The Care Quality Commission
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Barnet General Hospital

Overall: Requires improvement read more about inspection ratings

Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ (020) 8216 4000

Provided and run by:
Royal Free London NHS Foundation Trust

Important: This service was previously managed by a different provider - see old profile

All Inspections

4 June 2021

During an inspection looking at part of the service

We carried out an unannounced focused inspection in the maternity unit of Barnet Hospital on 4 June 2021. We did not rate the maternity service on this occasion and the rating of good remains for the service.

Although Barnet Hospital’s maternity service had not been inspected since August 2016, when we rated it good overall, we carried out an inspection because we received information giving us concerns about the safety and quality of maternity services.

As this was a focused inspection, we only inspected three of the key questions in maternity services (safe, effective and well led).  

Focused inspections can result in an updated rating for any key questions that were inspected if we have inspected the key question in full across the service and/or we have identified a breach of regulation and issued a requirement notice, or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

We inspected maternity care throughout the unit so we could get to the heart of the service user experience. During the inspection, we needed to understand the women’s journey and make sure that women and babies were kept safe from harm and that staff were supported with their training and decision making. To do this we visited the antenatal, triage, maternity day assessment unit (MDAU), the antenatal/postnatal ward (Victoria ward), the Labour ward and the midwifery led birth centre.

We did not inspect the community midwifery teams because the services were carrying out care within the community. The maternity services were in the process of making the changes necessary to meet improvements identified following a recent inspection at the trusts other maternity site. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

How we carried out the inspection

The inspection was led by one CQC inspector who was supported by an experienced obstetric specialist advisor and a midwifery specialist advisor. The inspection team was overseen by Nicola Wise, Head of Hospital Inspection.

On the day of the inspection, we visited five key areas of the maternity unit. We observed two staff handovers/safety huddles, five episodes of women care and spoke with two women. On site we reviewed 14 sets of electronic patient records and seven maternity guidelines.

We spoke with five band 6 midwives, six band 7 midwives, three specialist midwives, including the practice development midwife, the midwives who monitor and investigate incidents and oversee risks, one support worker and one student midwife. We also interviewed two of the consultant midwives, one for the Barnet General Hospital site and cross site community consultant midwife, four consultants, four junior doctors, two registrars, the medical risk lead, the clinical director for the Barnet site, and the cross site group director of midwifery.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

11 December to 10 January 2019

During a routine inspection

Our rating of services went down. We rated it them as requires improvement because:

  • We rated safe and responsive at this hospital as requires improvement and we rated effective, caring and well-led as good.
  • We rated three of the four services inspected, during this inspection, as requires improvement overall.
  • Many of the issues identified during the previous inspection, which impacted on the safety and responsiveness of the service and had not yet been addressed by the hospital’s leadership team.
  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance. However, staff we spoke with were aware of their responsibility to protect vulnerable children and adults.
  • Medicines were not always stored in accordance with published guidance. Although many aspects of medicines were managed safely, storage of medicines, and intravenous fluids, was not always safe or secure. Staff did not always monitor storage temperature accurately to ensure it was not harmful to medicines. In some areas there was a risk, due to lack of security measures, that unauthorised persons might gain access to, or tamper with medicines intended for patients.
  • Best practice guidelines for care and treatment of patients with mental health needs were not consistently followed. Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. The trust policy on restraint was out of date and did not follow current best practice guidance.
  • The hospital did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. In some areas, there was a high turnover and vacancy rates amongst nursing staff and not always enough staff to ensure shifts were safe at all times.
  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations. There were a high number of patient bed moves and discharges at night. Overcrowding in A&E was a regular occurrence due to lack of space and lack of capacity to meet service demand.
  • Whilst the trust had effective systems for identifying risks and planning to reduce them, risks were not always being dealt with in a timely way. Some department level risks had not been identified or adequately addressed. Not all risks identified during our inspection were on the hospital’s risk register; therefore we were not assured that senior leaders had appropriate oversight of these issues.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The hospital generally controlled infection risk well. Staff kept themselves, equipment, and the premises clean. They used control measures to prevent the spread of infection.
  • 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.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used findings to improve them.
  • Staff cared for patients with compassion, kindness and respect and provided emotional support to patients to minimise their distress. Patients and those close to them, were involved in decisions about their care and treatment.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The hospital engaged with patients, staff, and local organisations to plan and manage services.
  • The trust was committed to improving services by learning, promoting training, research and innovation.

2 - 5 February 2016

During a routine inspection

This was the first inspection of Barnet Hospital under the new methodology. We have rated the hospital as Good overall with all core services rated as Good. 

Barnet Hospital is a Good Hospital providing good levels of care and treatment across all of the eight core services we inspected.

We carried out an announced inspection between 2 and 5 February 2016. We also undertook unannounced visits during the following two weeks.

We inspected eight five core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Maternity and Gynaecology, Services for Children, Critical care, End of life care and Outpatients and diagnostic services.

Our key findings were as follows:

  • Staff were proactive in reporting incidents and we saw evidence of learning taking place as a result of incidents. Learning was shared with all staff via safety briefings and posters were displayed within the department.
  • Staff we spoke with were aware of their responsibilities to protect vulnerable adults and children. All staff were fully aware of the duty of candour and were able to give examples of how they applied this requirement in practice.
  • The needs of people living with dementia were being met, staff showed good understanding of the condition. The environment was good for patients living with mental ill health.
  • We found where patients were unable to consent to restraint, no mental capacity assessment had been undertaken and no best interest decisions had been recorded. This meant that patients had their liberty restricted without hospital staff being able to evidence that the patient did not have the capacity to agree to the treatment plan.
  • The trust used a combination of National Institute for Health and Care Excellence (NICE) and Royal College guidelines to direct the treatment they provided and policies, procedures and local guidance were being reviewed to ensure they met NICE guidance. However following the acquisition of Barnet Hospital by the Royal Free Hospitals NHS Foundation Trust staff were still able to access the policies and procedures from the Barnet and Chase Farm NHS Hospitals Trust which could lead to confusion.
  • Where risks were identified such as falls and pressure area management there were action plans to resolve or manage them in a timely fashion.
  • The theatre recovery area is regularly used  to accommodate patients overnight.
  • There was very effective multidisciplinary team working between doctors, nurses, physiotherapists and other allied health professionals. The electronic patient record allowed information to be shared proactively between staff groups to ensure good coordination of patient care.
  • Staff were supported by their managers and there was a culture of openness to learn and develop services. They were also supported by managers and the education team to develop their knowledge and skills to improve the quality of care provided to patients.
  • The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels and nursing levels were generally complaint to both Royal College of Nursing (2013) and British Association of Perinatal Medicine standards (2011) for staffing children’s wards and neonatal units .
  • There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).
  • The Royal Free London NHS Foundation Trust and it’s staff recognised that provision of high quality, compassionate end of life care to it’s patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.
  • The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators and link nurses at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.
  • The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.
  • The trust had consistently not met the referral to treatment time standard or England average since April 2015.
  • There had been a deterioration in the 62 cancer wait times compared with the national standard.
  • The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

We saw several areas of outstanding practice including:

  • We observed dynamic nursing leaders who supported clinical environments are were essential in the development and achievement of best practice models.
  • The neonatal unit at Barnet hospital was very well equipped and offered outstanding levels of compassionate care delivered by all grades of staff from across the whole of the multidisciplinary team .
  • The neonatal unit had level 2 UNICEF accredited baby friendly status where breast feeding was actively encouraged and mothers are given every opportunity to breast feed their babies.

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

Importantly, the trust must:

  • The trust must take action to ensure compliance with The National Patient Safety Agency (NPSA) alert PSA001 issued 31st January 2011.
  • The trust data base of clinical guidelines and procedures hosted via “freenet” should be updated as soon as possible.
  • The recovery area ambiance of theatre must be altered to protect children from witnessing upsetting sights and hearing frightening sounds.
  • Theatre recovery staff must be receive PILS training.
  • The trust must address the issue of the day surgery unit being used to accommodate patients overnight.
  • The trust must ensure the 62 day cancer wait times are met in accordance with national standards.
  • Embedding of fresh eyes for review of CTGs
  • Ensure that emergency drugs such as Sodium Bicarbonate and Adrenaline are removed from the Rescusitaires.

In addition the trust should:

  • The trust should ensure the swab, needle and instrument policy is ratified and new practices are embedded in all relevant departments across all sites.
  • The trust should ensure a safer surgery policy is produced and ratified.
  • The trust should ensure that there is an electronic system in place to flag patients who may require additional support.
  • The trust should ensure fridges are replaced on Damson ward.
  • The trust should ensure appropriate storage of medicines in the day surgery unit.
  • The trust should introduce the use of POSSUM scoring.
  • The trust should ensure the call bells in theatres are improved to be louder.
  • The trust should ensure that RTT is met in accordance with national standards and England averages.
  • The trust should ensure all staff interacting with children have the appropriate level of safeguarding training.
  • The trust should ensure security of prescription forms is in line with NHS Protect guidance.
  • Ensure emergency medication is stored safely and access to these drugs is controlled.
  • The hospital should ensure that all staff undertake mental capacity assessments and record best interest meetings to ensure that they can evidence that staff are working the legal framework of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS) training.
  • Ensure that good standards hygiene practices are followed in clinical areas such as hand hygiene and bare below area.
  • The trust performance in the National Safety performance improves to meet the England average.
  • The trust ensures that staff mandatory training on the medicine wards meets the trust target of 95%.
  • Arrangements around equipment storage should be reviewed so that shower rooms are not used.
  • The ward environments for individuals living with dementia should be improved.
  • Improve antenatal risk assessments.
  • Undertake a maternity acuity staffing assessment to identify staffing requirements for the merged service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

5/6 September 2014

During an inspection looking at part of the service

Barnet Hospital provides acute health services and specialist treatments and therapies to more than 500,000 people living in Barnet, Enfield, Haringey, East Harrow, South Hertfordshire, South Essex and Waltham Forest. It is a modern acute hospital with more than 450 beds. Barnet General Hospital became part of the Royal Free London NHS Foundation Trust on 1 July 2014.  

We inspected this hospital on 5 and 6 September 2014 in response to concerns of patients and relatives about the standard of care on some wards. 

This was a responsive unannounced inspection undertaken by three inspectors from CQC and one specialist advisor in elderly care and general nursing practice. The medical services within three wards, Olive. Juniper and Rowan were inspected.  We have identified that the service was not compliant with some regulations following this inspection. We have not rated the service overall as this was a focused inspection in response to specific concerns raised. However, a further comprehensive inspection will be undertaken in the future to determine ratings at all services within the trust.

Prior to the CQC on-site inspection, CQC considered a range of quality indicators captured through our intelligent monitoring processes. In addition, we sought the views of a range of partners and stakeholders.

The inspection team make an evidenced judgment on five domains to ascertain if services are:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led.

Whilst we noted some good practice there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve staff training for dementia.
  • The provider must improve communication from medical and nursing staff to patients and their relatives to ensure patients (and relatives) have a better understanding of their treatment and staff understand better the needs of their patients.
  • Improve the hygiene standards on Olive ward.
  • Ensure that medicine cabinets are kept locked when they are not under the direct control of authorised staff.

In addition the trust should:

  • Ensure hand hygiene audits take place and the results are recorded on the ward notice boards.
  • Ensure patient’s non-medical aspects, such as communication needs, are handed over by nursing staff and taken into account in delivering care.
  • Ensure patients and their relatives are involved in discharge planning.

During this inspection we found that the essential standards of quality and safety were not being met in some areas. As a result of our findings, we have issued the trust with compliance actions. We have asked the provider to send CQC a report that says what action they are going to take to meet these essential standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals