Whipps Cross University Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Staff had effective systems to raise concerns both formally and informally however we were not assured that they were always using them to report all incidents. We were told by staff that they did not routinely report missed dose medications or late administration of time critical medications as an incident. An electronic incident reporting system was used. Patients experienced long waiting times after their initial triage to then be seen by a clinician. Time critical medicines were not always given on time. We saw delays in the initial administration of antibiotics and Parkinson’s medication. We observed thorough handovers between ambulance crews and ED staff during our assessment, however, we observed these were subject to delays resulting in ambulance crews waiting to handover their patients in the corridor. The service’s electronic patient record system had the capacity to flag patients who had various conditions including Parkinson’s disease however we did not see evidence that these flags were being appropriately used by staff. There was not an effective approach to assess and manage the risks of infection, that was in line with current relevant national guidance. Clinical staff were not always changing their gloves, washing their hands or cleaning equipment between patient care. The trust’s infection, prevention and control policy was also out of date. However, we received positive feedback from staff regarding communication and multidisciplinary team working with partners. Staff said they had good relationships with mental health colleagues who provided liaison support from a neighbouring mental health trust. Staff described good relationships between the paediatric emergency department and paediatric team.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not assured that people were confident about raising concerns. We were not assured that staff always reported concerns or incidents. We were told by staff that they did not routinely report missed dose medications or late administration of time critical medications as an incident. There were protocols for the use of rapid tranquilisation, but two nurses we spoke with were not clear about the requirement for physical health monitoring needed after rapid tranquilisation. The trust’s policy stated that this should take place every 30 minutes. It was not clear if this was audited.

We were not assured that staff were confident to report incidents and were supported when things went wrong. Not all of the staff we spoke to knew what they should report and when. Staff told us the trust’s formal reporting system was easy to use. We were not assured that staff saw incidents as an opportunity to learn and improve. However, when we spoke with leaders, they told us they met to discuss learning from incidents and looked at improvements to patient care. They were able to describe themes from incidents and changes to practice as a result.

Staff had effective systems to raise concerns both formally and informally however we were not assured that they were always using them to report all incidents. An electronic incident reporting system was used. 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. In the last 12 months, there were 3220 incidents reported within the emergency department. Of these, 3080 incidents were categorised as ‘no harm’, 120 as ‘low harm’, and 20 as ‘moderate harm’. We viewed the minutes for monthly mortality and morbidity meetings which were held for the emergency department. The meetings provided an opportunity for serious incidents to be presented and discussed, actions noted and lessons to be learned. The minutes showed a good attendance by different levels of medical staff and discussions around incidents and learning. The duty of candour (DoC) is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Staff had a good knowledge of duty of candour and, senior staff were clear about their responsibilities in relation to DoC.

Once triaged, patients understood where they were on the hospital pathway and their treatment plan. Waiting times within ED were not visible on arrival or at any time through the patient’s journey through the ED. Patients experienced long waiting times after their initial triage to then be seen by a clinician. During our inspection, we saw that this was often in excess of 12 hours. On inspection we saw mental health patients experiencing long waits for transfer to specialist mental health services outside the hospital. We observed thorough handovers between ambulance crews and ED staff during our assessment, however, we saw that these were often subject to delays which resulted in up to four ambulance crews waiting to handover their patients in the corridor at one time. Ambulances were not always able to access the ED immediately. We observed and staff confirmed that they could not always provide one-to-one, or two-to-one observations for mental health patients as recommended following assessment by the psychiatric liaison team, due to having insufficient staff. On the day of the inspection there was only one registered mental health nurse (RMN) on duty despite three being scheduled to work. Healthcare assistants (HCAs) from other areas were called to support the majors area of the ED, however with 17 mental health patients in the department at one time, despite more RMNs coming in, there were still insufficient staff to carry out the one to one and two to one observations required. This presented a serious risk.

We received positive feedback from staff regarding communication and multidisciplinary team working with partners. Staff said they had good relationships with mental health colleagues who provided liaison support from a neighbouring mental health trust. Staff described good relationships between the paediatric emergency department and paediatric team. Leaders told us senior doctors discussed patients with junior doctors before discharge from the ED, in accordance with Royal College of Emergency Medicine (RCEM) guidelines. Staff told us that patient flow was delayed due to lack of available beds within the hospital. Staff described challenges in accessing beds for patients with mental health concerns which led to patients remaining in the department for extended periods.

We did not receive any positive feedback from partners regarding communication and multidisciplinary team working with emergency department staff. For example, ambulance crews described wait times were “high a lot of the time”.

Safety and continuity of care were not always a priority throughout people’s care journey. We did not see that the service always worked collaboratively and in a joined-up approach in regard to safety that involved them along with staff and other partners. This included admissions and discharge. Care and support were not sufficiently planned and organised with the users of the service in mind. The service was at times overrun with patients many of which were being cared for in the corridor. There was not always a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was not always proactive and effective. Staff followed sepsis six guidelines to manage adults and children with sepsis. However, records we reviewed showed poor staff compliance with sepsis pathways. We also found that that trust’s sepsis ED guideline was out of date and had a next review date of 2021. The trust did not audit patient records, however matrons carried out random spot checks on each shift. They used a nurse in charge booklet which included medicines management checks, safety checklist checks, ligature checks for mental health cubicles and quality checks of nurse’s documentation for fundamentals of care.

Staff we spoke with could demonstrate an understanding of safeguarding and how to take appropriate action. Staff were able to provide examples of the types of concerns they would raise a safeguarding referral for. Staff were aware of the safeguarding team and said they would go to them for any advice or support. Leaders described how the safeguarding team worked within the department to review pathways for children and young people with mental health concerns or children who may have been subjected to harm. In the last 12 months, the emergency department had made 263 safeguarding referrals.

There was an understanding of safeguarding and how to take appropriate action. Staff were able to articulate the different forms of abuse. They were able to detail how they would report safeguarding concerns and how they could access the emergency department’s safeguarding lead. Staff we asked knew how to raise safeguarding alerts or concerns to the various local authority multi-agency safeguarding hubs (MASH) in the area. Agency nursing staff we asked said they had been informed that they should raise any safeguarding concerns they had with the nurse in charge. Staff followed safe procedures for paediatric emergency department. Access to the paediatric emergency department was via a door buzzer system, staff carried electronic passes used to gain entry.

We viewed the trust’s safeguarding adults policy which was up to date, however the safeguarding children policy was out of date. We were told that the policy had been out for consultation and comments and was in the process of being updated to go to the policy group in the next two months. Staff received training in adult and children safeguarding levels 1, 2 and 3. As of July 2024, 85% of medical staff in the emergency department had completed safeguarding adults level 1 which was above the trust target of 80%. 76% of medical staff had completed safeguarding adults level 2 and 63% of medical staff had completed safeguarding adults level 3 training which was below the trust target of 80%. 85% of medical staff in the emergency department had completed safeguarding children level 1 training which was above the trust target of 80%. However, 71% of medical staff had complete safeguarding children level 2 and 44% had completed safeguarding children level 3 which was below the trust target of 80%. From the data sent through to us by the trust, 98% of nursing staff in the emergency department had completed both levels 1 and 2 of adult safeguarding training. 98% of nursing staff had completed both safeguarding levels 1 and 2 of safeguarding children training. However, 75% of nursing staff in the majors area of the ED had completed level 3 safeguarding children training which was below the trust target. We were told that mandatory training compliance was discussed at the trust’s governance meetings and any gaps were managed by practice development nurses and matrons within the nursing cohort. Medical or operational managers emailed medical staff to chase up on their mandatory training compliance.

Whilst the electronic patient record system had the capacity to flag patients who had various conditions including Parkinson’s disease, we did not see evidence that these flags were being appropriately used by staff. We observed staff sought consent from patients throughout their treatment.

Staff used safety huddles to communicate if patients required any additional care or had a change in need. Staff said within ED staff worked well together. Some staff told us the psychiatric liaison team would quickly evaluate patient needs, provide crisis management, and prescribe necessary medications. However, the service routinely was unable to provide the support advised by the psychiatric liaison team because of insufficient numbers of staff available to provide one to one or two to one nursing. Although nursing staff were trained in de-escalation, only security staff were permitted to carry out physical restraints on patients. Staff said that security staff were reluctant to use physical holds, for fear of repercussions, especially with children. The impact of only non-clinical staff doing this should be considered, particularly if a patient needs to be held to administer rapid tranquilisation, or to prevent a patient from absconding when they present a serious risk to themselves or others. The service had systems in place to support patients who frequently attended the emergency departments. This enabled staff to treat patients who frequently attended the unit more consistently.

We reviewed evidence which demonstrated that the service engaged with partners to understand and manage risks by thinking holistically. However, due to the issues with staffing levels we were not assured that patient’s needs and care requirements were met in a way that was safe and supportive. Mental health partners reported a good working relationship with ED staff.

Staff had access to a psychiatric liaison team to assist with adults and children with mental health concerns. The team were based outside of the department in another building within the hospital grounds. They were available 24 hours a day. In the seven months since the start of January 2024, 33 mental health patients had absconded from the ED, with sufficient concerns for their safety or others to involve alerting the police. The trust had an observation and escalation policy which covered the deteriorating patient however this had not been updated since it was approved in December 2018 and the policy stated that it should be reviewed every 3 years after the approval date. The trust told us an updated policy was currently going through the consultation process before going to the trust’s policies committee for approval.

On inspection we observed patients were triaged in dedicated areas within the emergency department. Patients were cohorted in the corridor from the ambulances. Protocols were in place which detailed the use of the mental health assessment room in the majors area, which automatically locked, and did not provide a limit as to how long a patient could be kept in this room, although it was clear that they should be supervised at all times. The location of the mental health assessment room for adults in the majors section, and the paediatric mental health assessment room, presented difficulties for other physically vulnerable patients nearby. Neither of the assessment rooms had en-suite facilities which meant patients had to be escorted to other areas to use toilet facilities. Children exhibiting challenging behaviour might also be risk assessed and moved to an adult assessment room. We did not see a sign displayed to advise patients in the mental health assessment room that there was CCTV in operation. There was a lack of privacy when patients shared personal information at main reception.

Staff told us that mental health patients were not left in the mental health assessment room alone for significant periods of time. There was no access to a clock for patients in these rooms, or regular nurse and doctor checks. Placement in a locked room is classed as seclusion. We were told by staff that mental health patients often experienced long waits. Leaders acknowledged there were some gaps in the completion of resuscitation trolley checks, there were expired consumables on the difficult airway trolley, and some consumable equipment was not always immediately available in line with best practice.

During our inspection we checked consumables within the department and found a number of items which were past their expiry date. The ED mostly had enough suitable equipment to help them to safely care for patients. Swipe card access was in use throughout the ED. This ensured the department remained secure. Waiting areas were mostly visible from the reception areas. However, there were no screens displaying any information about waiting times. Security staff were present in ED 24 hours a day, seven days a week. The children’s ED was suitable for children and young people.

Hazardous and clinical waste was responsibly managed. The department’s fire safety and other emergency systems were tested and maintained.

We spoke to 15 patients during our inspection. The majority of those patients told us that they had been waiting a long time in the department but that they were having a fairly positive experience. They all said they felt safe within the department. They said that they would feel they would have benefitted from clear and real time information on waiting times.

Throughout our inspection, we found the skill mix of staff to be mostly suitable for the needs of the emergency department with the exception of RMNs to provide one to one and two to one nurse care and observation of mental health patients. The actual staffing levels on the whole met the planned levels. Senior staff had oversight of the staffing within the department and moved staff around to ensure areas were as safe as they could be. However, they did have difficulty always managing surges in demand. Nursing staff told us that whilst the department was usually staffed to the planned staffing level, they felt that, due to the complexity and number of patients presenting at the department, additional nursing staff were needed. There were sufficient registered paediatric nurses working during the inspection. The department had challenges around recruitment of band 6 nursing staff and had begun to provide internal opportunities through development and study offers to staff at junior grades. Shortfalls in staffing had been identified as a risk on the divisional risk register. The trust was aware of low junior doctor numbers at registrar level which was partly due to a national shortage of middle grade doctors at this level within the ED as well as local difficulties with recruitment. This had been identified on the divisional risk register with controls in place including the use of locum and agency doctors to backfill the rota and an ongoing recruitment plan including overseas recruitment, development of new types of posts such as a chief registrar and weekly recruitment meetings with HR. ED adult and paediatric nursing staffing was also on the divisional risk register. Controls in place included daily safety and capacity meetings to review staffing, a development programme for band 5 succession planning and secondment opportunities at band 6 and band 7 across the trust.

Staffing levels were discussed at various meetings including bed meetings. We observed staff working in multidisciplinary teams during our on-site visit. We observed junior staff receiving teaching and supervision. During the inspection we were told that three security staff were scheduled to be in the department. However, on the first day of the inspection there was only one member of security staff in majors in the morning, further security staff did come onto shift in the afternoon. Some staff said they thought more security staff were needed, especially since there was now reduced police presence following Right Care Right Place implementation. We saw consultants working clinically in the department. They led the treatment of the sickest patients, advised more junior doctors, and ensured a structured clinical handover of patient’s treatment when shifts changed. Junior doctors spoke positively about working in the emergency department.

The service provided mandatory training in key skills however some compliance rates did not meet the trust targets. Mandatory training for medical staff in the ED was below the trust target of 80% with a 72% average compliance of the 14 modules. The lowest compliance was 44% for safeguarding children level 3 and 63% for IPC clinical and 63% for safeguarding adults level 3. For nursing staff in the majors and minors areas of ED, the average compliance rate was 93% of the 14 modules. The lowest score was for nursing staff in majors at 75% for safeguarding children level 3. Mandatory training compliance was discussed at all governance meetings. If any gaps or trends were identified, this was managed by the practice development nurses within the nursing cohort. Medical managers sent emails to medical staff groups if there were not in compliance with mandatory training. The trust told us that ED consultant numbers had improved. The overall fill rate for medical staff was 82% rising to 87% with the current recruitment pipeline. The overall fill rate for nursing staff was 80.4% rising to 82% with the current recruitment pipeline.

There was not an effective approach to assess and manage the risks of infection, that was in line with current relevant national guidance. Clinical staff were not always changing their gloves, washing their hands or cleaning equipment between patient care. We observed three members of staff who were not bare below the elbow. We raised these concerns with the hospital leadership after the first day of the inspection but did not see any improvement during the second day of inspection. Waste was segregated into clinical; household and recycling and appropriate signage was in place.

Following the inspection, the trust told us of the following immediate actions to improve compliance in the emergency department. These actions included: identification and appointment of a medical and nursing champion in each of the clinical areas to pose check and challenge. In addition, audits had been commenced on every shift. The trust had also implemented a weekly ED/IPC governance meeting week where the improvement plan was reviewed and updated. In addition to this, the trust had introduced a QR code for IPC audit upload which fed into the overarching improvement plan and the weekly governance meeting. The trust had also brought forward the ‘Gloves off’ initiative for immediate implementation. The initiative encourages staff to stop using single use gloves when carrying out certain activities for non-infectious patients. The focus instead is on better hand hygiene before and after these activities. A 4-week secondment of an IPC clinical nurse specialist had also begun to support the work within the department.

Clinical staff were not always changing their gloves, washing their hands or cleaning equipment between patient care. All areas we visited were visibly clean and had suitable furnishings which were well-maintained. Furnishings, such as chairs and flooring, were wipeable and easy to clean. We did not find any dust in hard to reach places. Cleaning records were up-to-date and demonstrated all areas were cleaned regularly. The cleaning supervisor carried out quality checks three times a day and completed documentation to demonstrate this. Sharps bins were clean and were not overflowing. All sharps bins we observed had been set up correctly with the date from when they were first used documented on them.

The trust’s infection, prevention and control policy was out of date and had a review date of 2022. The trust told us that the policy was currently under review. The service undertook monthly hand hygiene audits which showed in an overall compliance rate of 65% over the last 12 months. This was below the trust target which was 90%. Poor hand hygiene was observed during the inspection. We viewed the quarterly environment and practice audit reports for majors, paediatrics, resus and initial assessment in the emergency department. The initial assessment area’s report for May 2024 showed 59.3% compliance. Areas of concern included cluttered nurse’s stations, visible dust on patient equipment, poor staff knowledge around cleaning products to use on patient equipment, lack of staff awareness of actions implemented where there are low use water outlets in the clinical area, incorrect use of masks, limescale on washbasins, and an overfilled sharps bin. The majors area report for May 2024 showed 58.8% compliance. Areas of concern included the cleanliness of patient equipment and dust on high touch points. The paediatric emergency department report for May 2024 showed 71.9% compliance with the cleanliness of equipment and environment being the main concern across the department. The resus area’s report for May 2024 showed 68.9% compliance. Areas of concern was around the cleanliness of patient equipment.

Patients told us they received information about newly prescribed medicines and were given the opportunity to ask questions about them. Most patients we spoke to were offered pain relief when in pain. We saw staff administer pain relief in a timely way to patients who needed it. One patient told us they were ‘well looked after’ and they received regular monitoring.

Staff told us there was often difficulties in obtaining non routine or urgent stock from the pharmacy. They told us this was down to difficulty accessing porters and the distance between the inhouse pharmacy and the ED. They told us this had led to instances where time critical medicines had been delayed. Staff told us they did not always report incidents, including when time critical medicines were delayed. This often due to time constraints and the acuity of the area. However, staff spoke highly of the dedicated pharmacist support. They were visible on the unit and accessible to staff. There was remote clinical support available to the unit outside of normal hours. Staff told us they had easy access to medicine resources to support them in their role including national and local guidelines. Staff told us that local leaders supported them in their role. However, staff who were not regular with the service were not always given an induction that allowed them to carry out the role effectively. We spoke to agency nurses who had not been given computer log-ons to record nursing notes or medicine administrations. The ED was also supported by a pharmacy assistant who helped manage medicines processes including ordering, receiving, and maintaining stock of medicines. The children’s ED used a paper sepsis triage tool to support nurses passing over care to the doctors when triaging children. Staff received training in medicines management. They received ongoing training in the form of teaching sessions from the pharmacy team. At the time of the assessment, training rates for staff was at 94.5%. Medicine management audits were completed regularly via an electronic system. Scores varied across the department. Issues were reviewed at the medicines safety and management committee. Staff learned from safety alerts to improve practice. We saw records of safety alerts being actioned and recorded.

Time critical medicines were not always given on time. We saw delays in the initial administration of antibiotics and Parkinson’s medication. Staff told us that administration of other time critical medicines such as insulin were often delayed. We could not be assured that time critical medicines were always given in a timely manner. We saw mobile computer terminals left unlocked and unattended with personal patient data on screen. We saw some patients’ own medicines being stored in unlocked drawers in the ED. Access was not limited to authorised staff. Medical gas was easily accessible. However empty cylinders were not always stored securely. We saw cylinders left unattended in a public area. Staff told us that this was a regular occurrence. Medicines used in resuscitation were available for immediate use. They were secured with tamperproof seals and were routinely checked. Controlled drugs were stored in a central location within the ED. They were stored in line with legislation and records of administration were completed in line with guidance.

Patients who were self-administering their own medication kept medication on them as there was no allocated storage system. The service had an out of date self-administration policy and staff could not describe how they would use it to support patients in the ED. There was a process for supplying medicines to patients including to take out medications, outpatient prescriptions, and FP10 prescriptions. Prescription stationary was securely stored with access limited to relevant staff. However, FP10 prescribing was not available to all areas of the emergency department. Staff told us this could sometimes cause issues in supplying medicines to patients at out of hours times. There was a sepsis flag and proforma available on the electronic systems to help staff identify and support patients with sepsis. However, we did not see these always used in the records we reviewed. The service had an electronic system for recording of notes and medicines administration. They had access to information regarding patient histories. The service had recently employed a dedicated pharmacist who supported all areas of the ED. They identified patients who required additional support with medicines and highlighted them to doctors and nurses. The pharmacist also supported medical staff in medicines reconciliations for patients being admitted to the hospital. The service told us they were looking to expand the availability of this support to include out of hours.