Archived: West Middlesex University Hospital NHS Trust

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. Chelsea and Westminster Hospital NHS Foundation Trust were deemed the preferred bidder in April 2013. Processes have been slow subsequent to the announcement however following our inspection, it was announced on 19 December 2014 that the merger with Chelsea and Westminster Hospital 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 North West London 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 between25 and 29 November 2014 and an unannounced inspection on 9 Dec 2014 and 13 Dec 2014.

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 (EoLC); and outpatients and diagnostic imaging

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: A&E; surgery; services for children and young people; EoLC; and outpatients and diagnostic imaging.

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

Overall this hospital requires improvement.

Our key findings were as follows:

Safe

• Staffing levels in A/E did not consistently meet the required standards for consultant cover or nursing and tools to detect the deterioration of patients were not used consistently.
• That whilst a recruitment strategy is in place midwifery staffing levels were significantly below that recommended for the number of deliveries thus creating an increased risk to patient safety
• Staffing levels in nursing and ultrasonography was impacting upon the quality of care received by patients in the Early Pregnancy Unit.
• We found that Infection control procedures and practice was followed and hand gel was readily available at many points for use by staff and visitors. The facilities were clean, well maintained and hygienic across the trust.
• Surgical consultant capacity led to issues in orthopaedics and general surgery and a lack of consultant involvement in emergency surgery
• We observed inconsistent application of WHO briefing in surgery
• Medicines management in the emergency department was not robust leading to the highest number of reported incidents across the Trust

Effective

• The trust did not have a robust policy and document management system leading us to identify a number of out of date documents in clinical areas.
• Whilst the incident reporting system (DATIX) was readily accessible evidence that there was a strong culture of learning from incidents was not apparent in all areas.
• We found that care was largely provided in line with national best practice guidelines and we observed good clinical practice by clinicians during the inspections.

• Not all national and local audits were completed, and some recent audits did not have associated action plans or a strategy to check whether performance was improving.
• Performance in the stroke audit had deteriorated from the previous level A to level C and remained at level C for this period.

Caring

• We observed patients being treated with dignity, respect and compassion even when teams were under pressure.

• Patients considered that they had been given sufficient information and counselling by qualified healthcare professionals to enable them to make informed decisions about their care and treatment.
• The NHS Friends and Family Test (FFT) indicated that 91% of respondents (25% response rate) said they were likely or very likely to recommend the hospital to friends or family

Responsive

• Patient flow from the emergency department was impeded leading to the time spent in the emergency department (average 290 minutes) exceeding the national average (140 minutes)
• That strategic planning and staffing for the management of the dying patient were below expected standards and not responsive to the needs of this group of patients.
• The trust did not have an Acute Oncology Service and therefore was not responding to the needs of acutely medically ill cancer patients.
• The absence of appropriate orthogeriatrician support led to only 3% of elderly patients with fractured neck of femur (hip fracture) were seen by an orthogeriatrician.
• Efforts to meet the five day patient letters targets included the issue of a high percentage of unverified patient letters (43%) from surgery with no retrospective audit plan.
• We heard consistent reports of delays in the provision of medications for taking away at discharge
• There was a high number of outpatients clinics cancelled creating inconvenience for patients and the potential for delays in diagnosis.

Well-led

• The Trust had a long term vision and its experienced leadership was fully engaged and influential in the planned merger and ‘shaping a healthier future’. However not all departments could demonstrate a local vision and plan that connected with the Trust strategy.
• The protracted merger process had resulted in a high use of interim senior managers and to some extent planning blight. Surgery in particular had suffered from unstable management support.
• Inconsistent leadership in the SCBU was undermining good care leading to a lack of clear clinical governance and documentation management.
• The culture of the organisation was largely reported as positive, open and transparent; however we did receive reports of what some staff considered to be a blame culture.

We would add that most patient, carer and patient relative feedback was positive and we saw many examples of staff giving treatment in a caring and compassionate way. The physical environment in the hospital was well maintained, clean and hygienic with staff following infection control guidelines and protocols.

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 in A&E 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 so 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 so patients are discharged in a timely way or transferred to areas treating their speciality.
• 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.
• The trust should review the culture of the A&E to explore the reasons for low morale and reported conflict amongst some staff.
• Improve surgery theatre use to prevent late starts and theatre overruns.
• Review the surgical pathway for children and adults.
• Review physiotherapy at weekends for all patients not just those on enhanced recovery programmes to assist rehabilitation.
• Increase weekend consultant ward rounds in surgery and include Sunday.
• Ensure sufficient beds on surgical wards to improve treatment of surgical patients in specialty beds.
• Improve cleanliness and hygiene in the Special Care Baby Unit (SBCU).
• Formalise multidisciplinary approach to care on the SBCU.
• Share the outcome and learning from audits to staff on the SBCU.

Professor Sir Mike Richards

Chief Inspector of Hospitals