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King George Hospital Requires improvement

We are carrying out a review of quality at King George Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 January 2020

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

  • We inspected urgent and emergency services during this inspection to check if improvements had been made since our last inspection. The overall rating for the service was requires improvement. The rating for well-led and safe improved to good. Effective and caring remained good and responsive went down to requires improvement.

  • The overall rating for critical care improved to good. The ratings for effective, responsive and well-led improved to good, whilst safe remained the same as requires improvement and caring as good.

  • The rating for children and young people’s services stayed the same at requires improvement. The ratings for caring and well-led improved to good. The ratings for safe, effective and responsive stayed the same, as requires improvement.

  • The overall rating for end of life care stayed the same. Effective improved to good, whilst the other ratings remained as good.

  • We previously inspected outpatients services jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.
Inspection areas

Safe

Requires improvement

Updated 9 January 2020

Effective

Good

Updated 9 January 2020

Caring

Good

Updated 9 January 2020

Responsive

Requires improvement

Updated 9 January 2020

Well-led

Requires improvement

Updated 9 January 2020

Checks on specific services

Medical care (including older people’s care)

Updated 5 August 2019

Services for children & young people

Requires improvement

Updated 9 January 2020

  • The rate of mandatory training compliance for medical staff did not meet trust targets. Data provided to us following inspection demonstrated that mandatory training compliance for foundation year junior doctors within the division stood at 65%, with GP trainees also only achieving 74% compliance.
  • There were some issues with infection control. The cleaning of toys in the playroom was not always completed and recorded. In addition, the monthly cleaning audit results were not provided to us, with only four months of compliance scores provided between November 2018 and August 2019. Other infection control audits did not seem to be consistently carried out.
  • There were some issues with the completion of the Paediatric Early Warning Score (PEWS) and children’s site practitioners could not provide 24-hour cover due to vacancies within the team.
  • There was lack of pre-operative assessment processes for children in place for before the day of surgery.
  • At the time of inspection, staff felt that nursing skill mix was not always ideal, with a high proportion of newly qualified nurses and healthcare assistants on some shifts.
  • Although the service had enough medical staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm, at the time of inspection, the level of medical cover was variable. However, a business case for 10 new consultant posts and six new registrar level posts had been agreed and these posts were being recruited into.
  • There were minor inconsistencies in documentation and the paper-based notes could sometimes be hard to track and locate. There was a backlog of non-urgent clinic letters waiting to be sent to children’s GPs.
  • Some medicines were not always given in a timely manner and delays in the preparation of take-home medicines could sometimes delay the discharge of children.
  • Knowledge of duty of candour was variable amongst staff.
  • Results from the General Medical Council survey for doctors in training (2019) fell below expectation, and some staff indicated that access to continuous professional development (CPD) was restricted due to the trust being in financial special measures.
  • There was limited provision for children who required occupational therapy or physiotherapy services.
  • There were no provisions or adjustments regarding the care of adolescents on the ward and in children being seen in other areas of the hospital.
  • There was no schooling provision on Clover ward, with individual provision being made for children of school age.
  • There was still limited support available for children with mental health needs.
  • People could not always access the service when they needed it and receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge children and young people were not consistently in line with national standards. There was lack of pre-operative assessment processes for children in place for before the day of surgery.
  • Some feedback indicated that the divisional leaders were not always visible at King George hospital. Some staff felt that the hospital was forgotten or overlooked by senior staff at times.
  • The service did not have effective systems and processes to provide assurance over the accuracy and completeness of data at a trust wide level. The information systems were not consistently integrated and secure.

However:

  • The service usually had enough nursing staff to care for children and keep them safe. Staff understood how to protect children from abuse and managed safety well. Staff assessed risks to children and acted on them. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Most staff worked well together for the benefit of children, advised them on how to lead healthier lives, and supported them to make decisions about their care. Most key services were available seven days a week.
  • Staff treated children with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children, young people and families.
  • The service planned care to meet the needs of local people, took account of most children’s individual needs, and made it easy for people to give feedback.
  • Leaders supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. On the whole, staff felt respected, supported and valued. They were focused on the needs of children receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children and the community to plan and manage services and all staff were committed to improving services.

Critical care

Good

Updated 9 January 2020

  • Although the service had challenges regarding medical and nurse staffing, the service ensured there were enough staff with the right qualifications, training and experience to keep patients safe from avoidable harm.
  • The trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns.
  • Staff kept detailed records of patients’ care and treatment. Most of the records we reviewed were clearly written and dated, with legible signatures.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
  • The service demonstrated effective internal and external multidisciplinary (MDT) working to benefit patients. Staff supported each other to provide good care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
  • Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. Staff provided emotional support to patients, families and carer.
  • The service planned care to meet the needs of local people considering patients’ individual needs and preferences. For example, the trust used individualised ‘hospital passports’ for patients with learning difficulties to help staff understand the patient’s likes and dislikes to make them more comfortable.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, valued and supported to develop their skills.
  • The critical care unit had an open culture which staff described as a “small family”. Patients, their families and staff could raise concerns without fear.
  • Senior leaders had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.
  • The senior leadership team used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.
  • Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

However, we also found:

  • Although staff were aware of the recent never event and told us the incident and learning had been discussed, we found the communication regarding the action points was poor and the revised checklist had not been implemented fully during the time of the inspection.
  • Given the trust had had similar never events historically, staff we spoke with were not aware of the National safety standards for invasive procedures (NatSSIPs) which had been in place since February 2018. We found the location of the NatSSIP on the intranet was not easy to find and had not been included in other relevant departments where it was applicable.
  • Despite the unit controlling infection risk well and all the areas we checked being visibly clean with no clutter in the corridors, we found the ultrasound probe was not clean despite having a ‘I am clean’ sticker on it.
  • Although the service had systems and processes in place to safely prescribe, store, administer and record medications, we found two intravenous fluids that were out of date.
  • Despite most key services being available seven days a weekly to support timely patient care, we found the speech and language therapy team were only available via referrals. However, staff told us the team were responsive.

End of life care

Good

Updated 9 January 2020

Our rating of this service stayed the same. We rated it as good because:

Maternity and gynaecology

Updated 18 December 2013

Maternity and family planning services were safe and effective.  Patients reported that midwives were caring and responsive and staff were positive about the service they provided.

Systems were in place for reporting and reviewing incidents to ensure that appropriate action was taken. Midwives used comments and complaints to improve women’s experiences of care and had responded proactively to these.

Surgery

Good

Updated 22 June 2018

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

  • There was a positive incident reporting and investigation culture.
  • Monthly performance reports monitored harm free care. There was good evidence of acting on identified risks and good analysis at safety briefings and safety huddles.
  • All wards reported zero infections for MRSA and C-diff.
  • Equipment was kept in good order and was appropriately stored. Theatres were clean and well organised.
  • Medicines were stored appropriately and securely.
  • Staff were trained in safeguarding and had a clear understanding of what constituted a concern and how to escalate this.
  • The surgery division was meeting the trust target of 90% for mandatory and compliance rated training.
  • Pain relief was being managed effectively and the development of nursing competency documents included pain management.
  • A practice development nurse had been newly appointed within the surgery division which had traditionally been a corporate role. Practice educators have also been appointed to theatres to support staff learning and training. Meaningful work had been carried out to scope compliance with training and competence.
  • There was an effective multidisciplinary team working environment and multidisciplinary input in theatres, recovery and the wards.
  • There were good response rates to the friends and family test. Results were very positive and all fifteen patients and five relatives we spoke with told us staff were caring and compassionate.
  • Complaints were appropriately investigated and reviewed and staff worked with patients to resolve any issues as they arose.
  • There were numerous assessment processes in place that supported meeting people’s individual needs.
  • Every elective patient received pre assessment at the trust hospital that hosted the specialty. In pre assessment we found that all clinic rooms were being utilised.
  • Compliance against a trust target of 92% for referral to treatment (RTT) was recorded as a 12 month rolling trend rate of 78.5%. However, it also showed the last two month average to be 86%.
  • Patients told us they were given useful information regarding their treatment and what to expect.
  • There were clear lines of accountability within the governance structure that effectively monitored and reported up on performance and risk.
  • There was a clear leadership and staffing structure within the surgery division to manage activity and oversee care.
  • Staff felt there was now visible leadership, which had been highlighted as an area requiring attention in a previous staff survey.
  • There was a positive working culture.

However:

  • The infection control team did not have a system to identify trends in infection and data was trust wide and not broken down by site. There were no records for ordinary streptococcal infection.
  • The adult day unit sometimes had Saturday and Sunday operating lists, so the unit’s ward was opened. With only one trained nurse on duty, there were potential issues around who was supervising the unit.
  • Consent was being taken on the day of surgery for both day cases and major (inpatient) surgery. This could impact on both the patient and theatre schedules if the patient was assessed as lacking capacity.
  • Specialties and divisions confirmed their compliance with NICE guidance by email, which was accepted. Compliance with NICE guidance was not being audited.
  • There was not sufficient medical cover to meet the needs of the surgical wards at weekends or evenings. There was a lack of access to occupational therapy, dietetic, and speech and language therapy services at weekends.
  • Patients told us that medical and ward staff were emotionally supportive. However, there was no dedicated counselling or psychology service available for surgery patients.
  • We found that theatre lists were inefficient. There were a low number of cases being put through. Most clinics did not start on schedule, with late start times and early finishes, which seemed to be accepted as the norm.
  • Relatives and carers were not restricted from staying overnight when this was appropriate. However, there were no makeshift beds or mattresses available to make this more comfortable.
  • There were some parking bays for blue badge holders close to the entrance of the hospital which were free of charge. However, disabled parking bays in the main car park incurred the normal charge and the free parking bays were often full.
  • At the time of inspection, both divisional director and service manager posts had become vacant with no substantive replacement appointed.

Urgent and emergency services

Good

Updated 9 January 2020

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Outpatients

Good

Updated 9 January 2020

  • Staff could not monitor and assess risks to patients on waiting lists effectively. There was the risk of harm to patients because of delayed access to treatment. Patient records were not always stored securely so could potentially be viewed by unauthorised people. The service did not always manage safety incidents well as learning was not always shared with staff. The service missed opportunities to improve safety processes and prevent future incidents.
  • The service did not consistently plan and provide care in a way that met the needs of local people and the communities it served. The service did not have the required capacity to meet patient demand. People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not consistently in line with national standards. Many patients had to wait a long time for appointments.
  • Leaders did not have access to reliable information systems. The service lacked effective systems and processes to provide assurance over the accuracy and completeness of performance and waiting time data. Multiple serious incidents had highlighted gaps in validation and assurance processes, weaknesses in IT systems and identified risks to patient safety. This meant senior staff were not fully aware of the risks and challenges impacting on the quality and safety of the service.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. They managed medicines well.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Leaders were visible and approachable in the service. They supported staff, and each other, and worked as a strong, cohesive leadership team to encourage improvement and deliver the vision and strategy of the service. Leaders and staff actively engaged with patients, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.