Watford General Hospital

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

Part of the inspection was announced taking place from 30 August 2017 to 1 September 2017 during which time Watford Hospital, St Alban’s Hospital and Hemel Hempstead Hospital were all inspected. We carried out the unannounced inspection on the 12 September 2017.

This was the third comprehensive inspection of the trust. The trust was rated as inadequate overall and was placed into special measures in September 2015. The last inspection took place in September 2016, where the trust and was rated requires improvement overall. It remained in special measures.

Urgent and emergency care services was rated inadequate during our last inspection in September 2016. Medical care, surgery, services for children and young people and outpatients and diagnostics were rated as requires improvement in 2016.Critical care, maternity and gynaecology and end of life care were rated as good.

At this inspection we rated Watford General Hospital as requires improvement overall.

During this inspection, medical care and surgery were rated as requires improvement. Critical care, maternity and gynaecology, services for children and young people, end of life care and outpatients and diagnostics have been rated as good. This means all these services, except medical care and surgery, have improved and provide a better service to their patients. However, emergency services were rated inadequate.

We saw several areas of outstanding practice throughout Watford General Hospital. For example:

• There were a number of outstanding innovations in the children’s emergency department to support the needs of parents, children and younger people. This included support from voluntary groups charities and volunteers to tackle important issues such as mental health and suicide awareness.
• The set up and design of the children’s emergency department as an environment to children was outstanding as it enabled the service to undertake interventions on children quickly. The design and space for a district general hospital was unique and was modelled on the set up of the tertiary children’s units.
• We observed outstanding care interactions provided by staff to children in the emergency department and in the children’s observation bay.
• The pathways of care in the children’s emergency department, their effective use within the department on patients was outstanding.
• Staff kept patients at risk of harming themselves safe without depriving them of their liberty. There was an effective process for prompt senior nurse assessment and the provision of enhanced care for patients at risk. An enhanced care team was receiving training to make sure they provided patient centred care.
• The “iSeeU” initiative provided women who were separated from their babies at birth the opportunity to use face-time technology to see their baby receiving care and treatment on the neonatal care unit.
• The pilot Phoenix team provided a case loading service for women with uncomplicated pregnancies who wanted to give birth at home or at the birth centre. The team sent a congratulations card to every mother who was part of their team once they had delivered their baby.
• An electronic referral pathway had improved the care for infants with prolonged neonatal jaundice. The pathway had been developed in partnership with GPs, health visitors, community midwives and local commissioners. This had resulted in a reduction in the referral to appointment time (under 48 hours) and the overall time for parents to receive their child’s results was two weeks from referral.
• The diagnostic imaging service monitored its compliance by auditing best practice relating to patients receiving chest radiography. Guidance from the Royal College of Radiologists (RCR) states that it is best practice to undertake chest radiographs on patients in the poster anterior (AP) upright position, apart from when this is not appropriate due to immobility or ill health. Following an audit performed within the diagnostic imaging department, staff embraced the importance of change in practice especially in difficult casualty situations.

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

Importantly, the trust MUST:

• The trust must ensure governance quality systems in ED, including the reporting of incidents, identification of risk and management of risk registers provide assurances that the service runs safely and effectively.
• The trust must ensure that the staffing levels on duty are based on acuity, and ensuring the numbers on duty for nursing, medical and support staff are sufficient to ensure safe care.
• The trust must ensure that appropriate action is taken to improve the culture within the emergency department.
• Ensure that there are processes in place to complete patients’ venous thromboembolism risk assessments on admission and repeated assessments 24 hours after admission in line with national guidance.
• Ensure that patient risk assessments are detailed with information to allow an accurate assessment of the patients’ clinical condition.
• Ensure that there are processes in place to manage and report mixed sex accommodation as incidents and where possible prevent patients of the opposite sex being cared for in the same clinical area.
• Ensure that patient personal identifiable information is not displayed or discussed openly within earshot of unauthorised persons.
• Ensure that staff working within the DVT clinic are competent at the identification of medicines and contraindications.
• The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. A formal decision specific mental capacity assessment must be undertaken of the patient’s ability to understand this decision and to participate in any discussions.
• Ensure that all staff caring for patients under 18 years of age complete safeguarding children level three training.
• Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
• Ensure that World Health Organisation (WHO) five steps to safer surgery checklists are completed in their entirety.
• Ensure that infection prevention and control standards are maintained in treatment rooms where minor operations are performed.
• Ensure that all risks within the outpatient department are included in the departmental risk register.
• Ensure clinical staff within the radiology department are up-to-date on fire and evacuation training.

The trust SHOULD:

• Review the arrangements for the collection of blood samples from the emergency department.
• Review ambulance offload and handover times in the emergency department.
• Consider how to effectively learning from complaints is fully implemented to improve patient experience.
• Develop an integrated governance system for the children’s emergency department, ensuring there are effective reporting system, and management of risk processes.
• Ensure that all staff maintain all infection control and prevention practices.
• Patients’ nutrition and fluids should be accurately recorded and totalled daily.
• Ensure theatres are compliant with national standards, including the ventilation in the theatre preparation rooms.
• Take steps to ensure the facilities for day surgery patients are appropriate.
• Patients should not be nursed in recovery or ESAU overnight.
• Ensure patients whose surgery is cancelled are treated within 28 days of the cancellation.
• Ensure all surgical patients have access to timely treatment after referral.
• All relevant staff, including junior doctors, should be trained to recognise and respond to signs of sepsis.
• All patient records should be available at pre-operative assessment clinics.
• The route in which the painkiller Paracetamol is to be administered should always be clearly documented in patients’ prescription charts.
• Audits of the WHO Surgical Safety Checklist and five steps to safer surgery are improved to assess how well teams are participating in the checks.
• Surgery services should fully participate fully in implementing the National Local Safety Standards for Invasive Procedures.
• The audit programme should be managed effectively and that actions identified are completed and re-audited. This should include an audit of the recognition of sepsis and the treatment provided to patients with signs of sepsis.
• All staff should comply with the trust’s hand hygiene policy.
• Standards of cleanliness and hygiene continue to be monitored on Starfish ward.
• Patients should be discharged from the critical care unit within four hours of the decision to discharge, to improve the access and flow of patients within the critical care unit (CCU).
• Patients requiring admission to CCU should be received in four hours of the decision to admit.
• A microbiologist should have daily input to the ward rounds on CCU to review patients care in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
• Take actions to reduce the incidence of mixed sex breaches in the critical care unit.
• Local mortality and morbidity review meeting minutes should include clear delegated actions and monitoring of these.
• The risk register contains all current risks identified to the provision of the critical care service.
• Ensure the service reviews its processes to provide at least 50% of nursing staff with a post registration critical care qualification in line with GPICS standard (2015) and mitigate for any gaps.
• Medicines should be stored within the recommended temperature range.
• All medicines given are documented in line with national guidance.
• All equipment is safety tested annually.
• Resuscitaires should be checked daily.
• Symphysis-fundal height measurements (maternity) are clearly plotted on growth charts.
• Actions should continue to be taken to reduce the caesarean section rate.
• Actions should be taken to improve the perinatal mortality rate and reduce the number of full term babies admitted to the neonatal care unit.
• All complaints are investigated and closed in a timely manner.
• Reduce the number of medical outliers to the gynaecology ward.
• Take action to reduce staffing vacancies and turnover of staff.
• Consider reconfiguring the neonatal unit as its current configuration meant there was insufficient space, which did not reflect current guidelines.
• Continue to monitor the movement of children from the inpatients’ wards to the operating theatre along a corridor that was not fit for that purpose.
• Consider ways of improving the environment for children in the operating and recovery areas of the trust.
• Access to emergency equipment should not be impeded.
• Dietary supplements should be stored securely.
• All staff should receive training in a major incident exercise or undergo major incident training.
• The information system for the diabetes service should meet the needs of the service.
• Consider ways to improve the response to the Friends and Family Test in children’s services.
• Continue to monitor the level of cancelled outpatient appointments over six weeks in children’s services.
• Consider how to improve the results of the next Picker survey in children’s services.
• Review the risk register process to ensure the trust was aware of the risks for the end of life care and mortuary services.
• The main outpatient department should have a dedicated area suitable to care for patients on a stretcher, bed or wheelchair.
• Decontaminate reusable naso-endoscopes in a washer-disinfector at the end of each clinic to meet best practice, as outlined in the Department of Health Technical Memorandum (HTM) 01-06 Decontamination of flexible endoscopes.
• Ensure staff are up-to-date on the mental capacity act and deprivation of liberty safeguards training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

This was the second comprehensive inspection of the trust the first taking place in April and May 2015. It was rated as inadequate overall and went into special measures in September 2015.

Part of the inspection was announced taking place between 6 and 9 September 2016 during which time the hospitals that make up the trust, Watford General Hospital, St Albans Hospital and Hemel Hempstead Hospital were all inspected. Unannounced inspections were undertaken of Watford Hospital and Hemel Hempstead on the 19 September 2016.

We have rated Watford General Hospital as requires improvement overall. Medicine, emergency services, critical care, maternity and gynaecology and end of life care were all rated inadequate in September 2015. Emergency services remain inadequate, however, all, except critical care, maternity and gynaecology services and end of life care, which have now been rated good, have been rated as requires improvement. This means all these services, except emergency services and services for children and young people, have improved and provide a better service to their patients. There was one outstanding rating, caring within children and young people’s services.

Our key findings were as follows:

• Most staff were aware of their roles and responsibilities in the management and reporting of incidents, however this was not consistent in all areas of the hospital. The hospital had a lower rate of incidents compared to the national average. This can be an indicator that not all incidents are being reported. In addition, feedback from incidents and evidence of learning from them was inconsistent throughout the hospital.
• Duty of candour was poorly known amongst most trust staff and there was limited evidence that it had been applied routinely.
• There had been one never event which occurred in the maternity service. A root cause analysis had been undertaken and there was evidence of learning from this event and actions taken to mitigate future risk.
• There were effective safeguarding procedures in place for both adults and children. Staff had received appropriate training, in most departments. However, not all who dealt with children and young people were trained to level three, which is the expected standard.
• Patients did not have their mental capacity assessed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice. There was no trust database relating to the total number of patients, the expiry of initial authorisation or the date of external assessment. This meant that patients were potentially being deprived of their liberty without appropriate authorisation made. Locally, some wards had understanding of those patients who were being cared for under a deprivation of liberty safeguard (DoLS). In addition, the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form did not prompt staff to complete a capacity assessment as part of the decision making process.
• Provision for patients who had a mental health problem was poor in the emergency department.
• The trust was making improvements to the organisation of outpatient clinics. However, clinics still frequently over-ran and some patients told us they had experienced long delays. The length of time patients waited to be seen was not monitored. The trust’s patient administration system had no facility for recording when patients were seen and the information was not collected manually.
• There was a notable culture of acceptance regarding the waiting time breaches in the emergency department with many relating to time to see a clinical decision maker or receive treatment from a doctor. This had improved at the unannounced inspection.
• The percentage of patients discharged, admitted or transferred within four hours was consistently around 83%, against a target if 95%.
• The number of ambulance handover delays over 30 minutes totalled 2,535, putting the trust in the top quartile of all trusts in England. Between November 2015 and August 2016, the trust has had 2107 black breaches.
• The percentage of patients leaving the department before being seen was higher, at 6.5%, than the England average of 3%.
• The percentage of emergency admissions via A&E waiting from four to 12 hours from the decision to be admitted ranged from 12% to 44% against the England average of 8%.
• Referral to treatment performance had been improving since the last inspection, and exceeding the target for some clinics. However, due to poor performance in certain clinics only 86% of patients met this target from May 2016 to September 2016.
• Data for September 2016 showed that the trust had fallen below the national 93% target that all suspected cancers should be referred to a consultant and seen within two weeks; only 89.4% of patients were seen within this time period. For breast cancer, for the year to date only 76% patients had been seen within two weeks.
• The Five Steps to Safer Surgery checklist were not consistently used; there was a mixture of five and three step processes in operation.
• The management and storage of medications was not always safe. There was varied practice regarding the safe management and storage of patients own controlled drugs. Treatment room temperatures consistently exceeded recommended temperatures.
• Staffing levels were below the trust targets. Mandatory training compliance did not meet the trust target of 90% in all subjects, including basic life support. Not all staff had received an annual performance appraisal. This was a concern we raised in our previous report.
• Although we saw that all departments appeared to be clean, Patient-led assessments of the care environment (PLACE) audits for cleanliness and privacy and dignity were below the England average. We found that there was some poor practice around privacy and dignity in outpatients.
• The Intensive Care National Audit and Research Centre (ICNARC) results 2016 showed the critical care unit had a higher than national average for delayed discharges of 14% compared to the national average of 5%. The trust was in the worst 5% of units for this element. On occasions the unit was unable to admit or discharge patients due to the unavailability of beds. This resulted in single sex breaches. Patients could be nursed in theatre recovery for over 10 hours whilst waiting for a bed either in the critical care unit (CCU) or on the ward. We found that patients experienced multiple moves within admission areas, and were frequently transferred between areas overnight.
• Patients told us that the care they received was good and that they felt safe and in most departments. We saw patients were treated with dignity, respect. During our inspection the weather was hot; we saw that in most departments there was no provision for ensuring patients received extra fluids during this time.
• Staff had undergone sepsis training and were able to recognise and treat sepsis according to national guidelines.
• The numbers of MRSA, Methicillin Sensitive Staphylococcus Aureus (MSSA), and Clostridium difficile, reported between June 2015 and May 2016 were lower than the England average. Between June 2015 and June 2016 there were low numbers and prevalence rates of pressure ulcers, falls with harm and catheter acquired urinary tract infections reported.
• The children’s emergency department was outstanding in terms of environment. Children and young people had a dedicated resuscitation area away from the adult department, which was set up with equipment and medicines for children. The medicines storage and management of medicines in the children’s emergency department was exemplary.
• Relationships between staff, patients and relatives were strong, caring and supportive. Staff regularly went above and beyond for the children and young people who used their services and valued their emotional wellbeing
• Staff treated all patients with kindness, dignity and respect. All patients and their carers that we spoke with told us that staff were kind, caring and included them in the planning of care and treatment.
• Patients moving from children’s services to adult services were prepared in advance for the transition by individual specialist consultants and nurses.
• Nursing staff completed local induction training when they joined the outpatient department. We saw the training programme which included training on the use of equipment within the department and a medicines competency assessment. Induction programmes were developed to meet the needs of different staff groups for example for trained nurses and healthcare assistants.

We saw an area of outstanding practice in the children’s emergency department where children were seen promptly.

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

Importantly, the trust MUST:

• Ensure that care for patients with mental health issues in the emergency department is safe by ensuring that they are cared for in a safe environment, that their safety is risk assessed, and that staff are suitably trained to meet their needs, as well as keep staff safe from harm.
• Ensure governance quality systems, including the reporting of incidents, duty of candour, completion of local audits, learning from incidents and complaints and ensuring the risk register is up to date.
• Ensure that observations of patients who could be acutely unwell are undertaken in a timely way and escalated as required.
• Ensure the timely completion of patient records.
• Ensure that patients who have been in the emergency department for more than six hours are reviewed by a senior clinician and are risk assessed.
• Ensure that there is a provision for the offering of regular drinks to patients during their time in the emergency department.
• Ensure that there are appropriate systems in place to track the patients and the expiry of those being treated under a deprivation of liberty safeguards.
• Ensure that staff completing ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms where a person lacks capacity to make an informed decision or give consent act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
• Ensure that all staff caring for patients less than 18 years of age has completed safeguarding level 3 training.
• Ensure the safe management of medicines at the hospital complies with Home Office 2016 guidelines on the security of controlled medicines. This includes patients’ own medication.
• Ensure that there are procedures in place for the safe management of temperatures within treatment rooms and areas where temperature sensitive medications are stored.
• Prescriptions for syringe pumps must comply with the trust’s prescribing standards.
• Ensure that mandatory training compliance meets trust targets of 90%, including blood transfusion training.
• Devise an action plan to address the shortfall between appraisal rates and the trust target and make sure that the trust target is reached.
• Ensure staff in outpatients comply with the trust’s hand hygiene policies.
• Ensure treatment rooms where invasive procedures take place are clean.
• To improve the percentage of patients to be seen within 18 weeks of referral from a GP for an outpatient appointment.

• To improve the percentage of patients waiting to see a consultant with a suspected cancer to meet the national target of 93%.

Action the hospital SHOULD take to improve

• Review the arrangements for the collection of blood samples from the emergency department.
• Provide training to staff in dementia awareness, learning disabilities and complex needs.
• Review the escalation plan for the emergency department and make this effective in practice.
• Review staff training and knowledge on the Mental Capacity Act and DoLS.
• Review ambulance offload and handover times in the emergency department.
• Limited numbers of staff in the emergency department had been trained in safe breakaway. No staff members had received training in ethical control and restraint. Consider increasing the number of staff in the emergency department who have been trained in safe breakaway, and in ethical control and restraint.
• Consider learning and outcomes from complaints.
• Consider developing a vision and strategy for the future of the emergency department.
• Consider lack of staff engagement across the emergency department and work towards improving this.
• Reduce the number of patient moves out of hours within admissions and ward areas.
• Consider undertaking a risk assessment in relation to the lack of a dirty utility area in the emergency surgical admissions unit.
• Review processes and practice so that venous thromboembolism risk assessments are consistently completed and repeated according to trust policy and that the proforma used to complete assessments is fit for purpose.
• Consider further training for staff around Deprivation of Liberty safeguards to ensure that all staff are aware of when it is appropriate to consider an application to meet patients’ needs and protect their rights when necessary.
• Review processes so that patients are discharged from the critical care unit (CCU) within four hours of the decision to discharge to improve the access and flow of patients within CCU.
• Consider how to meet the needs of patient requiring admission to CCU at all times.
• Review the microbiologist input to the ward rounds on CCU to review patients care daily, in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
• Take actions to reduce the incidence of single sex breaches in CCU.
• Review procedures and practice so that all medicines are administered and documented in accordance with trust policy and national standards.
• Review the process for obtaining tablets for patients to take home to reduce high volumes being received in pharmacy during the afternoon which they are unable to action in a timely manner.
• Review procedures and practice so that modified obstetric early warning score observation charts are completed and acted on in accordance with trust policy.
• Take the required actions to meet the 62 day referral to treatment time for patients with suspected gynaecological cancers.
• Review the consultant cover in palliative care staffing levels. The consultant cover in palliative care staffing levels were below the National Institute of Health and Care Excellence (NICE) guidelines, commissioning guidance for palliative care published collaboratively with the association for palliative medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK.
• Within end of life care, the service should collect effective information on the percentage of patients who were discharged to their preferred place within 24 hours.

Professor Sir Mike Richards

Chief Inspector of Hospitals