Updated 28 March 2024
This report describes our judgement of the quality of care provided by this trust. We based it on a combination of what we found when we inspected and other information available to us. It included information given to us from people who use the service, the public and other organisations.
Our overall rating of the trust stayed the same. We rated them as requires improvement because:
- We rated safe, effective, responsive and well-led as requires improvement, and caring as good.
- We rated the medical core services we inspected as requires improvement. This was requires improvement for safe, responsive and well led, and good for effective and caring.
- The rating of the well led assessment was requires improvement.
- In May 2023 we carried out an unannounced inspection of maternity services as part of the national maternity inspection programme. This rated safe as inadequate and well led as inadequate and the overall ratings for maternity services went down to inadequate.
- In rating the trust, we took into account the current ratings of the services not inspected at this time.
Well led assessment:
Our rating of well-led went down. We rated it as requires improvement because.
- Further work was needed to improve the culture of the trust with associated improved results in the NHS staff survey. Whilst the trust was largely a positive place to work, there were still services where staff interactions were not appropriate and where additional support was needed to achieve sustained cultural improvement. Where staff were not working well together this could have an adverse impact on the quality of patient care. In some cases, these teams had experienced difficulties for several years, or the services had improved but this had not been sustained. Whilst additional support had been provided in maternity, there was not enough appropriate support to other teams to achieve long term cultural improvements.
- The investigations as part of formal processes to address HR issues, such as cases of bullying and harassment, were often taking too long and causing stress and anxiety to the individuals concerned. This was monitored but further work was needed to ensure sustained improvements.
- Whilst the trust had a leadership development programme, further work was needed to ensure staff managing front line services had received the development and support needed to perform their roles to a high standard. There were a number of staff, performing these roles who had recently been promoted and did not yet have the skills and experience to manage a busy service and support the staff team effectively.
- Although work had taken place to review the capability and capacity of the executive leadership team, an ongoing review will be needed to ensure senior leaders have the capacity to manage the changes needed as part of the ongoing work to merge with the Royal Free London group.
- Further input was needed for the trust’s strategy to be embedded across all levels of the organisation. The Patient First Strategy used quality improvement as a delivery model and this approach needed to be understood and applied by staff across all levels of the organisation. Further developments were needed to the enabling strategies including the clinical and estates strategies to improve outcomes for patients.
- The trust needed to improve the timeliness of its complaint investigation work, incident investigations and mortality review work. This was important for patients, families and staff who are waiting to hear the outcomes of these processes. It was also needed to ensure any lessons learnt were shared to improve services for other people.
However:
- Leaders were committed and had an appropriate range of skills and experience to lead the and its services. They understood the priorities and issues the trust faced and were identifying actions to address them. We found that the trust was responding robustly to the findings of the maternity inspection report, and in partnership with external stakeholders was making improvements to the service. They were visible and approachable in the service for patients and staff. The board was reflective of the workforce population and community served.
- The trust was grounded and connected to the local community. This was reflected in the insight displayed of the needs of the diverse local population and the staff working at the trust. Trust leaders were active participants in the integrated care system and worked to improve the health outcomes for their local population.
- We found that all the leaders and staff we met were passionate and committed to delivering high quality patient care. The trust board and senior leadership team displayed sincerity on an ongoing basis. We found all the members of the board we spoke with to be open and honest during our inspection.
- The trust had effective structures, systems and processes in place to support the delivery of its strategy including board sub committees, divisional committees, team meetings and senior management meetings.
- The trust collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
- Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. There were a number of active patient groups such as, Maternity Voices, youth group and Achieving a Better Community (ABC) parents. There was evidence that these groups had taken patients’ views into account in the design of services.
- The trust has active staff networks which included, LGBT+, Ethnicity, Multi-Faith & Belief and the Women’s Network. The chairs we positive about the trust’s values and the leadership team’s ability in promoting equality and fairness in the workforce. The group were particularly confident in the CEO and gave examples where she had shown a caring and supportive approach to staff concerns when they were raised with her.
Medical care service:
Our rating of this service at the North Middlesex University Hospital location stayed the same. We rated it as requires improvement because:
- The service did not always have enough staff to care for patients and keep them safe. This affected staff's ability to perform key tasks. For example, four-hourly observations were not always taken on time, patients who required repositioning to manage pressure ulcers were repositioned less frequently than advised by their care plan, or staff did not always undertake a follow up assessment for patients at risk of malnutrition.
- Not all staff had up to date training in life support. The trust did not confirm staff had training in the Mental Capacity Act, dementia awareness, and Deprivation of Liberty Safeguards. Not all staff were appraised by managers to ensure they were competent and to identify their development needs. This means staff were not always adequately supported to develop their skills.
- The service had delays in reviewing safety incidents and identifying learning lessons from them. The service did not operate an effective process for prompt identification of learning from deaths, they had many outstanding death reviews.
- Staff did not always follow systems and processes when safely prescribing, administering, recording, and storing medicines. We found that some patients may not have received their medication.
- The service explained delays in responding to complaints, they were frequently unable to meet the timelines set within the trust complaints management policy. This potentially delayed the identification of learning from complaints and making improvements.
- Managers did not routinely monitor if staff took prompt actions in response to sepsis. Staff did not always undertake a follow up assessment for patients who were at risk of malnutrition or obesity.
- Staff did not always plan discharges in advance to allow patients to plan ahead, to ensure all appropriate arrangements were ready when required, and to manage bed capacity effectively. Occasionally patients were transferred at night on short stay medical wards.
However:
- Staff understood safeguarding procedures and how to protect patients from abuse.
- The service controlled infection risk well.
- Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them in making 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 using reliable information systems.
- Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.