The Whittington Hospital

The Whittington Hospital has approximately 320 beds, and is registered across 3 locations registered with CQC: Whittington Hospital (includes community services) , Hanley Primary Care Centre (GP practice and community centre) and St Luke's Hospital (Simmons House) multi-disciplinary MH service for 13-18 year olds with emotional and mental health problems.

We carried out an announced inspection between 8 and 11 December 2015. We also undertook unannounced visits on 14, 15 and 17 December 2015.

We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, Services for children, End of life and Outpatients and diagnostic services.

This was the first inspection of Whittington Hospital under the new methodology. We have rated the trust as good overall, with some individual core services as requires improvement.

In relation to core services most were rated good with critical care and outpatients and diagnostics rated as requires improvement.

Our key findings were as follows:

• During our inspection we found staff to be highly committed to the trust and delivering high quality patient care.
• We saw staff provided compassionate care and patients were positive about the care they received and felt staff treated them with dignity and respect.
• The trust had vacancies across all staff groups, but was recruiting staff and staffing levels were maintained in services through the use of bank and agency staff.
• Staff were aware of how to recognise if a child or adult was being abused and received good support and training from the trust's safeguarding team.
• The trust had an incident reporting process and staff were reporting incidents and receiving feedback. Learning was shared across ICSU’s which encompassed acute and community service.
• The trust had promoted duty of candour and this was seen to be cascaded through the organisation.
• We observed effective infection prevention and control practices in the majority of areas we inspected.
• Patient care was informed by national guidance and best practice guidelines and staff had access to polices and procedures.
• Patients had their nutritional needs met and received support with eating and drinking.
• There was good team and multidisciplinary working across all staff groups and with clinical commissioning groups, voluntary organisations and social services to deliver effective patient care.
• We found evidence of good compliance with the World Health Organisation (WHO) surgical safety checklist, with good completion of the three compulsory elements: sign in, time out and sign out.
• There were processes in place to ensure staff attended training on the Mental Capacity Act 2005 and the majority of staff demonstrated a good practical understanding of this, with variability in some services,
• Staff understood and responded to the needs of the different population groups the trust served and worked hard to meet the needs of individual patients.
• Patients were largely treated in timely manner with the trust meeting national access targets and performing higher than the England average, with the exception of the cancer two week wait standard, although it was noted that improvements were being made against that standard.
• The emergency department (ED) performed better than the average ED in England in the speed of initial assessment, the timeliness of ambulance handover, and the percentage of people staying for more four hours in the department. However, there were times when there were no in-patient beds available and patients remained in ED for a long time.
• The trust had introduced the ambulatory care unit, which engaged stakeholders across the health and social care economy to avoid unnecessary hospital admissions and transfer their ongoing care needs to the most appropriate provider.
• Patient flow out of theatres and critical care, impacted on patient movement and service capacity.
• Executive and non executive members of the trust were visible in most areas, in both acute and community settings.
• The trust had a clear vision and strategy, the development of this into local strategies were in place in some areas, but were still being developed in some cases.
• Staff were positive about how their local and senior managers engaged with them.

We saw several areas of outstanding practice including:

• Whittington Health NHS Trust worked with clinical commissioning groups (CCGs) and other providers to improve the responsiveness of emergency and urgent care services for local people. The Ambulatory Care Centre, which opened in 2014, provided person-centred hospital level treatment without the need for admission.
• Within the Ambulatory Care Centre we observed good multidisciplinary working across hospital services, including diagnostics, care of the elderly physicians, therapists, pharmacists, and medical and surgery specialities to provide effective treatment and care.
• Elderly care pathways had been well thought out and designed to either avoid elderly patients having to go to ED or if they do, making sure that their medical and social care needs are quickly assessed.
• Within the ED there was outstanding work to protect people from abuse. The lead consultant and nurse for safeguarding coordinated weekly meetings attended by relevant trust wide staff to discuss people at risk and to make plans to keep them safe.
• Within children and young people’s services responsiveness was demonstrated through close working arrangements with community-based services including the ‘hospital at home’ service which ensured that children could expect to be cared for at home via community nursing services.
• The trust provided ‘Hope courses’ for patients who had been on cancer pathways to get together outside of hospital, and hear from motivational speakers including talks on personal wellbeing, nutrition and recovery care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Within the Emergency Department (ED) there was not sufficient consultant cover and there were vacant middle grade medical posts, covered by locum (temporary) doctors, which poses a risk to delivery of care and training staff.
• Within acute outpatient departments the hospital must improve storage of records and ensure patient’s personally identifiable information is kept confidential.
• Within the acute outpatient setting, improve disposal of confidential waste bags left in reception areas overnight.
• Within surgery and theatres review bed capacity to ensure patients are not staying in recovery beds overnight.
• Within critical care the trust must review capacity and outflow of patients. We observed significant issues with the flow of patients out of critical care and found data suggesting 20% of patient bed days were attributed to patients who should have been cared for in a general ward environment. This led to mixed sex accommodation breaches, a high proportion of delayed discharges from critical care and a number of patients discharged home directly from the unit
• Within critical care the service must review governance processes and use of the risk register. We were concerned there was a culture of underreporting incidents and near misses and the importance of proactive incident reporting should be promoted.
• Within critical care staff did not challenge visitors entering the unit and we were concerned patients could be at risk if the unit was accessed inappropriately.
• Within maternity services the department must ensure the information captured for the safety thermometer tool is visible and shared with both patients and staff in accessible way.
• Within maternity the service must ensure the safety of women undergoing elective procedures in the second obstetric theatre and agree formal cover arrangements.
• Within palliative care the service did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital.
• Within palliative care services staff were not always aware of patient’s wishes in regards to their ‘preferred place of death’. They did not always record and analyse if patients were cared for at their ‘preferred place of care’.

In addition the trust should:

• Take further action to improve safe nurse staffing levels across the surgery service, particularly within main operating theatres and recovery.
• Improve consistency of labelling medical equipment that is clean across surgery wards and operating theatres.
• Ensure healthcare assistants on surgery wards are given competency appropriate tasks and supervision at all times.
• Improve bed management across the hospital to ensure post-operative patients are allocated to a ward in a safe and timely way.
• Ensure all recorded risks in the surgery service are addressed in a timely way.
• Improve engagement with consultant surgeons and anaesthetists working in the surgery service.
• Improve leadership support and capacity within operating theatres.

Professor Sir Mike Richards

Chief Inspector of Hospitals