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Dartford and Gravesham NHS Trust

  • Darenth Valley Hospital, Darenth Wood Road, Dartford, Kent, DA2 8DA

Latest inspection summary

Last inspected 5-6 December 2013

These checks were made using our new inspection model for NHS hospitals. If we are taking enforcement action, we highlight it below.
The ratings below are the result of a pilot undertaken to help us confirm how we will to rate at different levels of an organisation.

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Summary of inspection on 5 and 6 December 2013

Darent Valley Hospital offers a comprehensive range of acute hospital-based services to around 270,000 people in Dartford, Gravesham, Swanley and Bexley. The hospital opened in September 2000. The hospital building is run as part of a private finance initiative. This means the building is owned by The Hospital Company (Dartford) Limited, a private sector company, and the trust leases the building. Darent Valley Hospital now has around 463 inpatient beds and specialties that include day-care surgery, general surgery, trauma, orthopaedics, cardiology, maternity and general medicine. The hospital has a team of around 2,000 staff.

Dartford and Gravesham NHS Trust was selected as part of the Chief Inspectors of Hospitals’ first new inspections as a trust considered to be in the middle ground between low and high risk of poor care. This inspection focused on Darent Valley Hospital.

Dartford and Gravesham NHS Trust is registered for the following regulated activities to be provided at Darent Valley Hospital:

  • Diagnostic and screening procedures
  • Maternity and midwifery services
  • Surgical procedures
  • Termination of pregnancies
  • Transport services, triage and medical advice provided remotely
  • Treatment of disease, disorder or injury.

Since the trust registered with the Care Quality Commission (CQC) in 2010, Darent Valley Hospital has been inspected four times. At the last inspection in November 2012 the trust was found to be compliant with all regulations inspected.

Our inspection team included CQC inspectors and analysts, doctors, nurses, patient ‘Experts by Experience’ and senior NHS managers. Experts by Experience have personal experience of using or caring for someone who uses this type of service. The team spent two days visiting the hospital, and two further unannounced visits were conducted the following week. One of these included an evening/night time visit.

Maternity, outpatients, children’s services and end of life care were found to be good. In all services across the hospital, most staff were committed to the trust and said it was a supportive environment to work. Patients were generally positive about their experience and the care they received.

The trust faced challenges after the recent collapse of merger plans, and it had not yet developed an alternative vision for the organisation. There were a number of examples of good practice and examples of shared learning in the hospital, although in some cases the changes in practice in response to learning from serious incidents took up to 12 months to implement. The main challenge was the demand on the accident and emergency (A&E) department and the rise in emergency admissions. A significant causal factor had been the recent reduction of acute services in the immediate vicinity. The trust was managing issues on a day by day basis but not solving the key underlying problems, in particular bed management/capacity and inappropriate attendance at A&E. It is acknowledged that the trust cannot solve these problems on its own, as they will require a whole healthcare community approach.

The trust had taken action in some areas where staffing issues had been identified. This had included increased nursing staff levels on some wards, an increase in the number of porters in the pharmacy department and the recruitment of additional midwives. In A&E there were insufficient numbers of nurses qualified in the care of children and a high use of locum middle grade doctors, which had the potential to impact on patients’ safety.

Patients’ dignity was being compromised by the continued use of mixed sex wards and facilities in the Clinical Decision Unit where staff told us they always have mixed sex accommodation and the Medical Assessment Unit, which we observed as a mixed sex ward. This also occurred in the intensive care area when patients no longer required intensive care. Patients’ right to privacy was being compromised by personal information being on display in open areas, for example on computer screens in the A&E and confidential information being discussed in public areas such as corridors. The area in the operating theatre where people were received into the department also compromised patients’ privacy and dignity, as it was an open area. Since April 2011, the hospital’s bed occupancy rate had consistently been above the national average of 86.5%, rising as high as 96.1% for the period of April to June 2013. This was impacting on patient safety through the use of additional beds in areas not designed or equipped for this purpose.

In some areas, the trust was considering and implementing national guidelines, but in A&E we found guidance was not always being followed, for example with the management of children’s pain. Also some of the guidance that was available was not the most current such as resuscitation guidelines. Staff told us that the trust was a supportive environment in which to work and that training was available, though its own training records showed that attendance at the trust’s mandatory training was below its expected level. This was as low as 66% in some areas compared to the trust’s target of 85%. There was a system in place to monitor attendance at the trust’s mandatory safety training and follow up non-attendance, but this was ineffective in some cases. There were 285 members of staff whose training was out of date and were not booked to attend a session.

Overall, we found a culture where staff were positive, engaged and very loyal to the organisation. The staff and management were open and transparent about the challenges they faced.

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Background information for inspection on 5 and 6 December 2013

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Inspection areas

Summary of inspection on 5 and 6 December 2013

Medical care, surgery, critical care, maternity, end of life care and outpatients were found to be safe. In other areas staff told us that patients’ safety was sometimes being affected by the hospital’s high bed occupancy and the use of additional beds in areas not designed to be used for patient care. The trust had identified challenges with staffing, and in some cases it had taken action to address the issues. However, concerns remained in the accident and emergency (A&E) department, where there were insufficient nurses qualified in the care of children and a high use of locum middle grade doctors. This had the potential to have an impact on patient safety. Care pathways had been implemented to manage the risks associated with pressure ulcers, venous thromboembolism and urinary tract infections. Most staff were clear about their responsibilities to report incidents, though in some areas staff felt that they did not hear about the outcomes of these. The trust investigated serious incidents and produced reports and action plans. However, it could take the trust up to a year to implement learning. Patients were also being placed at risk in the A&E department due to the layout of the triage facilities in the minors area, the area where people walk in to the department and the lack of clear signage. This meant that patients’ needs may not have been addressed in a timely manner as they had not been triaged or booked into the department. We had no concerns about the way patients were triaged in the majors area of the department.

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Summary of inspection on 5 and 6 December 2013

Maternity, outpatients, children’s services, medical care, surgery, intensive care and end of life care were found to be effective. The integrated discharge team had developed good links with the community and the hospital social services department. This was helping to ensure effective discharge planning for patients on all inpatients areas. In A&E, pain relief was being well managed and assessed for adults but not for children, meaning that effectiveness was not being monitored in line with national guidelines. Guidelines in some areas had been reviewed and updated. However, in A&E there was guidance that was out of date or not the most current version and therefore not in line with national or good practice guidance which had the potential to impact on the effectiveness of care and or treatment. The trust had introduced new initiatives to help with the care and support of patients with dementia that had been effective.

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Summary of inspection on 5 and 6 December 2013

Maternity, outpatients, children’s services, medical care, surgery, intensive care, accident and emergency and end of life care were found to be caring. Patients in all areas told us that they were well cared for, received the information they required and that their questions were answered. In all areas we observed a caring approach from most staff. We also observed that there was a dementia buddies scheme in place, which was supported by volunteers.

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Summary of inspection on 5 and 6 December 2013

The trust demonstrated that it had responded to a number of different issues in order to ensure that people got the treatment and care they needed. These included: the need to ensure effective, safe and timely discharge; staffing levels; the care of patients with dementia; and safe use of naso-gastric tubes. Of concern was that the hospital bed occupancy levels had been consistently above the national average of 86.5%, rising as high as 96.1% for the period of April to June 2013. The trust was actively reviewing its current position, had implemented a number of actions including opening additional beds and was looking at ways to create a sustainable trust for the future. Though there was still the potential for patient’s to be placed at risk if they could not be cared for in the right area to ensure their needs were met in a timely way. There was a complaints system in in place, and it had been reviewed in recognition that the trust had not been consistently responding to complaints in a timely way.

There were occasions when we saw that patients’ privacy was not always respected, with personal and confidential information on display. For example, in open areas in the A&E on computer screens, and discussions were witnessed taking place in open areas and in areas other than the wards where they could be overheard. In the medical assessment unit and the intensive care unit, patients were being cared for on mixed sex wards and in some areas, had to share bathroom facilities with members of the opposite sex. People who were no longer in need of intensive care but not able to move to a general ward also had their dignity compromised by the lack of bathroom facilities available on the unit.

In addition we were concerned that patients’ privacy and dignity was not always respected in the operating theatre. This was because the area where patients were received in to the department was open and more than one patient could be in this area at any one time. We were also concerned by some of the practice observed around the consenting of patients for surgical procedures.

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application/pdf icon Quality report published 7 February 2014 919.79KB

Summary of inspection on 5 and 6 December 2013

The trust faced challenges following the recent collapse of the merger plans, and it had not yet developed an alternative vision for the organisation. There were a number of examples of good practice and examples of shared learning in the organisation. However, in some cases changes in practice in response to learning from serious incidents took up to 12 months to implement. Although senior staff felt that there was an emerging vision, this had not yet been formally agreed. There was said to be a strong executive team that was visible throughout the trust which was supported by staff. The executive team had a clear understanding of the key risks in the organisation, particularly the current situation in A&E and the trust’s occupancy levels. The trust had implemented a number of actions, but there had not been any clear measurable improvements. There were no clear timelines with projected outcomes and impacts.

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CRM ID:RN7

What our icons mean

All standards were being met when we inspected the service. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required improvements.
At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.


What does a grey cross mean

At least one standard in this area was not being met when we inspected the service and we required improvements.

What happens next
The service will tell us how it is making improvements. Once we are happy that the improvements have been made, we will update our judgement to show a green tick. Other times, we may have to carry out a 'follow-up' inspection to check improvements.


How can I get more information
Our inspector's report will give you more information about why the service received a grey cross. You can also contact the service directly or visit its website for more details on any improvements it has made.



What does a red cross mean

At least one standard was not being met when we inspected the service and we took enforcement action.

What happens next
The type of enforcement action we take depends on the seriousness of our inspector's findings, and the service must make improvements before we update the judgement on our website.


How can I get more information
Our inspector's report will give you more information about why the service received a red cross. You can also contact the service directly or visit its website for more details on any improvements it has made.