Whipps Cross University Hospital

We last inspected the maternity service at Whipps Cross Hospital in July 2016. We carried out an unannounced inspection between 15 and 17 October 2019.

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

• The service had taken steps to address the areas of improvement from the previous inspection. During this inspection, the service had dealt with or shown improvement for most of the previously reported areas of improvement.
• The practice development midwife (PDM) organised mandatory training for staff one year in advance and worked in coordination with the shift roster system which meant that staff booked in for mandatory training were not included in shift allocation.
• The trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns.
• The Female Genital Mutilation (FGM) team achieved the first UK court conviction against FGM in February 2019 and was a finalist for a national award for the Lotus clinic.

• All the areas we inspected were visibly clean, tidy, and clutter free. The equipment store rooms were well organised with secure access and we saw evidence that equipment was routinely, and regularly serviced and calibrated.
• Although the maternity service used the modified early obstetric warning score (MEOWS), we found 11 out of 19 records (58%) we reviewed, showed the frequency of observation for MEOWs was missing. We raised this with the trust who responded with a thorough action plan that included daily audits, staffing training and cross site peer reviews. The daily audit results demonstrated improvements had been made.
• Although the service had challenges regarding midwifery staffing, the service ensured there were enough staff with the right qualifications, training and experience to keep women safe from avoidable harm.
• Staff kept detailed records of patients’ care and treatment. Most of the records we reviewed were clearly written and dated, with legible signatures and risk assessments had been completed.
• Stock management of medicines was consistent across all maternity areas and medicines that needed to be kept below a certain temperature were stored in locked fridges. Controlled drugs (CD) management across all maternity areas was good.
• Staff were encouraged to raise concerns and to report incidents and near misses. The division effectively shared learning from incidents and good practice with staff through regular meetings.
• The service demonstrated effective internal and external multidisciplinary team (MDT) working to benefit patients. Staff supported each other to provide good care.
• Staff reported a supportive and developmental environment with good learning opportunities to maintain and develop their skills and knowledge.
• The maternity service was taking part in eight research studies and displayed information leaflets regarding the studies for the public to view.
• Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
• Women told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. Staff provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people considering patients’ individual needs and preferences. For example, the trust used individualised ‘hospital passports’ for patients with learning difficulties to help staff understand the patient’s likes and dislikes to make them more comfortable.
• The service exceeded the Better Births Strategy’s national target for the percentage of women booked into continuity of care (CoC) pathways and personalised care.
• The maternity service was refurbishing the estates to improve women’s experience and kept expecting mums informed ahead of their appointments.
• The service had introduced one-stop clinics; for example, the one-stop twin clinic, to improve patient experience by reducing the volume of appointments and visits to the hospital.
• The service dealt with concerns and complaints appropriately and investigated them in the required time frame and learned lessons from the results, which were shared with all staff.
• Although the divisional team structure had been finalised six weeks prior to the inspection, staff demonstrated awareness of the leadership team and described them as supportive, visible and approachable.
• Senior leads had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.
• The service actively and openly engaged with women, staff, the public and local organisations to plan and manage services.
• The maternity service was involved in quality improvement programmes which included process mapping and patient experience. For example, the induction of labour (IoL) quality improvement project had revised the outpatient pathway, processed mapped every step of woman’s journey through the IOL pathway and included patient experience feedback.

However:

• Although the service had implemented a National safety standard for invasive procedures (NatSSIPs) proforma checklist after two never events in August 2018, further work was required to ensure it was fully embedded.
• Despite the service having numerous alcohol dispensers in all the areas, we observed inconsistent hand hygiene practice amongst all staff groups. However, the service reported zero incidences of hospital-acquired infections and women told us they regularly saw staff using alcohol gel and wash their hands.
• Although we had no medicines management concerns in the service, the service did not have a dedicated pharmacist which meant we had no assurance that medicines reconciliation was taking place in line with trust policy. Senior leads told us this was a historical, trust wide issue which was on the Clinical Support Services (CSS) risk register. However, a pharmacy technician had been in place for the last six months as a bridge to further resource and staff told us the pharmacy technician was supportive and accessible.
• Most women and relatives we spoke with told us the car parking at the hospital presented challenges in reaching appointments on time.
• Although senior leads told us the intranet had information on freedom to speak up guardians, we found staff had inconsistent awareness of them. 

Following this inspection, we told the trust that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Nigel Acheson 

Deputy Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it them as requires improvement because:

• Since our last inspection of acute services at Whipps Cross Hospital in 2016, 2017 and 2018, the trust had addressed or shown improvement for most of the previously reported concerns and requirement notices, for which we commend them. Evident improvements included significantly improved standards of care, dignity and privacy in medical care, the improved culture around medicines management, and improved record keeping in surgery. However, we found several areas of improvement to address such as the pockets of bullying in the emergency department and the maintenance of equipment and the environment.
• Although the trust had improved referral to waiting times (RTT) in the surgical service, further improvement was required to ensure the trust was meeting the national standard. In outpatients, only one specialty met the national RTT target.
• In outpatients, we also found substantial waiting lists for clinic appointments with relatively high cancellation and did not attend rates. Although rebooking and follow-up practices varied between specialties, individual specialties such as ophthalmology scheduled ad-hoc clinics to reduce waiting lists and meet local demand.
• Patient flow within the hospital remained an ongoing challenge and impacted other services such as bed occupancy in critical care. In the surgical service, late starts, patients discharge out of hours and cancelled operations had not improved.
• The trust did not meet the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge. Performance between January and July 2018 (86%) was worse that the England average but just above the London average (85.8%).
• Although the trust had improved the culture in areas such as the eye treatment centre in outpatients and medical care services, we found pockets of bullying in the emergency department which the leadership team did not have oversight of.
• Staff feedback on development opportunities varied between each service. In medical care, doctors in training were very positive about the support and teaching they received whilst outpatients staff told us they had inconsistent access to training and development opportunities.
• The trust did not provide up to date monitoring data for mandatory training, staff vacancies, sickness and turnover rates and appraisal completion rates for outpatient services. Similarly, in diagnostics, the trust did not provide a breakdown of mandatory training compliance rates for nursing or medical staff by module.
• Although the trust had shown improvement in staffing levels in some services, the trust still had challenges with staffing in some of the services we inspected. The emergency department had high nursing and consultant vacancy rates. Managers told us processes in human resources (HR) had contributed to delays for the appointed nurses from overseas to start.
• The availability of equipment continued to present challenges for staff in some services. The diagnostic service had a significant amount of aging equipment which was prone to breakdown which had resulted in clinic delays and early closure. Surgical staff witnessed similar issues in accessing equipment or getting broken equipment repaired despite the trust making a significant investment in replacing equipment which urgently needed replacing.
• The diagnostic service had no schedule in place for quality assurance testing of the home computers and did not complete regular quality assurance checks on equipment including mobiles, despite being advised to do so by the medical physics expert’s advice.
• Although senior leaders and service managers had, for the most part, a good understanding of risks to the service, the trust did not have oversight of some issues despite them being logged on the risk register. Service leads did not mitigate risks appropriately in some instances. Radiographers raised concerns about personal safety at night due to the location of an equipment. Although the service lead was aware of this and had acquired an additional machine, the location had still not been determined.
• Although the fire safety group and operations team had improved fire safety in the hospital, we found partially blocked fire escapes routes on Cedar ward and Faraday ward and a lack of assurance around fire safety within outpatients, including poor organisation we observed during an evacuation.
• The trust’s response rate to the NHS Friends and Family Test (FFT) had been lower than the national average. Staff told us the low response rates were due to the trust recently changing to an electronic method of collecting FFT data and individual teams had developed initiatives to address this.

However, we also found:

• The trust had addressed the warning notice issued for medicines management in the April 2018 inspection of surgical services. In most cases, we found improvement in the storage of medicines and Controlled Drugs and improved staff awareness of policies overall. However, further improvements were still required for example with tracking the dispensing of pre-packs.
• Most staff had good awareness of incident reporting, how to raise concerns and duty of candour. There was an open culture of incident reporting and a willingness to learn from incidents for most services except for outpatient services.
• There were comprehensive, clearly defined and embedded processes to protect people from abuse. Staff were knowledgeable about safeguarding and were confident to escalate concerns. Staff were aware of their responsibilities as set out in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
• All areas of the hospital we inspected were visibly clean, tidy, and clutter free with adequate supplies of personal protective equipment (PPE) available for use when required. Although we observed good compliance with infection prevention and control across the hospital, hand hygiene audit results for the emergency department required significant improvement.
• The trust had introduced measures to better anticipate and manage patient risks including an improved integration of the national early warnings scores (NEWS) system. Although staff had good knowledge of what to do in the event of a patient deteriorating, we found inconsistent NEWS documentation in patient records in the emergency department.
• Throughout our inspection, we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. Ward staff worked closely with staff across acute and community services as well as practitioners in the local health economy.
• Staff demonstrated compassion to patients and their relatives in all the services we inspected. Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. However, there were some isolated incidents where patients felt staff were too busy to provide the support they needed.
• Most people using the trust’s services were treated with dignity and respect with significant improvements in medical care. However, we found patient dignity and privacy was compromised in the GP x-ray department changing area and in outpatients where there was a lack of screens for procedures such as taking blood pressure.
• Staff delivered patient care in line with good practice and evidence-based guidance from relevant bodies. Most of the staff we spoke with told us they could easily access policies and guidelines on the trust intranet.
• Dedicated teams provided care to patients living with dementia or a learning disability and support to staff using national resources to aid communication. Although, the trust had recently refurbished three medical wards to national dementia friendly standards, the emergency department and outpatients’ environments were not dementia friendly.
• The trust had only one learning disability clinical nurse specialist across all the trust sites. However, staff within the pre-assessment unit took innovative steps and had developed a patient passport having researched the needs of patients living with a learning disability.
• Although the estates remained a challenge for the trust and obtaining funding for site re-development was an ongoing piece of work, the trust had still made improvements to the environment to provide a better and safer patient experience. However, the outpatients’ environment required further improvement.
• The trust’s nurse education team provided specialist training opportunities to clinical staff, including simulations and interactive workshops. Some services had practice development nurses (PDN) who provided training to update nursing skills.
• The trust had a range of services available to support patients. For example, bereavement services, 24-hour chaplaincy and access to translation and advocacy services for patient where English was their second language.
• The service dealt with concerns and complaints appropriately and investigated them in the required time frame including future actions and any learning for staff.
• Most staff we spoke with felt they were listened to by service and trust leadership and felt they could approach managers if they needed support.
• A patient forum provided oversight of care standards and presented their experiences in board meetings in line with the trust’s engagement strategy.
• Most of the services we inspected had shown improvements in implementing a strategy for the service. Services such as critical care, the emergency department and medical care had developed a strategy with staff involvement and with external partners with a focus on the frail elderly.
• Leadership structures were clearly embedded for most services except for outpatient services. The trust had made notable improvements in the governance structure in the surgical and medical service.