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Kidderminster Hospital and Treatment Centre Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 20 June 2017

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire, with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire, as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection at Kidderminster Hospital on 8 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

Overall, we rated Kidderminster Hospital and Treatment Centre as inadequate, with one of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

  • Managers did not have clear oversight of mixed sex breaches or the need to report them in line with national guidance
  • Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
  • Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
  • Not all staff had had undertaken the mandatory training required, including safeguarding children’s training, Mental Capacity Act 2005, Deprivation of Liberty Safeguards and insulin management.
  • Appropriate systems were in not in place for the management of controlled drugs within the endoscopy unit.
  • Resuscitation equipment was not fit for purpose in an emergency situation. In the MIU we found an empty oxygen cylinder and out of date paediatric airway masks.
  • Pain in children attending the MIU was not always managed effectively. We found children were not always assessed for pain and associated pain scores were not always documented.
  • Medical notes were not always locked away safely.
  • Medicines were not always stored safely. For example: medication fridge temperatures in the MIU were above the recommended temperatures for storing medicines and vaccines.
  • Limited use of local audit meant that some outcomes with regards to patient safety, care and effectiveness were not fully understood.
  • The NHS Friends and Family Test (FFT) had been suspended in children’s clinics since the service reconfiguration. Patients’ feedback could not be used to monitor and improve services.
  • Nursing staff competency assessment records in the children’s clinic were all out of date.
  • Examination protocols for standard x-ray examinations were not routinely reviewed and not subject to document control. Patients were unable to access the majority of services in a timely way for initial assessments, diagnoses and/or treatment.
  • There was a lack of radiation protection infrastructure.
  • Examination protocols for standard x-ray examinations were not routinely reviewed and not subject to document control. Patients were unable to access the majority of services in a timely way for initial assessments, diagnoses and/or treatment.
  • Staff were caring and respectful towards patients. Patients’ privacy and dignity was protected and staff adapted their approach to meet the individual needs of patients
  • There was an on-site Resident Medical Officer to cover services seven-days a week.
  • There were areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve:

  • Ensure patients privacy, dignity and confidentiality is maintained at all times.
  • Establish female genital mutilation and child sexual exploitation training that is to be completed by all staff working in children and young people’s services.
  • Ensure administration of controlled drugs are always documented contemporaneously with signature as appropriate.
  • Ensure that medicines are always stored within the recommended temperature ranges to ensure their efficacy or safety.
  • Ensure all equipment is in date and used, stored and maintained in line with manufacturers’ instructions.
  • Ensure that resuscitation equipment is readily available for use when required without posing a risk.
  • Ensure that there is an effective system in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
  • Ensure that equipment is checked as per policy.
  • Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
  • Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
  • Ensure they are carrying out patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
  • Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
  • Ensure there is a strategy in place for diagnostic and imaging services that staff are aware of.
  • Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
  • Ensure there is a process for collecting data regarding the effectiveness of the children’s outpatients department to recognise and plan where improvements can be made.
  • Ensure mixed sex breaches are reported as required.
  • Ensure patient notes are stored securely and safely.
  • Increase staff awareness of the trust’s incident reporting procedures and risk matrix tool.
  • Ensure staff complete the required level of safeguarding training, including safeguarding children.
  • Ensure staff compliance with mandatory training meets trust target of 90%.
  • Ensure all staff receive an annual appraisal.
  • Ensure staff receive appropriate clinical supervision.

In addition, the trust should:

  • Ensure there is a clear consistent approach to streaming patients in the minor injuries unit at all times, to ensure patients with the most urgent needs are prioritised.
  • Ensure every child has a pain assessment and pain scores are documented.
  • Ensure pain relief given to children is audited in the minor injuries unit.
  • Ensure that guidelines are in date and are in line with national best practice guidance.
  • Ensure patient outcomes are collected, monitored, analysed and used to drive service improvements.
  • Ensure there is a clear minor injuries unit strategy.
  • Consider developing a formal clinical audit plan, including regular, local audit of documentation, environment, equipment and hand hygiene. Then share the results with staff to improve patient care.
  • Ensure all additional training identified is completed by staff.
  • Ensure that World Health Organisations’ Five Steps to Safer Surgery checklists is reviewed and completed appropriately.
  • Review the systems in place to ensure staff feel safe, respected and valued within the workplace.
  • Ensure staff have knowledge of the key objectives within the service.
  • Consider involving staff in strategic plans and developments within surgical services.
  • Review the number of cancelled operations in line with the national average of 6%.
  • Review the choices offered to patients about where they are discharged too for continuing care.
  • Record templates should be developed that clearly identify where information should be recorded.
  • Record meetings where performance in the children’s clinic is discussed.
  • Ensure there are appropriate and child friendly waiting areas for children and young people and provide appropriate environments for them, including room temperatures.
  • Take action to address the ‘did not attend’ appointment rate for new children and young people’s clinic appointments.
  • Ensure complaints are investigated within the timescales stated in the trust’s complaints policy.
  • Ensure there is a clear flow of information from the children’s clinic to the board via effective governance processes.
  • Ensure there is senior oversight of the minor injury unit.
  • Ensure there are suitable arrangements for the maintenance, renewal and replacement of equipment and medical consumables.
  • Ensure that risks are identified, escalated and acted on without delay.
  • Ensure that processes are in place to assess, monitor and mitigate risks relating to service users.
  • Ensure that systems and processes are operated effectively.
  • Ensure that records and information in relation to equipment is accurate, analysed and reviewed by people with the appropriate skills and competence to understand its significance.
  • Ensure effective governance measures are in place to ensure staff adhere to trust policies and processes.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the

section

29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 June 2017

Effective

Requires improvement

Updated 20 June 2017

Caring

Good

Updated 20 June 2017

Responsive

Requires improvement

Updated 20 June 2017

Well-led

Inadequate

Updated 20 June 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 20 June 2017

We rated maternity and gynaecology as requiring improvement because:

  • Environmental checks were inconsistent. Systems for monitoring equipment safety were not robust.
  • Limited use of local audit meant that some outcomes with regards to patient safety, care and effectiveness were not fully understood. This was especially noticeable with regards to documentation and assessment.
  • Compliance with mandatory training modules remained below the trusts target of 90%.
  • Multiple sets of patient notes led to gaps in information in some records that we saw.
  • Senior leaders were not always visible and some had limited capacity due to multiple roles.
  • New pathways were not dated or referenced with up to date evidence.
  • Staff had a poor understanding of female genital mutilation, child sexual exploitation, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Leaders had told us that all staff had been trained in these areas.
  • Medical staff vacancy rates in obstetrics and gynaecology were above the national average, leading to cancellation of clinics.
  • There was no awareness, amongst staff, of major incident plans or roles that individuals would take should there be a major incident.
  • Midwives were not rotated to different areas, potentially resulting in loss of some skills.

However:

  • All staff considered patients’ needs, were respectful and caring in their interactions.
  • Staff were valued and respected. There was open and honest communication between staff and managers. Local leaders were visible and approachable.
  • Divisional leaders had a clear vision and strategy for maternity services.
  • Incident, comments and complaints processes were thorough; lessons were learned and disseminated well. However, the target to complete these was often missed.
  • Nursing and midwifery leaders were always available on the telephone or email.

We rated maternity and gynaecology as requiring improvement because:

  • Environmental checks were inconsistent. Systems for monitoring equipment safety were not robust.
  • Limited use of local audit meant that some outcomes with regards to patient safety, care and effectiveness were not fully understood. This was especially noticeable with regards to documentation and assessment.
  • Compliance with mandatory training modules remained below the trusts target of 90%.
  • Multiple sets of patient notes led to gaps in information in some records that we saw.
  • Senior leaders were not always visible and some had limited capacity due to multiple roles.
  • New pathways were not dated or referenced with up to date evidence.
  • Staff had a poor understanding of female genital mutilation, child sexual exploitation, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Leaders had told us that all staff had been trained in these areas.
  • Medical staff vacancy rates in obstetrics and gynaecology were above the national average, leading to cancellation of clinics.
  • There was no awareness, amongst staff, of major incident plans or roles that individuals would take should there be a major incident.
  • Midwives were not rotated to different areas, potentially resulting in loss of some skills.

However:

  • All staff considered patients’ needs, were respectful and caring in their interactions.
  • Staff were valued and respected. There was open and honest communication between staff and managers. Local leaders were visible and approachable.
  • Divisional leaders had a clear vision and strategy for maternity services.
  • Incident, comments and complaints processes were thorough; lessons were learned and disseminated well. However, the target to complete these was often missed.
  • Nursing and midwifery leaders were always available on the telephone or email.

Medical care (including older people’s care)

Updated 8 August 2017

We carried out a focused inspection on 11 and 12 April 2017 to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected one part of the five key questions but did not rate it. We observed the following improvement to the endoscopy suite since our last inspection:

  • Appropriate systems were in place for the management of controlled drugs within the endoscopy unit.

However, we also found that:

  • Not all staff had completed their medicines’ management training in the medical care service. Figures from the trust showed a completion rate of 30% against a trust target of 90%. This meant that not all staff had up-to-date knowledge relating to potential risks associated with medicines.
  • The Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training was mandatory training and only 33% of medical care staff were up-to-date on this training. This was below the trust target of 90%.

Minor injuries unit

Updated 8 August 2017

We carried out a focused inspection on 11 and 12 April 2017 to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected one part of the five key questions but did not rate it. We found that:

  • Resuscitation equipment was not fit for purpose in an emergency situation. The defibrillator was not ready for use, as the electronic pads had expired at midnight on the night before our inspection.
  • The unit had a process in place for the monitoring of fridge temperatures where medicines were stored. However, there was no evidence of follow-up processes when areas of concern had been highlighted.

Surgery

Updated 8 August 2017

We carried out a focused inspection on 11 and 12 April 2017 to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected one part of the five key questions but did not rate it. We found that:

  • The hospital had addressed the mixed sex accommodation breaches observed during our previous inspection.

Services for children & young people

Requires improvement

Updated 20 June 2017

We rated services for children and young people as requiring improvement because:

  • Staff were not aware of any guidance to support them in identifying what incidents should be reported. This created a risk of under reporting of incidents.
  • Incident reports did not always identify learning. This meant there was a risk of both the service and staff not learning from incidents.
  • Record templates were not always clear and did not contain columns on documents that clearly identified where height and weight should be recorded.
  • Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
  • Level three safeguarding children’s training was not always face to face and was not updated annually; this was not compliant with the guidance on safeguarding training.
  • The operating theatres sometimes had young people on theatre lists. Staff in the main theatres were not trained to level three in safeguarding. In addition, staff were not trained in paediatric immediate life support (PILS).
  • The safeguarding supervision policy stated on the intranet, that it was ‘in development’. There were though, some policies relating to safeguarding children that were not available on the trust intranet, including a ‘no allegations policy’; and a ‘managing celebrity visits’ policy.
  • There was no clinical audit plan for the children’s clinic. There was little evidence that continual improvement of the service and compliance with best practice was identified or actions taken to address shortfalls.
  • The women and children’s division had introduced a performance dashboard to monitor patients’ outcomes. There was little evidence that performance in the children’s clinic was discussed.
  • We viewed nursing staff competency assessment records and found these were all out of date. This meant the hospital could not be sure that staff were competent in all the skills required for their role.
  • There had been no training for nursing staff to enable them to recognise sepsis.
  • There was no formal clinical supervision for nursing staff. Supervision was provided by an outpatient’s manager via telephone as they worked at another location. However, the manager also worked in WRH as an advanced nurse practitioner and could only offer staff telephone support when there were quiet periods at WRH.
  • The NHS Friends and Family Test (FFT) had been suspended in children’s clinics since the service reconfiguration. Patients’ feedback could not be used to monitor and improve services.
  • The ‘did not attend’ (DNA) appointment rate for new children and young people’s services appointments was regularly above the trust’s target of 7%.
  • The allergy service had a waiting time of up to 14 weeks due to the service only having one consultant.
  • As a result of the emergency service reconfiguration which took place during the spring of 2016, the children’s service did not have a clear vision, and did not have a long-term strategy. Staff were unaware of the vision and values for the children’s outpatients’ service as these were not defined.
  • The governance framework was not effective because there was no evidence that information flowed between the directorate and divisional governance or quality meetings.
  • Monthly divisional governance meetings were not consistently adhering to their terms of reference. This included: not focusing on themes and trends from incidents; safeguarding training performance, being reported as mandatory training, and not broken down to include compliance with level three safeguarding training. Discussions in regards to the divisional risk register focused on the number of risks recorded rather than how they were being managed. There had been little discussion around how the children’s services transitional period was being managed.
  • The outpatients manager had not been allocated any contracted hours for service leadership and they were fitting this in with their ANP role at WRH. This meant it was likely that staff would not receive timely supervision and advice.

However:

  • The environment was observed to be visibility clean and staff followed correct protocols.
  • Medicine cupboards and treatment rooms were sufficiently secure to prevent unauthorised access.
  • Overall, care records were generally written and managed well. However, record templates were not always clear, and did not contain columns on documents to clearly identify where height and weight should be recorded.
  • Medical and nursing staffing levels were planned and reviewed in advance, based on an agreed number of staff per shift.
  • The trust had a major incident plan in place. However, staff were not aware of a local formal business continuity plan.
  • The trust’s 95% target for referral to treatment time (RTT) for non-admitted children and young people receiving an appointment within 18 weeks was regularly met.
  • Staff who worked in the children’s clinic took the time to interact with patients and their parents in a manner which was respectful and supportive.
  • All of the patients and parents we spoke with told us that staff were kind and caring and that they felt well looked after.
  • Feedback from the CQCs children and young people’s survey 2014 was largely similar to other trusts including privacy and about care and treatment and staff friendliness.
  • Staff communicated with children, young people and their families in a way that they could understand their care and treatment. Staff understood the impact that a patients care, treatment and condition had on them and those close to them.
  • Children, young people and their families said they could be involved in their own care and treatment if they wished.
  • There was a range of information available on the children’s clinic.
  • Services in the children’s clinic took into account the needs of different children and young people. Consideration had been given to children and young people’s age and gender as well as any disabilities.
  • Transition arrangements were in place for patients approaching adulthood to ensure children and young people had access to appropriate support and the skills required to take control of the management of their continuing care.
  • There was good teamwork and committed staff in the children’s clinic.

Outpatients

Inadequate

Updated 20 June 2017

We rated outpatients and diagnostic imaging as inadequate because:

  • There was a lack of radiation protection infrastructure.
  • Examination protocols for standard x-ray examinations were not routinely reviewed and not subject to document control. Patients were unable to access the majority of services in a timely way for initial assessments, diagnoses and/or treatment
  • The trust did not consistently meet all cancer targets for referral to treatment times.
  • Staff we spoke with were unaware of any patient harm reviews undertaken to mitigate risks to patients who had breached the RTT / cancer waits.
  • We could not ensure that all equipment was suitable for purpose. We saw a blood pressure monitoring machine had not been calibrated. Aging and unsafe equipment across the trust that was being inadequately risk rated with a lack of capital rolling replacement programmes in place.
  • Whilst staff were aware of their roles and responsibilities with regards to reporting patient safety incidents, incidents reporting in outpatients was low and where incidents had been reported, the dissemination of lessons learnt was insufficiently robust.
  • The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.
  • Not all nursing and medical staff had had appropriate levels of children’s safeguarding training.
  • Compliance with mandatory training had improved since the last inspection. Training figures showed training compliance met the trust’s target of 90%.
  • There were moderate to high level of clinic cancellations with less than six weeks’ notice across particular specialties.
  • Hand hygiene and arms bare below the elbow audits were not regularly carried out with only one weekly audit carried out so far in the current financial year.
  • There was a shortage of medical staff across all specialities. This meant there could be a delay in patients being seen for new or follow-up appointments.
  • We were not assured that all complaints were dealt with in a timely manner and in accordance with trust policy.
  • We could not be assured the service had a robust, realistic strategy for achieving the priorities and delivering good quality care.

However:

  • Staff were dedicated and caring staff. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.
  • The premises were visibly clean.
  • The process for keeping patients informed when clinics overran was good.
  • There were effective systems in place regarding the handling of medicines.
  • FP10 prescription pads were stored securely.
  • Patient’s medical records were accurate, complete, legible, up to date and stored securely.
  • Leadership within the outpatient’s team was visible however, the management of risk was insufficiently robust and further improvements were necessary.
  • Staff were proud to work at the hospital. They were passionate about the care they provided for their patients and felt they did a good job.