Regulators have found some improvements at a London hospital’s accident and emergency department that was previously rated as “inadequate”, but also highlighted a raft of other problems across the organisation.
Nurse staffing shortages, checks on agency staff and a poor culture, especially in the maternity unit were all highlighted by inspectors.
“There is still a long way to go at the hospital as a whole”
Most areas of care viewed at North Middlesex University Hospital NHS Trust were considered by inspectors as needing to improve.
The Care Quality Commission published its latest report on North Middlesex on Friday, based on a comprehensive inspection in September.
The trust has been rated as “requires improvement” overall, and also for being safe, effective, caring, responsive and well-led.
In addition, of the eight core services assessed, seven were rated as “requires improvement” – urgent and emergency services, medical care, critical care, maternity and gynaecology, services for children and young people, end of life care, and outpatients and diagnostic imaging. In contrast, the CQC rated surgery as “good”.
Earlier this year, the regulator had rated urgent and emergency care services at North Middlesex University Hospital as “inadequate” following an unannounced inspection in May.
“Our staff are determined to keep on improving with their help and support”
At the time, the CQC issued the trust with a “warning notice” requiring significant improvements in the emergency department.
Professor Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “I am pleased to report that the situation in North Middlesex’s emergency department has improved.”
But he added: “While services are no longer Inadequate, there is still a long way to go at the hospital as a whole.”
He noted that the CQC had worked in partnership with NHS Improvement and NHS England to ensure that the trust had support in the period since the warning notice was issued.
However, the regulator highlighted other key areas of improvement that were needed, including further progress in A&E, based on the latest inspection.
Too many patients were waiting to be assessed after they arrived in A&E, and they were also waiting too long to be dealt with. A&E was not meeting the target time to admit, transfer or discharge 95% of patients within four hours of their arrival.
“There’s no surprise the emergency department is not meeting its targets”
Meanwhile, nurse staffing levels could be “unpredictable” and did not always meet national guidance, said the CQC in its report on the trust.
Safety checks on agency nurses were inconsistent and poorly managed, it warned, and inspectors were not assured that patients were being cared for in the “right place at the right time, by adequately qualified staff”.
The CQC also warned that the trust’s culture was “not consistently one of fairness, openness, transparency, honesty, challenge and candour”.
Staff reported bullying, harassment and discrimination among staff at all levels in the maternity unit, said the CQC. When staff raised concerns they felt they were not treated with respect.
Also in maternity services, inspectors observed that privacy and dignity were not always protected and staff did not always address patients in the appropriate manner.
Overall, the trust’s culture was “in places defensive with poor collaboration” between different departments and “high levels of conflict” in some units were reported to CQC.
Sir Mike Richards
The trust was told by the CQC that it must improve mandatory training levels for medical and nursing staff.
It must also ensure medical and nursing staff are “fully trained and able to identify and support the needs” of patients with learning disabilities or dementia.
In addition, it must provide one-to-one care to all women in labour, produce and ratify an end of life care strategy, and send out bereavement surveys to the relatives of patients who have died within the hospital.
In contrast, inspectors found feedback on caring from patients and relatives was generally good and they felt they were treated with courtesy, respect and compassion by staff. Staff maintained patients’ privacy and dignity.
The hospital consistently met the referral to treatment standard and performed better than an average English hospital. The percentage of patients seen within two weeks for all cancers was higher than the national average.
Also, the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment were higher than the national average and above the standard target of 96%.
Trust chief executive Libby McManus, who joined the trust in July, said: “We are delighted that the CQC has recognised the significant and focused work put in by our committed staff and by our partners in the NHS and the community.
“We have already improved patient safety and the quality of care and we will continue to do so,” she said. We want our patients and the local community to know that they can have renewed trust and confidence in the hospital’s services.”
She added: “Our staff are determined to keep on improving with their help and support.”
North Middlesex University Hospital NHS Trust is medium-sized acute trust with around 450 beds. The hospital serves more than 350,000 people living in Enfield and Haringey and the surrounding areas, including Barnet and Waltham Forest.
Kate Osamor, Labour MP for Edmonton, said: “Too many of my constituents are waiting in the emergency department. With over 500 people visiting in any one day, there’s no surprise the emergency department is not meeting its targets.
“The situation has somewhat improved, following the unannounced inspection of the urgent and emergency services in May 2016, when the services were rated ‘inadequate’,” she noted.
But she added: “It is deeply concerning that leadership of the maternity and gynaecology department is deemed ‘inadequate’. Inspectors reported, patients privacy and dignity were not always protected, while safety checks on agency nurses’ were inconsistent and badly managed.”
“The trust requires improvement to demonstrate a safe, effective, caring and responsive hospital,” she said. “The trust needs to respond to the report.”