The Whittington Hospital

Updated 28 April 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at The Whittington Hospital.

Whittington Health NHS Trust is an integrated care organisation based in North Central London. The trust provides maternity services at The Whittington Hospital to a population of approximately 500,000 people living in Islington, Haringey and those living in Barnet, Enfield, Camden, and Hackney. The maternity service at the hospital comprises of a consultant led labour ward, birthing pools, midwifery led unit, home birthing team, 2 dedicated obstetric operating theatres and recovery areas, antenatal clinic, antenatal and postnatal wards, day assessment unit and a triage area. From January 2022 to December 2022, there were 3,044 deliveries at the trust.

We last carried out a comprehensive inspection of the maternity and gynaecology service in 2016. The service was rated requires improvement for safe and good for effective, caring, responsive and well-led. The service was judged to be good overall. We previously inspected maternity jointly with the gynaecology service, so we cannot compare our new ratings directly with previous ratings.

We inspected the maternity service at The Whittington Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice unannounced focused inspection of the maternity service, looking only at the safe and well-led key questions.

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

• Our ratings of the Maternity service did not change the ratings for the hospital overall. We rated safe as requires improvement and well-led as good and the hospital as good. Our reports are here:

The Whittington Hospital – https://www.cqc.org.uk/location/RKEQ4

How we carried out the inspection

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.

Updated 8 July 2016

We rated Medical care (including older people's care) as good overall because most patients were kept safe while they are being cared for at The Whittington Hospital. Patients who are at risk of deteriorating were monitored and systems were in place to ensure that a doctor or specialist nurse was called to provide the patient and ward staff with additional support. The trust had an open culture and had systems that allowed them to learn from clinical incidents. The medical wards had enough doctors and nurses to keep people safe.

We found that care on medical wards was provided in line with national and local best practice guidelines. Audits were being undertaken and there was good participation in national and local audits that demonstrated good outcomes for patients. Patient morbidity and mortality outcomes were well within what would be expected for a hospital of this size and complexity and no mortality outliers had been identified. Although there was a good knowledge of the issues around capacity and consent, the levels of staff training in these areas was low.

Patients received compassionate care and were treated with dignity and respect. Most of the patients and relatives we spoke with said they felt involved in their care and were complimentary about the staff looking after them. One person told us: “It’s great, they look after me well here. They are so nice and take an interest in how I am getting on”. The medical division had good results in patient surveys and results indicated an improvement in the views of patients over the last 12 months.

The medical division is effective at responding to the needs of its patients from all parts of its community. The hospital operational management team had a good understanding of status of the hospital at any given time. Bed availability was well managed. Elderly care pathways had been well designed to ensure that elderly patients were assessed and supported with all their medical and social needs. The hospital had designed pathways that if possible kept patients out of the emergency department (ED). The Ambulatory Care Unit and Hospital at Home provided effective alternate pathways for GPs and other referrers.

The Medicine, Frailty & Networked Service Integrated Care Service Unit (ICSU)is well led. Divisional senior managers had a clear understanding of the key risks and issues in their area. The division had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis. Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. They described the hospital as a good place to work and as having an open culture. The most consistent comment we received was that the hospital was a friendly place to work and people enjoyed working with their teams.

Updated 8 July 2016

We rated services for children and young people as good overall because;

We saw that there were systems in place to ensure good governance and monitoring of standards for children, young people and infants who required acute medical care and surgical intervention and investigations.

Staff were proud to work for the trust and it was clear from speaking to parents that the public perception of the Whittington trust was very good. Inter-professional working was exemplary throughout children’s services.

Staff were aligned to, and supported the trust wide mission and vision. Leadership of individual aspects of children’s services was good with staff speaking positively about their immediate team leaders. The aspirations of the chief executive and his management team were fully supported by the staff.

Updated 20 March 2020

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

• We attended a nurse handover and found although it included allocation of nurses to patients, it did not include discussion of patient risk or complexity and was not structured. Senior staff we spoke with stated that nursing handovers and huddles were under review. Critical care also did not include daily safety huddles.
• We observed on inspection that staff may be involved in delivering support for other patients at times of high activity, meaning that their allocated patient may be left unattended. Although this was for a short period of time, we did not observe nursing staff discussing with colleagues that a patient allocated to them would be left unattended.
• The majority of critical care staff did not have transfer training to manage the transfer of patients, which meant that patients might be transferred to other services by staff without the required training.
• We did not see evidence of a consistent audit process for monitoring compliance with best practice for IPC. Staff were also unsure if there was an IPC link nurse for the ward, or who monitored IPC performance.
• Staff we observed were not using personal protective equipment (PPE) while delivering patient care. Staff stated that the trust policy was PPE was only needed if there were expecting to come into contact with bodily fluids and that this had been communicated to staff, however we observed some staff consistently using PPE while others did not. Senior staff for the service recognised this would be inconsistent practice, and that it would follow the matter up with the IPC leads for the trust.
• In critical care the 90% target was not met for any of the nine mandatory training modules for which medical staff were eligible.
• At the time of the inspection, the service did not have a matron. The clinical manager, who was providing interim cover for the matron post, was also responsible for several other roles, both across critical care and hospital wide. This meant they had limited time to spend on the ward and on management duties for critical care.
• There were limited opportunities for staff to work together across disciplines and meet together as a multidisciplinary team (MDT). This was reflected in conversations with staff, who stated that while there was a good working relationship across disciplines, staff could be “siloed”.
• The service did not have a patient or family satisfaction survey to monitor the experience of patients and relatives using their service. This was also identified as an issue at the previous inspection.
• On inspection staff stated there had been a significant tension between staff because of leadership issues within the service. Staff suggested that there had been bullying behaviour, and that this could have impacted on retention of experienced nursing staff. Divisional leadership stated that leadership for critical care was on the risk register, as the issue was not yet resolved.
• Staff stated that since the time of the last inspection morale for critical care staff on the ward had been low. Staff survey results for the division showed that it was below the trust average across nine of the ten main questions.
• The critical care ward did not have a long-term strategy or vision in place, and senior staff recognised that there was a need to provide consistent ward level leadership. This was also the case on the previous inspection of critical care.
• CCU did not have a local risk register, with risks relating to critical care reflected on the overall divisional risk register. We reviewed the risk register provided by the trust prior to inspection and found it did not reflect the key issues we identified. The main risks identified for the division related mainly to surgery rather than to the critical care provision.
• Although there was an assessment pathway for delirium and dementia, screening for dementia was inconsistently completed. On CCU we found patients who started treatment pathways for delirium but an assessment had not been completed or was not in their records. We observed that clinical governance records had mentioned a reminder for staff to complete this pathway.

However:

• The service used systems and processes to safely prescribe, administer, record and store medicines. Controlled drugs were stored and managed appropriately.
• At the time of the last inspection we found inconsistencies in record completion. Patient records on this occasion were legible and generally well completed.
• The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm, and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns.
• Patients said staff treated them well and with kindness. We spoke with four patients on the critical care ward during the inspection. Family members were also positive about the care the patients received and stated that staff members were professional and welcoming.
• Staff understood and respected the individual needs of each patient and showed understanding and a non-judgmental attitude when caring for or discussing patients with mental health needs.
• Delivery of care on the critical care unit (CCU) was informed by standards and recommendations in the Guidelines for the Provision of Intensive Care Services (GPICS), developed by the Faculty of Intensive Care Medicine (FICM).
• Critical care were part of the peer review process for the North East North Central London Adult Critical Care Network (NENCL). The review was carried out in October 2018, led by critical care experts from other network services, and feedback from the review was positive.
• Ward level nursing leadership was provided by an interim manager for critical care, who had overall responsibility for the day to day running of clinical areas. At the time of inspection, the interim manager had been in post for two months. Both ward and senior staff we spoke with were very positive about the contribution they had made since they were appointed, and the impact they had on improving morale.
• There was a governance framework in place which oversaw service delivery and quality of care. This included monthly clinical governance meetings across critical care, led by speciality leads and attended by ward staff and allied health professionals.
• At the time of the last inspection, we identified that a follow-up clinic was not provided to all patients with did not comply with Faculty of Intensive Care Medicine (FICM) standards. On this inspection we found this process much improved.
• CCU had significantly improved the number of monthly delayed discharges by improving communication and monitoring, as well as the discharge process, since the time of the last inspection.

Updated 8 July 2016

We rated End of Life Care as good overall because;

We found that staff providing end of life services were caring, the service was effective and well led. However, the safety of end of life services provided at Whittington Hospital required improvement. The end of life services also required improvement across the responsive domain.

Patients told us staff were caring and compassionate and that they were involved in planning their care and making decisions. We observed staff being respectful and maintaining patients’ dignity, there was a strong person centred culture. Patients in their last days were suitably assessed and their nutritional and hydration needs were met. Care and treatment was delivered in line with current evidence-based standards. Patients had appropriate access to pain relief. The trust had scored much better than the national average for clinical indicators in the national care of the dying audit. Palliative care and end of life team members were competent and knowledgeable.

There were no serious incidents relating to end of life care in the hospital. Staff received appropriate end of life training. They knew how to report concerns.

There was good end of life care awareness across the hospital. The trust appointed both, a non-executive lead, and an executive director to take lead and provide representation of end of life care at board level. Specialist palliative care team members felt supported in their work and worked well as a team. Staff were clear about their roles and their involvement in decision making and demonstrated a positive and proactive attitude towards caring for dying people.

However, not all staff had received adequate training including training in operating syringe pumps, Mental Capacity Act or training related to patients' deprivation of liberty. Patients DNR CPR forms were not always completed accurately. The trust did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital and provision of seven day services. They did not monitor discharge times and if there were any obstacles to patient’s discharge. There was no formal rapid discharge pathway to ensure speedy discharge of patients who wished to die at home or another location. Staff did not always record and analyse if patients were cared for at their ‘preferred place of care’. The trust did not gather and analyse patients and relatives views in relation to end of life care to inform service delivery and planning.

Updated 28 April 2023

Updated 8 July 2016

We rated the outpatient services overall as requires improvement because;

Effective and safe systems were not always in place to monitor and manage risks to patients.

Outpatient staff showed an understanding of the need to report incidents, However, staff were not consistent in reporting incidents and they were not always reported in line with trust policy. This meant the trust did not have an oversight of all incidents that occurred within outpatient services.

We saw that learning from incidents was inconsistent across the specialities and learning from incidents was not shared across the outpatient department as a whole.

Patients’ personal identifiable information was not always kept confidential or stored securely. We saw patient personal information left on top of open trolleys in some clinics unobserved by staff and confidential waste and patient records left unsecured in reception areas overnight. This meant there was a risk of patient records and personal details being seen or removed by unauthorised people.

Systems and processes were not always reliable or appropriate to keep people safe. This meant there was a risk patients were waiting longer than appropriate to be seen.

Infection control standards required improvements. For example, we found risk assessments were not always completed and all nursing staff did not follow infection control processes.

Outpatient and diagnostic imaging services did not identify all risks to patients or effectively manage risks that had been identified.

Patients were not always treated with dignity and patient’s privacy was not always respected.

Trust-wide governance systems were not strongly established and there was a lack of adherence to, and knowledge of, policies and procedures.

Most patients were positive about the care they received.

Managers of outpatient departments were accessible and respected by staff.

Updated 20 March 2020

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

• The service had enough staff to care for patients and keep them safe. Staff mostly understood how to protect patients from abuse. Staff assessed risks to patients. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff mostly 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. Most 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 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.

However:

• Mandatory training compliance was below the trust target.
• The service did not always manage medicines well.
• Most staff were not aware of Female Genital Mutilation (FGM).
• The service did not always control infection risk well.
• Staff did not always record the daily checks of essential clinical equipment.
• Staff did not always keep good care records.
• Managers did not always operate effective governance processes. However, they were working towards this.
• Staff did not understand the service’s vision and values, and how to apply them in their work. However, staff were aware of trust strategy, and applied it in their work.

Updated 20 March 2020

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

• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided emotional support to patients, families and carers to minimise their distress. Staff understood the patient's personal, cultural and religious needs.
• The service managed patient safety incidents well. When things went wrong, staff apologised and gave patients honest information and suitable support. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service controlled infection risk well.
• The service had enough nursing, medical, and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• The service used systems and processes to safely prescribe, administer, record and store medicines.
• Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. They gave patients enough food and drink to meet their needs and improve their health. The service made adjustments for patients’ religious, cultural and other needs.
• Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service provided care and treatment based on national guidance and evidence-based practice.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Leaders and staff actively and openly engaged with patients, staff, the public and local organisations to plan and manage services.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients' consent. They knew how to support patients who lacked the capacity to make their own decisions or were experiencing mental ill-health.
• Key services were available seven days a week to support timely patient care. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They also worked with others in the wider system and local organisations to plan care.
• It was easy for people to give feedback and raise concerns about the care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear.
• The service collected reliable data and analysed it. The staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were secure.
• All staff were committed to continually learning and improving services.

However:

• The service did not make sure doctors completed the mandatory training required to keep their knowledge and skills up to date.
• Staff appraisal rates did not meet the trust target.
• The department did not provide therapeutic environment for patients with mental health conditions.
• Staff were not clear on the trust’s rapid tranquilisation policy. Within the first hour post rapid tranquilisation patients had not had any physical health checks recorded.