Critical Care:

We rated safe, effective and caring as good and responsive and well-led as requires improvement. The rating of safe improved since our last inspection. Our overall rating of this service

stayed the same

. We rated it as

requires improvement

because:

• There was a lack of local oversight of equipment maintenance and safety testing.
• The service was not meeting the trust’s target for staff completing mandatory.
• Although the incident reporting culture on the unit had improved, not all delayed discharges and mixed sex accommodation breaches were reported as incidents.
• The service did not meet all best practice recommendations set out within The Faculty of Intensive Care Medicine (FICM) Core Standards for Intensive Care Units.
• Speech and language therapy (SALT) was not available at weekends.
• There was no dedicated psychological support service for the unit and staff told us that many patients would benefit from this.
• Some relatives felt engagement and communication from staff could be improved. They did not always felt fully informed.
• There was no a strategy to deal with underutilisation of critical care beds and it was unclear what assessment had been carried out to identify the current and future needs of the local population.
• There were ongoing issues with patient flow. The majority of patients were delayed over the recommended four hours before being discharged to a different ward.
• Not all patients who were ventilated on the unit were offered a follow-up clinic due to lack of no administrative support. This did not meet best practice recommendations set out within FICM Core Standards for Intensive Care Units
• There was very little information visibly available to support relatives and visitors.
• There was no internal referral system to refer patients to a psychological support service. Instead, the patient’s GP was contacted and ask to make a referral.
• Opportunities to learn from complaints were missed. We did not observe any leaflets about how to make a complaint visibly displayed on the unit or within the designated relatives’ rooms.
• It was unclear what the long-term plans were for the future of the service. The uncertainty over the future of the unit had a negative effect on staff morale.
• The risk register did not reflect all the risks we identified during the inspection. We were not assured that there were effective systems for identifying, monitoring and mitigating risks.
• There was limited evidence that staff and patients’ views were gathered to improve and plan the service.

However:

• Staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse
• Staff adhered to the hospital policy of being ‘bare below the elbows’ to reduce the risk of infection.
• There was a clear escalation policy for any suspected cases of sepsis.
• Patient records were clear, up-to-date and available to all staff providing care.
• Learning and feedback from incidents was shared with staff via email, at handovers and team meetings. Staff were able to give us examples of learning from incidents.
• Staff used appropriate risk assessments and care bundles to reduce the risk of patient harm.
• Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients.
• Patient outcomes were mainly in-line with, or better than, the national average for comparable units.
• We saw evidence of good multidisciplinary working between staff on unit and different specialities.
• Consultant-led ward rounds took place twice daily, seven days a week.
• Patients and relatives were treated with compassion and kindness. They offered emotional support and reassured patients.
• Patients’ family members and carers were provided with on-site accommodation within the nearby ‘relatives’ room’ to allow them to stay at the hospital overnight.
• There was a positive and friendly culture on the unit. Staff supported each other and valued input from their colleagues. Staff told us they felt confident to raise concerns or ask questions.
• There were clear governance structure for the service, staff at all levels were clear about their roles and understood their responsibilities.

Outpatient Department:

We rated safe, responsive, caring and well-led as good. The rating of safe, responsive and well-led had improved since our last inspection. Our overall rating of this service

improved

. We rated it as

good

because:

• There were clear procedures in place for the care of patients who became unwell or patients who deteriorated whilst waiting at the clinic.
• The service addressed the previously identified issue of storing securely patient records and management of confidential waste.
• The service improved the availability of patient records in clinics.
• The service significantly reduced staff sickness.
• Evidence-based guidelines, recommendations, best practice and legislation were applied to patients’ treatment and care.
• Staff were competent for their roles.
• Good multidisciplinary team working helped staff understand and meet the range and complexity of patients’ needs. Each service specialty had its own multi-disciplinary team meeting.
• Staff understood the relevant consent and decision making requirements of legislation and guidance.
• Staff demonstrated compassion and kindness as they put patients and their relatives at ease.
• The service took account of patients’ individual needs and was designed to meet the needs of the local population, including specialist clinics.
• There was a ‘one stop’ breast cancer clinic and a separate ‘one stop’ clinic for patients with a suspected skin cancer.
• The trust is performing consistently better than the England average for cancer waiting times.
• Divisional leaders were visible and were proactive in engaging with patients and staff.
• The departmental nursing staff won the trust annual ‘acute team of the year’ award.
• Risks were generally understood and shared by all staff across the department.

However:

• Incidents were not consistently reported and we were not assured that staff fully understood what constituted an incident.
• Information about patient outcomes was not routinely collected and monitored by the department.
• The department’s ‘did not attend’ rate was higher than the England average.

There were continuing capacity issues in certain clinics due to overbooking. In some cases, patient appointments were cancelled on the day.

Four inspectors, including a tissue viability advisor (with expertise in pressure ulcer prevention and management), conducted visits to five wards: Betty Mansell Ward (Surgical/Gynaecology), Mercers Ward (Oncology/Haematology/ Gastroenterology), Montuschi Ward (General Medical), Victoria Ward (Surgical and Medical), and Meyrick Ward (Care of Older People). We conducted observations on the wards, spoke to 15 patients or relatives, 17 staff members and looked at 16 patient records.

People we spoke with who used the services at the Whittington Hospital told us that they received a good level of care, treatment and support. Comments included “They are absolutely superb,” “They talk to you,” “They work hard,” “They are supportive,” and “You don’t even need to press the call bell, they are here all the time.”

We found that significant improvements had been made in the care of older people with general medical needs on other specialist wards, to ensure that their needs were met and they were protected from the risk of unsafe care.

Nine inspectors, including a dementia advisor conducted visits to eleven wards/departments: Cavell Ward (Stroke Rehabilitation), Cloudesley and Meyrick Wards (Care of Older People), Cearns and Cellier Wards (Maternity), Mercers Ward (Oncology/Haematology/ Gastroenterology), Betty Mansell Ward (Surgical/Gynaecology), Mary Seacole North and South Wards (Short Stay Medical Assessment Units), Emergency Department and a number of Outpatients Department. We conducted observations on the wards, spoke to 60 patients or relatives, 40 staff members and looked at 20 patient records. Following the inspection we requested information from the Patient Advice and Liaison Services Department and the Trust’s Clinical Governance Team.

Most people we spoke to who used the services at the Whittington Hospital told us that they received a good level of care, treatment and support, and some were very proud of their local hospital. People were generally very complimentary about the staff and said that they explained and answered questions about their care and treatment. Very few people we spoke with had complaints about the service they had received. Our observations of care and discussions with patients and staff identified some areas for improvement in some services provided. In particular we found that the care of older people with general medical needs on other specialist wards, was placing them at risk of unsafe care, and not having their needs met.

The inspection was undertaken by two compliance inspectors commencing on 29th May 2012. It included visits to the Child Development Centre at St Ann’s Hospital, the Paediatric Assessment Unit at North Middlesex Hospital, the Children in Care team at Bounds Green Health Centre, Health Visitors at Tynemouth Road Health Centre, and Clinical Governance at the Whittington Hospital, as well as attending the Integrated Additional Support Network Panel. We provided a feedback session to the Trust on 26th June 2012.

Overall we spoke with over 20 parents or young people, and over 30 staff members including a range of therapists, receptionists, doctors, nurses and health visitors. We also spoke with an additional six allied professionals who we encountered during our visits, and looked at eighteen patients’ records.

Parents and young people spoken to gave us very positive feedback about services. Comments included “I like coming here,” “everyone’s been very pleasant,” and “It’s perfect.” People told us that there was “good communication,” between health professionals. They were particularly appreciative of flexible appointments, as one person noted “they talk to each other and fix appointments on the same day.”

People said that they were told what to expect, and were listened to during appointments and given enough time. However some recent problems were described with interpreter services, which were being addressed by management.

Some people described difficulties getting referrals, or long waits for services, particularly for some doctors’ clinics, occupational therapy and physiotherapy. There were also significant backlogs for children in care waiting for initial and review health assessments, and for pre-adoption medicals, and for Health Visitors to conduct visits to new born babies. It was understood that these shortfalls related to high levels of safeguarding work undertaken within the local authority. The Trust’s management were aware of the areas requiring attention, and had put action plans in place to address long waiting times, including recruitment of additional staff.

People found the location of the Child Development Centre (CDC) convenient, however concerns were raised about its state of repair. There was far greater satisfaction with facilities at Bounds Green and Tynemouth Road Health Centres. Staff advised that the CDC was due to be relocated. It was hoped that the move would be to a purpose built facility including staff from education and social services, in order to provide children in Haringey with a high standard of joined up support.

People spoke highly of the support provided to them by staff of all disciplines. Comments included “the doctor spoke to us very nicely,” “people were very polite and professional,” and “I like the staff – they are approachable, interactive and understanding.” However some people were concerned that they were seeing different people on each occasion, indicating that there was a lack of continuity of staff. Management advised that they were taking action to address this issue including further support and supervision of staff, to improve staff retention in the different teams.

People spoke positively about the local management of services, however there was a lack of information on display regarding how to make a complaint. Where complaints had been made, or incidents had occurred, these were addressed appropriately. Whilst local audits were being undertaken of services provided, the Trust were aware of the need to provide more centralised quality assurance systems in order to monitor the quality of services for children in Haringey.

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.

This respite service is due to be closed once alternative provision can be found for respite care for the current client group. The service has started to provide outreach work to support people with complex health needs in the community. This is part of the development of a new nurse led service for people who have complex health needs, which will be fully implemented when the current respite service closes.

We spoke to or spent time with three people staying at the service. People indicated that they felt comfortable at the unit, although they only stayed there for short stays. They were given choices about their day to day lives, and had formed good and supportive relationships with staff and management.

People had access to healthcare professionals when needed, and received appropriate support with their physical needs. Their privacy and dignity was respected and they were supported to undertake some activities outside of the unit.

Some improvements are needed with regard to records kept at the unit including activity records and staff supervision records, in the interests of people receiving support from the service.

Over 20th and 21st October 2011, 10 inspectors, including a pharmacy inspector, conducted visits to 18 wards/departments:

Cearns, Murray, Labour and Cellier Wards (Maternity), Thorogood Ward (Elective Orthopaedic), Cloudesley Ward (Care of Older People/Stroke Rehabilitation), Coyle Ward (Surgical Trauma/Orthopaedic), Nightingale Ward (Respiratory Medicine), Mercers Ward (Oncology/Haematology/Gastroenterology), Mary Seacole and Mary Seacole South Wards (Short Stay Medical Assessment Units), Cavell Ward (Care of Older People), Critical Care Unit (Intensive Care), Emergency Department, Pharmacy Discharge Lounge, Outpatients, Neonatal Intensive Care and the Patient Advice and Liaison Services Department. We conducted observations on the wards, spoke to approximately 70 patients or relatives, 45 staff members and and looked at approximately 20 patient records.

Most people we spoke to who used the services at the Whittington Hospital told us that they received a good level of care, treatment and support, and some were very proud of their local hospital. People were generally very complimentary about the staff and said that they explained and answered questions about their care and treatment. Very few people we spoke to had complaints about the service they had received, however few people were aware of the complaints procedures for the Trust.

Our observations of care and discussions with patients and staff identified some areas for improvement in some services provided, in order to ensure that the Trust remains compliant with the Health and Social Care Act 2008.

Patients and visitors were positive about the Whittington Hospital and praised the vast majority of staff as caring and hard working. Patients told us that staff treated those more dependent than themselves with kindness, for example when helping them to eat. People generally felt that they had been given enough information but medication was sometimes an area where people wanted to know more. They said that they and their families had been involved in decisions and they had received helpful support from professionals. One person noted ‘they always tell me who cares for me – they talk to me and tell the doctor things I want to ask.’ Another advised ‘anything you ask – they do – I don’t want to go home!’ However some patients said that they had to wait a long time for call bells to be answered, particularly at night, and several patients did not have enough information about the facilities available on the ward.

Most of the people we spoke to said there was a choice of meals and were satisfied with the food. One person noted ‘I’m asked if I want large or small portions, and given quite a few drinks, and encouraged to drink them.’ However some people did not find the hot meals appetising and were not always offered alternatives by staff on the ward. Some people felt that their cultural preferences were not sufficiently catered for. People advised that they were weighed regularly and some people had their fluid and food intake monitored. None of the other patients we interviewed had missed a meal.

The Whittington Hospital has approximately 320 beds, and is registered across 3 locations registered with CQC: Whittington Hospital (includes community services) , Hanley Primary Care Centre (GP practice and community centre) and St Luke's Hospital (Simmons House) multi-disciplinary MH service for 13-18 year olds with emotional and mental health problems.

We carried out an announced inspection between 8 and 11 December 2015. We also undertook unannounced visits on 14, 15 and 17 December 2015.

We inspected eight core services: 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.

This was the first inspection of Whittington Hospital under the new methodology. We have rated the trust as good overall, with some individual core services as requires improvement.

In relation to core services most were rated good with critical care and outpatients and diagnostics rated as requires improvement.

Our key findings were as follows:

• During our inspection we found staff to be highly committed to the trust and delivering high quality patient care.
• We saw staff provided compassionate care and patients were positive about the care they received and felt staff treated them with dignity and respect.
• The trust had vacancies across all staff groups, but was recruiting staff and staffing levels were maintained in services through the use of bank and agency staff.
• Staff were aware of how to recognise if a child or adult was being abused and received good support and training from the trust's safeguarding team.
• The trust had an incident reporting process and staff were reporting incidents and receiving feedback. Learning was shared across ICSU’s which encompassed acute and community service.
• The trust had promoted duty of candour and this was seen to be cascaded through the organisation.
• We observed effective infection prevention and control practices in the majority of areas we inspected.
• Patient care was informed by national guidance and best practice guidelines and staff had access to polices and procedures.
• Patients had their nutritional needs met and received support with eating and drinking.
• There was good team and multidisciplinary working across all staff groups and with clinical commissioning groups, voluntary organisations and social services to deliver effective patient care.
• We found evidence of good compliance with the World Health Organisation (WHO) surgical safety checklist, with good completion of the three compulsory elements: sign in, time out and sign out.
• There were processes in place to ensure staff attended training on the Mental Capacity Act 2005 and the majority of staff demonstrated a good practical understanding of this, with variability in some services,
• Staff understood and responded to the needs of the different population groups the trust served and worked hard to meet the needs of individual patients.
• Patients were largely treated in timely manner with the trust meeting national access targets and performing higher than the England average, with the exception of the cancer two week wait standard, although it was noted that improvements were being made against that standard.
• The emergency department (ED) performed better than the average ED in England in the speed of initial assessment, the timeliness of ambulance handover, and the percentage of people staying for more four hours in the department. However, there were times when there were no in-patient beds available and patients remained in ED for a long time.
• The trust had introduced the ambulatory care unit, which engaged stakeholders across the health and social care economy to avoid unnecessary hospital admissions and transfer their ongoing care needs to the most appropriate provider.
• Patient flow out of theatres and critical care, impacted on patient movement and service capacity.
• Executive and non executive members of the trust were visible in most areas, in both acute and community settings.
• The trust had a clear vision and strategy, the development of this into local strategies were in place in some areas, but were still being developed in some cases.
• Staff were positive about how their local and senior managers engaged with them.

We saw several areas of outstanding practice including:

• Whittington Health NHS Trust worked with clinical commissioning groups (CCGs) and other providers to improve the responsiveness of emergency and urgent care services for local people. The Ambulatory Care Centre, which opened in 2014, provided person-centred hospital level treatment without the need for admission.
• Within the Ambulatory Care Centre we observed good multidisciplinary working across hospital services, including diagnostics, care of the elderly physicians, therapists, pharmacists, and medical and surgery specialities to provide effective treatment and care.
• Elderly care pathways had been well thought out and designed to either avoid elderly patients having to go to ED or if they do, making sure that their medical and social care needs are quickly assessed.
• Within the ED there was outstanding work to protect people from abuse. The lead consultant and nurse for safeguarding coordinated weekly meetings attended by relevant trust wide staff to discuss people at risk and to make plans to keep them safe.
• Within children and young people’s services responsiveness was demonstrated through close working arrangements with community-based services including the ‘hospital at home’ service which ensured that children could expect to be cared for at home via community nursing services.
• The trust provided ‘Hope courses’ for patients who had been on cancer pathways to get together outside of hospital, and hear from motivational speakers including talks on personal wellbeing, nutrition and recovery care.

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

Importantly, the trust must:

• Within the Emergency Department (ED) there was not sufficient consultant cover and there were vacant middle grade medical posts, covered by locum (temporary) doctors, which poses a risk to delivery of care and training staff.
• Within acute outpatient departments the hospital must improve storage of records and ensure patient’s personally identifiable information is kept confidential.
• Within the acute outpatient setting, improve disposal of confidential waste bags left in reception areas overnight.
• Within surgery and theatres review bed capacity to ensure patients are not staying in recovery beds overnight.
• Within critical care the trust must review capacity and outflow of patients. We observed significant issues with the flow of patients out of critical care and found data suggesting 20% of patient bed days were attributed to patients who should have been cared for in a general ward environment. This led to mixed sex accommodation breaches, a high proportion of delayed discharges from critical care and a number of patients discharged home directly from the unit
• Within critical care the service must review governance processes and use of the risk register. We were concerned there was a culture of underreporting incidents and near misses and the importance of proactive incident reporting should be promoted.
• Within critical care staff did not challenge visitors entering the unit and we were concerned patients could be at risk if the unit was accessed inappropriately.
• Within maternity services the department must ensure the information captured for the safety thermometer tool is visible and shared with both patients and staff in accessible way.
• Within maternity the service must ensure the safety of women undergoing elective procedures in the second obstetric theatre and agree formal cover arrangements.
• Within palliative care the service did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital.
• Within palliative care services staff were not always aware of patient’s wishes in regards to their ‘preferred place of death’. They did not always record and analyse if patients were cared for at their ‘preferred place of care’.

In addition the trust should:

• Take further action to improve safe nurse staffing levels across the surgery service, particularly within main operating theatres and recovery.
• Improve consistency of labelling medical equipment that is clean across surgery wards and operating theatres.
• Ensure healthcare assistants on surgery wards are given competency appropriate tasks and supervision at all times.
• Improve bed management across the hospital to ensure post-operative patients are allocated to a ward in a safe and timely way.
• Ensure all recorded risks in the surgery service are addressed in a timely way.
• Improve engagement with consultant surgeons and anaesthetists working in the surgery service.
• Improve leadership support and capacity within operating theatres.

Professor Sir Mike Richards

Chief Inspector of Hospitals