The National Hospital for Neurology and Neurosurgery

Updated 11 December 2018

The National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, is the UK's largest dedicated neurological and neurosurgical hospital. It provides services for the diagnosis, treatment and care of all conditions that affect the brain, spinal cord, peripheral nervous system and muscles.  Services include specialist neurosurgery, a brain tumour unit, the Hyper-acute Stroke Unit (HASU), an acute brain injury unit, a pioneering neuro-rehabilitation unit, the UK's first interventional MRI scanner, the largest specialised neurosurgical Intensive Therapy Unit (ITU) and the only neuromedical ITU in the country. It is a major international centre for research and training.

The hospital has 219 inpatient beds, six theatres and two intensive therapy units (ITUs). The hospital also had a large outpatients service, with 171,541 appointments taking place in 2017/18.

The hospital had just completed a substantial refurbishment program to improve the clinical environment and patient experience. The work included refurbishing four theatres and opening two new theatres as well as increasing the number of inpatient beds including additional intensive care beds.

Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk to was available and took place between 24 July and 7 August 2018.

During the inspection we spoke with over 60 patients and their relatives, and over 200 members of staff including doctors, nurses, allied health professionals, managers, support and administrative staff. We looked at over 60 sets of patient records and observed a range of meetings including multidisciplinary meetings, safety huddles, ward rounds and patient handovers.

Updated 11 December 2018

This was the first time we have rated this location.

We rated the hospital as good because:

• We rated effective, caring, responsive and well-led as good, and safe as requires improvement.
• We rated all services inspected as good.
• The hospital managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Learning from incidents was discussed in departmental and governance meetings and action was taken to follow up on the results of investigations. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff understood how to protect patients from abuse and there were effective systems in place to protect people from harm. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff provided evidence based care and treatment in line with national guidelines and local policies. There was a program of national and local audits to improve patient care. Patient outcomes were better than the national average. The hospital was involved in the development of national professional guidelines.
• There was effective multidisciplinary team working. Relevant professionals were involved in the assessment, planning and delivery of patient care. New admissions were discussed at the multidisciplinary admissions meeting for the hospital which was supported by medical, nursing occupational therapy and physiotherapy staff, social care and continuing health care representatives.
• Staff had opportunities for further development. Staff could apply for additional training if it was relevant to their role. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Feedback from patients confirmed that staff generally treated them with respect and with kindness and our observations of interactions between staff and patients and relatives showed staff were sensitive and respectful. Most patients we spoke with said they felt involved in their care and had the opportunity to ask questions.
• Services were developed to meet the needs of patients. The service was undergoing a redevelopment programme to expand the service and improve patient experience.
• The service took account of patients’ individual needs. Staff used flags on the electronic patient wards boards to indicate if a patient was at risk of falling, was living with dementia, had a risk of developing pressure ulcers or needed assistance at meal times. This helped improve care by making sure patients got the attention and support they needed.
• Staff felt valued, were supported in their role and had access to opportunities for learning and development.
• The leadership team had a clear vision and strategy and there were action plans in place to achieve this. Staff were committed to delivering the vision of being a leading hospital for neurological disorders and were aware of how their role contributed to the broader vision and strategy of the hospital.
• The hospital was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The service provided multiple examples of their leading role in world leading research projects.
• The trust’s exemplar ward accreditation programme focused on improving patient experience, safety and quality and efficiency and was led by frontline staff.
• The service had extensive engagement with patients via focus groups held by hospital specialities and events hosted by charities and other organisations. This engagement was used to drive improvement and innovation in the hospital services.

However:

• Medical staffing in critical care was not in line with professional standards. Pharmacy and therapy staffing levels were also below the recommended guidelines.
• There were high nursing vacancies at the time of inspection. The vacancy rate was 18.4%, much higher than the trust target of 6.5%. However, there were recruitment plans in place and new staff were expected to start later in 2018.
• There were two different charts in place for identification and escalation of deteriorating patients, albeit for different purposes, which some staff reported as confusing.
• Mandatory training in key skills for medical staff, including safeguarding training, fell below the trust’s target for compliance.
• Whilst we saw many examples of good practice in relation to medicines management, the trust’s policies for safe storage and management of medicines were not always followed consistently.
• Although the service generally controlled infection risk well, we observed staff did not always comply with hand hygiene protocols.
• Resuscitation equipment was not always checked on a regular basis.
• Fluid balance management was not consistent. We found in some records there were gaps in recording and the patient’s total fluid intake had not been monitored.
• Patients told us about communication issues. Patients were not always informed of clinic delays, instructions from staff were at times unclear and letters to themselves or GPs were not always received.
• Reception staff across some of the areas we visited did not always appear welcoming to patients and at times ignored patients or reacted in a discourteous manner. However, we also saw other examples of where staff treated patients with respect and kindness.
• Patients discharged from the intensive therapy units did not have access to a specific ITU follow up clinic contrary to best practice.

Updated 11 December 2018

This was the first time we have rated this service.

We rated it as good because:

• There was a clear leadership structure. The National Hospital for Neurology and Neurosurgery came under the specialist hospitals board. At a local level neurology, neuromuscular complex care centre, neuro-psychiatry, therapies, stroke, each had their own clinical leads and local governance fora. Ward managers were supported by matrons who worked across wards and worked across site.
• Across the wards, performance was monitored. The trust exemplar ward accreditation programme focused on patient experience, safety and quality and efficiency and was led by matrons who undertook the quality rounds monthly of their wards and reported their finding which identified areas for improvement across the wards.
• Staff were committed to delivering the vision of being a leading hospital for neurological disorders. Staff were aware how they contributed to the broader vision and strategy which included assisting in research, providing good care on the wards and in the day care unit treating high number of patients.
• There was a culture of honesty, openness and transparency. We saw evidence of senior staff carrying out duty of candour responsibilities which detailed the involvement and support of patients or relatives in serious incident reports.
• Policies, procedures and guidelines had been developed in line with national policy. These included the National Institute for Health and Care Excellence (NICE) guidelines. Staff worked closely with national leads and were involved in the development of NICE guidelines. Policies, procedures and guidelines were available to all staff via the trust intranet system and staff demonstrated they knew how to access them.
• Patients had access to dietician and speech and language therapy (SALT) services. SALT worked closely with nursing and medical staff in assessing and supporting patients with eating, drinking and swallowing needs. Patients needing an urgent assessment were assessed within 24 hours.
• The National Hospital for Neurology and Neurosurgery had a lower than expected risk of readmission for non-elective admissions between February 2017 and January 2018 when compared to the England average.
• There was effective multidisciplinary team working in the ward areas. Relevant professionals were involved in the assessment, planning and delivery of patient care. New admissions were discussed at the multidisciplinary admissions meeting for the hospital which was supported by medical, nursing occupational therapy and physiotherapy staff, social care and continuing health care representatives.
• Staff had opportunities for further development. Staff could apply for additional training if it was relevant to their role. Practice development educators for supported nursing staff for their revalidation and new nurses in the preceptorship programme.
• We saw clinical staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. All of the patients we spoke with were very positive about the staff who provided their care and treatment. They told us the nurses were kind, caring and listened to their concerns.
• Young people with neuro muscular conditions transitioning from children’s to adult’s service were able to be supported by family members overnight. The needs of families were accommodated; arrangements were made to so that treatments were undertaken at the same time to prevent multiple hospital visits.
• Most patients we spoke with said they felt involved in their care. On the neuro rehabilitation unit patients and their relatives were involved in setting their short and long term goals. On the Hughlings Jackson ward staff assisting patients writing out the questions they wanted to ask so they could be part of the consultant ward round.
• Chaplaincy services were able to support patients who needed them. The chapel at The National Hospital for Neurology and Neurosurgery a chapel was open 24/7. A chaplain was available for advice and direct pastoral support via on call 24/7.
• From April 2017 to March 2018, 87.7% of individuals at The National Hospital for Neurology and Neurosurgery did not move wards during their admission, and 13% moved once or more. This meant the trust was focussed on getting patients a bed on a ward for their speciality.
• Staff used flags on the electronic patient wards boards; to indicate if a patient was at risk of falling, was living with dementia, had a risk of developing pressure ulcers or needed assistance at meal times. This helped improve care by making sure patients got the attention and support they needed.
• Patients were able to access the internet via the hospital Wi-Fi, which meant they are able communicate with friends and relatives via their mobile phones or tablets.
• Volunteers spent their time talking to patients, and helping with at lunch, tea and coffee. A volunteer told us they had received training on topics such as privacy, dignity, confidentiality, hygiene, and safeguarding.
• The National Hospital for Neurology and Neurosurgery took an average of 27 days to investigate and close complains which was better than the trust. Between June 2017 and June 2018 there were 10 complaints about medical care.
• On the wards we saw evidence of good practice in relation to hand hygiene.

However:

• Serious incidents and near misses and key learning from completed serious incidents and internal reds from across the trust were discussed monthly at the patient safety committee meeting. However, not all the staff we spoke with told us that they were made aware of incidents from across the hospital.
• From April 2017 to March 2018, there were 103 moves at night at The National Hospital for Neurology and Neurosurgery. This was not responsive to patient needs and meant patients had their sleep disrupted.
• Mandatory training in key skills for medical staff, including safeguarding training, fell below the trust’s target for compliance.
• On one ward, controlled drugs were being stored in a wooden lockable cabinet. This does not comply with their medicines storage policy or safe custody regulations 1973. However, controlled drugs were recorded and handled appropriately with two nurses signing when controlled drugs were being administered.
• Fluid balance management was not consistent. We checked nine records and found most were complete, three had not been completed appropriately, there were gaps in recording and had not been totalled to reflect the patients intake or output of fluids.
• Patients being offered pain relief and the assessing patient’s pain was variable across the wards. The trust’s own internal data identified that between January 2018 to June 2018 patients reporting that hospital staff did everything they could to help control their pain was between 50% and 100% and patients having their pain assessed was between 58% and 100%.
• Mental Capacity Act 2005 level 3 for nursing staff was below the trust target of 90%. The completion rate was 77.8%.

Updated 11 December 2018

• There were effective systems in place to protect people from harm. Learning from incidents was discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.
• Staff provided evidence based care and treatment in line with national guidelines and local policies. There was a program of national and local audits to improve patient care. Patient outcomes were better than the national average.
• Staff were aware of their responsibilities under the mental capacity act and we saw appropriate records were in place in patient’s notes.
• Feedback for the services inspected were mostly positive. Staff respected confidentiality, dignity and privacy of patients.
• Services were developed to meet the needs of patients. The service was undergoing a redevelopment programme to expand the service and improve patient experience.
• There was good local leadership on the ITU. Staff felt valued, were supported in their role and had opportunities for learning and development. Staff were positive about working in the ITU.
• The leadership team had a clear vision and strategy and there were action plans in place to achieve this. There was a robust governance structure, both within critical care and within the directorate.

However:

• Medical staffing was not in line with professional standards. Pharmacy and therapy staffing levels were not in line with recommended guidelines.
• Patients discharged from the intensive therapy units did not have access to a specific ITU follow up clinic contrary to best practice.

Updated 11 December 2018

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so; however some compliance with some training failed to meet trust targets.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service planned for emergencies and staff understood their roles if one should happen.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• The service ensured patients had access to enough food and drink to meet their needs. The service made adjustments for patients’ religious, cultural and other preferences.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• The trust planned and provided services in a way that met the needs of local people.
• People could access the service when they needed it. Waiting times from referral to treatment were in line with good practice.
• The service took account of patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• The trust was better than the England average for the referral to treatment times for neurology.
• Cancer wait times for brain tumours which was the demographic seen by the hospital were better than the operational standards for the 31-day and 62-day waits.
• The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The service provided multiple examples of leading role in world leading research projects. Areas within outpatient serviced demonstrated innovative practices.
• The service had extensive engagement with patients via focus groups held by hospital specialities and events hosted by charities and other organisations. The engagement was used to drive improvement and innovation in the hospital services. The service also provided ample opportunity for engagement between frontline staff and senior managers.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Nursing and allied health staff were encouraged to take on advanced roles.
• The service had an extensive 20 year vision for what it wanted to achieve. Hospital and departmental goals were set and initiatives undertaken that were in line with trust vision and national polices.
• The service used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• The department had managers with the right skills to run the service.
• The service had a sound governance system with processes to monitor performance on a regular basis.
• The service had systems for identifying risks and planning to eliminate them.

However:

• Resuscitation equipment was not always checked on a regular basis.
• Feedback from patients told us about communication issues. Patients were not always informed of clinic delays, instructions from staff were at times unclear and letters to themselves or GPs were not always received.
• Reception staff across all areas we visited, except therapies, were not always welcoming to patients and at times ignored patients or reacted in a discourteous manner
• We observed excessive waiting times within outpatient clinics and nearly all patients we spoke with complained regarding waiting times.

Updated 11 December 2018

• The hospital had just completed a substantial refurbishment programme to improve the clinical environment and patient experience. The work included refurbishing four theatres and opening two new theatres as well as increasing the number of beds for neurosurgical patients including intensive care beds.
• The neurosurgery service provided care and treatment based on national guidance and evidence of effectiveness. They assessed staff compliance with guidance and identified areas for improvement. Action was taken to address any non-compliance that had not been agreed as best practice.
• The audit plan was robust and prioritised topics according to national guidance, response to serious incidents, other similar investigations and litigation which represented a systematic approach to improvement.
• The hospital had a vision for what it wanted to achieve and workable plans to turn it into action.
• The senior managers showed broad awareness of the main risks within their service and had action plans to address them.
• There was a systematic programme to monitor quality and stimulate improvement in safety and effectiveness by learning from relevant data through comparative dashboards and the Exemplar Ward Programme which supported clinical teams to implement standard processes and reduce unwarranted variations for patients.
• Doctors, nurses and other healthcare professionals generally worked together as an integrated team to benefit patients.
• Staff understood how to protect patients from abuse. A proportion of the patients attending the hospital were living in vulnerable circumstances because of neurological impairments and staff had a working knowledge of the mental capacity act and, deprivation of liberty safeguards.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately and was committed to learning from when things went well and when they went wrong.
• Feedback from patients confirmed that staff generally treated them with respect and with kindness and our observations of interactions between staff and patients and relatives showed staff were sensitive and respectful.
• The service promoted research and innovation for example a non-invasive procedure to map motor areas of the brain, such as language, prior to surgery which had reduced the accuracy and length of some procedures, and the use of deep brain stimulation to improve some symptoms of Parkinson’s disease.

However:

• Although the service generally controlled infection risk well, staff compliance with hand hygiene needed to improve.
• Mandatory training in key skills for medical staff, including safeguarding training, fell below the trust’s target for compliance.
• There were different parameters for escalation in the NEWS charts and a recently introduced observation chart to support recognition of cauda equina symptoms in complex spine patients. Whilst the charts served different purposes some staff reported this as confusing.
• Patient records were spread across several different locations including three electronic systems, as well as the main paper based records. An electronic health record system was to be introduced in March 2019 to rationalise this.
• There had been limited clinical outcomes benchmarking, but the trust used benchmarking to peers across a range of performance metrics including length of stay to drive service improvements.
• The service collected and managed information adequately to support all its activities but some systems such as the surgical admissions process were cumbersome.
• There were nursing vacancies at the time of inspection. The vacancy rate was 18.4%, much higher than the trust target of 6.5%.There was a recruitment plan and new starters were expected in the autumn.