North Middlesex University Hospital

Updated 16 May 2025

The North Middlesex University Hospital is a medium-sized hospital with 633 beds and employs just under 4,000 staff, serving a population of around 640,000 people living across Enfield and Haringey. As of 1 January 2025, North Middlesex University Hospital has become part of the Royal Free London group. The hospital provides a range of NHS hospital services, this assessment looked at Maternity services. We carried out this unannounced focused inspection on 28 and 29 January 2025 as a follow-up of the inadequate rating in 2023. 

The rating from Maternity has been combined with ratings of other services from last inspections. See our previous reports to get a full picture of all other services at North Middlesex University Hospital. The rating of the hospital remains requires improvement. 

Updated 28 January 2025

The North Middlesex University Hospital is a medium-sized hospital with 633 beds and employs just under 4,000 staff, serving a population of around 640,000 people living across Enfield and Haringey. As of 1 January 2025, North Middlesex University Hospital has become part of the Royal Free London group. Maternity services are provided at this site. North Middlesex University Hospital’s maternity unit comprises of a consultant led labour ward, a midwife led birthing unit and a joint maternity antenatal and postnatal ward. Outpatient services are also provided in the maternity day unit, triage unit, antenatal clinic and in the community. From January to December 2024, there were 3,387 babies born at this hospital.

We last inspected maternity services at North Middlesex University Hospital on 24 May 2023 as part of the national maternity inspection programme. We inspected the safe and well-led domains and rated both as inadequate. The trust took immediate action to address the concerns, and we received information to demonstrate this.

We conducted this unannounced focused inspection on 28 and 29 January 2025 as a follow-up of the inadequate rating in 2023.

We spoke with various members of the maternity team including maternity assistants, junior doctors, registrars, consultant obstetricians and anaesthetists, student midwives, band six and seven midwives, specialist midwives, consultant midwives, safeguarding and perinatal mental leads for maternity, matrons and the quadrumvirate. We received feedback from two women and birthing people who had used the maternity service

Safe:

The service did not always have a good learning culture. Managers did not always make sure medical staff completed mandatory training. Managers did not always manage incidents appropriately. Red flag data was not always submitted accurately. The facilities did not always meet the needs of people. Control of substances hazardous to health standards were not always followed.

However:

Managers made sure midwifery staff received mandatory training and regular appraisals to maintain high-quality care. People were protected and kept safe. There was enough equipment to meet the needs of people. Which were improvements from the last inspection.

Well-led:

Staff did not always feel supported to give feedback and were not always treated equally, free from bullying or harassment. The service did not manage cultural issues raised by staff in a timely manner. Governance systems were not fully embedded. People with protected characteristics did not always feel supported.

However:

Leaders and staff had a shared vision and strategy. Leaders were visible and knowledgeable. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. Which are improvements from the last inspection.

Continued breaches were; medical staff training compliance, timely data submission to external bodies, leadership, poor culture within the service and the absence of a fully operational governance team.

Updated 28 March 2024

Updated 25 October 2019

• We found inconsistencies in stock management of medicines across the service except for Sunrise ward. On Rainbow ward we found a significant amount of expired medicines on the resuscitation trolley and grab bag despite the monthly check being completed the night before the inspection. Therefore, we were not assured there were comprehensive governance processes in place at ward level.
• Although the service had dedicated staff member in place to monitor paediatric and neonatal guidelines, we found many of the paediatric policies were out of date. Examples included Management of Febrile Neutropenia (April 2019) and Extravasation of Cytotoxic Medicine (April 2019).
• During this inspection we were told about the backlog for discharge summaries of which the oldest dated back to October 2018. Although the trust submitted information after the inspection to confirm the backlog had been cleared, we were not assured at the time of the inspection that appropriate risk assessments had taken place as only a 10% sample was reviewed with no target date set to clear the back log.
• The CYP service did not have a non-executive director to represent the service at trust board level. This meant the trust had limited oversight of the performance, issues and risks in the service.
• Although the trust had made some improvements to ensure there was at least one nurse per shift in each clinical area who was trained in advanced paediatric life support (APLS), the trust’s work was still ongoing during our inspection.
• We reviewed 24 records across all the CYP areas inspected and found inconsistencies with the quality of documentation. For example, staff did not always follow trust policy when completing paediatric early warning score (PEWS) observations and the records did not include any narrative to explain why.

However:

• The trust had addressed the previous requirement notices from the last inspection and had made improvements in the mandatory training rate compliance, security of Rainbow ward and the appraisal completion rate.

• During the last inspection we advised the trust to ensure that staff had adequate mental health training including the Mental Health Act. On this inspection, we found the trust had made improvements to address this. Staff in paediatrics were receiving training in Mental Capacity Act (MCA) at the time of the inspection and the trust had started a ‘We can talk’ programme which provided mental health training for all staff.
• Staff understood how to protect children and young people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• 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 and took account of patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.

Updated 14 September 2018

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

• Nurse staffing levels consistently met minimum standards set by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS). The matrons had significantly reduced nurse vacancies in the previous 12 months and at the time of our inspection there were no vacancies for staff nurses or senior staff nurses.
• Since our last inspection there had been significant improvements in the working culture of the unit which resulted in more motivated staff and a stabilised team.
• A new sustainability strategy included a nurse leadership development programme, an increase in the number of education and audit nurses and a new research programme from July 2018.
• Fire safety training and practices had been significantly improved since our last inspection and a dedicated fire officer led new strategies and standards. Where we found areas for more embedded improvement, we were assured of swift action.
• The unit was highly rated in most areas by a critical care network peer review in November 2017.
• In May 2018 the unit was rated as fourth highest performing area in the hospital’s ‘perfect ward’ quality audit tool, reflecting 97% overall.
• A dedicated audit and research team led innovative projects and studies to identify strategies to improve patient care and outcomes. They also contributed to the Intensive Care National Audit Research Centre (ICNARC) and ensured the audit programme effectively benchmarked practice. The unit was not a national outlier in any measure.
• We found consistently good standards of risk assessment in patient documentation and in practice observations, including in relation to sepsis management.
• The team demonstrated a proactive, motivated and multidisciplinary approach to learning from incidents, including the introduction of innovative or exploratory solutions.
• Feedback from patients and relatives overall was positive and people told us staff delivered care with privacy and dignity.
• Overall 2% of patients experienced a non-delayed, out-of-hours discharge to a ward. This was a significant improvement of 8% from the previous year.
• The unit received low levels of complaints, with six received between June 2017 and June 2018.
• There was a coherent leadership structure in place and all staff said they felt supported and respected.
• The senior team encouraged staff to be involved in audits and research, which they designed to improve patient experience and outcomes.

However:

• Doctor staffing levels did not meet FICM or ICS minimum standards during out of hours periods, including periods when the ratio of junior doctors to patients was 1:23.
• Although we saw several areas of improvement, we were not assured these were fully embedded or consistently followed. This included with regards to fire safety in the environment, infection control standards, dementia screening and application of the Mental Capacity Act (2005).
• The unit could not demonstrate consistently good practice in relation to infection control, including with hand hygiene.
• Staff did not classify incidents consistently, which meant the senior team did not have assurance of a tracking system to identify trends and themes.
• There was evidence from various sources of a need to further improve communication between doctors and nurses, including from incident reports and a critical care network peer review.
• We found inconsistent and variable understanding of the Mental Capacity Act (2005) and of mental capacity assessment protocols.
• The service had not successfully addressed long-term recurring instances of out of hours and delayed discharges.
• At our last inspection in September 2016 we rated critical care as requires improvement overall, which reflected good in effective, caring and responsive and requires improvement in safe and well led.

After that inspection we told they trust they should improve the following areas:

• Staff knowledge of safeguarding policies and procedures.
• Nurse to patient ratios.
• Support and supervision of staff.
• Demonstration of appropriate personal skills by staff when delivering care.
• Learning from infection prevention and control audits.

At that inspection we also found several issues with fire safety in the unit, including a lack of named fire wardens, a lack of staff training, incomplete electrical safety testing and a risk assessment action plan that had not been completed. A large number of staff had spoken with us on the condition of anonymity to raise concerns about the working culture and leadership. At this inspection we found the trust and critical care team had begun to address these issues, with some areas still in progress.

To come to our ratings, we spoke with 27 members of staff in a variety of roles and levels of seniority as well as five patients and two relatives. We reviewed the care records of 11 patients and looked at over 45 other pieces of evidence, including the minutes of meetings and audit records. We spent time observing staff deliver care and attended handovers, ward rounds and meetings.

Updated 14 September 2018

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

• The SPCT operated Monday to Friday 9am until 5pm. During our previous inspection, they were working the same hours; this does not follow national guidance which states a seven day face to face service should be provided for palliative and EOLC patients. The trust had approved a business case to allow this service to comply with national guidance, however the SPCT was still to fully recruit.
• We found cleaning fluids that should not be in use following a European Directive, were still being used by the trust. Sharp and dangerous items were being washed by hand in this disinfectant and this posed a health and safety risk. There were no risk assessments, SOP’s or IPC policies associated with the mortuary. Items of equipment were being reused, when disposable items were available and should have been used.
• Within the mortuary, we found specimens stored in formalin were being kept in a non-ventilated room with no immediately accessible fire extinguisher. We were informed an IPC assessment and a risk assessment of the mortuary would take place as soon as possible.
• Palliative and EOLC patients not under the care of the SPCT did not always have a mental capacity assessment (MCA) completed prior to a do not attempt cardio pulmonary resuscitation (DNACPR) order being considered.
• Not all palliative or EOLC patients were given a treatment escalation plan (TEP). The SPCT also felt they needed to improve their processes to ensure all palliative and EOLC patients were offered advanced care planning (ACP) options to ensure they achieved their preferred place of care (PPC)/ preferred place of death (PPD).
• Psychological support was available to all patients that were palliative and end of life; however, patients with cancer were offered counselling as a separate service and those patients with a terminal non-cancer diagnosis were offered counselling with the SPCT or chaplaincy instead. This was not an equivalent service and therefore non-cancer patients did not receive the same level of psychological care as those with a cancer diagnosis.
• The chaplaincy and faith provision within the trust was mainly available for Christian and Muslim faiths. Some other religions were catered for by way of a religious script, however this was not always seen or available. We commented on this during our previous inspection, however no changes had been made.
• We noted during our 2016 inspection that the multi-faith room was used as a trust meeting room. This meant it was unavailable to those who may have required access at various times. We brought this to the attention of the chaplaincy, however, we found on this inspection the room was still being used for meetings.

However:

• Incidents and complaints for palliative and EOLC were being recognised by the trust and the SPCT. They had worked with the complaints team to capture trigger words that would send the incident to the SPCT. They were reviewed, investigated, and the learning was disseminated to the rest of the team and the trust. This was an improvement since our last inspection.
• The trust had introduced innovative approaches to improve care; this included a flickering LED candle and an explanation being placed on the reception desk of each ward that had an EOLC patient. This alerted other people to the situation so that they were more mindful and would keep the ward more peaceful for the patient and their family.
• Controlled drugs (CD’s) and syringe drivers were appropriately maintained, stored and used by the SPCT and wards. The CD’s were checked daily and in line with national guidance.
• Pain relief was available as and when required by all palliative and EOLC patients. To cover out of hours situations, the SPCT did anticipatory prescribing for their patients as appropriate.
• Since the 2016 inspection, the speech and language therapists (SLT) team had become more involved with patient care and decision making than before. They were more involved with palliative and EOLC patients.

Updated 14 September 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

• The OPD leadership team advised it did not have any risks on the divisional risk register and did not hold a local risk register. This meant that the department had no sight of any risks within the department which did not reflect our findings on inspection such as staffing levels, paediatric patients being treated in the OPD, and lost or missing records.
• The OPD leadership team had a plan to improve patient services and an implementation plan in place. Both programmes were in the early stages of being rolled out. The leadership team was new with the clinical lead and acting head of OPD being in post less than 3 months and not yet had the time to make the improvements. This was similar to the last inspection.
• The matron for the OPD was not responsible for all the clinics that operated out of the department which mean there was lack of oversight across the whole department.
• Senior managers could not be assured that OPD staff were learning from incidents across the trust. A review of OPD nursing, administrative and phlebotomy staff meetings showed incidents were not discussed.
• The trust did not monitor waiting times for patients, and this was one of the main concerns raised by patients that we spoke with during the inspection. Patients told us that there waits had varied from 15 minutes to an hour.
• Staff reported that they did not feel able to report incidents of verbal and physical abuse against them and did not feel they had as they had the same rights as patients. They did not report these incidents at times because they did not think their voice would be heard.
• Staff felt there were limited opportunities for progression within the OPD as it was a small staff team. Staff also reported there were limited learning and development opportunities and felt they were missing out on professional development. This was similar to the last inspection.
• Staff we spoke with did not always demonstrate understanding of the safeguarding process. Staff in areas where children under age 18 attended were not aware who held Safeguarding level 3 training.
• Safeguarding adults level 2 training were below the trust target of 90% for the fracture clinic (86%) and phlebotomy staff (40%). Safeguarding children level 2 level training for phlebotomy staff (81%) was also below the trust target.
• Mandatory training in key skills for staff within the phlebotomy was below the trust targets of 90% in seven of the eight core areas. The overall completion rate was 50%.
• There was no clear responsibility of who oversaw the cleaning of the children’s play areas or documentation to support this. Daily clinical and environmental schedules were not available in all the clinics, which meant the trust could not be assured that daily cleaning was being undertaken by staff in outpatients. This was similar to the last inspection.
• Paediatric resuscitation equipment or paediatric resuscitation medications were not in areas where paediatric patients were seen.
• There was no baseline acuity tool for nursing staff in outpatient clinic as staffing levels were based on the number of clinic that are run. Senior staff advised that the staffing levels within the OPD clinics were had not been reviewed whilst the number of clinic operating had increased. This was similar to the last inspection.
• We did not see any evidence of appropriate tools for patients that were non-verbal, with learning disabilities, or dementia. In the pain management clinic there were no standardised pain assessment tools available.
• Nursing staff we spoke with reported there were some limited learning and development opportunities, but frequently they were unable to attend due to staff shortage and there was not cover.
• Across the OPD we saw little evidence of health promotion information available for patients.
• During the inspection we observed that people could be over heard when reception staff checked people’s personal data on the electronic record, there was no signage asking people to wait at a discrete distance from the reception.
• The outpatient department did not have a dedicated room that could be used when breaking bad news or holding private conversations.
• Signage in the department was not always clear; it was not always clear where patients should sit in the main waiting areas. We also observed that patients were getting lost as some of the signage directing patients to clinics were not clear.
• There were very few information leaflets for patients, relatives and carers available in other languages other than English. This was similar to what we found at the last inspection.

However:

• The Trust was meeting the cancer waiting times for people seen within 2 weeks of an urgent GP referral performing better than the 93% operational standard for the period January to December 2017 for people being seen within two weeks of an urgent GP referral. Performance deteriorated in the latest two quarters from July to December 2017 although it was still above the operational standard.
• The trust was meeting the referral to treatment time of seeing patients within 18 weeks. From March 2017 to February 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways was consistently better than the England overall performance. The latest figures for February 2018 showed that 92.6% of patients were treated within 18 weeks versus the England average of 88.9%.
• Staff described good team and peer support; they felt they worked well as a team. We observed good interactions between nursing, administrative, medical staff, patients and relatives working together to achieve good outcomes for patients.
• We found that suitable arrangements were in place for the secure storage of prescription sheets and FP 10’s prescription pads as these were locked away at night and put into rooms at the start of clinics.
• Records reviewed showed evidence that consent was gained for care and treatment where appropriate.
• Staff were aware of their roles and responsibilities under the Mental Capacity Act 2005 (MCA) regarding mental capacity assessments and Deprivation of Liberty Safeguards (DoLS). Staff knew how to contact mental health liaison service
• Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were seen to be very considerate and empathetic patients. Patients we spoke with were positive about the staff that provided their care and treatment.
• Patients who were living with dementia, had a learning disability, or suffered from mental ill health would be identified on their patient records and given priority in clinic to be seen quickly.
• Staff were able to signpost patients to chaplaincy and counselling to patients who needed them, and nursing staff were available in some clinics to offer support.
• Patients told us staff helped them to understand their care and treatment, and that medical staff took time to ensure they answered their questions and felt confident in treatment.

Updated 14 September 2018

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

• The trust had dealt with areas we highlighted as needing to be improved in our previous inspection in September 2016. For example, in our previous report we reported that patients with pressure ulcers had not had the incident electronically logged. During this inspection we found he trust had not had any incidents of grade 3 or 4 pressure ulcers in the previous 12 months. However, staff were aware of the procedure for logging pressure ulcers as incidents.
• In our previous report we reported that the reporting of actions from mortality and morbidity meetings was not formalised to allow learning and actions shared across the trust. During this inspection we found the trust had introduced actions logs and a named member of staff had responsibility for disseminating information across the trust.
• There was evidence of learning from ‘Never Events’ and incidents. In our previous report dated September 2016 we reported that actions in response to never events were not fully implemented. However, during this inspection we found the trust had addressed this and clear action plans were in place and monitored by the trust.
• Records were complete, well managed and stored securely. During our previous inspection, we found there was a lack of clarity in how changes to theatre lists were communicated to doctors and theatre staff. During this inspection we found this had improved as theatre lists indicated any changes implemented to the lists following dissemination to staff.
• During our previous inspection we reported that the hospital did not comply with national guidance, Health Building Note 26 (HBN 26). However, work was in progress on a review of the catheterisation laboratory (cath lab) location to ensure the hospital met the requirements of HBN 26.
• In our previous inspection in September 2016 we reported that theatre utilisation was low. In response theatres were monitored to determine reasons for delays. For example, theatre start and finish times were monitored.
• In our previous report we reported that the departmental risk register did not fully indicate
• how risks were mitigated and who was responsible for implementing actions. However, during this inspection we found the risk register contained mitigation of risk and a named person with responsibility for the risk.
• We also found that staffing was sufficient to meet the needs of the patients. Staff moved across surgical services to ensure safe nursing staffing levels could be maintained. The trust used locum staff where required, there had been no unfilled medical shifts in the previous 12 months.
• Patients and relatives told us they felt involved in decisions about their or their loved-ones care and treatment. We spoke to 12 patients across the surgical wards who felt the staff were friendly and listened carefully to their needs.
• Patients’ needs were assessed and care was evidence based. Care delivery reflected national best practice guidelines. The trust had introduced a range of new clinical pathways since our previous report in September 2016.
• Patients’ outcomes were monitored and compared with similar services. The service contributed to national clinical audits. This had resulted in theatres reporting 100% compliance with the WHO checklist.
• The service contributed to national clinical audits for surgery. The overall performance for elective admissions was better than the England average.
• There was good multidisciplinary working within different speciality surgery services. Staff from the surgical assessment unit (SAU) attended bed meetings with staff from the emergency department (ED). Risk assessments were reviewed at the meetings for all ‘outlier’ patients; these are patients who are in hospital wards that do not provide specialist care for their conditions.
• Most staff had received annual appraisals. From February 2017 to January 2018, 90% of staff within surgery at the trust had received an appraisal compared to a trust standard of 90%.
• Patients pain was managed effectively. The staff told us they had good access to pain management advice from the trust’s acute pain service following patients’ surgery.
• Staff were caring and compassionate to patients’ needs. For example, from February to April 2018 Ward S3 achieved a response rate of 58%, with 100% of these patients responding they would recommend the service.
• Patients we spoke with feedback were continually positive about staff and the care they received.
• Patients received care that was centred on their individual needs. The trust had good support arrangements for patients with additional needs.
• Divisional and team leaders had the capacity and capability to run a service providing quality sustainable care.
• There was a strategic vision for surgery. The surgery and cancer division had produced divisional objectives for 2018 and 2019.
• There was a supportive, honest and open culture among staff. Candour, openness, honesty and transparency were evident throughout the service.
• There was an effective governance structure in place. There was a divisional dashboard which included all key performance indicator (KPI) metrics. A divisional performance report was produced monthly and shared with the trust’s board.

However:

• We found training compliance was not meeting the trust’s standards in some mandatory training modules. For example, 54% of staff had completed PREVENT, this is training to identify and prevent radicalisation.
• During our previous inspection we reported that Individual venous thromboembolism risk
• assessments (VTE) were not fully completed. During this inspection we identified that staff were still not recording VTE assessments fully. However, in mitigation the trust had identified this and work was in progress on the rolling out of new VTE assessment tools to simplify recording processes.
• In our previous report dated September 2016 we reported bowel cancer patients’ related data suggested the risk-adjusted two-year post-operative mortality rate was much higher than the national average. Staff said the trust was of the opinion that there were discrepancies with the trust’s data submissions. In response a data clerk had been appointed in 2017 to rectify the issue. The trust also highlighted that individual surgeons had published mortality outcome measures that fell within accepted ranges.
• During our previous inspection we reported average length of stay at the hospital was longer than the England average for elective trauma and orthopaedics, general surgery and urology patients. The trust said this was due to a coding issue and procedures in coding had been changed in response. However, the change in procedure wouldn’t be reflected in results until 2018 data was published.
• Signage on lifts and corridors in the hospital’s tower block did not direct patients, staff and visitors to the correct surgical service.
• Complaints were not always closed in accordance with timescales set out in the trust’s complaints policy.

Updated 25 October 2019

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

• The service had suitable premises and equipment and looked after them well.
• Staff understood how to protect patients from abuse and the service worked collaboratively with other agencies to do so. Staff underwent training on how to recognise and report abuse and they knew how to apply it.
• The majority of nursing staff received up-to-date mandatory training. The overall mandatory training compliance for nursing staff was 92.7% which was better than the trust target of 90%.
• The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
• The service made sure staff were competent for their roles. Patients were cared for by staff with the right qualifications, skills and knowledge to provide safe care.
• The emergency service was planned and delivered in a way that met the diverse needs of the local and surrounding population. Patients’ needs and preferences were considered and acted on to ensure services were delivered to meet those needs.
• Staff understood the impact of patients care, treatment or condition to their wellbeing and those close to them. Staff provided emotional support to patients to minimise their distress.
• The trust and service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
• There was a culture and focus of continuous learning, innovation and improvement in the service to improve patient outcome.
• There were effective systems of governance that looked at quality and performance. Staff understood their roles around governance and there were structures for reposting and sharing information from the department to the division and board and down again.

However, we also found areas for improvement:

• Adult immediate life support level 3 for nursing staff was 71% and worse than trust target of 90%. There was low compliance for the medical staff on all the paediatric and adult intermediate and basic life support trainings (73%) and on fire safety (74%).
• There were systems and processes to control and prevent the spread of infection and the department was visibly clean, tidy and free of any odours. However, the service did not control infection risk well and staff did not always adhere to good hand hygiene practice.
• Staff did not always follow systems and processes when safely prescribing, administering, recording and storing medicines. Medicines were not always within the use by date and had been administered to patients after they had expired.
• Staff did not always complete risk assessments for each patient swiftly and updated the assessments to minimise patients’ risk. However, staff identified and quickly acted upon patients at risk of deterioration.
• From April 2018 to March 2019, 79% of required staff in urgent and emergency care received an appraisal which was below the trust standard of 90%. During inspection the appraisal rates for medical staff (23.3%) and paediatric nursing staff (80.1%) were not compliant with the trust standard in the new annual appraisal cycle.