100% 100% (n=581,697)

Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'. 1Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Includes breech and vaginal (non-assisted) deliveries

(Source: Hospital Episodes Statistics (HES)) As of April 2019, the trust had no active maternity outliers. (Source: Hospital Evidence Statistics (HES)) The table below summarises London North West University Healthcare NHS Trust performance in the 2018 MBRRACE-UK Perinatal Mortality Surveillance Report for births in 2018


Trust performance

Comparison to other trusts with similar service

provision

Meets national

standard?

Stabilised and risk-adjusted perinatal mortality rate (The death of a baby in the time period before, during or shortly after birth is a devastating outcome for families. There is evidence that the UK’s death rate varies across regions, even after taking into account differences in poverty, ethnicity and the age of the mother.)

4.95 (4.45 to 6.13)

Up to 10% lower than the average

for the comparator group

No current standard

(Source: MBRRACE-UK)

Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. We were told that there were specialist midwives for the following areas: bereavement, safeguarding, diabetes, female genital mutilation (FGM), breastfeeding, antenatal and new born screening, and a consultant midwife with a remit to promote normality in pregnancy. We spoke with the antenatal and new-born screening coordinator who told us that she was supported in her role by two midwives, who were specialists in infectious diseases in pregnancy, and a further midwife who was a specialist in haemoglobinopathy. We spoke with a speciality trainee doctor in his sixth year (ST6) who felt that midwifery staff were competent. The midwifery assistants we spoke with told us that they had full confidence in the doctors and midwives. A practice educator told us how the service ensured that arrangements were in place for training to deliver competence in: interpretation of cardiotocogram (CTG), new-born screening, and assessment of fetal growth in all settings including recording and escalation.


In ensuring competence for interpretation of CTGs, we were told that a new assessment tool had been introduced, and that from May 2019, a CTG training session had been incorporated into the Practical Obstetric Multi-Professional Training (PROMPT) day, which was to include obstetricians. In addition, we were told that there was a K2 perinatal training programme (PTP), which is an online, interactive e-learning tool covering a comprehensive array of topics in fetal monitoring and maternity crisis management, including competency assessments covering all modules. For new-born screening, we were told that face-to-face new-born screening training had been part of annual mandatory training, however since May 2019, classroom-based training days had been reduced to two days, with new-born screening being eliminated from mandatory training. To counter this, we were told that to ensure staff were compliant with the current national NHS Screening Programmes, the ‘Health Education England E-learning Package’ for new-born screening had been introduced in July 2019. During the inspection, we spoke with a midwife who confirmed that antenatal and new-born screening updates had been removed from the mandatory training programme. However, she was unable to say what the expectation would be for midwives to keep updated in this area of their practice as she hadn’t been advised that there was an e-learning package that was to be introduced. For the assessment of fetal growth in all settings including recording and escalation, the service had introduced the Saving Babies Lives care bundle in September 2018. In addition, staff received training in SFH measurement, and the use of the international chart. This was included in mandatory training as part of CTG training sessions and other ad-hoc training. We were shown an email which detailed results from the 2018 obstetrics and gynaecology general medical council (GMC) national trainees survey. Of the achievements highlighted where the department had made significant improvements, were: the department meeting the GMC training standards for general practice vocational training scheme (GPVTS) and speciality trainees in almost all domains, scoring highest in the domains – overall satisfaction, adequate experience, curriculum coverage, study leave and local departmental teaching. From April 2018 to March 2019, 83.5% of required staff in maternity received an appraisal compared to the trust target of 85.0%. The breakdown by staff group can be seen in the table below:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)






All staff 304 364 83.5% 85.0% No

In maternity two of the five staff groups including medical staff met the trust target, with the compliance rate for nursing staff being just below the target. From April 2018 to March 2019, 85.0% of required staff in maternity at Northwick Park Hospital received an appraisal compared to the trust target of 85.0%.

Staff group April 2018 to March 2019

Staff who Eligible Completion Trust Met


received an appraisal

staff rate target (Yes/No)






All staff 226 266 85.0% 85.0% Yes

In maternity at Northwick Park Hospital three of the five staff groups including medical staff met the trust target, with the compliance rate for nursing staff being close to the target. (Source: Routine Provider Information Request (RPIR) – Appraisal tab)


Doctors, nurses and other healthcare professionals worked together as a team to benefit women. They supported each other to provide good care. We observed considerate communications between medical and midwifery staff during our periods of observations on the maternity units. However, we were concerned that in some cases, for reasons unknown, not all specialities attended all meetings or handovers. We were told by a consultant who was an intrapartum lead, that staff attended PROMPT training as a multidisciplinary (MDT) team once a year. Included on this training were live drills on various emergencies. A specialist trainee doctor told us that communication between antenatal ward and the staff covering the labour ward was inadequate, as patients were often left on the antenatal ward with ruptured membranes for few days and the labour ward team was not aware. We were told that MDT working between the obstetric team and anaesthetists could be better as anaesthetists did not do ward rounds with them on the obstetric observation bay but would attend if requested. Consultant obstetricians attended handover in the morning but not in the evening. We were not provided with reasons for why this was occurring. We were later told by the trust that consultant obstetricians were available by telephone for the evening handover. We attended a safety briefing at 8am on 3 July 2019, which was followed by a handover. The safety briefing was led by the ward manager for labour ward. The briefing was an MDT approach, with midwives from various clinical areas, anaesthetic staff, and night and morning obstetric staff. There was evidence of good multidisciplinary team collaboration, with safety information on issues arising being discussed, e.g. a fridge where blood was stored was not working but had been reported. Ina addition, forms to be completed after patients had given giving blood was not being filled in adequately and stickers not being returned to the laboratory and staff were reminded that they should be doing this. The labour ward manager also reminded midwives to check resuscitaires at the beginning of shifts. The handover was attended by midwifery staff who had worked the evening shift, an obstetric specialist registrar (SpR) and senior house officer (SHO) who had also worked the evening shift, an obstetric SHO, a SpR working the day shift, and an anaesthetic SpR. We observed that a consultant obstetrician arrived late to the handover at 8.25am. However, we were told that lateness of this kind was not a normal occurrence. The handover was led by the outgoing night-time SpR. Plans were made for all women and there was good multidisciplinary team working.


We were told that community midwives did not participate with others to jointly facilitate classes with health visitors or practice nurses on health promotion initiatives, such as smoking cessation or lifestyle programmes. We were provided with information of a monthly ‘Joint Multi-Agency Psychosocial Maternity’ meeting that took place. Members included: a lead midwife and named safeguarding midwife, a safeguarding midwife, a named nurse for children’s safeguarding, a perinatal mental health specialist midwife, a teenage specialist midwife, consultant obstetrician with a specialist interest, and a liaison health visitor. The terms of reference for this meeting stated that its objectives were to: promote the safety of vulnerable adults and children; prevent potential problems being missed; discuss, triage and signpost referrals while maintain confidentiality; formulate care plans; and share information between professionals on a need to know basis. The terms of reference specified that this meeting would be minuted, however we were not provided with any. There was also a ‘Fortnightly Localities (Brent, Harrow & Ealing) Psychosocial Maternity’ meeting that took place.

Seven-day services

Key services were available seven days a week to support timely care. The service confirmed that maternity in-patients had scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy and pathology. We were told by the clinical director that there was a consultant obstetrician on the delivery suite (labour ward) seven days a week from 08:00 to 20:00 and resident consultant cover 2 nights per week. We were also told that maternity inpatients had timely consultant reviews and access to diagnostics, interventions, key services and ongoing review across the week. The maternity day assessment unit (DAU) had extended its opening hours in response to service demand just over a year ago. It functioned for 12 hours a day between the hours of 8am to 8pm seven days a week. Previously it had been open between the hours of 9am to 5pm Monday to Friday. The antenatal department was open from 8am to 5pm. The maternity triage provided an assessment service for women 24 hours a day, seven days week, where a pathway was decided as to whether a woman would be: discharged, admitted to the delivery suite for further assessment, admitted to the midwifery led unit, or the DAU.

Health promotion

Staff gave women practical support and advice to lead healthier lives. Good evidence was seen of women receiving information with regards to the flu and pertussis vaccination. We saw several posters around the maternity unit encouraging women to breastfeed. One poster that we saw encouraged breastfeeding to twin babies.


Staff supported women to make informed decisions about their care and treatment. They

followed national guidance to gain patients’ consent. They knew how to support women


who lacked capacity to make their own decisions or were experiencing mental ill health.

They used agreed personalised measures that limit women’s liberty.


A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for qualified nursing staff in maternity is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




39 47 83.0% 85.0% No

In maternity the target was met for both of the MCA training modules for which qualified nursing staff were eligible. The DoLS training module did not meet the trust target, however the completion rate was close at 83.0%. A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for medical staff in maternity is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



49 61 80.3% 85.0% No

In maternity the target was met for the MCA training module and was below the target for the DoLS training module for which medical staff were eligible. A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for qualified nursing staff in maternity at Northwick Park Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




39 47 83.0% 85.0% No

In maternity the target was met for both of the MCA training modules for which qualified nursing staff at Northwick Park Hospital were eligible. The DoLS training module did not meet the trust target, however the completion rate was close at 83.0%.

A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for medical staff in maternity at Northwick Park Hospital is shown below:


Staff Eligible Completion Trust Met


trained staff rate target (Yes/No)



41 51 80.4% 85.0% No

In maternity the target was met for the MCA training module and was below the target for the DoLS training module for which medical staff at Northwick Park Hospital were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)

We saw staff verbally gaining consent before commencing any treatment. We saw staff fully explained procedures and associated risks of accepting treatment or not consenting to treatment. The four midwives whom we spoke with over the duration of the inspection had a variable understanding of the mental capacity act (MCA) and deprivation of liberty safeguards DoLS. Two of the four showed a good understanding. One of the other two midwives showed a reasonable understanding and the fourth midwife, with a little prompting, was able to give some evidence of understanding. Two maternity support workers (MSWs) that we spoke with, showed no real

understanding of MCA or DoLS. the service caring?


Compassionate care

Staff treated women with compassion and kindness, respected their privacy and dignity,


We spoke with a total of twelve women during the inspection, who were all at various stages of their pregnancy. We spoke with five women on the postnatal ward who had all delivered their babies, and one woman on the ward who had attended the service to be induced and monitored. We spoke to two additional women in the antenatal department and four women on the labour ward. Women and their partners were positive about the care they received. All the women and partners we spoke with told us that they had been treated with kindness, dignity, and respect. We saw good interactions between staff, women and their relatives. For example, staff explaining how personal medication was managed in the hospital to a partner. Women commented that staff were responsive and that call bells were always answered in a timely way. We observed a midwife rush to answer a call bell on the antenatal ward. We observed an interaction between a midwife and mum, with a focussed discussion around breast feeding. We observed very good informative communication from the midwife, demonstrating an approach, which was kind and supportive. Staff maintained patients’ privacy and dignity by pulling curtains around patients before undertaking examinations or providing care. The women that we spoke with also confirmed that staff treated them with and respect and provided care and support that was dignified. When asked, patients were able to tell us the name of the midwife that was in charge of their care on that day. Only one woman had reported that she had had two midwives during her antenatal care, but this was because her first midwife had gone on annual leave, however we were told that there had been a good handover between the two midwives. Some women made an observation that they didn’t have the same midwife during their labour that they had for their antenatal care. It hadn’t been explained to them that they would have a named


midwife through their antenatal and postnatal care but not their intrapartum care (during the act of birth), as community midwives did not deliver babies in the hospital. The view of women who used the service generally reflected positive experiences they encountered whilst using the service. We saw photographs of all staff displayed within the department. This helped patients to identify staff members during their stay. Friends and family test performance (antenatal), London North West University Healthcare NHS Trust:

From April 2018 to March 2019 the trust’s maternity Friends and Family Test (antenatal) performance (% recommended) was generally similar to the England average for most of the period. Friends and family test performance (birth), London North West University Healthcare NHS Trust:

From April 2018 to March 2019 the trust’s maternity Friends and Family Test (birth) performance (% recommended) was generally similar to the England average, although performance was worse than the England average in September, October and December 2018 as well as January 2019. Friends and family test performance (postnatal ward), London North West University Healthcare NHS Trust:

From April 2018 to June 2018 the trust’s maternity Friends and Family Test (postnatal ward) performance (% recommended) was generally similar to the England average, the trust provided no data for May 2018.


Over the 12 month period from April 2018 to March 2019 the trust provided data for June 2018 only. In that month the trust scored 89% for friends and family test for post natal in the community compared to an England average of 98%. (Source: NHS England Friends and Family Test) The trust performed worse than other trusts for two out of 19 questions in the CQC maternity survey 2018.

Area Question Score RAG

Labour and birth

At the very start of your labour, did you feel that you were given appropriate advice and support when you contacted a midwife or the hospital?

8.1 About the

same

During your labour, were you able to move around and choose the position that made you most comfortable?

7.6 About the

same

Did you have skin to skin contact (baby naked, directly on your chest or tummy) with your baby shortly after the birth?

9.4 About the

same

If your partner or someone else close to you was involved in your care during labour and birth, were they able to be involved as much as they wanted?

9.5 About the

same

Staff during labour

and birth

Did the staff treating and examining you introduce themselves? 8.9

About the same

Were you and/or your partner or a companion left alone by midwives or doctors at a time when it worried you?

6.8 About the

same

If you raised a concern during labour and birth, did you feel that it was taken seriously?

7.7 About the

same

If attention was needed during labour and birth, did a staff member help you within a reasonable amount of time

7.9 Worse

Thinking about your care during labour and birth, were you spoken to in a way you could understand?

8.8 Worse

Thinking about your care during labour and birth, were you involved enough in decisions about your care?

8.2 About the

same

Thinking about your care during labour and birth, were you treated with respect and dignity?

8.6 About the

same

Did you have confidence and trust in the staff caring for you during your labour and birth?

8.7 About the

same

Care in hospital after the

birth

Looking back, do you feel that the length of your stay in hospital after the birth was appropriate?

7.6 About the

same

Looking back, was there a delay in being discharged from hospital?

4.8 About the

same

Thinking about response time, if attention was needed after the birth, did a member of staff help within a reasonable amount of time?

7.1 About the

same

Thinking about the care you received in hospital after the birth of your baby, were you given the information or explanations you needed?

7.7 About the

same

Thinking about the care you received in hospital after the birth of your baby, were you treated with kindness and understanding?

8.1 About the

same

Thinking about your stay in hospital, was your partner who was involved in your care able to stay with you as much as you wanted?

5.1 About the

same


Thinking about your stay in hospital, how clean was the hospital room or ward you were in?

8.1 About the

same

(Source: CQC Survey of Women’s Experiences of Maternity Services 2018)

Emotional support

Staff provided emotional support to women, families and carers to minimise their distress. They understood women's personal, cultural and religious needs. Bereavement midwives provided 1:1 care in the separate bereavement room. A local charity provided families with memory boxes to enable parents in keeping mementoes of their baby. The community bereavement midwives provided on-going support to families following discharge. Midwives told us they could signpost women or their partners to ‘talking therapies’ with a mental health charity and local counselling services. Women were assessed for any extra care needs they may require at booking with the community midwives. This included an assessment for post-natal anxiety and depression. We observed that women were supported with breastfeeding after giving birth and we were told that a woman’s discharge would be delayed if it was found that she was finding it difficult to initiate breastfeeding.


Staff supported and involved women, families and carers to understand their condition and make decisions about their care and treatment. We heard staff support women to make informed choices and be involved with their care. The women we spoke with shared their birth experiences with us and told us that they were always listened to and supported by the midwife caring for them. Partners we spoke to were very happy with the care and their involvement. Women discharged home were provided with information about the signs and symptoms they should look for and told if they experienced any of them to seek advice.





to plan care.

The service’s ‘Reduced Fetal Movement’ (RFM) guideline stated that to improve maternal education regarding the importance of fetal movements, all women should receive an advice leaflet by 24 weeks to educate regarding the importance of self-monitoring movements as a marker of fetal wellbeing. The guideline also stated that each encounter with a health care professional should include a discussion regarding fetal movements. We saw a ‘saving babies lives’ leaflet that was handed to women, which gave useful information about why babies


movements are important, and what to do if a woman was to detect a reduction or complete stop in fetal movements throughout their pregnancy. We also saw a Royal College of Obstetricians and Gynaecologists flowchart for optimum management of reduced fetal movements that clinicians would use to assess a woman with reduced fetal movement. The service’s ‘Born Before Arrival (BBA) or Unplanned Home Birth’ guideline stated that if a woman experienced an abnormal delivery, ambulance crews had been advised that the best clinical management for a woman is for them to transfer the woman to an obstetric unit without delay. In this case they should not request midwifery assistance. If, however, the ambulance crew had assessed the situation and requested assistance, then a midwife should attend the scene. The definition of a BBA is one where a birth happens outside of a hospital, which has not been planned, and happens without the presence of a midwife. In the event of a BBA, the role of the labour ward coordinator/maternity bleep holder is to contact the available community midwife and disseminate the necessary information and request that the community midwife attends the scene. Should the woman or baby require transfer in to the maternity unit, the labour ward coordinator must inform the labour ward obstetric registrar and neonatal registrar of the pending admission, as senior obstetric support may be required. The guideline stated that the responsibility of the attending midwife is to receive a proper handover from the attending London Ambulance Service (LAS) crew and monitor maternal and fetal wellbeing, to assess if the birth is imminent. In addition, the labour ward coordinator/maternity bleep holder must be regularly updated on events and should the woman or baby require transfer to the maternity unit, the midwife must be present in the ambulance. A datix should also be completed. We were told by the consultant midwife that the MSLC had been replaced by the Maternity Voices Partnership (MVP) and that the LNWH MVP had been initiated in May 2018, with the MVP working alongside the maternity unit to provide a service that met the needs of the women and families the unit serves. The MVP is an NHS working group: a team of women and their families, commissioners and providers (midwives and doctors) working together to review and contribute to the development of local maternity care. The work plan for 2019/2020 was to: support the hospital/trust maternity initiatives, expand the MVP network, raise the community awareness of MVP and build on the ‘15 Steps for Maternity’. The ’15 Steps for Maternity’ is a toolkit for women and their families to improve the quality of care in maternity services and include themes such as: ‘welcoming and informative’, ‘friendly and personal’, ‘safe and clean’, ‘organised and calm’, which are then broken down into several questions to be explored further for observation. The consultant midwife told us that the maternity unit had undertaken the 15 Steps and been involved with the community review. We asked the question, “How does the service ensure women are not in labour and giving birth in areas not designated as a labour ward?”. The senior midwifery manager told us that women are educated in the antenatal period about the signs of labour. Women who presented to triage with a query regarding their labour were triaged promptly and signposted to the delivery room on the delivery suite (labour ward) or to the birth centre if they were deemed as low risk. However, if a woman presented as very distressed, with delivery being imminent, then she would be transferred straight to one of the delivery rooms on the labour ward to be assessed. There had been two incidents in the last six months relating to women giving birth in a non-designated labour ward area. From June 2017 to December 2018 the bed occupancy levels for maternity were generally higher than the England average, fluctuating over the six quarter period.


(Source: NHS England)


The service was inclusive and took account of women’s individual needs and preferences.

Staff made reasonable adjustments to help women access services. They coordinated care

with other services and providers.

There were facilities for partners to stay. An identified named partner or family member could stay overnight with all women on the midwifery led unit (MLU) and on Florence ward. This process was managed by operating a sign in register for that named person to sign. The named person was also given a wristband that they would show to the ward clerks on entry to the units, which allowed them to come and go as they pleased. The ward clerks were responsible for issuing the wristbands. Normal visiting hours for visitors not identified as the named partner or family member, were between 12pm to 2pm and 5pm to 7pm. Relatives had access to toilet facilities and drinks in the patients’ kitchen in the ward areas. There was a trust canteen, coffee shop, retailer, fruit store and paid laundry service that women and their relatives had access to. The service had accessing to interpreting services, which included face-to-face interpretation and telephone interpretation. We were told that the service used interpretation a lot of the time because there was a significant number of women using the service who did not speak English. Interpretation was used booking at antenatal stage, sometimes when women were in labour, when women were being discharged, especially if there had been complications that arose at birth. The most widely used languages were: Romanian, Polish, Gujarati, Arabic, and to a lesser degree Urdu and Somalian. There was a newly built bereavement room called the ‘Myrtle Suite’ that was situated on the delivery suite but away from all the delivery rooms. The room was furnished with a double bed, microwave, kettle, fridge and tea and coffee provisions. The room was spacious and airy and


looked out onto the hospital grounds, with frosted glass windows with snowflake designs on them. There was a ‘Myrtle Suite’ folder that was kept in the room for the benefit of the patients. Within this folder contained leaflets about a stillbirth and neonatal death charity and information about how patients could go about getting keepsakes for their babies such as classic framed casts and impressions, bespoke family commissions and freestanding statues. We observed hospitality staff going around with drinks and sandwiches at 12:30 for triage patients. We saw an inpatient steamed lunch and dinner menu which catered for different nutritional needs such as, vegetarian, gluten free, and easy to chew.

Access and flow

People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge women were in line with national standards. There were 5845 births in the maternity service for the period June 2018 to May 2019. The number of women who were booked by 12 weeks in the year to date from June 2018 to May 2019, was 93% of women. The service set a target of 95% of all women to be booked by 12 weeks, however in March 2019, only 88.7% as a percentage of the 526 bookings that were undertaken in that month was achieved. The trust set a target for a percentage of homebirths that it wanted to achieve. The target was 1.5% of overall homebirths for the year. However, between June 2018 and May 2019, the service only achieved 0.2% of homebirths in that period. We spoke with a community midwife who told us that there were various reasons why the uptake of homebirths had been below the target. We were told that women were not opting for a homebirth because it was not their method of choice. In addition, we were told that there could be circumstances where women who were booked in for a homebirth may have been transferred into a hospital because of fetal distress or maternal compromise, such a bleeding or preeclampsia. Women were told of any staffing issues that would impact on them being able to have a homebirth. The ‘Maternity Triage’ guidelines stated that “Triage is to provide immediate assessment to pregnant women who attend the Maternity Unit in order of priority, then triage them to the correct area for care, or send them home, as appropriate. This will ensure that women will be directed to the area most suitable for their care.” Assessment was to take place within 15 minutes and should not take more than 30 minutes. All women who went through triage were seen by the triage midwife. The triage midwife was an experienced midwife who referred women on to an obstetrician as necessary when women required medical review. Some of the inclusion criteria for admission to triage included women who were 20 weeks pregnant and above: high risk women with suspected spontaneous ruptured membranes (or if low risk, then assessment should be performed on midwifery led unit); women reporting altered/reduced fetal movements following auscultation (the action of listening to sounds from the heart, typically with a stethoscope) of the fetal heart by the triage midwife; abdominal pain, women requiring routine review who present outside of the day assessment unit operating hours; and women presenting with antepartum haemorrhage. Community midwives provided care in children’s centres, GP practices and the home. They provided antenatal and postnatal care from the first pregnancy appointment until discharge, usually around 10 days after birth, when they hand over care to the health visiting team. Women had 24-hour access to the triage phone line for advice or if they were in labour or experienced any immediate problems, such as bleeding. The triage system for all women went


through a dedicated triage midwife and depending on the women’s needs they were bought into the day assessment unit (DAU), triage, or directly to labour ward. Clinics that ran in the antenatal department included: fetal medicine, maternal medicine, a clinic run by the perinatal mental health team, diabetes, a clinic by the endocrine team, a clinic for teenage pregnancy, a multiple pregnancy clinic, an infectious diseases clinic, a dietetic clinic ran jointly with diabetes. There were sign on the wall in the antenatal department that showed which staff were on duty and the current waiting time for antenatal clinics. On the first day of our inspection, waiting times were up to one hour. We were told by members of staff working in the antenatal department that clinics were often delayed due to the doctor being late, or if there were too many patients and not enough rooms. Staff in the antenatal department told us that sometimes when there was a shortage of rooms for clinics, then they would sometimes have to use rooms in the gynaecology department or use a small office room that was normally reserved for the lead midwife. Staff felt that this office room was not conducive for holding scan checks or bookings because it was small and there was no window. Staff told us that they had highlighted this to management, but they hadn’t taken steps to address it. We were informed by midwives that there was not always enough clinic space to give results and we were informed that women were given the choice of waiting for a clinic room to become available or being given their results in quiet corner but not inside the clinic. We were shown emails that dated back to November 2017, where consultants and midwives had escalated the issue of room availability. When we raised clinic capacity with the senior management team in our interview with them, the head of midwifery told us staff were encouraged to utilise all spaces and needed to be flexible. A midwife described a situation where patients who were attending the antenatal department for a scan, and who exhibited an abnormality in their scan results, should be seen by the doctors in the antenatal clinic to review the scan and patient and then make a plan. We were told that this was not always happening because doctors were already overbooked to see a patient on a given day, and as such they would decline to see these patients. The midwife would describe having to impress upon the doctors in the antenatal department to see those patients with abnormal scan results. She reported that her colleague had emailed the doctors about these occurrences and they responded with the matter being discussed in clinical governance. There were 11 rooms on the delivery suite. The rooms were spacious and medical folders were kept in the room for the ease of the nurse. We were told by the ward manager for Edith and Florence ward that discharges were quite smooth, but there could sometimes be delays in discharges because of the availability of doctors to review women and babies. Delays in discharge on Florence ward, we were told could have been because a woman had sepsis and consequently would have been given intravenous (IV) medicine. Before these women could be discharged, they would have to be reviewed by a doctor and then change their antibiotics over to oral antibiotics. We were told that Edith Ward was no longer being referred to by that name but by the midwifery led unit (MLU). This unit was for women who were deemed as low risk and Florence ward, an obstetric led unit, was for women who were high risk. We were told that the MLU did not have any caesarean women on this unit but did have some women who had uncomplicated instrumental deliveries, using forceps or vacuums. The MLU had 16 beds and we were told that previously it had 18, but two of the rooms had been converted for a low risk and a high-risk clinic. There was a team of caseloading midwives that would see women from during their antenatal care right


through to their postnatal care. Case loading is a model of care where midwives carry their own caseload of women to form trusting relationships and provide care throughout the woman’s experience of pregnancy. There was one clinic a week and these would see one of six midwives in the team. Women with medical issues would be seen in the high-risk clinic and babies of these women would be delivered on the delivery suite. We were told by the ward manager on the MLU that there was a plan to have a caesarean section case loading team. The ward manager for the MLU told us that the unit had introduced an outpatient balloon induction of labour; a balloon induction is a method for inducing labour. This meant that women would still have their inductions but would still be under the low risk team, because whilst they were being induced, the method did not require medicines to induce them. We were told that before women were discharged, midwives would undertake a group discussion with them about what to expect following their delivery, and this included baby checks from a neonatologist, midwife checks on mother and baby, as well as checks to ensure that women were coping well and were breastfeeding without difficulty. If women were first time mothers and breastfeeding hadn’t been properly established, then at times they were kept in for an additional day if it was deemed necessary. On this unit, some women went home within six to twelve hours. Hearing tests were completed for the baby and if there were any issues, then they would refer the baby to an audiologist as an outpatient. The community midwifery team was overseen by a matron, a deputy matron and then midwives within those teams. There were three teams that served the borough of Brent and two teams that served the borough of Harrow. The three teams covering Brent, were called ‘Harmony’, ‘Lotus’ and ‘Sapphire’ and covered locations such as Harlesden, Stonebridge, Wembley, Cricklewood, Ealing, Perivale, Kingsbury and Greenford. The two teams covering Harrow - Hope and Grace team, covered parts of Pinner, North and South Harrow, Kenton, Wealdstone and Stanmore. We were told that if women did not attend their antenatal clinics on two consecutive occasions, then midwives would carry out a visit to that woman’s home. On the first failed attempt to attend an appointment, then the women would be sent a second appointment letter. We saw a ‘Failure to Access’ policy, which outlined procedures for following-up with women who did not attend (DNA), or for women who moved out of the borough antenatally. appointments. Women were given a schedule for antenatal clinics, which occurred at their initial booking appointment, then at regular intervals of two and several weeks right up to 41 weeks. We were told that this schedule was rigid for first time mums, but appointments would be less if the woman had had a baby before. Postnatal visits started the day after a woman was discharged from the hospital. A midwife would then see the woman again on day 5, which we were told was mandatory because this is when the heel-prick test of the baby occurred. If a woman had had a caesarean, then on this day she would also have her sutures removed too. Providing mother and baby were considered well at this appointment, then a plan for her to be discharged from postnatal care would happen at day 10 but not before. We were told that at the first postnatal visit, midwives would assess any deviation from the norm i.e. the baby not feeding, or the mother having high blood pressure. In these circumstances, additional visits would be planned for and liaison between midwives, GPs and health visitors would occur. The senior midwifery manager told us that women deemed as low risk, were triaged to the midwifery led unit to prevent unnecessary admission to the delivery suite (labour ward) and identified low risk women on the delivery suite were transferred to the midwifery led unit.


We were told by a deputy matron for antenatal care, that to ensure that patients were regularly seen through their pregnancy, the antenatal care was scheduled at the first booking consultation and discussed. The schedule could also be found in the patient’s handheld notes. Patients were referred to the community midwife for antenatal care, including shared care with the obstetricians. Patients referred for community midwifery services were sent appointments for their antenatal care for the whole of their pregnancy and women who did not attend their appointments were followed up in line with ‘Failure to Access Antenatal and Postnatal Care’ guidelines. The attendance for high risk patients was monitored by a new case-loading team, who had recently commenced booking and performing antenatal care for high risk patients, which at times could be shared with the obstetric consultant and the community midwifery team.


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 women in the investigation of their complaint. From April 2018 to March 2019 the trust received 42 complaints in relation to maternity at Northwick Park Hospital. The trust took an average of 39.1 working days to investigate and close complaints, this was in line with their complaints policy, which states complaints should be should be answered within 40 days. At the time of reporting eight complaints were still open. These had been open for an average of 35.0 working days. A breakdown of complaints by type is shown below:


Percentage of total



Others 4 9.5%



2 4.8%



Total 42 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab) We were told that one complaint had been referred to the Parliamentary and Health Service Ombudsman (PHSO). We saw 21 framed compliments cards on the labour ward. Comments ranged from, “thank you so

much for all of your help during our first pregnancy and for being so lovely”, thank you for the

compassion you show mums every day”, and “thank you for the amazing support and care given

to me and my family in delivering baby on 27/3/19”.

From April 2018 to March 2019 there were four compliments received for maternity at the trust


(2.1% of all received trust wide). All four compliments were made about Northwick Park Hospital. The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab)


Leadership

Leaders did not always have the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. However they were not visible and approachable in the service for patients and staff. The maternity service was part of the women’s and children’s division. It was led by a clinical director, head of midwifery, and divisional general manager. The clinical director and general manager reported operationally to the chief operating officer. The head of midwifery reported operationally to the general manager. Line duty responsibilities for the clinical director, head of midwifery and general manager were with the trust medical director, chief nurse and chief operating officer respectively. There were three matrons (one for inpatients, one for community and antenatal, and the other for the delivery suite). These matrons had reporting channels up to a senior midwifery manager, who reported up to a consultant midwife, then up to a deputy head of midwifery, who sat just under the top tier of leadership. The ward manager for the midwifery led unit told us that she felt supported by the senior leadership team. There were concerns about the lack of visibility and lack of regular daily contact with the senior leadership team of the maternity department. Staff told us that the head of midwifery and senior midwifery team did not acknowledge them when visiting the department. Staff in the antenatal department told us that they would only see the senior midwifery team when they were considering adding additional clinics to the department or if they knew CQC were coming. We were told that it was the matron for this department who would often check in on staff and ask them how they were.

Vision and strategy

The service did not have a formal vision and strategy in place for what it wanted to achieve. We spoke with the senior leadership team of the maternity service who told us that the strategy for the forthcoming three years was to focus on the culture within the service and look at building better relationships with staffing groups. The general manager for the service informed us that the leadership of the service wanted to allow for the outcome of a recent staff consultation to pass before starting a piece of work that involved collaborating with staff in writing a vision and strategy for the service. The clinical director spoke of creating a clinical strategy, which was to provide a gold standard service. He spoke of human factors and practical obstetric multi-professional training (PROMPT) as being areas that could underpin the strategy.

After the inspection the trust told us that the maternity unit was an active partner in the north west London local maternity system and worked alongside partner trusts and stakeholders to deliver the national strategy: Better Births maternity transformation programme. The unit also had a vision to


provide a more personalised service to women and their families and to ensure women received continuity of care.

We saw posters on the wards which described the quality aims, which reflected the service’s priorities over the next five years. These included: caring with humanity, dignity, compassion and kindness; providing safe effective harm-free care; working with patients, their families and their carers; to recognise, and maximise their reputation for midwifery, nursing and AHP excellence; and developing a talented and skilled workforce.

Culture

Staff did not feel respected, supported and valued. The service did not have an open culture where staff could raise concerns without fear. Staff were not able to raise concerns without fear of reprisal. There was one incident which our inspectors witnessed during our inspection, where several members of staff within the antenatal department had raised concerns about the availability of consultation rooms to hold clinics for women, often having to hold them in gynaecological department consultation room (if available). During an interview with the senior leadership team, we raised this was a concern and we were told by the head of midwifery that staff needed to flexible and they were encouraged to utilise all spaces within the hospital where possible. Following on from this interview, we later found out that staff working in the antenatal department had been approached by senior staff and who described feeling threatened and bullied into disclosing which members of staff had divulged information to the CQC inspection team about the lack of capacity in the clinic rooms. We observed that these staff were visibly upset and distressed and were anxious and fearful for the future of their jobs in the department but also about a further line of questioning from senior leaders of the service later on that day. We raised this with the chief nurse who commenced an independent investigation into this. There were systemic issues around culture within the maternity service. When we spoke with the senior leadership team about some of the concerns we had around staff feeling that there were never enough staff on shift, the general manager responded to us by telling us that, “It’s our job to help staff get through their perception of what staffing should be. Staffing perception has been a historical issue”. We found that this admission spoke to a culture of decisions being made without informing or in consultation with staff. One CQC inspector also witnessed a senior member of staff using language that demonstrated a lack of patient empathy We had been approached by midwives who told us that the handling of the recent band 7 staff consultation process had been poorly managed. We were told that staff morale was deteriorating because of staffing pressures, with many staff going off sick, and stress triggering conditions in staff such as collapsing. We were made aware of several members of staff going off work sick because of the culture of the organisation. However, midwives did report that they would try to support one another. We received up to date data for vacancies and sickness rates for midwives from March 2019 to August 2019. Data showed that there was a 13.5% average vacancy rate and 6.6% average sickness rate which were both higher than the trust target of 11% and 4% respectively. We were told that there was a culture and values working group which started in May 2017 and was held every month. It was attended by: the executive directors for HR, the director for organisational development and learning, the chief nurse, and the HEART ambassadors. The working group had primarily started out with the aim of implementing and embedding the HEART values in staff appraisals, inductions, mandatory training and within meetings. There were different


workstreams within this working group and we were told by the administrator that she was part of the ‘reward and recognition’ workstream. We were approached by two consultants who told us that culture in the maternity department was not open but that of a “cover up”. We were told of a lack of inter-personal warmth and allegations of bullying from within the department’s senior leaders. This sentiment was also shared with several midwives that we spoke to throughout the inspection. One of the consultants told us that he did not involve the midwives in decisions and appeared unbothered by the skill mix. The other consultant told us that there had been no recent meetings between senior managers in the department and consultants, and that this had been escalated to the medical director. However, nothing had been done to address this. Both consultants did not want to give their name for fear of reprisal. We raised our concerns in relation to culture and poor relationships to trust senior managers as part of our initial feedback at the end of the inspection. There had been no recent examples of mediation sessions which had previously occurred with independent mediators. Examples that we were given, dated back to 2016 and 2017. The first took place in November 2016 in Foetal Medicine and was between four consultants, the general manager (GM) and the clinical director (CD). The mediation agreement was signed on 16 November 2016. The second mediation took place in July 2017 between 23 members of staff, which included the medical director, the DGM, the CD, consultants, the divisional lead for women and senior midwives and this mediation agreement was signed on 13 July 2017. We were shown a multi-functional room in the maternity reception, which was also used as a health and wellbeing room, that staff could use if they felt stressed and tired. There were mindfulness and deep breathing sessions that ran within this room on Thursday and Fridays between 9am to 3:30pm. During its use, the room was equipped with partition screens that displayed sceneries such as the sun, sea and sky. These screens were squared off to create a box like environment, with a backdrop of dimmed lights and calming music and that was played in the background. We looked at 19 evaluation forms, which rated the room and experience as “excellent”, with comments ranging from: “would absolutely recommend the health and wellbeing room to my colleagues” and “overall the smell and ambience is nice”. We were told that there were discussions around how the room could be used for staff who worked nights.

Governance

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. There were daily datix meetings led by the risk manager, attended by a multidisciplinary team of midwives, and was also sometimes attended by the intrapartum lead consultant. The outcome of these meetings fed into weekly governance meetings that were held on a Wednesday. We spoke with the risk manager, who told us that the datix meetings promoted an open culture and gave them an opportunity to close some of the datix’s there and then. In addition, we were told that this was also a good opportunity for them to pick up on safety issues, and to send out timely messages of the week. This meeting had picked up the term ‘neonatal admissions’, which went to a weekly avoiding term admissions into neonatal units (ATAIN) meeting. The weekly risk meeting was attended by the risk manager, the matron for the labour ward, a consultant obstetrician, the senior midwife manager and a neonatal consultant. In this meeting, potential serious incidents (SIs) were discussed, round table discussions were had, and the risk manager wrote a report which went to the senior management team to sign off. In addition, there was a Clinical Incident Review group which met on an ad-hoc basis if an SI had occurred.


There were weekly multidisciplinary ATAIN meetings attended by consultant neonatologists, consultant obstetricians, senior midwives, the neonatology matron, and middle grade neonatal staff. All cases of term admissions from the labour ward were reviewed and lessons learnt. The team looked at antenatal, intrapartum factors which could or could not have prevented the admission of a baby to the neonatal unit (NNU). The intrapartum lead said they had seen a reduction in term baby admissions to the NNU. We asked the ward manager on the maternity led unit (MLU), which meetings she attended in her role. She told us that she attended the datix meeting every morning; every fortnight would attend an infant feeding meeting; a senior midwives meeting (when the matron was not around); a ward meeting for both the MLU and Florence ward, which she chaired; clinical governance meeting which she would sometimes attend but would normally be attended by the matron; and the ATAIN meeting. We were told that the matron would attend IPC meetings and the senior midwives meeting but would be attended by the ward manager if the matron was not around. At this meeting, issues such as sickness, training, appraisals, staffing and equipment were discussed. A specialist trainee doctor told us that she received the risk newsletter and sometimes would read it. During the daily huddle meetings, we saw effective discussion around patients’ needs and clear indication of women who needed extra vigilance.


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 service had completed a staffing skills review however the trust indicated to us that this had resulted in some staff unhappiness. When we spoke with the senior leadership team for maternity, we were told that the top risks for the service were the following: the consultation over recruitment and that this was on the risk register; consultant cover on the day assessment unit (DAU), which had been mitigated by getting cover until 5pm. It was identified that there had been a universal issue with not being able to find information easily within perinatal notes. The current vacancy rate of 23% was also highlighted as a risk, however we were told that the service did not have an issue with recruiting to their vacancies. The vacancy rate was encompassed in the overall maternity recruitment risk. There were six active risks on the risk register. These risks were: maintenance of maternity records, maternity recruitment, medical cover in the day (DAU), post natal records in maternity, resuscitaires in maternity, and security in maternity. Risks relating to staffing were given a rating of “6”, with assurances given that there was now ongoing recruitment. A progress review as of 13 June 2019, was that the recent staff consultation had meant that posts had been frozen. These posts had now been reopened and there was a proactive recruitment campaign underway, and staff were being redeployed where necessary. The security in maternity risk had been given a risk rating of “8”. Causes of this risk were that a private company were working on Level 7 of the building and main doors in the main reception area of maternity block, could be prised open. The issue with the main doors being prised open had been resolved by having them repaired and seating in the main reception area had been relocated so that people did not sit near the entrance. During out inspection we were told of concerns around the time it took for staff to access emergency drugs from the automated medicines cabinet in the event of an emergency however this was not on the risk register.


We also found that the issues relating to the systemic issues around culture within the service was not included on the risk register. We were told by the labour ward lead that there had been fluctuation in emergency caesarean section (CS) rates within the unit over the past few months. There were ongoing reductions in CS rate for the months April 2018- March 2019. The emergency CS rate for the unit for this period was between 17.1-19.7%. This was comparable to rates in similar units in the region. The service did however register an increase in emergency CS rates in May and more recently in July 2019. To mitigate this, the unit was currently involved in streamlining the induction of labour pathway to ensure shorter Induction to delivery interval. It was felt that a high percentage of emergency caesareans were being done for failed induction of labour, and a more effective pathway with use of intracervical balloon to prime the cervix would help bring down rates of category two caesareans. In addition, it had been recognised that there needed to be improvement in instrumental delivery training. Trainees had been sent to hands on instrumental delivery course in a tertiary level London unit and RCOG accredited Basic Surgical Skills course was run in the Trust in July 2018, to improve trainee confidence levels.


The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required. We saw an example of a staff member locking their computer when she left her work area to deal with a query that required her to be away from her desk. We also saw the same member of staff who had superuser privileges, assist a colleague who had locked herself out of the patient record computer system. We observed locked confidential waste bins on the wards.

The storage of records on both Edith ward (the Birth Centre) and Florence ward (antenatal and postnatal ward) were in trolleys kept within the area designated as a work station for staff. These trolleys were unlocked; however, during our period of observation on both areas, we did not see these areas left unattended. Staff told us they could access policies and guidelines on the trust intranet and that had access to enough computers to do so.

Engagement

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. The consultant midwife told us that the LNWH Maternity Voices Partnership, which sought the views of women to help shape their experience in the services, were the ways in which that information was gathered and acted upon to shape and improve the maternity service and culture. The ’15 Steps’ programme had informed the service that their noticeboards were not user friendly and hence the design was changed to a simpler format. The head of midwifery told us that the maternity service had close working partnerships with the local maternity system (LMS), local authorities and CCGs, bringing together maternity commissioners, providers and stakeholders to deliver maternity transformation as part of the Sustainability and Transformation Plan (STP). The two key elements of this plan were to: deliver the LMS STP plan and implement the full recommendations from Better Births, National Maternity


Strategy by 2020/21; and implement the care bundle to halve still births by 2025. The role of the LMS was to enhance maternity and new-born care across the sector with a view to achieving delivery of high quality, evidence based, clinically effective and cost-efficient maternity and new-born services. The LMS aimed to achieve this purpose by focusing on the needs of women, the new-born and their families, promoting system integration across structural boundaries and encouraging collaborative approaches to shared learning and service development. The service had gone through a consultation, following a table-top exercise that had looked at staffing and skill-mix. We were told that the outcome of this exercise had revealed that the service had too many band 7 midwives and the recommendation from that was for the management to look at all of the staff’s contracts and align them with the better births programme. There had been a three-month pre-consultation period starting in January 2019, which led into the formal consultation. We were told by the head of midwifery that engaging staff through the consultation process had been a slow, methodical process. In addition, we were told that there had been twice weekly engagement sessions during the consultation, which ran between January and May, and there was always a representative from HR in the meeting, as well as the Freedom to Speak up Guardian.


All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research. The anaesthetic lead for the labour ward provided us with information about quality improvement projects happening in 2019. These included: standardisation of referrals to anaesthetic antenatal clinics and moving to a computer-based referral; a post-dural puncture headache (PDPH) care pathway had been developed, which was to standardise management of women with PDPH and improve communication with GPs; and a multidisciplinary enhanced maternity care teaching for midwives planned for October 2019.


Central Middlesex Hospital Acton Ln

Park Royal

NW10 7NS

Tel: 020 8965 5733

https://lnwh.nhs.uk/central-middlesex-hospital/

Medical care (including older people’s care)


The medical care service at the trust provides care and treatment for a number of specialties across the three hospital sites with a total of 697 medical inpatient beds located across 36 wards and departments. Central Middlesex Hospital:

Ward name Specialty Number of

inpatient beds

Gladstone 1 Specialist rehabilitation service 24

Gladstone 2 Geriatric medicine 24

Gladstone 3 Geriatric medicine 24

Gladstone 4 Orthopaedic rehabilitation 18

(Source: Routine Provider Information Request – Sites tab) Phototherapy for the treatment of dermatological disease is available at all three sites. (Source: Routine Provider Information Request – Context Acute tab) The trust had 79,222 medical admissions from January to December 2018. Emergency admissions accounted for 29,492 (37.2%), 1,094 (1.4%) were elective, and the remaining 48,636 (61.4%) were day case. Admissions for the top three medical specialties were:

• General medicine 31,041 admissions

• Gastroenterology 28,256 admissions

• Clinical haematology 5,944 admissions (Source: Hospital Episode Statistics)



Mandatory training

The service provided mandatory training in key skills to all staff. However, there was

inaccurate evidence regarding the completion of training by medical staff, meaning that the

service could not be assured that they had those key skills.

The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in medicine at Central Middlesex Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)









face) 55 77 71.4% 85.0% No


At Central Middlesex Hospital in medicine the target was met for six of the nine mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for medical staff in medicine at Central Middlesex Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



Health & safety 27 33 81.8% 85.0% No






At Central Middlesex Hospital in medicine the target was met for none of the eight mandatory training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)


The matron for nursing told us additional training sessions had been booked for Fire safety acute clinical; Manual handling - level 2 (face to face) and Resuscitation (BLS) training for nursing staff. Nursing staff told us that the mandatory training was meaningful. They told us that where training was online, they were given time to complete this. The matron for the service had access to staff’s mandatory training records and sent reminders when training was due for renewal.

The medical leadership recognised they had failed to meet the trust’s mandatory training target of 85% in all of the modules. They said, however, that this was due to the way in which mandatory training for the medical team was recorded. A significant number of the medical team completed their mandatory training under a service level agreement with another NHS trust. In addition, they told us there were problems with the online recording of mandatory training which meant that it flagged that training was due for renewal when this was not the case. However, this meant, conversely, that it was possible that some medical staff had not completed the relevant mandatory training as the records were not sufficiently accurate to provide assurance they had.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for qualified nursing staff in medicine at Central Middlesex Hospital is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



PREVENT 73 80 91.3% 85.0% Yes



At Central Middlesex Hospital in medicine the target was met for four of the five safeguarding training modules for which qualified nursing staff were eligible. It should be noted that both the safeguarding level 3 modules had a low number of eligible staff. This, therefore impacted significantly on the percentage performance. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in the medicine at Central Middlesex Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



PREVENT 19 33 57.6% 85.0% No


At Central Middlesex Hospital in medicine the target was met for one of the three safeguarding training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) As with mandatory training, the medical leadership were not able to provide accurate records of medical staff safeguarding training completion rates. All of the staff we spoke with had a clear understanding of their responsibilities to safeguard patients. They knew how and when to raise a safeguarding referral. A significant number of staff were able to describe safeguarding concerns they had raised, and their outcome. Staff had a clear understanding of PREVENT and female genital mutilation (FGM). There was a safeguarding lead within the hospital who provided support, guidance and training to staff in respect of safeguarding. Their details were displayed on posters on each of the wards. However, the majority of nursing staff we spoke with were not aware of the name or contact details of the safeguarding lead.


The service controlled infection risk well. Staff used equipment and control measures to

protect patients, themselves and others from infection. They kept equipment and the

premises visibly clean.

All of the ward areas were clean.

We observed cleaning staff routinely cleaning the wards in line with cleaning schedules, as well as

responding appropriately to spillages.

There were handwashing sinks throughout the wards and in each of the patient bays. In addition,

there was alcohol hand sanitising gel available throughout the wards and at the entrance and

exits. We observed staff, patients and visitors making use of the gel appropriately. Staff sanitised

their hands before and after all patient contact. All staff were bare below the elbow at all times, in

line with best practice.

There was an infection prevention and control (IPC) link nurse within the service.

In addition, the matron undertook a regular walk around review of the service, assessing it against

criteria based on the CQC’s inspection framework. This included assessing the cleanliness and

IPC on each of the wards. At the time of our inspection, all of the wards had scored over 80% for

IPC. Following each of the matron’s audits, action plans were provided to the ward to ensure

continuous improvement.

All patients were screened for MRSA and this was documented in their notes.

The wards made use of isolation rooms for patients with infections or at significant risk of infection

to prevent their spread. These rooms were appropriately signposted for staff and visitors. We

observed staff entering the rooms using advanced personal protective equipment (PPE) including

aprons and gloves when entering these rooms. On exiting the rooms, staff removed and disposed

of their PPE appropriately before returning to the main ward area.

Some patients in isolation had their doors propped open as they required additional observation

from staff passing by, if, for example, they were at increased risk of falls. However, where this was

the case, this had been appropriately risk assessed and there was documentation to support this.


In 2018/19, NHS Improvement set the trust an objective to have no more than 36 healthcare

acquired cases of C.diff. In response to this, the trust reviewed and refreshed all control measures

and benchmarked these against three other acute London trusts. However, at the end of 2018, the

service reported 46 cases of C.diff (one fewer case than the previous year). We were told that

there was ongoing work around compliance with the trust’s antibiotic guidelines to reduce hospital

associated cases.

The Trust reported a total of six Meticillin-Resistant Staphylococcus Aureus (MRSA) bloodstream

infections at the end of 2018. This is significantly higher than the previous year, but there was no

link between any of the cases.


The design, maintenance and use of facilities, premises and equipment generally kept

people safe. Staff were trained to use them. Staff managed clinical waste well. However,

wards were not dementia friendly.

The environment on the wards was not dementia friendly. The signage had not been designed with dementia patients in mind. Further, some areas of Gladstone 4 were cluttered with equipment, which may have made it difficult for patients with dementia to get around. The consumables store in Gladstone 4 was on a shelving unit besides the nursing station. This meant that patients and visitors could potentially access the consumables. Some of the consumables were potentially dangerous, for example sharps. Equipment was maintained and checked regularly to ensure it continued to be safe to use .The equipment was clearly labelled stating the date when the next service was due. All mobile electrical equipment that we looked at had up to date Portable Appliance Testing (PAT) certification. We examined the resuscitation equipment on all of the medical wards and areas. All of the trolleys were appropriately stored and fully equipped. Staff carried out daily checks of the resuscitation equipment and recorded this on a booklet on the trolley. Staff told us that they had access to the equipment they needed to meet the needs of the patients receiving care. Some of the junior doctors told us, however, that the service needed more computers on wheels so they could access patients’ detailed medical histories at the point of care. There were yellow sharps bins available throughout the service. These were appropriately labelled signed and dated and were not over-filled. There were separate clinical and non-clinical waste bins which were clearly labelled.


Staff completed and updated risk assessments for each patient and took action to remove

or minimise risks. Staff identified and quickly acted upon patients at risk of deterioration.

Staff assessed patients in key areas such as falls, skin integrity, venous thromboembolism (VTE), and nutrition on admission using national risk assessment tools. In all of the records we looked at, staff had completed appropriate risk assessments including VTE, nutrition, pressure ulcers and skin integrity. Staff made use of the national early warning score (NEWS) to identify deteriorating patients based on variations in different observations such as heart rate, blood pressure and oxygen levels. NEWS scores were accurately calculated and recorded in patient notes.


Staff escalated deteriorating patients to medical staff in accordance with a hospital-wide escalation policy based on the NEWS system. At night, there was out of hours medical cover within the hospital, with a medical registrar, senior house officer, a resuscitation officer, anaesthetist and a resident surgical officer on site. Medical staff told us that, in the event of a patient deteriorating, they had a lot of support. The service carried out monthly NEWS audits on the completion and calculation of the NEWS score. Performance was above 90% on all wards in the months January to March 2019. The service operated a “ward tagging system” where patients at increased risk of falls would be

kept in the same bay, and a member of staff would be assigned to the bay at all times. If the

member of staff needed to leave the bay, they had to wait for another member of staff to relieve

them.

Patients at risk of deterioration were discussed in daily safety huddles ward rounds and board meetings, where members of the multidisciplinary team (MDT) reviewed individual patient treatment plans and conditions. Whilst the service had exclusion criteria that meant it did not accept patients with pre-existing sepsis, the service followed a protocol for the management of sepsis and patients with suspected sepsis. Staff were able to identify signs of sepsis and were aware of the protocol.

Nurse staffing

Medicine annual staffing metrics



Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Qualified Nurses

88.0 2.5% 12.7% 4.7% 25,738

(14.9%)

13,907

(8.0%)

7,468

(4.3%)

Nursing assistants

99.9 -7.0% 14.1% 6.8% 36,694

(22.2%)

2,884

(1.7%)

1,002

(0.6%)


Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and

midwives in medicine at Central Middlesex Hospital were not stable and may be subject to

ongoing change.

Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in medicine at Central

Middlesex Hospital were not stable and may be subject to ongoing change.

Monthly sickness rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in medicine at Central Middlesex Hospital showed an upward trend from August 2018 to December 2018.


Monthly sickness rates from April 2018 to March 2019 for nursing assistants in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.

Monthly bank hours from April 2018 to March 2019 for qualified nurses, health visitors and midwives in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.



midwives in medicine at Central Middlesex Hospital showed a shift from October 2018 to March

2019. Senior staff told us that they endeavoured to use the same agency staff wherever possible,

in order to ensure consistency. Agency staff were required to complete an induction on arrival at

the ward. We saw evidence of inductions having being completed.

Monthly bank hours from April 2018 to March 2019 for nursing assistants in medicine at Central Middlesex Hospital showed an upward trend from April 2018 to August 2018.

Please see Medical staffing section below for all staffing metrics

Medical staffing

From April 2018 to March 2019, the breakdown of WTE staff in post in medicine at Central Middlesex Hospital is shown in the chart below.

Medicine annual staffing metrics



Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available


available hours)


hours)

All staff* 274.5 0.8% 16.0% 6.0%

Medical staff 28.9 5.1% 37.7% 0.1% 3,989

(11.9%)

4,059

(12.1%)

6,601

(19.6%)

* All staff includes other staff groups not specifically shown in the above table ** The trust has confirmed that the medical staffing turnover figures include planned rotation, which inflates the rate. Both nursing and medical staff told us that the wards were usually fully staffed.

Monthly vacancy rates from April 2018 to March 2019 for all staff in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.


Monthly vacancy rates from April 2018 to March 2019 for medical staff in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.

Monthly turnover rates from April 2018 to March 2019 for medical staff in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.

Monthly sickness rates from April 2018 to March 2019 for medical staff in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.


Monthly agency and locum hours from April 2018 to March 2019 for all staff in medicine at Central Middlesex Hospital showed a shift from October 2018 to March 2019.

Monthly locum hours from April 2018 to March 2019 for medical staff were not stable and may be subject to ongoing change. (Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Nursing bank agency and Medical locum tabs) In January 2019, the proportion of consultant staff reported to be working at the trust was similar to the England average and the proportion of junior (foundation year 1-2) staff was the same. Staffing skill mix for the 375 whole time equivalent staff working in medicine at London North West University Healthcare NHS Trust: This


Consultant 43% 45%



Junior* 20% 20%



(Source: NHS Digital - Workforce Statistics - Medical (01/01/2019 - 31/01/2019)

There was a doctor trained in the speciality of General Internal Medicine immediately available at

all times in the service. We were told that these members of staff had up-to-date competences in

adult life support.

Records



The hospital used both electronic and paper patient records. The majority of data was recorded on

paper.

During the inspection, we examined 20 sets of patients’ records across medical wards. We found

that patients’ records were overall properly completed and entries timed and dated with a legible

signature.

Records were appropriately and safely stored.

Records contained details of mental health needs and dementia needs where appropriate. Staff

told us they considered the patients’ medical history on admission in order to identify any pre-

existing mental health conditions, learning disability, autism or dementia.

Bank and agency staff had access to electronic records.

Medicines

Staff followed systems and processes when safely prescribing, administering, recording

and storing medicines.

Medicines were stored securely in locked trolleys and doors were locked to treatment rooms with

access restricted to appropriate staff. Controlled drugs were stored securely and managed

appropriately.

Staff reviewed patient’s medicines regularly and provided specific advice to patients and

carers about their medicines.

We saw that nursing staff introduced themselves to patients before offering them medicines. They



visited the wards Monday to Friday to review prescriptions and advise medical staff when doses

needed to be revised. The pharmacist reviewed medicines and information provided to discharged

patients.

Staff stored and managed all medicines and prescribing documents in line with the

provider’s policy.


performed to ensure that they were fit for use in accordance with trust policy. Medicines were

stored at appropriate temperature range including medicines which needed to be stored in

refrigerators.

Staff followed current national practice to check patients had the correct medicines.




The service had systems to ensure staff knew about safety alerts and incidents, so patients

received their medicines safely.

All patient medicine allergies were recorded clearly on their notes.

Staff knew how to report incidents via the trust’s electronic reporting system. Staff we

spoke with felt confident in raising an incident should they need to.



Staff supported patients to make informed decisions about their care and treatment. They followed


Incidents

The service generally managed patient safety incidents well. Managers investigated

incidents and shared lessons learned with the whole team and the wider service. When

things went wrong, staff apologised and gave patients honest information and suitable

support. Managers ensured that actions from patient safety alerts were implemented and

monitored. However, some staff told us that they did not always report incidents and near

misses formally.

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2018 to April 2019, the trust reported no never events for medicine. (Source: Strategic Executive Information System (STEIS))

Trust level: In accordance with the Serious Incident Framework 2015, the trust reported 24 serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from May 2018 to April 2019


A breakdown of the incident types reported is in the table below:


Percentage of total




Pressure ulcer 3 12.5%


Pending review 1 4.2%

Screening issues 1 4.2%

Total 24 100.0%

There was one incident reported at Central Middlesex Hospital; this was a slip/trip/fall that occurred in May 2018. (Source: Strategic Executive Information System (STEIS))

The matron for medical care told us that patient falls was one of the primary risks to patient care

and that, as a result, they had taken significant action to reduce the risk of falls. This included the

introduction of “tagging bays” and an increased use of one to one care for wandering patients. On

the safety thermometer for each ward, the number of fall-free days was recorded. This fed into the

matron’s overall “rating” for the ward during their audit.

Staff reported incidents via an electronic reporting system. Incidents that were reported were

escalated and investigated appropriately and the learning from incidents shared with staff. Staff

told us that when they raised an incident, they always received feedback. Further, they were able

to describe incidents that had occurred on other wards and the learning that had arisen from them.

However, some staff told us that they did not always complete an electronic incident report. A

significant number of staff told us that where they had a concern or had witnessed a low level or

near miss incident, they informed the relevant nurse in charge and the issue was resolved in a

timely manner. They said that, in these circumstances, they did not always then complete an

electronic incident report. This meant that the service was potentially missing learning

opportunities from incidents and was not necessarily able to identify common themes.

Following a Coroner’s Court Inquest in April 2019, the service dietitian and speech and language

therapy (SALT) teams had introduced a ward communication safety tool. This was completed at

the end of each shift and provided to the next team as part of the handover. The form required the

nurse in charge to document the number of patient falls in the last 24 hours; the number of

patients with category two to four pressure ulcers; the number of patients assigned red tray meals;

the number of patients with LD; those subject to DoLS; receiving one to one care; confused

patients; patients with national early warning scores (NEWS) of five or above; health and safety

issues and the number of complaints or concerns.

Safety thermometer

The service used monitoring results well to improve safety. Staff collected safety

information and shared it with staff, patients and visitors.

The Safety Thermometer is used to record the prevalence of patient harms and to provide


immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported 55 new pressure ulcers, 16 falls with harm and 21 new urinary tract infections in patients with a catheter from March 2018 to March 2019 for medical services. Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter acquired urinary tract infections at London North West University Healthcare NHS Trust:

1


2

Total Falls (16)

3

Total CUTIs (21)


(Source: NHS Digital - Safety Thermometer)

The safety thermometer was prominently displayed on information boards on each of the wards and carried up to date information.







Clinical pathways, policies and procedures followed national guidance such as those from National

Institute of Clinical Excellence (NICE) and Royal College of Emergency Medicine (RCEM)

guidelines. These included management of sepsis, fractured neck of femur, acute coronary

syndrome, allergic reaction, and first seizure. Policies we reviewed included a review date and

were within date. Staff were able to access policies easily via the intranet.

The service used a sepsis screening programme, of which staff were aware and followed a

standardised sepsis management pathway in accordance with best practice guidance from NICE

and the UK Sepsis Trust.

Patients were reviewed at a consultant-led multi-disciplinary team ward round once every 24

hours.


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 needs.

The wards operated a ‘protected mealtimes’ policy. This meant visitors were asked not to visit the

wards at mealtimes to allow patients to eat their meals uninterrupted. Staff were also asked to

observe the policy and to not arrange treatment or assessments at patients’ mealtimes. There

were signs outside each of the wards detailing the policy.

Nursing staff screened patients at risk of malnutrition on admission using the Malnutrition Universal Screening Tool (MUST) tool. In the notes we checked, MUST scores had been appropriately calculated and recorded. There was a team of dietitians working within the service. The dietitians were based along with the

other Allied Health Professionals (AHP)s in an office on Gladstone 4. One of the dietitians we

spoke with told us that medical staff and nurses frequently approached them for informal advice as

well as referring patients to the dietitian’s team where appropriate.

Dietitians attended multidisciplinary team (MDT) meetings and contributed to discussions

regarding appropriate nutrition and hydration. We saw assessments and advice from dietitians and

therapists in the notes we examined. These dietary requirements were communicated to other

staff including catering staff.

Due to the number of frail elderly patients, the dietitian team had been working on a project with

the catering team to increase the protein levels in the food for some patients. This included the

addition of cheese into meals. This was under review at the time of our inspection, with a view to

sharing the findings more widely across the trust.

The speech and language therapy and dietitian teams had worked together to create an

information sheet for staff regarding new international guidelines regarding the terminology for

various thicknesses and consistencies of foods for patients at risk of choking.

There was a red tray system for staff to identify those patients who were at risk of choking. All

patients with dementia received a red tray.

We observed a healthcare assistant helping a patient to eat.

Patients generally spoke highly of the food in the hospital.

Pain relief


Staff assessed and monitored patients regularly to see if they were in pain, and gave pain



We spoke to three patients about pain relief. They told us that their pain was appropriately

managed.

Nursing staff used a pain scoring system of one to ten (with one being the least pain) to assess

patient’s pain levels; this was recorded in patient notes and pain relief given if required. There was

also a pain scoring system using images for patients who were non-verbal.

There was a trust-wide pain team who supported staff to manage the needs of patients with acute

and chronic pain in the hospital. Clinical nurse specialists and consultants in this team undertook

regular ward rounds.

Patient outcomes

Staff monitored the effectiveness of care and treatment. They used the findings to make

improvements and achieved good outcomes for patients. The service had been accredited

under relevant clinical accreditation schemes.

From January 2018 to December 2018, patients at the trust had lower than expected risks of readmission for elective and non-elective admissions when compared to the England averages. Patients in gastroenterology and medical oncology had lower than expected risks of readmission for elective admissions.

Patients in clinical haematology had a similar to expected risk of readmission for elective admissions. Elective Admissions – Trust Level:

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity.

Patients in general medicine and clinical haematology had lower than expected risks of readmission for non-elective admissions.

Patients in geriatric medicine had a similar to expected risk of readmission for non-elective admissions. Non-Elective Admissions – Trust Level:



(Source: Hospital Episode Statistics - HES - Readmissions (01/01/2018 - 31/12/2018)) From January 2018 to December 2018, patients at Central Middlesex Hospital had lower than expected risks of readmission for elective and non-elective admissions when compared to the England averages. Patients in clinical haematology and diabetic medicine had lower than expected risks of readmission for elective admissions.

Patients in rheumatology had a similar to expected risk of readmission for elective admissions. Elective Admissions - Central Middlesex Hospital:

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

Patients in general medicine had a higher than expected risk of readmission for non-elective admissions.

Patients in clinical haematology and geriatric medicine had lower than expected risks of readmission for non-elective admissions. Non-Elective Admissions - Central Middlesex Hospital:


The table below summarises the trust’s performance in the 2017 National Lung Cancer Audit.



Trust performance


Meets national

standard?

Crude proportion of patients seen by a cancer nurse specialist (Access to a cancer nurse specialist is associated with increased receipt of anticancer treatment)

61.7% Does not meet the audit aspirational

standard

Case-mix adjusted one-year survival rate (Adjusted scores take into account the differences in the case-mix of patients treated)

44.9% Good practice No current standard

Case-mix adjusted percentage of patients with Non-Small Cell Lung Cancer (NSCLC) receiving surgery (Surgery remains the preferred treatment for early-stage lung cancer; adjusted scores take into account the differences in the case-mix of patients seen)

25.5% Good practice ✓

Case-mix adjusted percentage of fit patients with advanced NSCLC receiving systemic anti-cancer treatment (For fitter patients with incurable NSCLC anti-cancer treatment is known to extend life expectancy and improve quality of life; adjusted scores take into account the differences in the case-mix of patients seen)

70.9% Within expected

range ✓

Case-mix adjusted percentage of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy (SCLC tumours are sensitive to chemotherapy which can improve survival and quality of life; adjusted scores take into account the differences in the case-mix of patients seen)

58.6% Within expected

range

(Source: National Lung Cancer Audit)

The table below summarises Central Middlesex Hospital’s performance in the 2017 National Audit of Dementia.



Audit’s Rating Meets national

standard?

Percentage of carers rating overall care received by the person cared for in hospital as Excellent or Very Good (A key aim of the audit was to collect feedback from carers to ask them to rate the

90.9% Top 25% of all

trusts No current standard


care that was received by the person they care for while in hospital)

Percentage of staff responding “always” or “most of the time” to the question “Is your ward/ service able to respond to the needs of people with dementia as they arise?” (This measure could reflect on staff perception of adequate staffing and/or training available to meet the needs of people with dementia in hospital)

96.3% Top 25% of all

trusts No current standard

Mental state assessment carried out upon or during admission for recent changes or fluctuation in behaviour that may indicate the presence of delirium (Delirium is five times more likely to affect people with dementia, who should have an initial assessment for any possible signs, followed by a full clinical assessment if necessary)

55.6% Middle 50% of

all trusts No current standard

Multi-disciplinary team involvement in discussion of discharge (Timely coordination and adequate discharge planning is essential to limit potential delays in dementia patients returning to their place of residence and avoid prolonged admission)

85.7% Middle 50% of

all trusts No current standard

(Source: National Audit of Dementia) During our inspection we observed good MDT involvement in discussions of patient discharge. However, only the complex discharge team attended the stranded patients meeting with the local authority social work teams to discuss challenges to discharge. This meant that the complex discharge staff took responsibility for representing clinical decisions made by specialists to the social work teams at meetings at which the clinical decisions were directly relevant.

Competent staff

The service made sure staff were generally competent for their roles. Managers appraised

staff’s work performance and held supervision meetings with them to provide support and

development.

Staff generally had the skills, qualification and experience to carry out their roles safely. However,

we had concerns that some healthcare assistants who were assigned to supervise wandering

patients with dementia and cognitive impairment lacked sufficient training in the appropriate

methods of intervention for these patients.

In addition, the hospital was unable to provide adequate assurance of the overall mandatory

training compliance of medical staff.


From April 2018 to March 2019 81.1% of staff within medicine at Central Middlesex Hospital received an appraisal compared to a trust target of 85.0%.

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)




Add prof scientific and technic 5 7 71.4% 85.0% No


Healthcare scientists 0 2 0.0% 85.0% No


In medicine at Central Middlesex Hospital two of the six staff groups met the trust target, including medical and nursing staff. (Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Staff who had had their appraisals described them as meaningful. They said they were given

opportunities to identify areas for development and, where possible, were supported to do so.

Medical staff in particular spoke highly of their appraisals. They said they received appropriate

professional challenge and gained insight into their own practice through the process. They said

they were usually supported to pursue further learning and development.




There was a good multidisciplinary working environment within the service. The departmental

allied health professionals were based in an office on Gladstone 4. One of the speech and

language therapists (SALT) told us that working in the shared office meant that there was shared

learning between the team. It also meant that the teams could discuss patients at greater length.

We attended a multidisciplinary team (MDT) meeting. The meeting was well attended and well

conducted. All staff were listened to at the meeting and constructive challenge was given.

There was a complex discharge team within the department, who were responsible for liaising with

the local authorities to arrange packages of care for patients in the community.

The discharge team and senior leadership team said that meetings with the local authority social

work teams were worthwhile, but did not always achieve the desired outcome for the patient.

Some of the AHP team said that they did not feel that the social workers recognised or accepted

their clinical decision making. Following the inspection, the trust told us, the therapy lead for

Central Middlesex Hospital attended the stranded patients meeting weekly and was deputised by

the lead for occupational therapy in their absence.


Seven-day services

Key services were available seven days a week to support timely patient care. However, some of this was on an on-call basis.

There was access to a consultant 24 hours a day seven days a week. Some of the availability was

on an on-call basis.

The pharmacy had a weekday inpatient dispensary service between 8am and 5pm. A resident

pharmacist was on-call outside of these times.

Patients had access to endoscopy on weekdays.

Allied health professionals operated Monday to Friday between 8.30am and 6pm.

Health promotion


There were posters throughout the service directing patients to services to support alcohol

reduction and smoking cessation.

Policies and standard operating procedures encouraged staff to staff to signpost patients to these

services, though there was little formal documented evidence of this.

There was a weekly gym class held in the physiotherapy gym for staff. There were also group

physiotherapy sessions for ward patients who were able to attend.



followed national guidance to gain patients' consent. Some staff knew how to support

patients who lacked capacity to make their own decisions or were experiencing mental ill

health.


A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 for qualified nursing staff in medicine at Central Middlesex Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



60 69 87.0% 85.0% Yes

In medicine the target was met for both of the MCA and DoLS training modules for which qualified nursing staff were eligible.

A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 for medical staff in medicine at Central Middlesex Hospital is shown below:



Staff

trained

Eligible

staff

Completion

rate

Trust

target

Met

(Yes/No)



13 23 56.5% 85.0% No

In medicine the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

All of the staff we spoke with had a clear understanding of the Mental Capacity Act and the

Deprivation of Liberty Safeguards.

We checked 10 completed MCA forms all of which were appropriately completed. In addition, we

checked six DoLS applications, of which five were appropriately completed. One of the DoLS

included a transcribing error in the box for extending the period of the deprivation of liberty. We

drew this to the attention of the nurse in charge.

There was a significant patient population within the service who were the subject of DoLS.

Staff used measures that limit patients' liberty appropriately. However, there was limited

training for staff as to the practical application of care for patients with deprived liberties.

Whilst staff had a clear understanding of the DoLS, there was not always evidence that the

restrictions contained within the DoLS were appropriately applied, or that staff had received

training to apply them appropriately. For example, during our inspection we observed a number of

patients who were subject to DoLS who were assigned one to one care, to ensure that they did not

injure themselves or other patients when wandering the wards and did not leave the wards. There

was no detail in these patients’ care plans, however, as to how the one to one staff were meant to

intervene to prevent the patient leaving the ward, or to move them away from potentially

dangerous situations. We observed a number of instances of one to one staff standing by whilst

patients became agitated or picked up potentially harmful objects such as cleaning signs without

intervening.


Compassionate care



The Friends and Family Test response rate for medicine at the trust was 28% which was better than the England average of 24% from March 2018 to February 2019. The response rate at Central Middlesex Hospital over the same period was 32%. A breakdown by ward at the site is below.



4. The total responses exclude all responses in months where there were less than five responses at a particular

ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12 month period.

5. Sorted by total response. 6. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in

seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.

7. The response rate for this ward is omitted due to an issue with the data.

(Source: NHS England Friends and Family Test)

Staff spoke about patients with care and compassion and the majority of patients described staff

as caring. We observed caring interactions between staff and patients.

Emotional support

Staff provided emotional support to patients, families and carers to minimise their distress.

They understood patients' personal, cultural and religious needs.

The majority of patients we spoke with said that staff were supportive.

There was a multi-faith chaplaincy service within the hospital to administer to patient’s religious

needs. Where a chaplain of a specific faith was not available, the chaplaincy team had links with

faith leaders within the community, whom they would invite into the hospital.

We observed positive interactions between staff and patients. For example, one member of staff

took the time to discuss a patient’s dog with them and to assure them that their dog would be well

cared for after it had been transferred to RSPCA care.


Staff supported patients, families and carers to understand their condition and make

decisions about their care and treatment.

We observed staff introducing themselves to patients on arriving at their bedside. Further, we

observed a doctor explaining what she was doing and why to a confused patient as they carried

out an examination. One patient in a side room said that staff did not always take the time to

introduce themselves.

As a significant proportion of patients stayed on the wards for prolonged periods, staff told us they

got to know the patients well. Staff were able to describe the likes, dislikes and habits of the

patients they cared for.



The service 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.

Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19

Endoscopy CMH 1,851 42% 97% 89% 95% 98% 98% 96% 97% 96% 94% 96% 91% 95% 95%

Gladstone 2 432 N/A4 89% 93% 100% 92% 89% 93% 100% 93% 73% 94% 90% 88%

Ward nameTotal

Resp1,2

Resp.

Rate

Percentage recommended3 Annual

perf1


All of the wards had single-sex bays and side rooms so that patients with more complex needs

and those requiring isolation to prevent the spread of infection could be appropriately cared for.

The service took patients from the other hospitals within the trust, in order to free up beds

elsewhere. Consequently, the majority of patients were those who required rehabilitation and were

awaiting transfer into the community.

A significant proportion of patients had dementia, mental health, substance misuse or housing

needs. Staff told us and we observed that a number of patients presented with challenging

behaviour. Staff did not receive specific training in handling this. There were, however, dementia

champions within the service, who were available to advice and support staff with care for patients

with dementia.

There were procedures in place for staff to call the hospital security team if a patient became

physically aggressive.

The complex discharge team worked with social workers from the local boroughs to overcome

obstacles to discharge.


Staff made some adjustments to help patients access services.

Staff used a telephone translation service for patients for whom English was not their first

language. We saw evidence in a patient’s notes of a translator being used appropriately for a

patient consenting to treatment. For the significant proportion of patients had dementia and other

cognitive impairments, a psychiatrist attended the ward round once a week to discuss the care

plans of these patients.

Patients with learning disabilities had “passports” in their patient notes, which set out their needs

and care preferences.

Wards were wheelchair accessible and there was additional support available for patients who

were blind or deaf.

Patients’ personal preferences were not always recorded in their notes.

Patients with dementia had the Alzheimer’s Society’s “this is me” document in their notes. This

was a document completed by the patient’s family, carer or friend, often with input from the patient

to describe their likes and dislikes and care preferences. Senior staff told us that they had

introduced a similar form for all patients with cognitive impairment within the service, and that this

had subsequently been adopted across the trust. However, when we checked patient records, we

viewed six forms, of which only one was completed.

The environment on the wards was not dementia friendly. There was limited interaction or

stimulation for patients with dementia and cognitive impairment.

The environment on the wards was not dementia friendly. There were break out rooms on each of

the wards where patients and their relatives could sit. However, these had not been designed to

stimulate patients with dementia. In addition, there were no specific activities for patients with

dementia.

The matron told us that there was a plan to introduce a dementia lunch club to the wards. Whilst

this was not operational at the time of our inspection, the service had acquired a specialist table to

facilitate this and was considering options for how best it should be run.


Patients could order food in accordance with their dietary requirements, for example from Halal,

Kosher or vegetarian menus.

Access and flow

There was poor flow out of the service, although this was largely due to external factors. Numerous patients had complex needs which meant it was difficulty to secure ongoing care for them. There were some difficulties in the discharge pathway out of the hospital into local authority- funded care.

People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat patients were in line with national standards. From February 2018 to January 2019 the average length of stay for medical elective patients at Central Middlesex Hospital was 13.5 days, which was higher than England average of 5.9 days and the trust average of 9.2 days. For medical non-elective patients, the average length of stay was 19.9 days, which was higher than England average of 6.2 days. Average length of stay for elective specialties:

• Average lengths of stay for elective patients in geriatric medicine and diabetic medicine were higher than the England averages.

• Average length of stay for elective patients in Gastroenterology was lower than the England average.

Elective Average Length of Stay - Central Middlesex Hospital:


Average length of stay for non-elective specialties:

• Average lengths of stay for non-elective patients in diabetic medicine and clinical haematology were lower than the England averages.

• Average length of stay for non-elective patients in geriatric medicine was higher than the England average.

Non-Elective Average Length of Stay - Central Middlesex Hospital:



(Source: Hospital Episode Statistics) Senior staff recognised that the average length of stay was significantly longer than the trust and England averages. They told us this was due to the cohort of patients within the service. Patients were transferred to the hospital from Northwick Park Hospital and, to a lesser extent, from Ealing Hospital. Discharge planning for patients usually began on their admission to the hospital, or had begun earlier, prior to their transfer to the hospital from elsewhere within the trust. A significant proportion of patients within the service were classified as complex discharge patients. Patients who had been in the hospital for a period of more than 14 days were discussed at a daily “stranded patients” meeting. This was attended by the hospital’s complex discharge teams as well as social workers from the surrounding boroughs. Where patients were from outlying boroughs or other parts of the country, social workers from those boroughs would be invited to join via telephone link. We observed a “stranded patients meeting”. Whilst the meeting was well conducted, little progress was made to address the barriers to discharge for the patients discussed. For example, one patient who was discussed had been assessed as requiring one to one care. This was being contested by the local authority, who were of the view that one to one care may not be necessary and had asked the trust to withdraw one to one care for a period of time in order to assess whether it was in fact needed. The trust team responsible for the patient’s care plan were unwilling to do so. Following the meeting no agreement had been reached. Staff told us that a significant number of patients within the service were medically well, but could not be discharged as there was not sufficient support available to them within the community. This was reflected by the senior leadership team and by the complex discharge team. All staff reflected difficulties in ensuring effective discharge from the hospital to the local boroughs. They told us that they did not always feel that their expertise was listened to. They described differing levels of difficulty in the discharge pathways with each of the boroughs. Whilst these difficulties were recognised by the senior leadership team, there was no evidence of any action to address the structural issues behind this. From March 2018 to February 2019 the trust’s referral to treatment time (RTT) for admitted pathways for medicine fluctuated around the England average, with performance slightly worse over the second half of the year from September 2018 onwards.


(Source: NHS England) Six specialties above the England average for admitted RTT (percentage within 18 weeks).


General medicine 100.0% 96.8%

Geriatric medicine 100.0% 96.3%

Neurology 100.0% 90.1%

Rheumatology 100.0% 95.0%

Cardiology 96.1% 81.3%

Dermatology 85.3% 81.6%

Two specialties were below the England average for admitted RTT (percentage within 18 weeks).


Thoracic medicine 90.9% 94.2%

Gastroenterology 86.4% 92.9%

(Source: NHS England) The trust reported that, although they monitor patient moves including multiple ward moves and step downs, data does not identify ward moves due to non-clinical reasons therefore figures for this section have not been provided. (Source: Routine Provider Information Request (RPIR) – Ward moves tab) From April 2018 to March 2019, there were 4,077 patients moving wards at night within medicine. A breakdown of numbers of moves by site and ward is in the table below.


Northwick Park Hospital 3,163 77.6%



Total 4,077 100.0%

Central Middlesex Hospital


Roundwood suite 145 32.4%

Gladstone suite - rooms 26-37 128 28.6%


Gladstone suite 2 - rooms 14-25 91 20.3%

Gladstone suite 1 - rooms 1-12 59 13.2%

Gladstone suite - rooms 38-46 25 5.6%

Total 448 100.0%

(Source: Routine Provider Information Request (RPIR) – Moves at night tab) As a significant proportion of patients within the service had dementia and other forms of cognitive impairment, moves at night should have been kept to a minimum. Senior staff told us that the majority of the moves at night related to patients being admitted from the medical assessment unit at Northwick Park, where they had been assessed as requiring hospital admittance, but not of sufficient acuity to be accepted into the medical wards there. They told us that they worked to reduce the number of moves at night within the hospital, but had limited power to reduce the number of night time transfers into the hospital.


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. From April 2018 to March 2019 the trust received 26 complaints in relation to medicine at Central Middlesex Hospital. The trust took an average of 44.9 working days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting four complaints were still open. These had been open for an average of 40.0 working days. A breakdown of complaints by type is shown below:


Percentage of total


8 30.8%




3 11.5%



Others 1 3.8%



1 3.8%

Total 26 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab) Senior staff told us that they took patient complaints seriously, and saw them as an opportunity for learning. Some staff were able to describe learning and changes of practice that had arisen from patient and relative’s complaints. However, these tended to relate to the care of specific patients rather than changes to practice overall.


From April 2018 to March 2019 there were 72 compliments about medicine at the trust (38.1% of all received trust wide). Of these, five compliments were about Central Middlesex Hospital. The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab)


Leadership

There was a triumvirate leadership team for medical care: a divisional head of nursing for

integrated medicine, the divisional general manager for medicine and a clinical director for

integrated medicine. The senior leadership team recognised the challenges the service faced,

particularly in respect of the average length of stay of patients and their complex additional needs.

The senior leadership team had taken some action to address these concerns, through the

introduction of a roving MDT meeting, attended by the divisional head of nursing. As part of this,

the team attended each of the wards weekly to discuss all patients who had been in the hospital

more than 14 days. At this meeting, the divisional head of nursing would review each of the

blockages to discharge and try to put actions in place to address them, offering supportive

challenge to staff. The leadership team told us that they were keen to “put the onus back on social

care” to find patients packages of care in the community or places in rehabilitation centres or

nursing homes.

Whilst this was proactive on the part of the leadership team to address the issues in the service,

this was being done on a case by case basis. The senior leadership team had not taken concrete

action to address the overall system issues causing the delays to discharge, for example efforts to

improve relations between the local authority safeguarding team and ward staff.

Staff spoke highly of the local leadership on each of the wards and of the matron for the service.

The junior medical staff we spoke with spoke highly of the medical leadership and education within

the service.

The majority of staff we spoke with, however, described a disconnect between the leadership of

the service within the hospital and with the overall trust leadership. In particular, there was a

concern that as the service was used as an “overflow” from other hospitals within the trust, it was

not prioritised for development or input from the trust leadership team. Further, some staff were

concerned about the longevity of the service. They said that the trust’s senior leadership team

were not visible within the hospital.

Vision and strategy

There was a lack of vision and strategy for the service. The senior leadership team were unclear

about future plans for the service. They said that they had not been able to develop a clear vision

or strategy as there was a lack of clarity from the overall trust leadership and from the CCGs about

the vision and strategy for the trust as a whole and that, therefore they had not been a solid

framework for them to work in to develop a strategy.


Some of the junior staff we spoke with expressed concern at the lack of a long term strategy for

the service.

Culture

Staff spoke highly of the culture within the service. They said there was a positive team-working

environment and they were proud of the care they gave.

Medical staff in particular said they enjoyed the culture within the service. Junior doctors said that

the majority of senior grade doctors made time to listen to their queries and to pass on knowledge.

All of the staff we spoke with told us that they were supported in their career progression within the

service. They said that they were encouraged to undertake additional training and courses.

Governance

There were monthly clinical governance meetings held jointly with the medical services from

Ealing Hospital. Senior staff told us that this allowed for shared learning across both sites. The

governance meeting focussed on newly identified risks, performance and assessed the services

against the trust’s version of the CQC framework.

The medical care service was made up of eleven specialties based across the trust. The clinical

leadership team told us that they had recently introduced monthly service line reviews, where each

of the specialities provided data to the governance team who then picked a speciality for a “deep

dive” to assess the quality of service delivery. In addition, at each of the clinical governance

meetings a member of staff from one of the specialties was required to attend and talk in more

detail about their service. This was done on a rotation basis.

We had sight of the notes of service-wide clinical governance meetings, which indicated that they

were well attended.

In addition, there were clinical governance meetings for each of the medical specialities. Mortality

and morbidity reviews were a standing item on the agenda of these meetings. Reports from the

specialities’ governance meetings were provided to the overall clinical governance team for review

at their monthly meetings.

Senior staff recognised the challenge of ensuring that learning and decisions arising out of

governance meetings was shared with staff. They told us that to address this they had introduced

a weekly safety communication huddle for all ward staff. There was a monthly theme for these

meetings, for example falls risk management, on which staff would be asked to focus.


There was a trust-wide risk register. Significant divisional risks could be escalated to the trust-wide

risk register, following discussion by the trust’s senior leadership team.

Within medical care there was a local risk register which covered the medical care service across

the trust. We had sight of the risk register. At the time of our inspection, there were 22 open risks

on the register. All of the risks on the register had mitigating action points against them. The risk

register was reviewed at monthly clinical governance meetings and any additional actions

reported.

The senior leadership team were sighted on the risks on the register. However, the highest scoring

risks related mainly to the other hospital sites within the trust.

One risk, however, related to the movement of patients at night into the hospital, in particular

where patients were admitted from other trusts and where the patients had dementia. The


leadership team recognised that this usually resulted in a longer hospital stay for the patient and

added to their confusion. However, whilst there were actions in place to mitigate the impact this

had on the patients themselves, there were limited mitigating actions to reduce its occurrence.


The executive team and senior management had sight of the quality standards from the trust quality dashboard which was published monthly. The quality dashboard provided information on operational performance relating to patient safety, referral to treatment targets, patient experience, and clinical effeteness. There were arrangements in place which ensured data such as serious incidents were submitted to external providers as required. The service followed best practice for information governance, for example the use of a secure email system.

Engagement

There was a trust wide newsletter shared with all staff.

The matron for the service sent email updates to staff containing important news and learning from

incidents, complaints and concerns. In addition, this was shared at daily ward safety huddles,

immediately following handover.

The service engaged the public through the use of “you said, we did boards” in each of the ward

areas. In addition, friends and family test (FFT) data was displayed on the information boards in

each of the wards.


The speech and language therapy team had equipment and skills to provide video swallow

assessments for patients. This meant that staff had a clearer understanding of patient’s

swallowing abilities and were able to cater to them more effectively.

The allied health professionals organised learning sessions which could be attended by all staff to

raise awareness of their roles and to share learning and best practice.

Surgery


The surgical department at the trust comprises 21 wards/departments across four sites. A list of the wards and the specialties they cover are in the table below: Northwick Park Hospital:


Dowland Ward Urology

Edison Ward Surgery, surgical assessment unit (SAU),

gynaecology


Eliot Ward General surgery and vascular

Evelyn Ward Trauma & orthopaedics

Fletcher Ward Gastroenterology

Gray Ward Maxillo-facial surgery

Sainsbury Private patients

Theatres admissions unit (TAU) All surgery

Theatres Theatres



Abbey Ward Surgery

Ambulatory care and diagnostics (ACAD) pre-

assessment Surgery

ACAD recovery Surgery

ACAD theatres admissions unit Surgery

ACAD theatre Surgery

Brent emergency care and diagnostics

(BECAD) theatre Surgery

Ealing Hospital:


Ward 3 North Surgical admissions unit

Ward 7 North General surgery

Ward 7 South Trauma & orthopaedics

Theatres Theatres

St Marks Hospital:

Ward name Specialty

Frederick Salmon Ward Colorectal Surgery

Jonson Ward Intestinal rehabilitation unit

(Source: Routine Provider Information Request (RPIR) – Sites tab) The trust had 40,000 surgical admissions from January 2018 to December 2018. Emergency admissions accounted for 14,277 (35.7%), 20,096 (50.2%) were day case, and the remaining 5,627 (14.1%) were elective. (Source: Hospital Episode Statistics)

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training


The service provided mandatory training in key skills to all staff but not everyone had completed it. The trust set a target of 85% for completion of mandatory training. Trust level: A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)










In surgery the target was met for eight of the nine mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




Health & safety 317 453 70.0% 85.0% No






In surgery the target was met for none of the nine mandatory training modules for which medical staff were eligible. None of the 12 eligible medical staff completed the manual handling – level 2 (face to face) training module. Central Middlesex Hospital surgery department: A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in surgery at Central Middlesex Hospital is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)









face) 54 63 85.7% 85.0% Yes

In surgery the target was met for all eight mandatory training modules for which qualified nursing staff at Central Middlesex Hospital were eligible.

A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for

medical staff in surgery at Central Middlesex Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



Health & safety 9 14 64.3% 85.0% No






In surgery the target was met for none of the eight mandatory training modules for which medical staff at Central Middlesex Hospital were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) Mandatory training rates were below trust target for medical staff. As consequence, the service

had developed an action plan to improve compliance rates, which included to increase mandatory

training sessions during monthly governance days, monthly mandatory training compliance rates

to be circulated and develop new e-learning modules for training. A new electronic training

platform allowed new rotation doctors to be able to access e-learning modules and complete this

prior to arrival to the trust. The system also allowed transfer of previously completed training from

other trusts.

Staff we spoke with confirmed they participated in mandatory training relevant to their role.

A team of practice development nurses monitored uptake of mandatory training in the service.

Staff received email reminders when training updates were due and senior nursing staff in theatres

and wards had oversight of mandatory training compliance. Staff were supported to undertake


training during work time. Training was delivered by e-learning (most modules) or in a classroom

or clinical setting.

Safeguarding

Staff understood how to protect patients from abuse but trust targets for completion of safeguarding training had not been met for medical staff.

Safeguarding training completion rates The trust set a target of 85% for completion of safeguarding training. Trust level: A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)





PREVENT 485 508 95.5% 85.0% Yes


In surgery the target was met for five of the six safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)





PREVENT 201 453 44.4% 85.0% No

In surgery the target was met for one of the five safeguarding training modules for which medical staff were eligible. Central Middlesex Hospital surgery department: A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for


qualified nursing staff in surgery at Central Middlesex Hospital is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

PREVENT 62 63 98.4% 85.0% Yes



The target was met for all of the three safeguarding training modules for which qualified nursing staff in surgery at Central Middlesex Hospital were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for medical staff in surgery at Central Middlesex Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



PREVENT 6 14 42.9% 85.0% No

The target was met for none of the three safeguarding training modules for which medical staff in surgery at Central Middlesex Hospital were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)

Data provided showed that the service did not meet targets for safeguarding training of medical

staff. The service had developed an action plan to improve safeguarding training completion rates

together with mandatory training compliance.

Staff we spoke with were aware of how to access the safeguarding policies on the hospital’s

intranet. All staff we spoke with were aware of their responsibilities to protect vulnerable adults and

would take the appropriate action if they were concerned about a patient. For example, by

contacting senior staff on duty, the safeguarding team and submitting a report on the electronic

incident reporting system. Staff we spoke with were aware of the trust safeguarding leads for

adults and children.

There was information on the hospitals safeguarding procedure displayed on the notice boards on

the wards and in theatres for staff to refer to, including the contact details for the safeguarding

team. There were arrangements to safeguard adults and children from abuse and neglect which

took account of relevant legislation and local requirements. Staff worked in partnership with other

agencies to ensure patients were helped, supported and protected.


The service controlled infection risk well.


All areas of the surgical department we visited were visibly clean and tidy. All equipment we

checked was clean and had ‘I am clean’ stickers to demonstrate when they had been sanitised.

We observed staff complying with trust policy in relation to hand washing and remaining bare

below the elbows.

Cleaning was provided by an external company and cleaners followed a standard operating

procedure for cleaning of ward and theatres, which described what, when and how items and

areas needed to be cleaned by which staff group. Daily theatre cleaning checklists included a pre-

list and last case clean. We saw completed daily cleaning checklists in wards and theatres. The

lead nurse in each theatre took responsibility for signing that all staff had cleaned their areas. The

operating department practitioners (ODPs) signed off their own checklists in the anaesthetic

rooms. Cleaning of equipment was done every morning and “I am clean stickers” were removed

from items before being brought into theatre rooms. The external cleaning company performed

weekly compliance walk arounds and the ward and theatre managers received feedback and

action if necessary. The latest compliance score before our inspection was 98%.

Throughout the surgical department we saw sufficient hand wash facilities and wall mounted hand

sanitiser dispensers in corridors. Attention was drawn to these with hand hygiene notice boards.

Staff in all areas had access to personal protective equipment (PPE) such as gloves and aprons.

We observed that theatre staff wore the appropriate PPE during surgical procedures.

Data provided showed that hand hygiene audit results were 98% for the ward and 94% for

theatres in July 2018 to June 2019. This was above the trust target of 90%.

Hand hygiene results were part of the infection prevention and control (IPC) dashboard, which was

updated monthly and gave an overview of compliance with MRSA screening, infections, PPE and

cleaning of facilities. The dashboard provided divisional oversight and triggered further escalation

if required.

There was an infection prevention and control policy and the department had infection prevention

and control (IPC) link nurses for different areas. IPC nurses were available to support staff with

IPC related topics, undertake IPC reviews, offer advice and provide teaching.

Staff told us that all patients were screened pre-operatively for Methicillin Resistant

Staphylococcus Aureus (MRSA) in line with local policy. Data provided showed that the target of

100% compliance rate was met for the department in July 2018 to June 2019. Between July 2018

and June 2019, there had been no reported cases of MRSA infections, C. diff infections or E. coli

infections on the surgical ward.

Data submitted to the National Surgical Site Surveillance System showed a surgical site infection

(SSI) rate of zero for hip and knee operations in 2018. This was better than the national

benchmarks of 0.8% (hip) and 0.7% (knee).

Waste management practices were observed and complied with the hospital policy and good

practice guidelines for segregation of waste. Sharps bins were labelled and dated and bed linen

was bagged appropriately. Sluices were clean, tidy and well organised.

Decontamination of surgical equipment was outsourced to a certified external company providing

medical device reprocessing in line with the trust’s decontamination policy.


The service had suitable premises and equipment and looked after them well.


All areas we visited were well organised, clean and well lit. The elective surgery ward contained 20

beds; two bays with four beds and 12 single rooms. Men and women were accommodated in

separate bed bays. There were adequate shower and toilet facilities. There were curtains around

beds in bay areas to ensure privacy.

There were two operating areas. The orthopaedic operating area had three theatres, all with

laminar flow and adjacent anaesthetic rooms. The general operating area had six theatres for

elective day cases of different specialties. All theatre areas were well maintained and well

equipped. Storage cupboards were well stocked and organised. Theatre staff told us they checked

in advance to ensure equipment was available and met the needs of the surgical procedures

scheduled that day. Staff told us there were sufficient supplies of equipment and spare equipment

was always available. We saw documented daily checks carried out on equipment prior to use in

line with Association of Anaesthetists of Great Britain and Ireland (AAGBI) safety guidelines: Safe

Management of Anaesthetic Related Equipment (2009).

The stage one recovery area looked after patients immediately after surgery. Each bed space was

equipped with all necessary devices for monitoring and treatment. From here, patients were

transferred to separate stage two recovery areas, for female and male patients. Patients ready to

be discharged after day case surgery waited in a discharge lounge on the same floor, equipped

with comfortable seating. Patients undergoing orthopaedic procedures were usually transferred to

the ward from recovery.

Emergency equipment, including resuscitation trolleys on wards and in theatres, had been

checked and was ready for use. Tamper proof seals on resuscitation trolleys were present, as

required by trust policy and changed regularly. We saw completed checklists and a fully stocked

resuscitation trolley on the ward where we broke the seal to look at the contents. Records showed

that daily checks of medicines stock on the resuscitation trolleys had been performed to ensure

that they were fit for use in accordance with trust policy.

There was a trust wide management of medical equipment and devices policy to ensure that

medical devices met relevant safety and quality standards, were suitable for purpose and were

maintained in a safe and correct working condition and operated competently in accordance with

required standards and procedures.


Staff completed and updated risk assessments for each patient.

There were processes in place to reduce the risks to patients undergoing surgery. These included

the use of the World Health Organisation (WHO) surgical safety checklist, a tool to improve the

safety of surgery.

During our inspection, we witnessed two cases in theatres where safety checklist steps were

completed correctly.

The five steps to safer surgery audit results provided by the trust showed 100% implementation

rate for July 2018 to June 2019. Compliance rates for the completed steps of the checklist were

100%, except for brief/debrief, which showed a 97% compliance during the same period.

Patients attended a pre-assessment visit prior to their operation date. During this appointment,

clinical specialist nurses discussed risk factors and referred patients into services if appropriate,

for example diabetes specialist services.


All surgical procedures were consultant-led. Patients were reviewed by a consultant surgeon or

consultant anaesthetist irrespective of pre-operative mortality risk.

The hospital had a major haemorrhage protocol in place in case of major blood loss and urgent

need for blood transfusion. Blood for transfusion was not stored on site as the risk profile of

patients undergoing surgery at this hospital was low.

Nursing staff recorded and monitored patients’ clinical observations in line with National Institute of

Clinical Excellence (NICE) guidance. The hospital wards used the National Early Warning Score 2

(NEWS2) to identify deteriorating patients. The National Early Warning Score 2 (NEWS2) is a

scoring system that identifies patients at risk of deterioration or needing urgent review.

Observations were recorded on paper charts in patients’ records together with the calculated level

of risk. The service undertook monthly NEWS2 snapshot reviews. Results showed a compliance

rate of 100% in July 2018 to June 2019 for the surgical ward. We looked at NEWS2 charts in

patient records and found them to be completed correctly.

Staff used a sepsis pathway, which was included in the NEWS2 patient observation chart,

together with an acute kidney injury pathway. The service offered sepsis training for staff and there

was a sepsis standard operating procedure and flowcharts for staff to follow in case of suspected

sepsis, based on national guidance. Staff on the wards showed us sepsis boxes which contained

immediate equipment needed in suspected sepsis.

Staff told us that if they had concerns relating to a patient’s condition, an on-site surgical junior

doctor would be called to assess the patient. If appropriate, staff would inform the patient’s

consultant or the site practitioner team who received referrals for patients who had deteriorated

based on their NEWS2 score and in accordance with the hospital escalation plan. The site

practitioner nurse reviewed and escalated patients for admission to critical care and followed a

standard operating procedure.

There was a daily safety brief in the morning to share information within the teams and identify the

resuscitation team. There were resuscitation and difficult airway trolleys available and staff knew

where they were located.

There were internal and cross-site bed management meetings every day to discuss patient

admissions, cancellations, bed capacity and patient discharges. We witnessed one of those

meetings and it was well structured, succinct and relaxed in atmosphere. It was attended by the

site manager, theatre coordinator, matron and nurse in charge of surgical ward.

Staff completed risk assessments for every patient upon admission using risk assessment tools.

Patients were assessed for risk of falls, malnutrition, moving and handling, pressure ulcers, and

venous thromboembolism (VTE). We saw examples of prescribed prophylaxis treatment for

prevention of VTE in patient records we reviewed. Data provided showed 100% compliance rate

for VTE risk assessment compliance in July 2018 to June 2019 for the surgical ward.

Adult basic life support was part of mandatory training for nursing staff and data provided showed

that training compliance met trust target. Recovery staff and doctors were trained in immediate life

support (ILS) or advanced life support (ALS), however, the trust did not provide completed training

rates. All staff that participated in the cardiac arrest bleep were ALS trained.

Nurse staffing


The service had nursing staff with the right mix of qualification and skills, to keep patients

safe and provide the right care and treatment. However, nurse vacancy rates were above

trust target.

From April 2018 to March 2019, the breakdown of WTE staff in post in surgery at Central Middlesex Hospital is shown in the table below.




Annual vacancy

rate

Annual turnover

rate

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

Qualified nurses

177.3 22.4% 18.1% 7.5% 8,652 (3.5%)

14,945 (6.0%)

35,423 (14.2%)

Nursing assistants

54.8 -3.4% 7.8% 5.1% 11,008 (13.9%)

0 (0.0%)

0 (0.0%)


3.3 -7.8% 19.9% 0.5%

Vacancy rates:

Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Central Middlesex Hospital showed an upward trend from April 2018 to August 2018 and from November 2018 to March 2019.


Monthly vacancy rates from April 2018 to March 2019 for nursing assistants in surgery at Central Middlesex Hospital were not stable and may be subject to ongoing change.

Sickness rates

Monthly sickness rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Central Middlesex Hospital showed a downward trend from April 2018 to September 2018. Bank, locum and agency staff usage:


Monthly bank hours from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Central Middlesex Hospital were not stable and may be subject to ongoing change.

Monthly agency hours from April 2018 to March 2019 for qualified nurses, health visitors and midwives in surgery at Central Middlesex Hospital showed a shift from October 2018 to March 2019. (Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Nursing bank agency and Medical locum tabs) The nursing team on the ward monitored staffing levels every day. This information was updated

daily on a quality board, which was displayed at the ward entrance. In case of staff shortage,

managers would take actions, such a requesting temporary staff or moving staff from other areas.

The service used a safer nursing care tool to calculate nurse establishment numbers and review

staffing levels.

Staffing for all surgical areas was discussed at a local safety huddle every morning where acuity,

dependency and staffing numbers were reviewed. The meetings were chaired by the head of

nursing or matron. Staffing was flexed in advance based on surgical activity and staff would

transfer cross-site as required.

The chief nurse received a monthly safe staffing report for all areas with actions taken and

presented it to the trust board. The safe staffing report of March 2019 showed fill rates of 105%


and 99% for day and night nurse shifts on the surgical ward. Fill rates for nurse staff were 97% for

the pre-assessment unit, 77% for theatre admission unit, 105% for theatres and 91% for recovery.

During our inspection, the ward, recovery and theatres were safely staffed with enough nurses and healthcare assistants (HCAs). Staffing rotas we looked at confirmed this and allowed for required rest periods. Theatre duty rotas showed that the staffing levels during surgical procedures was compliant with recommendations from the Association for Perioperative Practice (AFPP). There was an overseas nurse recruitment programme to help reduce vacancies. We spoke with international nurses on the surgical ward who commended the support and training they had experienced.

Medical staffing

The service had enough medical staff, with the right mix of qualification and skills, to keep

patients safe and provide the right care and treatment.




Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

Medical staff 12.3 9.4% 47.8% 4.3% 0

(0.0%) 0

(0.0%) 2,574

(18.8%)

** The trust confirmed that the medical staffing turnover figures included planned rotation, which inflated the rate.

Monthly vacancy rates from April 2018 to March 2019 for medical staff in surgery at Central Middlesex Hospital showed a shift from October 2018 to March 2019.


Monthly sickness rates from April 2018 to March 2019 for medical staff in surgery showed a downward trend from November 2018 to March 2019. Staffing skill mix for the whole-time equivalent staff working at London North West University Healthcare NHS Trust: This


Consultant 42% 49%



Junior* 11% 11%



In January 2019, the proportion of consultant staff reported to be working at the trust was lower than the England average and the proportion of junior (foundation year 1-2) staff was the same. Medical staffing levels in theatres complied with the standards of the AfPP. Junior doctors at various levels covered the ward 24-hours, seven days a week. There was 24-hour, seven day a week on-call rota for consultant surgical cover on site. An anaesthetic registrar provided cover on site 24 hours, seven days a week. For theatre cases out of hours an anaesthetic consultant was available on call.


Medical staff performed daily ward rounds in the morning and afternoon. Staff on the wards felt supported by doctors and told us there was senior medical support available when needed. The increase in medical staffing vacancy rate was explained by anaesthetic consultants retiring around the same time and the difficulty of recruiting into these posts. Recruitment processes were in place and ongoing.

Records

Staff kept detailed records of patients’ care and treatment.

The hospital utilised a combination of electronic and paper records. Admission notes, risk

assessments, care plans, observations, nursing or medical documentation, consent forms and

anaesthetic protocols were kept in paper records. Imaging and blood test results were stored

electronically. Paper records were stored appropriately in lockable trolleys or cupboards and

electronic records were not left on screens. Access to the computers and patient confidential

information was password protected, with staff having access via personal logins and passwords.

Bank and agency staff were given login access before starting their work to allow them to access

information.

Care plans were individualised or based on a surgical pathway. We reviewed 11 patient records

and found them to be complete with observations, vital signs, care plans, risk assessments and

documentation by nursing, allied health professions and medical staff.

Staff used paper drug prescription charts. We saw allergy status documented in five prescription

charts we reviewed.

Care summaries were sent out to the patient’s GP on discharge to ensure continuity of care within

the community. Patients also received a copy of their discharge letter with their latest medication

prescription to share with the GP.

Within theatres, there was a standard operating procedure, which outlined the process for

documenting and tracing surgical implants. The implant details including the unique serial number

were recorded in the patient record.

Medicines

The service followed best practice when storing, prescribing, giving and recording

medicines.

There was a trust policy for the safe and secure handling of medicines in clinical areas, which

outlined measures to ensure that storage and handling of medicines throughout the trust met

necessary legal requirements.

Medicines were stored securely in locked trolleys and doors were locked to treatment rooms with

access restricted to appropriate staff. Controlled drugs were stored securely and managed

appropriately. We checked CD registers and found appropriate record-keeping regarding checks

and administration.

We found medicines and fluids were stored neatly and securely in cupboards within a locked clinic

room, including medicines which needed to be stored in refrigerated conditions. The treatment

rooms were clean and had adequate handwashing facilities available, as well as adequate space

to prepare medicines. There were appropriate facilities for the disposal of medicines.


We saw that nursing staff introduced themselves to patients before offering them medicines, they


visited the surgical wards Monday to Friday to review prescriptions and advise medical staff when

doses needed to be revised. The pharmacist reviewed medicines and information provided to

discharged patients. Pharmacists did not routinely visit recovery areas, but staff were able to

contact pharmacists for advice if required.

We made observational checks with respect to ordering, storage, administration and disposal of

medicines on the surgical ward, in recovery and theatres. Staff on the ward told us there was daily

contact with a pharmacist.

Cupboards were organised and drugs were in date in all surgical areas we visited. Room and

fridge temperatures in clinical treatment rooms were digitally measured and controlled. Medicines

were stored at appropriate temperature range including medicines which needed to be stored in

refrigerators. We saw documentation of room and fridge temperatures within the recommended

ranges for the previous weeks. Staff knew who to contact if temperatures were out of

recommended range.




Nursing staff used Patient Group Directions (PGDs) to give medicines in recovery. There was a

procedure in place to review them. PGDs are written instructions which allow specified healthcare

professionals to supply or administer particular medicines in the absence of a written prescription.

We checked PGD’s being used by the nursing team and saw this was being used effectively to

support patient access to pain relief in a timely way.

Medicines management audit results showed 99% compliance rate for the ward and 100% for

theatres between July 2018 to June 2019.

Medicine management training for nursing staff showed 83% compliance rate at the time of

inspection.

Prescribing, including regular medicines, as required, and take-home items, was undertaken by

medical staff. We looked at five prescription charts and found no delayed or omitted doses of

medication. Allergies were clearly documented in the prescription charts.

There was an antibiotic stewardship programme run by the pharmacy team. Data provided

showed that the trust wide target of 90% prescriptions reviewed was met in 2018.

Incidents

The service managed patient safety incidents well.

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

From May 2018 to April 2019, the hospital reported two never events for surgery, details of which are below:


Date of incident

Site Never Event type


Wrong implant/prothesis


Retained foreign object


One of the never events occurred during a hip replacement procedure and resulted in a femoral head and socket mismatch. The root cause identified in the investigation was the failure to follow standard operating procedures for implantation of prosthesis. Lessons learnt and recommendations were documented and shared among the teams.

Trust level: In accordance with the Serious Incident Framework 2015, the hospital reported 3 serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from May 2018 to April 2019. Central Middlesex Hospital:


Percentage of total



Total 3 100.0%

(Source: Strategic Executive Information System (STEIS)) The hospital used an electronic incident reporting system. All staff we spoke with were familiar

with how to report incidents on the system.

Incident feedback was shared in monthly team meetings for the wards and theatres and were

attended by allied health professionals, nursing and medical staff. New incidents and shared

learning from previous incidents were shared with staff through emails, newsletters, at safety

huddles and departmental meetings. Learning from incidents was shared trust wide, for example

theatre staff were aware of details of a never event that had occurred at the other site.

Incidents were reviewed at the divisional quality and safety meetings. Trust-wide issues were

monitored every month at executive level through the SI monitoring report and the quality report,

which included actions to support improvement.

The service reported 432 clinical incidents for surgical services at Central Middlesex Hospital in

July 2018 to June 2019, including 60 near miss incidents. There were 353 incidents (82%)

resulting in no or low harm, 17 resulting in moderate harm and two resulting in severe harm.

Serious incidents (SI) are those that require investigation. Evidence submitted relating to the

occurrence of SI demonstrated that a root cause analysis (RCA) investigation of the SI was

undertaken. Recommendations were made following the investigation. We saw two examples of

comprehensive RCA undertaken following never events, including shared learning,

recommendations and action plan. The RCA reports were presented at clinical governance and

staff meetings.


The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of ‘certain

notifiable safety incidents’ and provide reasonable support to that person. Staff we spoke with

were aware of the requirements and we found that it was embedded into practice in the service.

We saw one example of duty of candour being applied and handled with according to regulations

with letters containing an explanation of the situation and apology.

Mortality and morbidity (M&M) meetings took place regularly to discuss cases when patients had deceased. Deaths were reviewed, lessons learned and actions were documented and shared. We saw minutes of M&M meetings of different surgical specialities, which we found well attended and comprehensive.

Safety thermometer

The service used safety monitoring results well.

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection took place one day each month. Data from the Patient Safety Thermometer showed that the trust reported 34 new pressure ulcers, five falls with harm and five new catheter urinary tract infections from March 2018 to March 2019 for surgery. Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter acquired urinary tract infections at London North West University Healthcare NHS Trust:

1


2

Total Falls (5)

3

Total CUTIs (5)






The service provided care and treatment based on national guidance and evidence of its

effectiveness.

Medical staff followed local guidelines and policies, based on National Institute for Health and

Care Excellence (NICE), Association of Anaesthetist of Great Britain and Ireland (AAGBI) and

Royal College guidelines. The policies we reviewed confirmed this and were within date. Staff had

access to most recent guidelines and policies on the trust wide intranet. There were local audits

with respect to high impact interventions, for example intravenous cannulation. The service’s audit

programme also contained various national audits for different surgical specialities.

Surgical services were managed in accordance with National Confidential Enquiry into Patient

Outcome and Death (NCEPOD) recommendations, for example, all elective high-risk patients

were seen by anaesthetist and fully investigated in pre-assessment clinics.

We observed staff following local policies and procedures based on AfPP 2016 guidance with

respect to swab counts, as well as surgical instrumentation. Policies were readily available to staff

in key areas, including on the intranet.

Within the theatre areas, we observed that staff adhered to the NICE guidelines CG74, which

relate to surgical site infection prevention, following recommended practice with respect to

minimising the risk of surgical site infections.

There was a sepsis standard operating procedure and flowcharts for staff to follow in case of

suspected sepsis. Staff utilised a sepsis pathway, which was included in the NEWS2 patient

observation chart.


Staff gave patients enough food and drink to meet their needs and improve their health.

Nutritional needs of patients were assessed by nursing staff as part of the admission process in

the initial assessment and when patients’ circumstances changed. The wards used a nutrition

screening tool to assess patients for the risks of dehydration or malnutrition. Staff referred patients

to the dietitian team, if required. We saw completed malnutrition screening in the patient records

we reviewed.

Staff adhered to protected mealtimes on the ward for patients to encourage eating and provided

assistance where needed.

We saw that fluid balance charts were completed where patients had to have their fluid intake and

output measured and monitored.

Doctors prescribed medicine as needed to manage nausea and vomiting.

Staff had access to a nil by mouth policy with guidance for pre-operative fasting, providing

information regarding intake of fluid and food before elective surgery.


The service had scheduled to undertake a three-month audit of fasting times for July 2019.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain.

Pre-operative assessment included information about the patient with respect to existing pain

management, such as the pain relief medicines they took. Appropriate pain relief was noted to be

prescribed for patients in the prescription charts that we looked at. The matron undertook monthly

quality walkabouts on the ward and one of the topics were about effective pain management. Data

provided showed a 100% score for the ward in the last 12 months.

The patients we spoke with confirmed that they had been asked about their pain and had been

given pain relief in a timely manner.

Some patients were prescribed patient controlled analgesia, which is a method of allowing the

patient in pain to control their infusion pump, for example morphine. Doctors reviewed this

postoperatively.

Staff utilised a 0-10 pain score and we saw evidence of documentation in patient records we

reviewed. Different pain assessment tools were in use for different patient requirements, for

example patients with cognitive impairment or limited English.

There was a pain management team available by referral if needed. All nursing or medical staff

could make referrals and staff confirmed there was good access. Pain link nurses were trained to

provide advice and support for the ward.

Patient outcomes

Managers monitored the effectiveness of care and treatment and used the findings to

improve them.

From January 2018 to December 2018, all patients at the trust had a similar to expected risk of readmission for elective admissions when compared to the England average. Urology patients at the trust had a similar to expected risk of readmission for elective admissions when compared to the England average. Colorectal surgery patients at the trust had a higher than expected risk of readmission for elective admissions when compared to the England average. General surgery patients at the trust had a lower than expected risk of readmission for elective admissions when compared to the England average. Elective Admissions – Trust Level:



All patients at the trust had a similar to expected risk of readmission for non-elective admissions when compared to the England average. General surgery patients at the trust had a similar to expected risk of readmission for non-elective admissions when compared to the England average. Trauma and orthopaedics and ear, nose and throat (ENT) patients at the trust had higher than expected risks of readmission for non-elective admissions when compared to the England averages. Non-Elective Admissions – Trust Level:


(Source: Hospital Episode Statistics - HES - Readmissions (01/01/2018 - 31/12/2018)) Central Middlesex Hospital: From January 2018 to December 2018 all patients at Central Middlesex Hospital had a higher than expected risk of readmission for elective admissions when compared to the England average. Trauma and orthopaedics, ophthalmology and general surgery patients at Central Middlesex Hospital had a higher than expected risks of readmission for elective admissions when compared to the England averages. Elective Admissions - Central Middlesex Hospital:

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity

All patients at Central Middlesex Hospital had a similar to expected risk of readmission for non-


elective admissions when compared to the England average. The table below summarises the trusts performance in the 2018 National Bowel Cancer Audit.


Trust performance


Meets national

standard?


88.9% Good Good is over

80%

Risk-adjusted post-operative length of stay >5 days after major resection (A prolonged length of stay can pose risks to patients)

77.9% Worse than

national aggregate

No current standard

Risk-adjusted 90-day post-operative mortality rate (Proportion of patients who died within 90 days of surgery; post-operative mortality for bowel cancer surgery varies according to whether surgery occurs as an emergency or as an elective procedure)

2.3% Within

expected range

No current standard

Risk-adjusted 2-year post-operative mortality rate (Variation in two-year mortality may reflect, at least in part, differences in surgical care, patient characteristics and provision of chemotherapy and radiotherapy)

20.9% Within

expected range

No current standard

Risk-adjusted 30-day unplanned readmission rate (A potential risk for early/inappropriate discharge is the need for unplanned readmission)

16.2% Worse than expected

No current standard

Risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection (After the diseased section of the bowel/rectum has been removed, the bowel/rectum may be reconnected. In some cases, it will not and a temporary stoma would be created. For some procedures this can be reversed at a later date)

48.5% Within

expected range

No current standard

(Source: National Bowel Cancer Audit) The table below summarises the trust’s performance in the 2018 National Vascular Registry.


Trust performance


Meets national

standard?

Abdominal Aortic Aneurysm Surgery (Surgical procedure performed on an enlarged major blood vessel in the abdomen)

Case ascertainment (Proportion of eligible cases included in



the audit)

Risk-adjusted post-operative in-hospital mortality rate (Proportion of patients who die in hospital after having had an operation)


range

No current standard

Carotid endarterectomy (Surgical procedure performed to reduce the risk of stroke; by correcting a narrowing in the main artery in the neck that supplies blood to the brain)



Crude median time from symptom to surgery (Average amount of time patients wait to have surgery after the onset of their symptoms)

5 days Not applicable ✓

Risk adjusted 30 day mortality and stroke rate (Proportion of patients who die or have a stroke within 30 days of their operation)


range

No current standard

(Source: National Vascular Registry) The table below summarises the trust’s performance in the 2018 National Oesophago-gastric Cancer Audit.


Trust performance


Meets national

standard?

Trust-level metrics (Measures of hospital performance in the treatment of oesophago-gastric (food pipe and stomach) cancer)


>90% Better No current standard

Age and sex adjusted proportion of patients diagnosed after an emergency admission (Being diagnosed with cancer in an emergency department is not a good sign. It is used as a proxy for late stage cancer and therefore poor rates of survival. The audit recommends that overall rates over 15% could warrant investigation)

1.0% Better No current standard

Risk adjusted 90-day post-operative mortality rate (Proportion of patients who die within 90 days of their operation)

Not eligible Not

applicable No current standard

Cancer Alliance level metrics (Measures of performance of the wider group of organisations involved in the delivery of care for patients with oesophago-gastric (food pipe and stomach) cancer; can be a marker of the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results. Contextual measure only.

Crude proportion of patients treated with curative intent in the Cancer Alliance

41.5% Similar No current standard


(Proportion of patients receiving treatment intended to cure their cancer)

(Source: National Oesophago-Gastric Cancer Audit)

The table below summarises London North West University Healthcare NHS Trust performance in the 2018 National Ophthalmology Database Audit. (Audit of patients undergoing cataract surgery)


Trust performance


Meets national

standard?

Trust-level metrics (Measures of hospital performance in the treatment of cataracts


92.2% Not available No current standard

Risk-adjusted posterior capsule rupture rate (Posterior capsule rupture (PCR) is the index of complication of cataract surgery. PCR is the only potentially modifiable predictor of visual harm from surgery and is widely accepted by surgeons as a marker of surgical skill.

0.6% Within

expected range

No current standard

Risk adjusted visual acuity loss (The most important outcome following cataract surgery is the clarity of vision)

0.3% Within

expected range

No current standard

(Source: National Ophthalmology Database Audit) The service participated in the National Joint Registry. (Audit of hip, knee, ankle, elbow and shoulder joint replacements) Data for April 2017 to March 2018 showed that Central Middlesex Hospital performed 450 primary total knee replacements. This was higher than national average (228). In the same period, there had been 223 primary hip replacements. This was similar to national average (226). Primary knee and hip surgeries accounted for 93% of all surgical procedures in that period. Data showed that the 90-day mortality and revision rate were within expected range for primary knee and hip operations carried out at Central Middlesex Hospital between August 2013 and August 2018. (Source: National Joint Registry) In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations:

• Groin Hernias

• Varicose Veins

• Hip Replacements

• Knee replacements Proportions of patients who reported an improvement after each procedure can be seen on the


right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left. These changes are measured in a number of different ways, descriptions of some of the indicators presented are below. The visual analogue scale (EQ VAS) is asking to mark health status on the day of the interview on a vertical scale. The bottom rate (0) corresponds to "the worst health you can imagine", and the highest rate (100) corresponds to "the best health you can imagine". The EQ-5D-5L questionnaire has two parts. Five domain questions ask about specific Issues namely mobility self-care usual activities pain or discomfort anxiety or depression. The EQ-5D-5L uses 5 levels of responsiveness to measure problems. The range is; no problem - disabling/extreme. The Oxford Hip Score (OHS) is a patient self-completion report on outcomes of hip operations containing 12 questions about activities of daily living, a simple scoring and summing system provides an overall scale for assessing outcome of hip interventions.

In 2016/17 performance on groin hernias was worse than the England average for both indicators. For hip replacements, performance was better than the England average for the EQ VAS score, worse than the England average for the EQ-5D index and similar to the England average for the Oxford Hip Score. For knee replacements performance was better than the England average for the EQ VAS score and worse than the England average for the EQ-5D and Oxford Knee Score. For varicose veins, performance was worse than the England average for the Aberdeen Varicose Vein Questionnaire and EQ VAS score and about the same as the England average for the EQ-5D index. (Source: NHS Digital)

Competent staff

The service made sure staff were competent for their roles. Managers did not always

effectively appraise all staff’s work performance.


Trust level: From April 2018 to March 2018, 87.1% of required staff in surgery received an appraisal compared to the trust target of 85.0%. The breakdown by staff group can be seen in the table below:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)




technical 48 56 85.7% 85.0% Yes





All staff groups 1,045 1,200 87.1% 85.0% Yes

In surgery four of the seven staff groups met the trust target, including nursing and medical staff. Central Middlesex Hospital: From April 2018 to March 2018, 88.9% of required staff in surgery at Central Middlesex Hospital received an appraisal compared to the trust target of 85.0%. The breakdown by staff group can be seen in the table below:

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Allied health professionals 3 3 100.0% 85.0% Yes



technical 10 11 90.9% 85.0% Yes





At Central Middlesex Hospital four of the six staff groups met the trust target, including nursing and medical staff. (Source: Routine Provider Information Request (RPIR) – Appraisal tab) All new staff, including agency staff underwent a local induction and orientation before starting

their roles. We were shown evidence of induction documentation for staff during our inspection.


Staff were supernumerary and did not work out of hours during the first four weeks. They were

given competency books and were assigned a mentor and a buddy for additional support.

Practice development nurses were available for staff to support them in achieving competencies or

training goals. Staff we spoke with said they had good access to their practice development

nurses and felt supported.

There were clinical education training courses for registered nurses and healthcare support

workers. Leadership programmes were offered for experienced nurses. There were opportunities

to undertake post registration courses such as mentorship, orthopaedic nursing, master level

degrees or attendance at conferences.

The trust offered an operating department practitioner apprenticeship where trainees rotated

across theatres on all sites.

Different theatre band five nurses told us they had good support and back-up if needed and were

not left in theatres without a senior member of staff. Another member of staff told us about being

supported completing a masters module. Junior doctors had protected training sessions twice a

week.


Staff of different kinds worked together as a team to benefit patients.

We saw evidence of multidisciplinary team (MDT) working in patient records we reviewed. Nurses

reported good access to and effective support from doctors, physiotherapists, dietitians,

occupational therapists and the pharmacy team.

Multi-disciplinary ‘huddle’ meetings took place in theatres daily, during which performance was

discussed, as well as bed availability and cancellations.

A multi-professional therapy team provided input to patients within the department and consisted

of physiotherapists, occupational therapists, dietitians and complex discharge co-ordinators. A

multidisciplinary meeting took place every morning on the ward to discuss patients. It was held by

the nurse in charge, together with the physiotherapist and the occupational therapist.

Staff involved social care workers and community healthcare services when planning discharge of

patients with complex needs. Discharge planning was initiated after admission for all patients, staff

referred to a dedicated discharge team if required. All patients were discharged with a letter

containing clinical information about their hospital stay, which could be shared with the GP. The

letter contained telephone numbers to contact in case of any further questions or queries.

Seven-day services

There was 24-hour, seven day a week on-call rota for consultant surgical and anaesthetic cover

on site. Junior doctors at different levels of training were on site 24 hours a day and seven days a

week. An anaesthetic registrar provided cover on site 24 hours, seven days a week. For theatre

cases out of hours an anaesthetic consultant was available on call.

The service provided a daily unplanned theatre service, with an on-call theatre team.

Physiotherapy, occupational health, dietitian and speech and language therapy services were

available Monday to Friday from 8.30am to 4.45pm. Physiotherapists also covered the wards on


weekends on site and on-call out of hours. An occupational therapist was available on site on

Saturday mornings.

The pharmacy service was available Monday to Friday from 8.30am to 5pm and Saturdays from

9am to 3pm. Outside of these times, there were two on-call pharmacists available for advice and

support.

There was 24 hours, seven days a week access to diagnostic imaging.

Health promotion

Patients told us they were given instructions for pre- and post-operative exercises to do at home.

This was also part of the joint school, where orthopaedic patients received information about their

hip or knee replacement.


Staff understood how and when to assess whether a patient had the capacity to make

decisions about their care.

Trust level:


A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for qualified nursing staff in surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


303 321 94.4% 85.0% Yes


In surgery the target was met for both of the MCA and DoLS training modules for which qualified nursing staff were eligible.

A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 at trust level for medical staff in surgery is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



162 329 49.2% 85.0% No

In surgery the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible.



A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for qualified nursing staff in surgery at Central Middlesex Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



26 27 96.3% 85.0% Yes

In surgery the target was met for both of the MCA and DoLS training modules for which qualified nursing staff at Central Middlesex Hospital were eligible. A breakdown of compliance for MCA and DoLS training modules from April 2018 to March 2019 for medical staff in surgery at Central Middlesex Hospital is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


1 1 100.0% 85.0% Yes


In surgery the target was met for one of the two MCA and DoLS training modules for which medical staff at Central Middlesex Hospital were eligible, however it should be note that this related to one member of eligible staff. (Source: Routine Provider Information Request (RPIR) – Training tab) Senior staff we spoke with were aware of the principles of Deprivation of Liberty Safeguards

(DoLS) and the relevance to their patients. However, staff told us they rarely came across it and

had not issued one in the past year.

Staff were aware of best interest’s decisions in accordance with legislation when patients lacked mental capacity to decide. They were able to explain best interest decisions, when to apply and where to document this. Staff understood the relevant consent and decision-making requirements of legislation and guidance including the Mental Capacity Act 2005. We observed staff obtaining consent from patients before care was delivered. The trust’s consent policy was based on Department of Health and Royal College of Surgeon’s guidance documents and referenced relevant legislation including the Human Rights Act 1998, Human Tissue Act 2004 and the Mental Capacity Act 2005. Staff supported patients to make informed decisions about their care and treatment. They followed


Written consent was obtained on the day of surgery by the patient’s surgeon. Patients we spoke

with confirmed they had completed a consent form and had received a full verbal and written

explanation of their care and treatment beforehand during the initial consultation and the pre-

assessment. Patient notes contained a copy of patients’ consent forms. The 11 sets of notes we

reviewed confirmed that all consent to surgical procedure forms were signed, dated and legible.

But not all included the risks and benefits of the procedure the patient was undergoing. However,


a consent form audit showed 100% compliance rate for completion of consent forms in April to

June 2019.

There were checks that consent had been obtained on arrival in theatre and before the

administration of anaesthesia. This was in accordance with the World Health Organisation (WHO)

surgical safety checklist and best practice guidance.


Compassionate care

Staff cared for patients with compassion.

Staff treated patients in a caring and compassionate manner. We observed staff being kind,

respectful and polite when speaking to patients and delivering care. The patients and relatives we

spoke with provided positive feedback about the treatment and care they received from the

hospital staff and commended the “brilliant nursing staff” being “out of this world”. One patient said

about the team: “Lovely, good quality people”.

We observed that patients’ privacy and dignity were respected in theatres as well as on the wards.

Curtains around bed spaces were drawn when patients received care and patient details were not

openly displayed.

The friends and family test (FFT) asked patients how likely they were to recommend the hospital

to friends and family if they needed similar care or treatment. The answers for July 2018 to June

2019 showed an average of 96% for the surgical ward with a response rate of 36%.

Patients received comment cards to fill in with positive or negative comments upon admission. We

saw thank you cards and positive comments displayed in ward areas we visited. This meant that

patients had taken the time to thank staff in writing.

Compassionate care was part of the trust’s vision and staff said this was included in their

supervisions, appraisals and team meetings.

Emotional support

Staff provided emotional support to patients to minimise their distress.

All the patients and relatives we spoke with told us they felt supported throughout their journey.

Patients said the support provided by staff from consultation, pre-assessment and surgical

intervention was good. Patients told us that this included both the clinical and non-clinical staff. A

patient told us that staff helped him feel relaxed.

Patients said that when they needed psychological support staff had organised for them to see the

mental health team or a psychologist.

The palliative specialist care team provided emotional support as part of the end of life care pathway

and ensured this continued as part of patient’s care plan if they were discharged to a hospice or

home.

Staff knew how to access multi-faith spiritual support through the chaplaincy and spiritual service

on site, available for patients and relatives. Chaplains visited patients and their families on request

and there was a quiet room in the hospital.



Staff involved patients and those close to them in decisions about their care and treatment.

We saw staff explaining to patients and their relatives about the care and treatment that was being

provided. Patients informed us that they were given sufficient information both pre- and post-

procedure. Patients and their relatives told us that they could ask staff about their care and

treatment. The patients we spoke with felt involved in decision making and repeated that

communication was very good.

During our observations of ward rounds we saw doctors introduced themselves to patients and explained what they were doing and why. Similarly, nurses introduced themselves when meeting patients for the first time and explained the care they were about to provide. During our observations of care in theatres we saw staff consistently reassured patients to put them at ease and encouraged them to ask questions about their planned procedure.

A patient on the ward told us that he was seen daily by his doctors who took time to explain his

treatment and answer questions.

Each bed space had wipe clean boards with the names of staff looking after them written on them

each day. We saw consultants’ names on boards near patients’ beds and patients we spoke with

knew who their named consultant was.



The trust planned services in a way that met the needs of local people.

Surgical services provided care to elective patients with pre- and peri-operative low risk profile.

Admissions were planned in advance and predominantly day cases. Patients with high risk profile

were admitted to Northwick Park Hospital.

The hospital did not provide level three care. The service had four extended recovery beds with

one-to-one nursing care for patients requiring closer monitoring postoperatively. Patients

unexpectedly requiring level two or three care for more than 24 hours postoperatively were

transferred to Northwick Park Hospital. Staff told us that this was a rare occurrence.


The service took account of patients’ individual needs.

Staff told us they were aware of different requirements of patients with special needs undergoing

surgery. For example, ophthalmology patients were offered extra assistance and were given a

cubicle close to the operating area waiting for the procedure.

Staff could access interpreters for patients whose first language was not English by contacting in-

house interpreters, or through a telephone interpreting service.

Dementia awareness training was part of trust corporate induction, which all staff attended when

starting to work. There was generally good ward staff awareness about patients living with

dementia and staff were aware that caring for them required a different approach in some

instances. There were further information packs available for patients with cognitive impairment

and dementia link nurses were available for additional support.


Staff told us that patients with learning disabilities (LD) would normally arrive with their LD

passport, which held relevant information about the patient. Staff told us they would try to contact

the relevant carer or care worker to get information about the patient. Staff from the pre-

assessment team told us that they would see patients with LD very quickly and fast track them

through the clinic. Theatre staff told us they would be made aware of patients with learning

disability or living with dementia during pre-list briefs and information would be recorded on the

theatre list.

All surgical areas had wheelchair access and there were toilet facilities available with wheelchair

access on all floors.

Patients we spoke with were generally satisfied with the quality and variety of food, which was

available for different cultural or religious preferences.

Staff, patients and visitors had access to a multi-faith room within the hospital as well as a multi-

faith chaplaincy service.

Access and flow

People could not always access the service when they needed it. Waiting times from

referral to treatment were not always in line with national standards. However, the average

length of stay for elective surgery was shorter than the England average.

Trust Level – elective patients: From February 2018 to January 2019 the average length of stay for patients having elective surgery at the trust was 4.1 days. The average for England was 3.9 days. The average length of stay for patients having elective trauma and orthopaedics surgery at the trust was 3.2 days. The average for England was 3.7 days. The average length of stay for patients having elective colorectal surgery at the trust was 8.9 days. The average for England was 7.0 days. The average length of stay for patients having elective urology surgery at the trust was 2.1 days. The average for England was 2.5 days. Elective Average Length of Stay – Trust Level:


Trust Level – non-elective patients: The average length of stay for patients having non-elective surgery at the trust was 3.9 days. The average for England was 4.7 days.


The average length of stay for patients having non-elective general surgery at the trust was 3.0 days. The average for England was 3.7 days. The average length of stay for patients having non-elective maxillo-facial surgery at the trust was 1.0 days. The average for England was 1.6 days. The average length of stay for patients having non-elective trauma and orthopaedics surgery at the trust was 11.0 days. The average for England was 8.4 days. Non-Elective Average Length of Stay – Trust Level:


Central Middlesex Hospital - elective patients: From February 2018 to January 2019 the average length of stay for patients having elective surgery at Central Middlesex Hospital was 2.4 days. The average for England was 3.9 days.

From February 2018 to January 2019 the average length of stay for patients having elective trauma and orthopaedics surgery at Central Middlesex Hospital was 3.3 days. The average for England was 3.7 days. From February 2018 to January 2019 the average length of stay for patients having elective general surgery at Central Middlesex Hospital was 1.1 days. The average for England was 3.9 days. From February 2018 to January 2019 the average length of stay for patients having elective urology at Central Middlesex Hospital was 1.1 days. The average for England was 2.5 days. Elective Average Length of Stay - Central Middlesex Hospital:


Referral to treatment (percentage within 18 weeks) - admitted performance


Trust level: From March 2018 to February 2019 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was worse than the England average.

(Source: NHS England) Referral to treatment (percentage within 18 weeks) – by specialty Trust level: Two specialties were above the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.


Urology 81.9% 75.9%

Trauma & orthopaedics 70.8% 58.7%

Four specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery.


General surgery 48.3% 71.9%

Oral surgery 46.8% 56.8%

Ophthalmology 45.4% 64.9%

Ear, nose & throat (ENT) 28.9% 60.6%

Trust level: A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice Over the two years, the trust reported no cancelled operations where the patient was not treated with 28 days. Percentage of patients whose operation was cancelled and were not treated within 28 days - London North West University Healthcare NHS Trust:


Cancelled Operations as a percentage of elective admissions - London North West University Healthcare NHS Trust:

Over the two years, the percentage of cancelled operations at the trust was higher than the England average, following a similar trend to England over the four quarters. Cancelled operations as a percentage of elective admissions only includes short notice cancellations. (Source: NHS England) The trust reported that although they monitor patient moves including multiple ward moves and step downs, data does not identify ward moves due to non-clinical reasons therefore figures for this section have not been provided. (Source: Routine Provider Information Request (RPIR) – Ward moves tab) From April 2018 to March 2019, there were 851 patients moving wards at night within surgery. A breakdown of numbers of moves by site and ward is in the table below.



St Marks Hospital 101 11.9%



Total 851 100.0%




Abbey suite 1 rooms 1-5 2 100.0%

(Source: Routine Provider Information Request (RPIR) – Moves at night tab)

Theatre utilisation rate was an average of 72 % between April 2018 and March 2019.

Consultants saw patients in clinics and referred them for surgical procedures. Bookings were

made by the trust’s scheduling service. Orthopaedic procedures were often planned with

postoperative ward care, other specialties offered day case surgeries.

The surgical pre-assessment clinic was nurse led. Appointments were offered on five days a week

where patients underwent medical clerking, blood tests or imaging in preparation for surgery.

Patients were referred for further tests or specialist review. An anaesthetist led clinic reviewed

patients two or three times a week as requested by the team.

Patients undergoing surgery would usually be admitted on the day of surgery. Administration staff

phoned patients three days before admission to help reduce cancellations.

Patients were seen on the surgical admissions unit on the day of surgery. However, staff told us

that the order of patients on the theatre lists was decided on the day and theatre lists were not re-

printed. This could potentially lead to sending the wrong patient to theatres. However, staff told us

that communication between surgical admission and theatres was good, staff were aware of the

order of patients and a wrong patient had not been sent to theatres in the past.

Recovery was organised in two stages. All patients were initially transferred to recovery stage one.

From there, patients were transferred to the ward or recovery stage two, which comprised of

separate areas for female and male patients. Patients were then transferred to the discharge

lounge before going home.

The trust had an 18-week initiative to reduce the backlog of admissions especially in ENT and

general surgery and employed an external provider to perform surgeries on weekends. A

substantive member of staff was on site to support and act as a point of reference for any queries.

The services were monitored in monthly performance meetings with representation from clinicians

and operational staff looking at the KPIs as well as the outcomes from patients.

During the period July 2018 to June 2019, the hospital reported 11% (973 out of 8752) theatre

surgical procedure cancellations, including paediatrics. Reasons for cancellations were operation

not needed, bed capacity, equipment unavailable, patient did not attend, refused or feeling unwell.

One of the measures in place to reduce cancellations was the phone call three days before

admission.

Discharge arrangements were put into place as soon as possible in the patient journey. Staff told

us that assessments by physiotherapists or occupational therapists took place before discharge

and that the hospital’s discharge team would organise care packages when required. When

indicated, referrals to the district nursing team were arranged by the nurse in charge.

As part of the discharge process, patients were provided with medication to take home, the

discharge letter with clinical information and a follow-up appointment in the outpatient department.

The documents included phone numbers to call in case of problems or questions.



The service treated concerns and complaints seriously, investigated them and learned

lessons from the results, and shared these with all staff. However, not all were responded

to within the timeframe set by the trust.

From April 2018 to March 2019 the trust received 202 complaints in relation to surgery at the trust (18.3% of total complaints received by the trust). The trust took an average of 64.1 working days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be answered within 40 days. At the time of reporting 36 complaints were still open. These had been open for an average of 60.6 working days. A breakdown of complaints by type is shown below:


Percentage of total



29 14.4%






6 3.0%



2 1.0%


2 1.0%



Others 1 0.5%

Consent to treatment 1 0.5%

Total 202 100.0%

Central Middlesex Hospital: From April 2018 to March 2019 the trust received 30 complaints in relation to surgery at Central Middlesex Hospital. The trust took an average of 49.5 working days to investigate and close complaints, this was not in line with their complaints policy, which stated complaints should be answered within 40 days. At the time of reporting 11 complaints were still open. These had been open for an average of 62.6 working days. A breakdown of complaints by type is shown below:


Percentage of total






2 6.7%


2 6.7%


1 3.3%




Total 30 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab) From April 2018 to March 2019 there were 64 compliments received for surgery at the trust (33.9% of all received trust wide). Of these, 34 were at Northwick Park Hospital, two were at Central Middlesex Hospital and the remaining 28 were at other sites. The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab)

Complaints and learning were on the agenda of divisional quality and safety meetings and the

outcome of each investigation was shared with the staff involved. Case studies were presented by

investigating managers at the quarterly complaints working group, where peer support and

learning about the investigation process as well as the outcome could be identified. Complaints

and learning were also discussed at monthly team meetings.

Patient advice and liaison services leaflets and posters were visible in service areas and on the

wards, informing patients how to raise a concern or make a complaint. Leaflets were available in

different languages upon request.

Staff told us that, where possible, they would resolve any issues with patients informally, prior to a

formal complaint being made. Any concerns raised by patients on the wards would be addressed

immediately by the member of staff or escalated to the nurse in charge or matron. If possible,

issues were resolved immediately to patients’ satisfaction.


Leadership

Managers had the right skills and abilities to run a service providing high-quality

sustainable care.

The service was part of the surgery directorate of the trust’s surgery, critical care, outpatients & St.

Marks division. The divisional general manager, divisional director and divisional director of

nursing formed the clinical directorate leadership team for the service.

The theatre matron was responsible for theatres and theatre recovery areas and reported to the

director of nursing. A matron was responsible for the adult ward and reported to the director of

nursing. The ward manager was supported by a supernumerary nurse in charge. Staff informed us

they had good access to the managers, as they were very visible and had their offices within


clinical areas. Matrons undertook monthly walkabouts in their areas, which involved talking to staff

and patients.

Staff spoke highly of the support and leadership managers provided. Staff of all levels told us they

felt valued as team members and felt listened to. The immediate management team was

supportive and accessible. Staff received regular communications from the trust executive team

and there were open monthly meetings that staff could attend.

Vision and strategy




The service’s vision was committed to the trust’s goal of delivering outstanding care and patient

experience.

The strategy was aligned to the need to support a growing emergency pathway, to support an

aging population and to maintain and grow specialist services. The service opted to create a single

specialty elective surgical centre focused on orthopaedics and to create a multi-specialty elective

surgery hub, including sub-specialties in day surgery, minimally invasive and/or robotically

assisted procedures.

Staff had varying understanding of the service’s vision and strategy with senior staff being in

general more aware of it.

Culture

Managers were successfully promoting a positive culture that supported and valued staff.

However, the service did not monitor staff survey results at service or division level.

The trust took part in the annual NHS staff survey. Trust wide results showed that in 2018, about

22% answered they had experienced staff discrimination during the previous 12 months and 71%

believed the organisation provided equal opportunities for career progression or promotion.

However, the trust was not able to provide staff survey results by site.

During our inspection, we found an inclusive and constructive working culture within the surgery

service. Staff we spoke with felt that Central Middlesex Hospital was a good place to work.

Theatre staff from different areas told us that management had implemented positive changes and

that things had improved over the last two years. Nurses and doctors reported approachable and

supportive colleagues and described good teamwork and supportive managers. Consultants we

spoke with praised the supportive and close working relationship with their colleagues.

Staff we spoke with felt encouraged to develop and improve their skills. For example, they felt

supported by the trust to undertake training courses.

The trust had a whistleblowing policy in place and freedom to speak up guardians were available

for all staff to voice concerns.

Staff we spoke with were aware of the requirements of duty of candour and we found that it was

embedded into practice in the service. We saw two examples of duty of candour being correctly

applied.


Governance

The trust used a systematic approach to continually improve the quality of its services and

safeguarding high standards of care by creating an environment in which excellence in

clinical care would flourish.

There was a solid governance framework in place to support the delivery of the strategy and good

quality care.

Monthly divisional quality and safety meetings were chaired by the divisional director and reviewed

risks, incidents, outcomes, complaints, patient feedback and audits. We saw meeting minutes,

which showed high attendance and a comprehensive agenda including actions. Senior staff

disseminated learning and information in local meetings.

Different wards held monthly meetings to disseminate updates, learning and information. The

theatre user group had monthly meetings, chaired by the clinical lead, to discuss a fixed agenda,

for example equipment issues. Staff on the wards and in theatres told us that besides monthly

ward meetings, the daily team brief would be used to share updates, new incidents or feedback.

Divisional governance days were organised monthly with training sessions for staff, updates,

feedback and mortality meetings. We observed a governance day for theatres and found it to be

well attended, comprehensive and informative.

Incident reporting feedback sessions were held twice monthly for the wards and were attended by

allied health professionals, nursing and medical staff.

The trust shared feedback from serious incidents to all staff in a newsletter, which included shared

learning and any resulting changes to policies and procedures.


The trust had effective systems for identifying risks, planning to eliminate or reduce them,

and coping with both the expected and unexpected.

The surgical risk register was reviewed regularly and contained a description of the risk, ratings,

any controls in place, actions required, ownership, assurances, expected date of completion and

review dates. Managers and senior staff were aware of the risks in their service areas. All staff

could add risks to the register. Various meeting minutes evidenced that risk registers were

regularly reviewed, discussed and updated. Risks of the divisional risk register were reviewed at

monthly divisional quality and safety meetings and fed into the trust risk register.

The trust had a business continuity plan in place, as well as winter plan, which included discharge

support actions, promoting flu vaccination and collaboration with colleagues.

The trust had an annual audit programme with local and national clinical audits in relation to this

core service to improve performance and support safety. Audits were reviewed regularly at local

and divisional levels.


The trust collected, analysed, managed and used information well to support all its

activities, using secure electronic systems with security safeguards.


Confidential waste bins were available in each clinical and administrative area and information

security and governance was a part of the trust’s mandatory training. Staff followed

recommendations to prevent against data loss or breaches of confidentiality. For example, we

observed staff logging off computers before leaving the station.

Paper records contained patients’ clinical updates, reviews, theatre documentation and clinic

letters. The electronic patient record system contained clinical data about patients, including

laboratory test results, microbiology results, imaging reports and images.

Engagement

The trust engaged well with patients, staff, the public and local organisations to plan and

manage appropriate services and collaborated with partner organisations effectively.

The trust took part in the NHS annual staff survey. Data provided from 2018 NHS Staff Survey:

London Summary showed an overall engagement score of 3.75 for the trust. This had slightly

decreased (3.77) compared to 2017. However, the trust was not able to provide staff survey

results by site.

The trust actively sought patient feedback through the friends and family test (FFT) and patients

were given comment cards to fill in on admission.

The service organised monthly joint school sessions for patients undergoing hip or knee

replacement. The sessions had input from different allied health profession groups and gave

patients opportunity to receive detailed information and ask questions.


The trust was committed to improving services by learning from when things went well and

when they went wrong, promoting training, research and innovation.

The service offered shoulder surgery using regional anaesthesia with patients being awake. This

allowed for faster recovery and mobilisation.

The service took part in an ophthalmology project, led by NHS England’s elective care

transformation programme in collaboration with the Royal College of Ophthalmologists that

encouraged new ways of working. Central Middlesex Hospital was one of the first services to

introduce virtual glaucoma clinics to gather diagnostic information without the need for patients to

travel to the hospital. Patients were only called in for appointments if necessary and helped

provide people most at risk of sight loss get faster treatment while saving others unnecessary

journeys.

Services for children and young people The services for children and young people at Central Middlesex were mainly day surgery. This included surgery for ear, nose, throat (ENT), dental, removal of lumps and maxillofacial surgery. There were no overnight beds on-site. Therefore, the child’s expected recovery time must be four hours or less post operation. Patients were admitted to another hospital in the trust for unanticipated events leading to an overnight stay. The children’s ward, known as the Rainbow Unit operated two different clinics for paediatric patients on three different days. These clinics were for sickle cell anaemia and dietetics. The


service saw children from the age of two to 15 years and 365 days. Any child over the age of 16 would be seen in an adult setting. Children were seen at the hospital either for surgery or for an outpatient appointment in the Rainbow Unit. Children attending the hospital for surgery would visit Area One, for a preassessment, the Recovery Ward was used for children waiting for their surgery and post-surgery. The Recovery, Stage One, area was used to remove any breathing apparatus immediately post-surgery.

Facts and data about this service London North West University Healthcare NHS Trust provides a range of children’s services across all three hospital sites, with inpatient services predominately based at Northwick Park Hospital. Northwick Park Hospital:

• Jack’s place (27 beds)

• Neonatal unit and neonatal intensive care (23 beds)

• Special care baby unit

• Paediatric high dependency unit

• Paediatric day care (eight beds) – open Monday to Friday, 8am to 6pm

• Paediatric oncology

• Chaucer outpatients unit - open Monday to Friday, 8.30am to 5pm Ealing Hospital:

• Charlie Chaplin outpatients (ward 10 north) – open Monday to Friday, 8.30am to 6pm Central Middlesex Hospital:

• Rainbow children’s unit

• Ambulatory care and diagnostics (ACAD) paediatric pre-assessment unit.

• Theatres

• Pre-assessment known as Area One

• Recovery Stage One

• Recovery ward (Source: Routine Provider Information Request (RPIR) – Sites tab, Context acute tab) Trust level: The trust had 10,283 spells from February 2018 to January 2019. Emergency spells accounted for 63.5% (6,533 spells), 35.0% (3,596 spells) were day case spells, and the remaining 1.5% (154 spells) were elective. Percentage of spells in children’s services by type of appointment and site, from February 2018 to January 2019, London North West University Healthcare NHS Trust:


Total number of children’s spells by Site, London North West University Healthcare NHS Trust:

Site name Total spells

Northwick Park Hospital 8,872

Ambulatory Care & Diagnostics Centre 899

Ealing Hospital 295

St Mark's Hospital 199

Central Middlesex Hospital 18

This trust 10,283

England Total 1,147,968

(Source: Hospital Episode statistics)


Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone completed it at Central Middlesex hospital.

The mandatory training was comprehensive and met the needs of children, young people and

staff. Clinical staff completed training on clinical infection control, conflict resolution, information

governance, equality diversity and human rights, health and safety, fire safety, basic life support

and manual handling. Managers monitored mandatory training and alerted staff when they needed

to update their training. There was a structured induction programme that all staff completed when

they commenced employment. Staff we spoke with who had recently joined the service spoke

highly of the induction process.

The trust set a target of 85.0% for completion of mandatory training. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for qualified nursing staff in children’s services is shown below:



Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


Fire safety community clinical 6 6 100.0% 85.0% Yes









In children’s services the target was met for seven of the ten mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 at trust level for medical staff in children’s services is shown below:



Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)

Fire safety community clinical 2 2 100.0% 85.0% Yes



Health & safety 68 84 81.0% 85.0% No






In children’s services the target was met for two of the nine mandatory training modules for which medical staff were eligible. We requested data on sepsis 6 training for nursing staff and was given conflicting information. We were told from the surgical team that sepsis 6 training had been part of on-going training during ward huddles, quiet times and within clinical governance meetings. We were also told that Sepsis 6 was not recorded on the trusts training database and therefore there was no written record. However, senior divisional members of staff were able to provide data that showed that 91.67% of nurses in paediatrics had sepsis training. It was unclear if this was trust wide data. The trust only reported data for the ACAD paediatric surgical pre-assessment unit at this site. A breakdown of compliance for mandatory training courses from April 2018 to March 2019 for qualified nursing staff in children’s services at Central Middlesex Hospital is shown below:



Staff trained

Eligible staff

Completion rate

Trust Target

Met (Yes/No)









Manual handling - level 2 (face to face) 34 37 91.9% 85.0% Yes

In children’s services the target was met for all of the eight mandatory training modules for which qualified nursing staff at Central Middlesex Hospital were eligible. The trust reported no medical staff working within the ACAD paediatric surgical pre-assessment unit. (Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding

Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies to do so. Staff knew how recognise and report abuse and they knew how to apply it. However, the trust reported incomplete training records for safeguarding children level 3. Not all clinical staff working with children were trained in safeguarding children level 3. However,

we could see that plans were in place to ensure all staff received this training. Staff were booked

onto this training one at a time, as it was an all-day training event away from the hospital. This was

not in compliance with the appropriate level set out in the intercollegiate document Safeguarding

Children and Young People: roles and competencies for Health Care Staff published in March

2014.

Staff we spoke with were able to identify and report abuse and neglect. Staff knew who the

identifiable lead responsible for co-ordinating communication for children at risk of safeguarding

issues. All staff were familiar with the reporting policies at the hospital and had the safeguarding

lead contact information to hand.

There was a safeguarding supervision nurse and peer review doctors in place for all staff. Staff we

spoke with had an awareness of child sexual exploitation and female genital mutilation and

understood the law to detect and prevent maltreatment of children.

We spoke with the named doctor and named nurse for safeguarding. We were told that there was

a safeguarding steering group which was held monthly. However, we were informed that there

was no paediatric surgical representation from this hospital at this meeting. Minutes of the meeting

were sent to all the divisions and information was shared on the trust communication bulletin. We

spoke with a paediatric consultant who showed us examples of trust safeguarding peer review

reflections that were conducted every two months by staff, learning was shared with staff at the

trust. There had not been any safeguarding peer reviews for children and young people services

at the Central Middlesex hospital.

The trust had up to date policies on supervision, children’s safeguarding, domestic violence and

abuse, prevent and abduction. The safeguarding children strategy was last reviewed in April 2015

and was out of date.

Staff were able to recall the last time that they had raised a safeguarding concern.

Staff we spoke with in Recovery Stage One told us that children were cared for in a mixed four

bedded recovery bay with adults. Children stayed in Recovery Stage One for up to 30 minutes. If a


patient in this area was distressed curtains were closed, if the patient was a child, parents were

asked to assist.

The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for qualified nursing staff in children’s services is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



PREVENT 117 122 95.9% 85.0% Yes



In children’s services the target was met for four of the five safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in children’s services is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)




PREVENT 51 84 60.7% 85.0% No

In children’s services the target was met for one of the four safeguarding training modules for which medical staff were eligible. The trust only reported data for the ACAD paediatric surgical pre-assessment unit at this site. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 for qualified nursing staff in children’s services at Central Middlesex Hospital is shown below: The tables below include PREVENT training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)

PREVENT 36 37 97.3% 85.0% Yes





The target was met for three of the four safeguarding training modules for which qualified nursing staff in children’s services at Central Middlesex Hospital were eligible. None of the six eligible staff completed the safeguarding children level 3 training module. We spoke with a paediatric sickle cell nurse who worked in the Rainbow Unit and who had attended level 3 safeguarding training in the last three months. The trust reported no medical staff working within the ACAD paediatric surgical pre-assessment unit. (Source: Routine Provider Information Request (RPIR) – Training tab)

We requested up to date data on safeguarding level three training for medical staff which showed

that 100% of consultant paediatricians were compliant and 93% of trainees and other medical staff

were compliant with safeguarding level three training across the trust.

We requested the chaperone policy and training data for all staff working with children at the

hospital. We were given an in-date trust policy for Intimate Examination, Care and Chaperone.

The policy was detailed and made clear references to children and young people treated at the

trust. We were not provided with training records for staff.


The service did not control infection risk well. Staff used some equipment and control

measures to protect children, young people, their families, themselves and others from

infection. They kept equipment clean. However, we found the Rainbow Unit untidy, we

could not be assured that children’s toys were regularly cleaned and there was of a lack of

infection prevention information for children.

In Recovery Stage One the environment was clean and well maintained. We saw sufficient

personal protective equipment such as gloves and gowns of all sizes, and staff adhered to the

bare below the elbows policy. We saw green in date “I am clean” stickers on two patient monitors

and blood pressure machines. We saw hand washing basins and hand washing instructions

outside each bay in Recovery Stage One.

We were informed by some staff members that the outpatients had closed on Monday 01 July, one

day before the inspection. Other staff members thought the ward had closed on Friday 28 June

the weekend before the inspection. However, the outpatient’s department appeared to be still in

use and had a paediatric haemoglobinopathy clinic on the first day of the inspection and a

paediatric dietitian clinic running twice a week. We saw the outpatient’s department was dusty,

there was a dirty hand hygiene dispenser and dirty taps in the female toilets. We saw a dirty blood

pressure machine and dusty suction unit. There were no hand washing facilities in the height and

weight room.

In the Recovery Ward there were no preventative infection control measures or handwashing

posters for children, including in the toilets. There was no policy for toy cleaning and limited

assurance or information for parents that toys were cleaned. Staff we spoke with told us that the

toys were cleaned using anti-septic wipes. We did not see a schedule for toy cleaning. The

infection control policy in place was a trust wide policy, and not specific to children and young

people services. Following the inspection, the trust submitted a decontamination policy and a toy

cleaning record, but these were not seen during the inspection.


Staff called parents the day before the surgery to make sure the child was fit for surgery. If a child

had vomiting or diarrhoea the child was advised not to come in and surgery was postponed for this

child.

We requested hand hygiene compliance audits from the last six months which showed an average

compliance rate of 86.5%.

In the CQC Children and Young People’s Survey 2016 the trust scored 8.57 out of ten for the question ‘How clean do you think the hospital room or ward was that your child was in?’ This was about the same as other trusts. (Source: CQC Children and Young People’s Survey 2016, RCPCH)


The design, maintenance and use of facilities, premises and equipment kept people safe.

There were facilities for disabled and baby changing in the Rainbow Unit but staff told us

they believed that the Rainbow Unit was shut. Staff were trained to use equipment. Staff

managed clinical waste well.

Senior nurses reported that there had been no environmental changes to improve the services for

children since the last inspection.

Children, young people and their families could reach call bells and staff responded quickly when

called.

Paediatric patients recovered from surgery in the adult recovery area, known as Recovery Stage

One. We were told that there was one bay dedicated to paediatric recovery which could house

four beds in total. However, we saw adults being recovered in this same area at the same time as

children. This meant that children were not protected from hostile sights and sounds. Guidelines

for the Provision of Anaesthetic Services 2015 states that it is mandatory to have a child recovery

area that is separated from an adult area, or at least screened.

We saw there was appropriate equipment available for paediatric patients such as paediatric blood

pressure cuffs, paediatric face masks of different sizes and a paediatric resuscitation trolley.

We looked at five pieces of equipment in the paediatric resuscitation trolley in Recovery Stage

One. This included airway syringes, trachea tubes, cuffed tracheal tube, cuffless tracheal tube and

sodium chloride. All pieces of equipment were in date. The medical sharps bin in Recovery Stage

One had a first use date of 10 April 2019 and a to be closed date of 10 July 2019.

In the pre-assessment area, known as Area One, there was an adult resuscitation trolley in the

corridor with a paediatric grab bag. Items in the paediatric grab bag were checked and all were

found to be in date such as the paediatric pocket air mask. The nearest paediatric resuscitation

trolley was upstairs in Recovery Stage One. There had been no scenario testing or evidence to

see if the paediatric resuscitation trolley was accessible in a timely manner or if this was safe. The

resuscitation policy booklet was last updated in 2013.

Staff carried out daily safety checks of specialist equipment in the surgical department. We were

assured that the resuscitation trolley in the recovery ward had been checked daily and were able

to see these records. However, the resuscitation trolley in the Rainbow Unit had not been checked

since 27 June 2019. It was not clear who was responsible for checking this trolley.


The rooms in pre-assessment were decorated for children, however there was no facility for

children to play whilst waiting to be seen. The two dedicated clinic rooms for paediatric patients

had faded stickers on the walls and were very sparse with little distraction facilities.

There were facilities for disabled and baby changing in the Rainbow Unit but staff told us they

believed that the Rainbow Unit was shut. There were no changing facilities in the height or weight

room and there was no easy access to disabled toilets in the Rainbow Unit. The disabled toilet

was behind a shut door, that required pressing a green buzzer for access. There were no signs to

inform patients or carers that there was a disabled toilet behind this door.

Staff disposed of clinical waste safely.


Staff did not complete risk assessments for each child and young person to remove or

minimise risks. Staff relied on experience and knowledge to identify children and young

people at risk of deterioration.

Staff did not use a nationally recognised tool to identify deteriorating patients. The service did not

use Paediatric Early Warning Signs (PEWS) or a validated acuity score system to assess patients.

PEWS are clinical manifestations that indicate rapid deterioration in paediatric patients, infancy to

adolescence. PEWS scores are objective tools that incorporate the clinical manifestations that

have the greatest impact on patient outcomes. Instead there was a heavy reliance on staff

knowledge, experience and patient observation to identify a deteriorating patient. Patient

observations were not documented.

Staff we spoke with said that there was no specific paediatric skills training for recovery nurses in

Recovery Stage One. We requested data on this and the trust told us that all nurses in Recovery

Stage One cover the paediatric aspect of recovery in their university courses. We requested data

to look at the recovery paediatric policy but was provided with the Paediatric Surgical Service: Peri

Operative Anaesthetic/ Analgesic guidance. The document contained what medication was

required for paediatric post-op recovery but nothing else. Clear recovery guidelines are set out in

The Association of Anaesthetics of Great Britain and Ireland 2013, Standards for Children’s

Surgery 2013 and British Anaesthetic and Recovery Nurse Association 2012.

For a deteriorating patient the service used an adult transfer form instead of the Children’s Acute

Transport Services (CATS). CATS is primarily funded to transport critically ill children to a regional

paediatric intensive care unit. Staff we spoke with were competent in making a call to the cardiac

crash team and were aware of the specific instructions required when calling about a paediatric

patient. For deteriorating patients, the service called the emergency services on 999, anaesthetists

were called for assistance to keep the child safe until medical transfer.

We were told that there was at least one nurse per shift in each clinical area trained in European Paediatric Life Support (EPLS) or Advanced Paediatric Life Support (APLS). However, assurance that the right staff were on shift regarding EPLS/ APLS was not clearly demonstrated on staff rotas and we could not be assured that this was always the case. This was because senior staff who compiled the rota relied on personal knowledge of staff training completion rates. At the time of the inspection there were three members of staff that were not compliant with EPLS/APLS out of seven staff members. Staff we spoke with told us that there was a risk that not all information required to undertake a pre-assessment risk assessment was available, especially for patients seen from outside of the trust. Often these patient’s notes were missing a GP referral and a full medical history.


The service had not ensured that there was any development of Local Safety Standards for Invasive Procedures using the national Safety Standards for Invasive Procedures.

We requested the sepsis policy and training records for nursing and medical staff post inspection. We received the Emergency Department/ Acute Medical Unit Paediatric Sepsis Screening and Action Tool for children under the age of five years. The tool was from the UK sepsis trust and the trust logo was missing from the second page. We were not provided with a tool for children over the age of five, or a sepsis policy. Training records we received were for paediatric nurses which was at 91.67%, we did not receive training records for medical staff. It was unclear if this was trust wide data or data specifically for children and young people services and this hospital.

In the CQC Children and Young People’s Survey 2016 the trust scored 7.68 out of ten for the question ‘Were the different members of staff caring for and treating your child aware of their medical history?’ This was about the same as other trusts. In the CQC Children and Young People’s Survey 2016 the trust scored 9.62 out of ten for the question ‘Were you given enough information about how your chid should use the medicine(s) (e.g. when to take it, or whether it should be taken with food)?’ This was about the same as other trusts. CQC Children and Young People’s Survey 2016 questions, safe domain, London North West University Healthcare NHS Trust

Question Number

Question Age

group Trust score

RAG

6 How clean do you think the hospital room or ward was that your child was in?

0-15 adults


20 Were the different members of staff caring for and treating your child aware of their medical history?

0-15 adults


36

Were you given enough information about how your child should use the medicine(s) (e.g. when to take it, or whether it should be taken with food)?

0-15 adults


0-15 adults = asked of parents and carers of children up to 15 years of age (Source: CQC Children and Young People’s Survey 2016, RCPCH)

Nurse staffing

Please see Medical staffing section for all staffing metrics

The service had enough staff with the right experience to keep children, young people and

their families safe from avoidable harm and to provide the right care and treatment.

Managers gave new staff a full induction.

The nursing staff had access to a senior children’s nurse for advice at all times. The service had

enough nursing staff, of all of which were band 6 to keep children and young people safe. There

was a dedicated pre-assessment and surgical day care team that was staffed by the same

paediatric nurses.

We were not assured that there was always at least one nurse per shift in each clinical area that

was trained in APLS/EPLS, and we were uncertain if staff amongst themselves were aware of who

this nurse was at all times.

The service did not rely on bank or locum staff to fulfil shifts.


Medical staffing

The service had enough medical staff with the right qualifications and experience. However not all medical staff had EPLS/ALS training. There was no consultant paediatrician on site during times of peak activity on operational days.

There was no consultant paediatrician available in the hospital during times of peak activity on

operational days. Some staff were aware that there was no paediatrician available at the hospital,

other staff had only realised this two weeks ago. The service was able to refer to the consultant of

the day or week, who was based at a different hospital in the trust. Staff believed that all

anaesthetic staff members had EPLS/APLS training however, we spoke to an anaesthetic

consultant who told us that they had not had EPLS/APLS training.

We asked for EPLS/APLS data for all medical staff at Central Middlesex Hospital that see and

treated children, but we was provided with trust wide data and was unable to extract data

specifically for this hospital.

From April 2018 to March 2019, the breakdown of WTE staff in post in children’s services is shown in the chart below.

Children’s services annual staffing metrics (April 2018 to March 2019)


Annual vacancy

rate

Annual turnover

rate**

Annual sickness

rate

Annual bank

hours (% of

available hours)


available hours)


available hours)

Trust target 11.0% 13.0% 4.0%

All staff* 520.9 20.7% 31.8% 7.2%

Qualified nurses

126.4 41.0% 18.7% 6.2% 26,923 (10.0%)

37,371 (13.9%)

48,085 (17.9%)

Nursing assistants

52.3 9.2% 21.2% 9.9% 2,486 (4.0%)

0 (0.0%)

10,641 (17.0%)

Medical staff 91.4 2.4% 53.2% 6.2% 1,916 (1.6%)

0 (0.0%)

4,914 (4.1%)


156.5 15.0% 36.6% 8.0%



The service had an increasing vacancy rate for medical staff. Monthly vacancy rates from April 2018 to March 2019 for qualified nurses, health visitors and midwives in children’s services are not stable and may be subject to ongoing change.

Monthly vacancy rates from April 2018 to March 2019 for medical staff in children’s services showed a shift from October 2018 to March 2019.


Monthly vacancy rates from April 2018 to March 2019 for allied health professionals in children’s services showed a shift from October 2018 to March 2019. The service had low and reducing turnover rates for medical staff. Monthly turnover rates from April 2018 to March 2019 for all staff groups in children’s services appear to be stable with only random variation over the whole period.

Sickness rates for medical staff were low and reducing.

Monthly sickness rates from April 2018 to March 2019 for nursing assistants in children’s services showed a downward trend from October 2018 to March 2019.


Monthly sickness rates from April 2018 to March 2019 for medical staff in children’s services showed a shift from October 2018 to March 2019.


midwives in children’s services showed a shift from October 2018 to March 2019.

Staffing data on vacancy, turnover, sickness and bank/locum rates provided by the trust did not separately identify staff within children’s services at Central Middlesex Hospital. (Source: Routine Provider Information Request (RPIR) – Vacancy, Turnover, Sickness, Nursing bank agency and Medical locum tabs) The service had a good skill mix of medical staff on each shift and reviewed this regularly. In January 2019, the proportions of consultant and junior (foundation year 1-2) staff reported to be working at the trust was similar to the England averages. Staffing skill mix for the 81 whole time equivalent staff working in services for children and young people at London North West University Healthcare NHS Trust:


This Trust

England average

Consultant 42% 43%



Junior* 7% 6%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen speciality ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)

Records

Staff kept detailed records of children and young peoples’ care and treatment. Records

were clear, but sometimes children were seen with an incomplete set of records.

Records were stored securely. We saw patient records were always kept in a locked cabinet on

the Recovery Ward.

We looked at four medical patient records on the Recovery Ward, we saw that patients had

observations, height and weights taken, a clear allergy status and consent for surgery. We did not

see any pain assessments recorded for patients. In one medical record we saw that the theatre

checklist had not documented that the consent form had been checked prior to surgery.

In the Rainbow Unit we were told by staff that some patients were seen without their full medical

record. Where this was the case a temporary set of notes was made for the patient, which

included clinic letters. This usually happened after a patient was admitted to another hospital in the

trust. This meant that patients were seen without their previous medical history or growth charts.

Following the inspection, the trust told us, in the event that a child was seen with a temporary set

of notes at pre-operative assessment (POA), the complete record was requested straight away

from the clerks.

There were systems in place to flag on record where a child had particular needs, including child

protection. Information was uploaded to the integrated children’s system live which pulled

information into the patients database as a red alert for child protection queries. If a child is under

child protection a blue sheet is placed at the front of the child’s medical notes to highlight this. In

sickle services, children in need or at risk are identified. The clinical nurse specialists reviewed

these cases at safeguarding meetings held with social services, psychologists, consultants and

the safeguarding lead. Documentation of these meetings were kept in patients records. For

paediatric patients having surgery, health and social issues were explored during the pre-operative

assessment and were recorded and investigated. This included mental health assessments where

appropriate services such as the mental health team were liaised with where necessary.

For surgical patients a discharge summary was sent to the patient’s GP, school nurse or relevant

others to ensure continuity of care. All attendances and non-attendances were followed up with a


clinic letter to the GP and other professionals where relevant. GPs and other professionals were

able to communicate with the service though emails, letter and telephone calls. Staff we spoke to

thought that there was effective communication both ways. A clinic letter was sent to the GP after

every visit for patients being seen in the sickle cell clinic. The clinical nurse specialist followed

patients care into the community by providing home visits. All children had a clinical care plan for

school.

GPs did not have direct access to patients records however, GPs were able to speak to

consultants or specialists registrar over the phone for advice if required.

Medicines

The service used systems and processes to safely prescribe, administer and record

medicines. Storage of medicines complied with national guidelines. However, fridge

temperature monitoring in the recovery ward was not recorded.

Staff followed systems and processes when safely prescribing, administering, recording and

storing medicines. There was a paediatric pharmacist that oversaw the surgical unit and there

were no controlled drugs kept on the Recovery Ward for paediatric patients. Nursing staff were

aware of policies on administration of controlled drugs as per the Nursing and Midwifery Council

Standards for Medicine Management. We looked at the medicine cabinet by the nurses station in

the Recovery Ward, which remained locked at all times whilst we were on inspection. The keys

remained with the nurse in charge at the time. The cabinet was neat and stored to take away

medicines and stock medicines. We checked seven different medications in the cabinet and all

were found to be in date. There was a drug fridge in the Recovery Ward that housed one

medicine, but there were no records of fridge temperature monitoring. We checked the

temperature on the day of the inspection and the temperature was in range. However, fridge

monitoring in ACAD paediatrics was recorded.

We found one out of date children’s British National Formulary (BNF) in room one in the Rainbow

Unit. This was raised with a senior member of staff from the pharmacy department and the BNF

was promptly removed. The BNF in the Recovery Ward was in date, was specifically for children

and was the latest edition.

Staff followed current national practice to check children and young people had the correct

medicines. Children’s weight was clearly documented and prescriptions were appropriate for the

child’s weight and age. Allergies were clearly documented in all paediatric records we looked at.

The service provided written advice for medicines on leaflets such as paracetamol, which would

make it easier for parents to administer the medicines.

Incidents


and near misses and reported them appropriately. Managers investigated incidents and

shared lessons learned with the whole team and the wider service. When things went

wrong, staff apologised and gave children, young people and their families honest

information and suitable support. Managers ensured that actions from patient safety alerts

were implemented and monitored.

Incidents were reported on an electronic reporting system. Incidents were filtered by this system

and sent to the most appropriate manager. Feedback was sent via email to the person who

reported the incident.


Incidents in the surgical department were discussed at daily huddles, via group emails, daily chats

and team meetings. Staff reported good feedback from incidents. Most communications on

incidents was done via email as most staff were part time, this assured senior members of staff

that all staff were up to date on incidents and feedback. In the last 12 months there had been one

incident that resulted in no harm to the patient, this incident was raised at the next clinical

governance meeting. There were no incidents reported in the last 12 months which a required a

duty of candour. The duty of candour is a regulatory duty that relates to openness and

transparency and requires providers of health and social care services to notify patients (or other

relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that

person, under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities)

Regulations 2014. Staff we spoke to struggled to articulate what was meant by a duty of candour

until prompted.

The service had no never events.

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2018 to April 2018, the trust reported no never events for children’s services. (Source: Strategic Executive Information System (STEIS)) In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in children’s services which met the reporting criteria set by NHS England from May 2018 to April 2019. (Source: Strategic Executive Information System (STEIS))

Safety thermometer

The NHS Safety Thermometer is an inpatient survey and was not applicable to the children

and young people service at Central Middlesex Hospital as there were no inpatient services

at this site.

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and no new urinary tract infections in patients with a catheter from March 2018 to March 2019 for children’s services. The paediatric Recovery Ward did not contribute to the NHS Safety Thermometer. (Source: NHS Digital)




The service provided care and treatment based on national guidance and evidenced-based

practice, but had no evidence or audits to support this. Managers checked to make sure

staff followed guidance. Staff protected the rights of children and young people subject to

the Mental Health Act 1983.

The service did not participate in any accreditation schemes such as You’re Welcome

(Department of Health) or Baby Friendly (United Nations International Children’s Emergency

Fund).

The service did not comply with national audits and did not benchmark their service against other

similar services. There was no local audit undertaken to indicate compliance with guidelines.

Staff we spoke to said that senior staff members updated staff of any changes in regard to the

National Institute for Health and Care Excellence (NICE). However, staff we spoke with were not

aware of how this was committed to or acted on.

Staff protected the rights of children and young people subject to the Mental Health Act and

followed the Code of Practice.


Staff encouraged children, young people and their families to bring in food from home.

Staff made sure children, young people and their families brought in enough food from home to

eat and drink. Parents were asked to bring in their child’s favourite food and snacks. This meant

that the child had something familiar and something to look forward to post surgery. There was no

specific children’s menu at the hospital. The hospital had a canteen where parents could purchase

food for themselves or for their child. Tea and coffee facilities were provided to parents once all

children had been operated on.

Staff fully and accurately completed children and young peoples’ fluid and nutrition charts where

needed.

Pain relief

Staff assessed and monitored children and young people regularly to see if they were in

pain and gave pain relief in a timely way. They supported those unable to communicate

using suitable assessment tools and gave additional pain relief to ease pain.

Staff assessed children and young peoples’ pain using a tool and gave pain relief in line with

individual needs and best practice. Pain scores were measured between zero and three, zero

being no pain and three being unbearable pain. Assessment tools in the form of picture faces were

used to assess pain in those children unable to communicate.

Children and young people received pain relief soon after requesting it. Medical staff prescribed,

administered and recorded all pain relief accurately.

Parents were encouraged to have paracetamol and or alternative appropriate pain killers for

children at home post-surgery.

The service had a gold standard that patients should wake pain free. The service aimed to give

the majority of pain relief to the child before they woke up as it was often too late after. This was

because an upset child is very difficult to administer oral pain relief to.

Patient outcomes

Staff did not monitor the effectiveness of care and treatment.


The service did not participate in relevant national clinical audits.

There was no audit schedule in place for paediatric patients attending services at the hospital. Staff on the Recovery Ward were not involved and did not contribute to any audit for children and young people services except for one dental audit. We requested this audit from the trust but was told that paediatric dentistry was tendered in 2017 and transferred out to another provider. Staff we spoke with said that if there was an audit this was normally done by the matron and comments for improvements or changes were fed back to staff. Staff could not recall audits or changes made for some time. The service did not monitor or audit fasting times for children pre-surgery. Staff we spoke with were unsure of how long a paediatric patient was left to fast but were sure that sometimes paediatric patients were left fasting for longer times than expected. This meant the service could not pinpoint areas of improvement to shorten the fasting times for paediatric patients. The service did not conduct local audits such as the Patient-Led Assessment of the Care Environment (PLACE). A PLACE audit provides motivation for improvement by providing a clear message directly from patients about how an environment or service may be enhanced. Staff we spoke with had not heard of a PLACE audit. The service also did not participate in the NHS England 15 steps challenge. The 15-step challenge focuses on seeing care through a patient or career’s eyes and exploring their first impressions. We saw two audits on health and safety and infection prevention control however, this was not specific to children and young persons services. Central Middlesex Hospital did not participate in the National Paediatric Diabetes audit. (Source: National Paediatric Diabetes Audit) Central Middlesex Hospital did not participate in the National Neonatal Audit Programme. (Source: National Neonatal Audit Programme) The trust did not participate in the Paediatric Intensive Care Audit (PICANet). (Source: PICANet) No analysis of emergency readmission rates following an elective admission for persons aged under one is provided as no speciality at the trust had six or more readmissions from December 2017 to November 2018. For patients aged 1-17 years old, there was a lower percentage of patients readmitted following an elective admission compared to the England average for paediatrics and a higher percentage of patients readmitted following an elective admission compared to the England average for paediatric ear nose and throat.

Emergency readmissions within two days of discharge following elective admission among the under 1 age group, by treatment specialty

(December 2017 to November 2018)

Specialty London North West Healthcare NHS Trust England

Readmission rate

Discharges (n)

Readmissions (n)

Readmission rate

No speciality at this trust had six or more readmissions.


Emergency readmissions within two days of discharge following elective admission among the 1-17 age group, by treatment specialty



Readmission rate

Discharges (n)

Readmissions (n) Readmission

rate

Paediatrics 0.4% 1,680 6 0.8%

Paediatric ear nose and throat

0.8% 716 6 0.6%

Notes: This table shows the two treatment specialties at the trust with the highest volumes of readmissions; only those specialties where the trust had six or more readmissions recorded are shown in the tables.

The tables below show the percentage of patients (by age group) who were readmitted following an emergency admission. The tables show the three specialties with the highest volume of readmissions and only those specialties where six or more readmissions recorded are shown in the table. The data shows that from December 2017 to November 2018 there was a lower percentage of under ones readmitted following an emergency admission compared to the England average for paediatrics. For patients aged 1-17 years old, there was a lower percentage of patients readmitted following an emergency admission compared to the England average for paediatrics and accident and emergency and a similar percentage of patients readmitted following an emergency admission compared to the England average for general surgery.

Emergency readmissions within two days of discharge following emergency admission among the under 1 age group, by treatment specialty (December 2017 to November 2018)


Readmission rate

Discharges (n)


rate

Paediatrics 1.5% 1,234 18 3.6%

No other speciality at this trust had six or more readmissions.

Emergency readmissions within two days of discharge following emergency admission among the 1-17 age group, by treatment specialty


Specialty

London North West Healthcare NHS Trust England

Readmission rate

Discharges (n)


rate

Paediatrics 1.1% 4,292 48 2.9%

General surgery 4.3% 461 20 4.2%


Accident and emergency

1.8% 393 7 2.3%

Notes: These tables show the three treatment specialties at the trust with the highest volumes of readmissions; only those specialties where the trust had six or more readmissions recorded are shown in the tables. (Source: Hospital Episode Statistics) The trust performed better than the England average for the percentage of patients aged 1-17 years old who had multiple readmissions for asthma and epilepsy but worse than the England average for diabetes.

Rate of multiple (two or more) emergency admissions within 12 months among children and young people for asthma, epilepsy and diabetes (for children aged under 1 year and 1 to 17 years).

(January 2018 to December 2018)

Long term condition

London North West Healthcare NHS Trust

England

Multiple admission

rate

At least one

admission (n)

Two or more admissions

(n)

Multiple admission

rate

Asthma

Under 1 - - - 10.0%

1 to 17 11.2% 215 24 15.7%

Diabetes

Under 1 - - - 17.6%

1 to 17 27.8% 36 10 12.6%

Epilepsy

Under 1 0.0% * 0 32.6%

1 to 17 18.2% 44 8 29.1%

Note - For reasons of confidentiality, numbers below six and their associated proportions have been removed and replaced with ‘*’. (Source: Hospital Episode Statistics)

Competent staff



development. However, we found a number of policies out of date.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of

children, young people and their families. However, there were clinical educators for theatre and

stage one recovery, but not on the recovery ward.

Managers gave all new staff a full induction tailored to their role before they started work.

We looked at the policy file in the Recovery Ward, we looked at 15 policies in total and found none

to be in date. The out of date policies had not been disposed of. This included policies on

paediatric prescribing, paediatric surgical peri-operative anaesthetic and analgesia, latex allergy,

upper airway obstruction and ear, nose and throat classification admissions. The policy for do not


consent blood products was last issued in April 2012 and due for revalidation in April 2014. The

emergency paediatric transfer bundle was last issued in 2010. We informed senior staff of these

findings.

Managers supported staff to develop through yearly, constructive appraisals of their work. From April 2018 to March 2019, 87.6% of staff within children’s services at the trust received an appraisal compared to a trust target of 85%.

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)

Healthcare scientists 2 2 100.0% 85.0% Yes

Additional professional, scientific and technical

1 1 100.0% 85.0% Yes


Allied health professionals 141 155 91.0% 85.0% Yes




Total 403 460 87.6% 85.0% Yes

Only two staff groups did not meet the trust target of 85%, however all groups had a completion rate of over 80%. The trust only reported data for the ACAD paediatric surgical pre-assessment unit at this site. From April 2018 to March 2019, 80.8% of staff within children’s services at Central Middlesex Hospital received an appraisal compared to a trust target of 85%.

Staff group



appraisal

Eligible staff

Completion rate

Trust target

Met (Yes/No)


1 1 100.0% 85.0% Yes




Total 42 52 80.8% 85.0% No

At Central Middlesex Hospital only two staff groups met the trust target of 85%, however nursing staff had a rate close to the target. (Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Managers made sure all staff attended team meetings or had access to full notes when they could

not attend.

Managers were aware that specialist paediatric training was required for the role and had booked

in this training for all staff.




children, young people and their families. They supported each other to provide good care.

Informal meetings were held in pre-assessment regarding paediatric patients. Paediatric nurses,

surgeons and anaesthetists discussed any ailments and pre-conditions a patient may have, for

example, asthma, weight and heart conditions.

Staff referred children and young people for mental health assessments when they showed signs

of mental ill health for example depression.

The service had access to a paediatric pharmacy in operational hours. Children that required

physiotherapy or occupation therapies were referred to a different hospital in the trust.

There were no qualified play specialists available in areas that children and young people were

seen and treated, e.g. wards, outpatients, clinics and before a surgical operation, paediatric

nurses fulfilled this role. Senior staff we spoke with told us that the introduction of a play specialist

would have reduced the number of nursing staff due to budget constraints.

Paediatric patients were not discharged home later than 6pm. If a paediatric patient was unable to

go home on the same day of surgery a decision to transfer the patient was made before 5pm. The

paediatric patient would be transferred to a different hospital within the trust. We saw that all

discharge paperwork was thoroughly completed and that patients were given post discharge

phone calls within 24 hours by one the paediatric nurses. Parents were given contact details of the

recovery unit and phone numbers to call out of hours if they had any concerns. In an emergency

parents were asked to go to their nearest accident and emergency department.

In the CQC Children and Young People’s Survey 2016 the trust 8.69 scored out of ten for the question ‘Did the members of staff caring for your child work well together?’ This was about the same as other trusts. (Source: CQC Children and Young People’s Survey 2016, RCPCH)

Seven-day services

Key services were available Monday- Friday to support timely patient care.

The service operated Monday to Friday, and there were provisions in place for surgeries taking

place on a Friday. All parents were telephoned within 24 hours post-surgery, including on a

Saturday if surgery was booked on a Friday. Patients were given contact numbers of the Recovery

Ward and also advised to call their GP for advice. For emergencies parents were advised to take

their child to their nearest urgent care centre or accident and emergency department.

Children and young people were reviewed by consultants depending on the care pathway.

Staff could call for support from doctors and other disciplines, including mental health services and

diagnostic tests, between the operational times of 8am to 6pm and between Monday to Friday.

Health promotion

Staff did not give children, young people and their families practical support and advice to

lead healthier lives.

There was no health promotion directed to children and young people in either the Rainbow Unit,

pre-assessment area or in recovery areas.

The service did not have relevant information promoting healthy lifestyles or support on the ward

or on Rainbow Unit.


Staff did not assess each child and young person’s health when admitted or provided support for

any individual needs to live a healthier lifestyle.


Staff supported children, young people and their families to make informed decisions

about their care and treatment. They knew how to support children, young people and their

families who lacked capacity to make their own decisions or were experiencing mental ill

health.

Staff understood the relevant consent and decision-making requirements of legislation and

guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989

and 2004 and they knew who to contact for advice. Staff understood how and when to assess

whether a child or young person had the capacity to make decisions about their care. When

children, young people or their families could not give consent, medical staff and legal teams

made decisions in their best interest, considering their wishes, culture and traditions.

Staff gained consent from children, young people or their families for their care and treatment in

line with legislation and guidance. Staff made sure children, young people and their families

consented to treatment based on all the information available. Staff clearly recorded consent in the

children and young peoples’ records.

Staff understood Gillick Competence and Fraser Guidelines and supported children who wished to

make decisions about their treatment. The service had a thorough consent policy in place which

included information on best interest decisions and on Gillick competency. Gillick competence is a

term used in medical law to decide whether a child under 16 years of age is able to consent to his

or her own medical treatment without the need for parental permission or knowledge.

Staff could describe and knew how to access policy and get accurate advice on Mental Capacity

Act and Deprivation of Liberty Safeguards. The policy was in date and was due to be reviewed in

February 2020. Clinical staff completed training on the Mental Capacity Act and Deprivation of

Liberty Safeguards but had not achieved the trust’s target. Staff we spoke with said they had not

needed to use physical restraints on a child. When a child was distressed they would encourage

parental involvement to sooth and hold their child.

All nursing staff completed training on the Mental Capacity Act and Deprivation of Liberty

Safeguards.


Clinical staff completed training on the Mental Capacity Act and Deprivation of Liberty Safeguards

achieving the Trust’s target.

A breakdown of compliance for MCA and DoLS training courses from April 2018 to March 2019 at trust level for qualified nursing staff in children’s services is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)


2 2 100.0% 85.0% Yes




In children’s services the target was met for all of the MCA and DoLS training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from April 2018 to March 2019 at trust level for medical staff in children’s services is shown below:


Staff trained

Eligible staff

Completion rate

Trust target

Met (Yes/No)



12 24 50.0% 85.0% No

In children’s services the target was not met for either of the MCA and DoLS training modules for which medical staff were eligible. The trust reported no separate MCA and DoLS training figures for qualified nursing staff or medical staff at Central Middlesex Hospital. (Source: Routine Provider Information Request (RPIR) – Training tab). The trust performed about the same as other trusts for all five questions relating to effectiveness in the CQC Children and Young People’s Survey 2016. CQC Children’s Survey questions, effective domain, London North West University Healthcare NHS Trust:

Question Number

Question Age

group Trust score

RAG

21 Did you feel that staff looking after your child knew how to care for their individual or special needs?

0-15 adults


other trusts

9 Did staff play with your child at all while they were in hospital?

0-7 adults


other trusts

19 Did different staff give you conflicting information?

0-7 adults


other trusts

33 During any operations or procedures, did staff play with your child or do anything to distract them?

0-15 adults


other trusts

54 Did hospital staff play with you or do any activities with you while you were in hospital?

8-11 CYP


other trusts

0-7 adults = asked of parents and carers of children up to seven years of age 0-15 adults = asked of parents and carers of children up to 15 years of age 8-11 CYP = asked of children aged from eight to 11 years of age (Source: CQC Children and Young People’s Survey 2016, RCPCH)


Compassionate care


Staff treated children, young people and their families with compassion and kindness,

respected their privacy and dignity, and took account of their individual needs.

Staff were discreet and responsive when caring for children young people and families. Staff took

time to interact with patients and those close to them in a respectful and considerate way. Staff

preserved confidentiality, privacy and dignity when interacting with patients and their main carers.

Staff followed policy to keep care and treatment confidential.

We saw that children were not left unsupervised, and always had a parent carer or nurse with

them at all times.

Staff understood and respected the individual needs of each child and young person and showed

understanding and a non-judgmental attitude when caring for or discussing those with mental

health needs. We saw that staff working with paediatric patients were well prepared to work with

and communicate with children.

Children, young people and their families said staff treated them well and with kindness. Parents

we spoke with described staff as caring and helpful both in the Rainbow Unit and in the surgical

department. We saw staff interacting with patients and parents who used the service in a

respectful and considerate way.

We spoke to a patient’s father who described the care as ‘beautiful’ and 12 out of 10. The father

said that the consultant took the time to explain, and that they saw the same doctor all the time.

Questions were directed to his child, but with his fathers involvement.

The trust performed worse than other trusts for three questions and about the same as other trusts for the remaining seven questions relating to compassionate care in the CQC Children and Young People’s Survey 2016. CQC Children and Young People’s Survey 2016 questions, compassionate care, London North West University Healthcare NHS Trust:

Question Number

Question Age

group Trust score

RAG

10 Did new members of staff treating your child introduce themselves?

0-7 adults


other trusts

14 Did you have confidence and trust in the members of staff treating your child?

0-15 adults


trusts

22 Were members of staff available when your child needed attention?

0-15 adults


other trusts

42 Do you feel that the people looking after your child were friendly?

0-7 adults


trusts

43 Do you feel that your child was well looked after by the hospital staff?

0-7 adults


trusts

44 Do you feel that you (the parent/carer) were well looked after by hospital staff?

0-15 adults


other trusts

58 Was it quiet enough for you to sleep when needed in the hospital?

8-15 CYP


other trusts

64 If you had any worries, did a member of staff talk with you about them?

8-15 CYP


other trusts


74 Do you feel that the people looking after you were friendly?

8-15 CYP


other trusts

75 Overall, how well do you think you were looked after in hospital?

8-15 CYP


other trusts

0-7 adults = asked of parents and carers of children up to seven years of age 0-15 adults = asked of parents and carers of children up to 15 years of age 8-15 CYP = asked of children aged from eight to 15 years of age (Source: CQC Children and Young People’s Survey 2016, RCPCH)

Emotional support

Staff provided emotional support to children, young people and their families to minimise

their distress. They understood patients’ personal, cultural and religious needs.

Staff gave children, young people and their families help, emotional support and advice when they

needed it.

Staff supported children, young people and their families who became distressed in an open

environment and helped them maintain their privacy and dignity.

Staff understood the emotional and social impact that a child or young person’s care, treatment or

condition had on their, and their families wellbeing.

Parents we spoke with said they felt confident in leaving the ward and their child’s care with staff

on the ward.

The trust performed about the same as other trusts for the all five questions relating to emotional support in the CQC Children and Young People’s Survey 2016. CQC Children and Young People’s Survey 2016 questions, emotional support, London North West University Healthcare NHS Trust:

Question Number

Question Age

group Trust score

RAG

7 Was your child given enough privacy when receiving care and treatment?

0-7 adults


other trusts

29 If your child felt pain while they were at the hospital, do you think staff did everything they could to help them?

0-15 adults


other trusts

45 Were you treated with dignity and respect by the people looking after your child?

0-7 adults


other trusts

65 Were you given enough privacy when you were receiving care and treatment?

8-15 CYP


other trusts

67 If you felt pain while you were at the hospital, do you think staff did everything they could to help you?

8-15 CYP


other trusts

0-7 adults = asked of parents and carers of children up to seven years of age 0-15 adults = asked of parents and carers of children up to 15 years of age 8-15 CYP = asked of children aged from eight to 15 years of age


(Source: CQC Children and Young People’s Survey 2016, RCPCH)


Staff supported and involved children, young people and their families to understand their

condition and make decisions about their care and treatment. They ensured a family

centred approach.

Staff made sure children, young people and their families understood their care and treatment. We

spoke with the parent of a patient in the Recovery Ward who told us that their pre-assessment

clinic appointment was 10 days ago and that staff had explained the processes to both parent and

child.

Staff talked with children, young people and their families in a way they could understand, using

communication aids where necessary. In the Rainbow Unit we saw a health care assistant

interacting with a patients mother well, to make her feel at ease. We saw a nurse providing a

thorough explanation of how to obtain medication with the involvement of the paediatric patient.

We saw a good rapport with the family and the nurse.

Staff made sure children, young people and their families were involved in their care and

treatment. We saw that a family was invited into a clinic room in the Rainbow Unit to undertake

their child’s blood test. We saw parents carrying their child into the anaesthetic room in surgical

gowns, which meant that the service was trying to minimise the time that separated a child and

parent. This also meant that children were able to see their parents face right before being given

the anaesthesia.

Children, young people and their families could give feedback on the service and their treatment

and staff supported them to do this. A high proportion of children, young people and their families

gave positive feedback about the service in the Friends and Family Test survey. The feedback

from the Friends and Family Test was positive.

Staff supported children, young people and their families to make advanced decisions about their

care.

Staff supported children, young people and their families to make informed decisions about their

care.

The trust performed better than other trusts for four questions and about the same as other trusts for the remaining 17 questions relating to understanding and involvement of patients and those close to them in the CQC Children and Young People’s Survey 2016. CQC Children and Young People’s Survey 2016 questions, understanding and involvement of patients, London North West University Healthcare NHS Trust:

Question Number

Question Age

group Trust score

RAG

11

Did members of staff treating your child give you information about their care and treatment in a way that you could understand?

0-15 adults

8.85 About the same as other

trusts

12 Did members of staff treating your child communicate with them in a way that your child could understand?

0-7 adults


trusts


13 Did a member of staff agree a plan for your child’s care with you?

0-15 adults


trusts

15 Did staff involve you in decisions about your child’s care and treatment?

0-15 adults


trusts

16 Were you given enough information to be involved in decisions about your child's care and treatment?

0-15 adults


trusts

17 Did hospital staff keep you informed about what was happening whilst your child was in hospital?

0-15 adults


trusts

18 Were you able to ask staff any questions you had about your child’s care?

0-15 adults


trusts

31 Before your child had any operations or procedures did a member of staff explain to you what would be done?

0-15 adults


trusts

32

Before the operations or procedures, did a member of staff answer your questions in a way you could understand?

0-15 adults


trusts

34 Afterwards, did staff explain to you how the operations or procedures had gone?

0-15 adults


trusts

39 When you left hospital, did you know what was going to happen next with your child's care?

0-15 adults


trusts

41 Do you feel that the people looking after your child listened to you?

0-7 adults


trusts

59 Did hospital staff talk with you about how they were going to care for you?

8-15 CYP

9.61 Better than other trusts

60 When the hospital staff spoke with you, did you understand what they said?

8-15 CYP


61 Did you feel able to ask staff questions?

8-15 CYP


62 Did the hospital staff answer your questions?

8-15 CYP


trusts

63 Were you involved in decisions about your care and treatment?

8-15 CYP


trusts

66 If you wanted, were you able to talk to a doctor or nurse without your parent or carer being there?

12-15 CYP


trusts

69 Before the operations or procedures, did hospital staff explain to you what would be done?

8-15 CYP


70 Afterwards, did staff explain to you how the operations or procedures had gone?

8-15 CYP


trusts

72 When you left hospital, did you know what was going to happen next with your care?

8-15 CYP


trusts


0-7 adults = asked of parents and carers of children up to seven years of age 0-15 adults = asked of parents and carers of children up to 15 years of age 8-15 CYP = asked of children aged from eight to 15 years of age 12-15 CYP = asked of children aged from 12 to 15 years of age (Source: CQC Children and Young People’s Survey 2016, RCPCH)





to plan care.

In the Recovery Stage One we saw that children were being cared for in the same bay as adults. On one occasion there were two paediatric patients in the same bay as one adult. The curtains had been left open and there was no clear segregation. Both paediatric patients had their parents with them at the time.

The service had systems to care for children and young people in need of additional support,

specialist intervention, and planning for transition to adult services.

Managers monitored and acted to minimise missed appointments. Managers ensured that

children, young people and their families who did not attend appointments were contacted.

The service had Wi-Fi which meant that children, young people and their families could keep in

touch with each other and with friends via social media.

There were limited facilities available for parents and relatives, such as a quiet area for when a

parent’s child is in surgery.

There were clear physical and social criteria for admission to the paediatric surgical unit. The

physical criteria included no acute or chronic conditions, the patient must be a minimum of two

years of age for general anaesthetic, the child must not be over or under weight, and the child

must be categorised American Society of Anaesthesiologists (ASA) One or Two. ASA One is a

normal healthy patients and ASA Two is a patient with mild systemic disease. The social criteria

were that the patient had to live within one-hour’s drive from the hospital; must be contactable on

the telephone at home; must have an English-speaking family member nearby for the first 24

hours post-surgery and the child and family must be prepared or capable to care for post-surgery

child at home. Patients who did not meet these criteria were treated at another hospital in the trust.

The trust performed worse than other trusts for one question and about the same as other trusts for the remaining 16 questions relating to responsiveness in the CQC Children and Young People’s Survey 2016. CQC Children and Young People’s Survey 2016 questions, responsive domain, London North West University Healthcare NHS Trust:

Question Number

Question Age

group Trust score

RAG

4 For most of their stay in hospital what type of ward did your child stay on?

0-15 adults


trusts


5

Did the ward where your child stayed have appropriate equipment or adaptations for your child's physical or medical needs?

0-15 adults


trusts

25 Did you have access to hot drinks facilities in the hospital?

0-15 adults


trusts

26 Were you able to prepare food in the hospital if you wanted to?

0-15 adults


trusts

28 How would you rate the facilities for parents or carers staying overnight?

0-15 adults


trusts

55 Was the ward suitable for someone of your age?

12-15 CYP


trusts

8 Were there enough things for your child to do in the hospital?

0-7 adults


trusts

24 Did your child like the hospital food provided?

0-7 adults


trusts

37 Did a staff member give you advice about caring for your child after you went home?

0-15 adults


trusts

38 Did a member of staff tell you who to talk to if you were worried about your child when you got home?

0-7 adults


40

Were you given any written information (such as leaflets) about your child’s condition or treatment to take home with you?

0-15 adults


trusts

56 Were there enough things for you to do in the hospital?

8-15 CYP


trusts

57 Did you like the hospital food? 8-15 CYP


trusts

71 Did a member of staff tell you who to talk to if you were worried about anything when you got home?

8-15 CYP


trusts

73 Did a member of staff give you advice on how to look after yourself after you went home?

8-15 CYP


trusts

2 Did the hospital give you a choice of admission dates?

0-7 adults


trusts

3 Did the hospital change your child’s admission date at all?

0-7 adults


trusts

0-7 adults = asked of parents and carers of children up to seven years of age 0-15 adults = asked of parents and carers of children up to 15 years of age 8-15 CYP = asked of children aged from eight to 15 years of age 12-15 CYP = asked of children aged from 12 to 15 years of age (Source: CQC Children and Young People’s Survey 2016, RCPCH)



The service was inclusive and took account of children, young people and their family’s

individual needs and preferences. Staff made reasonable adjustments to help patients

access services. They coordinated care with other services and providers. However, there

was a lack of patient information leaflets designed for children and young people.

We saw good use of The Royal College of Anaesthetist (RCOA) leaflets on having a general

anaesthetic. However, overall there was a lack of patient information leaflets designed for children

and young people.

Staff worked with local Clinical Commissioning Groups and had produced up to date transition

protocols for young people aged between 16 to 18 years old for each speciality. This meant that

there were clear steps to follow when a child transitioned into a young adult. Different protocols

were in place for each ailment. 14- 16-year olds were educated about managing their conditions

and 15 to 16-year olds were introduced to attending consultations on their own. Staff we spoke

with told us that they would ask parents to join consultations at different times to their child in order

for their child to get use to attending appointments alone. Children were introduced to staff

members in the adult clinics, including nurses and doctors, this was to allow children to get used to

seeing different faces and to meet their clinical team before the transition. Children were also

offered a tour of the adult wards. 16-year olds were able to be seen in paediatric clinics but

admission to the trust would be in an adult ward.

Senior staff we spoke with were proud that patients received a good continuity of care. Paediatric

patients were seen by the same nurse at pre-assessment and on the day of their surgery. The

same nurse if possible would make a phone call to the patients parents 24 hours after discharge.

Pre-assessment appointments were arranged with parents, and parents were offered a suitable

time for them.

Children were encouraged to bring their own pyjamas on the day of their surgery.

In the Rainbow Unit there was information for children and young people living with sickle cell

anaemia, sickle cell societies and activities. We also saw a facts poster on the measles, mumps

and rubella (MMR) vaccine and information leaflets on Rainbow trust children’s charity

safeguarding children, child sexual exploitation and sickle cell young stroke survivors.

The use of interpreters was pre-determined at the pre-assessment stage. If an interpreter was

required at this stage staff could use an interpretation service over the phone to communicate with

the patient and the parents. On the day of surgery, an interpreter was booked to go into the

anaesthetic room with the patient and parent. Post-surgery the interpreter would go through all the

relevant patient information leaflets with the parents and the child. Information leaflets were only

available in English.

There was no play specialist. However, children and parents had access to play preparation

booklets for surgeries.

There were no separate toilet facilities in the children’s surgical unit for children, parents or carers

who required the use of a wheelchair. There were also no baby changing facilities or areas where

mothers could breastfeed with privacy.

Access and flow

People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge children and young people were in line with national standards.


All paediatric patients that were having surgery in this hospital were pre-planned and were day

cases only. All paediatric patients were discharged on the same day of their surgery. Managers

and staff worked to make sure that they started discharge planning as early as possible. There

were no facilities for paediatric patients to stay overnight. If it became apparent that a child needed

to stay overnight they were transferred to another hospital in the trust.

We saw robust processes in paediatric surgery, demonstrated when a patient who cancelled their

pre-assessment appointment was subsequently cancelled for their surgery. Phone calls were

made to all patients one day before their surgery to reduce did not attend (DNA) rates. We asked

for DNA rates for the paediatric surgical department and the Rainbow Unit. We were told that

between April 2018 and March 2019 there was a 2.5% DNA rate for surgical patients. We were not

provided with data for DNA rates for children seen in the Rainbow ward. If a patient had three non-

attendances in a row, social services would be contacted. A letter would be sent to the patient’s

parents after the second non-attendance to inform them that social services would be contacted in

there was a third non-attendance. The safeguarding lead of the trust was also notified.

We requested data for referral to treatment time (RTT) for paediatric patients at Central Middlesex

Hospital. However, the RTT data collected by the trust was by specialty and not per hospital site.

The trust informed us that it was impossible to separate this data between hospital sites.

The overall cancellation rates for clinics run by the paediatric team at the hospital for the last 12

months was 38%. This was due to annual leave, sickness and vacancies. 37% of the cancelled

clinics were moved to another hospital in the trust and the remaining clinics were rescheduled at

the hospital. The trust was unable to provide cancellation rates for paediatric surgeries as the data

was collected via hospital number and the trust was unable to filter out paediatric patients.

Theatre lists were prioritised and carefully ordered considering age, procedure and special needs.

This information was shared with parents via the parents information booklet. We requested data

on how long children waited for their operation, but this information was not collected or monitored

by the service.

Children requiring surgery were initially seen at the pre-assessment stage known as Area One. On

the day of surgery children were taken to a paediatric ward called the Recovery Ward. From here

children would be taken into theatre and then taken back to a recovery area known as Stage One

Recovery. Once children awoke from surgery they were taken back to the Recovery Ward.

Throughout the hospital there was poor signage to show members of the public where the

paediatric surgical department was. We spoke to a patient’s mother who had arrived early for her

child’s surgery. The parent could not find the Recovery Ward as there were no signposts and

found this very stressful. When the parent finally found the Recovery Ward a nurse told them that

they were required to book in at the main reception downstairs, which had not been staffed when

the mother had walked past the reception previously. The parent found this experience stressful

and said that this had made them feel more anxious about the surgery. Other parents we had

spoken to had also had similar poor experiences.

From April 2018 to March 2019, neonatal critical care bed occupancy at the trust was better than the England average.


Note: data relating to the number of occupied critical care beds is a monthly snapshot taken at midnight on the last Thursday of each month. (Source: NHS England)


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.

Families knew how to complain or raise concerns. The service clearly displayed information about

how to raise a concern in patient areas. Staff understood the policy on complaints and knew how

to handle them. Managers investigated complaints and identified themes.

However, we did not see a child friendly complaint process appropriate for children and young

people of different age ranges to easily access and use.

From April 2018 to March 2019 the trust received 30 complaints in relation to children’s services at the trust (2.7% of total complaints received by the trust). The trust took an average of 37.6 working days to investigate and close complaints; this is in line with their complaints policy, which states complaints should be should be answered within 40 days. At the time of reporting two complaints were still open. These had been open for an average of 41.0 working days. A breakdown of complaints by type is shown below:


Percentage of total




Others 3 10.0%


Total 30 100.0%

From April 2018 to March 2019 there were three complaints about children’s services at Central Middlesex Hospital. The trust took an average of 30.3 working days to investigate and close complaints. This is in line with their complaints policy, which states complaints should be should be answered within 40 days. All complaints were closed at the time of reporting. A breakdown of complaints by type is below:


Percentage of total



Others 1 33.3%


Total 3 100.0%

Two of the complaints related to the Rainbow Unit and the remaining complaint related to the paediatric audiology service. (Source: Routine Provider Information Request (RPIR) – Complaints tab) From April 2018 to March 2019 there were two compliments about children’s services at the trust (1.1% of all compliments at the trust). Both compliments were for Northwick Park Hospital. The trust did not provide a summary of themes identified within compliments. (Source: Routine Provider Information Request (RPIR) – Compliments tab) Is the service well-led?

Leadership

Leaders had the right skills, knowledge, experience and integrity required for the job role.

This was a largely nurse led unit. There was minimal consultant paediatric or senior managerial

oversight. Lines of accountability were confused.

We were unclear in relation to leadership accountability in the department. The matron in charge

was responsible for the paediatric surgical department and was well-regarded. The trust told us

that the matron had a clear line of reporting for the surgical aspects of her role, reporting to the

Head of Nursing and in turn to the Divisional Head of Nursing. However, the matron was not

accountable to the leads under the women and services division of the trust.

None of the staff spoken to seemed to know who was responsible for overseeing the Rainbow

Unit, since a lot of the clinics had moved to another hospital in the trust. We found a lack of clarity

over where the overall responsibility and accountability of children and young people services lay

within Central Middlesex Hospital. We also found a lack of clarity for how and where this service

communicated or escalated issues into the trust.

Nurses we spoke with said that they did not see or meet any of the trust executive management

team, but that there was a poster at the hospital with photos of all the executive team. Staff we

spoke with said that they could look up the organisational structure on the intranet if they wanted

to. Staff we spoke with were unsure if there was a representative at board level for paediatric

services and said that they would not be able to point out who was the divisional head of nursing.

Nurses we spoke with spoke highly about their matron and said that the matron often provided

clinical support in busy periods.

Consultants we spoke with had job plans which were addressed yearly.

Mental health leads were clearly established for the trust and had the appropriate expertise.

Vision and strategy

Staff were not aware of a departmental strategy but had displayed the trust’s Heart values

outside of the Recovery Ward.


All staff we spoke with were unsure of the status of children and young people services operating

in the outpatient Rainbow Unit. Many staff stated that this clinic had been closed recently.

However, on the first day of inspection, we found a paediatric sickle cell clinic was being held once

a week, and a paediatric dietitian clinic was being held twice a week.

Culture

Nurses we spoke with were proud of the Recovery Ward and said that they worked well

together. They said the matron kept them informed of changes and that they had a good rapport

with the matron.

Nurses described the culture within the paediatric surgical department as open and transparent.

Nurses we spoke with said that communication between nurses and medical staff was strong and

that they were able to challenge medical staff when they needed to.

Governance

There was a lack of governance in relation to out of date policies and associated audits

demonstrating that the care being delivered was compliant national standards and best

practice.

We were not assured that the service was guided or supported via a paediatric surgical network.

We were told by senior staff that there was an overarching paediatric surgical board meeting that

was held twice a year. Staff we spoke with were unsure if this meeting was documented and was

unclear on when the last meeting was and was unsure of what the representation was at this

meeting. We requested minutes for the last three meetings, we received four meeting minutes

from October 2018, February 2019, April 2019 and July 2019. There was little reference to the

children and young people’s services at Central Middlesex in the first three meetings. However, in

the July meeting minutes there was reference to the hospital’s children’s services which was held

three days post inspection. The medical director was questioning why children’s clinics were

relocated from the hospital, the divisional head of nursing explained that the main reason for the

move was the safety of children. The division was aware of the paediatric haemoglobinopathy

clinic running at the hospital but was not aware of the paediatric dietitian clinic running from the

hospital; both these clinics sat under the integrated clinical services division.

Staff were informed of changes via email, but there were no assurance systems in place that staff

had read or acted on these changes for example, read receipts on emails.

We saw documented evidence of staff meetings held, but there was no time period set for how

often these meetings occurred. We requested the minutes from the last three team meetings and

we were provided with minutes from May 2017, September 2017 and July 2018. There were no

other relevant meeting minutes obtained from the trust in regards to the children’s services at

Central Middlesex.

We were told by senior staff that there was a clinical governance meeting held every month apart

from in December and August. This meeting was in a standard format and covered policies,

procedures, breaches, incidents, and complaints. We requested to see minutes for this meeting

from the last six months. We were provided with the meeting minutes from December 2018 and

March 2019 only. The meeting was a children’s services directorate clinical governance meeting

for the whole trust. It was unclear whether or not staff from children’s and young people services

from Central Middlesex hospital attended the meetings and there was no reference to Central

Middlesex in the minutes we reviewed.


We asked senior staff at the hospital when they had last raised a safeguarding concern. The last

concern raised was in May 2019. Senior staff within the children’s division at a different hospital in

the trust had not heard of this safeguarding concern and thought it was unnecessary to be in the

loop of this safeguarding referral.


There were no audits against the Royal College of Surgeons Standards for Children’s

Surgery. Children’s Surgical Forum of The Royal college of Surgeons of England 2013.

We asked to look at the current risk register for paediatric services in the hospital. We were shown

the risk register for April 2015- from four years previously. From the documentation we saw it

appeared that there had been no updating of the risk register since April 2015. Risks were graded

either low, moderate, high or extreme and there were five risks in total. This included privacy and

dignity in children’s Recovery Ward (no single sex facilities) rated extreme. The number of

paediatric services based at different hospitals in the trust rated high. Theatre scheduling rated

high. Medical records unavailable for pre-assessment and recovery rated high and no inpatient

bed available post-surgery for patients needing an overnight stay or not fitting discharge criteria,

rated moderate.

We looked at six risk assessments that had been completed for the Recovery Ward and theatres.

This included the fire safety recorded management checklist, last undertaken in January 2019. A

generic theatre risk assessment, including visual checks of items and escape routes last

undertaken in January 2019, with ongoing actions. A security, violence and aggression risk

assessment with some risk assessments out of date such as risk of theft or damage to trust

premise or trust assets, last undertaken in October 2017 and due for renewal in October 2018. Out

of the six risk assessments we looked at one partial risk assessment was out of date.

Senior staff we interviewed described their top risks as the transition process from this hospital to

another hospital in the trust and the service for paediatric patients provided at this hospital. This

did not reflect the five risks found in the 2015 risk register which was out date, which was kept in

Recovery Stage One and referred to by nurses working in recovery. The senior staff we had

interviewed seemed to be unaware of the transition protocols that we had seen on the inspection

for 16 to 18-year-old patients. When we asked what was on the risk register we were told that the

main risk was that Recovery Stage One was open plan with limited side rooms, this was

documented on the April 2015 risk register.

There were two paediatric resuscitation trolleys upstairs in Recovery Stage One and in the

Recovery Ward, but no paediatric resuscitation trolley in area one preassessment. We highlighted

to senior staff that there had been no scenario testing or evidence to see if the paediatric

resuscitation trolley was accessible in a timely manner or if this was safe. This had not been

documented as a risk on the risk register.

There was no paediatrician based at this hospital. However, nurses on the Recovery Ward had

telephone access to the paediatrician consultant of the week and their contact number when

required.


If was not clear who was responsible for cascading information upwards to the senior

management team and downwards to the clinicians and other staff on the front line.


There was no holistic understanding of performance which sufficiently covered and integrated

peoples views with information on quality, operations and finances. There was no information

captured to measure improvement.

There were no clear or robust service performance measures which were reported or monitored.

Information technology systems were not used effectively to monitor and improve the quality of

care.

Engagement

Senior staff were proud of the continuity of care offered to patients. Paediatric patients

would normally see the same nurse in pre-assessment, on the day of their surgery and the

same nurse would call the patient within 24 hours of surgery.

Staff completed an annual staff survey, we requested the latest staff survey results from the trust.

However, the trust was unable to provide this, we were told that the staff survey was matched

against the organisational hierarchy outlined in the electronic staff record and that this does not

provide results by service and site.

There was a good staff retention rate and staff were offered exit interviews on leaving the hospital.

There was a team email that staff could use to update one another, pre-assessment information

that required chasing and provide handovers when necessary. There was also a social text

message group that staff had to communicate non-work-related agendas such as social

gatherings.

The Recovery Ward displayed a ‘you said’ ‘we did’ action board. However, this was behind a

patients bay and was inaccessible throughout the inspection to the CQC and to service users.


We saw a lack of senior management and senior clinician involvement to drive learning,

continuous improvement and innovation. The lack of audit meant that the service had no base

upon which to start building any improvements and the lack of up to date policies indicated a lack

of awareness and motivation to drive improvements to meet as yet unknown standards in any

revised and updated policies.

London North West University Healthcare NHS Trust

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