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Kettering General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 February 2018

A summary of our findings about this service appears in the Overall summary.

Inspection areas

Safe

Requires improvement

Updated 27 February 2018

Effective

Requires improvement

Updated 27 February 2018

Caring

Good

Updated 27 February 2018

Responsive

Requires improvement

Updated 27 February 2018

Well-led

Requires improvement

Updated 27 February 2018

Checks on specific services

Critical care

Good

Updated 12 April 2017

Overall, we rated the critical care service as good because:

  • There were systems in place to protect patients from harm and a good incident reporting culture.
  • The department complied with the Department of Health’s Health Building note HBN 04-02, which sets standards for critical care units.
  • Effective infection control practices were in place throughout the unit and visitors were encouraged to take part in the prevention of infection.
  • Safe numbers of staff cared for patients using evidence-based interventions.
  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.
  • Patient’s pain, nutrition and hydration was appropriately managed.
  • Intensive Care National Audit and Research Centre data showed the intensive care unit to be in line with the England average for all areas except delayed discharges.
  • Staff were compassionate and put patients at the centre of the work. They obtained consent prior to procedures and maintained patient privacy and dignity.
  • Complaints were dealt with in a constructive and timely way, ensuring that patients or relatives were kept up to date with any actions resulting from their complaint.
  • Staff had access to communication aids and translators when needed, giving patient the opportunity to make decisions about their care, and day to day tasks. There were very few complaints about the services and staff dealt with complaints appropriately.
  • Dementia training and staff guidance was suitable and staff showed a good understanding of how to provide quality care for those living with dementia.
  • There was good local leadership on the unit and staff reflected this in their conversation with us.

However, we also found that:

  • There was a lack of sufficient pharmacy support within the department, leading to potentially avoidable medicine incidents.
  • The critical care outreach team was not fully established to provide the necessary support and education to the rest of the hospital.
  • There was no delirium screening process in place.

Outpatients and diagnostic imaging

Good

Updated 27 February 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The service had enough 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.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The trust generally planned and provided services in a way that met the needs of local people. Improvements in service delivery had been made since the last inspection.
  • The service had managers at all levels with the right skills and abilities to run a service working to provide high-quality sustainable care.
  • The service used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by aiming to create an environment in which excellence in clinical care would flourish.

However:

  • The service did not always have suitable premises.
  • The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research, and innovation, but further work was required to embed this practice.
  • The service did not consistently monitor the effectiveness of care and treatment to use the findings to improve them.
  • Patients could not always access the service when they needed it. Waiting times from treatment were not in line with good practice but were improving in line with the trust’s recovery plan.

Urgent and emergency services

Inadequate

Updated 27 February 2018

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

  • The service did not always manage patient safety incidents well and did not control infection risk well.
  • The service did not have suitable premises and this meant that the care for children, and adults was not in accordance with national guidance and best practice recommendations.
  • The service did not always give or keep records of medicines well.
  • Staff did not always keep appropriate records of patients’ care and treatment. Records were not always completed, up-to-date or available to all staff providing care when required.
  • Staff did not always have a clear understanding of how to protect patients from abuse. Knowledge around safeguarding children was varied, and safeguarding children level three training rates for doctors were lower than expected at 76%.
  • Staff did not understand how to support the needs of patients with mental health or complex conditions such as learning disabilities. Life support modules had the lowest completion rates for mandatory training.
  • Patients arriving by ambulance were not always clinically prioritised to determine who needed to treatment first; the assessment was undertaken after handover, which was done in order or arrival by ambulance. Patients did not receive observations or receive treatment in a timely manner.
  • Some outcomes of care were below the expected levels, and had not been escalated but the service was working to improve these.
  • Within the children’s department, work was needed to improve the competencies of nurses, who were not registered children’s nurses.
  • Staff knowledge of Mental Capacity Act (MCA) was limited and not all medical staff had received MCA training.
  • The trust was not able to plan and deliver services in a way that met the needs of local people. The reception area of the department was not supportive of people’s privacy and dignity needs and had not changed since the last inspection.
  • Access to care was not always timely. The trust failed to meet the national standard for being admitted, transferred or discharged within four hours of arrival between October 2016 and September 2017 and was generally worse than the England average throughout the period.
  • The trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted for this trust was consistently worse than the England average.
  • The culture of the department was a concern with staff not accepting the risks identified during previous inspections, and subsequently not willing to accept and embrace changes to improve the overall quality of care.
  • Governance systems did not always link effectively. The trust had improved their systems for identifying risks; however, the planning to eliminate or reduce them was not always effective.

However:

  • The service generally had enough staff with the right qualifications, skills, training and experience.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff mostly cared for patients with compassion. Throughout the inspection, we observed examples of care where doctors and nurses were kind and compassionate towards acutely unwell patients and treated them with dignity.
  • The service generally took account of most patients’ individual needs. Food and drink was available to those who were in the department for any length of time.
  • The emergency department had local leaders with the right skills and abilities to run a service with a vision of providing high-quality sustainable care. The matron and clinical lead were recognised as good leaders within the department.
  • Mortality and morbidity review processes were well established in the service and were mostly effective.

Maternity and gynaecology

Requires improvement

Updated 27 February 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • Not all medical staff completed their mandatory training. In eight out of the ten mandatory training modules, medical staff were below the trust’s target of 85%, with three modules below 50% compliance.
  • Although staffing levels and skill mix was planned and reviewed so that women and their babies received safe care, the midwife-to-birth ratio was above the national recommended 1:28 for 11 out of the 12 months between November 2016 and October 2017.
  • The maternity service did not adequately monitor the effectiveness of care so was not able to use findings to consistently improve practice. The service did not take timely action to address problematic areas on their maternity dashboard. For example, induction of labour flagged as amber or red for a whole 12-month period.
  • The trust’s perinatal mortality rate was worse than trusts of a similar size and complexity. However, the service had taken appropriate action to address the results of the maternal, newborn, and infant clinical outcome review programme (MBRRACE audit).
  • Women, who had experienced a miscarriage before 20 weeks gestation, were not always cared for in a single room.
  • Women were not always offered their dating scan within the appropriate time range. This meant that the recommended method of screening for Down’s syndrome was not always offered.
  • Medical staff engagement with clinical governance and risk was poor. There was no medical staff representation at the clinical governance meetings in October and November 2017, and no representation at the risk meetings in all meeting minutes we reviewed.
  • The management of the local audit programme was not effective. Not all audits completed within the service were documented on the programme.
  • The systems for identifying risks and planning to eliminate or reduce them was not always effective. Not all risks identified during the inspection were documented on the maternity service risk register.
  • Ward staff were not aware of the escalation and management processes for when the ambient room temperature in treatment rooms exceeded 25°C, the recommended maximum temperature for storing medicines.

However:

  • There were clear systems, processes, and practices in place to ensure that women and babies were kept safe from avoidable abuse. There was a dedicated team of midwives who provided support, care, and treatment to women who were deemed to be in vulnerable circumstances.
  • The service generally managed patient safety incidents well.
  • The service controlled infection risk well. All areas of the maternity services were visibly clean and tidy.
  • Patients received assessments, treatment, and observations in a timely way.
  • Staff had the right qualifications, skills, and knowledge for their roles. The service had processes in place to monitor competence, identify training needs, and support new staff. Mandatory compliance figures for midwifery staff had improved and met the trust target.
  • The majority of women spoke with were positive about their care and treatment. They were treated with kindness, dignity, and respect.
  • The maternity planned and provided services in a way that met the needs of local people. They worked closely with commissioners, the local authority, clinical networks, and other stakeholders to plan delivery of care and treatment for the local population.
  • The maternity service had local leaders with the right skills and abilities to run a service with a vision of providing high-quality sustainable care.
  • Trust board oversight of the maternity service had improved since our last inspection. For example, we saw evidence that the head of midwifery presented the maternity risk register to senior staff at the risk management steering group in November 2017, and presented the Maternity Safety Improvement Plan to the trust board in March 2017.
  • The service engaged well with patients, staff, the public and local organisations. There was an active maternity voices partnership (MVP), which meant that service user views were considered.

Medical care (including older people’s care)

Requires improvement

Updated 12 April 2017

Overall, we rated medical care as requires improvement. Three key questions, safe, effective and well led were rated as requires improvement and caring and responsive were rated as good. We found that:

  • Care plans did not always reflect the needs of patients and deteriorating patients were not always managed effectively. Nurses had not always followed the escalation process for high-risk patients by informing a doctor when a patient’s NEWS score was raised or when the patient’s oxygen saturation showed a downward trend.
  • Patients were exposed to the risk of receiving inappropriate care and treatment due to poorly written and incomplete care plans. For some patients, there were no individualised care plans; in some cases, the same written care needs were simply copied to a new sheet and changing needs had not been reflected or incorporated.
  • Patients’ individual care records were not always written and managed in a way that kept patients safe. Patients’ medical notes were mainly kept in lockable trolleys which were not locked when not in use and in some wards, they were kept on open shelves in the bays. This meant that confidential information was not always kept in accordance with the Data Protection Act 1998.
  • There were not enough registrars and junior doctors to cover the medical wards out of hours, especially between 5pm to 9pm (Monday to Friday) and at weekends.
  • Doctors told us there was no electronic handover system and no electronic list of priority patients to alert them to problems out of hours and at weekends in the medical wards. The hospital did not operate a multi-speciality hospital at night team. Working to seven day working in the service was variable.
  • The coronary care unit had nurse staffing numbers that were below the recommended number stipulated by the British Cardiovascular Society.
  • Entries on prescription charts had been cancelled without being signed and dated. Medicine reconciliations had not always been done. Patients had not always been assessed for needing prophylactic medication to combat venous thromboembolisms (VTEs).
  • Outcomes for patients were variable. The hospital had produced poor results in two national audits it had recently participated in. The Sentinel Stroke National Audit Programme (SSNAP) audit showed a poor score of D and E in all four quarters of the reporting year. The hospital participated in the 2015 National Diabetes Inpatient Audit: it was worse for 13 out of 15 indicators than the England average.
  • Discharges were sometimes delayed due to patients having to wait for ongoing care packages.
  • Compliance with dementia awareness training was variable across wards
  • Complaints were not always handled in a timely manner.
  • Risks identified by the service were not being assessed, monitored and mitigated via an effective, comprehensive risk register. Risks we identified on inspection were not recognised by the service, including the failure to escalate deteriorating patients, poor junior doctor cover for medical wards, and the poor completion and storage of patients’ records. We were therefore not assured staff at every level in the service had an effective understanding of all the risks to patient safety and were able to assess, mitigate and monitor all known risks.
  • Not all staff were fully aware of the service’s plans to remodel the beds in the service, which was designed to improve patient flow. Some staff described it as a ‘stop, start’ process with delays in the reconfiguration of beds and wards. Staff were not generally aware of the timescales for this reconfiguration.

However, we also found that:

  • Staff treated patients with compassion, kindness, dignity and respect. Patients gave positive feedback about the care and service provided.
  • Despite significant staffing pressures, generally patients’ needs were met at the time of the inspection. Actual staffing levels were comparable to the planned levels for most of the wards we visited.
  • Generally, the design, maintenance and use of facilities and premises met patients’ needs. The maintenance and use of equipment kept people safe from avoidable harm. Appropriate infection control procedures were being followed.
  • Arrangements were in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements. Overall, the service was just below the hospital target of 85% for statutory and mandatory training at 83%.
  • Pain of individual patients were assessed and managed appropriately. Patients’ nutritional and hydration needs were appropriately assessed and the food and fluid charts were well maintained.
  • Staff generally had the right qualifications, skills, knowledge and experience to do their job. A multi-disciplinary team approach was evident across wards
  • The service had an effective escalation procedure in use for supporting demand for beds.
  • Staff understood and respected patients’ personal, cultural, social and religious needs, and took these into account and services were generally planned and delivered in a way that took account of the needs of different patients. The dementia strategy was being implemented and appropriate care was provided for patients living with dementia.
  • Patient flow and bed capacity to meet demand had been a significant pressure for the hospital for a number of months. Senior managers were in ongoing discussions with commissioners and stakeholders regarding the most appropriate ways of managing the DTOC position as the medical care beds being used were placing a significant pressure on the effective patient flow through the service.
  • Leaders within the service, of all levels, were generally visible and approachable. Staff told us that the senior leadership team, including both senior management and lead clinicians and nurses, were generally visible and effective.
  • Staff felt involved in the hospital’s CARE values which brought staff together to discuss ways to improve services and provide quality care to patients. Staff felt supported and able to speak with the lead nurse if they had concerns.
  • There were a large number of volunteers from the local community working in various departments in the hospital.

Diagnostic imaging

Inadequate

Updated 27 February 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as inadequate because:

  • The service did not have safe systems in place for recognising and responding to patient risk. The service was not managing the potential risks to patient safety due to significant concerns about unreported images. The trust took urgent action to address this once we raised it as a concern.
  • The service did not have enough 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. Safeguarding training requirements were not clear.
  • The service had not always provided care and treatment based on national guidance and evidence of its effectiveness. The service had not followed the guidelines issued by the Royal College of Radiology on non-radiology clinicians reviewing images. Managers failed to make sure staff followed guidance.
  • The service had not always monitored the effectiveness of care and treatment in order to use the findings to improve. Appropriate audits had not been done to ensure quality of practice was maintained.
  • The service had not always made sure that staff were competent for their roles. Reviewing of images by non-radiology staff was not in accordance with Royal College of Radiology guidelines.
  • Patients could not always access the service when they needed it. Waiting times for some patients exceeded six weeks before diagnostic imaging was carried out and this had not consistently improved over the past year.
  • The service lacked leadership capacity to run a service providing high-quality sustainable care. The service did not have a clear strategy and vision for what it wanted to achieve and lacked workable plans to turn it into action.
  • The clinical governance of diagnostic imaging was not adequate. There was no effective auditing and monitoring of the numbers of images delayed for extended periods. The service had not been managing and monitoring the service effectively to drive improvement or to mitigate risks to patients.
  • The service did not consistently collect, analyse, manage, and use information well to support all its activities, using secure electronic systems with security safeguards.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well. Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date, and available to all staff providing care. The service generally prescribed, gave, and stored medicines well.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

Surgery

Requires improvement

Updated 27 February 2018

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

  • The service provided mandatory training in key skills but did not ensure all medical staff completed it. Basic life support training compliance was poor for medical and nursing staff. There was an action plan in place to address this.
  • The service did not control infection risk well in all areas or always have suitable premises in all areas. Systems to ensure equipment was well looked after required improvements.
  • Managers investigated incidents and however there was a lack of formal systems to share lessons learned with the whole team and the wider service.
  • The service monitored the effectiveness of care and treatment but inconsistently used the findings to improve them.
  • Patients could not always access the service when they needed it but performance was improving. Waiting times from referral to treatment and arrangements to admit, treat, and discharge patients were improving.
  • Lessons learned from complaints were not always shared with all staff members effectively.
  • The service did not always have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The interventional radiology (IR) service was not continuously available. There was no rota or fixed cover out of hours and therefore no IR service out of hours.

However:

  • The service had enough staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff generally kept appropriate records of patients’ care and treatment. The service prescribed, gave, and recorded medicines well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The trust generally planned and provided services in a way that met the needs of local people.
  • The service had managers at most levels with the right skills and abilities to run a service providing high-quality sustainable care.

Services for children & young people

Requires improvement

Updated 27 February 2018

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

  • The assessment and management of risks to patient safety had generally improved but some risks remained.
  • The service did not always have enough medical and nursing staff with the right qualifications, skills, training, competencies, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff did not always keep appropriate records of patients’ care and treatment. Not all records were clear, up-to-date, and available to all staff providing care.
  • Waiting times for treatment were not meeting national standards but were improving.
  • The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected, but these were not always effective.
  • The service had a vision for what it wanted to achieve but workable plans to turn it into action were not yet in place.
  • The service had not always planned and provided services in a way that met the needs of local people. Paediatric radiology provision was limited but arrangements were in place with another NHS trust to mitigate this.

However:

  • The service monitored the effectiveness of evidenced-based care and treatment and used the findings to improve them. Outcomes were generally better than national averages.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Managers across the service were promoting a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

End of life care

Good

Updated 12 April 2017

We rated the service as good for the safe, caring, responsive and the well-led key questions and requires improvement for effective. We found that:

  • There were systems in place to protect patients from harm and a good incident reporting culture.
  • Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of life.
  • The hospital had a replacement for the Liverpool Care Pathway (LCP) called the ‘Guidance to implement care for the dying patient, and their family and friends’. The document was embedded in practice on the wards we visited.
  • Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff. There were clear documented reasons for the decisions recorded.
  • Patients were happy with the care they received and felt involved in their care planning at the end of their life. Nurses, doctors and the specialist palliative care team (SPC) demonstrated compassionate patient centred care throughout the inspection.
  • Relatives rated end of life care provided by nurses and doctors to their relative at the end of life, as ‘excellent to good’.
  • Sixty volunteers supported the chaplaincy service through a hospital wide patient-visiting programme, which included support to patients at the end of life.
  • Care and treatment was coordinated with other services and other providers. The specialist palliative care team (SPCT) had good working relationships with discharge services and their community colleagues. This ensured that when patients were discharged their care was coordinated.
  • All adult wards had end of life care champions who were trained in specialist end of life care and were a direct link to the SPCT.
  • The SPCT saw 100% of patients within 24 hours of referral.
  • The hospital had an executive and a non-executive director on the hospital board with a responsibility for end of life care.
  • There was a clear vision and strategy for end of life care supported by an outcome based work plan, led by the transformational lead nurse and medical lead for end of life care.
  • Risks regarding the management of bariatric patients in the mortuary were identified on the support services risk register.
  • Risks associated with end of life care were recorded within individual clinical business units (CBU) and recorded on the corporate hospital risk register. Staff had taken action to mitigate against risks.

However, we also found that:

  • The hospital performed worse than the England average for the five clinical outcomes in the End of Life Care Audit: Dying in Hospital (NCDAH) 2014/15, published 2016.
  • The hospital had scored particularly poorly for the multidisciplinary recognition of patients dying, communication regarding plans of care, and meeting the spirituality and religious needs of patients.
  • The hospital was not collecting information on the percentage of patients discharged to their preferred place of death within 24 hours.
  • The service did not provide face-to-face access to specialist palliative care for at least 9am Monday to 5pm to Sunday. This did not meet the recommendations from the National Institute for Health and Care Excellence (NICE) guidelines for end of life care for adults.
  • There was no practice educator post in the SPCT in line with national guidance.