Watford General Hospital

Updated 22 December 2021

West Hertfordshire Hospitals NHS Trust provides acute hospital services for people living in west Hertfordshire and surrounding areas. The trust serves a population of around 388,493. Acute services are provided from three sites, St Albans city hospital, Hemel Hampstead General Hospital and Watford General hospital. The trust has 643 acute beds across the three sites (June 2021).

The maternity service based at Watford General hospital delivered 4,131 babies from April 2020 to March 2021. The trust provides a choice of three birth settings: homebirth, birthing centre or the consultant led delivery unit. The low-risk birthing unit was temporarily closed in June 2021 to release midwifery staff to support the consultant led delivery unit.

The service is provided by a team of consultant obstetricians who provide consultant presence on the delivery unit, supported by training grade doctors and midwives who work across the inpatient areas. Community maternity services are provided by seven teams of midwives. The maternity service has specialist midwives including a midwife who leads on bereavement and offers ongoing support to women and their partners who have suffered a pregnancy loss.

We carried out an unannounced focused inspection of the maternity service at Watford General Hospital on 13 October 2021, in response to maternity safety incidents. At the time of our inspection the service was operating under the COVID-19 infection prevention and control measures. During the inspection we followed the focused inspection methodology for maternity services.

Our rating of the maternity service went down. We rated it as requires improvement. See the Maternity section below for details.

Updated 17 June 2020

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

• The service had enough staff to care for patients and keep them safe. Staff mostly had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They generally managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

• 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. People could access the service when they needed it and did not have to wait too long for treatment.

• 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.

However:

• Although the service provided mandatory training in key skills to all staff, not all medical staff completed it. Not all medical staff were up to date with safeguarding training. This was a concern we raised at our last inspection.

• Although most of the areas we visited were clean, we observed some wards which had not been cleaned regularly. Cleaning schedules were not always signed and dated to evidence regular cleaning took place. We found old cleaning schedules in the bathroom on Cassio ward which were dated April 2019.

• Cleaning materials that were covered by control of substances hazardous to health (COSHH) were not always locked and secured in line with legislation. We found sluices where COSHH material was stored were unlocked on some of the wards we visited.

• Although the service generally used systems and processes to safely prescribe, administer, record and store medicines, we found the indication and review dates for patients commenced on antibiotics was not always recorded in charts we reviewed on the acute admissions unit (AAU). When antibiotics are prescribed, the indication and a review date should be recorded, to ensure antibiotics are not continued for any longer than is necessary. This was a concern raised at our last inspection. On AAU, patient weights were not always recorded on drug charts for venous thromboembolism prophylaxis. The anticoagulation and thromboprophylaxis policy states to adjust doses of medication based on patients’ weights. We also observed some prescription charts with medications crossed off and not signed by doctors. It is good practice to sign and state the reason why medication was stopped.

Updated 10 January 2018

Overall, we rated services for children and young people as good for safe, effective, caring, responsive and well-led because:

• Staff were confident to report incidents and staff were encouraged to raise concerns. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was cascaded to staff and actions were taken to minimise risk and prevent incidents from reoccurring. This was an improvement from our previous inspection in September 2016 where feedback from staff had been mixed as to whether incident reporting was encouraged.

• At our previous inspection in September 2016 there had been a significant division of staff concerning opinion and practice in the neonatal unit. Some staff felt this might have had an impact on patient care. Following a thematic review and implementation of the recommendations there was evidence of good local leadership from clinicians and managers. Consultants in the neonatal unit were working well together.
• There was clear and visible leadership from the divisional clinical lead, clinicians, the lead nurse, matrons and managers who were approachable and fully engaged with providing high quality child centred care.
• All staff were aware of the Duty of Candour Regulation and knew how to apply it which was an improvement from our last inspection in September 2016.
• At our previous inspection in September 2016 staff did not always follow the correct security procedures for entering and exiting the neonatal unit, Starfish and Safari wards. During our inspection we observed it was not possible to enter or leave the ward and unit without being challenged by staff who always followed the correct security procedures.
• At our previous inspection in September 2016 there was no safety thermometer on Starfish ward which was contrary to guidelines issued by the NHS. A safety thermometer was implemented in April 2017 which reported 100% harm free care on Starfish ward for the period April to July 2017.
• At our previous inspection in September 2016, children who showed signs of deterioration were not always escalated to a senior nurse or doctor. During our latest inspection we saw in patient records that patients were appropriately escalated to either the nurse in charge or the doctor, whichever was indicated.
• At our previous inspection in September 2016, there were gaps in management and support arrangements for staff, such as mandatory training and appraisal. During our latest inspection all staff in children’s services were achieving 93% for mandatory training and appraisal.
• At our previous inspection in September 2016, there were a high number of cancellations of outpatient appointments for children. Children’s services had reduced cancellation rates for appointments less than six weeks. There was an improving picture for cancellations over six weeks.
• We observed the majority of staff followed best practice guidance for infection control to reduce the risk of infection through staff washing their hands, using personal protective equipment and following sterile techniques.
• Suitable arrangements were in place for the management of medicines which included the safe ordering, prescribing and dispensing, recording handling and storage of medicines. There was a paediatric pharmacist in post.
• Staff treated children with kindness, dignity and respect. All parents and children we spoke with told us how “wonderful” the service was and staff always went the ‘extra mile’ when caring for children and families. There was a strong child centred culture across the service and staff told us how “proud” they were to work in the children and young people’s service.
• Staffing levels were safe for the number and acuity of children. There were effective measures in place to ensure that when there was increased activity, staff numbers increased. There were sufficient medical staff in post to provide 24 hour, seven day a week care for babies, children and young people.
• There were practice nurses in post to identify and deliver individual and service wide training needs. Staff had the relevant experience, knowledge and qualifications to care for and treat patients.
• There was effective multidisciplinary team working. This included, safeguarding services, mental health services, dieticians, physiotherapists and occupational therapist, play specialists and pharmacists. There were effective working relationships with other trusts, tertiary services and external organisations.

However:

• At our previous inspection in September 2016, there was insufficient space, which did not reflect current guidelines, in the neonatal unit. During our inspection we saw there was still insufficient space. A thematic review had been undertaken which had identified the unit to be safe in the interim and mitigating arrangements were in place to manage patient flow and safe staffing levels on a daily basis.
• Children who were moved from inpatient wards to the operating theatre travelled along a corridor that was not fit for that purpose. However, a risk assessment was in place and a health and safety review had been undertaken to mitigate the risks to children and young people.
• Operating theatre and recovery arrangements did not consider adequately the specific needs of children.
• Standards of cleanliness and hygiene were not consistently maintained on Starfish ward. We raised this at the time of the inspection and senior staff immediately addressed the issues.
• The information technology system for the paediatric diabetes service was not fit for purpose and required the clinical team to spend extensive periods of time on non - clinical activities.
• Results from the Picker 2016 national inpatient survey for children’s services were worse than the trusts previous survey in 2014. Results were worse than average compared to similar trusts in 2016.
• The children’s service took an average of 47 days to investigate and close complaints compared to the trust standard of 25 days.
• Children’s services were incorporated into the trust clinical strategy 2015 - 2020 and the children’s services strategy 2017. However, not all staff in the service were clear about the longer term development of children’s services at the trust.
• Although efforts were being made by the service to engage children and carers in feedback about the service, response rates around the Friends and Family Test were consistently low.

Updated 10 January 2018

We rated this service overall as good because:

• Leaders fostered a culture where patient safety was the highest priority. This was supported by an active incident reporting culture, maintenance of healthcare records, medicines management and the appropriate level of monitoring for patients.
• Staff attended mandatory training, completed competencies, received annual appraisals of their development needs and received support from the unit’s professional development nurse.
• The unit contributed to the Intensive Care National Audit and Research Centre (ICNARC) that monitored patient outcomes and mortality indicators. The annual report for 2016/17 showed the unit was performing as expected (compared to other similar services) in all the indicators, except for two related to delayed discharges.
• Despite the delays encountered with discharges from the unit, patients were not being transferred out to wards in the hospital overnight nor transferred to other units as a result.
• The critical care unit nursing and medical staffing was in line with guidance for the provision of intensive care services (GPICS 2015).
• The unit had an active research and development programme and patients’ care and treatment was assessed and delivered according to national and best-practice guidelines.
• There were low infection rates and good adherence to infection prevention and control policies, including use of handwashing and personal protective equipment.
• Patients were treated with dignity, respect and kindness. The critical care team were committed to involving patients and their relatives in care and treatment decisions.
• The service was provided in appropriate facilities to care for critically ill patients and relatives and visitors had access to appropriate areas of the unit.

However:

• Systems and processes related to the maintenance of equipment were not always effective. We found five items of equipment that had not been serviced appropriately. We raised this issue and it was addressed during our inspection.
• Staff were not clear how often the contents of the difficult airway trolley should be checked.
• The unit did not meet the guidance for the provision of intensive care services (GPICS 2015) standard of 50% of nursing staff having a qualification in critical care. This was 42% at the time of the inspection.
• Despite actions being taken in conjunction with the trust regarding delayed discharges, this remained an issue for many patients in the critical care service. This also reflected in the increasing number of mixed sex accommodation (MSA) breaches, from June 2016 to May 2017, there were on average 10 each month.
• Delayed discharges from critical care appeared to impact the services ability to always admit critically ill patients in a timely manner.
• Divisional level mortality and morbidity meetings included critical care services. However, local review minutes were brief and actions to be taken were not always clear.
• There were risks to the provision of the critical care service we found were not included in the risk register. For example, the delays with servicing equipment.
• The microbiologist was available on call and attended the unit three times a week. This did not meet the daily requirement as stated in GPICS (2015).

Updated 10 January 2018

We rated the service as good for the safe, caring, responsive and the well-led key questions. End of life services requires improvement across the effective key question:

• The service was in breach of Regulation 11: Need for Consent Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: There was no evidence, that decision specific mental capacity assessments were always fulfilled when staff completed DNACPR forms

• There were systems in place to protect patients from harm and a good incident reporting culture.
• Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of life.
• The trust had a replacement for the Liverpool Care Pathway (LCP) called the ‘individualised care plan for the dying patient’ (ICPDP). The document was embedded in practice on the wards we visited.
• The service had produced a detailed action plan to address the shortfalls and issues raised by the national care of the dying audit of hospitals (NCDAH) 2014 to 2015. Local audits were in place to measure the effectiveness and outcomes of the service.
• Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff.
• Relatives were happy with the care their relatives had received and felt involved in their care planning at the end of their life. Staff demonstrated compassionate patient centred care throughout the inspection.
• Care and treatment was coordinated with other services and other providers. The specialist palliative care team had good working relationships with discharge services and their community colleagues. This ensured that when patients were discharged their care was coordinated.
• All adult wards had compassionate care champions who were trained in providing end of life care and were a direct link to the SPCT.
• The SPCT saw 91% of patients within 24 hours of referral.
• The trust had an executive and a non-executive director on the trust board with a responsibility for end of life care.
• There was a clear vision and strategy for end of life care.

However:

• We could not find evidence that decision specific mental capacity assessments were always fulfilled when staff completed DNACPR forms. In 11 forms we reviewed, the doctor implied the patient did not have capacity. However, in four (36%) of these cases, we could not see any evidence a formal decision specific mental capacity assessment had been undertaken of the patient’s ability to understand this decision and to participate in any discussions. This meant that staff did not act in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice.
• The trust had systems in place to identify risks. The trust was aware of the risks for the end of life care and mortuary services.

Updated 22 December 2021

Updated 10 January 2018

Overall, we rated the outpatients and diagnostic imaging service as good because:

• Since our previous inspection in September 2016, an outpatient quality improvement plan (QIP) had been implemented. This included all issues raised during the previous inspection and we found that 14 out of 15 had been completed in August 2017. Performance data had improved since the plan was implemented and the service was performing in line with their planned trajectory.
• There was a positive incident reporting culture across the services provided. We saw robust departmental learning from a recent never event.
• Our last inspection in September 2016 highlighted issues with non-compliance with hand hygiene and lack of hand hygiene audits. We found this had improved during our inspection in August 2017. Good standards of hand hygiene were maintained and the department was compliant with hand hygiene audits.
• Patient records were stored securely in locked rooms and trolleys. This was an improvement since our last inspection.
• Radiation protection in the diagnostic imaging department was robust and supervisors were appointed in each clinical area. Medical physics experts and radiation protection supervisors actively worked with staff to provide advice and ensure compliance with safety standards.
• Nurse staffing levels were appropriate with minimal vacancies and staffing levels met patient needs.
• Staff in all departments were aware of the actions they should take in case of a major incident.
• Risk to patients on the waiting list for outpatient appointments was discussed at weekly meetings. Clinical assessments were conducted if patients waited 30 weeks or more for outpatient services.
• Care and treatment was delivered in line with evidence-based guidance, standards and best practice.
• The diagnostic imaging department was working towards the Imaging Services Accreditation Scheme (ISAS).
• There was a comprehensive clinical audit programme in the radiology department to monitor compliance with trust policy and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). Results showed consistent compliance and actions taken to improve.
• Appraisal rates met the trust target, which was an improvement since the previous inspection.
• Multidisciplinary meetings were held in various specialties so that all necessary staff were involved in assessing, planning and delivering patient care.
• Patients were treated with compassion, kindness, dignity and respect.
• Chaperones were available throughout the outpatient and diagnostic imaging services. Information on the chaperone policy was displayed in clinical rooms and waiting areas.
• Patients we spoke with felt well informed about their care and treatment.
• Our last inspection identified issues with patients being treated in the corridor in dermatology. During this inspection, there was a dedicated room for wound care. This was an improvement.
• Improvements had been made in the ophthalmology department to maintain patient confidentiality. During our previous inspection, two orthoptists shared a clinic room and saw patients at the same time, which did not maintain confidentiality. At this inspection we found that clinic rooms were no longer shared.
• During our last inspection, we were not assured that patients had timely access to treatment as the trust performed worse than the England average for the percentage of patients receiving an outpatient appointment within 18 weeks of referral. However, this had improved and met the England average from April 2017 onwards.
• The trust had improved its performance for cancer waiting times and was meeting the national standard in four out of five measures.
• Patients had timely access to diagnostic imaging services and the percentage of patients waiting more than six weeks was lower than the England average.
• Diagnostic imaging services were available seven days a week and patients were able to change appointments to suit their needs.
• Outpatient specialties held additional evening and weekend clinics to reduce the length of time patients were waiting.
• Our last inspection identified issues with lack of written information for patients prior to their appointment, for example, what to expect on the day. During this inspection, we saw letters contained detailed information for patients. This was an improvement.
• Poor communication between medical and nursing staff was highlighted at our previous inspection for example, clinics were held that nursing staff were unaware of. During this inspection, staff said this had improved.
• Staff completed a weekly monitoring of waiting lists and clinics flexed to meet any changes in demand or noted increased numbers.
• A new cardiac suite had been opened and magnetic resonance imaging (MRI) was available seven days a week to meet the needs of patients.
• There was good awareness of the needs of patients with a learning disability and dementia. Twiddle muffs were introduced for patients living with dementia attending the diagnostic imaging department to assist with restlessness as promoted by the dementia society.
• Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
• Staff felt that managers were visible, supportive and approachable.
• All staff we spoke with felt respected and valued. The culture across outpatient and diagnostic imaging services encouraged openness, candour and honesty.
• Patients, relatives and visitors were actively engaged and involved when planning services. Clinical leads led an outpatient user group to gather information on patient experience.
• Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients. Radiology governance and risk management processes were robust and effective.
• The service had leadership, governance and a culture, which were used to drive and improve the delivery of quality person-centred care.
• There were high levels of staff satisfaction, and individuals were proud to work for the trust.

However:

• We saw evidence that learning from incidents was shared across Watford General Hospital, Hemel Hempstead Hospital and St Albans City Hospital; however, this learning was predominantly within divisions and did not include services provided by different divisions. For example, staff in the main outpatient department which was run by the medical division were unaware of any learning from the never event that occurred in ophthalmology, which was run by the surgical division.
• The World Health Organisation (WHO) five steps to safer surgery checklists had not been completed consistently for patients who had undergone minor surgery with local anaesthetic. For example, we looked at five patient records in the dermatology clinic and saw safety checklists had not been completed in three out of five records.
• Not all band 5 nursing staff who had direct contact with children in outpatients had received level three safeguarding children training.
• Compliance with fire safety training in the radiology department was below the trust target of 90%. Non-clinical staff compliance was 78% and clinical staff compliance was 73%.
• Patients attending the clinic for the first time and identified as having a learning disability or living with dementia did not always have their records or referral letter flagged. This meant any adjustments could not be made prior to their attendance to facilitate their journey through the department.
• Risks that were identified during both the previous and most recent inspections, such as missing records were not on the departmental risk register.

Updated 17 June 2020

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

• 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. Staff assessed risks to patients and acted on them. They generally managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

• 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, 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.

However;

• Medical staff did not always keep up to date with their mandatory training.

• The service did not always control infection risk well. On several occasions we saw theatre staff did not wash their hands post pre-operative assessment.

• The design, maintenance and use of facilities, premises and equipment could not always keep people safe. However, the service had well advanced plans to refurbish their main operating theatres and a theatre development plan was now at the enabling stage.

• Staff did not always keep good care records. Resuscitation and treatment escalation plan records we checked were not always complete and certain information was not always easy to locate in order. Some speciality notes were not easily located within patient records.

• Staff did not always support patients to make best decisions about their care. Mental capacity assessment (MCA) forms we checked were incomplete for four patients that lacked capacity. The ‘best interests’ decision (BID) factors’ side of the form was only completed on one of these.

• People could not always access the service when they needed it. Some surgical specialties had long waits for treatment. This was due to capacity issues in theatres. We saw delayed theatre start times due to last minute theatre changes for an emergency case and a patient with multiple cancellations. Theatre utilisation measures for touch time missed trust target by at least 10%.

Updated 17 June 2020

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

• Staff completion of care records was variable in quality. Some records we looked had gaps, for example, missing entries, dates, signatures and important information such as weight.
• Staff did not always carry out daily safety checks of specialist equipment. For example, not all resus trolleys had recorded checks to ensure they were in date and ready to use in the event of an emergency. The entries on the trolley checklists were inconsistently completed.
• Staff in the resuscitation area sat on chairs that were torn which could present as an infection prevention control issue.
• Staff assessed patient’s pain using a recognised tool however, did not always provide pain relief in line with individual needs and best practice.
• Medical staff had not kept up-to-date with their mandatory training. Medical staff were compliant in just two of the 15 mandatory training modules.
• Staff did not always store cleaning materials safely in line with national guidance.
• People could not always access the service when they needed it. Although a number of initiatives had been introduced to improve access and flow, the service was not meeting any of the national standards and consistently performing worse than the national average in some areas.

However;

• The service had enough staff to care for patients and keep them safe. Staff mostly had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them. They generally managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• 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.