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Kettering General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 May 2019

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

  • We rated safe, effective and responsive as requires improvement and caring as good.
  • The overall rating for well led at the core service level was requires improvement. However, we rated well led trust wide, which is a separate rating, as good.
  • We rated four of the trust’s core services as requires improvement and four as good. Diagnostic imaging is considered an additional service and was rated as good.
  • During this inspection we did not inspect surgery, critical care, children and young people or end of life care. The ratings published following previous inspections are part of the overall rating awarded to the trust at this time.

Inspection areas

Safe

Requires improvement

Updated 22 May 2019

Effective

Requires improvement

Updated 22 May 2019

Caring

Good

Updated 22 May 2019

Responsive

Requires improvement

Updated 22 May 2019

Well-led

Requires improvement

Updated 22 May 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 22 May 2019

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

  • We observed both nursing and medical staff not adhering to appropriate hand hygiene practice.
  • Patient risk assessments were not always completed or monitored to identify risks or prevent a deterioration in clinical condition.
  • The nurse vacancy rate was significantly higher than the trusts average vacancy rate.
  • The service did not have enough medical staff with the right qualification, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment most of the time.
  • Records were not always stored securely.
  • Risk assessment and care planning documentation was not always completed.
  • Medicine charts were not always fully completed.
  • Pain assessments and care plans were not completed for all patients.
  • The service took longer than the trust target to investigate and close complaints.
  • Audit frameworks and action plans to improve the service were not always effective in ensuring patient risk assessments, such as pain, pressure ulcer and falls assessments were completed in line with policies and procedures.
  • Agency staff did not have access to effective systems to allow them to record incidents.

However:

  • The service met the trust set target of 85% for completion in the majority of mandatory training modules.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Patients were provided with food and drink to meet their needs and improve their health.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff worked together as a team to benefit patients.
  • Relevant staff, teams and services were available seven days per week for assessing, planning and delivering patients’ care and treatment.
  • Most people could access the service when they needed to.
  • The trust planned and provided services in a way that met the needs of local people.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust generally collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • 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 service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

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.

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.

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.

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.

Urgent and emergency services

Requires improvement

Updated 22 May 2019

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

  • Not all nursing staff had completed mandatory training, for example medicines management and sepsis.
  • The design, maintenance, and use of facilities and premises did not always meet patients’ needs.
  • There were no systems in place to prevent queueing patients overhearing conversations between reception and streaming staff at the reception desk.
  • Risks to patients were not always assessed appropriately.
  • Records of patients care and treatment were not kept up to date and did not contain all the information required.
  • Patients receiving intravenous fluids did not have fluid balance charts completed.
  • Patients pain was not always managed effectively.
  • The emergency department failed to meet any of the national standards for the Royal College of Emergency Medicine (RCEM) audits.
  • Staff did not always receive an appraisal.
  • The service was unable to plan and provide services in a way that met the needs of local children.
  • Patients could not always access care and treatment in a timely way.
  • Complaints were not always responded to in a timely manner.
  • Due to the infancy of the ED senior leadership team, changes and improvements were yet to be embedded.
  • Whilst they had a framework in place for governance, mortality and morbidity meetings were not minuted.
  • The service did not have effective arrangements in place to ensure information and data used to monitor, manage and report on performance was accurate.
  • Patient engagement was limited.
  • There was little evidence of any other innovations or research since the previous inspection.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.
  • Patients that arrived by ambulance were assessed immediately.
  • There were enough medical and nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Whilst outcomes of care did not meet national standards, they were being monitored and the service used the findings from audits to improve patient outcomes.
  • The service had processes in place to ensure staff were competent for their roles.
  • Staff of different disciplines worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff were committed to supporting people to live healthier lives.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously. They investigated them and learned lessons from the investigations.
  • The emergency department (ED) had a new senior leadership team, with the right skills and abilities to run a service.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers across the service were starting to promote a positive culture that supported and valued staff.
  • The service engaged with staff to plan and manage appropriate services.
  • The new senior leadership team were committed to improving services.

Diagnostic imaging

Good

Updated 22 May 2019

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

  • Significant improvements had been achieved within the service since our last inspection. The reporting backlog had almost cleared and reporting turnaround times dramatically reduced. This had been achieved as a result of increasing the reporting capacity through use of locum consultants and increased outsourcing to teleradiology providers. The service had an operational plan to create a sustainable and cost-effective reporting team and to move away from reliance on third party support.
  • New key performance indicators (KPI’s) and reporting processes were introduced to measure improvements, and to facilitate the ongoing management of the reporting workload. The service was now working to, or very close to, its agreed KPIs for most modalities. The leadership team understood the challenges to service provision and actions needed to address them.
  • Patients could access the service when they needed it. Waiting times to treat patients were generally in line with good practice. Most patients received diagnostic imaging within the six-week target.
  • Staff were committed to providing the best possible care for patients. Staff felt ownership for the service and were proud to be part of the diagnostic and imaging service.
  • There was a strong, visible patient centred culture. Staff were highly motivated and inspired to provide care and treatment that was kind, compassionate and promoted patients’ dignity, and respected people’s needs. Staff of all disciplines worked together as a team to benefit patients.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to delivery of care because of lessons learned.
  • The service made sure staff were competent for their roles. Mandatory training in key skills was provided to all staff and the service made sure most staff completed it. Staff were encouraged to develop their knowledge, skills and practice.
  • The service had enough medical 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 outsourced activity to ensure timely treatment was provided. Recruitment into the radiologist workforce remained an ongoing challenge, however, locum doctors were used as an interim measure to keep people safe from harm.
  • The service had suitable premises and equipment and looked after them well. Although the cardiac investigation unit remained cramped since the last inspection, plans were in place to expand and improve the environment.

However:

  • Not all the environment was maintained in accordance with Department of Health guidance. Flooring in the x-ray rooms within the breast unit did not comply with relevant Health Building Note (HBN) requirements.
  • Complaints were not responded to in a timely manner.
  • A clinical director/lead was not in place to provide additional support and oversight of the service.

Maternity

Good

Updated 22 May 2019

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

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff completed and updated risk assessments for each patient.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
  • Women’s and babies’ nutrition and hydration needs were identified, monitored and met. There was access to an infant feeding specialist to assist women and babies when needed.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress. Women’s emotional and social needs were as important to staff as women’s physical needs, and there were ongoing support for bereaved women and their families.
  • The maternity service planned and delivered services in a way that met the needs of the local people. The importance of choice and continuity of care was reflected in future maternity care provision. The service 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 took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss, throughout their time in hospital and return home.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • The service engaged well with women, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

  • Although the service provided mandatory training in key skills to all staff they did not ensure all staff completed it. Mandatory training compliance was variable and did not meet the trust target of 85% in all topics
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. However, complaints were not responded to in a timely manner.

Outpatients

Good

Updated 22 May 2019

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

  • Mandatory training in key skills were provided to all staff.
  • Staff understood how to protect patients from abuse and were aware of the requirement to work well with other agencies to do so.
  • Infection risk was controlled well in most areas. The environment was clean and organised.
  • Systems and procedures were in place to assess, monitor and manage risks to patients.
  • There was enough nursing and medical 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 kept appropriate records of patients’ care and treatment.
  • Medicines were prescribed, dispensed, administered, recorded and mostly stored in accordance with best practice.
  • Staff recognised incidents and most staff reported them appropriately.
  • Policies were aligned and referenced to national guidance, such as National Institute for Health and Care Excellence (NICE) guidelines.
  • Some outpatient areas monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff were competent for their roles. Supervision meetings were held across most specialities to provide support and monitor the effectiveness of the service. Appraisal rates had increased since our last inspection.
  • Staff from all disciplines worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Patients were treated with compassion, kindness, dignity and respect, when receiving care. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.
  • The outpatient’s department generally planned and provided services in a way that met the needs of local people.
  • Some improvements had been made to the amount of time patients waited from referral to treatment (RTT).
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff.
  • The service had managers at all levels with the right skills and abilities to run a service working to provide high-quality sustainable care. Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The vision for the outpatients’ department continued to be one that focused on the delivery of safe and high-quality patient care.
  • The outpatients’ department had effective systems for identifying risks and timely plans to eliminate or reduce risks.
  • The service collected, analysed, managed and used information to support all its activities, using secure electronic systems and security safeguards.
  • The service engaged well with staff and collaborated with partner organisations effectively.
  • There was an improvement plan which detailed aims and objectives. We found some service improvements had been made since our previous inspection in 2017.

However:

  • Medical staff compliance with mandatory training was low for some training modules.
  • Premises or facilities were not always suitable for their intended use. Some areas were overcrowded.
  • Lessons learned from incidents were not always shared with the wider service and other specialities.
  • Not all patients could access the service when they needed it.
  • Complaints were not always responded to in a timely manner.
  • There was further work required to ensure all levels of the governance structure functioned effectively to ensure joint working and shared learning across specialties.