You are here

Kingston Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 July 2016

Kingston Hospital NHS Foundation Trust provides local services, primarily for people living in andaround Kingston-Upon-Thames. The trust provides services to approximately 350,000 people and provides a full range of diagnostic and treatment services, including emergency care, day surgery and maternity services. Our key findings were as follows:

Safe

  • Improvements were required for the safe storage of medicines in outpatients, theatres, some wards, and the emergency department. In particular with regard to recording of fridge temperatures, and restricting accessibility to storage facilities.
  • Improvements were required to ensure equipment used for patient treatment and care had routine safety and maintenance checks.
  • Improvements were required to ensure there was enough surgical instrumentation available in theatres.
  • Staff understood their responsibilities to raise concerns, to record safety incidents, and near misses, and to report them. However, incident reporting was not fully embedded in everyday practice within the emergency department.
  • Safety goals were set and performance was monitored using information from a range of sources.
  • People who used the services were told when they were affected by something that went wrong, and were informed of any actions taken as a result. However, letters written to people did not always contain a formal apology.
  • Staff and relevant individuals were involved in thorough and robust investigative reviews, where incidents or adverse events arose.
  • With the exception of the emergency department, lessons learned and action taken as a result of investigations were shared with staff and changes in practice implemented.
  • The environment in which people received treatment and care was clean and there were reliable systems to prevent and protect people from a healthcare-associated infection. Despite this, staff working in the emergency department did not always follow recommended hand hygiene practices.
  • The majority of staff had received effective mandatory training in the safety systems, processes and practices.
  • Risk management activities and procedures used by staff helped to ensure peoples safety needs were identified and responded to.
  • There were sufficient staff with appropriate skills to ensure the safe delivery of treatment and care in most areas.
  • There was a high number of new and inexperienced nursing staff in the emergency department and not enough permanent shift leaders or doctors to cover the rota.

Effective

  • People's consent to treatment and care was sought in line with legislation and guidance. People were supported to make decisions and where a person lacked mental capacity to consent to treatment or care staff made 'best interest' decisions. However, mental capacity assessment were not always carried out where patients required mechanical restraint on medical wards. Best interest decisions had not always been recorded for the interventions taken.
  • Staff generally had an understanding and awareness of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS), but some staff reported not having formal training in either subject.
  • People’s needs were assessed and care and treatment was delivered in line with legislation, standards and evidence based guidance.
  • A multidisciplinary team of staff worked collaboratively, and were supported to deliver effective treatment and care by relevant and current evidence-based guidance, standards, best practice and legislation.
  • Monitoring of the effectiveness of services was taking place and outcomes from such activities were generally used to improve standards and quality.
  • People receiving treatment and care were not discriminated against. Individual care needs took into account; age, disability, gender, pregnancy and maternity status, race, religion or belief and sexual orientation.
  • People’s nutrition, hydration and pain needs were assessed and action was taken by staff to meet their immediate and changing needs.
  • Technological equipment was generally available and used by staff to monitor and deliver treatment and care.
  • Staff had the right qualifications, skills, knowledge and experience to undertake their roles and responsibilities. They had access to appropriate developmental training and were supported by senior staff through a range of approaches. Staff had opportunities to receive feedback on their performance.

Caring

  • People were treated with kindness, dignity, respect and compassion whilst they received care and treatment from staff.
  • Staff took into account and respected people’s personal, cultural, social and religious needs.
  • Staff were observed to take the time to interact with people who used the service and those close to them in a respectful and considerate manner. They showed an encouraging, sensitive and supportive attitude towards people receiving treatment and care, and those close to them.
  • People who used the services and those close to them were involved as partners in their care. Staff communicated with people so they understood their care, treatment and condition. They recognised when people needed additional information and support to help them understand and be involved in their care and treatment and facilitated access to this.
  • People were given appropriate and timely support and information to cope emotionally with their care, treatment or condition.
  • Staff encouraged participation from those close to people who used the services, including carers and dependents. People were encouraged and supported to manage their own health, care and wellbeing and to be as independent as able.

Responsive

  • Services had been planned and delivered to meet the needs of people within the local population. Stakeholders and other providers were involved in planning and delivering services.
  • The emergency department was not meeting the national target of seeing and treating 95% of patients within four hours of arrival. Ambulance hand over times were not always achieved.
  • The facilities and environment were being developed in some areas in order to meet the changing needs of the population using the services. Further improvements were needed in some areas to ensure privacy was not compromised and to meet the needs of particular groups of people. This including patients attending the emergency department with mental health related matters. The Critical Care Unit environment was not conducive to meeting the needs of patients, visitors and staff.
  • Services were accessible and took into account the individual needs of people who used them. This included vulnerable individuals and people with a physical disability, learning disabilities, and those living with dementia. Some environmental improvements were needed to areas where people living with dementia were receiving treatment and care.
  • People were given the help and support they needed to make a complaint. With the exception of the emergency department, complaints were handled effectively and confidentially, with a regular update for the complainant and a formal record was kept. The outcome was explained appropriately to the individual in an open and transparent manner. Lessons learned from concerns and complaints were acted upon by staff.

Well-led

  • There was a clear vision and a set of values, with quality and safety the top priority, which was understood by staff. Core services had robust, realistic strategies targetedtowards achieving the clinical priorities set by the trust and aimed at delivering good quality care; staff knew what their responsibilities were for delivering this. Targets were continuously reviewed.
  • The majority of clinical areas were well led, with strong and effective governance arrangements to oversee quality, safety and risk management.
  • Most staff reported effective leadership, with approachable and supportive line managers, who operated in an open and responsive culture. Some theatre staff reported challenges with visibility and direction of the main theatres leadership, with a need for more constructive engagement. Theatre leaders had recognised staff morale was an area for improvement and had put in place a number of interventions.
  • Staff in the majority of areas reported feeling respected and valued, and were enabled to contribute to service delivery and improvements.
  • There was a systematic programme of clinical and internal audit, which was used to monitor quality and systems to identify where action should be taken. There were arrangements for identifying, recording and managing the majority of risks, along with mitigating actions.

We saw several areas of outstanding practice including:

  • The Wolverton Centre, for providing comprehensive sexual health services; for provision of service alerts for vulnerable patients, including young people, and those with a learning disability.
  • A comprehensive dementia strategy, which enabled staff to support people living with dementia. A dedicated dementia improvement lead provided visibility and support to staff, ensuring positive interventions were implemented. The carer’s support pack, therapeutic activities and a memory café contributed to the enhancement of services.
  • The trust’s engagement with ‘John’s campaign’, promoted the rights of people living with dementia to be supported by their carers in hospital. To facilitate this, there was open visiting and a free car park for respective carers and relatives. Family members and carers were offered beds to stay overnight if needed.
  • The specialist palliative care (SPC) team stood out as highly skilled and effective. They supported staff to provide good quality, sensitive care to patients at the end of life and to the people close to them.
  • Staff of all disciplines demonstrated an impressive understanding of their role in addressing the needs of people at the end of life and of providing sensitive and compassionate care.
  • The paediatric diabetes team were a top performer in the National Paediatric Diabetes audit 2014 to 2015 due to HbA1C rates being better than the England average.
  • The trust participated in the Sentinel Stroke National Audit Programme (SSNAP), and achieved an A rating for the period January 2015 to March 2015.
  • The Physiotherapists in the critical care unit had reduced the length of stay for their patients through the early implementation of rehabilitation.
  • The engagement and involvement of volunteers was recognised as an invaluable team to support service delivery.
  • Patient pathway co-ordinators in outpatients had impacted positively on the effectiveness of appointment arrangements.

However, there were also areas of where the trust needs to make improvements. Importantly, the trust must:

  • Ensure that individuals who lack capacity are subjected to a mental capacity assessment and best interest decisions where they require restraint. Such information must be recorded in the patient record.
  • Make improvements to ensure medicines are not accessible to unauthorised persons; are stored safely, and in accordance with recommended temperatures.
  • Make improvements to the systems for monitoring of equipment maintenance and safety checks in order to assure a responsive service.
  • Ensure that the Duty of Candour is adhered to by including a formal apology within correspondence to relevant persons and that such a record is retained.
  • Ensure the management, governance and culture in ED, supports the delivery of high quality care.
  • Improve the quality and accuracy of performance data in ED, and increase its use in identifying poor performance and areas for improvement.
  • Ensure all identified risks are reflected on the ED risk register and timely action is taken to manage risks.

In addition the trust should:

  • Review patient outcome measures to consider how performance can be improved.
  • Staff should have timely access to regular training with respect to the Mental Capacity act (2005) and Deprivation of Liberties Safeguarding.
  • Review length of stay and ways of decreasing this in care of the elderly and cardiology services.
  • Take steps to embed debriefings after operating lists across all surgery services, as part of the World Health Organization (WHO) Surgical Safety Checklist.
  • Ensure better compliance with hand hygiene and cleaning of clinical equipment in the emergency department.
  • Review the skill mix and flexibility of staff within ED in order to respond to changes in activity levels and demand surges.
  • Improve ED staffs understanding and compliance with the trust's incident reporting procedures, complaints handling and application of learning from these.
  • Ensure there is accurate performance information in the ED.
  • Seek ways of consistently improving patient flow through the ED.
  • Ensure the systems for routine safety processes such as recording timely observations of patients, checking resuscitation equipment, and making sure medicines and cleaning chemicals were stored safely.
  • Ensure adequate and safe facilities for patients with mental health needs.
  • Ensure staff use computers securely in ED and do not share login cards
  • Improve staff engagement in main operating theatres.
  • Establish a robust system for ensuring required surgical instruments are readily available.
  • Increase visibility and leadership engagement within theatres.
  • Optimise pre-assessment procedures in order to limit cancellations on the day of scheduled surgery.
  • Take steps to ensure all nursing staff understand how to communicate with vulnerable and elderly patients in an appropriate way.
  • Improve responsiveness of nursing staff to patient call bells at weekends.
  • Consider how the environment and facilities in the CCU could be improved.
  • Review CCU records in order that capacity assessments can be documented.
  • Explore the benefits of having a follow up services available for patients who have used CCU so they are able to reflect upon their stay and can address long term psychological concerns.
  • Review maternity service bed capacity in order to address the increasing activity.
  • Ensure midwifery staff have access to required equipment.
  • Review staffing levels in maternity services in order to avoid delays of induction and elective caesarean sections.
  • Ensure children have an appropriate waiting area in the fracture clinic.
  • Review areas used by children and young people with a focus on age appropriate décor.
  • Ensure staff working in children's and young people's services have access to up to date editions of the British National Formulary (BNF).
  • Ensure registered nursing staff levels in children's and young people's services are in accordance with RCN and BAPM guidelines.
  • Review the specialist palliative consultant and nursing presence at the hospital in order to maintain progress towards meeting the provision of excellent end of life care.
  • Review the environment of the chapel and multi-faith facilities.
  • Consider how the environment on medical wards and in outpatients can be developed to enhance the experiences of people living with dementia.
  • Provide greater privacy for inpatients who attend the CT scanning unit.
  • Reinforce best practice around the use of appropriate interpreters.
  • Ensure information about chaperones is made easily available in all OPD clinics.
  • Ensure waiting times and clinic delays are appropriately displayed and communicated to waiting patients.
  • Have a consistent approach to sending reminders to patients about their appointments, to minimised non attendance.
  • Ensure that patient examination couches are checked and maintained as appropriate in the general outpatient area.
  • Address recommendations made by the Anti-Terrorism Squad for the safe monitoring of radionuclide medicine delivery.
  • Ensure proper systems are in place to facilitate governance meetings in each outpatient service.
  • Consider how daily cleaning schedules can be completed and quality checks and sign off of these are routinely undertaken.
  • Arrangements around equipment storage should be reviewed so that shower rooms are not used.
  • Utility rooms containing hazardous chemicals should be locked, with additional provision for secure storage of such products.
  • Fire safety precautions should be reinforced with staff to ensure fire doors are not propped open.
  • The policy for medicines management is followed to support the use of patients own medicines.
  • Review existing arrangements to ensure that suitable governance and assurances mechanisms are in place with regards to the trust's statutory duty to ensure that directors are fit and proper.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 14 July 2016

Effective

Requires improvement

Updated 14 July 2016

Caring

Good

Updated 14 July 2016

Responsive

Requires improvement

Updated 14 July 2016

Well-led

Requires improvement

Updated 14 July 2016

Checks on specific services

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)

Requires improvement

Updated 14 July 2016

Overall we found the medical care services at Kingston Hospital requires improvement.

  • We found where patients were unable to consent to a mechanical restraint, no mental capacity assessment had been undertaken and no best interest decisions had been recorded.

  • Staff reported they had no specific training in Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS) training.

  • Patient outcome measures including National Heart Failure Audit, Myocardial Ischemia National Audit Project (MINAP), National Diabetes Inpatient Audit (NaDIA) the trust scored below the England average.

  • In care of the elderly and cardiology, which represented the majority of activity, the average length of stay was worse than the England average. In care of the elderly it was 15 days compared to the England average of 10 days and for cardiology it was 9 days compared to 5.6 days which was the England average

  • We found equipment was stored in the shower rooms, utility rooms were not locked and hazardous chemicals had not been locked away.

  • Fire doors were sometimes propped open.

  • Equipment such as blood pressure machines and suction pumps on resuscitation trolleys had not been safety tested within the last 12 months.

  • Medication trolleys were not chained to walls or immobilised when not in use.

  • The trusts policy for medicines management was not being followed to support the use of patients own medicines (PODs).

  • The vacancy rate across all the medical services wards as of 31st January 2015 was 25.8% of nursing staff.

  • Patients’ medical notes were not stored securely and regular observations to check mittens were not restricting the patient’s circulation were not being recorded. There was no review date on the documentation.

  • Staff had access to translation services for patients for whom English was not a first language. Staff we spoke with told us they knew the service was available but they tended to use staff from the hospital who could speak various languages or ask patients relatives to interpret. This is poor practice as staff could not be confident the information that the patient was being told was what staff had wanted to convey to the patient.

However;

  • People were cared for by staff that were kind caring and compassionate in their approach.

  • Patients and their relatives were positive about their experience of care and the kindness afforded them.

  • There was a positive culture of incident reporting and there were established processes for investigating incidents.

  • Staff were aware of their role in relation to safeguarding children and adults living in vulnerable circumstances.

  • The trust was one of 13 trusts awarded with an A rating in the Sentinel Stroke National Audit Programme (SSNAP) for their performance in January to March 2015.

  • The hospital’s endoscopy services were Joint Advisory Group (JAG) accredited.

  • The service had responded to the needs of an ageing population and were developing services to improve the experience of patients living with dementia.

  • A number of initiatives had been developed to ensure the service met people’s individual needs and those of vulnerable groups.

  • Across medical specialities complaints were discussed at monthly clinical governance meetings, these identified learning and action points

  • There was good leadership and management within the medical specialities with clear strategies on how the services were to develop.

  • There was an appropriate system of clinical governance in the medical specialities, which identified quality and risk issues. Trends could be readily identified and learning was disseminated to staff.

  • We found staff and patients were engaged with the development of medical specialities, and saw examples of innovative practice.

Urgent and emergency services (A&E)

Requires improvement

Updated 14 July 2016

The Emergency Department at Kingston Hospital required improvement.

  • There were not enough permanent, experienced staff who understood the ED systems to lead the many newly qualified staff, as well as agency and locum staff.
  • The department did not consistently meet the national target of seeing and treating 95% of patients within four hours of arrival, even on days they were not full. The department regularly missed other related targets such as receiving ambulance patients within 15 minutes, although performance had improved enough to reduce the number of financial penalties.
  • Staff did not routinely follow recommended systems and processes for keeping people safe from avoidable harm.
  • The design of accommodation in some areas did not protect patients’ privacy and dignity, or the confidentiality of patient discussions with clinicians.
  • The department’s comparative performance in national audits about emergency care was not good and they were slow to make improvements.
  • Accommodation for mental health patients was poor and they often had long waits in ED.

  • There was not a culture of continuous improvement. Staff did not routinely use information from incidents and complaints to provide a better service to patients.

However;

  • There were arrangements to protect people from abuse and safeguarding processes were robust.

  • We saw staff interacting in a caring and compassionate way with individual patients
  • The recognition of the needs of people living with dementia and provision for children were good.
  • ED staff were introducing processes to help staff meet national targets and there had been some improvements.
  • Some key senior staff vacancies had been filled which had the potential to improve leadership and governance.

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.

Intensive/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.

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.

Outpatients

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.