Care Quality Commission finds 'poor culture' at Northwick Park's Maternity Department amidst multiple allegations of bullying. Emergency Dept more positive but the hospital still requires improvement

From the Care Quality Commission

The Care Quality Commission (CQC) has told London North West University Healthcare NHS Trust that it must make improvements at Northwick Park Hospital, following an inspection of the maternity service and the emergency department.

CQC carried out an unannounced focused inspection of the maternity service in April in response to information of concern received about the care of mothers and babies in the department. Following the inspection, the overall rating for the maternity service went down from requires improvement to inadequate. The ratings for the safe and well-led domains also went down from requires improvement to inadequate. The caring, effective and responsive domains were not rated during this inspection.

Inspectors also carried out an unannounced focused inspection of the emergency department to follow up on concerns regarding the quality and safety of the service and found that significant improvements had been made. At the time of the inspection in April, the department was under adverse pressure due to the COVID-19 pandemic. The emergency department was not rated during this inspection, so the previous rating of requires improvement remains in place.

The overall rating for Northwick Park Hospital remains unchanged and is requires improvement.

Nicola Wise, CQC’s head of hospital inspection, said:

“We were very concerned by our findings at Northwick Park hospital’s maternity department. There was a poor culture overall and there were multiple allegations of bullying amongst the staff. This is completely unacceptable. Nobody should have to work in an environment where they feel intimidated.

“Staff told us about one consultant who refused to help a junior midwife when asked, and other consultants who went home instead of discharging patients. We were also told about staff shouting at each other, and a midwife shouting at a patient because she could not understand English. A member of staff shouted at one of our inspectors, after mistaking them for a colleague.

“Some staff said they had raised concerns about the poor attitude amongst the senior management team, but that leaders did not listen. Other staff said they were frightened to speak out, for fear of repercussions, and some claimed they had been told by management only to say good things when asked. The knock-on effect of working in such an environment, is that when things go wrong, the fear of being blamed prevents people from raising concerns and reporting incidents, so lessons are not learnt and shared amongst the wider team.

“The executive leadership team is aware of the concerns our inspectors highlighted and we are assured that the team is implementing improvements while seeking support from stakeholders in the local healthcare community. We will keep a close eye on progress and will reinspect to ensure that improvements have been made and fully embedded.

“The situation in the emergency department was more positive. In general, it was well run, with enough staff with the right skills, qualifications, training and experience to keep people safe and provide the right care and treatment. However, nursing vacancies remain a challenge, although the leadership team was in the process of recruiting staff in order to improve the situation. We also pointed out a potential risk in the department that senior leaders were not aware of and need to address.”

Inspectors found the following areas of concern in the maternity department:

• The leadership team of the maternity service at Northwick Park Hospital had been recently established and because they had only been in post for a short time, the new team did not yet have a proper governance structure in place, and was therefore unable to provide assurance that they had the skills and abilities to run the service, or to implement meaningful changes that improved the safety of the service
• Not all leaders were aware of challenges to the service. Some did not know what was on the risk register and there were some longstanding issues that had not been addressed. Staff reported that not all leaders were visible, and they felt leaders did not act in a timely way to address the issues in the service
• The trust reported 13 serious incidents between March 2020 and March 2021, which included eight perinatal (baby) deaths over a five-week period, during July and August last year, which is a very high number over such a short period. The trust escalated this to the North West London Integrated Care System (ICS) for an external review and the trust had an improvement plan in place to address issues identified in the ICS report
• Doctors, nurses and other healthcare professionals did not always work well together as a team or support each other to provide good care. Most staff that inspectors spoke to had concerns about staffing levels and the high use of agency staff. Staff often had to miss lunch breaks as a result of insufficient staff cover
• The trust was unable to provide assurance that it had effective systems in place to ensure that medical and midwifery staff had the competence, skills and experience to safely care for, and meet the needs of, women and babies using the service
• Mandatory training did not meet the trust’s target. Although staff understood how to protect women from abuse, safeguarding training compliance was not always meeting the trust target and domestic violence assessments were not always documented
• Staff did not always complete and update risk assessments for each patient and did not always remove or minimise risks
• The service did not always manage patient safety incidents well. Incidents were not always reported in a timely way or lessons learned shared amongst the wider service
• During the inspection, concerns were raised regarding delays in the induction of labour for women and an allegation that some women were waiting more than 72 hours to be induced. The trust had completed an audit of patient records in April which showed that half of the women were induced within 48 hours, but the other half experienced delays.

In the emergency department, inspectors found:

• Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff
• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service had enough medical staff to ensure safe care was provided at all times
• Staff felt respected, supported and valued and they were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff, could raise concerns without fear
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so
• The service generally controlled infection risk well. Staff wore the right personal protective to keep themselves and others safe from cross infection. Patients had an assessment of their infection risk on arrival at the department and staff allocated them to the correct areas
• The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service
• Patients could access the service when they needed and were able to access treatment promptly. The trust had significantly improved its patient handover and treatment time performance
• However, senior leaders were not aware of all the risks in the department. Staff were responsible for changing the filters on masks, but the leadership team did not monitor, or have oversight of this. In addition, patient safety checklists were not consistently filled all records that were reviewed.