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Inspection Summary


Overall summary & rating

Good

Updated 30 August 2018

Our rating of services improved. We rated it them as good because:

  • Staff treated people with the kindness, dignity, respect and compassion while they received care and treatment and there was a strong, visible, person-centred culture.
  • Staff took the time to interact with patients and those close to them in a respectful and considerate way. Patients told us they valued their relationships with staff and felt that they often went ‘the extra mile’ for them when providing care and support.
  • Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
  • The trust planned and provided services in a way that met the needs of local people and of individuals who required additional support. The trust had placed significant emphasis on meeting the needs of people living with dementia and had a series of arrangements in place to care for and improve the experience of those patients at the hospital.
  • There was a clear, strong, clinical leadership presence in the emergency department. Leaders understood the challenges to good quality care and identified the actions needed to address these.
  • Managers across the trust promoted a positive culture that supported and valued staff. Staff felt respected, supported and spoke highly of their job despite the pressures, and were committed to delivering a good service.
  • The medical care service had a clear vision and set of values, with quality and sustainability as the top priorities. Leaders understood the challenges to quality and sustainability, and had pro-active ongoing action plans in place to address them.
  • The design, maintenance and use of facilities, premises and equipment, and standards of cleanliness and hygiene were in line with trust policies and procedures, and with best practice. We noted improvement in equipment storage, use of fire doors and equipment safety testing since our last inspection. Recent rebuilding work had been designed by the staff to meet the needs of local people.
  • Documentation, training and staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards had improved since our last inspection. Staff understood how to protect patients from abuse and had training on how to recognise and report abuse and they knew how to apply it.
  • There were good safeguarding systems, processes and practices in place to keep people safe, and these were well communicated to staff. Safeguarding training rates were above the trust target of 85%, with 100% compliance in child safeguarding.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff could access training to develop their skills and were supported to do so.
  • The trust planned and reviewed staffing levels and skill mix so that people received safe care and treatment. Although there were higher vacancy rates on some medical wards, there were processes in place to manage it to avoid any negative impact on patients.
  • The trust performed better than the England average for people being seen within two weeks of an urgent GP referral, and receiving treatment within 31 days for suspected cancer.
  • Staff carried out comprehensive risk assessments for patients and risk management plans were developed in line with national guidance. An electronic patient records system contained a series of prompts and checks relating to patient risk. Staff could not move on to the next section of the record until they had completed mandatory prompts or checks.
  • All levels of governance and management functioned effectively and interacted with each other appropriately.

However:

  • Oral liquids in drugs trolleys and stock rooms were not always appropriately labelled to show when they had been opened. This meant there was a risk that staff would be unaware of when use of an oral medicine should be discontinued.
  • In the outpatients department, about 50% of the resuscitation equipment had expired items on them; however, this was resolved by the time of our unannounced inspection.
  • All mandatory training rates did not meet the target of 85%, with conflict resolution and manual handling having the poorest compliance. The completion rates of some mandatory training modules for nursing staff in medical care were low.
  • Medical staffing was not at establishment in the emergency department, with half of the middle grade doctor posts vacant.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED. The trust was not meeting the four-hour standard, even when the department was not busy.
  • Staff did not have access to diagnostic services such as computerised tomography (CT) scans and ultrasound scans seven days a week. Staff told us they could only obtain diagnostic procedures for patients during the night or over the weekend on an emergency basis, and this required a consultant referral.
  • In the outpatients department, the locks were broken on one trolley containing patient records. This meant that although patients records were out of sight which maintained confidentiality, there was a risk that they could be accessed by unauthorised persons.
  • In the outpatients department, not all areas controlled the risk of infection well. In one area, the premises were visibly clean, but most of the hand washing gels were empty. We observed some clinicians not washing their hands between patients and others not wearing appropriate personal protective equipment (PPE).
Inspection areas

Safe

Good

Updated 30 August 2018

Effective

Good

Updated 30 August 2018

Caring

Outstanding

Updated 30 August 2018

Responsive

Good

Updated 30 August 2018

Well-led

Good

Updated 30 August 2018

Checks on specific services

Critical care

Good

Updated 14 July 2016

The Critical Care Unit (CCU) was good in a number of areas; however, current facilities were inadequate and did not meet the standards required. The unit environment was no longer fit for purpose. The bed spaces did not comply with HBN0402 critical care environment requirements; the unit was cramped, with limited storage space for necessary equipment and supplies. There were very few windows and little natural daylight. There were no toilets or shower rooms for patients and staff, visitors and patients all use the same toilet facilities. There were no current plans in place to improve this.

  • Staffing levels were reviewed continually using an established acuity tool and there were enough staff to provide care and treatment in accordance with guidelines. Nurse staffing levels had been managed well and improving the skill mix was a high priority with appropriate strategies in place to mitigate risk. We observed good multidisciplinary working to ensure high quality patient care and good patient outcomes.

  • Infection prevention and control was considered by all staff to be a high priority and there were robust systems in place to ensure compliance. Audit outcomes and low infection rates demonstrated high standards.

  • Staff at all levels demonstrated a culture in which patients and relatives were involved in aspects of their care when appropriate. Staff were caring and compassionate to patients, relatives and colleagues.

  • Staff in the department told us they felt respected, valued and supported by the matron and clinical lead. The matron was seen to have a visible and active approach to supporting and developing staff in the unit. We observed a friendly, open and honest culture throughout critical care, where staff felt able to ask questions and seek support and guidance when needed.

Outpatients and diagnostic imaging

Requires improvement

Updated 14 July 2016

We rated the outpatients and diagnostic imaging services provided at Kingston Hospital as requiring improvement, as the services were not always safe and responsive.

  • Medicines were not always stored safely and checks on emergency resuscitation equipment were not performed routinely. Other items of equipment used for patient care had not always received and annual service or maintenance check.

  • Incidents and adverse events were reported and investigated. Lessons arising from these were learned and improvements had been made when needed. However, people did not always receive a written apology in accordance with the duty of candour.

  • The method for tracking medical records was reliable; however, patient original records were not always available prior to appointments.

  • Peoples privacy was not always achieved in outpatient and diagnostic areas.

  • People were not always made aware of waiting times.

  • There were no designated outpatient areas designed specifically to meet the needs of individuals living with dementia.

    However;

  • Cleanliness and infection control procedures were adhered to and potential risks to the service were anticipated and responsive actions planned.

  • There were sufficient staff with the right skills to care for patients. Staff who had been provided with induction, mandatory and additional training specific for their roles.

  • Staff had appropriate safeguarding awareness and people were safeguarded from abuse.

  • The hospital was significantly better than the national average for new to follow up ratios for the period between July 2014 – June 2015.

  • Cancer referral targets had improved and most had been met for quarters one to three, 2015/16.

  • Referral to treatment times were better than the England average.

  • The new to follow up outpatient rates of 29 to 38 against the national figure of 25 to 55, were significantly better than the national average between July 2014 and June 2015.

  • Waiting times for echocardiograms and portable monitoring for cardiac patient were three to four weeks at the time of our visit, which was good when compared to other similar services .

  • A multidisciplinary team approach was in effect across services provided within the outpatients and diagnostic imaging department.

  • Patients treatment and care was delivered in accordance with their individual needs. Patients told us they felt involved in decisions about their care and they were treated with dignity and respect.

  • People’s concerns and complaints were listened and responded to and feedback was used to improve the quality of care.

  • The leadership, governance and culture with the outpatient and diagnostic imaging services promoted the delivery of person centred care.

  • Staff were supported by their local and divisional managers and were encouraged to contribute to the development of the services.

  • In the main, risks were identified and addressed at local level or escalated to divisional or board level if necessary.

Urgent and emergency services

Good

Updated 30 August 2018

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

  • The design, maintenance and use of facilities, premises and equipment kept people safe. Recent rebuilding works had added a new entrance area, waiting area, streaming cubicles, urgent treatment centre and majors waiting area. The resuscitation area had expanded to include two more bays, and the major’s area expanded by 5 purpose built dementia friendly cubicles. The new bays and cubicles had been designed by the staff for the needs of the local people.
  • There were good safeguarding systems, processes and practices in place to keep people safe, and these were well communicated to staff. Safeguarding training rates were above the trust target of 85%, with 100% compliance in child safeguarding.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment. There was an extensive education programme in place for all staff that included team ‘away days’. They had recently educated and developed a highly skilled team of nurses and paramedics to work in the resuscitation area of the department.
  • We saw all people treated with the kindness, dignity, respect and compassion while they received care and treatment in the emergency department. There was a strong, visible, person-centred culture. Staff were motivated to offer care that was kind and promoted patients’ dignity. People told us they value their relationships with the staff team and feel that they often go ‘the extra mile’ for them when providing care and support
  • Services were planned to meet the needs of local people and systems were in place to identify patients that required additional support. People could access care and treatment in a timely way. The newly opened urgent treatment centre treated patients with minor injuries and illnesses and helped decongest majors and maintain patient flow.
  • There was a clear, strong, clinical leadership presence in the department. Leaders understood the challenges to good quality care and identified the actions needed to address these. Staff felt respected, valued and supportive and spoke highly of their job despite the pressures, and were committed to delivering a good service.

However:

  • Mandatory training rates did not meet the target of 85%, with conflict resolution and manual handling having the poorest compliance.
  • Medical staffing was not at establishment. We saw that half of the middle grade doctor posts were vacant.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED. The trust was not meeting the four-hour standard, even when the department was not busy.

Outpatients

Good

Updated 30 August 2018

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

  • Staff understood how to protect patients from abuse and had training on how to recognise and report abuse and they knew how to apply it.
  • Staff cared for patients with compassion and empathy. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives. We saw staff comforting patients and carers and a high level of engagement with patients and their families. Feedback from patients confirmed that staff treated them well and with kindness.
  • Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
  • The trust had improved their staff understanding of the processes involved in exercising the duty of candour, in particular what they should do at a practical level including record keeping.
  • The service provided care and treatment based on national guidance and monitored evidence of its effectiveness to improve outcomes.
  • There were enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff were able to access training to develop their skills and were supported to do so.
  • The trust planned and provided services in a way that met the needs of local people and of individuals who required additional support.
  • Staff of different professions worked together as a team to benefit patients.
  • The trust performed better than the England average for people being seen within two weeks of an urgent GP referral, and receiving treatment within 31 days for suspected cancer.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run the service providing high quality sustainable care and had vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers across the trust promoted a positive culture that supported and valued staff. There was good team work within the teams. Teams were proud of their service and this was evident in the good interpersonal relationships we witnessed.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things went well and when they went wrong.

However;

  • Not all areas controlled infection risk well. We observed some clinicians not washing their hands between patients and others no wearing appropriate personal protective equipment’s (PPE’s) in some areas of the OPD.
  • In one area, the premises were visibly clean but most of the hand washing gels were empty; that meant appropriate infection control measures were not in place to prevent the spread of infection.
  • About 50% of the resuscitation equipment’s had expired items on them, however this was resolved on our unannounced inspection.

Maternity and gynaecology

Good

Updated 14 July 2016

Overall we rated maternity and gynaecology services as good. This was because:

  • We found the service provided safe and effective care in accordance with recommended practices.

  • Women could give birth at home, in the midwife-led unit or in the consultant-led delivery suite.

  • There was a separate gynaecology ward, which provided support for other female patients who could not be accommodated on one of the medical wards.

  • Staff were confident about reporting incidents and dealing with emergencies, knowing these would be reviewed and any lessons learned would be shared with colleagues.

  • Leadership was strong and well respected.

  • There was a culture of learning and a desire to improve the service.

  • The response of the service to the alert on perinatal mortality was thorough and it was grasped as an opportunity for additional learning and improvement.

  • Staffing levels were appropriate on ward areas. Additional midwives had been recruited and their numbers could be increased if the unit became busy.

  • Community midwife services were operating well but were nearing full capacity.

  • The individual needs of women were taken into account and they were offered compassionate care and emotional support from staff.

  • Equipment was sufficient to meet the needs of women and their babies.

  • The new bereavement room and services had been welcomed by women and midwives. The written feedback from women and their families was positive.

  • Staff were positive about the hospital and the services they were able to offer women and their families. They were proud to be part of the team and committed to providing high standards of care.

  • There was some pressure on bed capacity and the service was unable to increase the number of births per year without additional space in which to expand the service.

  • The service would also need additional medical staff to support a greater number of births and greater support in the community.

Medical care (including older people’s care)

Good

Updated 30 August 2018

  • The design, maintenance and use of facilities, premises and equipment, and standards of cleanliness and hygiene were in line with trust policies and procedures, and with best practice. We noted improvement in equipment storage, use of fire doors and equipment safety testing since our last inspection
  • Staff carried out comprehensive risk assessments for patients and risk management plans were developed in line with national guidance. An electronic patient records system contained a series of prompts and checks relating to patient risk. Staff could not move on to the next section of the record until they had completed mandatory prompts or checks.
  • The trust planned and reviewed staffing levels and skill mix so that people received safe care and treatment. Although there were higher vacancy rates on some wards, there were processes in place to manage it to avoid any negative impact on patients.
  • We found that documentation, training and staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards had improved since our last inspection.
  • Staff treated patients with dignity, kindness and compassion. We saw that staff took the time to interact with patients and those close to them in a respectful and considerate way.
  • The trust had placed significant emphasis on meeting the needs of people living with dementia and had a series of arrangements in place to care for and improve the experience of those patients at the hospital.
  • Leaders understood the challenges to quality and sustainability the medical care service faced, and had pro-active ongoing action plans in place to address them.
  • The medical care service had a clear vision and set of values, with quality and sustainability as the top priorities. Senior leaders told us the vision for the medical care service was to be a specialist care of elderly location, providing services seven days a week.
  • All levels of governance and management functioned effectively and interacted with each other appropriately.

However:

  • Oral liquids in drugs trolleys and stock rooms were not always appropriately labelled to show when they had been opened. This meant there was a risk that staff would be unaware of when use of an oral medicine should be discontinued.
  • We noted the locks were broken on one trolley containing patient records. This meant that although patients records were out of sight which maintained confidentiality, there was a risk that they could be accessed by unauthorised persons.
  • The completion rates of some mandatory training modules for nursing staff were low.
  • Staff did not have access to MRI scans and ultrasound scans seven days a week. However, CT scans were available seven days a week. Staff told us they could only obtain diagnostic procedures for patients during the night or over the weekend on an emergency basis, and this required a consultant referral.

Surgery

Good

Updated 14 July 2016

We found the surgery service at Kingston Hospital was safe, effective, caring, responsive to patients’ needs and well-led.

  • The surgery service at Kingston Hospital had a good overall safety performance and patients were protected from harm.
  • There were low rates of serious incidents and no never events.
  • We found good processes for reporting and escalation of incidents and good sharing of learning from incidents.

  • Clinical areas were visibly clean and there was good compliance with hygiene processes.

  • Staffing needs were based on acuity of patients.

  • There was a good understanding of the trust’s duty of candour and major incident policies amongst clinical staff.

  • There were good patient outcomes across surgical specialties and care was delivered in line with relevant national guidelines.

  • The trust performed well in national clinical audits.

  • There were short length of stay and low readmission rates.

  • Patients had effective and timely pain relief.

  • Doctors in training and newly qualified nurses felt well supported with good supervision and good training opportunities.

  • There was good multidisciplinary team (MDT) working between doctors, nurses and allied health professionals.

  • Staff across the surgery service were friendly, caring and professional, and patients were treated with dignity.

  • Friends and Family Test results were consistently very good across surgery wards with a good response rate.

  • The trust provided a number of services to improve outcomes for local people.

  • Patient flow from admissions, through theatres and onto to surgery wards was satisfactory and bed availability was managed effectively.

  • There were very good systems and provision of care for patients with complex needs, such as those living with learning disabilities and dementia.

  • We found a cohesive and supportive leadership team, with well-established members of staff.

  • There was a clearly defined strategic plan for each of the surgery service lines.

  • Matrons and ward managers were very visible on the wards and the consultant body within the service provided clear clinical direction.

  • There were comprehensive and robust governance and risk management processes in place.

  • The World Health Organization (WHO) Surgical Safety Checklist was well-embedded in theatres but we did not find evidence of end of list debriefings to complete the five steps.

However;

  • There was insufficient availability of sterile equipment and mechanical faults on equipment in theatres.
  • There were some challenges with low staff morale in theatres.
  • There were some incidents of sub-optimal pre-assessment leading to cancellations on the day scheduled for the operation.
  • Some patients felt the provision of information for elderly patients could be improved.

Services for children & young people

Good

Updated 14 July 2016

We found children and young people’s services were good overall.

  • Children and young people who were at risk of deteriorating were monitored and systems were in place to ensure that a doctor or specialist nurse was called to provide the patient and ward staff with additional support.
  • The service had an open culture and was prepared to learn from clinical incidents.
  • Across children and young people’s services there were enough medical and nursing staff to keep patients safe. The trust found it difficult to recruit new nursing staff; but was able to effectively fill gaps by using bank and agency staff.
  • Attendance at mandatory training was above the 90% trust target.
  • We found care was provided in line with national and local best practice guidelines.
  • Clinical audit was undertaken and there was good participation in national and local audit that demonstrated good outcomes for children and young people.
  • We observed good clinical practice by clinicians during our inspection. There was a good knowledge of the issues around consent among staff.
  • Children and young people received compassionate care and were treated with dignity and respect. All of the children, young people and relatives we spoke with said they felt involved in their care and were complimentary about the staff looking after them. One person told us: “The care has been excellent. I’m really happy with all the levels of care.” The children and young people’s division had good results in the children’s survey.
  • The division were effective at responding to the needs of its community.
  • Children and young people’s care pathways had been well designed to ensure children and young people were assessed and supported with all their medical and social needs.
  • The paediatric admissions unit (PAU) provided effective alternate pathways for GPs and other referrers.
  • Children and young people’s services were well led; divisional senior managers had a clear understanding of the key risks and issues in their area.
  • The service had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis.
  • The service had a risk register which covered most of the key risks.
  • Staff spoke positively about the high quality care and services they provided for patients. They described the hospital as a good place to work and as having an open culture.

End of life care

Good

Updated 14 July 2016

We found end of life care at Kingston hospital was well-led, effective and safe. Caring was outstanding.

  • Hospital services were arranged to enable all aspects of end of life care to be delivered holistically, with care and compassion as a basic principle.

  • Staff of all disciplines and levels of seniority demonstrated an impressive understanding of their role in addressing the needs of needs of people near the end of life and those close to them. The specialist team and ward staff provided care and support sensitively and compassionately.

  • The Specialist Palliative Care team were highly skilled and responsive. The hospital guide to care for people in the last days of life followed national good practice and the SPC team was leading its rapid and effective implementation across the hospital. They provided an extensive training programme, advice, information and tools to support the use of the guide. Hospital staff, including senior nursing staff, consultants, trainee doctors, nurses and health care assistants understood their role in providing this care.

  • There was trust wide commitment to developing excellent end of life care at the hospital. The end of life steering group effectively contributed to and monitored the trust end of life strategy. The group had broad membership, including members of the public, external agencies and a non-executive member of the trust board.

  • There were many examples of multi-disciplinary work to improve practice, for example on care of older people wards, the intensive care unit and the acute assessment unit. There was collaboration between the specialist team, ward staff, the chaplaincy service and the pain team to meet the physical and non-physical needs of patients. The specialist team worked with the local authority, and hospice and community health services to provide a seamless service. This included discharging people from hospital to their preferred place of dying.

  • Surgical services were taking steps to improve awareness of the need to treat patients holistically and of when to consider ending active treatment. The SPC team were moving their focus to wards that made fewer referrals to them in order to address gaps in knowledge and awareness.

  • The bereavement officer was responsive to the needs of relatives after the death of a patient. Mortuary and porter staff provided a safe and dignified service for the deceased.

  • The SPC team, ward staff, and the mortuary and bereavement staff were aware of the varied needs and expectations of different cultures at the end of life and after death.

  • The trust undertook regular audits of Do Not Attempt Cardiopulmonary Resuscitation orders and there had been improvements to practice, such as senior medical staff leading the discussions with patients or those close to them.

However;

  • At the time of our inspection the trust had not allocated funds to increase specialist palliative consultant and nursing presence at the hospital. This is needed to maintain progress towards meeting the aim of providing excellent end of life care.

  • The environment of the chapel and multi-faith facilities needed improvement.

  • Staff sometimes used relatives instead of interpreters to have important conversations with people at the end of life who did not speak English.