We carried out this inspection as part of our comprehensive inspection programme of all NHS acute providers and we inspected both of the trust’s locations of Hillingdon and Mount Vernon Hospitals.
Overall, this trust was rated as requires improvement with an inadequate rating for providing safe care and a good rating for caring. We rated it requires improvement for providing effective care, being responsive to patients’ needs and being well-led.
Our key findings were as follows:
- There were many concerns identified which present risks to patient safety.
- The trust was not complying with infection prevention and control standards.
- Staff records regarding training showed poor performance in key areas such as infection prevention and control, safeguarding and moving and handling.
- The trust is failing to effectively assess and monitor the quality of care it provides.
- The trust was delivering the key national performance indicators, such as ED waiting times with 95.2% of patients attending being treated, transferred or discharged across the A&E (87%) at Hillingdon Hospital and the Minor Injuries Unit (99%) at Mount Vernon Hospital.
- The trust had a very committed workforce, but there was a significant shortage of nursing staff which was compounded by additional wards being open.
- The trust performed better than expected in the number of patients acquiring clostridium difficile, however, they performed worse than expected for patients acquiring MRSA bacteraemia.
- There were many areas where the trust was aware of the challenges and risks and had logged these risks on local and corporate risk registers, however, there were often no plans or measures for implementation for when the risks were going to be addressed or when changes had been made, including:
- The risk that child protection issues could be missed due to a failure to follow agreed processes had been identified, but not addressed;
- The risk of admitting children with high dependencies to wards that aren’t appropriately staffed to meet their needs, has been on a risk register for over a year without being appropriately managed; and
- There were risks identified with the management of the storage of anaesthetic drugs where changes had been implemented, but were not sufficient to manage the risks.
We saw several areas of good practice including:
- The nurse practitioners in the Minor Injuries Unit made direct referrals to specialities both internally and externally to the hospital; this included tertiary referrals to specialists such as plastic surgery.
- The effective management of 18 week referral to treatment times for patients.
- The specialist care for children with diabetes, specifically the outreach work into schools.
- A maternity triage care bundle to promote consistency of care provided for women.
- Announced and unannounced “skills drills” training to rehearse obstetric emergencies.
- Good access to physiotherapy and occupational therapy and good multidisciplinary team working for surgical patients at Mount Vernon Hospital.
- Good multidisciplinary team working to support one stop outpatient clinics.
- Trainee doctors commented very positively on the support and mentorship they received while working at the trust.
- The critical care unit had physiotherapy presence seven days a week, and undertook ward rounds each day, as well as being available on call.
- The trust had a proactive specialist nurse for organ donation.
However, there were also areas of poor practice where the trust needs to make improvements:
The trust MUST
- Make sure it complies with infection prevention and control standards and that it monitors cleanliness against national standards.
- Assure itself that the ventilation of all theatres meets required standards.
- Address the risks associated with the numerous staffing establishment shortages across the trust.
- Make sure that staff are appropriately trained in safeguarding both adults and children, and that the trust regularly monitors and assesses the completion of actions agreed at weekly ‘safety net’ meetings.
- Make sure that all staff understand their responsibilities in relation to the trust’s systems and processes that exist to safeguard children.
- Make sure staff are trained and understand their responsibilities in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.
- Make sure that the use of keypads on wards does not unlawfully restrict patients’ liberty.
- Make sure that all staff receive the full suite of mandatory training that is required to minimise risks to patient safety.
- Make sure agency staff receive an appropriate local induction on to wards.
- Make sure that there are adequate numbers of paediatric staff trained in Advanced Paediatric Life Support as per the Royal College of Nursing’s recommended standard.
- Make sure of the effective operation of systems to enable the trust to identify, assess and manage risks relating to the health, welfare and safety of patients.
- Make sure that local leaders are held accountable if they do not routinely and accurately complete required audits.
- Make sure that trust premises are secure and that maternity and children’s areas and wards cannot be accessed by the public without staff knowledge and appropriate challenge when necessary.
- Make sure patients are protected against the risks associated with the unsafe use and management of medicines.
- Make sure patients and visitors are protected against the risks associated with unsafe or unsuitable premises.
- Make sure that there equipment is properly maintained and suitable for its purpose and that out of single use equipment is disposed of appropriately.
- Make sure that equipment is available in sufficient quantities in order to ensure the safety of patients and to meet their assessed needs.
- Make sure that records are accurately and appropriately maintained, are kept securely and can be located promptly when required.
- Make sure that early warning system documentation is appropriately maintained and that all staff react appropriately to triggers and prompts.
- Complete venous thromboembolism assessments as appropriate.
- Log the date of receipt of a complaint as the date the trust are first made aware of the complaint.
The trust should:
- Review the process for admitting patients to wards from the accident and emergency to make sure the process is effectively managed and that unnecessary delays in transferring patients are not occurring.
- Ensure there is a fixed rota for consultant cover out-of-hours for the critical care unit.
- Consider providing support from a Practice Nurse Educator for critical care nursing staff.
- Consider contributing to ICNARC data collection.
- Confirm the trust’s permanent bed capacity and an accurate base staffing establishment figure the trust projects it needs to deliver safe and effective care for this number of beds.
- Engage with local end of life care leadership to establish the trust’s strategy for the service.
- Make sure that appropriate translation services are available and are being utilised to meet patient need.
- Review the resourcing of medical secretaries to make sure they can meet patient need and the trust’s own targets for sending GP letters.
- Consider implementing the Friends and Family Test for all wards at the trust.
- Consider whether patient outcomes could be improved through dedicated consultant cover and / or consultant oversight for the Minor Injuries Unit.
- Consider auditing pre-operative starvation to make sure patients are not starved for significantly longer than required.
Professor Sir Mike Richards
Chief Inspector of Hospitals