We visted Beech Ward, an elderly care ward, following allegations of abuse that had been disclosed to the hospital through their whistleblowing procedure. The hospital reported to us that it had taken measures and actions to ensure that people were protected from the risk of further harm and that the allegations were being properly investigated.

This visit took place to ensure that people were being protected from harm and to look at the trust's immediate response to the disclosure.

People who use the service told us that the care and treatment they had received had been good and people were complimentary about the service they had received from nurses. We were told that nurses responded to buzzers in a timely manner and that people’s needs were being met. One person told us that communication could be better with the medical staff who had not spoken to the family about their relative’s health issues.

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

• Since our last inspection of acute services at Whipps Cross Hospital in 2016, 2017 and 2018, the trust had addressed or shown improvement for most of the previously reported concerns and requirement notices, for which we commend them. Evident improvements included significantly improved standards of care, dignity and privacy in medical care, the improved culture around medicines management, and improved record keeping in surgery. However, we found several areas of improvement to address such as the pockets of bullying in the emergency department and the maintenance of equipment and the environment.
• Although the trust had improved referral to waiting times (RTT) in the surgical service, further improvement was required to ensure the trust was meeting the national standard. In outpatients, only one specialty met the national RTT target.
• In outpatients, we also found substantial waiting lists for clinic appointments with relatively high cancellation and did not attend rates. Although rebooking and follow-up practices varied between specialties, individual specialties such as ophthalmology scheduled ad-hoc clinics to reduce waiting lists and meet local demand.
• Patient flow within the hospital remained an ongoing challenge and impacted other services such as bed occupancy in critical care. In the surgical service, late starts, patients discharge out of hours and cancelled operations had not improved.
• The trust did not meet the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge. Performance between January and July 2018 (86%) was worse that the England average but just above the London average (85.8%).
• Although the trust had improved the culture in areas such as the eye treatment centre in outpatients and medical care services, we found pockets of bullying in the emergency department which the leadership team did not have oversight of.
• Staff feedback on development opportunities varied between each service. In medical care, doctors in training were very positive about the support and teaching they received whilst outpatients staff told us they had inconsistent access to training and development opportunities.
• The trust did not provide up to date monitoring data for mandatory training, staff vacancies, sickness and turnover rates and appraisal completion rates for outpatient services. Similarly, in diagnostics, the trust did not provide a breakdown of mandatory training compliance rates for nursing or medical staff by module.
• Although the trust had shown improvement in staffing levels in some services, the trust still had challenges with staffing in some of the services we inspected. The emergency department had high nursing and consultant vacancy rates. Managers told us processes in human resources (HR) had contributed to delays for the appointed nurses from overseas to start.
• The availability of equipment continued to present challenges for staff in some services. The diagnostic service had a significant amount of aging equipment which was prone to breakdown which had resulted in clinic delays and early closure. Surgical staff witnessed similar issues in accessing equipment or getting broken equipment repaired despite the trust making a significant investment in replacing equipment which urgently needed replacing.
• The diagnostic service had no schedule in place for quality assurance testing of the home computers and did not complete regular quality assurance checks on equipment including mobiles, despite being advised to do so by the medical physics expert’s advice.
• Although senior leaders and service managers had, for the most part, a good understanding of risks to the service, the trust did not have oversight of some issues despite them being logged on the risk register. Service leads did not mitigate risks appropriately in some instances. Radiographers raised concerns about personal safety at night due to the location of an equipment. Although the service lead was aware of this and had acquired an additional machine, the location had still not been determined.
• Although the fire safety group and operations team had improved fire safety in the hospital, we found partially blocked fire escapes routes on Cedar ward and Faraday ward and a lack of assurance around fire safety within outpatients, including poor organisation we observed during an evacuation.
• The trust’s response rate to the NHS Friends and Family Test (FFT) had been lower than the national average. Staff told us the low response rates were due to the trust recently changing to an electronic method of collecting FFT data and individual teams had developed initiatives to address this.

However, we also found:

• The trust had addressed the warning notice issued for medicines management in the April 2018 inspection of surgical services. In most cases, we found improvement in the storage of medicines and Controlled Drugs and improved staff awareness of policies overall. However, further improvements were still required for example with tracking the dispensing of pre-packs.
• Most staff had good awareness of incident reporting, how to raise concerns and duty of candour. There was an open culture of incident reporting and a willingness to learn from incidents for most services except for outpatient services.
• There were comprehensive, clearly defined and embedded processes to protect people from abuse. Staff were knowledgeable about safeguarding and were confident to escalate concerns. Staff were aware of their responsibilities as set out in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
• All areas of the hospital we inspected were visibly clean, tidy, and clutter free with adequate supplies of personal protective equipment (PPE) available for use when required. Although we observed good compliance with infection prevention and control across the hospital, hand hygiene audit results for the emergency department required significant improvement.
• The trust had introduced measures to better anticipate and manage patient risks including an improved integration of the national early warnings scores (NEWS) system. Although staff had good knowledge of what to do in the event of a patient deteriorating, we found inconsistent NEWS documentation in patient records in the emergency department.
• Throughout our inspection, we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. Ward staff worked closely with staff across acute and community services as well as practitioners in the local health economy.
• Staff demonstrated compassion to patients and their relatives in all the services we inspected. Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. However, there were some isolated incidents where patients felt staff were too busy to provide the support they needed.
• Most people using the trust’s services were treated with dignity and respect with significant improvements in medical care. However, we found patient dignity and privacy was compromised in the GP x-ray department changing area and in outpatients where there was a lack of screens for procedures such as taking blood pressure.
• Staff delivered patient care in line with good practice and evidence-based guidance from relevant bodies. Most of the staff we spoke with told us they could easily access policies and guidelines on the trust intranet.
• Dedicated teams provided care to patients living with dementia or a learning disability and support to staff using national resources to aid communication. Although, the trust had recently refurbished three medical wards to national dementia friendly standards, the emergency department and outpatients’ environments were not dementia friendly.
• The trust had only one learning disability clinical nurse specialist across all the trust sites. However, staff within the pre-assessment unit took innovative steps and had developed a patient passport having researched the needs of patients living with a learning disability.
• Although the estates remained a challenge for the trust and obtaining funding for site re-development was an ongoing piece of work, the trust had still made improvements to the environment to provide a better and safer patient experience. However, the outpatients’ environment required further improvement.
• The trust’s nurse education team provided specialist training opportunities to clinical staff, including simulations and interactive workshops. Some services had practice development nurses (PDN) who provided training to update nursing skills.
• The trust had a range of services available to support patients. For example, bereavement services, 24-hour chaplaincy and access to translation and advocacy services for patient where English was their second language.
• The service dealt with concerns and complaints appropriately and investigated them in the required time frame including future actions and any learning for staff.
• Most staff we spoke with felt they were listened to by service and trust leadership and felt they could approach managers if they needed support.
• A patient forum provided oversight of care standards and presented their experiences in board meetings in line with the trust’s engagement strategy.
• Most of the services we inspected had shown improvements in implementing a strategy for the service. Services such as critical care, the emergency department and medical care had developed a strategy with staff involvement and with external partners with a focus on the frail elderly.
• Leadership structures were clearly embedded for most services except for outpatient services. The trust had made notable improvements in the governance structure in the surgical and medical service.