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Provider: East Kent Hospitals University NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2016

East Kent Hospitals University NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 750,000 across Dover, Canterbury, Thanet, Shepway and Ashford. The trust operates from three acute sites; William Harvey Hospital (WHH)Ashford, Queen Elizabeth the Queen Mother (QEQM) Hospital Margate and Kent and Canterbury Hospital. In addition local services including outpatients and diagnostics are provided from the Buckland Hospital Dover and The Royal Victoria Hospital, Folkestone.

The trust has over 1000 beds including 27 critical care beds and 67 children's beds. The trust receives over 200,000 emergency attendances , 94,000 inpatient spells and 727,000 outpatient attendances. There are 138,000 day case attendances. All core services are provided at both William Harvey Hospital and QEQM Hospital whilst at Kent and Canterbury Hospital there are no maternity beds and a minor injuries unit with an emergency care centre rather than a full emergency department service.

We carried out an announced inspection between 6th and 8th September 2016.

This is the third inspection of this trust. The first in March 2014 led to an overall rating of inadequate and as a consequence the trust was placed into special measures by Monitor. A supporting performance management structure has been placed around the trust including the placement of a Monitor director of improvement. Following our second inspection in July 2015 the trust showed significant signs of improvement and an overall rating of requires improvement applied. We also made the recommendation that the trust remained in special measures as leadership was not substantive and a number of service improvements were not fully embedded in practice.

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. The remaining services were not inspected as they had indicated strong improvement at our last inspection and our information review indicated that the level of service seen at our last inspection had been sustained.

Following this inspection we have re-rated the services inspected. For the other services we have maintained the ratings from the July 2015 inspection. We have aggregated the ratings to provide an updated overall rating for the trust of requires improvement.

Caring was rated as good and safe, effective, responsive and well led were all found to require improvement. We found that William Harvey Hospital, QEQM Hospital and Kent and Canterbury Hospitals as individual locations also all require improvement.

It is important to read the detail of this report. Whilst the overall trust rating has not changed from the inspection of July 2015 this report indicates a number of areas in which further significant improvement has been obtained, notably there are no longer any elements of the report that are rated inadequate.

Our key findings were as follows:

SAFE

  • There are delays in the transfer of patients from ambulances into the emergency department.
  • Completion of patients medical records was not comprehensive and consistent.
  • Staffing levels in medicine and maternity have continued to impact on the quality of patient care and experience.
  • Planned preventative maintenance of medical equipment, although improved, remained behind plan.
  • Issues around consistency of incident reporting in the emergency medicine departments had been addressed.
  • Access to cardiotacography CTG equipment in maternity services had been improved.
  • The assessment of patient risk had improved in the emergency care and maternity settings.
  • The ratings for safety had improved in all emergency care departments including a movement from inadequate to requires improvement in the ED at William Harvey Hospital

EFFECTIVE

  • Although deficiencies in audit results were addressed through action plans, the actions and timescales for completion were not always clearly defined.
  • The results for stroke and diabetes were worse than the England average for Kent and Canterbury Hospital, and in the case of stroke indicating a deteriorating trend.
  • The trust had not successfully attained the required standard for a number of the components of the NCDAH.
  • Although the end of life care pathway had been significantly improved it was in the early stages of implementation.
  • National and local audit was being undertaken in all services inspected. Audit was followed up by the completion of action plans to address deficiencies.
  • The trust had implemented documentation and training to replace the Liverpool Care Pathway.
  • The trust had improved its rate of sepsis screening.

CARING

  • All services inspected were rated as good. The culture of compassionate care that was reported at our last inspection had been maintained and was supported by feedback and our observations during this inspection.
  • Discussions with patients and carers indicated confidence in the level of involvement they have in their or their relatives care.
  • Issues relating to the emergency department reported following our last inspection had been resolved by the impact of improved leadership.
  • Patient surveys supported the observations of the inspection team.

RESPONSIVE

  • Access targets for emergency care, referral to treatment and cancer were not being attained.
  • Patients continue to be moved between wards to address capacity issues and patients are placed in beds within unsuitable specialty wards.
  • Patients on an end of life care pathway do not receive rapid discharge to support achieving their preferred place of death. The trust does not measure attaining preferred place of death.
  • Improvements in availability and use of data for bed management purposes, facilities and support to dementia patients and overall engagement with CCG's in planning of services have improved

WELL LED

  • 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.
  • Despite improvement, the national staff survey stillreports a high number of indicators that are in the worst 20% nationally.
  • Changes in performance and risk management remain relatively new and have yet to become fully embedded.
  • The trust board and executive are at full establishment and staff acknowledge greater visibility and clarity of direction within the organisation
  • The culture of the organisation continues on a trajectory of improvement with a continued reduction in bullying and harassment.
  • Staff at all levels are contributing to the improvement programme and as a result a momentum of improvement is apparent within the organisation

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.

Importantly, the trust must:

  • Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.

  • 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.

  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.

  • 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 generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

  • Take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure there are sufficient numbers of midwives to meet national safe staffing guidelines of 1:1 care in labour.

  • Ensure maternity data is correctly collated and monitored to ensure that the department’s governance is robust.

  • 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 that mental capacity assessments are in place for vulnerable adults who lacked capacity.

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

Inspection areas

Safe

Requires improvement

Updated 21 December 2016

Summary

During our inspection in July 2015 we identified significant improvements that allowed the trust to improve its rating for safety from inadequate to requires improvement.

Our findings at this inspection have led us to maintain a rating of requires improvement. This is because:-

  • Arrangements at both emergency departments did not afford for rapid transfer of ambulance patients into the department.
  • Completion of patients medical records was not comprehensive and consistent.
  • Staffing levels in medicine and maternity have continued to impact on the quality of patient care and experience.
  • Planned preventative maintenance of medical equipment, although improved, remained behind plan.

However

  • Issues around consistency of incident reporting in the emergency medicine departments had been addressed.
  • Access to cardiotacography CTG equipment in maternity services had been improved.
  • The assessment of patient risk had improved in the emergency care and maternity settings.

Incidents

  • A good reporting culture with respect to incidents had been developed across the trust. A consistent system was in place and staff were aware of how to use the system.
  • At our last inspection we reported an inconsistent approach to incident documentation in the emergency departments. This had been addressed.
  • The use of risk based newsletters to all staff continued to enhance the ability of the organisation to learn form incidents.
  • A robust process for the investigation of serious incidents had been maintained and the trust had improved its processes for the management of national patient safety alerts.
  • However, staffing pressures continued to create problems for staff in both emergency departments and maternity. This resulted in inconsistent occurrence of key meetings to discuss morbidity and mortality and a degree of under reporting in maternity due to time pressures.
  • The trust reporting of incidents relating to post partum haemorrhage lacked clarity. As a result there is the potential for the organisation to be unable to identify the scale of issue and act accordingly.

Duty of candour

  • The trust had developed a training package for staff to enhance understanding of duty of candour and this has had the positive impact of raising awareness. Systems for ensuring compliance and the audit of compliance still required development.

Cleanliness, infection control, equipment and environment

  • The trust had maintained an up to date infection control policy. Personal protective equipment and access to hand hygiene gels and washing facilities was appropriately provided. Waste was safely managed in all areas.
  • Our observations of practice and review of hand hygiene audits indicated a high level of compliance. Improvement from our last inspection was particularly noted in emergency care. However, this report has identified incidents of non compliance by medical staff on medical wards.
  • The July 2015 report identified that equipment was not always appropriately labelled as clean and ready for use. During this inspection we saw consistent use of green identification labels for this purpose.
  • As per our previous inspection we found the hospital environment clean. The trust had addressed the concerns relating to patient visibility in the emergency department at WHH and despite contractor delays was developing the children's area.However, during the inspection we observed that adult patients were still being treated in children's cubicles at Kent and Canterbury.
  • St Augustine ward at QEQM was highlighted in our last report. The ward was at that time being used as an escalation ward and was not considered by the inspection team to be fit for purpose. The trust has since refurbished the ward and clarified its purpose and equipped it accordingly.
  • Our report identified quiet room facilities were not always of a suitable design to provide an appropriate environment for relatives.
  • The report also identified environmental temperature issues in maternity, a lack of en-suite bathroom facilities and a general poor standard of accommodation in maternity at QEQM. This led to a sub-optimum environment for both staff and patients.
  • Staff reported that they had access to equipment required to deliver care. Resuscitation was checked and appropriately stocked although the report identified isolated occurrences of incomplete checks.
  • The trust had a history of insufficient provision of CTG equipment and this had been identified in both previous reports. At this report it was noted that this issue had been addressed by the procurement of more equipment.
  • The had identified that the planned preventative maintenance(PPM) of all equipment was a risk. A plan to ensure that 95% of medical equipment had PPM had been developed but at the time of our inspection only 69% compliance had been achieved.
  • Fire safety issues identified at the last inspection had been addressed.

Safeguarding

  • Similar to our last inspection we found robust arrangements for safeguarding at the trust. The people at risk team (PART) had continued to be effective in delivery of the policy. Awareness of the team had further improved from our last inspection.
  • Comprehensive training was available to staff. The emergency department had enhanced training in child safeguarding and improved its processes for identification of patients at risk. However, across all services inspected attendance at adult safeguarding was below that of other elements of mandatory training.

Staffing

  • The trust has continued to drive a number of recruitment initiatives to address the continuing issue of staff recruitment. All inspected areas reported that significant investment has been made by the trust to increase the staffing establishment.
  • The emergency department reported increase funding for consultants, paediatric nurses, practice development nurses and technicians. During our inspection we identified appropriate staffing numbers in all emergency departments.
  • 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, the trust has continued to drive recruitment of midwives. However, there remains a significant number of vacancies. The staff to mother ratio fluctuates between 1:30 and 1:32.  As a consequence 20% of women in labour are not afforded 1:1 care.
  • Where staffing gaps exist the trust utilise band and agency staff. Control measures for the induction and recruitment of these staff have been strengthened.

Assessment of patient risk

  • At our last inspection we identified issues relating to the assessment of patient risk in emergency departments. This included inconsistent observations and a lack of rapid assessment. Mental health patient assessment in the Clinical Decision Unit was also considered below acceptable standards.
  • At this inspection we observed the consistent use and documentation of early warning scores and the completion of regular observations in all services including the emergency department settings. This had been supported by electronic recording technology. The screening of sepsis patients had also significantly improved from November 2015.
  • Mental heath patients also received appropriate assessment in the emergency department.
  • However, the trust was responsible for 1300 “black breaches”  from October 2015 to July 2016. A black breach is when a patient waits more than 60 minutes to be handed over from the ambulance crew to the hospital staff. This is an issue on both WHH and QEQM but is more concern in the WHH ED. Between July 2016 and October 2016 delays of over 5% of ambulance handovers exceeded 60 minutes with the figure reaching 12% in October 2016.

  • The trust had processes to support patients identified as deteriorating, however the report noted the risk of slow response at night in medical services due to availability of doctors.
  • Comprehensive risk assessment processes were in place in maternity including assessment of obesity. However, VTE (Venous Thromboembolism) targets had not been achieved prior to May 2016 and this did not appear on the trust maternity dashboard.
  • In gynaecology operating theatres we  saw appropriate use of WHO (World Health Organisation) safer surgery checklists and documentation.

Medicines

  • The secure storage, temperature monitoring and management of medicines had improved in all areas inspected. However, the trust does have to give consideration to the monitoring of ambient temperatures as this can have an impact on efficacy of drugs stored at room temperature.
  • In our last report we commented on delays in preparation of medicines for patient discharge and inconsistency of service to wards. Although the trust has implemented a recruitment plan, pharmacy remains under staffed leading to continued inconsistency of service.

Records

  • At our last inspection we reported insecure records storage in the emergency departments and lack of standardisation of recording in medical services records.
  • This inspection reported that all services held records in a secure manner. However, the report also identified continued inconsistent practice and gaps in recording.
  • On medical wards, we reviewed medical records and whilst records were largely comprehensive we have identified gaps in recording.
  • Similarly when reviewing records related to end of life care we found largely comprehensive recording following the introduction of new guidance. However the records were not always easy to follow and copies of DNACPR not always retained. The recording of the ceiling of care was not always clear.
  • The trust had introduced increased audit of the quality and consistency of medical records. However, the sample numbers used were very small and did not provide assurance on overall quality of documentation.

Effective

Requires improvement

Updated 21 December 2016

Summary

Following the July 2015 inspection we rated the trust as inadequate for effectiveness. Both emergency care at WHH and end of life care services as a whole were rated as inadequate. This was a consequence of the failure to address, via action plans, results from emergency care audits and the failure to appropriately replace the Liverpool Care Pathway for end of life care patients.

Following this inspection we have rated the trust as requiring improvement for effectiveness. This is because:

  • Although deficiencies in audit results were addressed through action plans, the actions and timescales for completion were not always clearly defined.
  • The results for stroke and diabetes were worse than the England average for Kent and Canterbury Hospital, and in the case of stroke indicating a deteriorating trend.
  • The trust had not successfully attained the required standard for a number of the components of the NCDAH.
  • Although the end of life care pathway had been significantly improved it was in the early stages of implementation.

However:

  • National local audit was being undertaken in all services inspected including the National Care of The Dying Audit of Hospitals (NCDAH). Audit was followed up by the completion of action plans to address deficiencies.
  • The trust had implemented documentation and training to replace the Liverpool Care Pathway.
  • The trust had improved its rate of sepsis screening.

Evidence based care and treatment

  • Policies and procedures were in place in all services inspected. Policies and procedures were supported by appropriate guidance from national bodies.
  • In particular, there had been an extensive introduction of comprehensive new guidance for the pathway management of end of life care. This replaced the Liverpool Care Pathway and provides a significant improvement in terms of access to information for staff since our last inspection.
  • New models of care had been developed in medicine that utilised ambulatory care and acute frailty pathways.
  • However, the system was not well embedded and during the inspection we identified that checklists and prompts were not being consistently used. Our report indicates that recording of the 'end of life conversation' was not consistently being documented.
  • The trust participated in national audits. This included the NCDAH audit which had not been completed prior to our last inspection.
  • All services inspected had developed audit programmes and action plans to address deficiencies. However, audit plans were not always well planned leading to over commitment and under delivery. Actions described in action plans lacked clarity in some cases with a lack of re-audit plans to obtain assurance of delivery.
  • Pain relief was available for patients. Nurses held appropriate PGD (Patient Group Directions) to facilitate the use of pain relief medications. Tools were used to assess pain and this was facilitated by the use of intentional rounding. The trust had implemented tools for patients living with dementia and patients with learning difficulties. These had been absent in our last inspection.
  • However, we found examples in the emergency department where patients had not received timely pain relief. In the maternity service the waiting time for epidural pain relief was not being monitored. 

Patient outcomes

  • As at our last inspection there was no evidence or risk identified in the composite indicator of in-hospital mortality, the hospital standardised mortality rate (HSMR) or the summary level mortality indicator (SHMI).
  • The trust had participated in the 2015 NCDAH. The results indicated that the trust performed below the national average in all five clinical indicators and performed poorly in two. The trust achieved six of the eight organisational indicators. The trust had completed an action plan was to address deficiencies.
  • Royal College of Emergency Medicine audits indicated that the trust was not an outlier with exception of readmission rates which were consistently higher than the England average.
  • At our previous inspection we noted the deterioration in sepsis pathway outcomes. This has been incorporated into the directorate improvement plan and as a result all locations are now indicating significantly improved rates for screening for sepsis.
  • Results for the SSNAP (Sentinel Stroke National Audit Programme) were very positive for both WHH (improved from D to B) and QEQM (C to A). However, the results for Kent and Canterbury indicate a deterioration to D with two domains rated at E.
  • In the National Diabetes Inpatient Audit QEQM performed above the England average and WHH at the England average. However, Kent and Canterbury performed worse than the England average.
  • Maternity services were not identified as an outlier for clinical outcomes.

Competent staff

  • As reported in July 2015, departments largely had a structure that supported the maintenance of competence. Checks and controls were in place following recruitment and induction was planned.
  • A comprehensive portfolio of specialist nurses and midwives was in place. This had been enhanced since our last inspection by the development of over 100 end of life care link nurses.
  • An end of life care facilitator had also been recently appointed and was implementing a plan of communication with all staff groups to enhance capability in the management of patients on an end of life pathway. This strategy is still in early stages and as such our report identified some gaps in current competence of ward based staff. 
  • The overall appraisal rate for the trust was 82% against a trust target of 85%.

Consent, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS)

  • At our last inspection understanding of MCA and DoLs was indicated as an area for improvement.
  • Our findings on this inspection identified a significant improvement in the understanding of MCA and DoLS by staff.
  • During our inspection we reviewed processes for the application of DNA CPR (Do not resuscitate) orders. We found that discussions were not always documented and that in some case inappropriate reasons for application had been documented.

Caring

Good

Updated 21 December 2016

Summary

Following the inspection in July 2015 we rated the trust as good for caring. However, we also reported occasions when staff behaviour in the emergency department compromised patient privacy and dignity.

Following this inspection we have maintained the rating of good for caring. This is because:

  • All services inspected were rated as good. The culture of compassionate care that was reported at our last inspection had been maintained and was supported by feedback and our observations during this inspection.
  • Discussions with patients and carers indicated confidence in the level of involvement they have in their or their relatives care.
  • Issues relating to the emergency department reported following our last inspection had been resolved by the impact of improved leadership.
  • Patient surveys supported the observations of the inspection team.

Compassionate Care

  • During the inspection we observed a consistent approach to placing patient care and experience first by all staff.
  • We particularly noted the sensitivity and professional approach of the CNS for specialist palliative care. However, we saw all staff exhibiting these behaviours with patients.

Understanding and involvement of patients and those close to them

  • The patients and carers that we spoke to during the inspection all indicated that clear communication of care plans had been made and that they were satisfied with the degree of involvement in care that they had.
  • In maternity consideration to the partners needs was made and they felt fully supported by the department.
  • Although women attending maternity services reported receiving information in a jargon free style we did receive reports were they did not feel fully listened to by consultants and registrars.

Emotional support

  • At our last inspection we commended the chaplaincy services and family meetings as good practice. These have been built on across all services and we saw examples of patients being provided with emotional support.
  • In addition the SPC team had completed advanced communication skills training and some had undergone advanced training in psycho-oncology skills.
  • The trust chaplaincy provided spiritual and religious support. The chapel was could be attended 24 hours a day and had multi-faith facilities.

Responsive

Requires improvement

Updated 21 December 2016

Summary

Following the July 2015 inspection we rated the trust as requires improvement as a consequence of weak service planning in emergency departments and poor design of facilities for dementia patients.

Following this inspection we have maintained the rating of requires improvement. This is because:-

  • Access targets for emergency care, referral to treatment and cancer were not being attained.
  •  Patients continue to be moved between wards to address capacity issues and patients were placed in beds within unsuitable specialty wards.
  • Patients on an end of life care pathway did not receive rapid discharge to support achieving their preferred place of death. The trust did not measure attaining preferred place of death.

However:-

  • Improvements in availability and use of data for bed management purposes, facilities and support to dementia patients and overall engagement with CCG's in planning of services had improved.

Service planning and delivery to meet the needs of local people

  • The emergency department had enhanced planning and the management of flow by developing an operational control centre. Data used in the control centre provided situation and risk assessment information for use in bed management meetings. It also facilitated predictive modelling of patient flow.
  • The trust engaged in local systems resilience groups and had established an Urgent Care Board to plan and manage improvement.
  • The end of life care team worked with local CCG's and local authorities to plan end of life care pathways across sectors.
  • The trust had considered and implemented new medical models to support patient flow. This contributed to a developing clinical strategy that had been fully discussed with local CCG's.

Meeting individual needs

  • The care of patients living with dementia and those with learning disabilities had been improved by the introduction of specialist nurses. Communication tools for this cohort of patients had been developed and were in use.
  • Facilities had been adapted to provide assistance to patients with limited mobility. In addition equipment was accessible to staff to support the management of bariatric patients those with limited mobility.
  • Services to patients requiring mental health support had been improved by access to mental health liaison team and  improvement of facilities at Kent and Canterbury Hospital which had been previously considered inappropriate.
  •  Since our last inspection intentional rounding had become much more consistent in practice.
  • All wards provided protective meal times. Patients who may need support were identified and appropriately catered for.
  • The trust had worked with a local voluntary organisation to provide a 'home and settle' package. This ensured vulnerable patients had sufficient provisions and support when initially leaving hospital.

Access and flow

  • High and growing acuity and activity levels in all services continue to create problems with access to and flow through services.
  • Both emergency departments across the trust have not attained the emergency department access target of 4 hours and constantly performed below the English average between July 2015 and May 2016.
  • Data provided for May and June 2016 indicated that less than 50% of patients received first clinical assessment within 1 hour and less than 25% had a decision to admit within 2 hours. Attendance of specialist referral within 30 minutes occurred on less than 40% of the time.
  • The number of times a patient was moved to another ward was highlighted as an issue in our previous report. Although there is indication that this has improved data indicated that 3% of  patients were moved three or more times during their stay.
  • The integrated discharge team, enhanced information and regular discharge focussed bed meetings were all seen as positive contributors to the management of patient flow. However, the inspection identified that outliers (patients occupying beds in an inappropriate specialty) remain an issue. Of particular concern was the high percentage of gynaecology beds occupied by acute medicine patients during the inspection.
  •  The availability of one obstetric theatre at both WHH and QEQM results in delays to patients awaiting elective caesarean section.
  • The trust was not meeting the 18 week referral to treatment guideline for six of eight clinical specialties. In addition it was not meeting the 62 day time to treatment target for cancer patients and had not met the target for the last year.
  • The report from our last inspection identified the number of times the maternity units closed and diverted mothers to alternate locations as a significant issue. Action has been taken to significantly reduce this. However, a lack of clarity on data definitions was identified that may result in management not receiving appropriate assurance of regularity of occurrence.
  • The trust was not measuring the number of patients who achieved their preferred place of death. In addition, fast track arrangements had not improved from our last inspection with patients waiting weeks to be discharged to their preferred place of death.

Learning from complaints

  • Similar to the findings at our July 2015 inspection processes for learning form complaints were robust with themes identified and communicated to staff.

Well-led

Requires improvement

Updated 21 December 2016

Summary

Following the July 2015 inspection the trust was rated as requires improvement in well led.

Following this inspection we have maintained the rating of requires improvement. This is because:

  • 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.
  • Despite improvement, the national staff survey still reports a high number of indicators that are in the worst 20% nationally.
  • Changes in performance and risk management remain relatively new and have yet to become fully embedded.

However,

  • The trust board and executive are at full establishment and staff acknowledge greater visibility and clarity of direction within the organisation
  • The culture of the organisation continues on a trajectory of improvement with a continued reduction in bullying and harassment.
  • Staff at all levels are contributing to the improvement programme and as a result a momentum of improvement is apparent within the organisation.

Leadership of the trust

  • The executive and board are now at full substantive establishment. Chief executive, chief nurse and non-executive directors have all been appointed since our last inspection.
  • Our interviews with all board post holders indicated a highly engaged team with a clear and common view on trust strategy, risk and operational priorities.
  • The feedback from all focus groups was that staff were aware and appreciative of the increased visibility and accessibility that the style of the new executive team had brought. The chief executive and chief nurse were particularly commended by staff for visibility.
  • The board of governors met regularly and continued to exhibit strong support for the board and executive whilst being clear about its role in holding non-executive directors to account.
  • The trust operated a divisional structure consisting of four divisions which supported all three sites. Each division was led by a triumvirate of medical, nursing and managerial staff.
  • Prior to the inspection the divisional teams presented a progress report to CQC. Each division provided clarity on progress to date and identified key challenges and risks ahead. Each division delivered presentations with exceptional passion demonstrating a strong commitment to both the management of their own improvement plan and the overall trust strategy.
  • Key appointments had been made in emergency care, end of life care and maternity to address deficiencies identified in our last report.
  • However, our report indicated that practice at middle management level is still inconsistent to some degree and that managers in end of life care and maternity, due to only recently being appointed, have yet to maximise their impact.
  • The trust had recruitment and scrutiny processes for board level appointments that met the Fit and Proper Persons regulation.

Vision and Strategy

  • At our last inspection we reported the trust as having a clear mission. Since that inspection that mission has been further developed. The trust now has a stated vision of 'great healthcare from great people' and a mission of 'together we care: improving health and lives.
  • The also developed a set of values that consist of 'people feel cared for, safe, respected and confident we are making a difference. The trust has used vision, mission and values to set strategic priorities of patients, people, provision and partnerships.
  • At our last inspection we highlighted the requirement for a clear clinical strategy to address the complexities of providing services on three sites across a broad geographical area. The trust has made significant progress in the development of its clinical strategy and importantly sought engagement with its own staff and external stakeholders. However, there was some indication that non clinical staff felt less involved in the development of the clinical strategy.
  • Feedback from interviews and focus groups with staff indicated that the vision and strategic intent of the trust was being well communicated. As a consequence we saw services developing local strategy in line with the trust direction.
  • This was most notable in the two areas we described as deficient in our last report: emergency care and end of life care. Both these services now have clear direction. 

Governance, risk management and quality measurement

  • The trust has continued to review and develop its governance processes. Prior to our last inspection the trust had commissioned an external review of governance. Prior to this inspection a further external review had been completed. This review demonstrated improvement in processes and structure and good board capability but provided clear indication that further work is required in developing risk awareness and continuous learning for the board. The trust had a developmental plan to address the deficiencies.
  • The trust operated seven board committees. All had clear and well structured terms of reference and had been recently reviewed. They were all available on the trust website.
  • Board committee chairs provided a written report to the board which was also received by the Council of Governors.
  • The trust had recently introduced an integrated performance report. This detailed report was aligned to both the CQC key questions and the trust strategic priorities.
  • The quality governance committee was a key committee receiving assurance and reports from governance committee, patient safety board, clinical audit and effectiveness and patient experience committees.
  • Through our observation of the meeting and review of the minutes we determined that quality governance committee content was comprehensive. However, it was the view of the inspection team that committees reporting to the quality committee could be operating more rigorously to ensure assurance is provided and that issues are being addressed, rather than that challenge occurring at the quality governance committee. It was also not clear which risks were being highlighted to the board.
  • The processes of performance management had been enhanced with the introduction of executive performance reviews for each directorate. These meetings aimed to  drive integrated performance management into the organisation. We reviewed the urgent care and long term conditions division report and it was comprehensive in content including data on performance, workforce, finance and an assessment of high rated risks. As this was a recent introduction we were not able to provide indication of effectiveness.
  • In all services we saw an awareness of performance issues and local risk registers. There was a clear process for risk escalation.
  • The trust had recently appointed a complaints lead and complaints response time targets had been achieved in August 2016. 
  • In summary, the trust has done much to improve its governance and performance management processes but many of the changes had been recently implemented. Further work is required to ensure that practice becomes embedded and consistent across the trust.

Culture within the trust

  • The culture of the organisation had changed considerably since our first inspection in 2014. At our last inspection we reported improvement and a reinvigorated cultural change programme.
  • The trust had further developed a programme of cultural change under the banner of 'a great place to work'. This included executive development, a 'respecting each other campaign' and the introduction of values based appraisals.
  • More importantly interviews with staff and those attending focus groups corroborated the impact of these initiatives and reported significant improvements in incidents of bullying and harassment and the overall culture of the organisation. However, the trust must maintain vigilance as we did receive reports from some individuals who still felt bullied.
  • Our interviews and focus groups indicated that staff were largely positive and of good morale. There was a recognition that all staff had a role to play in delivering improvement and change.
  • The trust has a well developed approach to the management of equality and diversity. The trust board received a comprehensive annual equality report in June 2016.  There was a named board lead for equality and diversity and a supporting lead manager.
  • The trust had also completed the Workforce Race Equality Standard for 2016. This reported that although a disproportionate number of white staff were appointed following shortlisting and were accessing non mandatory training, BME staff reported lower levels of bullying and harassment from both staff and the public than white colleagues.
  • In response to the WRES the trust had compiled an extensive action plan. There were processes in place for the monitoring of the plan and at the time of inspection all actions were on track for completion.
  • The trust was a Stonewall Diversity Champion and advertised vacancies in Stonewall Starting Out Careers Guide.
  • The trust included both Two Ticks (positive about disabled people) and Age Positive logos on job adverts.

Public and staff engagement

  • The trust had initiated public engagement relating to the development of its clinical strategy. Further engagement is planned.
  • The trust had a membership scheme and holds an annual members meeting. The trust also publishes a magazine 'Your Hospitals' which is distributed across East Kent.
  • The trust holds part of its board meeting in public and encourages public attendance through its website.
  • The 2015 NHS staff survey indicated improvement in responses relating to motivation at work, contribution to improvements and communication between senior management and staff. However 11 indicators still remain within the worst 20% nationally.
  • For the measures relating to staff engagement, all  4 had shown signs of improvement. However, all 4 remained in the worst 20% nationally.

Innovation, improvement and sustainability

  • The trust had a well developed improvement plan that is clinically led. Strong governance processes underpin change that ensured the board was appropriately informed of progress.
  • The trust had invested in the development of business intelligence data and this was utilised to determine improvement plan progress.
  • The improvement hubs that were commended in our last report continued to be central to improvement activity. Many staff reported attending events at the hubs.
  • As a consequence, improvement discussions occurred at all levels of the organisation and change is becoming increasingly owned at divisional level.
  • Following our last inspection the trust had nine requirement notices relating to end of life care pathway, audit action plans, staff numbers, availability of equipment, safe environment, midwifery staff numbers, medicines management, storage of IV fluids and support to mental health patients. Our inspection indicated that significant improvement has been achieved against these notices. The two remaining concerns are staff numbers in midwifery and medicine and consistent approach to audit action plans.
  • The delivery of a clinical strategy is key to sustainability of the trust and it had made clear progress in its development.