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Darent Valley Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 March 2018

Our rating of this hospital stayed the same. We rated it as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 28 March 2018

Effective

Requires improvement

Updated 28 March 2018

Caring

Good

Updated 28 March 2018

Responsive

Requires improvement

Updated 28 March 2018

Well-led

Requires improvement

Updated 28 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 2 July 2014

The main outpatients department was a large area, with good access and seating for patients. Patients received effective treatment and information and felt happy with the care they received. The trust was monitoring appointment targets for waiting times and clinic start and finish times. It had sought the views of patients, and we saw that it had listened and responded to patient feedback by changing the layout of the department. Clinics were well managed and organised. When unavoidable delays occurred and clinics ran late, staff kept patients informed and provided them with information. Staff told us that they received training and supervision to enable them to provide effective care. All staff we spoke with told us that outpatients was a positive environment to work in.

Maternity

Good

Updated 28 March 2018

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

  • Overall, medicines were managed. The pharmacist visited daily and checked drugs and administration charts.
  • Incidents were discussed at handovers and morning meetings.
  • All staff we spoke to were aware of their responsibilities relating to Duty of Candour under the Health and Social Care Act (Regulated Activities Regulations) 2014.
  • Overall, care was being provided in line with the National Institute for Health and Care Excellence quality standards. We saw evidence that all guidance and policies within maternity services had been reviewed and were based upon current guidance.
  • The trust had achieved level three United Nations Children's Fund Baby Friendly accreditation in January 2018. The Baby Friendly Initiative is based on a global accreditation programme of United Nations Children's Fund and the World Health Organisation.
  • The maternity services key performance indicator dashboard recorded the service were consistently better than the trust’s target rate of 5% for third and fourth degree perineal tears during labour. (A perineal tear is a laceration of the skin and other soft tissue structures that, in women, separate the vagina from the anus).
  • Between April 2016 and March 2017, the total number of caesarean sections was as expected. The standardised caesarean section rates for elective sections as expected and rates for emergency sections were as expected.
  • There were comprehensive training and education opportunities available to staff. The trust employed two dedicated maternity education lead midwives. New midwives joining the trust completed a comprehensive preceptorship programme.

  • All supervisors of midwives were transferring to the professional maternity advocate role. Professional maternity advocate are experienced practising midwives trained to support and guide midwives to deliver care developed nationally and locally.
  • The October 2017 maternity newsletter informed staff of a new pathway for the mother and infant mental health service and gave staff guidance on how to refer to the service. Maternity services had recently been allocated a consultant psychiatrist for one day a week. The service also had a lead mental health midwife.
  • There had been no maternity unit closures between September 2016 and October 2017.
  • Complaints were responded to and closed in less than 25 workdays.
  • The antenatal unit was midwife led. Staff were committed to providing and promoting normal birth. Most women we spoke with told us they felt involved in planning and making decisions about their care.
  • We found a positive culture in maternity services. Staff reported that they felt supported by their immediate line management and that they had good working relationships with other specialties in the hospital.
  • Maternity had a dashboard that was used to monitor key performance indicators. The service’s strategic goals were monitored via the clinical solutions meeting. The meeting looked at maternity key performance indicators’ and decided strategy to meet or improve the Key Performance Indicators.
  • The maternity service had completed actions to meet the requirements of the ‘saving babies lives’ care bundle, with the aim of reducing stillbirths, neonatal deaths, and intrapartum brain injuries.

However:

  • The maternity education department specific database was not aligned to the trust’s mandatory training spreadsheet.
  • The ‘strategic and operational cleaning plan’ was out of date and overdue for review.
  • There was a lack of obstetric theatre nurses and operating department practitioners, 24 hours a day seven days a week, to support the anaesthetist if required. The service audited the use of theatre two between February and October 2017. The audit found in theatre two it was predominantly midwives scrubbing (86%), with most of these midwives (77%) coming from the delivery suite. In 23% of cases, midwives had to be utilised from other ward areas.
  • The midwife to birth ratio was 1:36, (this means there was 36 births to one midwife), this was identified on the trust’s risk register. The risk register acknowledged the midwife to patient ratio was not at the agreed level according to Birthrate Plus. The risk register also recorded that increasing case complexity and a high midwife to birth ratio increased risks to women and babies; the risk register also recorded that only one part time scrub nurse was available on the delivery suite. Following our inspection the trust informed us there were processes in place to mitigate the risk from the midwife to birth staffing ratio.
  • In June 2017, the proportion of consultant staff reported to be working at the trust was lower than the England average. The proportion of junior, foundation years one and two, staff was higher than the England average.
  • A never event involving a retained swab had occurred at the weekend, in October 2016. However, this followed a previous incident involving a retained gauze ball in August 2016 which was downgraded from a never event to serious incident. The service showed us evidence of the learning being communicated to staff following the retained swab event. However, learning from the October 2016 event had not been timely.
  • The trust was in the process of moving to electronic records. Staff told us there were issues with records being scanned onto women’s electronic health records, and records sometimes went missing for up to two weeks during transit to scanning.
  • The risk register did not contain timescales for when identified actions should be completed.

Maternity and gynaecology

Good

Updated 2 July 2014

We found that the midwifery unit provided safe and effective care for women. Feedback from women using the service was positive. They told us that staff were kind and sensitive to their needs and that they were given effective advice and support in their chosen method of feeding their babies. The service was well led with clear shared goals and objectives which were known to all staff we spoke with. Women said they had been well supported throughout their stay in the maternity services.

Medical care (including older people’s care)

Requires improvement

Updated 28 March 2018

Our rating of this service went down. We rated it as requires improvement because:

  • Staff did not have the required level of safeguarding training.
  • We saw poor adherence to infection control policies and these were not correctly monitored for compliance. Audit results were not consistent with what we witnessed on inspection. Wards were not always clean and infection prevention methods were not consistently used.
  • Maintenance of equipment was not in-line with trust policy or national guidance. We saw equipment that was not well maintained and not consistently cleaned to ensure the spread of infection was minimised.
  • Staffing was not always consistent, to allow for continuity of care and seven day working.
  • The use of escalation beds meant patients were sometimes cared for in beds that were not suitable, for example had no lighting and doorbells were used in place of call bells.
  • We saw wards still had mixed sex bays or shared toilet and shower facilities. This was a breach of our regulations and staff did not demonstrate an understanding of this regulation.
  • There was no clear vision and not all staff were aware of the departmental changes going forward.
  • We saw several breaches of confidential patient information across the department. This included patient information left displayed on screens and discussions about patients held in open areas.

However:

  • We saw good multidisciplinary working and patient focused staff. The needs of patients were considered at all stages of their treatment, both physically and psychologically.
  • Patients who required extra assistance or had specific needs had these met wherever possible. 

Urgent and emergency services (A&E)

Requires improvement

Updated 28 March 2018

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

  • Staff were not meeting the trust mandatory training targets.
  • Safeguarding processes were not effective at ensuring patients were protected from the risk of abuse.
  • Poor infection control standards went unaddressed.
  • There was a lack of robust audit to monitor and improve care quality.
  • Managing flow throughout the hospital presented as a challenge. This had a significant impact on the department’s ability to care for patients during busy times and to meet its national targets.
  • The systems and processes to learn from incidents and complaints were not embedded and therefore not being used to prevent recurrence or improve the service.
  • The chair patients on Cypress ward shared mix sex accommodation. At busy times, this area lacked space which meant patients dignity and confidentiality was not maintained.
  • There was a lack of nurse leadership and oversight in the department. A general manager and deputy had the leadership responsibility for urgent and emergency care and medicine. We considered the current structure and managerial approach to unsustainable, a risk to the organisation and staff personal wellbeing.
  • We were not assured the governance and risk management systems were effective.
  • Medical records were not stored securely.
  • Staff morale was low.

Surgery

Requires improvement

Updated 28 March 2018

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

  • Staff did not have the correct level of child safeguarding training, which ensured people were protected from the risk of abuse.
  • Compliance with mental capacity act training was poor amongst nursing staff. This meant they nursing staff may not be able to recognise patients or care for patients who lacked capacity.
  • Staff do not recognise incidents or near misses and did not always have time to complete incident forms.
  • There was evidence of learning from never events however, there was little evidence of learning from other incidents or action taken to improve safety.
  • Patients dignity, respect and confidentiality was not maintained in theatres.
  • Staff did not assess, monitor or manage risks to patients who use their services. Records showed that patient associated risks were not consistently assessed.
  • Infection control practices were not effective and hand hygiene practices in the recovery unit placed an unacceptable risk to patient safety. Audit results were not consistent with what we observed during our inspection.
  • There were not systems in place to ensure that emergency equipment was available and safe to use.
  • Substances that could cause harm were not stored securely in ward areas. This meant unauthorised personnel could gain access to them.
  • The delivery of high quality care was not assured by the leadership, governance or culture in place.
  • Care and treatment was not prioritised in line with national guidance. Emergency operations were not categorised in accordance with national guidance which placed patients at an increased risk.
  • Patient records were incomplete, poorly managed and not stored securely on ward areas. This meant patient confidentiality was not maintained and in an emergency it may be difficult to obtain essential information about the patient.
  • There was a failure to act upon identified risks. The lack of correct child safeguarding training, lack of paediatric life support training and unsafe medical cylinder storage had been previously identified as risks.
  • Staff in theatres did not have the required knowledge, training and skills to care for children. Staff had not received paediatric life support training despite regularly caring for children in recovery units.
  • There was not a process which ensured staff had the necessary skills and competence to perform their role within theatres. Staff completed a competency documents when they first started in the department but there was not a process for reviewing staff competence.
  • Staff, relatives and the internet were used to interpret for patients who did not speak English. This was not considered to be best practice.
  • There were not established procedures and practices in place for invasive procedures.

However:

  • During our inspection and review of records staffing was sufficient to meet the needs of the patients.
  • Patients and relatives told us they felt involved in decisions about their or their loved-ones care and treatment.
  • The service contributed to national clinical audits for surgery. For example the national laparotomy audit ,national joint register and the national hip fracture database.
  • There was good multidisciplinary working within different speciality surgery services. We observed and saw evidence of multidisciplinary input into patient care.
  • All staff had received annual appraisals.
  • Patients pain was managed effectively, staff and patients said there was good support from the acute pain service.
  • We observed that staff were caring and compassionate to patients’ individual needs.

Intensive/critical care

Good

Updated 2 July 2014

We found that the intensive care and critical care service was safe and effective, performing within expectations for a unit of its size according to the Intensive Care National Audit and Research Centre data. It was responsive to the needs of patients and had caring and attentive staff. We found that the unit was well led. Pressure was placed on the unit when transfer of patients was delayed due to bed occupancy challenges faced by the trust. Though the unit coped with the situation, these patients were cared for in a mixed sex environment and had to use the bathroom and toilet facilities in the adjacent ward.

Services for children & young people

Good

Updated 2 July 2014

In the main children’s department parents told us that staff were responsive to their needs and that they listened to them. They were included in decisions about the care and treatment of their children. They said staff responded quickly to requests for assistance. Patients received safe and effective care and treatment. The environment was well maintained and engaging for young people. There were sufficient numbers of staff on the wards and in the outpatient area, and there was a system for the management of staffing levels and skill mix to ensure children were cared for safely.

This was not the case in the A&E department where there was an insufficient number of nurses qualified in the care of children. We also found in the A&E department that national guidance was not being followed in relation to the management of pain in children.

The trust was monitoring the quality of the service and making changes were they were needed. The views of children and families were being used to inform the service provision in the main children’s department. There was a team in place to monitor and address any safeguarding concerns, and the trust had planned further developments.

End of life care

Good

Updated 2 July 2014

We found that end of life care provided at the trust was safe, effective, caring, responsive and well led. The trust no longer used the Liverpool Care Pathway and was in the process of reviewing its end of life pathway. The palliative care team worked closely with staff on wards to ensure that patients had individualised end of life care provided in a positive, supportive environment. The team also had close links to community services. Patients and their families were involved in decisions about care and treatment in a dignified, respectful manner. Staff spoke positively about the support they received from the team. They felt this improved the patient experience and ensured patients received choices regarding end of life care and treatment.