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Inspection Summary


Overall summary & rating

Updated 2 July 2014

The ratings in this report were awarded as part of a pilot scheme to test CQC’s new approach to rating NHS hospitals and services.

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 Apr-Jun 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 the trust’s own training records showed that attendance at the trusts mandatory training was below the trusts expected level. This was low as 66% in some areas compared to the trusts 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.

Inspection areas

Safe

Updated 2 July 2014

Medical care, surgery, critical care, maternity, end of life care and outpatients were found to be safe. In other areas staff told us that patient’s 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.

Effective

Updated 2 July 2014

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. 

Caring

Updated 2 July 2014

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 supported by volunteers. 

Responsive

Updated 2 July 2014

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 been above the national average of 86.5%, rising as high as 96.1% for the period of Apr-Jun 2013. The trust was actively reviewing its current position, had implemented a number of actions including opening additional beds and was looking to 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. Those people 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 patient’s 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. 

Well-led

Updated 2 July 2014

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. 

Checks on specific services

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)

Good

Updated 2 July 2014

Overall, the standard of care and treatment in medical care was good. Teams were well led and supported by leaders at all levels in the service. Staff were listened to and had access to specialist training. There was positive feedback from the patients, relatives and visitors who we spoke with. They described caring and responsive staff who met their treatment needs. On a number of wards changes had been introduced in October 2013. These included increased staffing numbers. During our visit we could see that improvements were taking place. However, there had been insufficient time for many changes to have become embedded. This meant that the hospital was still improving against current performance indicators. Patient records were generally up to date with full details available to ensure that staff could provide safe and consistent care. The use of window bays, witnessed during the unannounced visit, showed that there was pressure on the hospital to cope with the level of demand. Staff were concerned about the use of ‘window bay beds’ and the potential impact on quality and safety.

Urgent and emergency services (A&E)

Requires improvement

Updated 2 July 2014

We found that A&E had the potential to be unsafe as there were insufficient numbers of appropriately skilled staff to deliver care. This was because there were not enough nurses qualified in the care of children and the medical staff team was not staffed to the agreed capacity and skill mix. The triage system in the minors area led to some patients’ needs not being assessed a timely manner as it was not clear that patients were required to wait to attend triage in one area and then book in and wait in another area. Staff were not always able to access current national and best practice guidelines to deliver safe effective care.  Staff were caring and responsive about patients’ needs but did not always maintain patient privacy. We observed examples of good individual leadership at department level but there was evidence that ongoing safety issues, for example insufficient substantive staffing, had not been resolved at a higher level.

Surgery

Requires improvement

Updated 2 July 2014

Patients generally received safe and effective surgical care. We saw that some wards worked with fewer staff than needed. However the trust was aware of this and recruitment had taken place. A number of staff were due to commence employment in the new year. There was a multidisciplinary approach to providing effective patient care.

Staff we observed were caring. However, patients’ privacy and dignity were not always maintained. Staff responded appropriately to changes in patients’ care and treatment. Staff told us how they responded to the increased workload when admission numbers increased, particularly when extra beds were placed on the ward. However, actions the trust was taking to respond to fluctuating demands of the organisation did not prevent these situations reoccurring. Staff told us they worked in a well-led organisation. They told us the culture was open and transparent, and there was a clear willingness by all staff to learn.

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.

Outpatients

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.