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

• The trust did not provide full cover for an out of hours rota to cover gastroenterology. This meant patients were at risk of delay to treatment should they experience upper gastrointestinal bleed during out of hours.
• The hospital needed to improve in providing care for children, young people and adults who presented with mental health conditions.
• The trust did not have oversight of the use of restraint.
• Staff in outpatients felt they were discouraged from reporting incidents of verbal and physical abuse against staff.
• Records we reviewed in medical care services were of variable quality. There were no care plans implemented to support patients with falls or dementia in the day hospital unit. Endoscopy patients sometimes underwent procedure under sedation but staff failed to ask them to sign a disclaimer form to confirm they understood risks related to it and that they should arrange to be escorted after the procedure.
• Not all areas in maternity services were visibly clean during our inspection and we were not assured control were effectively in place to prevent the spread of infection.
• There was not always an advanced paediatric life support (APLS) trained staff member on shift in services for children and young people.
• Some of the data from trust’s pain assessment audit indicated that patients were not always offered sufficient analgesia or underwent regular pain assessment.
• The trust did not have complete oversight over how many patients were placed on Deprivation of Liberties Safeguards authorisations (DOLS) in the hospital as the ward staff did not inform the safeguarding lead of all the authorisations that were signed by staff.
• Mental capacity assessments had not always been completed by the clinician before filling out the best interests document.
• The emergency department did not achieve the four-hour Department of Health standard on any occasion between May 2017 and April 2018.
• The outpatient department did not monitor waiting times for patients.
• Across the outpatient department we saw little evidence of health promotion information available for patients.
• The chaplaincy and faith provision within the trust was mainly available for Christian and Muslim faiths.
• Complaints were not always closed in accordance with timescales set out in the trust’s complaints policy.
• The clinical governance structure was not yet fully embedded.
• There was a concern that current improvements in emergency department were not sustainable since there remained a heavy reliance on locum or agency medical and nursing staff.
• There was no board level lead for children’s services.

However:

• Overall, we saw improvement in incident reporting and we saw evidence of learning from ‘never events’
• Since the trust established ‘harm free panel’, the trust reported 57% reduction of hospital acquired pressure ulcers (grade 3 and above).
• The introduction of the fast initial treatment zone in the emergency department meant patients were streamed by a consultant or senior doctor most of the time.
• Risks to women were well-identified and managed by staff in antenatal care, intrapartum and postnatal care.
• In critical care, we found consistently good standards of risk assessment in patient documentation and in practice observations, including in relation to sepsis management.
• We observed effective multidisciplinary team working and good relationships and communication amongst various professionals involved in patients care and treatment.
• The surgical service contributed to national clinical audits for surgery. The overall performance for elective admissions was better than the England average.
• Women’s care and treatment in the maternity service was planned and delivered in line with current evidence-based guidance.
• The maternity service met expected patient outcomes for women in most areas, and in some areas exceeded these.
• We observed and were told patients were treated with kindness, compassion, dignity and respect.
• The maternity service provision met the needs of local people.
• There was increased awareness of the needs of patients with dementia and learning disabilities.
• There was a good handover process for medical patients placed on surgical wards and surgical patients on medical wards (outliers).
• The urgent care centre and the paediatric emergency department performed well in the Department of Health four-hour standard.
• The outpatient department was meeting the referral to treatment time of seeing patients within 18 weeks.
• Staff spoke positively of the leadership team.
• Since our last inspection there had been significant improvements in the working culture of the critical care unit and maternity services.

We visited the maternity unit and spoke to a number of women and their partners on T4, the antenatal and postnatal ward. Women were mostly very happy with the service provided to them. One woman told us that midwives ‘gave loads of advice’ and were ‘really supportive’, which was typical of the comments we received. Another woman told us that during the delivery of her baby staff were ‘were always talking to me and answered mine and my partner’s questions’. Scans and blood tests were fully explained and woman said they had received pain relief when they needed it. Some women felt there were not enough staff available on T4 at certain times but all felt safe on the unit.

When we visited the hospital we spoke to patients and relatives in Accident and Emergency, the children’s ward and M1 (a medical ward) and S3 (a surgical ward). Overall, patients were positive about the care and treatment they had received. They said they were treated with dignity and their privacy was respected. Treatment options and medication were explained in ways that were understood by patients. A child told us, ‘they are really good nurses, they do explain what they are doing’. Staff were described as ‘helpful’, ‘caring’ and ‘supportive’. Some patients told us that staff seemed very busy and were concerned they sometimes took a long time to respond when the call bell was used. All patients we spoke to said they felt safe in the hospital and felt listened to by staff.

The North Middlesex University Hospital NHS Trust is a medium-sized acute trust with around 515 beds, serving approximately 590,000 people living in Enfield and Haringey and the surrounding areas, including Barnet and Waltham Forest. In the 2015 Indices of Multiple Deprivation, both Enfield and Haringey were ranked in the most deprived quintile.

The trust had an annual revenue of around £250 million, and reported a deficit of £8 million, at the time of the inspection. The trust employs 2,458 staff. The trust provides a full range of adult, older people’s and children’s services across medical and surgical disciplines.

In 2015/16 the trust reported activity figures of 56,880 inpatient admissions, 348, 276 outpatient attendances and 171,840 admissions through the Accident and Emergency department.

We inspected all eight core acute services including: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, Services for children, End of life and Outpatients and diagnostic services.

We last undertook a comprehensive inspection at the trust in June 2014 when we rated the trust as requires improvement overall.

Following concerns we undertook an unannounced inspection of two medical wards and the ED in April and May 2016. We rated the medical service as requires improvement overall and the ED as inadequate. We also issued a Warning Notice to the trust requiring them to make improvements to the ED by the end of August 2016.

Our key findings were as follows:

• The emergency department (ED) was not consistently achieving the 15 minutes performance standard for initial review of all patients arriving at ED.
• The ED was not meeting the target time to admit, transfer or discharge 95% of patients within 4 hours of their arrival in the ED.

• Substantial improvements have been made since the last inspection in May 2016. There was improved clinical governance and leadership at department level and oversight of this at trust level.

• Patient records had not been completed consistently, frequency of intervention was not always recorded and there was no evidence that the care of patients had been increased to reflect individual needs. Patient records were not always kept confidential or stored securely.
• Staffing levels on the wards did not always reflect the safer staffing acuity tool to determine safe staffing levels.
• We found that medicines were generally stored securely and appropriately, including those requiring refrigeration. Regular expiry date checks were in place and there were suitable arrangements for ensuring medicines were available out of hours.

• Most observed interactions between staff and patients were positive. Feedback from patients and relatives was generally good and they felt they were treated with courtesy, respect and compassion by staff. Staff maintained patients’ privacy and dignity.
• The hospital consistently met the referral to treatment standard and performed better than an average English hospital.

• The departmental risk register did not fully indicate how risks were mitigated and who was responsible for implementing actions.

• Nurse staffing levels could be unpredictable and did not always meet national guidance. Safety checks on agency nurses were inconsistent and poorly managed.
• Care and treatment was consultant led and medical staffing levels met national best practice guidance.

• The culture was not one of fairness, openness, transparency, honesty, challenge and candour. Staff reported bullying, harassment and discrimination amongst staff at all levels in the maternity unit. They said when they raised concerns they felt they were not treated with respect. The culture was defensive with poor collaboration between the staff working in different departments. High levels of conflict were reported to us.
• We were not assured that patients were being cared for in the right place at the right time, by adequately qualified staff. This meant that patients may not receive timely care in the appropriate part of the service and be cared for by competent staff which put them at risk.
• The majority of women and those close to them were positive about the care and treatment they had received. Women were able to telephone Maternity Direct in working hours and triage out of hours for emotional support.

• The service had a lack of ownership or oversight of children being cared for in other areas within the trust where the care environment was suboptimum and the service did not have oversight of young people over the age of 16 years who were cared for in adult clinical areas of the trust.
• There was poor oversight of patients with learning disabilities who were not identified on admission.
• The service had effective systems to identify children who might deteriorate whilst receiving care and used the recently introduced Royal College of Paediatrics and Child health SAFE Programme based on work undertaken at the Cincinnati Children’s Hospital in the USA.
• NICE guidance for EoLC staffing showed a seven day service should be provided for EoLC, however this had not occurred. A business case was awaiting review.
• There was no non-executive director on the board responsible for EoLC.
• A minimum of 50% of registered nurses on every ward had received some form of training from the SPCT. This was the trust target.
• Overall, patients were treated with dignity, respect and care by staff. Although, some patients told us staff were rude and uncaring. Most patients spoke positively about staff but did not always feel well informed about their care and the procedures being undertaken.
• The proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment was below the national average and had deteriorated in the first quarter of 2016/17.
• The percentage of patients seen within two weeks for all cancers was higher than the national average. Also, the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment were higher than the national average and above the standard target of 96%.

We saw several areas of outstanding practice including:

• The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• Outpatient and diagnostic services had strong leadership. Staff were inspired to provide an excellent service, with the patient at the centre.
• The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.

• The paediatric clinical teams used the SAFE programme. North Middlesex Hospital had been one of 28 hospitals which had worked with the RCPCH in participating in a two

  year programme to develop and trial a suite of quality improvement techniques to improve communication, build a safety-based culture and deliver better outcomes for children and young people, known as SAFE.

  The SAFE programme was designed to reduce preventable deaths and error occurring in the UK’s paediatric departments.

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

Importantly, the trust must:

Urgent and Emergency Services

• The trust must ensure learning from incidents is more robust and shared with all staff.
• The trust must ensure that all medicines and instruments associated with a resuscitation are disposed of safely after use.
• The trust must ensure the renewal of advanced paediatric life support (APLS) certificates of those doctors and consultants whose certificates had expired
• The trust must improve mandatory training levels for medical and nursing staff.
• The trust must improve safeguarding adults level 2 training for medical and nursing staff.
• The trust must improve safeguarding children level 2 training for medical and nursing staff.
• The trust must improve hand hygiene levels especially amongst medical staff.
• The trust must ensure medical and nursing staff are fully trained and able to identify and support the needs of patients living with dementia.
• The trust must ensure medical and nursing staff are fully trained and able to identify and support the needs of patients with learning disabilities.
• The trust must improve appraisal rates of nurses.

Surgery

• The trust must ensure all actions in response to the never event are fully implemented.
• The trust must review and identify causes for the higher than the national average mortality rate as suggested by the bowel cancer and the national hip fracture audit data.

Outpatients and Diagnostic Imaging

• The trust must ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
• The trust must ensure there are appropriate processes and monitoring arrangements in place to improve the 32 and 61 day cancer targets in line with national targets.
• The trust must ensure there is improved access for beds to clinical areas in diagnostic imaging.

Maternity and gynaecology

• The trust must carry out an audit of the stillbirth rate for the period January to December 2016 and develop an action plan to address themes.
• The trust must provide one to one care in labour to all women.
• The trust must replace all damaged equipment in EGU and triage.
• The trust must monitor and report in VTE compliance.
• The trust must monitor the temperature of medicines storage.
• The trust must review waiting times in triage and develop an action plan to address themes.
• The trust must ensure mandatory training and multidisciplinary intrapartum care training targets are met.
• The trust must display cleaning schedules or checklists all clinical areas.
• The trust must ensure staff in maternity observe the ‘bare below the elbows’ policy.
• The trust must ensure patients have a named midwife.

End of Life Care

• The trust must code their complaints correctly to reflect palliative and end of life care complaints.
• The trust must send out bereavement surveys to the relatives of patients who have died within the hospital.
• The trust must produce and ratify an end of life care strategy.

In addition the trust should:

Urgent and Emergency services

• The trust should continue to make improvements to 15 minutes to triage time.
• The trust should maintain consistent achievement of 80% target of 15 minutes to ECG.
• The trust should ensure there is a supply of paediatric emergency medicines in the paediatric high dependency room.
• The trust should develop statement of purpose for escalation when a patient with a mental health illness absconds from the department.
• The trust should record children’s weights in paediatric patients' records.
• The trust should rectify IT issues in paediatric ED to ensure all PEWS scores are recorded.
• The trust should develop a chest pain pathway.
• The trust should develop a frailty pathway.
• The trust should ensure there is a sufficient number of wheelchairs available to facilitate timely ambulance handover of patients.
• The trust should improve patient comfort with the availability of snacks for patients 24/7.
• The trust should improve quality of major incident awareness amongst all staff.

Surgery

• The trust should ensure departmental risk register indicates how risks are to be mitigated and who is responsible for implementing actions.
• The trust should ensure staff improve recording of pressure ulcers, raise incidents and safeguarding alerts when appropriate.
• The trust should ensure reporting of actions from mortality and morbidity meetings is formalised and ensure learning and actions are shared across the trust.
• The trust should ensure individual venous thromboembolism risk assessments (VTE) are fully completed for all patients.
• The trust should improve average waiting time for a patient discharge prescription.
• The trust should improve utilisation rate for operating theatres and its efficiency.
• The trust should review if all qualifying patients are screened for dementia.

Critical Care

• The trust should ensure all staff have adequate knowledge of safeguarding policies and processes.
• The trust should ensure nurse to patient ratios are managed in relation to the individual needs of patients, including whether they are bedbound and/or cared for in a side room and in relation to the guidance of the ICS core standards for intensive care.
• The trust should ensure staff have appropriate support and supervision to meet their needs in relation to professional and contractual activity.
• The trust should ensure all staff who care for patients have the appropriate personal skills to demonstrate understanding and kindness.
• The trust should ensure learning from infection prevention and control audits are implemented by all staff.

Outpatients and Diagnostic Imaging

• The trust should ensure its target for compliance with mandatory training is met by staff.
• The trust should ensure there is access to seven day week working for radiology services.
• The trust should ensure staffing is improved in radiology for sonographers.

​Children and Young people services

• The trust should ensure that all children and young people up to their 19th birthday wherever they are cared for in the hospital should come under the governance of children’s services which will ensure that they have oversight of all children and young people wherever they are treated in the hospital.
• The trust should improve drug refrigerator temperature monitoring and replace faulty fridges with new equipment where required in order to ensure medication is safely stored.
• The trust should gather feedback from children and young people who use their services and use this information to inform and improve service planning.
• The trust should ensure that play provision for children in hospital should be enhanced to meet national standards.

Maternity and gynaecology

• The trust should develop a clear vision and strategy for the maternity and gynaecology service.
• The trust should review the group sessions for the first antenatal appointment.
• The trust should carry out a review of culture within maternity and use tools such as ‘walk in my shoes’.

Medical care (including older people’s care)

• The trust should ensure that staff report incidents through the online reporting system and there is a formal process for feeding back to staff.
• The trust should ensure Mortality and Morbidity review meetings are used to identify action points or lessons learnt and that these are recorded.
• The trust should ensure patient records are completed consistently and patient records are always kept confidential and stored securely.
• The trust should ensure staff wash their hands between patients and wear appropriate PPE.
• The trust should ensure that staffing levels on the wards reflect the safer staffing acuity tool to determine safe staffing levels.
• The trust should ensure nursing staff know how to use the settings for the pressure relieving mattress.
• The trust should ensure compliance with mandatory training meets the trusts target for infection prevention and control training, health safety and welfare, information governance, safeguarding, safeguarding children and fire safety.
• The trust should ensure that feeder cups and meals are left within easy reach of patients.
• The trust should ensure that staff are trained in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards and that staff seek patients’ consent before care or treatment is given.
• The trust should ensure that activities, such as cards, games or puzzles, are provided on the care of the elderly wards.
• The trust should ensure that staff have feedback about complaints or learning from them.

End of Life Care

• The trust should ensure they meet the minimum requirements for consultant staffing as set out within the Royal College of Physicians guidelines.
• The trust should provide a seven day face to face service as set out within NICE guidance for EoLC.
• The trust should carry out mental capacity assessments on all patients deemed to lack capacity prior to completing a DNACPR form in line with trust policy.
• The trust should keep the risk register up to date at all times.
• The trust should ensure patient care is delivered in line with the patients' care plans at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals