Archived: West Middlesex University Hospital NHS Trust

Updated 7 April 2015

The trust provides services from one main site at West Middlesex University Hospital, which is a small acute hospital in Isleworth, west London. The hospital serves a local population of around 400,000 people in the London boroughs of Hounslow and Richmond on Thames and neighbouring areas. The main commissioners of acute services are the clinical commissioning groups (CCGs) for Hounslow and Richmond.

The 2011 Census of England and Wales shows that half of Hounslow’s population was from an ethnic minority group. The largest ethnic minority group was Indian, which made up 19% of local residents, while other Asian made up 8% of the population and Pakistani 5%. The census for Richmond showed a population of around 187,000, which is small for a London borough. Richmond is also one of the least ethnically diverse boroughs in the capital, and has a non-white population of 14%.

Deprivation

Hounslow’s deprivation score is 156/326, and for Richmond it is 266/ 326 (the lower scores reflect higher levels of deprivation, and are based on a comparison between all 326 local authority areas in England). Hounslow is the ninth largest borough in London, while Richmond is the eighth largest by area and the least deprived.

The health of people in Hounslow is varied compared with the England average. Deprivation is lower than average, life expectancy for both men and women similar to the England average, but 12,400 children live in poverty. The life expectancy for men and women living in Richmond is higher than the England average, and deprivation lower than the England average.

Updated 7 April 2015

West Middlesex University Hospital is the main acute hospital for the West Middlesex University Hospital NHS Trust, which provides acute medical services to a population of around 400,000 people across the London Boroughs of Hounslow and Richmond on Thames and surrounding areas.

Following the board's decision that this trust would not meet the requirements for Foundation Trust status, it has been in negotiations to merge with another NHS trust. Following our inspection, it was announced on 19 December 2014 that the merger with Chelsea and Westminster NHS Foundation Trust had been approved by the Competition and Markets Authority.

The trust is planning for an increase in emergency and maternity attendances that will result from The London North West Strategy, "Shaping a Healthier Future".

We carried out this comprehensive inspection as part of our overall inspection programme of NHS acute trusts. We undertook an announced inspection of the trust between 25 and 29 November and unannounced inspections on 9 and 13 December.

We inspected all the main departments of the hospital: Urgent and emergency services (A&E),medical care,surgery,critical care,maternity and gynaecology,services for children and young people,end of life care, and outpatient and diagnostic imagery.

Overall this hospital requires improvement.

We rated the hospital good overall in the following departments: medical care,critical care and maternity and gynaecology. However, our inspection results rated the following services as requiring improvement: urgent and emergency services,surgery,services for children and young people,end of life care, and outpatients and diagnostic imaging.

While we rated the hospital as good overall in caring,it requires improvement overall in providing safe care,being responsive to patients' needs and being well-led. We rated the hospital overall as inadequate in providing effective care.

Our key findings were as follows:

• Most patient, carer and patient relative feedback was positive in relation to the care being provided by the hospital.
• We saw many examples in most areas of the hospital of staff giving treatment in a caring and compassionate way.
• We found care being delivered in a supportive atmosphere.
• Critical care wards were consistently good in relation to safe and effective treatment which was responsive to patient needs, delivered with compassion and in a well-led culture.
• The physical environment in the hospital was well maintained as well as clean and hygienic.
• The urgent and emergency care department had a calm and well managed response to heavy emergency demand on the Wednesday evening during our inspection visit.
• Uncertainty around the merger with another trust had resulted in a number of interim appointments in clincal and managerial areas. The trust had recently started to appoint to permanent posts notably Director of Nursing.
• There was widespread access to the Datix incident reporting system to allow staff to report incidents. However, feedback and learning to staff arising from those incidents was mixed in effectiveness.
• There was insufficient consultant support in palliative care and the trust overall had not given sufficient focus on end of life care.There were mixed levels of understanding of the compassionate care pathway.
• There were concerns about the leadership in the Special Care Baby Unit (SBCU) and this had an adverse effect on the performance overall of services to children and young people.
• The hospital has a limited acute oncology service.
• The trust did not have a robust document and policy management process. We found several examples of out of date policies in use on the wards.
• Ultrasound capacity in the early pregnancy unit was insufficient to meet demand.

We saw several areas of outstanding practice including:

We saw several areas of outstanding practice including:

• The A&E department had a calm and well-managed response to very heavy emergency demand on the Wednesday evening of our inspection visit. Management support was also well considered, calm and effective.
• We found the care and support given by the mortuary staff and patient affairs office to relatives after the death of their family member was exemplary.
• The innovative ‘heads-up’ structured approach to handover in medicine

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

Importantly, the trust must:

Address the midwife/mother ratio both in terms of immediate levels of care and the strategic planning for expansion of obstetric services.

• Review and act upon consultant and nursing staffing levels in Emergency Services
• Review the processes for the management of policies and procedures to ensure that staff has access to the most up to date versions.
• Review its provision of End of Life services; its palliative care staffing levels and support of end of life care on the wards.
• Ensure full completion of DNACPR forms
• In medicine, address the lack of an acute oncology service
• In surgery, improve the frequency of consultant ward rounds.
• Ensure full completion of WHO Checklists for surgery
• Remove the practice of unverified consultant patient discharge letters
• Improve leadership and effectiveness in the SBCU
• Address the issue of late availability of TTA medicines leading to late discharge or patients returning to collect them.

In addition the trust should:

• Further develop it’s strategies for ensuring that the organisation is learning from incidents and issues.
• Continue to clarify its strategic intent, stabilise leadership and continue to engage its workforce in planning for change.
• Review its pharmacy services to be more responsive to the needs of patients
• The trust should ensure that the room in the A&E department designated for the interview of patients presenting with mental ill health has a suitable design and layout to minimise the risk of avoidable harm and promote the safety of people using it.
• The trust should review the arrangements for monitoring patients in the A&E department to ensure clear protocols are consistently used so that changes in patients’ condition are detected in a timely way to promote their health.
• The trust should review the number and skill mix of nurses on duty in the A&E department to reflect Royal College of Nursing Baseline Emergency Staffing Tool (BEST) recommendations to ensure patients’ welfare and safety are promoted and their individual needs are met.
• The trust should review the number of consultant EM doctors employed in the A&E to reflect the College of Emergency Medicine (CEM) recommendations.
• The trust should respond to the outcome of their CEM audits to improve outcomes for patients using the service.
• The trust should review the arrangements for monitoring pain experienced by patients in the A&E to make sure people have effective pain relief.
• The trust should review the arrangements for providing people with food and drink and assessing their risk of poor nutrition so people’s nutrition and hydration needs are met.
• The trust should review their arrangements for assessing and recording the mental capacity of patients in the A&E to demonstrate that care and treatment is delivered in patients’ best interests.
• The trust should make arrangements to ensure contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.
• The trust should review some areas of the environment in A&E with regard to the lack of visibility of patients in the waiting area and arrangements for supporting people’s privacy at the reception, the observation ward and the resuscitation area.
• The trust should review the provision of written information to other languages and formats to that it is accessible to people with language or other communication difficulties.
• The trust should review the way it considers the needs of people living with dementia when they are in the A&E department.
• The trust should review their management of patient flow in the A&E department so patients are discharged in a timely way or transferred to areas treating their specialty.
• The trust should review the risk register in the A&E to make sure all identified risks are included and action is taken to mitigate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 7 April 2015

- Overall we found many aspects of the service were positive, but some areas including infection prevention and control and feedback and learning from incidents required improvement.

- Good arrangements for safeguarding children and babies were in place and staff were aware of their responsibilities. There was consultant cover seven days per week and the trust was recruiting additional consultants.

- Staff used evidence based guidelines and audits and peer reviews were taking place but feedback and learning from incidents, particularly on the SCBU needed to be improved.

- Children and parents we spoke with felt staff involved them in discussions and decisions about their care. On the children’s ward formal feedback was sought from parents and children. However, less formal feedback was obtained on the SBCU.

- Leadership in the main children’s services was good but changes and gaps in the leadership on the SCBU had impacted on the motivation and morale of staff.

Updated 7 April 2015

- Patients and relatives spoke highly of the care and treatment they received in the Intensive Treatment Unit and High Dependency Unit.

- The critical care unit (CCU) operated a model of care in line with guidance from the Intensive Care Society. Multidisciplinary (MDT) team working ensured patients received an holistic approach to care and treatment.

- Care and treatment was delivered by trained and experienced nursing staff who worked in dedicated teams with a clear reporting structure and staff support.

- The CCU participated in recommended national audits and local audits.There was a clear incident reporting system and staff felt able to report incidents and raise any concerns.

Updated 7 April 2015

- The specialist palliative care service (SPCT) at West Middlesex hospital was smaller than most hospitals of an equivalent size.The trust was providing 1/6th of the required specialist palliative care consultant cover recommended by national commissioning guidelines and 1.1 WTE consultant nurse specialist (CNS) cover against a recommended level of 1.6 WTE.

- There was no formal CNS cover for absences.

- There was no in-house out of hours consultant cover. This was provided by a local hospice.

- Staff told us that there was no trust End of Life Care( EOLC) policy or strategy. Staff reported there had been very little consistent senior management engagement.

- Staff were unsure who led on EoLC at Trust board level, although the medical director had recently been told that they had been given this board responsibility.

- We were told of future aspirations to bring patients’ EoLC to the forefront of staff minds through training and to develop integrated pathways that involved community services such as GPs and nursing homes. However the Specialist Palliative Care Team (SPCT)had little time to develop this or provide training to staff as their working day only allowed time for clinical support.

- While most hospital staff were complimentary about the support they received from the existing clinical nurse specialists (CNS), the Specialist Palliative Care Team did not have the resources to provide support to patients seven days a week.

- Where the service had been involved in patients' EoLC we saw appropriate recognition that the patient was dying, escalation procedures followed by details of discussions and advice were documented in detail. However we found there was a mixed response to how patients reaching the end of their life were cared for by nursing staff on the wards.

- Staff did not always recognise patients were in the stages of dying, and therefore escalation and appropriate support was not always given in a timely manner.

- There were weekly SPCT MDT meetings. However, meeting notes showed that these had only taken place on 30 out of the 52 weeks throughout the year.

- A majority of the ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) forms we viewed had been completed in full and appropriately. However documentation of mental capacity assessments was inconsistent.

- There were limited governance systems although some audits had taken place.

- There was no system to identify dying patients who were not already under the SPCT. Therefore there were patients and families not benefitting from specialist palliative care input and support when they could be.

- The care and support given to relatives after the death of their family member by the mortuary staff and patient affairs office to be exemplary. The Chaplaincy had a good working relationship with the SPCT in providing emotional and spiritual support to patients, relatives, friends and staff.

Updated 7 April 2015

- The maternity and gynaecology services had reported three never events between April 2013 and May 2014 , two of which related to retained swabs and one which related to a retained tampon. There had been a serious incident in September 2014 which had resulted in a patient being transferred from the maternity unit to the intensive treatment unit (ITU).These incidents had been thoroughly investigated and learning obtained from them.

- The service used the NHS safety thermometer to support the provision of safe care for women.

- Consultants were on duty seven days a week, supported by a team of registrars and junior doctors who were on site out of hours. Both doctors and midwives considered they worked in supportive teams.

- The service used a modified early warning score chart to measure patients’ conditions and to determine when prompt treatment was required. Staff knew how to raise concerns and how to make safeguarding referrals.

- The wards were clean and uncluttered. Equipment was appropriately checked and cleaned and had been serviced regularly.

- There was effective multidisciplinary working within the maternity department, with other services within the trust and with external organisations.

- Midwives felt supported by their line managers and by the supervisors of midwives. Junior doctors at all levels felt supported by consultants and registrars However, there was a shortage in the number of midwives employed and the staffing level and skill mix of nursing staff in the early pregnancy unit also raised concerns.

- Women had access to a full range of options for birth, subject to an appropriate risk assessment.

- Mothers and their partners we spoke with were generally complimentary about the service and the care they had received before, during and after the birth of their baby.

Updated 7 April 2015

- Medical wards provided safe patient care, which was in line with national best practice guidelines. Clinical audit was being undertaken and there was good participation in national and local audit with good outcomes demonstrated for patients.

- Most patients and relatives we spoke with said they felt involved in their care and were complimentary and full of praise for the staff looking after them.

- The medical division was well led; managers had a clear understanding of the key risks and issues in their area. Ward staff felt well supported by their ward sisters and matrons.

- However, staff were not always sufficiently trained to support patients who were living with dementia or those living with a learning disability.

Updated 7 April 2015

- Up to date policies and procedures were in place to support a safe service for patients using the outpatients and diagnostic imaging department.

- There were sufficient staff to run all the services. Incidents related to safeguarding were appropriately recorded and actions were taken in order to address them.

- Staff were caring and treated patients with dignity and respect.

- Medicines were securely stored in a locked medicines cupboard, and other medicines that require refrigeration were kept at recommended temperatures.

- The outpatient and diagnostic imaging areas were clean and equipment was maintained. However in some clinics cleaning schedule records were eihter poorly completed or not completed at all.

- Not all clinics ran on time and there was a need to reduce the number of cancelled clinics.

- There was active patient involvement to improve services. People who attended the outpatient department and diagnostic imaging department were positive in their comments about their care and treatment.

Updated 7 April 2015

- The department provided safe care and patients spoke positively about their treatment. There were enough staff on wards and in theatres and staff received appropriate training.

- Theatres had systems in place to maintain patients’ safety including team briefs and the World Health Organisation (WHO) theatre checklist.

- However,while there was evidence of good outcomes for many patients who underwent surgery, the hospital was not meeting the needs of some fracture patients as effectively as other hospitals, for example in hip treatment.

- There were limited services out of hours and at weekends.

- Most patients considered the surgical services were responsive to their needs. However, there was no shared vision for surgery at the hospital and a tendency for staff in sub specialities to work in silos, unaware of concerns in other sub specialities that others had.

- Medical staff did not seem well engaged with management issues. However, at ward level we saw good leadership and enthusiastic staff.

Updated 7 April 2015

- The trust did not meet The College of Emergency Medicine (CEM) recommendation that an A&E department should have enough consultants to provide cover 16 hours a day, 7 days a week.

- Nurse staffing levels did not consistently meet the Royal College of Nursing Baseline Emergency Staffing Tool (BEST) recommendations, which compromises patient safety. Tools for monitoring patient’s condition were not consistently used, which increases the risk of undetected deterioration in patient’s conditions.

- The department participated in clinical audits, but the results were not used effectively to improve patient outcomes. People’s nutrition and hydration needs may not be met because the arrangements for providing people with food and drink and assessing their risk of poor nutrition were not robust.

- There was a lack of consistency in how people’s mental capacity is assessed and recorded.

- The service did not fully take into account needs of the local multicultural population. Services were not delivered in a way that focuses on people’s holistic needs, such as those living with dementia.

- The facilities and premises did not always promote people’s privacy, dignity and confidentiality.

- Patient flow was poor and waiting times were above the national average due to capacity constraints.

- The systems for identifying and managing risk in the A&E need to be strengthened to support the delivery of safe and effective care.