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Kettering General Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 12 April 2017

Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 320,000 in north Northamptonshire, South Leicestershire and Rutland.

This was the second comprehensive inspection of the trust with the first taking place in September 2014, when it was rated as requires improvement overall. We also carried out an unannounced inspection to the emergency department and some medical care wards in February 2016. As this was a focused inspection, we did not rate the services inspected.

Part of the inspection was announced taking place between 12 and 14 October 2016, with an unannounced inspection taking place 24 October 2016.

Overall, we rated Kettering General Hospital NHS Foundation Trust as inadequate. We rated two key questions, safe and well led, as inadequate. We rated caring as good and effective and responsive as requires improvement.

Three core services were rated as inadequate: urgent and emergency care, children and young people and outpatients and diagnostic imaging. Three services were rated as requires improvement: medical care, surgery and maternity and gynaecology. Two services, which showed improvements since the last inspection, were rated as good: critical care and end of life care.

Our key findings were as follows:

  • Risks identified by the service were not being assessed, monitored and mitigated via effective, comprehensive risk registers. Risks we identified on inspection were not recognised by the service, including the failure to escalate deteriorating patients, poor junior doctor cover for medical wards, security and access to the children’s ward, paediatric nurse competent in the children’s ED and the poor completion and storage of patients’ records. We were therefore not assured staff at every level in the service had an effective understanding of all the risks to patient safety and were able to assess, mitigate and monitor all known risks.
  • There was not a holistic approach to the monitoring of safety and performance data, supported and informed by effective, ongoing clinical audits. Actions plans had not always been developed to address areas of risk or poor performance and those that were in place were not always effectively monitored.
  • The hospital had serious concerns around the accuracy and quality of its referral to treatment (RTT) data and reported position, with the correction of this being a hospital priority. The hospital was working on a plan of data improvement including education, training, changes to systems and process and validation of patient pathways. Some patients also experienced long delays waiting for treatment, specifically for urology, maxillofacial and ear, nose and throat (ENT). Patients and stakeholders were not involved in service development. In some cases, waits were in excess of 52 weeks. The service did not have the capacity to meet the needs of patients and ran additional clinics to manage waiting lists. There were long waiting lists for the majority of specialities, including medical oncology. The services’ own figures from October 2016 showed that 69% of patients were seen within 18 weeks against the national standard of 92%. The hospital was not nationally reporting referral to treatment time (RTT) performance at the time of inspection due to historical problems with the validity of data.
  • The hospital had taken action to minimise the delays in diagnostics and imaging reporting by outsourcing their radiology reporting. At the time of inspection, there were 11,733 images awaiting a radiology report. These were classified as non-urgent images.
  • Complaints were not always handled in a timely manner in almost all services.
  • Services risk registers were not comprehensive and any of the risks did not have sufficient assurance that mitigating actions were being monitored. Ward dashboards referred to some local risks but these were not systematically escalated to the service risk register.
  • There was a lack of capacity in the leadership team to consistently embed learning from incidents and audits throughout services to drive improvements. There had not been sufficient improvement in areas of concerns highlighted during our February 2016 inspection.
  • There were not enough registrars and junior doctors to cover the medical wards out of hours and at weekends. Doctors told us there was no electronic handover system and no electronic list of priority patients to alert them to problems out of hours and at weekends in the medical wards. The hospital did not operate a multi-speciality hospital at night team and handover was focused on medical care wards. Working to seven day working in the service was variable.
  • There were inadequate numbers of nursing and medical staff to meet the needs of patient’s in adults and children’s ED. There were not effective processes in place to ensure that all staff were competent to carry out the roles they were tasked within the ED. The coronary care unit had nurse staffing numbers that were below the recommended number stipulated by the British Cardiovascular Society. There was inadequate medical staffing cover in the children and young people’s service. The maternity service did not always have sufficient staff, of an appropriate skill mix, to enable the effective delivery of care and treatment. There were times the consultant obstetrician was not present on the labour ward as they would be covering obstetrics and gynaecology and undertaking elective caesarean section lists. The critical care outreach team was not fully established to provide the necessary support and education to the rest of the hospital. The neonatal unit did not always operate in accordance with the required staffing levels. The paediatric outpatient department was not always staffed by registered children’s nurses. Nursing staff in both fracture and ophthalmology clinics treated children but did not have level three safeguarding training in line with national recommendations. The trust took action to address this after the inspection.
  • The children’s waiting area did not provide adequate space for patients waiting to be seen and staff in the children’s ED were not able to observe patients waiting at all times in line with guidance. The ED did not have safe and adequate facilities or processes in place to manage patients who presented with mental health illness and were a significant risk to themselves and others.
  • Staff were not always completing safeguarding processes in line with hospital policy and had not received the appropriate level of training. In the ED, staff did not always follow safeguarding processes and safeguarding training levels did not meet the hospital’s target or national recommendations. Risks to patients had not been actioned. Only 37% of nursing staff and 29% of medical staff had completed safeguarding level three training at the time of the inspection. Not all staff had completed the required level of children’s safeguarding training.
  • The hospital did not have a baby abduction policy; it had a flowchart for staff to follow in an event of an abduction. The trust took actions to address this after our inspection. The environment on Skylark ward was not safe, particularly for patients who may be at risk of self-harm or suicide. The trust took actions to address this once we had raised it as an urgent concern.
  • The ED was not consistently meeting national targets for service delivery but it had shown improvements in the last three months with performance better that the England average. From July 2016 to October 2016, the average performance against the target was 88%. There were a substantial number of delayed ambulance handovers. This meant that patients were not always receiving an initial clinical assessment in a timely manner and ambulance crews were not made available to respond to 999 calls.
  • Nurses on medical care wards had not always followed the escalation process for high risk patients by informing a doctor when a patient’s NEWS score was raised or when the patient’s oxygen saturation showed a downward trend. There were NEWS charts which showed dates and times that were not clearly stated and some were not legible.
  • Patients were exposed to the risk of receiving inappropriate care and treatment due to poorly written and incomplete care plans. For some patients, there were no individualised care plans; in some cases, the same written care needs were simply copied to a new sheet and changing needs had not been reflected or incorporated.
  • Patients’ individual care records were not always written and managed in a way that kept patients safe from avoidable harm. Confidential information was not always kept in accordance with the Data Protection Act 1998.
  • Medicine storage was not always in line with the national guidance in outpatient areas. For example, fridge temperatures were not checked regularly in some outpatient areas. Expired medication was found in the cardiac unit. Patient’s medical notes were not always stored securely in some outpatient areas. Medicine reconciliations had not always been done. Patients had not always been assessed for needing prophylactic medication to combat venous thromboembolisms (VTEs).
  • Outcomes for patients were variable in medical care. The hospital had produced poor results in two national audits that the hospital recently participated in. The Sentinel Stroke National Audit Programme (SSNAP) audit showed a poor score of D and E in all four quarters of the reporting year. The hospital participated in the 2015 National Diabetes Inpatient Audit: the hospital was worse for 13 out of 15 indicators. There were mixed patient outcomes in surgery and not always an action plan to ensure improvements. Examples included the hip fracture audit and the bowel cancer audit.
  • Patient flow and bed capacity to meet demand had been a significant pressure for the hospital for a number of months. Senior managers were in ongoing discussions with commissioners and stakeholders regarding the most appropriate ways of managing the DTOC position as the medical care beds being used were placing a significant pressure on the effective patient flow through the service. Discharges were sometimes delayed due to patients having to wait for ongoing care packages.
  • All staff were passionate about providing high quality patient care. Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
  • Generally, staff understood their responsibility to report incidents both internally and externally. Feedback received was variable. Learning from incidents was not always effectively embedded throughout services.
  • Most areas of the hospital were visibly clean and were cleaned regularly. Generally, effective infection control procedures were in place.
  • Despite significant staffing pressures, generally patients’ needs were met at the time of the inspection in most areas. Actual staffing levels were comparable to the planned levels for most of the wards we visited.
  • Pain of individual patients were assessed and managed appropriately. Patients’ nutritional and hydration needs were generally appropriately assessed and the food and fluid charts were well maintained.
  • Staff understood and respected patients’ personal, cultural, social and religious needs, and took these into account and services were generally planned and delivered in a way that took account of the needs of different patients.
  • Local leaders within services were generally visible and approachable. Staff told us that the senior leadership team, including both senior management and lead clinicians and nurses, were generally visible and effective.
  • Most staff felt involved in the hospital’s CARE values which brought staff together to discuss ways to improve services and provide quality care to patients. Staff felt supported and able to speak with the lead nurse if they had concerns.
  • There were clear processes and procedures in place regarding the completion of the Five Steps to Safer Surgery checklist. Intensive Care National Audit and Research Centre data showed the intensive care unit to be in line with the England average for all areas except delayed discharges. The hospital had received the United Nations Children's Fund (UNICEF) Baby Friendly Initiative full accreditation for its maternity department.
  • The hospital had a replacement for the Liverpool Care Pathway (LCP) called the ‘Guidance to implement care for the dying patient, and their family and friends’. The document was embedded in practice on the wards we visited. Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff. There were clear documented reasons for the decisions recorded.

We saw several areas of outstanding practice including:

  • The hospital had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • Sixty volunteers supported the chaplaincy service through a programme of daily and weekly visits to wards and clinical departments. Volunteers attended a 10 week training programme, which included awareness sessions on end of life care, dementia, and hearing and visual impairment.
  • There was a well-embedded play worker team, funding was sourced through donations from local businesses as well as fund raising activities. This was used to pay for new equipment as well as weekly visits from a music therapist, pet therapist and magician. The unit had modern toys and facilities for the children including a new projector, which projected moving images onto the floor, which entertained children under the supervision of a play worker.
  • The hospital had launched a “Joint School” education session for hip and knee replacement patients. The aim was to give patients a clear indication of what to expect from their operation and what was expected form them by the hospital.
  • The hospital had launched a new laser operation to support patients who required treatment for benign enlargement of the prostate by using a light laser to reduce the size of the prostate. This process had reduced the surgical time and the length of stay was no more than one day.

However, there were also areas of poor practice where the hospital needs to make improvements.

Importantly, the hospital must take action:

  • Ensure that there are sufficient numbers of nursing and medical staff in adults and children’s ED to meet the demands of the population and ensure safe care is delivered. To ensure that staff working in children’s emergency department (ED) have the correct skills, competence and support to care for children.
  • Ensure there is a sufficient number of medical registrars and junior doctors to cover out of hours and weekend shifts at all times across medical care wards. To ensure there is the required level of consultant obstetrician presence on the delivery suite.
  • To ensure care and treatment are provided in a safe way for service users by following the British Cardiovascular Society guidance on nurse staffing numbers in the Coronary Care Unit. Ensure there is a sufficient number of nurses working in the Coronary Care Unit at all times.
  • To ensure a qualified children’s nurse works in the outpatient department in accordance with Royal College of Nursing guidance, ‘Defining staffing levels for children and young people’s services’ which states that, ‘a minimum of one registered children’s nurse must be available at all times to assist, supervise, support and chaperone children’.
  • To ensure that suitably qualified staff in accordance with the agreed numbers set by the hospital and taking into account national policy are employed to cover each shift. In the children’s and young people service, there must be suitable numbers of staff trained in Advanced Paediatric Life Support and / or European Paediatric Life Support.
  • Ensure that there are effective systems in place to prioritise, assess and treat all patients attending the ED. Ensure that there are effective processes in place to measure time to initial clinical assessment for ambulance handovers and self-presenting patients.
  • To review the streaming competency framework and ensure that staff in this position have the necessary skills to identify a deteriorating or seriously ill patient in adult and children’s ED. To ensure that all staff in outpatients who have direct contact and assess and treat children have the appropriate level of paediatric competencies to provide safe care and treatment.
  • To ensure the security of the paediatric ward and Rowan ward at all times and review security system on the postnatal ward to minimise the risk of visitors accessing the ward without being challenged.
  • Ensure staff in medical care follow the hospital’s medication policy in the safe prescribing, cancelling, handling, storage, recording and administration of medicines. Ensure staff follow the hospital’s medication procedure for obtaining medicines for patients out of hours. The disposal of controlled drug ampules which have only been partially administered to patients must be recorded in the controlled drug register in the children’s and young people service. To ensure that all medications are stored in outpatients areas in line with hospital policy and national guidelines.
  • Ensure that the safeguarding children and vulnerable adult policies include all relevant information, specifically, details about female genital mutilation, child sexual exploitation as well as the referrals process for vulnerable adults. Ensure that all staff are trained to the required level of safeguarding children’s training and adhere to hospital safeguarding policies.
  • To ensure all staff have the required statutory and mandatory training and effective systems are in place to monitor this. To ensure that staff in the radiology department are up-to-date on basic life support training. To ensure that radiation dose awareness in plain film by the radiographers is in line with national standards.
  • To ensure staff in ED and medical care have had sufficient training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
  • To ensure there are processes and procedures for staff in surgery to adhere to the Food Safety Act 1990 and the Food Hygiene (England) Regulations 2006 (Temperature Control Schedule 4 EU Regulation No.852/2004).
  • To ensure that theatre staff comply with the Standards and Recommendations for Safe Perioperative Practice 2011 by the Association of Perioperative Practice or the hospital’s operating theatre policy and the theatre standard operating procedure regarding the wearing of cover gowns and footwear when leaving and entering the theatre area.
  • To ensure staff are aware of the escalation policy including triggers for escalation in ED and medical care and that these process and reviewed and monitored. Ensure National Early Warning Score (NEWS) charts are filled in clearly, accurately and legibly.
  • Ensure that patients’ records are completed with appropriate information to understand their care plans. Ensure all patients have person-centred care plans that are well maintained and reflect appropriately patients’ changing needs and treatment.
  • Ensure all confidential patient information in medical care, surgery and gynaecology and outpatients and diagnostics are stored in accordance with the Data Protection Act 1998.
  • To monitor patients’ referral to treatment times, and assess and monitor the risk to patients on the waiting list in surgery, children and young people’s service and outpatients and diagnostic services.
  • To develop an effective programme of cyclical audits to measure performance with evidence-based protocols and guidance in the ED. To establish a system for continuous monitoring of action plans developed in response to local and national audits. To ensure all clinical guidelines are up to date and reviewed in a timely manner in the maternity and gynaecology service. To ensure the local maternity dashboard meets RCOG good practice No.7 Maternity dashboard, clinical performance and governance scorecard standards.
  • To ensure complaints are handled in line with hospital policy and effective systems are in place to monitor this.
  • To ensure all staff are supported to recognise and escalate potential risks to the safety and quality of care and treatment for all patients and to ensure effective systems are in place to assess, mitigate and monitor these risks. The hospital should ensure that the risk registers are accurate and reflective of risks in services.
  • To review the incident reporting processes in children’s and young people service to ensure all incidents are reported and investigated and that actions agreed correlate to the concerns identified, are acted on and lessons learned are shared accordingly. Ensure ligature audits are undertaken and acted upon in the children’s and young people’s service.

In addition the hospital should take action to improve:

  • To review the environment in reception area in ED so that patients’ privacy and confidentiality can be respected.
  • To monitor the dedicated mental health room so that it meets national recommendations and poses minimum risks to patients and staff.
  • Review ways to improve the ‘whole system approach’ to managing overcrowding in the ED.
  • To provide training to staff in dementia awareness, learning disabilities and complex needs in ED.
  • Review staff training and awareness of major incident policy and equipment.
  • To monitor that equipment in ED is properly maintained and checks for resuscitation equipment are completed in line with trust policy.
  • Consider ways to meet the standards in the intercollegiate document ‘Standards for children and young people in emergency care settings, 2012’.
  • To review the function and use of the emergency decisions unit to ensure that the eligibility criteria are being adhered to.
  • To review medical cover for the Discharge Lounge.
  • To continue to work to recruit full time staff in an effort to reduce the reliance on agency staff in medical care.
  • To monitor that fabric chairs and privacy curtains within the breast pre-assessment clinic have the date of cleaning identified.
  • To monitor that the processes and procedures in place to manage the medicines stored in all clinical rooms which exceed the required temperature.
  • To support all staff to understand the trust’s vision and strategy so that it is embedded within the service.
  • To review systems and processes that are in place to ensure the cleanliness of surgical wards.
  • To review pharmacy provision to meet the needs of the ICU and be in line with national guidance.
  • Review systems for staff in ICU to provide level three safeguarding children’s training.
  • To review the provision of the outreach service to allow effective utilisation of this service.
  • To review processes so that patients are discharged from the ICU within four hours of the decision to discharge to improve the access and flow of patients within the critical care unit.
  • To review processes so that the hospital meets the needs of patient requiring admission to ICU at all times.
  • To review the data collecting methods to monitor the length of time patients are nursed in recovery whilst either waiting for a bed in ICU or following discharge from ICU.
  • To record ambient room temperatures where fluids are stored that requires this, taking action when required.
  • Steps should be taken to improve multidisciplinary working within the department between medical staff, nursing staff and allied healthcare professionals.
  • To review seven day services in medical are and critical care to ensure patient needs are met.
  • To review assessment and screening of delirium for patients cared for in the ICU.
  • To review systems for recording essential checks on equipment, including resuscitation equipment in critical care.
  • To review facilities so women’s privacy and dignity is always protected on the delivery suite.
  • To review staffing in maternity so that sufficient staff to ensure midwife-to-birth ratio is at the national average of 1:28.
  • To review the current practice where women who were having a termination due to abnormalities were cared for on the delivery suite in rooms next to women delivering healthy babies and Gynaecology and obstetrics patients and women attending for these appointments shared the same waiting room.
  • Monitor processes for patients who present with mental health needs are suitably risk assessed when admitted to the children and young people’s service to ensure care and support provided meets their needs and that staff are competent to manage difficult behaviours, including restraint.
  • Monitor staff training in mental health needs of patients and in the use of tracheostomy in the children and young people’s service.
  • A comprehensive clinical audit plan should be developed, completed and monitored in the children’s and young people service. Policies which are out of date should be reviewed and revised.
  • A dashboard should be developed in the children’s and young people service to report on and monitor operational performance data each month. Business plans should be developed which consider accurate operational activity data and performance. Objectives should be clearly defined and supported with effective action plans.
  • To review the provision of a face-to-face specialist palliative care service, aiming to achieve as Monday to Sunday service, including bank holidays.
  • To review the data collected for patients so that the hospital can assess the number of referrals for patients with or without cancer.
  • To review the collection of data in order to assess the percentage of patients who were discharged within 24 hours to their preferred location.
  • To review the processes to in the mortuary so that medicines for coroner’s inquests are recorded on receipt and transfer to pharmacy for disposal.
  • To consider increasing the education and training provision in the SPCT in line with national guidance.
  • To monitor the safety of patients who wait over 40 weeks for non-urgent outpatient appointments.
  • To review how clinic waiting times and clinic delays are appropriately displayed and communicated to waiting patients.
  • To review facilities so that consultation rooms in all outpatient areas can accommodate wheelchair users when needed.
  • To review and monitor all patients on waiting lists to ensure effective prioritisation systems are in place to identify and minimise patient harm.
  • Review how the standard operating procedure for managing outpatient clinics cancelled within six weeks is implemented and embedded.

Due to level of concerns found across a number of services and because the quality of health care provided required significant improvement, we served the trust with a warning notice under Section 29A of the Health and Social Care Act 2008.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 12 April 2017

Effective

Requires improvement

Updated 12 April 2017

Caring

Good

Updated 12 April 2017

Responsive

Requires improvement

Updated 12 April 2017

Well-led

Inadequate

Updated 12 April 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 12 April 2017

We rated the maternity and gynaecology service as requires improvement overall. We rated the service as requires improvement for safe, responsive and well-led. We rated the service as good for effective and caring. We found that:

  • The service did not always have sufficient staff, of an appropriate skill mix, to enable the effective delivery of care and treatment. There were times the consultant obstetrician was not present on the labour ward as they would be covering obstetrics and gynaecology and undertaking elective caesarean section lists.
  • The locally devised maternity dashboard data did not meet Royal College of Obstetricians and Gynaecologist Guidelines (RCOG) good practice No.7 Maternity dashboard, clinical performance and governance scorecard. Risk information regarding maternity was not all available on all risk documents seen, and as a result, we were not assured the service had oversight of all information to monitor the service.
  • Rowan ward did not have sufficient security to minimise the risk of visitors accessing the ward without being challenged. The hospital did not have an abduction policy; it had a flowchart for staff to follow in an event of an abduction.
  • Compliance with mandatory training did not meet the hospital target.
  • Patient outcomes were variable: in the 2015 National Neonatal Audit Programme (NNAP), the hospital was below the NNAP standard for four of the five indicators. The caesarean section rate for 2015/16 was 30%, which was higher than the national average of 26.5%.
  • The hospital had serious concerns around the accuracy and quality of its referral to treatment (RTT) data and reported position. The hospital had not met the set targets for RTT waiting times non-admitted, admitted and incomplete. The service was monitoring their RTT performance as part of their improvement plan. Figures from October 2016, showed gynaecology was were performing below the national standard of patients being seen within 18 weeks. 76% of patients were being seen within 18 weeks, although below the national standard of 92%, the hospital was on track to achieve their trajectory target of 77% by the end of November 2016.
  • There was no data for the hospital’s performance on: 31 day wait for second or subsequent treatment, 31 day wait for second or subsequent treatment radiotherapy, 62 day wait for first treatment from consultant screening service referral : all cancers, maximum waiting time of 4 hours in A&E from arrival to admission, transfer or discharge.
  • Gynaecology services were not always responsive to patient’s needs for example; there were no side rooms on the gynaecology ward. This meant that women who were having a termination due to abnormalities were cared for on the delivery suite in rooms next to women delivering healthy babies.
  • The maternity and gynaecology clinics ran concurrently. Gynaecology and obstetrics patients and women attending for these appointments shared the same waiting room. This meant that patients who may be having difficulty in conceiving or had experienced a miscarriage were sharing the same area with pregnant women and this was not sensitive to their needs.
  • Lack of medical staffing resources to deliver the gynaecology clinic meant the service was breaching the referral to treatment times. Gynaecology was performing below the national standard of patients being seen within 18 weeks.
  • The service had not met the trust’s timescales for responding to complaints in the period August 2015 to July 2016, but following the introduction of a revised complaints’ policy in July 2016, with longer timescales for a response, improvements had been made in responding to complaints with an average response timescale of 27 days (in the period April to September 2016). This was now in accordance with the trust’s policy.
  • There was limited evidence to demonstrate information about midwifery issues were taken to the board therefore, we were not confident the board had oversight and understanding of issues affecting maternity service. There was evidence not all risks were identified and placed on the risk register
  • Whilst a new strategy for the service had been developed and implemented, it was not yet fully understood by all staff in the service. We were not assured progress against delivering the strategy was regularly monitored and reviewed.

However, we also found that:

  • There was good leadership at a local level, wards and units were well managed. Local leaders demonstrated they understood the challenges to good quality care and had identified the actions needed to address them.
  • Women and those close to them were positive about the care and treatment they had received.
  • The service provided a vulnerable midwifery team. A dedicated bereavement midwife led on bereavement services for women who had experienced pregnancy loss.
  • Individual care records were written in a way that kept people safe from avoidable harm.
  • The service used the World Health Organization (WHO) surgical safety checklists in maternity and gynaecological surgery. The overall compliance for the checklist was 100% between April 2016 and June 2016.
  • The hospital had received the United Nations Children's Fund (UNICEF) Baby Friendly Initiative full accreditation for its maternity department.

Medical care (including older people’s care)

Requires improvement

Updated 12 April 2017

Overall, we rated medical care as requires improvement. Three key questions, safe, effective and well led were rated as requires improvement and caring and responsive were rated as good. We found that:

  • Care plans did not always reflect the needs of patients and deteriorating patients were not always managed effectively. Nurses had not always followed the escalation process for high-risk patients by informing a doctor when a patient’s NEWS score was raised or when the patient’s oxygen saturation showed a downward trend.
  • Patients were exposed to the risk of receiving inappropriate care and treatment due to poorly written and incomplete care plans. For some patients, there were no individualised care plans; in some cases, the same written care needs were simply copied to a new sheet and changing needs had not been reflected or incorporated.
  • Patients’ individual care records were not always written and managed in a way that kept patients safe. Patients’ medical notes were mainly kept in lockable trolleys which were not locked when not in use and in some wards, they were kept on open shelves in the bays. This meant that confidential information was not always kept in accordance with the Data Protection Act 1998.
  • There were not enough registrars and junior doctors to cover the medical wards out of hours, especially between 5pm to 9pm (Monday to Friday) and at weekends.
  • Doctors told us there was no electronic handover system and no electronic list of priority patients to alert them to problems out of hours and at weekends in the medical wards. The hospital did not operate a multi-speciality hospital at night team. Working to seven day working in the service was variable.
  • The coronary care unit had nurse staffing numbers that were below the recommended number stipulated by the British Cardiovascular Society.
  • Entries on prescription charts had been cancelled without being signed and dated. Medicine reconciliations had not always been done. Patients had not always been assessed for needing prophylactic medication to combat venous thromboembolisms (VTEs).
  • Outcomes for patients were variable. The hospital had produced poor results in two national audits it had recently participated in. The Sentinel Stroke National Audit Programme (SSNAP) audit showed a poor score of D and E in all four quarters of the reporting year. The hospital participated in the 2015 National Diabetes Inpatient Audit: it was worse for 13 out of 15 indicators than the England average.
  • Discharges were sometimes delayed due to patients having to wait for ongoing care packages.
  • Compliance with dementia awareness training was variable across wards
  • Complaints were not always handled in a timely manner.
  • Risks identified by the service were not being assessed, monitored and mitigated via an effective, comprehensive risk register. Risks we identified on inspection were not recognised by the service, including the failure to escalate deteriorating patients, poor junior doctor cover for medical wards, and the poor completion and storage of patients’ records. We were therefore not assured staff at every level in the service had an effective understanding of all the risks to patient safety and were able to assess, mitigate and monitor all known risks.
  • Not all staff were fully aware of the service’s plans to remodel the beds in the service, which was designed to improve patient flow. Some staff described it as a ‘stop, start’ process with delays in the reconfiguration of beds and wards. Staff were not generally aware of the timescales for this reconfiguration.

However, we also found that:

  • Staff treated patients with compassion, kindness, dignity and respect. Patients gave positive feedback about the care and service provided.
  • Despite significant staffing pressures, generally patients’ needs were met at the time of the inspection. Actual staffing levels were comparable to the planned levels for most of the wards we visited.
  • Generally, the design, maintenance and use of facilities and premises met patients’ needs. The maintenance and use of equipment kept people safe from avoidable harm. Appropriate infection control procedures were being followed.
  • Arrangements were in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements. Overall, the service was just below the hospital target of 85% for statutory and mandatory training at 83%.
  • Pain of individual patients were assessed and managed appropriately. Patients’ nutritional and hydration needs were appropriately assessed and the food and fluid charts were well maintained.
  • Staff generally had the right qualifications, skills, knowledge and experience to do their job. A multi-disciplinary team approach was evident across wards
  • The service had an effective escalation procedure in use for supporting demand for beds.
  • Staff understood and respected patients’ personal, cultural, social and religious needs, and took these into account and services were generally planned and delivered in a way that took account of the needs of different patients. The dementia strategy was being implemented and appropriate care was provided for patients living with dementia.
  • Patient flow and bed capacity to meet demand had been a significant pressure for the hospital for a number of months. Senior managers were in ongoing discussions with commissioners and stakeholders regarding the most appropriate ways of managing the DTOC position as the medical care beds being used were placing a significant pressure on the effective patient flow through the service.
  • Leaders within the service, of all levels, were generally visible and approachable. Staff told us that the senior leadership team, including both senior management and lead clinicians and nurses, were generally visible and effective.
  • Staff felt involved in the hospital’s CARE values which brought staff together to discuss ways to improve services and provide quality care to patients. Staff felt supported and able to speak with the lead nurse if they had concerns.
  • There were a large number of volunteers from the local community working in various departments in the hospital.

Urgent and emergency services (A&E)

Inadequate

Updated 7 September 2017

As we only inspected parts of the five questions (safe, effective, caring, responsive and well led), we have not rated any key question or this core service overall.

We found areas where significant improvements had been made:

  • Patient privacy and dignity were respected at all times whilst patients were being cared for within the emergency department.
  • A designated mental health assessment room was available which complied with national guidance.
  • Risk assessments and triage tools were used for patients with mental health concerns, ensuring they were cared for with the correct level of observation in a safe, risk-assessed area.
  • Patients arriving by ambulance or self-presenting to emergency department (ED) reception generally received a timely initial time to clinical assessment.
  • There were clear systems in place to safeguard vulnerable children. The safeguarding policy now reflected national guidance. Safeguarding level three children training figures were now above the trust’s target of 90% for both nurses and doctors in the ED.
  • The paediatric emergency department was staffed with two registered nurses at all times. One of these would be a registered nurse (child branch), if not, there were processes in place to mitigate the risk to ensure paediatric competent nurses were on duty.
  • The paediatric emergency department was now kept secure, with staff ID badge ‘swipe’ access only.
  • Staff training in paediatric competencies had significantly improved since the last inspection.
  • The leaders of the ED had made significant progress to improve and address all areas of the warning notice.
  • Effective risk management processes were now in place, embedded and monitored.
  • Staff at all levels were aware of the concern raised at the last inspection and were involved in driving improvement in ED to address these concerns.
  • Staff felt that communication from the trust wide team down to the leaders of ED had improved.
  • ‘Black breaches’ were now reported formally at the trust board. Performance was monitored and used to drive improvements. All staff could explain what a ‘black breach’ was.

However, we also found that:

  • The hospital failed to meet the national standard for 95% of patients admitted, transferred, or discharged within four hours of arrival in the ED. In the period April 2016 to March 2017 performance was below the England average for all of the 12 months. Overall, for that period, the ED achieved 83% against an England average of 89%, but the trend over time was showing improvements in meeting this performance measure.
  • Although the time to initial clinical assessment had significantly improved and effective systems were in place, the ED was not yet meeting national guidance for 95% of patients to be seen within 15 minutes of the arrival time. However, during our inspection, all patients had an initial clinical assessment within 15 minutes.

Surgery

Requires improvement

Updated 12 April 2017

We rated the service as good for effective, caring and well-led and requires improvement for safe and responsive. Overall, we rated the service as requires improvement because:

  • The hospital had not provided data for referral to treatment time (RTT) for admitted performance for surgical services since November 2015. The service had a RTT recovery programme and was exceeding its trajectory of 77% by the end of November 2016. Private providers had been contracted to support the treatment to some of their patients.
  • Nursing staffing was not appropriate on Ashton ward whereby registered nurses left the ward unattended during the night shift at times. We raised this as a concern with the hospital and they took immediate action to ensure a registered nurse was on this ward at all times.
  • Infection control precautions were not always effective. We observed staff on Geddington and Deene B wards not decontaminating their hands after being in direct contact of care with patients. Clinical waste bins were conveyed through the maxillofacial service. These frequently leaked which meant there was a risk of infection control putting both staff and patients at risk. The breast pre-assessment clinic had fabric chairs and privacy curtains. The chairs and curtains had no date when last changed or cleaned which meant there could be a risk of cross infection due to inappropriate cleaning. Nursing staff did not adhere to the handling of food safely guidance. Theatre staff did not adhere to the hospital and national standards by wearing of cover gowns and footwear when leaving and entering the theatre area.
  • The environment within the maxillofacial service area was cramped and not conducive to patients who were partially sighted, hard of hearing or disabled. They had limited to no access to the x-ray room due to the entrance being too small for a wheelchair. This contravened the Equality Act 2010. The service had a business plan in place for the relocation of this area.
  • Medicines were not always stored or handled appropriately. Medicines were stored with sterile instruments, on open shelves within the maxillofacial service. Medicine clinical rooms (Geddington, Barnwell B and C, DASU and the surgical day case unit) had temperatures above the recommended 25º celsius which were detrimental to some drugs. We found topical medicines and liquids which had been used with no date of opening.
  • Patient records on DASU and Geddington ward were left unattended during our visit. Also on Geddington ward, records were kept in an unsupervised, unlocked room.
  • The environment of Barnwell wards B and C were found to be visibly dirty and very dusty. This was brought to the attention of senior staff and the hospital. During our unannounced visit on 24 October 2016, the ward had undergone a deep clean and it was visibly clean.
  • There were mixed patient outcomes and not always an action plan to ensure improvements. Examples included the hip fracture audit and the bowel cancer audit. This had not been identified on the surgical and anaesthetist risk register as an area of concern.
  • Reported complaints took an average of 69 days to investigate and close. This was not in line with the hospital’s complaint policy.
  • Staff had little awareness of the new CARE values introduced by the hospital.
  • Routine audits and monitoring took place across the service. However, not all audits had actions or outcomes to improve performance. This had not been identified on the service’s risk register.

However, we found that:

  • Staff understood the importance of reporting incidents and had awareness of the duty of candour process. The team meeting minutes identified shared learning from incidents.
  • There were clear processes and procedures in place regarding the completion of the Five Steps to Safer Surgery checklist.
  • Nursing handovers were well structured and comprehensive.
  • Training levels met the recommended target set by the hospital and staff understood their roles and responsibilities around the Mental Capacity Act 2005 and had an awareness of the Deprivation of Liberty Safeguards. The appraisal rates were just above the hospital target at 86% for the service.
  • Patients received care according to national guidelines such as the National Institute of Health and Care Excellence (NICE) and the Royal College of Surgeons.
  • Medical and nursing staffing was appropriate across almost all the surgical wards and in theatres. There was effective multidisciplinary team working that delivered coordinated care to patients. Staff had access to patient related information when required.
  • Patients were supported, treated with dignity and respect and were involved in planning their treatment and care. Feedback from patients and those who were close to them was positive about the way staff treated and cared for them.
  • The cancer 62 day standards showed the hospital had met 92% of its urgent GP referrals.
  • The ‘butterfly’ scheme was used to discreetly identify patients living with dementia. Staff had access to admiral nurses to provide support when required.
  • There was a clear governance structure in place within the surgical clinical business unit to review areas such as; infection control, incidents, health and safety, estates and policies.
  • There was a positive culture within the teams and staff felt supported by their managers. Staff confirmed the senior management team was visible, conducted daily walkabouts and often visited the ward and theatres to observe practices.

Intensive/critical care

Good

Updated 12 April 2017

Overall, we rated the critical care service as good because:

  • There were systems in place to protect patients from harm and a good incident reporting culture.
  • The department complied with the Department of Health’s Health Building note HBN 04-02, which sets standards for critical care units.
  • Effective infection control practices were in place throughout the unit and visitors were encouraged to take part in the prevention of infection.
  • Safe numbers of staff cared for patients using evidence-based interventions.
  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.
  • Patient’s pain, nutrition and hydration was appropriately managed.
  • Intensive Care National Audit and Research Centre data showed the intensive care unit to be in line with the England average for all areas except delayed discharges.
  • Staff were compassionate and put patients at the centre of the work. They obtained consent prior to procedures and maintained patient privacy and dignity.
  • Complaints were dealt with in a constructive and timely way, ensuring that patients or relatives were kept up to date with any actions resulting from their complaint.
  • Staff had access to communication aids and translators when needed, giving patient the opportunity to make decisions about their care, and day to day tasks. There were very few complaints about the services and staff dealt with complaints appropriately.
  • Dementia training and staff guidance was suitable and staff showed a good understanding of how to provide quality care for those living with dementia.
  • There was good local leadership on the unit and staff reflected this in their conversation with us.

However, we also found that:

  • There was a lack of sufficient pharmacy support within the department, leading to potentially avoidable medicine incidents.
  • The critical care outreach team was not fully established to provide the necessary support and education to the rest of the hospital.
  • There was no delirium screening process in place.

Services for children & young people

Inadequate

Updated 7 September 2017

As we only inspected parts of the five questions (safe, effective, caring, responsive and well led), we have not rated any key question or this core service overall.

We found areas where significant improvements had been made:

  • The clinical leadership provided by the paediatric lead nurse had been instrumental in the provision and maintenance of a safe and secure environment for children on Skylark ward.
  • There was a clear focus on patient safety, effective risk assessment, and management throughout the service which were owned by all staff.
  • Staff on Skylark ward were assessing, monitoring, and managing the risks to prevent or minimise harm to children and young people with mental health conditions.
  • Staff on Skylark ward were “owning” security issues and had developed effective working relationships with the security team.
  • Risk assessments for children and young people with mental health issues had significantly improved as had staff access and uptake of mental health and conflict resolution training.
  • Staff were able to demonstrate their competence in caring for children and young people with mental health issues and care was planned and delivered in line with evidence-based guidance.
  • Procedures and guidance available to staff was comprehensive and up-to-date and staff were able to respond appropriately to internal security arrangements that kept children and young people safe.
  • There was an effective system for identifying, capturing, and managing risks and issues at team and directorate level. The service risk register reflected the risks associated with the children and the adolescents mental health service (CAMHS) patients and children experiencing self-harm behaviour. This was reviewed and updated as required.
  • Nursing audits were monitoring care provided against expected standards.
  • There were positive relationships with the CAMHS who were open and responsive to the needs of children with mental health needs on Skylark ward.
  • Parents and children were extremely positive about the care and treatment they received regarding inpatient and outpatient services at the hospital. Parents were aware that some children and young people with mental health conditions were being cared for on the ward at times and told us they felt their child was ‘safe’ on Skylark ward.

However, we found that:

  • There were ‘blind spots’ in the CCTV coverage on Skylark ward. The trust took immediate action to address this once we had raised it as a concern.
  • Whilst the staff on Skylark ward were very aware of security issues, we observed visiting staff allowing other people to follow them into and out of the ward unchallenged. The trust took immediate action to address this once we had raised it as a concern.
  • Children and young people with mental health issues who exhibited violent and aggressive behaviours were inappropriately placed on Skylark ward, as there were no other appropriate placements available in the community. Whilst this was a system wide issue, this posed a pressure to staff and patients on the ward. This was reflective of system-wide pressures across the health economy.

End of life care

Good

Updated 12 April 2017

We rated the service as good for the safe, caring, responsive and the well-led key questions and requires improvement for effective. We found that:

  • There were systems in place to protect patients from harm and a good incident reporting culture.
  • Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of life.
  • The hospital had a replacement for the Liverpool Care Pathway (LCP) called the ‘Guidance to implement care for the dying patient, and their family and friends’. The document was embedded in practice on the wards we visited.
  • Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff. There were clear documented reasons for the decisions recorded.
  • Patients were happy with the care they received and felt involved in their care planning at the end of their life. Nurses, doctors and the specialist palliative care team (SPC) demonstrated compassionate patient centred care throughout the inspection.
  • Relatives rated end of life care provided by nurses and doctors to their relative at the end of life, as ‘excellent to good’.
  • Sixty volunteers supported the chaplaincy service through a hospital wide patient-visiting programme, which included support to patients at the end of life.
  • Care and treatment was coordinated with other services and other providers. The specialist palliative care team (SPCT) had good working relationships with discharge services and their community colleagues. This ensured that when patients were discharged their care was coordinated.
  • All adult wards had end of life care champions who were trained in specialist end of life care and were a direct link to the SPCT.
  • The SPCT saw 100% of patients within 24 hours of referral.
  • The hospital had an executive and a non-executive director on the hospital board with a responsibility for end of life care.
  • There was a clear vision and strategy for end of life care supported by an outcome based work plan, led by the transformational lead nurse and medical lead for end of life care.
  • Risks regarding the management of bariatric patients in the mortuary were identified on the support services risk register.
  • Risks associated with end of life care were recorded within individual clinical business units (CBU) and recorded on the corporate hospital risk register. Staff had taken action to mitigate against risks.

However, we also found that:

  • The hospital performed worse than the England average for the five clinical outcomes in the End of Life Care Audit: Dying in Hospital (NCDAH) 2014/15, published 2016.
  • The hospital had scored particularly poorly for the multidisciplinary recognition of patients dying, communication regarding plans of care, and meeting the spirituality and religious needs of patients.
  • The hospital was not collecting information on the percentage of patients discharged to their preferred place of death within 24 hours.
  • The service did not provide face-to-face access to specialist palliative care for at least 9am Monday to 5pm to Sunday. This did not meet the recommendations from the National Institute for Health and Care Excellence (NICE) guidelines for end of life care for adults.
  • There was no practice educator post in the SPCT in line with national guidance.

Outpatients

Inadequate

Updated 7 September 2017

As we only inspected parts of the five questions (safe, effective, caring, responsive and well led), we have not rated any key question or this core service overall.

We found that:

  • The total number of patients waiting over 52 weeks for their treatment on the admitted and non-admitted pathways had improved. This had reduced from 413 to 182 patients waiting.
  • Where things had gone wrong, duty of candour was maintained. This was evidenced in the medical notes of patients who had suffered moderate harm as a result of waiting for treatment.
  • The trust had carried out clinical harm reviews on 1,281 patients waiting over 52 weeks for their treatment. This represented 75% of all patients that had waited over 52 weeks.
  • The trust also had a prioritisation system for carrying out harm reviews for those patients waiting more than 46 weeks on incomplete RTT pathways for high-risk specialties.
  • There was oversight of the potential deterioration of patients waiting over 18 weeks. Staff communicated with patient’s GPs to find out about potential harm. Procedures were in place to prioritise patients whilst waiting on RTT pathways.
  • Managers in the service now had an effective oversight of the hospital’s RTT performance and could clearly show how the recording system worked and the number of patients waiting to be seen.
  • This improvement in understanding the hospital’s RTT position had been led by the trust’s chief operating officer (COO), who drove improvements and checked performance against agreed actions at the service’s two weekly ‘RTT Confirm and Challenge’ meetings.
  • Governance and risk oversight had improved so that the trust’s Board of Directors, and all external stakeholders, could be assured as to the trust’s ongoing RTT performance and potential risks to patient safety.
  • The trust had recruited its own team of data validators.

However, we also found that:

  • The trust was planning to carry out harm reviews on those patients who had passed away whilst on a waiting list.
  • The number of patients waiting for 31 weeks on an RTT pathway had increased from 9% to 27%. Managers were making plans to address this increase.