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William Harvey Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2016

The William Harvey Hospital (WHH) in Ashford, Kent is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT).

The William Harvey Hospital (WHH) is an acute 476 bedded hospital providing a range of emergency and elective services and comprehensive trauma, orthopaedic, obstetrics, general surgery and paediatric and neonatal intensive care services. The hospital has a specialist cardiology unit undertaking angiography, angioplasty, an analytical robotics laboratory that reports all East Kent’s General Practitioner (GP) activity and a robotic pharmacy facility. A single Head and Neck Unit for East Kent has recently been established and includes centralised maxillofacial services with all specialist head and neck cancer surgery co-located on the site.

Following our last inspection of the Trust in August 2015, we carried out an announced inspection between 5th and 7th September 2016, and an unannounced insection on 21st September 2016.

This is the third inspection of this hospital. This inspection was specifically designed to test the

requirement for the continued application of special measures to the trust. Prior to inspection we risk

assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection.

Overall we rated the William Harvey Hospital as Requires improvement

Safe

We rated The William Harvey Hospital as Requiring improvement for safe because:

  • Whilst 86% of patients were triaged within 15 minutes, only 34% had a clinician first assessment within one hour and only 17% a decision to admit within two hours. Attendance by a specialist within 30 minutes following referral was only achieved 35% of the time.

  • Ambulance handover figures for WHH showed an average of 168 occasions per month (July – October 2016) when vehicles were delayed beyond 60 minutes. This represented 7.8% of the total number of patient handovers and was worse than the regional average of 3%. During this period, WHH was consistently in the bottom four of 17 hospitals in the region.
  • There was a shortage of junior grade doctors and consultants across the medical services at the hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service, particularly out of hours and at night.
  • On medical wards staffing numbers have been increased and the trust monitors safe staffing levels. However, there was a lack clarity amongst staff about the acuity based tool ( to assess appropriate staffing for the complexity of patients cared for ) and leaves staff convinced that there is still insufficient staff on duty for many shifts.

  • In Maternity, a lack of staffing affected many areas of service planning and the care and treatment of women. This included not meeting national safe staffing guidelines, meaning 1 in 5 women did not receive 1:1 care in labour.

  • We found poor records management in some areas. Staff did not always complete care records according to the best practice guidance.

  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance. The trust did not have adequate maintenance arrangements in place for the 483 medical devices used in maternity and gynaecology.

However

  • We saw robust systems in place for reporting and learning from incidents both locally and trust-wide.

  • Ward and departmental staff wore clean uniforms and observed the trust’s ‘bare below the elbows’ policy. Personal protective equipment (PPE) was available for use by staff in all clinical areas.

  • The hospital was clean and met infection control standards.

Effective

We rated The William Harvey Hospital as requiring improvement for effective because:

  • Some documents and records supporting the learning needs of staff were not always completed and there were gaps in the records of training achieved.

  • Staff annual appraisals rates were worse than last year.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as diabetes services.

  • There was poor compliance in the use of the end of life documentation across the wards we visited which was reflected in the May 2016 documentation audit undertaken by the SPC team.

However

  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • We saw good examples of multidisciplinary working between all staff grades and specialities.

Caring

We rated The William Harvey Hospital as Good for care because:

  • Staff treated patients with kindness and compassion.

  • Staff responded compassionately when women in Maternity and Gynaecology needed help and supported them to meet their basic personal needs as and when required. Privacy and confidentiality was respected at all times.
  • Patients and relatives we spoke with were complimentary about the nursing and medical staff.
  • Patients were given appropriate information and support regarding their care or treatment and understood the choices available to them.
  • Responsive

We rated The William Harvey Hospital as requires improvement for responsive because:

  • Performance indicators such as patients being seen within four hours in A&E remained below trust target and national averages.

  • Delayed discharges remained a concern.

  • The hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.

  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.
  • Maternity staff had diverted women to another hospital on 28 times between January 2015 and June 2016 due capacity issues.

However

  • The trust employed specialist nurses to support the ward staff. This included dementia nurses and learning difficulty link nurses who provided support, training and had developed resource files for staff to reference. Wards also had ‘champions’ who acted as additional resources to promote best practice.

Well Led

We rated The William Harvey Hospital as requires improvement for responsive because:

  • No separate risk register was available for palliative /end of life care. A separate risk register would allow the risks to this patient group be discussed regularly at the end of life board, and allow plans to be made to alleviate any identified risks.

  • Changes in leadership in end of life care and maternity services had only recently been realised and as a result had yet to fully address the issues relating to these services.

  • In some areas risk management and quality measurement were not always dealt with appropriately or in a timely way. Risks and issues described by staff did not correspond to those
  • Where changes were made, appropriate processes were not always followed and the impact was not fully monitored in maternity and gynaecology services

However

  • Overall, the leadership, governance and culture within the ED was good and we saw examples of good practice regarding visibility of supervisors, comfort rounds and communication. Staff were supported by their managers and were actively encouraged to contribute to the development of the services.

We saw several areas of outstanding practice including:

  • Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.

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

Action the hospital MUST take to improve

  • Ensure the number of staff appraisals increase to meet the trust target. So that the hospital can assure itself that staff performance and development is being monitored and managed.
  • Ensure that all staff have attended mandatory training and address gaps in training records that make it difficult to determine if training meets hospital policy requirements.
  • Ensure that the trust audit programme is completed and that following audits action plans are submitted in a timely manner and these are fully implemented. To have assurance that best practice is being followed.
  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.
  • Ensure there are adequate maintenance arrangements in place for all of the medical devices in clinical use in accordance with MHRA (Medicines & Healthcare products Regulatory Agency) guidance.
  • Ensure maternity data is correctly collated and monitored to ensure that the department’s governance is robust.
  • Ensure that mental capacity assessments are in place for vulnerable adults who lacked capacity.
  • Ensure generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

Action the hospital SHOULD take to improve.

  • Ensure there are sufficient numbers of junior grade doctors and consultants across medical services to deliver a safe and effective service particularly out of hours and at night.

  • Reduce the number of bed moves for medical patients.
  • Ensure the bereavement suite on Folkestone ward meets the Department of Health Standards.
  • Review the physical environment within maternity services to ensure it meets the needs of the patients. Specifically temperature control
  • Ensure that the fast track discharge process is fully implemented for end of life patients to be discharged to their preferred place of care within a short time frame.

There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 December 2016

Effective

Requires improvement

Updated 21 December 2016

Caring

Good

Updated 21 December 2016

Responsive

Requires improvement

Updated 21 December 2016

Well-led

Requires improvement

Updated 21 December 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 21 December 2016

We rated this service as requires improvement because:

  • Lack of staffing affected many areas of service planning and the care and treatment of women including; not meeting national safe staffing guidelines, therefore 1 in 5 women did not receive 1:1 care in labour; staff did not have the time to attend risk meetings or complete incident forms.
  • The physical environment was not conducive to the safe care and treatment of women. The bereavement suite on Folkestone ward did not meet department of health standards. Some areas of the department were intolerably hot, although there had been some improvements on the delivery suite since our last inspection.
  • Hospital management did not ensure robust governance, for example, hospital data of the number of surgical abortions was incorrect as figures included women who had miscarried and had a surgical evacuation.
  • On our previous inspection, we found there was an ingrained bullying culture within women’s services. This had since improved, however the culture of the service needed more input to support the improvement journey. For example, innovation hubs had increased in popularity, however there was still a lot of disengagement amongst staff and at the time of inspection there was no audit of the hubs to monitor benefits.

However;

  • Staff were supportive of one another and worked well as a multidisciplinary team. Staff provided a caring, empathetic environment for women during their pregnancy and labour.
  • Care and treatment was evidence based and patient outcomes were in line with other trusts in England.

On this inspection we have maintained a rating of requires improvement.

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2016

We found the medical services at the William Harvey Hospital required improvement because;

  • There were insufficient numbers of junior grade doctors and consultants across medical services at the William Harvey Hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service particularly out of hours and at night.

  • We found there were nursing shortages across the medical services. The situation had improved due to the use of agency and bank staff. Although the trust had recruited overseas nurses, there remained staffing shortages on the wards. The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day basis. This meant, even when there appeared to be sufficient numbers of staff on duty according the rota, the acuity and complexity of the patients meant that nursing staff were under pressure to deliver an acceptable level of care.

  • Staff did not always complete care records in accordance with best practice guidance from the Royal Colleges. We found gaps and omissions in the sample of records we reviewed. The trust did not have a robust system in place to audit, monitor and review care records to ensure they always gave a complete picture of the assessments and interventions undertaken.

  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.

  • We found the hospital was not yet offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.

  • The hospital had improved the number of bed moves patients had during their stay. However, a fifth of all medical patients moved wards more than once during their stay. This meant the hospital transferred some patients several times before they had a bed on the right ward, which put additional pressures on receiving wards.

However;

  • The trust had a robust system for managing untoward incidents. Staff were encouraged to report incidents and there were processes in place to investigate and learn from adverse events. The hospital measured and monitored incidents and avoidable patient harm and used the information to inform priorities and develop strategies for reducing harm.
  • The trust prioritised staff training, which meant staff had access to training in order to provide safe care and treatment for patients.
  • Medical care was evidence based and adhered to national and best practice guidance. Management routinely monitored that care was of good quality and adhered to national guidance to improve quality and patient outcomes.

  • Consultants led on patient care and there were arrangements for supporting the delivery of treatment and care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.
  • Staff treated patients with kindness and compassion.
  • The trusts average length of stay for both elective and non-elective stays were better than the England average for the majority of medical specialities.
  • There was good provision of care for those living with dementia and learning difficulties. There were support mechanisms and information available to take individual patients needs into account.
  • The trust had clear corporate vision and strategy. The trust reflected the opinions of clinicians, staff and stakeholders’ when developing the strategy for medical services. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.
  • The trust had clearly defined local and trust wide governance systems. There was well-established ward to board governance, with cross directorate working, developing standard practices and promoting effective leadership. The trust acknowledged they were on an improvement journey and involved all staff in moving the action plan forward.

At our last inspection, we rated the service as Requires improvement. On this inspection we have maintained a rating of requires improvement but have seen improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Urgent and emergency services (A&E)

Requires improvement

Updated 21 December 2016

  

We rated the urgent and emergency services provided at William Harvey Hospital as requires improvement because:

  • Whilst 86% of patients were triaged within 15 minutes, only 34% had a clinician first assessment within 1 hour and only 17% a decision to admit within 2 hours. Attendance by a specialist within 30 minutes following referral was only achieved 35% of the time.
  • The WHH had an average of 168 60-minute breaches per month from July – October 2016. This represented 7.8% of the total number of patient handovers from ambulance staff and was worse than the regional average of 3%. WHH was consistently in the bottom four of 17 hospitals in the region.
  • The monitoring and reporting of training and other safety indicators such mortality and morbidity summaries were not always reliable. Adult safeguarding training figures were low across the directorate and children’s safeguarding training for doctors in the department was still below trust targets. While mandatory training rates for some staff groups had improved, others in the department remained below trust targets. We acknowledge that major incident training at WHH was better than the other sites we inspected, albeit below target.
  • Staff appraisal rates were worse than another A&E locations and the trust target. Lower completion rates makes it difficult for the department to assure itself that staff performance and development is being monitored and given sufficient attention. We found gaps in staff appraisals for key supervisors such as band seven nurses.
  • Auditing had improved since our last visit, although we found that action plans were not always submitted in a timely manner and where there was an action plan, the actions were not always fully implemented or communicated widely. This meant the department did not have full assurance that best practice was being followed or that problems were being identified quickly enough.
  • Delivery of performance indicators such as patients being seen within four hours remained below trust target and national averages.
  • Patients with mental health conditions who presented in the evening still had long waits before being assessed or admitted by the mental health team. However, the department had responded by employing mental health nurses to provide specialist care and support.
  • Delayed discharges remained a concern due to the impact on the A&E. However, as part of this response we observed an operational communications meeting, which showed the trust was addressing patient flow through the hospital and monitoring closely for risks that affected beds available for receiving patients from the department.
  • A range of positive initiatives have been implemented in this department along with others we observed at similar sites in the trust. Further harmonisation and sharing of best practice between all A&E locations would benefit patients and staff.

However,

  • We saw that new and dedicated facilities had been provided for children. Staff establishments for nurses had been increased and more specialist nurses had been recruited. We also saw well equipped and organised resuscitation facilities.
  • There were sufficient staff with the right skills to care for patients and staff had been provided with induction and additional training specific for their roles. A consultant had been appointed with sub-specialty in children, which complies with recommendations contained in the Standards for Children and Young People in Emergency Care Settings (Royal College of Paediatrics and Child Health, 2012).
  • Staff followed cleanliness and infection control procedures. Potential infection risks were anticipated and appropriate responses implemented and measured.
  • Patients’ treatment and care was delivered in accordance with their individual needs. Patients told us they were treated with dignity and respect.
  • We saw improvements in the way the department and the wider trust managed incident reporting and complaints. Lessons learned were widely communicated using a number of information systems.
  • Medicines were stored safely and checks on emergency resuscitation equipment had improved.
  • Overall, the leadership, governance and culture within the departments was good and we saw examples of good practice regarding visibility of supervisors, comfort rounds and communication. Staff were supported by their managers and were actively encouraged to contribute to the development of the services.

On this inspection we have changed the rating to requires improvement from inadequate, because we have seen improvements in the management of patients with mental health needs, assessments and improvements of the care environment, identifying high risk adults, training, preparedness for major incidents and incident reporting:

Surgery

Requires improvement

Updated 18 November 2015

Patients who used the service experienced safe, effective and appropriate care and treatment and support that met their individual needs and protected their rights. The care delivered was planned and delivered in a way that promoted safety and ensured that peoples individual care needs were met. Staff provided care that was compassionate and all patients were treated with respect and dignity. Patients had their individual risks identified, monitored and managed and the quality of service provided was regularly reviewed. Staff were competent and knowledgeable about their specialties on both the surgical wards and in the theatre units. Mandatory training was not always up to date and there were gaps in the knowledge and understanding with regard to mental capacity. We found the clinical environments we visited to be very clean, as were equipment items. Hospital-acquired infections were monitored and rates of infection were in an acceptable range. Outcomes for patients were good and the departments followed national guidelines. Departments undertook frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff. Complaints were investigated and handled in line with trust policy. Patient complaints and comments were used as an improvement tool to positively impact on patient care  delivery. Leadership in all areas had improved. Senior staff were visible, available and supportive to all staff.

Intensive/critical care

Good

Updated 18 November 2015

We found the service delivered at the William Harvey Critical Care unit (CCU) to be safe, effective, caring, responsive and well led.

However, we continue to recognise a concern with delayed discharges from the unit which may suggest problems with patient flow elsewhere in the hospital. Capacity in the unit was also a concern, given the 100% occupancy rates despite the additional two unfunded beds in operation. The location of these beds was not desirable but staff had taken reasonable steps to minimise the risk to patients and staff. We also noted a robust strategy and vision in the unit, but were uncertain about whether it reflected the trust vision. We acknowledge a recent change to the trust leadership, and the on-going financial challenges, which presented an obstacle to achieving the plan. We recognised the frustrations of staff in terms of the stagnant situation in which they find themselves due to the environmental and financial restraints. The CCU did not always manage to achieve the national recommendation of ensuring a supernumerary shift leader for all shifts. However, we acknowledge that there has been a significant improvement in supernumerary management cover since our last inspection. A standardised approach to inotropic infusion concentrations (modifies the force of muscle contractions) and meeting national guidance for the x-ray checking of Nasogastric (NG) tubes had been implemented across all three sites.

We found effective systems in place to ensure safe care. The care delivery was continuously monitored and assessed to ensure a high quality care for the patients using the service. There was a positive culture towards reporting and learning from adverse events, and a refreshingly positive emphasis put on avoiding recurrence.

The care delivered reflected best practice and national guidance. Needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. There were appropriate measures in place to ensure that patients were protected from the risk of acquiring hospital acquired infections, and staff were observed to follow trust infection control guidance.

Patients and their loved ones had their dignity and human rights respected and protected. The unit provided an ample and varied supply of information for relatives, and actively encouraged their feedback and comments. If a complaint was raised the service learned from the feedback given, and ensured that people felt listened to.

The relatives we talked with during the inspection were very complimentary about the service their loved ones had received, and the caring and approachable attitude of the staff. Relatives were also involved in the planning of care and told us that they had access to sufficient information about their loved ones’ condition. Patients had their right to consent to care respected and, where possible, formal consent was obtained. Staff were found to make reasonable adjustments to reflect the needs of their patients. The service provided a person centred bereavement service for families.

There were suitable arrangements in place for dealing with foreseeable emergencies. Patients had their health needs risk assessed and balanced with safety, and had their rights and preferences taken into consideration. We noted effective systems to ensure patients’ nutritional and pain needs were addressed and managed. Medication management reflected national and trust guidance.

The CCU had appropriate numbers of staff with the required skills to meet people's individual care needs. Staff were subject to competency-based learning and assessments, and were provided with support to learn, develop and progress professionally.

A multidisciplinary approach to care was noted, as was the provision of a seven day service. There was a consultant-led ward round twice daily which meant that patients conditions and progress were continuously monitored. There were effective systems in place to ensure that deteriorating patients had their care needs reviewed in a timely manner. This was also true of patients who were in ward areas as they had their conditions reviewed by the outreach team using an electronic monitoring system.

There was strong leadership in the CCU and staff expressed feeling valued and listened to. They voiced satisfaction with the local unit management and the support provided to them. Numerous steps had been put in place to address the culture concerns raised in the last inspection. Staff told us these measures had a positive impact on morale and on their working environment.

Services for children & young people

Requires improvement

Updated 18 November 2015

Performance showed a track record and steady improvements in safety. However, information about safety was not always comprehensive. The trust was using the Kent safeguarding children’s board (KSCB) safeguarding procedures. These were not trust specific. The trust had not produced an East Kent University NHS Foundation Trust (EKUNFT) children and young people’s safeguarding policy.

Padua ward, NICU and SCBU provided safe and comfortable environments for children. However, the waiting area in the WHH fracture clinic was not child friendly. The fracture clinic had a children’s bay in the clinic which staff had decorated in child friendly décor. However, there was no designated waiting area for children and their families; waiting room conditions were cramped and overcrowded.

Gap analysis had been conducted to identify staff that needed up-to-date training in children and young people’s safeguarding to an appropriate level. The training was being rolled out across the trust.

There was an increased risk that people could be harmed, due to medicines not being secure in children’s ward areas and adult medicines being placed on top of a children’s resuscitation trolley in the outpatients department. On Padua ward medicines fridge temperature had a number of omissions. A number of patient group directions (PGD’s) were out of date.

Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately. There were effective handovers and shift changes, to ensure staff could manage risks to people who use services.

Risks to people who use services were assessed, monitored and managed on a day-to-day basis. These include signs of deteriorating health, medical emergencies or behaviour that challenges. People were involved in managing risks and risk assessments were person-centred, proportionate and reviewed regularly.

Staff recognised and responded appropriately to changes in risks to people who use services.

Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Children and young people had good outcomes because they received effective care and treatment that met their needs. People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Padua ward had a practice development nurse who monitored staff practice to ensure consistency.

Children and young people had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. The expected outcomes were identified and care and treatment was regularly reviewed and updated.

There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services and service accreditation. The trust had achieved level 1 UNICEF Baby Friendly accreditation for supporting breastfeeding and parent infant relationships by working with public services to improve standards of care.

Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Staff were supported to deliver effective care and treatment through supervision and appraisal processes.

When people received care from a range of different staff, teams or services, this was coordinated. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of children and young people’s needs.

When children and young people were due to move between services their needs were assessed early, with the involvement of all necessary staff, teams and services; discharge and transition plans took account of patients individual needs, circumstances, on-going care arrangements and expected outcomes. Children and young people were discharged at an appropriate time and when all necessary care arrangements were in place.

Staff could generally access the information they needed to assess, plan and deliver care to people in a timely way.

Consent to care and treatment was obtained in line with legislation and guidance. Children and young people were supported to make decisions. Processes for seeking consent were appropriate.

Feedback from children, young people and families who used the service was mostly positive about the way staff treated people. Children and young people were treated with dignity, respect and kindness during interactions with staff and relationships with staff were positive.

Children, young people and their families were involved and encouraged to be partners in their care and in making decisions, with any support they needed. Staff spent time talking to children, young people and their parents. Children and young people were communicated with in a way they could understand. Children, young people and their families understood their care, treatment and condition. Parents told us staff worked with them to plan care and share decision-making about care and treatment.

Staff responded compassionately when patient’s needed help. Staff took appropriate steps on the ward to ensure patient’s privacy and confidentiality was respected.

Staff helped children, young people and their families to cope emotionally with their care and treatment. Patient’s social needs were understood. Children and young people were supported to maintain and develop their relationships with those close to them, their social networks and community. Parents were facilitated to stay on the ward over night or in accommodation specifically provided for parents.

Children and young people’s needs were met through the way services were organised and delivered. The importance of flexibility, choice and continuity of care was reflected in service provision. The needs of different patients were taken into account when planning and delivering care and treatment. Care and treatment was coordinated with other services and other providers.

Children and young people could access the right care at the right time. Access to care was managed to take account of patients’ needs, including those with urgent needs.

The appointments system was easy to use and supported people to make appointments.

Waiting times, delays and cancellations were minimal and managed appropriately. Services ran on time. Patients were kept informed of any disruption to their care or treatment.

It was easy for people to complain or raise concerns and they were treated compassionately when they did so. Complaints and concerns were always taken seriously, responded to in a timely way and listened to. Improvements were made to the quality of care as a result of complaints and concerns.

The values for children and young people’s services had been developed with elements such as compassion, dignity and equality. However, there was no long-term vision or strategy in place for children and young people’s services. The trust had conducted a recent strategic review of children and young people’s services, and concluded that the proposed strategy of children and young people’s services operating from one site was not viable. At the time of our inspection there was no decision pending on what the vision or strategy would be for children and young people’s services.

Children and young people’s staff were unaware of the trust’s strategic goals as the trust had not made a final decision about the future strategy for children and young people’s services.

The board and other levels of governance within the organization had undergone changes in the past 12 months. The chief nurse and director of quality had been instated as the children and young people’s services lead. The service’s structures, processes and systems of accountability were set out and understood by staff.

There was an effective process in place to identify, understand, monitor and address current and future risks. Performance issues were escalated to the relevant committees and the board through clear structures and processes. Clinical and internal audit processes were in place.

The leadership was knowledgeable about quality issues and understood what the challenges to children and young people’s services were, and took action to address them. However, monitoring at WHH was a challenge due to the matron being based in Maidstone.

Leaders at every level prioritised safe, high quality, compassionate care and promoted equality and diversity. The culture change programme encouraged cooperative, supportive relationships among staff so that they felt respected, valued and supported. However, staff reported that ward managers for children and young people’s services had been overlooked for administrative support.

There was evidence that the leadership had introduced processes that would actively shape the culture through effective engagement with staff, people who use services and their representatives and stakeholders. Senior leaders encouraged a culture of collective responsibility between teams and services. But, these processes were not embedded.

The children’s and young people’s service was proactively engaging with and involving all staff to ensure that the voices of staff were heard and acted on. The leadership actively promoted staff empowerment to drive improvement and a culture where the benefit of raising concerns was valued.

Senior leaders focus was on continuous learning and improvement at all levels of the organisation. Safe innovation was being supported and staff had objectives focused on improvements.

End of life care

Requires improvement

Updated 21 December 2016

We rated this service as requires improvement because:

  • The trust’s SPC team demonstrate a high level of specialist knowledge. A strong senior management team who were visible and approachable led them. The SPC team provided individualised advice and support for patients with complex symptoms and supported staff on the wards across the hospital. However, the SPC team were small and there were concerns regarding the sustainability of the service. We noted the planned improvements and the implementation of the end of life strategy would be difficult to apply due to the current available resources. These concerns had not changed since the last inspection.
  • We found an array of service improvement initiates had been introduced across the trust since the last inspection. This included end of life care plan documentation, the appointment of an end of life facilitator, identification of end of life care link nurses, a decision making end of life board with a membership of healthcare professionals from a variety of specialties within the trust and external stake holders. A slot at the Quality, Innovation and Improvement hub to spread the word and raise the profile of end of life care. All service improvements were based on national guidance. However, we found changes were recently implemented and more time was required to embed the changes into clinical practice, upskill staff and provide a robust training and education programme to ensure end of life care was delivered following national recommendations.
  • Since the last inspection, we found the training of junior and speciality doctors had improved with the SPC team invited to divisional meetings to present and raise the profile of the importance of good end of life care conversations and symptom control. We saw Clinical leads were championing end of life care however, further work was required to strengthen collaborate working with consultants.
  • Staff told us that since the last inspection end of life care had a much higher profile across the trust. However, we found on the wards that ceiling of treatments were not generally documented, poor completion of nursing notes which made it difficult to access if patients were being reviewed regularly. There were no mental capacity assessments in place for vulnerable adults who lacked capacity. DNA CPR orders were being countersigned by Registered Nurses (RN) without support being put in place around training and where a patient was identified as dying it was often confusing for staff as in many cases interventions were still being delivered.
  • End of life training was not part of the mandatory training programme. We found some nursing staff on the wards had received training whilst others had not .A RN in Accident & Emergency commented end of life care was poor on the unit, however, the SPC Nurse was able to tell us where end of life care was good across the hospital. Wards struggled with staffing levels and there were no extra staff in place to support end of life care.
  • 100 Link nurses had been identified to be the leads on end of life care at ward level. By November 2016, training of the link nurses was expected to be complete. However, more time was required for the link nurses to settle into their new roles, to support their colleagues, and improve quality. We found the end of life resources folders were generally available on the wards. These folders contained the necessary documentation for staff, which was an improvement since the last inspection.
  • The trust had access to the Medical Interoperability Gateway (MiG) system that enabled the trust to view, with consent, patients’ GP records meant that this information was available 24/7.However, this system did not allow the trust to update records or input care plans. No electronic palliative care record system was in place where providers shared information. Staff in Accident and Emergency told us communication between the hospital, community, and GP’s needed to improve to prevent inappropriate admissions to hospital
  • A fast Track discharge process was in place however, staff told us the system was not fast with some patients taking weeks to be discharged to their preferred place of care (PPC). Work had been undertaken since the last inspection however further work was required to ensure patients could be discharged within hours to their PPC.

On this inspection we have maintained a rating of requires improvement.

Outpatients

Good

Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, through structured audit and review the department was able to evidence improvements in health records management, call centre management, referral to treatment (RTT) processes, increased opening hours, clinic capacity and improved patient experience.

Although there was still improvement required in referral to treatment pathways the outpatients department and trust demonstrated a commitment to continuing to improve the service long term.

As a part of the strategy the trust had pulled its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.