East and North Hertfordshire NHS Trust

East and North Hertfordshire NHS Trust provides secondary care services for a population of around 600,000 in East and North Hertfordshire as well as parts of South Bedfordshire and tertiary cancer services for a population of approximately 2,000,000 people in Hertfordshire, Bedfordshire, north-west London and parts of the Thames Valley.

This trust has four main locations; Lister Hospital, Queen Elizabeth II Hospital (QEII), Hertford County Hospital and Mount Vernon Cancer Centre Hospital (MVCC), as well as five renal units, and a community childrens and young people’s service. The trust concluded its “Our Changing Hospital” programme in 2015, having invested £150m to enable the consolidation of inpatient and complex services on the Lister Hospital site, delivering a reduction from two to one District General Hospitals. Hertford County Hospital provides outpatient and diagnostic services. The Mount Vernon Cancer Centre provides tertiary radiotherapy and local chemotherapy services. The cancer centre operates out of facilities leased from Hillingdon Hospitals NHS Foundation Trust.

We carried out this inspection as part of our comprehensive inspection programme, which took place on trust sites during 20 to 23 October 2015. We undertook three unannounced inspections on 31 October, 6 and 11 November 2015.

Overall, we rated East and North Hertfordshire NHS Trust as requiring improvement with four of the five key questions which we always rate as being requires improvement (safe, effective, responsive and well led). Caring was rated as good.

Overall, we rated Lister Hospital, QEII and MVCC as requiring improvement and rated Hertford County Hospital and the community children’s and young people service as good. We inspected, but did not rate, the Bedford and Harlow renal units.

The main concern at the Lister related to the urgent and emergency care service which we rated as inadequate. Four of the other seven core services we inspected were rated as requiring improvement. Three services were rated as good: surgery, critical care and outpatients.

At the Mount Vernon Cancer Centre, we rated the medical care service as inadequate and two of the other four core services we inspected were rated as requiring improvement. Two services were rated as good: radiotherapy and outpatients.

Overall we have judged the services at the trust as good for caring. In most areas patients were treated with dignity and respect and were provided with appropriate emotional support. We found caring in the community children’s and young people’s service and in chemotherapy at MVCC to be outstanding. However, caring required improvement in one area – the urgent and emergency care service at the Lister site where patients were not always treated with dignity and respect.

Improvements were needed to ensure that services were safe, effective, and responsive to people’s needs and for being well-led.

Our key findings were as follows:

• Most staff we spoke to were friendly and welcoming.

• The trust had undergone an extensive change programme staff told us although this had been unsettling they thought it had been well managed

• The trust board were a stable team and the CEO particularly was seen by staff as highly visible and approachable

• In most areas staff interactions with patients were positive and showed compassion and empathy. However, the privacy and dignity of patients in the emergency department at Lister Hospital was not always respected.

• Feedback from patients was generally very positive.

• We found that there were governance systems in place to escalate issues and risks to the trust board. However the effectiveness of these processes varied between divisions.

• In some areas staff did not always report incidents.

• In some areas patient’s records such as observation and fluid balance charts were not always correctly completed.

• The triage system within the emergency department at Lister Hospital was not sufficient to protect patients from harm or allow staff to identify those with the highest acuity. Urgent action was taken to address this following it being brought to the trust’s attention.

• The emergency department did not consistently meet the four hour target for referral, discharge or admission of patients in the emergency department.

• Medicines were not always stored and handled safely in some areas we brought to the attention of the trust who took immediate action to address our concerns.

• Action identified as required following investigation of serious incidents on Bluebell ward were not being addressed in a timely or sustainable manner to ensure children were protected from avoidable harm. We brought this to the trust’s attention and the trust took urgent actions to address this.

• There was lack of understanding of the Mental Capacity Act (MCA) amongst some nursing staff.

• Generally there was a good standard of cleanliness. However, the condition of the estate in some areas made effective cleaning a challenge.

• There were a number of areas where the older estate needed improving. The trust was aware of this and was assessing areas of greatest risk.

• The environment at MVCC had not been well maintained and was in need of updating.

• The trust was very proactive in engaging with the local community and had exceptional engagement with young people.

• Safeguarding systems were in place to ensure vulnerable adults and children were protected from abuse

• Nurse staffing levels were variable during the days of the inspection, although in almost all areas, patients’ needs were being met.

• Medical staffing was generally appropriate.

• Working towards providing a seven day service was evident in most areas.

• Pain assessment and management was effective in most areas.

• Most patients’ nutritional needs were assessed effectively and met.

The Chief Executive and executive team demonstrated a good understanding of the challenges the trust faced, along with the commitment to address them and took decisive action in some areas immediately following the inspection.

To address the areas of poor practice, the trust needs to make significant improvements.

Importantly, the trust MUST:

• Ensure all required records are completed in accordance with trust policy, including assessments, nutritional and hydration charts and observation records.

• Ensure there are effective governance systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients including the timely investigation of incidents and sharing any lessons to be learned.

• Ensure effective systems are in place to ensure that the triage process accurately measures patient need and priority in the emergency department.

• Ensure that the triage process in maternity operates consistently and effectively in prioritising patient needs and that this is monitored.

• Ensure that all staff in all services complete their mandatory training in line with trust requirements.

• Ensure that patients who require urgent transfer from MVCC have their needs met to ensure their safety and that there is an effective process in place to handover continuing treatment.

• Ensure there is oversight and monitoring of all transfers.

We saw several areas of outstanding practice including:

• The trust’s diabetes team won a prestigious national “Quality in Care Diabetes” award in the best inpatient care initiative category.

• Following negotiations with the CCG the trust developed an outreach team to deliver seven day, proactive ward rounds specifically targeting high-risk patients. This included the delivery of a comprehensive set of interventions which included smoking cessation and structured education programmes for both the respiratory and diabetic services.

• The day surgery unit had been awarded the Purple Star, which is a recognised award to a service for improving health care for people with learning disabilities. We saw patients with learning disabilities and their relative receiving high levels of outstanding care.

• The ophthalmology department had implemented a minor injuries service. Patients could be referred directly from accident and emergency, their GP or opticians to be seen on the same day.

• Ophthalmology nurses had undertaken specific training to enable them to carry out intravitreal

• The Lister Robotic Urological Fellowship is an accredited and recognized robotic urological training fellowship programme in the UK by the Royal College of Surgeons of England and British Association of Urological Surgeons. This technique is thought to have significantly reduced positive margin rate during robotic prostatectomy and improved patient functional outcome.

• We saw some examples of excellence within the maternity service.The foetal medicine service run by three consultants as well as a specialist sonographer and screening coordinator is one example; the unit offers some services above the requirements of a typical district general hospital such as invasive procedures and diagnostic tests.The unit has its own counselling room away from the main clinic and continues to offer counselling postnatally.

• The service also offered management of hyperemesis on the day ward in maternity to minimise admission.

• The radiotherapy service provides IMRT (Intensity Modulated Radiotherapy) to a higher percentage of patients than the England average. The service provided a good range in IGRT (Image Guided Radiotherapy). Together these are indicators of a high quality radiotherapy service.

• The radiotherapy service had a strong reputation nationally as a major contributor to clinical trials.

• The radiotherapy service was accredited to the ISO 9001 quality standard.

• The cancer centre is one of the top ten centres in the country for research and innovation.

• Care shown to patients undergoing chemotherapy and the community children’s and young people’s service was outstanding.

• Effective multidisciplinary working was evident throughout all departments.

• All staff were proud to work for MVCC and many described it as a special place to work.

• The children’s community nursing (CCN) service, children’s continuing care (CCC) the specialist health visitors (HV,) community paediatrics and the school nursing service were identified as being creative and innovative in finding solutions to the complex care and support needs of CYP.

• Children were truly respected and valued as individuals and encouraged to self-care and were supported to achieve their full potential within the limitations of their clinical condition.Feedback from children who use the service, parents and stakeholders was continually positive about the way staff treated people. National audits for CYP in diabetes and epilepsy scored highly (100% for epilepsy and the fourth highest in the country for diabetes) for patient experience.

• Parents said staff did everything they possibly could to support the child and the family which exceeded their expectations.  Parents told us staff went the “extra mile” and gave examples of how staff had actively supported their child and the family throughout the care episode. 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall we rated the service as good with the service being outstanding for caring and good in all other areas.

We found Children’s Community Services (CCS) provided a caring and effective multidisciplinary and multiagency service for children and young people (CYP) who required assessment, support and intervention to ensure their wellbeing and development.

Services were provided in a child friendly environment by a highly skilled and empathetic workforce across all children’s community settings. Services provided at the Child Development Centre (Danestrete) and the Children’s Zone (QEII) included visit’s to a child’s home, nursery, school or other locality setting. This enabled the development of holistic packages of care for each child and minimised the need for multiple appointments and duplication of history taking and documentation.

Children were truly respected and valued as individuals and encouraged to self-care and were supported to achieve their full potential within the limitations of their clinical condition. Feedback from children who used the service, parents and stakeholders were continually positive about the way staff treated people. Parents said staff went the extra mile and the care they received exceeded their expectations.

Services were well-led and staff were aware of the wider vision of the trust and felt supported in their roles.

We spoke to 43 staff which included nurses, doctors, therapist’s teachers, care support staff and administrative staff.  We also spoke to five children and eight parents.