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The Tunbridge Wells Hospital at Pembury Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 March 2018

A summary of services at this hospital appears in the overall summary above.

Our rating of services stayed the same. We rated it them as requires improvement because:

Inspection areas

Safe

Requires improvement

Updated 9 March 2018

Effective

Requires improvement

Updated 9 March 2018

Caring

Good

Updated 9 March 2018

Responsive

Requires improvement

Updated 9 March 2018

Well-led

Requires improvement

Updated 9 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 3 February 2015

All the patients we spoke with told us that they had been treated with dignity and their privacy protected. They spoke highly of the staff in outpatients and radiology. They found staff polite and caring. However, many patients complained to us about the waiting times in the outpatient clinics.

Staff were reporting incidents and these were discussed at the clinical governance meetings within the directorates. There were systems in place to reduce the risk and spread of infection. Medicines were stored and administered safely. The department held its own training records which were up to date and demonstrated that most staff had attended mandatory training.

The trust had met their national targets and consistently performed higher than the national average in regard to radiology waiting times. There had been a backlog in reporting CT and MRI scans for several months but there was evidence at the visit that these were reaching resolution. There was an ongoing backlog in clinic letters being sent out that was not resolved. There was risk to patients receiving delayed or inappropriate treatment and considerable stress caused to the staff.

Staff demonstrated a commitment to patient centred care and we found many examples of such care and attention to patient conditions and preferences.

Maternity and gynaecology

Requires improvement

Updated 3 February 2015

The maternity services at Tunbridge Wells Hospital were well planned and organised. There were systems in place that ensured that safety was a priority. Women and their babies were treated in a well-equipped environment.

Women’s care and treatment followed national evidenced-based guidelines. Staff involved women who use the service as partners in their own care and in making decisions, with support where needed. Risks were effectively assessed and managed, there was a process for reporting incidents and any areas of learning were shared with staff in the maternity service.

However, the gynaecology service did not mirror the same robust approach to the recording of incidents on the electronic recording system. The maternity service demonstrated the trusts vision, being proud of the service they offered to women.

Investigations and internal reviews to look at interpersonal relationships within obstetrics and gynaecology consultants needed to be commissioned and completed and the findings fed-back to staff in order that longstanding cultural and behavioural issues amongst staff groups could be resolved.

Medical care (including older people’s care)

Good

Updated 9 March 2018

Our overall rating of this service improved. We rated it as good because since our last inspection in 2015, we saw a number of changes.

• There was an improved culture of incident reporting. Incidents were recorded on electronic systems that incorporated fail-safes about aspects such as duty of candour.

• Patients and relatives we spoke to gave positive feedback about the care they received on the unit.

• Staff showed compassion when dealing with patients and protected their privacy and dignity.

However:

• Medicines were better managed and more available, although some aspects of medicines management still needed improvement.

Urgent and emergency services (A&E)

Requires improvement

Updated 9 March 2018

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

• Staff had taken steps to address the three areas we told the trust they must improve at our last inspection. This had resulted in improved privacy and dignity in the CDU and significantly better communication skills demonstrated by the security team. However, although monitoring of the completion and quality of patient records had become more consistent there was limited evidence of improvement in overall standards.

• Audit results in the Saving Lives audit were variable and indicated inconsistent practices and data reporting in peripheral line insertion and catheter care bundles.

• From August 2016 to July 2017 the trust reported 364 “black breaches”, with an upward trend over the period.

• Triage processes were inconsistent and did not always keep people safe. In addition the results of triage records indicated a need for improved quality.

• A significant backlog of incident investigations and limited evidence of learning from incidents meant we were not assured safety improved as a result.

• There was very limited evidence of health promotion work or intervention despite a significant number of patients presenting with alcohol or drug overdoses or with suicidal intent.

However:

• The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust met the standard for all months over the 12 month period between September 2016 and August 2017.

• From September 2016 to August 2017, the trust reported no incidents classified as never events for urgent and emergency care.

• The unit performed consistently well in the national patient-led assessment of the care environment (PLACE) and in weekly environmental audits. In the previous 12 months, the unit performed better than national and trust averages in all categories.

• The recruitment of practice development nurses had significantly improved the training and professional development opportunities for staff. This improved tracking and assessment of staff competencies and enabled individuals in different roles to work and develop together.

• Systems were in place to ensure clinical practice was evidence-based, including from audits and national benchmarking.

• There was a demonstrable track record of well-coordinated multidisciplinary working that contributed to patient outcomes.

• From January 2017 the trust showed a general trend of improvement in performance against Department for Health access and flow metrics, including the national standard to be seen, discharged or admitted within four hours.

• There were clear and demonstrable improvements in clinical governance and leadership and this was reflected in the morale of staff and initiatives to improve performance and risk management.

Surgery

Requires improvement

Updated 9 March 2018

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

• While the service improved in some areas, it stayed the same or became worse in others.

• The escalated short stay surgery unit created risks to patient safety and dignity.

• The hospital had had two never events during the reporting period and one additional never event in the week before this inspection.

• Learning from incidents had not significantly improved since the prior inspection. Information about learning was not always complete and there was not a system to ensure learning was shared with staff.

• Capacity to manage the number of patients being admitted led to significant shortfalls in the responsiveness of the service. This issue was identified at the previous inspection and continued to require improvement.

• Some senior staff did not reflect an understanding of the risks in their departments.

• Significant challenges to recruiting caused gaps in rota coverage and high reliance on bank and agency staff. This issue was identified at the previous inspection and continued to require improvement.

• Resuscitation trolleys in the department were not tamper evident which meant items could be taken from the trolley or tampered with without staff knowledge. We raised this issue with the trust. The trust reported that it reacted throughout the trust immediately and effectively to rectify the issue by putting tamper-evident security on resuscitation trolleys.

However:

• The hospital had improved its supplication of World Health Organisation Safer Surgery Checklists. This was an improvement since our last inspection.

• The department had improved staff retention.

Intensive/critical care

Requires improvement

Updated 9 March 2018

Our overall rating of this service improved. We rated it as requires improvement because:

Since our last inspection in 2015, we saw a vast number of improvements in critical care.

• There was a good culture of incident reporting and learning, and all incidents were recorded on the trust wide electronic reporting system.

• Medicines were well managed.

• Patient outcomes were mostly in line with or better than other similar critical care units.

• Compliance with national guidelines had improved.

• Patients and relatives we spoke to gave positive feedback about the care they received on the unit.

• Staff showed compassion when dealing with patients and protected their privacy and dignity.

However:

• It was not clear if all intensive care unit deaths were discussed at the morbidity and mortality meetings.

• Delayed discharges from the unit remained an issue.

Services for children & young people

Good

Updated 9 March 2018

Our overall rating of this service improved. We rated it as good because:

• Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learn with the paediatric directorate.

• There was comprehensive assessment of children, including a history of any past or current mental health problems alongside the assessment of their physical health needs. This included age-related pain assessments and children’s pain levels were regularly assessed and acted upon.

• Children had individualised care pathways for their care and risk assessments were completed for all patients including National Paediatric Early Warning Scores in order to rapidly detect any child whose health was of deteriorating.

• Staff had training in the assessment and management of sepsis antibiotics were given in line with guidance. Reports on antimicrobial prescribing and sepsis management were escalated to the board through the trusts governance framework.

• Staff demonstrated an understanding of the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005, with regard to children over 16 years and the Children Acts 1989 and 2004.

• There was evidence of good multidisciplinary working both within the trust and with external stakeholders.

• The service was responsive to children, young people and their family’s needs. They delivered personalised care and took into account needs and choices of different people.

• There was a children’s strategy in place that staff we spoke to knew about and were committed to improving child health experiences and outcomes. There was a clear governance framework in place that was led by the chief nurse.

• Staff told us they were supported and felt valued; they thought highly of the matron who they said was very visible supportive and kept them well informed.

However:

• Although it was evident that lessons learned in the children’s services was shared within the directorate and practice changed as a result, it was less clear how learning was systematically identified, disseminated or audited across the trust.

• There were no safeguarding level 3 trained staff on adult wards where 16-18 year old patients were cared for.

End of life care

Requires improvement

Updated 3 February 2015

The SPCT were available five days a week for face to face contact and a local hospice provided telephone out-of-hours and weekend cover. Medicines were provided in line with guidelines for EoLC, but DNACPR forms were not consistently completed in accordance with trust policy. There were no standardised processes for completing mental capacity assessments.

The SPCT provided four study days per year for trained nurses And staff were able access palliative care study days provided by the Hospice in the Weald. Medical end of life training was delivered as part of the doctors formal education programme.This was delivered by the palliative care consultant and the trust clinical ethicist. Palliative care link nurses were present on the wards we visited but training had reduced recently due to staff shortages in the SPCT. Leadership of the specialist palliative care team was good and quality and patient experience was seen as a priority.

All patients requiring EoLC were referred to the SPCT, but often no input was required by the team. Referrals to the team supported audit processes within the trust. There was a multidisciplinary team (MDT) approach to facilitate the rapid discharge of patients to their preferred place of care.

Patients were cared for with dignity and respect and received compassionate care. Relatives of patients receiving end of life care were provided with free car parking.