Ealing Hospital

Updated 20 May 2022

Ealing Hospital serves an ethnically diverse population mainly in the London Borough of Ealing. Ealing hospital provides the following services:

•Urgent and emergency care

•Medical care (including older peoples care)

•Surgery

•Outpatients and diagnostics

•Critical care

•End of life care

•Children’s and young people services

We inspected medical care and surgery core services at our inspection on 9, 10 and 11 February 2022.

Medical care at Ealing Hospital was last inspected in August 2018 when it was rated and inadequate for safe and requires improvement for effective, caring, responsive and well led. Medical care was rated as requires improvement overall. A follow up inspection of medical care services was carried out in January 2019 but the rating was not reviewed because of the limited focus of the inspection.

At this inspection our overall rating of medical care stayed the same. We rated the service overall as requires improvement. We rated safe, responsive and well led as requires improvement and effective and caring as good.

During our inspection in February 2022 we visited seven integrated medicine division wards, and the ambulatory care unit, and the discharge lounge.

Medical services involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. Medical care at Ealing Hospital provided care and treatment in the following disciplines: stroke; care of the elderly; cardiology; dermatology; genitourinary medicine (GUM) and sexual health; infectious disease; respiratory; rheumatology; endocrinology and diabetes; neurology and gastroenterology.

The number of admissions for the three specialties most admitted to in the division of integrated medicine at Ealing Hospital between 1 November and 31 January 2022 were : general internal medicine (GIM), with 1039 admissions in the period or 83% of total admissions; cardiology with 120 admissions, or 10% of total admissions in the period; and geriatric medicine with 30 admissions, or 2% of total admissions in the period.

Gastroenterology was not part of the integrated medicines division; it was a specialty in the St Mark's division. In the period 1 November to 31 January 2022 there had been 581 admissions in gastroenterology.

We spoke with eight patients and one relative. We reviewed 10 sets of patient records. We also spoke with 28 members of staff, including qualified nurses, matrons, consultants, doctors, senior managers, and support staff.

We rated medical care at Ealing Hospital requires improvement overall because:

• The service did not always have enough nursing and support staff to keep patients safe. The service was mitigating the staffing risks during twice daily safety huddles. However, there was a 22% vacancy rate for band 5 nurses.
• We found a drawer in the catheterization labs with a range of out of date equipment and a monitor in the catheterization labs which did not have a servicing date. We also found out of date equipment on a resuscitation trolley in the acute medical unit (AMU). There was a risk that staff could inadvertently use out of date equipment.
• On Ward 6 South, we found discrepancies in the use of Waterlow scoring. This is a tool used for pressure area risk assessment. This meant that patients’ level of risk of developing pressure ulcers may not be accurately assessed and timely actions taken.
• Medical staff mandatory training in resuscitation was 72.2%. This was less than the 80% standard. This meant some staff may not have up to date skills in resuscitation.
• There was a lack of seamless services between the trust and other NHS providers of mental health care for patients temporarily on an acute ward waiting for transfer to a mental health facility. There was a risk of delays in patients care and treatment as a result of a lack of clarity about the responsibility for clinical decision making whilst the patient was an inpatient in the acute hospital.
• Due to a shortage of registered mental health nurses, the service had a policy of cohorting patients assessed as requiring enhanced observations or one to one care in a bay. However, we saw cohorted bays were not always observed by staff. There was a risk to patients if they were assessed as requiring enhanced observations or one to one care and this was not provided in accordance with their assessed needs at all times.
• The patient electronic record could only display a maximum of two patient needs on screen. This had led to staff not placing a magnetic identifier for the confusion care pathway above a patient’s bed. The lack of a visual prompt for staff led to a patient not receiving a scheduled review after 72 hours. There was a risk that without a visual prompt, staff working on the bay may not be aware of patients’ needs, unless they fully consulted patients’ electronic records.
• Records were not always stored securely. We found a patient’s ‘adult inpatient care needs assessment’ booklet next to the reception area in the acute medical unit (AMU). We saw a computer in the endoscopy reception which was unattended and not locked. There was a risk that unauthorised people could have accessed confidential patient information.
• Staff told us the trust’s senior executive team and some ward leaders were not visible at Ealing Hospital, as they were based off-site at Northwick Park Hospital.
• The signage enabling patients and visitors to navigate around the hospital was confusing for patients and visitors.
• Staff on the Older Persons Short Stay Unit (OPSSU) were using a printed copy of the infection prevention and control policy. There was a risk that staff may use an out of date policy instead of using the most up to date policies on the trust’s intranet.
• We saw a cracked shower chair and shower chairs with chipped enamel on the OPPSSU. This could pose a patient safety and infection control risk as microorganisms can thrive in cracked surfaces.
• Domestic staff on the acute medical unit (AMU) was not aware of control of substances hazardous to health regulations (COSHH), including the trust’s policies and guidance on COSHH.
• The trust was a large provider of cancer services but staff told us they did not have a local cancer strategy. This meant there was a potential risk that cancer services were not aligned to local commissioning and provision of services to support people during and after their cancer treatment.

However:

• The service managed safety incidents well and lessons were learnt from them.
• Staff 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 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 raise complaints.
• Staff understood the service’s vision and values, and how to apply them in their work and all staff were committed to improving services continually.

Surgery at Ealing Hospital was last inspected in August 2018 when it was rated requires improvement in safe, effective, responsive and well led and good in caring. Surgery was rated as requires improvement overall.

At this inspection our overall rating of surgery improved. We rated the service overall as good. We rated safe, effective, caring, well led as good and responsive as requires improvement.

We visited theatres, inpatient surgical wards, the theatre recovery unit and surgical assessment units.

To manage staffing and capacity during the COVID-19 pandemic, the trust had restructured surgical services and treatment pathways. Ealing Hospital provided elective surgery and patients underwent pre-assessment care at Central Middlesex Hospital. As part of our inspection of surgical care at Ealing Hospital and Northwick Park Hospital, we visited Central Middlesex Hospital to understand the pre-assessment pathway and the post-treatment therapy provided by allied health professionals. We have included the findings in this inspection report.

We rated surgery at Ealing Hospital good overall 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. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• 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 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:

• The service was not fully compliant with DHSC Health Technical Memorandum 07/01 and the Health and Safety Executive Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 in relation to sharps waste.
• The service had persistently high vacancy rates. At the time of our inspection the service had vacancies for 36 whole time equivalent (WTE) nurses. However, the number of nurses and healthcare assistants matched the planned numbers and vacancies were filled with bank and agency staff.

Updated 20 May 2022

Updated 31 August 2018

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

• Mandatory training rates for medical staff were low including for safeguarding level 3 training.
• Staffing remained a challenge for the service. There were significant vacancies in the community children’s nursing team and the staffing establishment was not sufficient for the level of staffing required on the children’s outpatients and day care unit.
• There was no protocol or standard operating procedure available for staff to follow if a child or young person became unwell on the outpatients and day care unit.
• The Women and Children’s division still did not have oversight of young people admitted to adult wards at Ealing Hospital. There was still no flagging system to identify young people who had been admitted to adult wards.
• Staff we spoke with felt learning was not shared effectively however the trust told us there were cross site governance meetings where staff could attend where learning was shared.
• Not all of the risks we identified at the Ealing Hospital site were on the risk register.
• Staff on the children’s outpatients and day care unit did not receive clinical or safeguarding supervision.
• Nursing staff had not received training in the recognition and management of children with sepsis.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. However, some clinical guidelines had not been reviewed in line with trust timescales.
• There was no longer a play specialist team at the hospital. A play specialist was being recruited but the post was to be shared with the other hospital site.
• The amount of time managers dedicated to the children’s services at Ealing Hospital remained very limited.
• Staff still felt unsettled and uncertain about the future provision of children’s services at Ealing hospital.

However:

• The trust planned and provided services in a way that met the needs of local people.
• There had been significant improvements in referral to treatment times since our last inspection, with consistently good overall compliance of over 95%.
• The service took account of the individual needs of children and young people including those with learning disabilities. The unit had a learning disability champion and encouraged the use of learning disability passports to help inform decision making.
• The community children’s nursing team and continuing care team supported transitional care needs and children with long term conditions. The team promoted bringing care closer to home and worked with children and young people to prevent and reduce hospital admissions.
• Staff were passionate about their work toward children and their families and focused on delivering patient centred care.

Updated 21 June 2016

Overall the critical care at Ealing was good. Patients were cared for by a safe number of competent staff who used evidence-based practice to achieve good outcomes. Staff had good access to patient information and current best practice guidelines as well as up to date research articles. Patient safety thermometer results were good and there was a proactive incident reporting culture.

We saw evidence that incidents were investigated appropriately, with learning points disseminated to unit staff, . h However, there was limited shared learning relating to incidents. The vision for the service focused on an improvement in quality and safety through investment in staff training and development.

We saw some evidence of innovation such as the development of the high flow oxygen service.

The critical care service was caring and patient privacy and dignity was maintained at all times. Staff knowledge and implementation of safeguarding was good and we saw evidence that regular patient risk assessments took place. Patients’ pain was frequently assessed and well managed by staff who ensured patient comfort at all times.

Multidisciplinary working was embedded on the unit, particularly during the weekly meeting.

Updated 21 June 2016

We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. However there were some concerns raised by specialist staff and from our observations about whether all generalist nurses, doctors and consultants had the expertise to recognise patients who were dying.

The knowledge base was described as “patchy” especially since the withdrawal of EOL and specialist palliative care induction training which had given all staff a base knowledge and understanding.

We were given examples of patients’ treatment and observations continuing when EOL had been identified. This could cause the patient unnecessary pain and discomfort at a time when these actions would make no difference to the patient’s health and wellbeing.

The Last Days of Life Care Agreement which replaced the Liverpool Care Pathway was not being used for any of the patients we reviewed, although ‘do not attempt cardio pulmonary resuscitation’ orders were in place. The completion of DNACPRs was variable. Some were not fully completed or discussed or signed off by a senior clinician.

The SPCT leads were focussed on raising staff awareness around EOLC. However they felt this should be more widely embraced in the trust.

Staff were aware of their responsibility in raising concerns and reporting incidents. However, we found there was apathy in reporting everything including near misses due to a lack of feedback and learning outcomes.

The SPCT at Ealing hospital did not feel engaged with the trust strategy and were unsure how it would affect services at Ealing Hospital.Although the lead for palliative and cancer services visited Ealing Hospital twice a week there was little local leadership on a day-to-day basis.

Updated 21 June 2016

Overall outpatient and diagnostic services at Ealing Hospital were good because there were systems in place to identify record and review incidents and staff were aware of how incidents should be escalated and recorded.

Outpatient and diagnostic services were visibly clean and there were processes to ensure cleaning was maintained.

We saw good evidence of how the diagnostic services benchmark their services through national and local audit activity and national guidelines including NICE and Royal College of Radiologists.

We found staff were compassionate, caring and proud to work at Ealing Hospital.

Mandatory training was provided however staff told us face to face training was often difficult to access or attend due to clinical commitments.

Hard copy records were not always available in time for clinics; the trust was aware of this and had started phased plans to integrate hard copy records in preparation for a move to an electronic record management system across all sites.

The service had a backlog of patients waiting more than 18 weeks for an appointment and had attempted to reduce waiting times for patients. There was a good system in place which highlighted the patients who had waited longest and should be clinically prioritised for the first available appointments.

Updated 20 May 2022

Updated 6 November 2019

Our rating of this service improved. We rated it as requires improvement because:

• 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.
• Our observation of patient records found that the grade of the clinician was not always clear and that the records were filled out inconsistently between different clinical areas.
• There was poor Deprivation of Liberty Safeguards (DoLs) training rates amongst medical staff. Only 53% of medical staff had completed the training.
• We found that the service still performed poorly in most of the Royal College of Emergency Medicine (RCEM) audits.
• We found that improvements could still be made in relation to severe sepsis and shock management. The service audit revealed that with regards to 2019 compliance, only 54% of patients had their observations measured, this was down from 2017 compliance where 98% of patients had their observations measured.
• Access to the service was not conducive to the overall patient experience. Patients had to wait for UCC triage before they were triaged in the emergency department.
• Waiting times decision to admit and arrangements to admit, treat and discharge patients were not in line with national standards. The service did not meet Royal College of Emergency Medicine guidelines for median time from arrival to treatment.
• The departments performance for Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival was poor. However, significant improvements had been made and performance was no longer consistently below the England average. The trust was continuously working with NHS Improvement to improve their performance. The trust had been above the England average for six months.
• The trusts unplanned re-attendance rate to accident and emergency within seven days was worse than the national standard of 5% and consistently worse than the England average.

However:

• At our last inspection we found that the service was still treating children instead of stabilising and transferring. At this inspection, we found that the service had overhauled its approach to paediatric patients presenting at the emergency department (ED). The service now had posters up both outside the service and within the waiting room letting patients know that they did not treat acutely unwell paediatric patients. If an acutely unwell paediatric patient presented at the service, they would stabilise and transfer to a neighbouring ED.
• At the last inspection we found that staff in the ED were not trained in the adequate life support training. We found that this had changed since our last inspection. All staff were either trained in Immediate Life Support (ILS) or due to be trained.
• At our last inspection we found that mandatory training rates were low – the 85% target was not met by medical staff in any modules and met by nursing staff in only three modules. The service had made efforts to ensure everyone completed mandatory training. At this inspection we found that the trust 85% target was met in all but one module by nursing staff and all but three modules by medical staff. Where there were gaps in training, we saw evidence that staff were placed on upcoming modules.
• At our last inspection, we found there was high medical and nursing vacancy rates with no real improvement since the inspection before. We found that the service had made real efforts to improve its vacancy rate and figures provided whilst on inspection stated that the nurse vacancy rate was 10%.
• At our last inspection we found that patient pain was not reassessed. At the time of this inspection we found that patient pain was reassessed at least every hour in line with RCEM guidelines.
• Previously, the rates of medical staff training in mental capacity act (MCA) was quite poor (27%). Figures provided whilst on this inspection showed that 96% of clinicians were trained in MCA.
• At our last inspection we found that patients were treated in corridors whilst waiting for a bed to become available. We saw no evidence of this whilst on inspection.
• Previously, appraisal rates in the emergency department were lower than the trust target of 85%. In the year prior to our inspection, 87% of staff in the ED had received an appraisal.
• It was reported at our last inspection that staff felt as though there was a lack of divisional and senior trust leadership presence. This was not the case whilst on inspection as staff spoke highly of management and knew members of the executive team by name.