Harefield Hospital

Updated 22 February 2019

Harefield Hospital in Hillingdon, North West London has more than 1,300 staff, five operating theatres and four catheter laboratories. Harefield Hospital has 168 beds, including beds for cardiac and thoracic surgery, cardiology, day-case unit, adult intensive care, the transplant unit. 

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity and took place between 16 and 18 October 2018. We inspected surgery core service at this location.

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust.

We spoke with 15 medical staff, over 30 nursing staff including managers, and over 10 other members of the multi-disciplinary team including perfusionists, physiotherapists and nurse practitioners.

Updated 22 February 2019

Our rating of services stayed the same. We rated the hospital as good because:

We rated safe, effective, caring, responsive and well-led as good.

Our rating for surgical services improved to outstanding. We rated safe and responsive good and effective, caring and well-led as outstanding.

• 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 hospital controlled infection risk well and used innovative approaches to reduce the rate of surgical site infections. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Key performance information reflected this.
• The hospital managed patient safety incidents well. Services were committed to an open safety culture where all safety issues raised by staff and patients were highly valued. Staff recognised incidents and near misses and reported them appropriately.
• The hospital continued to provide care and treatment that was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies. There continued to be a truly holistic approach to assessing, planning and delivering care and treatment to people who use the service.
• 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 preferences.
• 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 monitor the effectiveness of the service. We saw that staff were supported to maintain and further develop their professional skills and experience. We saw that practice educators were available in each ward and department to support staff.
• Staff of different kinds continued to work together as a team to benefit patients. Staff, teams and services were committed to working collaboratively and found innovative and efficient ways to deliver joined-up care to people who used services. For example, we saw the surgical service were split into care groups which were structures to involve MDT working. All relevant staff, were regularly involved in assessing, planning and delivering patients care and treatment. Staff worked well together to understand the range and complexity of people’s needs. There was a holistic approach to planning patients discharge, transfer or transition to other services which was started at the earliest possible stage.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff continued to involve patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services , amenities and care in a way that met the needs of all people using the service locally and nationally including patients and their families.
• The service took account of patients’ individual needs in a holistic manner including mental, emotional and social care needs.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

However,

• The hospital provided mandatory training in key skills to all staff. Compliance for nursing staff within surgical service was generally good and met the trust target, however, medical staff completion was below the trust target and there was a low completion rate of basic life support training.
• There was no standardised procedure within surgical services to ensure medicines and equipment used for organ retrieval were checked and re stocked within surgical service. Although staff told us this was a task completed at the beginning of every shift there was no assurance and no way of knowing if the bag had been tampered with.

Written patient information was not available in other languages and formats suitable for patients with sensory disabilities such as blindness

Updated 10 January 2017

• Patients were protected from avoidable harm. The working culture enabled staff to report incidents confidently and there was evidence of learning from incidents.

• Nurse and medical staffing consistently met the national best practice guidance of the Royal College of Nursing and the Faculty of Intensive Care Medicine.

• A team of practice facilitators and a practice educator worked in critical care to provide specialist training and learning to the clinical teams.

• Mandatory training mostly met the departmental target of 75%.

• Staff had a good understanding of safeguarding principles and knew what to do to keep people safe. Staff had access to specialist support if they needed help with safeguarding or child protection.

• Staff demonstrated good knowledge of the duty of candour and were able to explain when they would use this. Records we looked at showed us staff acted according to best practice.

• Care and treatment was delivered in line with national evidence based practice including from the Royal College of Nursing and the National Institute for Health and Care Excellence.

• Staff responded to and managed deteriorating patients in a way that managed risk and recorded observations regularly.

• A critical care outreach team provided a follow-up service for patients after they were discharged from ITU.

• There were clear governance structures in place and staff told us leaders were visible, supportive and approachable.

• Staff were clear on the strategy for critical care and knew what their role was in achieving this.

We also found some areas of outstanding practice:

• The work of the practice education team (four practice facilitators and a practice educator) where they provided teaching, learning support and supervision to staff.

• Innovative practices by the critical care outreach team (CCOT), for example spearheading an acute kidney injury reduction strategy in thoracic surgical patients following a large number of acute kidney injury referrals.

However:

• Mandatory training for safeguarding fell below the departmental target of 75% for safeguarding children level two in  the high dependency unit (HDU). Mandatory training also fell below the 75% target for infection control (70% ) and for equality and diversity(70%) in ITU.

Updated 10 January 2017

• There was an open and transparent culture across the trust, where staff felt comfortable to express their views and approach managers with their concerns. Learning from incidents and complaints were shared across the specialist team and the trust, now that data had been coded in such a way to allow this.

• The environment and equipment in both the hospital wards and the mortuary was suitable for purpose. Infection prevention control (IPC) measures were followed by staff from the mortuary, porters, specialist teams and while we observed care on the wards.

• Patient care records were completed with evidence that patients’ needs were appropriately assessed and monitored. Staff clearly documented do not attempt cardio pulmonary resuscitation (DNACPR) decisions and ceilings of care. They considered different treatment options and showed clear involvement of patients and relatives in treatment decisions. Pain relief, symptom control and nutrition and hydration were well managed and individualised to each patient. The service recognised individuals with complex needs and tailored their care accordingly.

• There were enough specialist nurses on the palliative care team to enable them to see all patients on their caseload. Care was delivered by a range of skilled staff who participated in annual appraisals and had access to further training as and when required.

• The specialist team had introduced end of life care (EOLC) champions that were based on all wards to assist, train and support ward staff with the care of patients at the end of life. Resource folders were accessible on all wards for staff to refer when they needed guidance or information on issues relating specifically to EOLC.

• A multidisciplinary team approach was evident both across the specialist team and across the hospital. Patients at the end of life were cared for compassionately and holistically, with input from psychology, chaplaincy, physiotherapists and other allied health professionals (AHPs) as necessary. The needs of relatives were also considered and addressed by the wards, specialist team and dedicated bereavement service.

• A recently developed EOLC strategy aimed to ensure that the specialist team were able to support other staff even further in the event of death. A detailed educational strategy was in place and due to be rolled out to ensure staff across the trust felt confident with caring for patients at the end of life. Regular meetings and forums took place that addressed issues in EOLC with various stakeholders. This included a specific EOLC steering group that met quarterly to discuss any issues specific to EOLC.

However:

• There was a lack of consultant presence at Harefield Hospital. There was currently only a 0.2 whole time equivalent (WTE) consultant, who was employed through a service level agreement with East and North Hertfordshire NHS Trust. The service had submitted a business case to the trust board for increased consultant cover but this was not yet in place.

• The trust had not introduced a validated assessment tool to document care of patients at the end of life when the Liverpool Care Pathway was discontinued in 2013. This meant a lack of consistency and knowledge across wards regarding care of patients nearing end of life.

• Data collection for issues relating to EOLC was an issue, limiting the amount of audit activity that the specialist team could take part in and use to improve patient outcomes.

• The specialist team’s core working hours were 8.30am to 5pm, Monday to Friday. This was contrary to national recommendations, stating that specialist palliative care should be available face-to-face, seven days per week.

Updated 10 January 2017

• There was a positive culture of incident reporting and there were established processes for investigating incidents. ‘Grand Rounds’ took place every week and learning from incidents was one of the topics often talked about. We saw that incidents and mortality was reviewed at the monthly Harefield Quality and Safety Group meetings for heart division and that action points were identified.

• All the wards we visited were visibly clean. Wards had daily cleaning schedules in place, we saw the daily cleaning schedules were up to date and signed. Weekly checks were carried out by a cleaning supervisor.

• The introduction of the electronic prescription system had reduced the number of medication related incidents and promoted the safe prescription and administration of medication.

• Medication was stored securely and controlled drugs were locked in cupboards and checks were always completed to ensure there was enough in stock.

• The hospital used a national early warning score (NEWS) system to identify patients whose condition was at risk of deteriorating. The use of NEWS was audited across the trust between January and March 2015. Recommendations and action plans were put in place following the audit to address areas highlighted in the audit which included dissemination to senior nurses, raising staff awareness and training.

• Although the wards had a vacancy rate of 18.5% whole time equivalents (WTE), we observed staffing levels were in line with planned staffing levels. Staffing levels were tracked throughout the day and nursing staff would be moved across the division as needed.

• Multidisciplinary working underpinned the care provided to patients. Consultant-led multidisciplinary board rounds were held on a daily basis Monday to Friday on Oak and Acorn wards and attended by clinical nurse specialist, nurse in charge and the registrar on call consultant.

• Care was provided in line with NICE guidelines. New NICE guidelines were presented to the standards committee and NICE quality standards were reviewed.

• The audit programme was formalised and there was a programme of current audits being undertaken. The Heart division contributed to clinical audits e.g. medication used for secondary prevention after percutaneous coronary intervention (PCI). This data came from the MINAP database which can be tailored to provide local information.

• A pain scoring system was used with patients across the wards. Staff had access to the pain management team which was led by a consultant anaesthetist and was available for patients for both chronic and acute pain.

• Patients’ nutritional needs were assessed using the Malnutrition Universal Screening Tool (MUST) as recommended by the British Association for Parenteral and Enteral Nutrition.

• Nursing staff had access to practice educators and ward based mentors. New staff were supernumerary on the wards for the first three weeks and received clinical supervision. Nurses told us there were opportunities for learning and development and they could access training online. The practice educators held study days to assist nursing staff with their Nursing & Midwifery Council (NMC) revalidation.

• Staff had access to allied health professionals such as speech and language therapists, dietitians, tissue viability specialist, physiotherapists and clinical nurse specialists.

• There were many thank you cards on display in Oak and Acorn wards demonstrating the gratitude of previous patients and their relatives and results from the NHS Friends and Family Test showed people would recommend the medical services provided by the hospital.

• Patient confidentiality was maintained by staff during handovers, multidisciplinary meetings and ward rounds. Nursing staff were allocated to specific bay and signs were in place to ensure patients were aware which nurse was caring for them. Patients told us their privacy and dignity was preserved at all times and care we saw supported this.

• All feedback from patients and their relatives was complimentary about the care they received on the medical wards; they told us staff were kind and tried to make them feel comfortable. Patients told us staff came quickly when they used the call bell.

• Patients were offered pre assessment clinics by telephone as the hospital provided services to patients from the local area and nationally.

• The hospital's transport services provided services to patients across the UK and also picked patients up from Gatwick airport.

• During the period February 2015 to January 2016, 80% (10,728) of patients experienced no ward move.

• Patients admitted over the age of 75 years were screened for dementia within 72 hours of admission for dementia.

• There was a complaints policy in place and staff knew how to access it. Staff understood how to manage complaints locally and who to refer to for resolution or escalation. Contact details for the Patient Advocate and Liaison Service (PALS) were visible across the hospital.

• The service was led by experienced clinicians with autonomy in decision making and a clear strategy for the service was in place.

• There were suitable governance arrangements in place. Clinical directors felt they were supported and described being supported top down and bottom up in shaping their services.

• There was evidence of engagement with the public and staff members. Staff were encouraged to develop ideas which could improve the quality and/or efficiency of the trust’s services.

• There was a positive culture across the Heart division, managers were supportive and approachable. Staff also had opportunities for personal development and felt respected and valued.

However:

• Hand gel was not clearly indicated which meant that staff or visitors may find it hard to find at the entrance to the wards/clinical areas. A hand hygiene audit undertaken in the cath lab for the period July 2015 to March indicated that medical staff and allied health professionals scored below the trust target of 90%.

• Compliance with mandatory training was below the trust's target of 75% for medical staff and allied health professionals.

• There was no on site pharmacy service available from 1pm on Saturdays and all day Sunday, this was covered by an on call service.

• During the period April 2015 to March 2016 the trust was below the England standard of 92% for referral to treatment (RTT) for cardiology (88%).
• During the period September 2014 to August 2015 the average length of stay for elective patients in cardiology at Harefield Hospital was higher (3 days) than the England average (1.9 days).

Updated 10 January 2017

• Safety procedures and maintenance contracts were in place for specialist equipment. Radiation protection and medical physics support were available and policies and procedures could be accessed by all staff.
• All medicines were stored securely and medical records were available for all patients in outpatient clinics.
• Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based and followed national guidance and staff worked together in a multi-disciplinary environment to meet patients’ needs.

• Staff were competent to perform their roles and took part in benchmarking and accreditation schemes.
• Outpatient and diagnostic services were delivered by caring, committed and compassionate staff and care was planned that took account of patients’ needs and wishes.
• The trust was consistently above the England average for the 31 day cancer waiting times from April 2015 to April 2016.
• Diagnostic waiting times were consistently better than the England average from January 2015 to January 2016.
• The ‘did not attend’ DNA rate was better than the England average from September 2014 to August 2015.
• The percentage of diagnostic waiting times over six weeks was lower than the England average between October 2013 and January 2016. The only exception was July 2015.
• The level of complaints received regarding outpatient services was consistently low. Staff worked to address any concerns raised by patients at first point of contact.
• Arrangements were in place to accommodate people in vulnerable circumstances.
• Managers and clinical leads were visible and approachable and had a good knowledge of performance in their areas of responsibility. There was an open and honest culture within the service, morale was good and there was evidence of continuous improvement and development of staff and services.
• Diagnostic and imaging services provided a number of examples of outstanding practice, including working with industry to develop new technologies.

However:

• The performance for the 62 day cancer waiting time was consistently worse than the England average from April 2015 to April 2016.
• Staff and patients told us some clinics regularly started late and led to longer waits for patients.
• Space across the hospital posed challenges for storing equipment.

Updated 22 February 2019

• We rated effective, caring and well-led as outstanding, and safe and responsive as good.
• The service demonstrated clear improvements which ensured patients were protected from avoidable harm. Since our last inspection the service had improved its use of the World Health Organisation Safer Surgery Checklist and ensured this was embedded in practice with a focus on all team members being present. We saw the service had improved the recording of National Early Warning Scores and ensured there was clear escalation processes.
• We saw innovative ways used before, during and after surgery, to protect patients from surgical site infections. Surgical site infection rated remained below the national average.
• The service continued to seek opportunities to participate in benchmarking and peer review. Accurate and up-to-date information about effectiveness was shared internally and externally and this information was used to improve services for patients.
• Patients continued to have comprehensive assessments of their needs, which included consideration of clinical needs (including pain relief), mental health, physical health and wellbeing and nutrition and hydration needs. The expected outcomes and discharge times were identified early on and care and treatment was regularly reviewed and updated.
• Staff continued to involve patients and those close to them in decisions about their care and treatment. We saw and were told that patients and their families were respected and valued as individuals and were empowered to be partners in their care, practically and emotionally.
• Staff went above and beyond to care for patients who had to stay in hospital long term. Staff tried to make the hospital a home away from home and provided patients with independence and activities where possible.
• The service planned and provided services, amenities and care in a way that met the needs of all people using the service locally and nationally including patients and their families. The service took account of patients’ individual needs in a holistic manner including mental, emotional and social care needs.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care and promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The culture was positive with a primary focus on patient care and experience.
• The service 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.
• The service engaged well and effectively with patients, staff, the public and local organisations to plan and manage appropriate services. The service was focussed on using views gathered from engagement to drive improvement efforts.
• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The service had been recognised for innovative practices which had proven results in positively impacting safety, care and outcomes.