The Care Quality Commission has rated North Middlesex University Hospital (NMUH) NHS Trust as Requires Improvement overall, following an inspection in May and June 2018.
NMUH was rated Requires Improvement for being safe, effective, responsive and well-led. It was rated Good for being caring.
CQC inspected all eight core acute services including: urgent and emergency care, medicine (including older people’s care), surgery, critical care, maternity, services for children, end of life care and outpatients service. CQC last undertook a comprehensive inspection at the trust in September 2016 when it was rated Requires Improvement overall.
Inspectors found there was no written protocol or policy for staff to follow in order to prevent patients at risk of suicide from leaving the emergency department before they were assessed and treated.
There was no separate mental health awareness training provided. The trust did not keep numbers of episodes of restraint - this meant that the trust did not have oversight of the use of restraint.
The trust did not provide full cover for an out of hours rota to cover gastroenterology. This was due to vacant consultant posts. This meant patients were at risk of delay to treatment should they experience upper gastrointestinal bleed during out of hours.
Staff in outpatients reported that they did not feel able to report incidents of verbal and physical abuse against them.
Most areas of the maternity service were tidy but not all were visibly clean during the inspection. Patients said the maternity department was not always clean.
In the emergency department staffing vacancy rates were high for medical and nursing staff.
Some of the data from trust’s pain assessment audit indicated that patients were not always offered sufficient analgesia or underwent regular pain assessment.
The outpatient department did not monitor waiting times for patients - this was one of the main concerns raised by patients during the inspection. Patients said that their waits had varied from 15 minutes to an hour. Across the outpatient department inspectors saw little evidence of health promotion information available for patients. The outpatient department did not have a dedicated room that could be used when breaking bad news or holding private conversations.
There was a concern that current improvements in emergency department were not sustainable since there remained a heavy reliance on locum or agency medical and nursing staff.
Caring was the one major category overall that had improved since CQC’s last inspection. It has gone from Requires Improvement to Good. Inspectors observed staff being kind and caring to patients. Patients and relatives felt they were treated with courtesy, respect and compassion by staff. Patients felt able to speak about their worries and said staff at the hospital were compassionate. Staff were sensitive to the needs of children and young people, and their families.
Women in the maternity service were positive about their care and treatment. Women felt involved in their care and were given an informed choice of where to give birth. Women said they were happy with their care and praised staff for being inclusive and supportive.
Inspectors also found evidence of some outstanding practice. The trust awarded funding to 15 projects put forward by staff to improve patient care in a ‘Dragons’ Den’ style competition. Staff were invited to present their ideas for spending of £200,000 made available by the trust’s charity to spend on improvements to patient care.
The Maternity service was especially caring and responsive to parents who had suffered a loss, such as miscarriage, stillbirth or neonatal death. They were committed to continually improving the care and services they provided for bereaved parents. The bereavement midwife had received two national awards and a national nomination for excellent and outstanding care and support for bereaved families. At the previous inspection, we found poor relations between different groups of staff and a bullying culture within the maternity service. At this inspection, there was a positive culture, which was focused on improving patient outcomes and experience. Staff were committed and proud to work at the trust.
The child protection lead was nominated for the British Association for the Study and Prevention of Child Abuse and Neglect and NSPCC Award for Child Protection trainer of the year and reached the top three in the country.
Actions the trust must now take include:
- The trust must follow the death review process and comply with the national guidelines.
- The trust must ensure that the restraint of patients is carried out by suitably trained staff, and that the episodes of restraint are recorded and monitored by the trust.
- The trust must ensure that patients with mental illness are cared for by staff trained in mental health. The trust must ensure that patients presenting to the hospital who are at risk of suicide are kept safe.
- The trust must ensure all shifts are covered and staffing levels always meet the required establishment to ensure patients’ needs are met and risk is prevented.
- The trust must provide a full cover for an out of hours gastroenterology rota to minimise the risk of delay to treatment.
The ratings tables for the trust can be found on pages 18-19 of the latest report.
Professor Ted Baker, England’s Chief Inspector of Hospitals, said:
“The Requires Improvement overall rating means there is still a long way to go to improve care at North Middlesex University Hospital NHS Trust, although there have been some improvements overall since our last inspection.
“I note that the rating for Caring is much improved and is now Good and that is a step in the right direction. I was encouraged by areas where we saw some outstanding practice, notably in the Maternity service. There was a commitment to continually improve the care and service provided.”
The CQC has also published the trust’s Use of Resources report, which is based on an assessment undertaken by NHS Improvement. Various factors are considered by NHSI, including a combination of data on the trust’s financial performance over the previous 12 months, NHS Improvement’s local intelligence and the trust’s assessment of its performance. As a result of this review the trust has been rated as Requires Improvement for use of its resources during the 2017/18 financial year.
The combined rating for the trust, taking into account CQC’s inspection for the quality of services and NHS Improvement’s assessment of the use of resources is Requires Improvement.
...there is still a long way to go to improve care at North Middlesex University Hospital NHS Trust
Professor Ted Baker, Chief Inspector of Hospitals