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Better Care Quality Commission rating reflects wide-ranging improvements

28 February 2017
Kate Ewer, head of communications

West Hertfordshire Hospitals NHS Trust has moved from ‘inadequate’ to ‘requires improvement’, with a leap in the number of services graded as ‘good’ and a dramatic drop in the number rated ‘inadequate’.

The CQC inspection, carried out in September 2016, involved around 50 inspectors who visited all three of the trust’s sites. As well as observing care at close hand, they interviewed frontline staff and the leadership team, spoke to patients and relatives and took soundings from key stakeholders. Before, during and after the visit, the inspection team considered nearly 1,000 documents; policies; patient notes; medical records and additional information in relation to specific questions.

The CQC used five key domain questions for their assessment of the trust, its sites and services – are they/is it: safe; effective; caring; responsive to patients’ needs; and well led. Then, one of four grades is applied to summarise performance against that domain: outstanding, good, requires improvement or inadequate. 

The number of ‘goods’ given as an overall rating or as a grade to show performance against the five key CQC questions has increased from 25 in 2015 to 40 in 2016.

The number of ‘inadequates’ given as an overall rating or as a grade to show performance against the five key CQC domains is now less than half that in the previous year. In 2015 there were 31 ‘inadequates’ – including the overall rating for the trust. The report following the 2016 inspections contains 15 ‘inadequate’ ratings.

Trust chairman Professor Steve Barnett said: “I am delighted with the overall results and even prouder of our staff who continue to drive up the quality of patient care with such great commitment.  

“The inspection in September was just one step in our journey to raise our standards higher still. Nearly seven months have passed and if the CQC visited us now, I’m confident they would see many more improvements resulting in an even better set of ratings.”

Chief executive Katie Fisher said: “At the heart of great patient experience is compassion and so I was really pleased – but not surprised – to see that the ‘caring’ domain for the trust overall has increased from ‘requires improvement’ to ‘good’.”

She said that alongside positive feedback for caring, there was a wealth of evidence about the quality and safety of care provided: “Our consistently low mortality rates put us in the top 10 per cent of the country and our low infection rates are incredibly impressive, with no MRSA blood infection since October 2015.

“Our stroke care has had an A rating in a national audit for the last two reporting quarters and the results from patients who are treated here following hip fractures show a massive reduction in the risk of death following surgery.

“These facts and the improvement observed by the CQC should give confidence that we routinely provide safe and high quality care for hundreds of patients every single day.”

Most of the trust’s inpatients are treated under the service area defined by the CQC as ‘medical care’ at Watford General Hospital. This includes stroke, care of the elderly and general medicine. Medical care is one of six service areas whose overall ratings have moved up from ‘inadequate’ to ‘requires improvement’.

End of life care at Watford General Hospital also achieved the same uplift. Inspectors commended the high level of support provided to patients and their families as well as the way the team kept their practice at or above national best practice guidelines.

There was good news for patients using outpatient and diagnostic services at both Hemel Hempstead and St Albans City Hospital, where the rating for this service has moved from ‘requires improvement’ to ‘good’.

Two areas made a significant improvement by moving up two ratings from ‘inadequate’ to ‘good’. Katie Fisher said: “I must congratulate the teams in maternity & gynaecology and critical care for this incredible achievement. Other services are already learning from their success so that they can follow suit.”

Inspectors commended the trust’s children’s emergency department, the treatment of patients with hip fractures and the hard work of the trust’s estate team in keeping the hospital’s estate as safe and clean as possible and contributing to low infection rates.

However, there were areas where more work is required. Urgent and emergency care at Watford General Hospital was rated ‘inadequate’ for a second year running.

Katie Fisher said: “Whilst individual care is often very good in this area, we know that the experience of patients is not as we would like, particularly when we are busy. We are seeing increases in ambulance attendances of more than 10 per cent and often at a time when our bed capacity is severely limited.

“We are increasing medical and nursing expertise in our emergency department, including using advanced nurse practitioners and we have reviewed our facilities for patients with severe mental health issues. There are plans for the estate which would help us expand the capacity in our emergency department and there is a real determination to provide a better experience for our patients. The work is underway and I am pleased to say that it is being tackled with the level of enthusiasm and dedication that I have come to expect from West Herts staff.”

Despite an ‘outstanding’ rating for the second year running in the ‘care’ domain for children and young people’s services, the overall rating for the service has shifted from ‘good’ to ‘requires improvement’. Inspectors judged that communication in the team needed to be improved around learning from incidents and raising concerns. The level of cancelled appointments was also noted.

Katie Fisher said: “We have taken on board the comments from inspectors and have already made changes to our procedures as well as the leadership arrangements.”

At Hemel Hempstead, there was a mixed picture related to more services (14) being reviewed, compared to eight in 2015. The overall rating has moved from ‘requires improvement’ to ‘inadequate’, despite outpatients & diagnostic services improving one rating to ‘good’.

Katie Fisher explained: “The CQC reviewed the medical care on Simpson ward in 2016 and rated it ‘inadequate’ which affected our overall rating for this site. The inspectors had concerns about whether we had the sufficient leadership and the appropriate level of experience and skills in place to meet the patients’ needs. We took immediate action by supporting the ward with more senior staff and have made changes to the criteria for admission onto the ward. Currently, we are in discussions with Hertfordshire Community NHS Trust on plans which would see the ward accommodating patients who, with some focused care and support, could leave the hospital setting and return home or to the next stage of their care.”

At St Albans City Hospital the overall rating had moved up from ‘inadequate’ to ‘requires improvement’ but for the minor injuries unit the rating was down from ‘good’ to ‘requires improvement’. The inspectors had raised the issue of ‘streaming’ patients in 2015 and did not feel that the trust had made the necessary improvements by the time of the inspection in 2016. The CQC has acknowledged that action has now been taken and that staff are complying with best practice guidelines for seeing patients in line with their clinical need and national standards.

Katie Fisher commented: “We were able to quickly assure the inspectors of the work we had done around streaming. The inspectors noted that 95% of patients attending the minor injuries unit are admitted, transferred or discharged within four hours of arrival at the unit.”

Moving away from specific service areas, inspectors praised progress with recruitment and also noted the percentage of savings made in 2015/16 – these are areas where the trust is bucking the national trend.

The chief executive said: “Reducing our reliance on agency nurses and doctors is great for patient care and is also likely to save around 7m compared to the amount we spent in 2015/16.”

Inspectors were concerned by the high number of inpatients who are well enough to leave hospital but are waiting for arrangements to be put into place for their return home or to a nursing or residential care setting. They observed that this limited the flow of patients through the trust.

The CQC has been assured that the trust will do all it can to improve its own processes, such as providing discharge letters and medication to take home more promptly. However, this is an issue requiring a whole system approach as many factors are out of the trust’s control. Presently, more than 10 per cent of patients occupying beds across the trust are medically well enough to leave but are delayed in doing so.

The CQC observed inconsistencies in the processes and training related to the care of patients with limited mental capacity or where there may be safeguarding concerns. This has now been addressed. In addition, although the CQC could see that improvements had started in the way that risk, incidents and complaints were being managed, more time was required in order to assess whether the changes were effective.

No enforcement actions were issued during the inspection and the vast majority of issues raised by the CQC were addressed immediately or within a matter of weeks.

Members of the Board and the CQC met last week to discuss the report. The meeting was also attended by representatives from Healthwatch, Herts Valleys Clinical Commissioning Group, the General Medical Council, NHS England, NHS Improvement and the Nursing & Midwifery Council.

Feedback from all of these key stakeholders was very positive, praising the commitment and honesty with which the trust had embarked on a journey of significant and tangible improvement.

Referring to whether or not the trust would move out of special measures, the CQC’s view was that at the time of the inspection it was not possible to judge how sustained the improvements were. A re-inspection is likely to be carried out in key areas within the next six months to determine whether the improvements are sufficiently sustained in order for the trust to move out of special measures.

Trust chairman Professor Steve Barnett, said: “There are yearly, monthly, weekly and even hourly metrics which provide myself and the Board with the assurance we need to show that West Herts is on the way up and maintaining our strong focus on providing the very best care for every patient, every day.

“We continue to see success in a range of clinical outcomes. This shows what a dedicated workforce we have. I would like to take this opportunity to thank them for their continued hard work.”

» View the Stakeholder presentation

Notes to editors

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to approximately half a million people living in west Hertfordshire and surrounding areas. It has 681 inpatient beds, approx. 4,500 staff (one of the biggest employers in the area) and in 2015/16 had a revenue of 299.8m. In that year there were 94,530 inpatient admissions and 454,558 outpatient attendances.

The CQC’s report in full can be found:- www.cqc.org.uk/provider/RWG

The tables below summarise the comparison in results between 2015 and 2016’s inspections.

Overall rating following 2016 inspection – requires improvement

domain

safe

effective

Caring

responsive

Well led

rating

Requires improvement

Requires improvement

Good

Requires improvement

Requires improvement

Overall rating following 2015 inspection – inadequate

domain

safe

effective

Caring

responsive

Well led

rating

inadequate

Requires improvement

Requires improvement

Requires improvement

inadequate

Domain ratings covering eight service areas at Watford General Hospital (same number as 2015)

rating

2015

2016

outstanding

1

1

good

11

21

requires improvement

15

14

inadequate

12

3

Overall site rating

inadequate

Requires improvement

Domain ratings across three services at St Albans City Hospital

(14 services were rated in 2016, compared to 13 in 2015)

rating

2015

2016

good

6

7

requires improvement

5

6

inadequate

2

1

Overall site rating

inadequate

Requires improvement

Domain ratings across three services at Hemel Hempstead Hospital

(14 services were rated in 2016, compared to 8 in 2015)

rating

2015

2016

good

3

4

requires improvement

4

6

inadequate

1

4

Overall site rating

Requires improvement

inadequate

Ends

For more information about our hospitals, visit www.westhertshospitals.nhs.uk. You can also join our near 5,324 followers on Twitter (twitter.com/westhertsNHS) or find us on Facebook (facebook.com/westhertsNHS).

  1. For more information, please contact Kate Ewer, Head of communications on: 01923 436 280 or email: info@whht.nhs.uk. Out of hours, please call 07900 228 031.
  2. For more information about our hospitals, visit www.westhertshospitals.nhs.uk. You can also join our 5,000+ followers on Twitter (twitter.com/westhertsNHS) or find us on Facebook (facebook.com/westhertsNHS).