London North West University Healthcare NHS Trust

Updated 20 May 2022

London North West University Healthcare NHS Trust runs Northwick Park Hospital, Ealing Hospital, Central Middlesex Hospital, St. Mark’s Hospital, and a range of community services across its local boroughs.

The trust employs more than 9,000 clinical and support staff and serves a diverse population of approximately one million people. The trust was last inspected in 2019 and was rated requires improvement overall.

The trust provides, urgent and emergency care, medical care, surgery, critical care, maternity, gynaecology, children and young people services, end of life care and outpatient services. The trust provides a range of community services including: dental services, sexual health services, paediatric audiology, musculoskeletal specialist and end of life care.

We inspected medical care and surgery core services at Northwick Park Hospital and Ealing Hospital on 9, 10 and 11 February 2022. Our inspection was unannounced to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received.

We also carried out an announced well led inspection of the trust on 8 and 9 March 2022. We rated the trust overall requires improvement for well led.

We issued requirement notices to the trust for medical care at Ealing Hospital. Details of these can be found under the Musts in the Areas for Improvement section.

We rated medical care at Ealing Hospital requires improvement overall because:

• The service did not always have enough nursing and support staff to keep patients safe. The service was mitigating the staffing risks during twice daily safety huddles. However, there was a 22% vacancy rate for band 5 nurses.
• We found a drawer in the catheterization labs with a range of out of date equipment and a monitor in the catheterization labs which did not have a servicing date. We also found out of date equipment on a resuscitation trolley in the acute medical unit (AMU). There was a risk that staff could inadvertently use out of date equipment.
• On Ward 6 South, we found discrepancies in the use of Waterlow scoring. This is a tool used for pressure area risk assessment. This meant that patients’ level of risk of developing pressure ulcers may not be accurately assessed and timely actions taken.
• Medical staff mandatory training in resuscitation was 72.2%. This was less than the 80% standard. This meant some staff may not have up to date skills in resuscitation.
• There was a lack of seamless services between the trust and other NHS providers of mental health care for patients temporarily on an acute ward waiting for transfer to a mental health facility. There was a risk of delays in patients care and treatment as a result of a lack of clarity about the responsibility for clinical decision making whilst the patient was an inpatient in the acute hospital.
• Due to a shortage of registered mental health nurses, the service had a policy of cohorting patients assessed as requiring enhanced observations or one to one care in a bay. However, we saw cohorted bays were not always observed by staff. There was a risk to patients if they were assessed as requiring enhanced observations or one to one care and this was not provided in accordance with their assessed needs at all times.
• The patient electronic record could only display a maximum of two patient needs on screen. This had led to staff not placing a magnetic identifier for the confusion care pathway above a patient’s bed. The lack of a visual prompt for staff led to a patient not receiving a scheduled review after 72 hours. There was a risk that without a visual prompt, staff working on the bay may not be aware of patients’ needs, unless they fully consulted patients’ electronic records.
• Records were not always stored securely. We found a patient’s ‘adult inpatient care needs assessment’ booklet next to the reception area in the acute medical unit (AMU). We saw a computer in the endoscopy reception which was unattended and not locked. There was a risk that unauthorised people could have accessed confidential patient information.
• Staff told us the trust’s senior executive team and some ward leaders were not visible at Ealing Hospital, as they were based off-site at Northwick Park Hospital.
• The signage enabling patients and visitors to navigate around the hospital was confusing for patients and visitors.
• Staff on the Older Persons Short Stay Unit (OPSSU) were using a printed copy of the infection prevention and control policy. There was a risk that staff may use an out of date policy instead of using the most up to date policies on the trust’s intranet.
• We saw a cracked shower chair and shower chairs with chipped enamel on the OPPSSU. This could pose a patient safety and infection control risk as microorganisms can thrive in cracked surfaces.
• Domestic staff on the acute medical unit (AMU) was not aware of control of substances hazardous to health regulations (COSHH), including the trust’s policies and guidance on COSHH.
• The trust was a large provider of cancer services but staff told us they did not have a local cancer strategy. This meant there was a potential risk that cancer services were not aligned to local commissioning and provision of services to support people during and after their cancer treatment.

However:

• The service managed safety incidents well and lessons were learnt from them.
• Staff gave patients enough to eat and drink and gave them pain relief when they needed it.
• Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to information.
• Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to raise complaints.
• Staff understood the service’s vision and values, and how to apply them in their work and all staff were committed to improving services continually.

We rated surgery at Ealing Hospital good overall because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The service was not fully compliant with DHSC Health Technical Memorandum 07/01 and the Health and Safety Executive Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 in relation to sharps waste.
• The service had persistently high vacancy rates. At the time of our inspection the service had vacancies for 36 whole time equivalent (WTE) nurses (12%). However, the number of nurses and healthcare assistants matched the planned numbers and vacancies were filled with bank and agency staff.

We rated medical care at Northwick Park Hospital requires improvement overall because:

• Indications of patients having venous thromboembolism (VTE) prophylaxis were not always specified on the prescription charts we viewed. This meant staff reading the prescription may not have information on patients VTE status.
• Records were not always stored securely. We saw records cupboards were not locked when not in use on Darwin ward. This meant unauthorised people may have been able to access patients’ confidential information.
• All staff did not consistently receive feedback from incidents. One member of staff on Darwin ward told us they were not aware of an incident that had happened on the ward.
• We saw a ‘do not attempt cardiovascular resuscitation’ (DNAR) form on Herrick ward where it was unclear whether the patient’s DNAR had been cancelled. Staff were unable to tell us the reasons for the cancellation.
• We saw a sharps bin in the discharge lounge stacked on top of another sharps bin. The sharps bin was open and had not been signed or dated. There was a risk of the sharps bin being knocked over and potentially causing harm to patients or staff.
• We saw a wheelchair with broken foot straps on the discharge lounge. There was a risk that staff may have used the wheelchair, even though staff had reported the wheelchair to the medical engineering department.
• The hospital was not meeting national standards in some areas of the myocardial ischaemia audit.

However:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risks well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

We rated surgery at Northwick Park Hospital good overall because :

• The service managed staffing well and maintained consistent levels of training and appraisals despite pressures on the service caused by COVID-19.
• Services were demonstrably multidisciplinary, and staff had established a wide range of new working opportunities to support patient outcomes.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Pharmacy cover on wards was limited due to short staffing. This meant pharmacists could not always join ward rounds and could not always review prescriptions daily.
• The service did not have a coherent, overarching vision for what it wanted to achieve. Individual departments and divisions developed their own strategies in the absence of a trust-level approach.

We carried out a well led inspection of the trust on 8 and 9 March 2022.

We rated well led for the trust as requires improvement overall because:

• We found that issues such as lack of adequate mental health provision for patients in crisis were a regular feature although the trust recognised the need to urgently address this issue.
• The trust Board was not representative of the population it served. However, we noted the trust had developed equality, diversity and inclusion strategies.
• The current trust strategy was in need of refreshing and updating to demonstrate more clearly its purpose within the integrated care system. The new chief executive recognised the need to renew the strategy linking clinical, finance, workforce, community and estates strategies.
• Despite a strengthened governance structure, the trust governance team was under-resourced, leading to late and incomplete information both externally and internally to the board.
• Further work was needed on the trust board assurance framework to ensure that actions were specific, measurable, actionable, relevant and timely (SMART).

However:

• The executive board and non-executives had developed in cohesiveness and visibility with a strong emphasis on improvements in performance and embeddedness.
• We noted improved clinical leadership and a greater involvement of the medical workforce in the ongoing work of the trust.

Updated 6 November 2019

Updated 6 November 2019

Updated 21 June 2016

The trust provides variety of services within the community including community nursing services provided by district nurses, community matrons and specialist nursing services. This includes long-term condition management and coordination of care for people with complex needs or multiple conditions, wound care, medicines management and acute care provided at home. Furthermore rehabilitation and reablement following illness or injury, community outpatients and diagnostic services and prevention and health promotion services. The community health service for adults provides services to a population of 828,000 people in areas of North West London. Community teams were based in 50 locally based sites, including health centres, GP practices and community hospitals, which span across London Boroughs of Brent, Ealing, and Harrow. The trust provided overall 1,350,700 community appointments in 2014/2015. It included over 447,000 of home visits made by district nursing teams and nurses working at night, 90,000 of musculoskeletal and physiotherapy team interventions, 75,500 podiatry appointments, 20,500 interventions by nutrition and dietetics team and 7,000 provided by the continence and bladder and bowel management teams. The trust employed about 1,950 community healthcare professionals providing out-of-hospital, community-based healthcare services.

On the week of the inspection we visited nine locations across the three boroughs where community teams were based. We accompanied community teams on home visits and spoke with 34 patients and some of their relatives and carers. We also spoke to 91 members of staff which included managers, doctors, nurses, healthcare assistants, allied health professionals such as physiotherapist, podiatrists, and dieticians among others.

Updated 21 June 2016

• We gave an overall rating for the Community health services for children, young people and families of Good because:

• Children and young people’s services were effective. Care and treatment was evidence based and staff were competent. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently.
• Services delivered by the trust were caring. Staff were dedicated and worked hard to ensure that patients received the best treatment and support possible. Patients were involved in decisions and understood the services being delivered to them. Emotional support was available to patients and their families who were dealing with difficult circumstances.
• Children and young people’s services were responsive to the needs of the people who used them. Generally, services were delivered to the right people at the right time within the commissioning framework of the trust. There were services in place to help protect vulnerable young people and children.
• The service was well led at the local level. We had varying feedback from staff regarding their view of their place within organisation and the level of staff engagement. Most staff we spoke with felt the acute service did not understand community services. They felt the focus of the organisation was on acute services and community services tended to get lost within the larger organisation.
• Staff were committed to providing a good service to their patients. However staff shortages and large caseloads placed too much pressure on staff resulting in them working extra hours. It was only due to the commitment of staff and the support of local managers’ services were being sustained.
• Staff generally reported good supportive leadership at local level and we met some very committed and enthusiastic managers who were working hard to develop and improve their services. With the exception of one team all staff were positive about the support they received.

However;

• The safety of children and young people’s services required improvement. This was because there were significant staff vacancies within the service in both nursing and therapy roles. The trust had developed the health visitor clinical academic hub, which had significantly helped to raise the profile of health visiting within the trust through publication of papers and nominations for national awards. With the work of the hub and streamlined recruitment processes there had been some success in recruitment but significant vacancies remained.
• The impact of vacancies was that many staff were trying to manage caseloads well above best practice guidance of 300 families per health visitor. Health visitors working in Brent and Ealing did not know how they would meet the requirement for all parents to have a visit at 28 weeks of pregnancy. This is a national target to be implemented from October 2015.

Updated 31 August 2018

Our rating of this service stayed the same. We rated it as good because:

• Staff reported incidents appropriately and they were investigated.
• Staff understood their safeguarding responsibilities and were aware of the safeguarding policies and procedures. Staff had up to date safeguarding training at the appropriate level.
• Medicines were stored, handled and administered safely.
• Risk assessments such as Legionella and fire safety had been completed and there were action plans in place.
• Appropriate systems were in place to respond to medical emergencies.
• Equipment was well maintained and fit for purpose.
• Staffing levels were appropriate and met patients’ needs at the time of inspection.
• Patients’ individual care records were comprehensively written in a way that kept people safe. Relevant information was recorded appropriately and staff had access to relevant details before providing care.
• Standards of cleanliness and hygiene were generally well maintained. Systems were in place to prevent and protect people from a healthcare associated infection.
• Staff had the necessary qualifications and skills they needed to carry out their roles effectively. Further training and development opportunities were available for staff.
• Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
• The service followed effective evidence based care and treatment policies which were based on national guidance.
• There was evidence of good multidisciplinary working with staff. Teams and services worked together to deliver effective care and treatment.
• During the inspection, we saw and were told by patients, that all staff working in the service were kind, caring and compassionate at every stage of their treatment.
• People were treated respectfully and their privacy was maintained in person and through the actions of staff to maintain confidentiality and dignity.
• Staff involved patients in aspects of their care and treatment. Information about treatment plans was provided to meet the needs of patients.
• There was an effective system to record concerns and complaints about the service.
• Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
• There was a very positive and forward looking attitude and culture apparent among the staff we spoke with.

However, we found that:

• Mandatory training was provided for staff. The service did not meet the trust’s target of 85% completion for mandatory training in manual handling - level 2 (face to face), information governance and Resuscitation (basic life support).
• The service had not completed X-ray audits in the last 12 months.
• The service did not have a comprehensive risk register. The risk register did not include the need to update the information technology including the software for the electronic dental care records. The service had not considered the risk of the clinical director managing the service on one day per week employment. The waiting list for endodontic treatment was 14 months at the Heart of Hounslow Centre for Health and there were 360 patients on the waiting list.

Updated 31 August 2018

Our rating of this service improved. We rated it as good because:

• Patient risk was effectively monitored through a multidisciplinary team approach. There was a clear process for identifying and responding to deteriorating patients, who were transferred to the acute hospital if necessary. Incidents were consistently and properly investigated and the outcomes fed back to staff.
• The community hospitals were clean. Cleaning schedules were followed and staff observed infection prevention protocols.
• Clinical staff were following NICE and other clinical guidance. Therapy teams effectively monitored patient outcomes.
• There was good and effective multidisciplinary team working, who provided one joined up service and provided patients with good outcomes.
• Health promotion was seen as an important part of preparing people to go home and to meeting patient need.
• Relatives and patients all told us that staff were compassionate. We were given clear examples of this, which included for patients who were more vulnerable or who had extra need.
• Senior staff told us of the professional expectation they had of staff and we witnessed staff working compassionately against the backdrop of staffing pressures.
• Community hospitals were aware of their integral role in trust pathways and worked well with both acute and community teams. Multidisciplinary staffing teams were meeting patient need, many of whom were in vulnerable circumstances.
• There was a service wide admissions criteria and the assessment process was reasonably proficient in identifying inappropriate referrals. The services worked towards discharge from day one.
• There were a low number of formal complaints. The service promoted swift resolution of any issues brought to them by patients and relatives.
• At the last inspection the trust, community leadership team and inpatient hospitals all worked in isolation. At this inspection community hospitals were working as one team, with unified protocols and a shared culture.
• At the last inspection there was no single clear process of management and clinical governance across the community hospitals. At this inspection there was one community hospital leadership group and the meetings structure was a shared one, across community hospital services.
• Meetings were taking place within community inpatient settings to assure themselves of quality monitoring. Audits were routinely occurring within community inpatient services.

However

• We found pockets of large vacancy rates for nurses and a reliance on a low number of bank staff. In some instances, healthcare assistants were being used to fill nurse shifts.
• The use of a safer staffing model for acute settings was being used. It did not adequately measure staffing need in rehabilitation settings and placed further pressure on staff to provide a quality service.
• There was a lack of psychiatry input for neurological patients, which was on the risk register. It meant that assessment of deteriorating mental health conditions, receiving advice on treatment and which medications worked best alongside neurological treatments was lacking.
• There was a lack of on-site security where the Willesden Community Rehabilitation Hospital was located. This raised a number of potential risks and was on the trust risk register. There were measures in place to keep wards secure. However, incidents that involved neurological patients becoming agitated or self harming had to be supported by ward staff only and remained a risk.
• There was a lack of supervision for lower grade doctors and out of hours medical support to the wards.
• The average length of stay on Robertson ward was stated as six to eight weeks, but many were going beyond this due to unmet social needs such as appropriate housing options.
• Community hospital staff experienced poor, time consuming access to essential online information systems.
• The divisional performance reports did not provide a complete picture of how community hospitals were performing. It was therefore not clear how the board were assured on how community hospitals were performing.
• A new trust medical director had reviewed medical cover and agreed that the current level of input would remain and the duty of care remained consultant led. However, there were gaps in supervision of junior grade doctors and out of hours support to the wards.

Updated 21 June 2016

Overall, the services provided by London North West Hospitals NHS Trust for community health End of Life care was rated as good because;

We found the community palliative care team (CPCT) for the London boroughs of Brent and Harrow and Ealing and Hounslow to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. However there were some concerns expressed by the CPCT’S whether all community generalist nurses who supported patients on a day-to-day basis had the skills and expertise to recognise when a patient who had reached the last 12 months or less of their life was deteriorating.

Some generalist community nurses were reported to be “task based” when caring for patients and did not always consider a patient in a whole or holistic way. We were given examples where generalist nurses had not spotted deterioration in a patient they were regularly caring for. However there was no evidence of harm to patients. We did observe some generalist nurses who were good at identifying changes and indications of deterioration in patients’ condition, such as end stage dementia. Others had specialist interest and skills in relation to specific patient groups such as learning difficulties.

Staff were aware of their responsibility in raising concerns and reporting incidents. However we found some incidents and concerns staff shared with us had not been reported through the electronic reporting system as would have been expected. This included missed appointments, telephone messages not being received, and delayed hospital discharges. There was a mixed response as to how often staff received feedback from reported incidents. Some staff told us they only received feedback relating to their own location, while other staff told us they also knew of incidents that happened in other areas of the trust; therefore we found an inconsistency in shared learning and improvement measures.

The community staff reported that local leadership was visible, accessible and responsive. Local managers had appropriate knowledge and experience to lead services and they were well aware of issues and challenges their teams faced. Staff felt empowered by their local team leaders and managers. However this was not reflected at trust level. Staff were unclear of the trust vision and reported feeling they would not be able to instigate or effect any change. The service level leads told us although there was trust board representation they did not feel that EOLC received the level of support it required to effect the change required to provide an integrated strategy which provided seamless, safe and high quality care for all patients across the trust’s locality.

At a local level the community palliative care team strove to educate, support and provide advice to community nurses, primary care providers and nursing/care homes. A recent education audit in Ealing and Hounslow identified that many community healthcare staff wanted EOLC training. The audit had secured funds and training was hoping to go ahead early in 2016.

The patients and relatives spoke positively about their interactions with the teams involved in their care. They described the staff as “kind” and that “nothing was too much trouble for them”. They told us they felt understood and able to raise any concerns they had. Patients records and care plans were regularly updated, matched the needs of the patient and were relevant to EOLC. Holistic assessments looked at the whole picture; the patient’s physical, emotional, spiritual, psychological and social needs were assessed and their carers’ views were taken into consideration. Pain relief, symptom management and nutrition and hydration needs were monitored, recorded and any changes were responded to.

Staff were able to explain their understanding of the Mental Capacity Act (MCA) 2005 and Deprivations of Liberty Safeguards (DoLS). They told us they would act in the best interests of the patient should they lack mental capacity to make decisions for themselves. They understood the patient’s carer should be consulted in gaining an understanding of what the patient would want when making best interest decisions and people could not consent on behalf of the patient unless they had a relevant legal directive to do so. All staff understood their role and responsibility to raise any safeguarding concerns.

The palliative care teams were committed to making end of life care a priority for the trust. However we found each team across the acute and community sites was approaching support for community patients in different ways and therefore care for patients was not equitable across all the London boroughs the trust supported. For example Ealing patients had overnight nursing support through Marie Curie, while patients in Harrow and Brent did not have access to this support; and Harrow patients with long term chronic conditions and identified at end of life were supported in their homes through a ‘virtual ward’ scheme which prevented unnecessary admissions to hospital, this was not provided to Ealing and Brent patients.

The acute and community palliative care teams were aware that although they had the expertise the push for improving and providing a seamless service should not fall on their shoulder alone as ”death and dying was everyone’s business” and therefore should be a trust-wide responsibility. To address this the end of life strategy committee included people such as those who had experienced the service, chaplaincy, GPs, community services, clinical nurse specialists, consultants, and other organisations such as Marie Curie.