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.

Northwick Park and Central Middlesex hospitals still require improvement - some child services 'Inadequate'

The Care Quality Commission inspected the London NW University Healthcare NHS Trust, which covers Central Middlesex Hospital and Northwick Park Hospital, in the summer.  The report has now been published and makes worrying reading.

Of most concern will be the red light 'Inadequate rating' for three areas of Services for Children and Young People at Central Middlesex Hospital.

The Commission said:

·       We found a lack of clarity over where the overall responsibility and accountability of children and young people services lies within Central Middlesex Hospital. We also found a lack of clarity for how and where this service feeds into the trust. 

·       Governance in children and young people services at Central Middlesex Hospital was weak. The risk register for the recovery ward was out of date. There was a lack of up to date policies and associated audits demonstrating that the care being delivered was compliant [with] national standards and best practice. We were not assured that the service was guided or supported via a paediatric surgical network. 

·       There was no clear evidence that areas from the last inspection for children and young people services had been addressed or necessary improvements made. 

·       In medical care, risks were mitigated and managed but there had been limited action to address risks directly.

·       The senior leadership team for medical care at Central Middlesex Hospital recognised the sometimes poor relationship between its staff and local authority staff, but there had been no action to address this

There were many issues regarding safety. The report says:

·       Our rating of safe stayed the same. We rated it as requires improvement because: 

·       The trust provided mandatory training in key skills however there was some confusion among midwifery staff as to the correct length of mandatory training and its content. Compliance rates for mandatory training and safeguarding training were below trust targets in the surgical services at Northwick Park Hospital and Central Middlesex Hospital. Not all clinical staff in children and young people services at Central Middlesex Hospital caring for children were trained to safeguarding level three however, plans were in place to ensure all staff received this training. 

·       In medical care at Central Middlesex Hospital, some staff did not always report incidents and, in particular, near misses. 

·       The trust did not always control infection risk well. Hand hygiene was not consistently being undertaken in maternity services. In children and young people services, the Rainbow Unit at Central Middlesex Hospital was found to be untidy and we could not be assured that children’s toys were regularly cleaned. 

·       Due to capacity issues in the emergency department at Northwick Park Hospital, patients were still being cared for on trolleys in the corridor which meant private conversations could be overheard. 

·       At our last inspection we found that the clinical decisions unit (CDU) was being used inappropriately to treat level two patients. Whilst the service assured us that this was no longer the case we did find that the area was being used as overflow for patients requiring inpatient beds and patients within the CDU could be there for over four hours and sometimes up to three days. In children and young people services at Central Middlesex Hospital, staff we spoke with in Recovery Stage One told us that children were cared for in a mixed four bedded recovery bay with adults. 

·       Staff at Central Middlesex Hospital did not use a nationally recognised tool to identify deteriorating patients, such as Paediatric Early Warning Signs (PEWS) or a validated acuity score system to assess patients. We were told that not all medical staff had European Paediatric Life Support (EPLS) or Advanced Paediatric Life Support (APLS) training. There was no paediatrician available on-site at Central Middlesex Hospital. Staff had to refer to the consultant of the day or week, who was based at a different hospital in the trust. Some staff were not aware of this arrangement. 

·       Some medicine storage areas did not meet national guidance for security for controlled drugs in the Northwick Park surgical service. 

However:

• Mandatory training compliance rates at Northwick Park and Ealing emergency departments had improved. Staff monitored patients who were at risk of deteriorating appropriately.

 The Commission fournd 'Outstandin Practice' in Urgent and Emergency Care at Northwick Park Hospital:

In Urgent and emergency care at Northwick Park Hospital-

The department had developed a patient sepsis video for parents whose children attend the paediatric emergency department with a fever or suspected infection. The video was a four minute video aiming to educate parents about the warning signs to look out for sepsis. 

The department had done a rotational shift with the local mental health trust. The purpose of this was for staff to get an ideas how the other service was run, learn and share knowledge and understanding to improve the way they worked together.

FULL REPORT HERE

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Action Plan for Brent SEND children services to be approved tonight

The Brent Health and Wellbeing Board will tonight consider a Written Statement of Action following concerns expressed following a joint inspection of the authority's and Brent Clinical Commissioning Group provision for chldren with special educational needs and disabilities. The officer's report states:

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Although some aspects of the inspection were very positive, a Written Statement of Action has been requested. Brent Council, Brent CCG and health providers have worked together to address these concerns and respond to them so that children in any setting can get the right health advice and treatment to support their education. The most challenging of these concerns to address is the waiting times issue that has arisen due to wider shortages of specialist NHS staff. Brent CCG has appointed a specialist Designated Clinical Officer to oversee and speed up the programme of health reforms. 


The inspectors required the local area to provide a Written Statement of Action in regard to the following concerns:

·      strategic leadership of the CCG in implementing the SEND reforms 


·      the fragmented approach to joint commissioning causing gaps in services 


·      the lack of opportunity for therapists to respond to draft EHC plans before they 
are finalised 


·      poor access to services for some vulnerable groups; in particular, to audiology, 
OT and speech and language therapy, limited opportunities for parental involvement when designing and commissioning 
services. 

The draft Written Statement for  Action can be found HERE.

It has to be submitted by October 23rd

 


Central Middlesex closes its doors for the last time and the community loses yet another amenity

It was significant that last night on Twitter someone reacted with shock to the news that Central Middlesex A&E will be closed today saying 'but that's my local hospital. I've it used since I was a kid!'

The remark indicates both our failure to get the message out in time to more people and thus moblise them, and also the sense of ownership that local people have for what many call 'Park Royal'.

Photo Sarah Cox

Symbolic protests took place this morning at  Hammersmith and Cen tral Middlesex A&Es to mark their closure.

On Monday the Council called for the closure to be delayed until Northwick Park A&E was in a fit state to take over Central Middlesex's role.

Yesterday evening at the Brent Council Scrutiny Committee, Cllr Mary Daly tore into the 'men in suits' behind the closure accusing them of failing in their 'duty of candour'.

Today the Central Middlesex A&E is closed.

In truth Brent Council was very slow to recognise the negative impact of the closure and while Ealing Councl was leafleting residents and advertising on buses, it was left to Brent Fightback and other campaigners to get the word out in Brent  with street leafleting and public meetings.

Campaigners attended consultations and  repeatedly pointed out the degree of deprivation of the population that used Central Middlesex; the health statistics for the area; low car ownership and poor transport links to Northwick Park; the presence of the large industrial estate at Park Royal with a high risk of industrial accidents; Wembley Stadium and major railway lines with the potential for major incidents (remember the Harrow train crash of1952 which killed 85 people?) and the strain on the ambulance service when, with only an Urgent Care Centre on the Central Middlesex site, needy patients will have to be transferred to Northwick Park.

After months of consultations and meetings none of these issues have been satisfactorily addressed and the Care Quality Commission's (CQC) report on Northwick Park and Centrasl Midddlesex Hospitals has added further doubt. Northwick Park was given a 'requires improvement rating' and Central Middlesex A&E a 'good'.

The 'men in suits' quickly moved into PR mode following that report, and before the closure, with a 'feel good' story about the new Northwick Park A&E, faithfully carried by the Kilburn Times LINK.

In fact the new unit will not be ready until November at the earliest and full operational changes until 2015.  There are concerns about the intervening period and Scrutiny called for further reports from the Hospital Trust.  Meanwhile some members of the Clinical Commissioning Group, with interests in  out-sourced services, are keen to bad mouth the hospitals and claim that they can offer something better.

Unfortunately the privatisation of health means that doctors and other staff often have private interests in health provision and there were calls from the public gallery last night for these interests to be declared at such meetings. 

I agree. 

Hospital Trust officials claimed at Scrutiny that the CQC's concerns were being addressed and that 20 new beds at Northwick Park would come into use today and help clear the backlog at Northwick Park A&E.  It would improve bed capacity by 20%.  They claimed that a new clinical and medical leadership team was now in place and would result in improvement.

In remarks that were not fully explored Scrutiny were told that the Trust would improve capacity at Northwick Park for the winter by looking for additional beds outside the hospital on other sites. This raises the prospects of the elderly being sent further afield during the peak illness periods which coincide with severe weather.

NW London Hospital's 'Requires improvement' rating raises serious questions about planned closures

Guest blog from local activist Sarah Cox on the Care Quality Commission's report LINK on the North West London Hospital s NHS Trust which includes Central Middlesex, Northwick Park and St Mark's hospitals.

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With only a few weeks to go before the A & E at Central  Middlesex closes for ever on September 10th, this report raises grave concerns. Patients from the most deprived areas of Brent which are served by Central Middlesex will be forced to travel to the A & E at Northwick Park which is short staffed and "requires improvement".

The report also reveals that:

Patient flow through Northwick Park Hospital was having an impact on people waiting in A&E, and pressure on the critical care units was so great that some people were being discharged too early and subsequently readmitted.

Time and again the Clinical Commissioning Group and the architects of the Shaping a Healthier Future project under which these closures are being implemented, have assured the community that, transformed into a Major Hospital in which all the services for a wide area are concentrated, Northwick Park Hospital would provide better services for patients. Time and again patients and community members who are concerned for the NHS expressed our doubts. Judging by this report, we were right to do so. The NW London Hospital Trust assured recent Overview and Scrutiny meeting of Brent Council, that Northwick Park Hospital will be ready to take on the extra patients when Central Middlesex A & E closes. Really?

This report is also critical of Maternity services at Northwick Park:

CQC also identified that maternity services required improvement to ensure women received a safe and effective service. Maternity was rated as Inadequate for responsiveness, as women could not always summon the assistance they required and individual needs were not being met.

 This is due to staff shortages, yet under the SaHF proposals, Hammersmith and Ealing Hospitals will lose their maternity services. Many patients who would have gone to Ealing for maternity care will have to attend NPH in future. Will it be able to cope?

Overall, Central Middlesex is rated good, but the report points out that many staff there feel isolated from the rest of the trust. Over the last few years, services have been transferred from CMH to NPH with staff often being required to move at a few days' notice. Many staff have said that they much prefer working at Central Middlesex, but are not given the choice.

Health campaigners believe that the changes being imposed on our hospitals are driven by financial considerations and the Government's policy of handing over our NHS to private companies who will run services for profit not the needs of the patients. 

REPORT SUMMARY