Northwick Park Hospital

Updated 20 May 2022

Northwick Park hospital serves an ethnically diverse population mainly concentrated in the London Borough of Harrow. Northwick Park Hospital provides the following services:

•Urgent and emergency care

•Medical care (including older peoples care)

•Surgery

•Maternity and gynaecology

•Outpatients and diagnostics

•Critical care

•End of life care

•Children’s and young people services.

We inspected medical care and surgery core services at our inspection on 9, 10 and 11 February 2022.

Medical care at Northwick Park Hospital was last inspected in August 2018 when it was rated requires improvement for safe, effective, responsive and well led and good for caring. Medical care was rated as requires improvement overall.

At this inspection our overall rating of medical care stayed the same. We rated the service overall requires improvement. We rated safe, and responsive as requires improvement and good for effective, caring and well led.

Medical services involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. Medical care at Northwick Park Hospital provided care and treatment in the following disciplines: regional rehab unit; stroke; care of the elderly; cardiology; dermatology; genitourinary medicine (GUM) and sexual health; infectious disease; respiratory; rheumatology; endocrinology and diabetes; neurology and gastroenterology.

During this inspection we visited Fielding, Dryden, Crick, Darwin, Haldane, Hardy, Gaskell, Jenner and Fletcher wards. We also visited the discharge lounge and endoscopy. We spoke with 25 staff members and viewed 24 patient records. We also spoke with six patients.

We rated medical care at Northwick Park Hospital requires improvement overall because:

• Indications of patients having venous thromboembolism (VTE) prophylaxis were not always specified on the prescription charts we viewed. This meant staff reading the prescription may not have information on patients VTE status.
• Records were not always stored securely. We saw records cupboards were not locked when not in use on Darwin ward. This meant unauthorised people may have been able to access patients’ confidential information.
• All staff did not consistently receive feedback from incidents. One member of staff on Darwin ward told us they were not aware of an incident that had happened on the ward.
• We saw a ‘do not attempt cardiovascular resuscitation’ (DNAR) form on Herrick ward where it was unclear whether the patient’s DNAR had been cancelled. Staff were unable to tell us the reasons for the cancellation.
• We saw a sharps bin in the discharge lounge stacked on top of another sharps bin. The sharps bin was open and had not been signed or dated. There was a risk of the sharps bin being knocked over and potentially causing harm to patients or staff.
• We saw a wheelchair with broken foot straps on the discharge lounge. There was a risk that staff may have used the wheelchair, even though staff had reported the wheelchair to the medical engineering department.
• The hospital was not meeting national standards in some areas of the myocardial ischaemia audit.

However:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risks well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff 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. 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.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. 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.

Surgery at Northwick Park Hospital was last inspected in November 2019 when it was rated good in safe, effective, caring and well led and requires improvement in responsive. Surgery was rated as good overall.

At this inspection our overall rating of surgery stayed the same. We rated the service overall as good. We rated safe, effective, caring, and well led as good and responsive as requires improvement.

We visited the following areas during our inspection: Gray ward, Eliot ward, Kingsley ward, surgical assessment units (SAU) on levels two, three, and four, the theatre assessment unit, the west London vascular and interventional service, the post anaesthetic care unit (PACU), the theatre recovery unit, the main theatre suite, and the discharge lounge. The service had 13 theatres, of which 11 were in use. One theatre was being refurbished and one theatre was being converted into a paediatric recovery.

To manage staffing and capacity during the COVID-19 pandemic, the trust had restructured surgical services and treatment pathways. Northwick Park Hospital provided non-elective surgery and patients underwent pre-assessment care at Central Middlesex Hospital. As part of our inspection of surgical care at Ealing Hospital and Northwick Park Hospital, we visited Central Middlesex Hospital to understand the pre-assessment pathway and the post-treatment therapy provided by allied health professionals. We have included the findings in our surgery report for Ealing Hospital.

We rated surgery at Northwick Park Hospital good overall because:

• The service managed staffing well and maintained consistent levels of training and appraisals despite pressures on the service caused by COVID-19.
• Services were demonstrably multidisciplinary, and staff had established a wide range of new working opportunities to support patient outcomes.
• 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.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. 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:

• Pharmacy cover on wards was limited due to short staffing. This meant pharmacists could not always join ward rounds and could not always review prescriptions daily.
• The service did not have a coherent, overarching vision for what it wanted to achieve. Individual departments and divisions developed their own strategies in the absence of a trust-level approach.

Updated 20 May 2022

Updated 31 August 2018

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

• Mandatory training completion rates for nursing and medical staff were not meeting the trust target.
• Processes and systems could not always be relied upon to protect children from abuse and harm. Children on the child protection register were not always identified, and arrangements for vulnerable patients between 16 and 18 years were not robust.
• There was a lack of appropriate assessment for children with mental health concerns during nights and weekends, which meant they may stay in hospital longer than necessary.
• Nursing vacancies were high across all areas of the service, with a high turnover rate between January and December 2017. This led to a high proportion of bank and agency staff being used to fill shifts.
• Nutrition and hydration assessments were not always completed. We found gaps in feeding charts and the frequency of patient assessment reviews.
• The pain tool, used by the service to assess and manage pain, was not consistently completed and reviewed.
• The children and young people’s service did not have a nursing lead for patients with a learning disability or mental health concern. Advice was sought from the Children and Adolescent Mental Health Service Monday to Friday, but there was no support at night or weekends.
• The service did not always provide a smooth and timely transition for patients moving between children and adult services. The trust did not have a transition policy and staff felt that guidelines required clarity.
• Bed space capacity during the winter months was not meeting the increasing demand, particularly for patients with higher and more complex needs. The inpatient ward was providing high dependency care although this was not yet funded and there was no designated area.
• Senior leaders of the trust were rarely seen on the children and young people’s wards. Medical staff told us there was no forum for them to raise ideas or concerns with the senior leadership team.
• Audits were regularly undertaken within the service to check that guidelines were being followed. However, robust action plans were not always put in to place when gaps were identified.
• The service did not have a forum for children and young people, and their carers, to provide feedback about the care and treatment received at the hospital.
• Most staff within the children and young people’s service said that communication could be improved. In particular, staff said ward meetings did not always go ahead. Emails with a brief summary were sent out to staff who missed meetings.

However:

• All areas within the children and young people’s service were visibly clean, and we found infection control protocols were adhered to.
• Paediatric early warning scores were routinely recorded to identify patients that may be deteriorating.
• We saw evidence of good multidisciplinary working throughout all areas of the children and young people’s service. Psychosocial and complex case meetings discussed the social and psychological wellbeing of patients.
• We observed compassionate care being provided across all areas of the children and young people’s service by nursing and medical staff.
• Children and their carers felt fully involved in their care and treatment. Doctors and nurses explained procedures in a relaxed and child friendly manner.
• Transitional care was provided on the neonatal ward, enabling mothers to stay with their baby whilst receiving hospital care, and preparing for discharge.
• The service had won a national patient experience network award for its’ use of technology and actively engaging with adolescent users of the diabetes services. This had led to a reduction in patient non-attendance at the diabetes clinics.

Updated 25 March 2019

• We have not reviewed the rating for this service because of the limited focus of this inspection. The rating therefore remains good overall.

Updated 21 June 2016

We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

The patients and relatives spoke positively about their interactions with the teams involved in their care.

The trust had responded to the withdrawal of the Liverpool Care Pathway. The trust used a holistic document which was in line with the five priorities of care, was called the ‘Last Days of Life Care Agreement' (LDLCA). However, this document was not compulsory to use across the hospital leading to difficulties in following some care plans.

Patients’ records and care plans were regularly updated, matched the needs of the patient and were relevant to EOLC.

There were some concerns raised by specialist staff and from our observations about whether all generalist nurses, doctors and consultants had the expertise to recognise dying; and had the skills to have difficult conversations about planning care for those at the end of their life.

The SPCT were focussed on raising staff awareness around EOLC. However they said that this should be a trust wide responsibility.

The trust had recently run a pilot training scheme for staff on the elderly care wards. However this is not yet part of mandatory training.

Staff were aware of their responsibility in raising concerns and reporting incidents.They were keen to report any incidents in relation to palliative and EOLC in order to drive improvement.

There were few complaints in relation to EOLC and staff told us they preferred to deal with concerns or issues at the time to try to deal with it prior to it becoming a formal complaint.All staff understood their role and responsibility to raise any safeguarding concerns.

We found that leadership of the SPCT was good at a local level, and all staff reported being supported by their line managers. The SPCT were able to communicate the trust's vision. However they were not always able to explain how this was going to be met. Cross site working was in its infancy and staff expressed a difficulty in doing more due to the difficulties in physically getting between the hospitals in the trust.

Updated 24 December 2021

Updated 21 June 2016

Outpatients and diagnostic imagingservices at Northwick Park Hospital did not consistently offer appointments within defined target times.

There was a system in place to highlight which patients had waited longest and should be prioritised for the first available appointments. The trust had attempted to reduce the backlog of patients waiting for appointments, but financial constraints meant that additional clinics had been stopped.

We found that management of risks associated with emergency situations in some areas within the outpatient services including haematology had not been appropriately recognised, assessed or managed.

We found that there were regular shortages of nursing staff of up to 20% in the outpatients departments.

We found the method for tracking medical records was not reliable. Notes were stored in the medical records department and were collected by medical records staff in preparation for outpatient clinics. Staff were not always aware of or have access to the incident reporting system through Datix.

We found limited evidence of the effectiveness of outpatient services and at times staff were not always caring or respectful of patients.

The services had begun to integrate across the three hospital sites following the merger in 2014, but there was more work needed.

We saw good evidence of how diagnostic services respond to patients’ needs and how outpatients track the progress of patients on the waiting lists for appointments.

Updated 20 May 2022

Updated 6 November 2019

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

• Safeguarding level three compliance was still below the trust target of 85%. However, the department showed us staff had been booked onto courses in order to improve this. Staff knowledge of safeguarding was also good and we found patients were appropriately safeguarded.
• The Clinical Decision Unit (CDU) was still admitting patients against the admission criteria in order to help prevent breaches within the department. Patients were being held on CDU who required and were waiting for a bed within the hospital.
• The department still faced significant issues with ambulance turnaround which led to high numbers of black breaches due to the volume of patients the department received on a daily basis. However, the service had improved the way patients were offloaded to ensure patient safety. The department had introduced a streaming team to assess patients on arrival by ambulance. This ensured patients observations and early warning scores were taken and they were streamed to appropriate areas of the department.

• Due to capacity issues patients were still being cared for on trolleys in the corridor which meant private conversations could be overheard. These patients were cared for by nurses allocated to the pit stop. Investigations such as blood tests were also being carried out in the corridor. Whilst this helped improve patient safety as they were being seen faster, it did not maintain privacy and dignity.
• Some doctors told us they were unable to attend training on a regular basis due to department being busy and workload.
• People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations relating to national standards.
• The departments performance for Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival was poor. However, significant improvements had been made and performance was no longer consistently below the England average. The trust were continuously working with NHS Improvement to improve their performance. The trust had been above the England average for six months.
• Black breaches and ambulance turn around were still significant issues for the department. However, a new streaming and offloading process had been put into place to improve patient experience and safety. There were plans to audit this in the future.

However:

• The department had improved its compliance with mandatory training for medical staffing. The majority of mandatory training was meeting the 85% trust target.
• Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas. We also found recording of pain scoring had improved for paediatric patients.
• The department had worked with the local mental health trust to improve risk management arrangements for mental health patients.
• The department now had a Practice Development Nurse (PDN) in post to support staff with their learning and education needs.
• The appraisal rate for nursing staff had improved and now met the trust target of 85%.
• Patients, families and carers were positive about the care across the service and we observed compassionate and courteous interactions between staff and patients.
• The Short Term Assessment, Rehabilitation and Reablement team (STARRs) provided intermediate care services for patients in Brent. The service provided a multi-disciplinary, holistic assessment of patients and supported early discharge.
• Staff and managers were clear about the challenges the department faced. They explain the risks to the department and the plans to deal with them. The top risks were shared with staff via the clinical governance newsletter.
• We found clinical governance arrangements were departmentally focused. There was a new a clinical governance team leading on urgent and emergency care services.