Our rating of services went down. We rated them as inadequate because:

• There was a deterioration in infection prevention and control since the time of the last inspection. We found inconsistencies in hand hygiene practice amongst staff, during ward rounds.
• Medicines were not always appropriately stored or checked in emergency department (ED).
• There was poor recognition of sepsis.
• There had been an improvement in safe levels of staffing although the trust needed to continue to work to increase substantive staff in post and reduce reliance on temporary staffing. Some services within the trust did not have enough permanent nursing and medical staff to ensure the provision of safe care and treatment. However, they used bank and agency staff to cover gaps in the staff provision.
• We found out of date copies of the major incident plan on some wards and this was against the trust’s own policy.
• The trust had not improved in relation to the testing of portable electrical equipment. We found that not all portable appliances had been tested.
• We were not assured that high-risk patient groups were screened for MRSA at pre-admission.
• Staff did not always maintain appropriate records of patients’ care and treatment. Records were not always clear, up-to-date and available to all staff providing care.
• We were not assured that the laser service met the Medicines and Healthcare Products Regulatory Agency safety standards.
• There was low participation in clinical audits and the trust performed poorly in some.
• Appraisal rates were low in some areas.
• Staff did not always understand their roles and responsibilities in relation to the Mental Capacity Act 2005, in particular in relation to Deprivation of Liberty Safeguards (DoLS).
• The trust did not audit the World Health Organisation (WHO) five steps to safer surgery in 2017.
• There were no pre-operative fasting audits for patients fasting before surgery.
• The trust did not always actively monitor the effectiveness of care and treatment and use this information to improve services.
• The trust did not meet the target to admit, discharge, or transfer and did not meet the standard that patients should wait no more than one hour for initial treatment.
• The A&E waiting area for patients who attended by their own means was very crowded with insufficient seating.
• We found that staff had poor awareness of the needs of people with learning disabilities.
• Translation services were not always offered to patients.
• The trust provided a range of information leaflets including support groups. However, similarly to the last inspection we did not see any information printed in any other language.
• Spaces within the were surgery division was not suitable for inpatients due to the lack of essential equipment and washing facilities.
• The trust’s investigation and closure of complaints was not in line with their complaints policy which states complaints should be completed in 30 days.
• Since the last inspection, there had been limited improvement in the facilities on the ITU for relatives and visitors.
• There were limited examples of departments supporting patients to manage their own health.
• The bereavement service had limited opening hours and inappropriate waiting areas for bereaved family members
• There was a large backlog of estates maintenance.
• Local risk registers did not always reflect risks described by staff in some areas.
• Matrons and managers within the trust did not have the capacity to effectively lead their teams due to pressures faced operationally.
• The senior management team had not taken note of all of the concerns raised at the previous inspection.
• We found that divisional and executive team were not visible in some areas and rarely some visited departments.
• Staff struggled to locate clinical guidelines quickly as the trust intranet search engine was not user friendly.
• The department had managers with the right skills to run the service; however senior nurses felt that their managerial duties were at times excessive of their role.
• We were not assured that there were adequate governance procedures for the laser service as set by the Medicines and Healthcare Products Regulatory Agency safety standards.

During our inspection of Hillingdon Hospital we visited the accident and emergency department, the maternity unit, care of older people wards, the stroke unit, children’s in patient wards and other in patient wards.

Patients confirmed staff treated them with respect and some patients described staff as “friendly and professional”. One patient said,” staff were very caring”. They don’t talk about you, they talk to you”. Another patient said “age has no bearing on how you are treated”. They said they were involved with their treatment and had this explained to them so they understood what their diagnosis was and the treatment available to them.

Patients told us they were able to discuss and ask questions about their diagnosis and treatment, which the doctors listened to and answered.

Patients said staff asked them how they would like to be addressed and used their preferred term of address. Patients in shared bays told us staff always drew the curtains if they needed any treatment, to maintain their privacy and dignity.

Patients told us they were asked about their religious and cultural needs and the hospital Chaplain provided support. A relative told us, “bad news is discussed with sensitivity, empathy and care”.

The hospital had also received a number of good reviews on the NHS choices website, with comments such as,” I was treated with dignity and respect by the hospital staff”, and “the hospital staff worked well together and I would recommend it to my friends and family”.

Patients told us they were happy with the food that was served to them. Comments included,” we can not fault the food”; we are happy with the variety of choices offered”.

We observed that people were treated with kindness and respect. They were involved in planning their care and were informed about their treatment. People received the care and treatment they needed from a team of different professionals who worked closely together.

People received a choice of different meals and their nutritional needs were assessed and monitored. People were provided with opportunities to give feedback on the care and treatment they were receiving or had received.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People using the service told us that the options for their care were explained to them. They said that that staff answered questions about their care and that they were able to make choices about how they were looked after. They said that staff had asked their permission before giving care or treatment and had explained why they were prescribed the medicines they were taking. The consensus of opinion of the food on offer was that it was ‘fine’. People said they had access to water at all times. They felt that their privacy and dignity was respected by staff and that they knew how to complain if they needed to. Everyone we spoke to was happy with the care and treatment they received at Hillingdon Hospital and praised the staff both for their hard work and for always being available to them.

When we inspected in October 2014, we told that the trust that it must make improvements, which included:

• Make sure it complies with infection prevention and control standards and monitors cleanliness against national standards.
• Assure itself that the ventilation of all theatres meets required standards.
• Make sure that staff are appropriately trained in safeguarding both adults and children, and that the trust regularly monitors and assesses the completion of actions agreed at weekly ‘safety net’ meetings.
• Make sure that all staff understand their responsibilities in relation to the trust’s systems and processes that exist to safeguard children.
• Make sure patients and visitors are protected against the risks associated with unsafe or unsuitable premises.
• Make sure that there equipment is properly maintained and suitable for its purpose.
• Make sure that equipment is available in sufficient quantities in order to ensure the safety of patients and to meet their assessed needs.
• Make sure that all staff receive the full suite of mandatory training that is required to minimise risks to patient safety.
• Make sure patients are protected against the risks associated with the unsafe use and management of medicines.
• Make sure that early warning system documentation is appropriately maintained and that all staff react appropriately to triggers and prompts.

Our key findings from this inspection were as follows:

• The inspection took place approximately three months after we published our comprehensive inspection report in February 2015. We found that the trust had responded appropriately to many of the key issues we highlighted at that time. In some areas however, custom and practice had not changed, despite systems and processes being implemented to deliver changes in practice.
• We observed improved practice in some areas in relation to hand hygiene and the use of personal protective equipment, however, some staff in A&E and on medical wards were not following best practice.
• We observed improved practice in the management of medicines in most departments. Where there were known issues plans were in place and steps had been taken to begin to address these issues and mitigate the risks. However, we found best practice was not always followed by all staff, with daily checks occasionally not happening as necessary and some areas left unsecured.
• It was evident that the trust had taken significant action to address estates deficiencies highlighted by the previous inspection. The trust had restructured its estates function, provided the capital works to the operating theatres and had moved to a less reactive, more planned maintenance service.
• The comprehensive work programme for theatres was on going at the time of our visit. The works to the operating theatres, both to date and planned, and the commitment to annual maintenance were in line with the Health Technical Memorandum (HTM) 03-01.
• The trust had implemented a new estates compliance reporting process to provide the organisation with a collective understanding of its risks and level of compliance against best practice and legal requirements.
• The trust was cleaning and auditing in line with the National Specifications for Cleanliness in the NHS.
• Children presenting to the trust's A&E were appropriately safeguarded as effective systems and processes were in place. Staff received appropriate training which had increased their awareness and key staff were deployed to oversee practice and promote good practice.
• Equipment was clean and staff had enough equipment to meet patient needs. Further supplies could be accessed in a timely way when required.
• Mandatory training figures had improved, the divisions we reviewed having made sure the targeted number of staff received mandatory training, including for infection prevention and control and safeguarding.
• Early warning score documentation was completed accurately and staff responded correctly to triggers and prompts as required.

Areas for improvement:

The provider should consider the concerns of the staff on children's wards about whether locks could hamper access in an emergency.

Professor Sir Mike Richards

Chief Inspector of Hospitals