We visited the emergency department, acute admissions unit (AAU,) a surgical ward, a medical ward, the stroke ward, a dementia ward, an orthopaedic ward and reviewed the governance services. We spoke to 29 patients who used service, 40 members of staff and members of the executive team.

People were mostly satisfied with the care they received. In most cases people were complimentary about the attitude of staff. We found that the trust had responded to concerns around mortality at the trust. Overall mortality rates at the trust had improved.

We found concerns with cleanliness and infection control across four departments visited. We found blood stains on the floor in one area that has not been cleaned. We noted it had dried to the floor at the time of being seen, therefore had been there for some time.

On the AAU we found areas of concern around staffing that were not consistent with our findings in the other areas visited. We were told by the executive team that the day of our visit was one of the busiest days for admissions.

We found that the governance and quality monitoring services were not effective. Concerns were identified about whether appropriate action in relation to risk management had been taken by the trust.

We found that the organisation was well led. The Executive team had responded well to areas of concern. Whilst reactive improvements were noted, long term sustainability will be monitored by the Commission.

The people we spoke to were happy with the care and treatment they had received at Watford General Hospital. They told us that their treatment had been explained to them and that their care had been delivered in a manner that promoted their dignity and independence. We were told that the staff were ‘wonderful’ and that they were ‘kind and caring and would do anything to ensure you were as comfortable as possible’. Some people told us that they were concerned about the patients who had a memory loss or a dementia and they told us ‘that they found their crying in the night sad and disturbing’.

We saw that staff were aware of infection control and that the hospital had systems in place that ensured that staff and visitors were aware of the risks of cross infection. Staff were aware of their duty of care to vulnerable adults and to children.

All the wards had protected meal times and there were systems in place to monitor, the food and fluid intake of the people.

All the people had care plans and risk assessments as appropriate.

We found that there were systems in place to assess and monitor all aspects of the running of the hospital.

Staff consistently told us that they found if increasingly difficult to meet the needs of the patients and that they worried about how they deliver care to people now and how they would cope in the future if the staffing levels were not reviewed.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

The parents of the children who use the service told us that they are very happy with the service. We were told that the staff are wonderful and that they are competent, calm, confident. We were told by the family of one child that the staff calm us in a very stressful situtation. We were told that the family felt the the staff were on the journey of caring for the sick child with them.

We did not receive any information from people who use the service during this review, and did not actively seek their views in this instance as this was not seen as an appropriate method of seeking evidence in the specific issues that had been raised about the service.

At this inspection, we inspected urgent and emergency care, medical care, surgery and maternity. We did not inspect urgent and critical care, services for children and young people, end of life care or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

Our rating of services stayed the same. We rated it them as requires improvement because:

• Our rating for safe remained requires improvement overall. Mandatory training compliance did not meet the trust target of 90% and safeguarding adults and children training compliance was below the trust target for medical staff.
• Our rating for effective remained good overall. The trust was not meeting the target of 90% for staff receiving appraisals, with one area at 54.6%. There remained a lack of monitoring of patient outcomes and compliance with evidence-based protocols in the UCC and MIU. This had previously been identified by the Care Quality Commission as an area which required improvement.
• Our rating for caring remained good overall. All services were rated good for caring. Staff cared for patients with compassion, kindness and respect. Feedback from patients and those close to them was positive about the way staff treated them. Patients felt supported and cared for by staff. Staff provided emotional support to patients to minimise their distress.
• Our rating for responsive remained requires improvement overall. Not all patients could access services when required. In ED, waiting times to be seen for treatment were generally higher (worse) than the England average. In surgery, waiting times from referral to treatment and arrangements to admit treat and discharge patients were not in line with good practice. In maternity, delays were reported in antenatal clinic waiting times (ANC) and Triage waiting times which had continued to be a theme from complaints. Complaints were not dealt with in a timely manner across the urgent and emergency care services, nor were lessons learned and shared at the MIU.
• Our rating for well led improved to good overall. Some of the issues identified in our 2017 inspection had not been resolved. For example, inpatient areas had patient names displayed on white boards in areas visible to visitors walking onto the ward. Service enhancements and improvements had not been sustained at the MIU and UCC. The ED did not have effective arrangements in place to ensure information used to monitor, manage and report on performance was accurate. Information was of a poor quality with a reliance on manual processes to extract data at the MIU and UCC; this was labour intensive and did not allow for real-time reporting.