Archived: Wexham Park Hospital

Updated 1 May 2014

Wexham Park Hospital is the trust’s main site and provides services to a large and diverse population of more than 465,000. The area it covers includes Ascot, Bracknell, Maidenhead, Slough, South Buckinghamshire, and Windsor. The trust has approximately 3,200 staff and a total number of 650 beds, with 588 on the Wexham Park Hospital site. 61 of the beds at Wexham Park Hospital are used for maternity, 57 for children, 93 for surgery, 12 for critical care, and the remaining number for various medical specialities. The trust had recently increased the bed capacity in A&E, paediatrics and wards and had plans to open more capacity later in 2014. The trust’s catchment increased as a consequence of the closure of an A&E department of another trust nearby in November 2012.

The trust became a foundation trust in 2007. In 2008/9, the trust faced significant financial challenges and in 2009/10 Monitor appointed a new chairman. At the time of the inspection, the executive team comprised members who were either interim appointments or relatively new in post, with only one member of the executive team in post for over three years. The chief executive had been in post for two years and four months (but had formally resigned, with a leaving date in March 2014) and the chairman had been in post for one year and three months. This instability in leadership, the financial challenges, and the absence of a consistent vision had evidently had an impact on Wexham Park Hospital’s standard of care and culture.

Wexham Park Hospital was in breach of a number of regulations and, in many instances, it has been providing care below the essential standards, as we found during two previous CQC inspections in May and October 2013. In May 2013, there were particular concerns about the care provided to patients in A&E and the impact this had on the ability of in-patient wards to provide the essential standards of care that are required by the regulations. Following that inspection, we issued a warning notice to the trust against Regulation 10: Assessing and Monitoring the Quality of Service Provision.

In October 2013, we followed up on the warning notice and found that the trust had made significant improvements in some areas, particularly in managing capacity issues in A&E at Wexham Park Hospital. However, during this inspection we found a number of significant concerns and issued six warning notices to the trust against Regulation 9: Care and Welfare of Service Users, Regulation 10: Assessing and Monitoring the Quality of Service Provision, Regulation 12: Cleanliness and Infection Control, Regulation 17 Respecting and Involving Service Users, Regulation 20: Records, and Regulation 22: Staffing. All these warning notices stated that Wexham Park Hospital must become compliant with all the regulations by 31 January 2014.

Following our inspection in October, we referred our findings to the local area team (NHS England), the General Medical Council, Monitor, the Health and Safety Executive and the commissioning department within the local authority. As healthcare regulator, Monitor subsequently appointed an improvement director to support the trust. We followed up the warning notices as part of our planned inspection in February.

Updated 1 May 2014

Wexham Park Hospital is the main site of Heatherwood and Wexham Park Hospitals NHS Foundation Trust and provides services to a large and diverse population of more than 465,000. The area it covers includes Ascot, Bracknell, Maidenhead, Slough, South Buckinghamshire and Windsor. The trust has approximately 3,200 staff and a total of 650 beds, with 588 on the Wexham Park Hospital site. The trust has recently increased the bed capacity to meet increased demand following an increase in its catchment area in accident and emergency (A&E), paediatrics and wards and had plans to open more capacity later in 2014.

The trust’s catchment area population includes a significant proportion ethnic minority groups and 30 languages are spoken in the area covered by the trust. The most common (excluding English) include Hindi, Polish, Urdu, Somali, Romanian and Punjabi.

The trust became a foundation trust in 2007. At the time of the inspection, the executive team (based at Wexham Park Hospital) comprised members who were either interim appointments or relatively new in post, with only one member of the executive team in post for over three years. The chief executive had been in post for two years and four months (but had formally resigned, with a leaving date in March 2014).

At the time of the inspection, Wexham Park Hospital was in breach of a number of regulations and, in many instances, it has been providing care below the essential standards, as found during two previous CQC inspections in May and October 2013. In May 2013, there were particular concerns about the care provided to patients in (A&E and the impact this had on the ability of inpatient wards to provide the essential standards of care. At the inspection in October 2013, improvements in A&E were noted to have been made. However, we found that Wexham park Hospital was in breach of eight regulations. We served compliance actions for breaches of two regulations (15 and 16). We also served warning notices for breaches of six of the regulations (9, 10, 12, 17, 20 and 22).

We gained views from partner organisations who expressed their concerns about the care provided at Wexham Park Hospital and the future sustainability of the trust.

Wexham Park Hospital provides the following regulated activities, which formed part of our inspection: diagnostic and screening procedures, management of supply of blood and blood derived products, maternity and midwifery services, surgical procedures, termination of pregnancies and treatment of disease, disorder or injury.

We carried out an announced inspection visit on 12 and 13 February. We held focus groups and drop-in sessions. We talked with patients and staff from many areas of the hospital. We observed how people were being cared for, talked with carers and/or family members, and reviewed patients’ records of personal care and treatment. We held two listening events when patients and members of the public shared their views and experiences of Heatherwood and Wexham Park Hospitals NHS Foundation Trust. Patients who were unable to attend the listening events shared their experiences via email or telephone. We carried out three unannounced visits, when we looked at how the hospital ran at night, the levels and type of staff available, how they cared for patients, and patient flow through the hospital.

The trust had a long history of turbulence, which was felt by our inspection team at Wexham Park. Financial shortfall and high turnover of senior leadership had resulted in poor outcomes in recent CQC inspections and expressions of increasing concern from multiple stakeholders. We found the trust had significant legacy from a history of financial challenges and the hospital had a culture that was not open with learning at its heart. Although the financial challenges had been addressed and improvements trust-wide were beginning to be made with external support from agencies, the trust remained very challenged. The future sustainability of the trust and its hospitals remained a concern. Although efforts had recently been made in response to concerns raised by CQC about Wexham park Hospital, they were still very much in their infancy.

The culture was one of learned helplessness and accusations of bullying and harassment were seen throughout. Although the chief executive was reported to have high visibility and communicated regularly with the frontline, she had recently resigned and was due to leave in March 2014.

The lack of bed capacity in the hospital meant that many patients were moved from ward to ward during their stay, which impacted on their continuity of care and consultants being unaware of where their patients were in the hospital.

Staff stated they did not always report incidents or concerns because when they had done so previously, there had not always been any feedback and nothing had changed as a consequence. There was a consistent theme that learning was not implemented to improve patient care.

Cleanliness and infection control

Infection rates were in line with the national average. There were still concerns regarding infection control in some areas of the hospital but improvement been made since CQC raised concerns CQC during the inspection in October 2013. The trust had carried out a full deep clean of the whole hospital recently to good effect.

Staffing

There was high use of agency and locum staff, both in nursing and medical staffing. The trust recognised it had a high turnover of nursing staff and was considering approaches to retain and recruit nurses at the time of our inspection. During the inspection we noted agency staff were not consistently being appropriately checked or given an induction on arrival to the ward.

Staffing in radiology was a particular concern. There were 11.7 vacancies for radiographers, although the trust was in the process of recruiting. The radiology department consistently operated with agency radiographers every weekend and there were no plans in place to change this approach.

There were low levels of staff satisfaction and many reported concerns about a ‘bullying and harassment’ culture from senior managers and above. There was a significant level of conflict within the organisation among medical staff, which was impacting upon effective multidisciplinary working. Clinical engagement through the hospital was relatively low, with evident conflict and lack of belief in managers from many clinicians. The trust was aware of this and had gained external support to take steps to improve this.

Updated 1 May 2014

The medical care of patients was too variable in its quality and safety. There were capacity constraints within Wexham Park Hospital and the high demand for beds led to patients being moved from ward to ward on numerous occasions for non-medical reasons. This resulted in a poor patient experience and impacted on their treatment due to inconsistency in continuity of care.

Temporary escalation ward space had been created to deal with the lack of capacity, but this was not always suitable for this purpose. In addition, many wards needed to have general medical patients on them, which impacted on the ability of other departments, such as cardiology, to treat patients and cancellation of elective procedures was routine.

Since CQC had raised concerns on medical wards following an inspection in October 2013, there had been new nurse management put in post and the staff recognised that in some instances improvements were being made to improve patient care. Although these changes were in their infancy, the staff felt the ward level leadership was improving.

There was a lack of permanent nursing staff on some wards, with a significant proportion of agency staff working on wards and caring for patients. During the unannounced inspection, all wards we visited had agency staff on the shift, and on one ward only agency staff were caring for the patients. This resulted in lack of continuity of care and treatment and, in some instances, poor knowledge of the patient’s condition. Overall ward staff numbers were low and patients’ care needs were not always being met. Patients were placed at risk of not receiving safe and appropriate care and treatment.

During the inspection it was noted that agency staff were not being appropriately checked or given an induction when arriving at the hospital. This meant that agency nurses were working on the ward without knowing where all equipment was kept and providing treatment to patients without them being checked as appropriately trained in all instances.

There had been a recent increase in junior doctors and this had improved their availability at night and weekends. Although clinical engagement was improving in certain areas, such as cardiology, this was not consistent throughout the directorate and this impacted on the ability for a learning and safety culture to be embedded throughout. There was a lack of clinical ownership of the need to drive improvements and for the monitoring to ensure that it was achieved and sustained.

Updated 1 May 2014

The care for children and young people was good. The treatment and care needs of children and infants were assessed and planned from referral to discharge, taking into account their individual needs and with reference to their parents. We found that children and infants received safe and effective care throughout the hospital.

We found that the paediatric services in the hospital were well-led by a very enthusiastic and committed team of staff.

Children who spoke with us said that the staff were kind and caring and that they received information that helped them understand what treatment and care they were receiving. The majority of parents who spoke with us commented positively on the service, the quality of care, and how both they and their child were treated with dignity and respect.

Staff were aware of best practice guidance for the safe and effective care of children and infants. The health and wellbeing of children, young people and infants was monitored using recognised assessment tools.

Children received pain relief according to their needs and with prescribed medicines. Staff were aware of their responsibilities for safeguarding children and arrangements were in place for looking after vulnerable children and infants. 

Updated 1 May 2014

Patients received safe and effective care when admitted to ITU. Patients and relatives we spoke with were very pleased with the care they received in ITU and spoke highly of the staff.

Clinical outcomes for patients in the unit were good, often above the national average.

Staff worked well together as a team and were enthusiastic about their work. However, we found the unit was functioning with an unacceptably high staff vacancy rate. This was identified on the trust’s divisional risk register and recruitment was in progress.

There was also a high number of non-clinical transfers of patients from ITU to other hospitals due to lack of capacity of their intensive care unit.   Patients who needed critical care were sometimes cared for by recovery staff in theatre because there were no available beds in ITU.

Updated 1 May 2014

Patients received safe and effective end of life care at Wexham Park Hospital. Patients’ care needs were being met and the service had established good working relationships with community services.

Most patients and their families were positive about the care and support they received, and said they were treated with dignity and respect by all staff they encountered.

Staff supported patients to be fully involved in their care and decisions. The end of life team was well-led at a local level, and staff were dedicated to improving standards of end of life care across the hospital as a core service for all patients who needed it.

However, the drive and vision was that of the palliative care leads and not through any trust-wide strategy, and providing good end of life care did not appear to be a priority for the trust.

There were capacity issues in the mortuary, which the trust was managing through extra capacity, but the pre-mortuary care provided by some of the nursing staff on some of the wards was not considered to be at the standard expected. This was recognised by the trust.

Updated 1 May 2014

We had significant concerns with regards to the quality and safety of care provided at Wexham Park hospital. There was an overall prevailing culture of bullying and lack of joined-up working across the multidisciplinary team. Incidents were not always being reported and there were accusations of improper downgrading of their severity alongside suggestions of defensive practice. Lack of leadership within the unit had left staff disengaged and distracted staff from patient centred care.

Although midwife to birthing ratios were often satisfactory, the department was heavily reliant on agency staff as there were 26.4 whole time equivalent vacancies for midwives. The consultant cover is in line with Royal College of Obstetricians and Gynaecologists guidelines, though we were given examples of how overnight staffing arrangements meant that some mothers were unable to deliver at the originally planned time.

We found that not all clinical guidelines had been updated, including those pertaining to emergencies such as maternal haemorrhage. Concerns had been raised both internally and externally with regards to the caesarean section rate for the unit. There did not appear to be a robust action plan to address this.

According to CQC’s maternity survey 2013, the trust performed in line with other maternity units, although we received mixed feedback during our inspection. Some new mothers were very positive whereas others gave us examples where they reported staff to be rude and not communicate well with them. 

Updated 1 May 2014

We found that some improvements were required to keep outpatients services safe for people at Wexham Park Hospital. These included better infection control and systems to ensure that people received treatment in a timely way.

We found that the hospital was good at caring for people on a one-to-one basis. Most front-line staff were respectful and considerate.

We found that the outpatient department was effective or responsive to patients’ needs. Insufficient work had been done to improve the booking and appointments systems, waiting times, and the cancellation of clinics. This resulted in many patients experiencing significant delays when attending outpatient clinics. In some instances, patients either received two appointments or failed to receive one at all. Delays were also linked to delays in radiology department, which meant patients were not having investigations carried out as planned prior to a follow up appointment.

Improvements were required to ensure that the service was well-led. At a local level there was good leadership, but this needed to be improved at senior management level to improve communication, learning, and improvements in outpatients.

Updated 1 May 2014

While many aspects of surgical care were safe, some areas required significant improvement. These included completion of the World Health Organisation’s (WHO) surgical safety checklist (a nationally recognised tool to reduce errors occurring in theatres). They also need to improve staffing levels and reduce the number of agency staff used on wards. When incidents occurred and were investigated, the learning from this was not always implemented to prevent it happening again and improve care.

There were concerns about the use of the theatre recovery area as a bedded area for patients when there not enough beds in the hospital wards. This meant patients were being recovered in areas where other patients were being visited by relatives, and eating and drinking.

Surgical procedures were effective and outcomes for patients were good. Data from national audits and databases showed that surgical outcomes were at, or close to, the national average.

We found that many of the staff we spoke with were compassionate and caring but they felt that workload pressures did not always give them sufficient time to spend with patients. Many patients spoke highly of surgical and ward staff, although there were some exceptions. Patients often felt that staff were responsive to their needs but that the hospital’s systems and processes were not.

One significant example of the hospital’s lack of responsiveness included the high number of cancelled or delayed surgical operations at short notice and the frequency with which patients were moved from one ward to another. There was a large volume of outliers (medical patients) on almost every surgical ward, which meant that many patients lacked continuity of care because they were being moved to different wards.

Inpatient surgical admission wards were well-led, but the hospital’s surgical division as a whole was not considered well-led due to various concerns associated with consultants not engaging with one another and as a consequence multidisciplinary working being ineffective. Surgical staff told us there was a culture of bullying and staff were discouraged from raising concerns. When staff raised concerns or suggested improvements, they said these were ignored, which made them feel disempowered and unable to effect necessary improvements in care.

Governance arrangements were poor, which meant systems and processes were not being monitored effectively. Multidisciplinary meetings were not consistently taking place, although good practice was noted in orthopaedics. This meant that all groups of staff were not reviewing cases as a team to aim to learn and improve patient care. There were inadequate systems for monitoring the performance of surgeons.

Managers were slow to implement changes as a result of incidents and never events (which is a nationally defined largely preventable patient safety incident).

Updated 1 May 2014

A&E had made significant improvements in the last 12 months following enforcement action taken by CQC. However, a number of significant improvements were still needed for the department to reach a ‘Good’ standard.

The vast majority of the time, the department provided safe care to patients. In particular, we found the Early Detection of Deterioration (EDOD) scoring system to be effective and well managed. This meant that, if patients rapidly deteriorated, the risk of them not being treated safely was reduced.

However, we were concerned that some patients spent a long period in A&E before a bed could be found in the hospital. For the first five weeks of 2014, the trust managed to reach the national four-hour target on just one occasion. In addition, the trust had been predominantly performing much worse than the England average, with patients waiting between four and 12 hours to be admitted. Since 2013, waiting times had steadily worsened.

There were no formal comfort rounds performed in the department and the patients we spoke to said that they had not been offered food or drink. Poor communication was also a commonly heard complaint. Patients were often on trolleys for over six hours, after which their risk of pressure ulcers increases. However, no risk assessments were undertaken.

Consultants displayed good knowledge about delivering the best clinical practice and the department participated in the national College of Emergency Medicine audits. We found that the clinical lead had a good knowledge of these audits and the issues that they had identified for A&E, but less certainty regarding the ways in which improvements were going to be implemented.