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Kettering General Hospital Requires improvement


Inspection carried out on 04 to 07 Feb 2019

During a routine inspection

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 carried out on 7th November 2017

During a routine inspection

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

Inspection carried out on 14, 15, 22 and 28 June 2017

During an inspection to make sure that the improvements required had been made

Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 320,000 in north Northamptonshire, South Leicestershire and Rutland.

Following the comprehensive inspection of the trust in October 2016, we rated Kettering General Hospital NHS Foundation Trust as inadequate. We rated two key questions, safe and well led, as inadequate. We rated caring as good and effective and responsive as requires improvement. Due to level of concerns found across a number of services and because the quality of health care provided required significant improvement, we served the trust with a warning notice under Section 29A of the Health and Social Care Act 2008.

On the basis of that inspection, we recommended that the trust be placed into special measures, which was confirmed by NHS Improvement.

This focused inspection took place on 14 and 15 June 2017, when we visited unannounced and inspected those services where significant improvements were required. We also carried out announced visits on 22 and 28 June 2017, to speak with senior leaders of the trust. We inspected part of the urgent and emergency care service, children and young people’s service and outpatients. We also looked at the governance and risk management systems across the hospital and at board level. As we only inspected parts of the five questions (safe, effective, caring, responsive and well led), we have not rated any key question, or any service, or the trust overall, at this inspection.

We found areas where significant improvements had been made:

  • Patient privacy and dignity in the emergency department (ED) were respected at all times
  • There was a designated mental health assessment room in the ED that complied with national guidance.
  • Staff showed care and compassion towards patients and their families. Patients told us they had been treated with kindness, dignity, and respect.
  • Risk assessments and triage tools were used in the ED for patients with mental health concerns, ensuring they were cared for with the correct level of observation in a safe, risk-assessed area.
  • Patients arriving by ambulance or self-presenting to emergency department (ED) reception received a timely initial time to clinical assessment.
  • There were clear systems in place to safeguard vulnerable children in the ED. The safeguarding policy now reflected national guidance. Safeguarding level three children training figures were now above the trust’s target of 90% for both nurses and doctors.
  • The paediatric ED was staffed with two registered nurses at all times. One of these would be a registered nurse (child branch), if not, there were processes in place to mitigate the risk to ensure paediatric competent nurses were on duty.
  • The paediatric ED was kept secure, with staff identity badges ‘swipe’ access only.
  • Staff training in paediatric competencies had significantly improved since the last inspection. Training compliance had improved since the recruitment of a practice development nurse, who was now monitoring compliance and performance in this area.
  • The leaders of the ED had made significant progress to improve and address all areas of the warning notice. Effective risk management processes were now in place, embedded and monitored.
  • Staff at all levels were aware of the concern raised at the last inspection and were involved in driving improvement in ED to address these concerns. Staff felt that communication from the trust wide team down to the leaders of ED had improved.
  • ‘Black breaches’ were now reported formally at the trust board and performance monitored and used to drive improvements. All staff could explain what a ‘black breach’ was.
  • The clinical leadership provided by the paediatric lead nurse had been instrumental in the provision and maintenance of a safe and secure environment for children on Skylark ward.
  • Parents and children were extremely positive about the care and treatment they received regarding inpatient and outpatient services at the hospital. Parents were aware that some children and young people with mental health conditions being cared for on the ward at times and told us they felt their child was ‘safe’ on Skylark ward.
  • There was a clear focus on patient safety, effective risk assessment and management throughout the children and young people’s service, which were owned by all staff.
  • Staff on Skylark ward were assessing, monitoring, and managing the risks to prevent or minimise harm to children and young people with mental health conditions. Staff on Skylark ward were “owning” security issues and had developed effective working relationships with the security team.
  • Risk assessments for children and young people with mental health issues had significantly improved as had staff access and uptake of mental health and conflict resolution training.
  • Staff were able to demonstrate their competence in caring for children and young people with mental health issues and care was planned and delivered in line with evidence-based guidance.
  • Procedures and guidance available to staff was comprehensive and up-to-date. Staff were able to respond appropriately to internal security arrangements that kept children and young people safe.
  • The service risk register reflected the risks associated with the children and the adolescents mental health service (CAMHS) patients and children experiencing self-harm behaviour and was reviewed and updated as required. Nursing audits were monitoring care provided against expected standards.
  • There were positive relationships with the CAMHS who were open and responsive to the needs of children with mental health needs on Skylark ward.
  • The total number of patients waiting over 52 weeks for their treatment on the admitted and non-admitted referral to treatment (RTT) pathways had improved. This had reduced from 413 to 182 patients waiting.
  • Where things had gone wrong, duty of candour was maintained.
  • The trust had carried out clinical harm reviews on 1,281 patients waiting over 52 weeks for their treatment. This represented 75% of all patients that had waited over 52 weeks.
  • The trust had a prioritisation system for carrying out harm reviews for those patients waiting more than 46 weeks on incomplete RTT pathways for high-risk specialties.
  • There was oversight on the potential deterioration of patients waiting over 18 weeks. Staff communicated with patient’s GPs to find out about potential harm. Procedures were in place to prioritise patients whilst waiting on RTT pathways.
  • Managers in the service had an effective oversight of the hospital’s RTT performance and could clearly show how the recording system worked and the number of patients waiting to be seen.
  • Governance and risk oversight had improved so that the trust’s Board of Directors, and all external stakeholders, could be assured as to the trust’s ongoing RTT performance and potential risks to patient safety.
  • The trust had recruited its own team of data validators.

However, we also found that:

  • The hospital failed to meet the national standard for 95% of patients admitted, transferred, or discharged within four hours of arrival to the ED from April 2016 to March 2017. The performance was below the England average for all of the 12 months. Overall, for that period, the ED achieved 83% against an England average of 89%, but the trend over time was showing improvements in meeting this performance measure.
  • Although the time to initial clinical assessment had significantly improved and effective systems were in place, the ED was not yet meeting national guidance for 95% of patients to be seen within 15 minutes of the time. However, during our inspection, all patients received an initial clinical assessment within 15 minutes.
  • The computer system the department used for triaging patients and capturing data was to be improved, so that the first set of clinical observations could be recorded. This would improve data collection and overall monitoring of this performance measure in the ED.
  • The trust was planning to carry out harm reviews on those patients who had died whilst on a waiting list.
  • The number of patients waiting for 31 weeks on an RTT pathway had increased from 9% to 27%. Managers were making plans to address this increase.

We found an area of outstanding practice:

  • The trust’s clinical harm review had been recognised as an ‘exemplar’ process and arranged for the trust’s process to be presented at the national elective care conference.

However, there were also areas of poor practice where the trust still needs to make improvements, where the trust should:

  • Review processes so that 95% of all patients that self-present and arrive by ambulance to the emergency department (ED) receive an initial clinical assessment within 15 minutes.
  • Review the trust arrangements with children and adolescents mental health services (CAMHS) and the local clinical commissioning group for the care of CAMHS patients and those patients with self-harming behaviours who are admitted to Skylark ward as a place of safety.
  • Continue to monitor the security arrangements on Skylark ward to stop visiting staff allowing other people to follow them into and out of the ward without challenging them.

  • Develop effective plans to seek to address the increase in the number of patients waiting on RTT pathways for over 31 weeks (which had increased from 9% to 27% at the time of the inspection).

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 12 to 14 and 24 October 2016

During a routine inspection

Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 320,000 in north Northamptonshire, South Leicestershire and Rutland.

This was the second comprehensive inspection of the trust with the first taking place in September 2014, when it was rated as requires improvement overall. We also carried out an unannounced inspection to the emergency department and some medical care wards in February 2016. As this was a focused inspection, we did not rate the services inspected.

Part of the inspection was announced taking place between 12 and 14 October 2016, with an unannounced inspection taking place 24 October 2016.

Overall, we rated Kettering General Hospital NHS Foundation Trust as inadequate. We rated two key questions, safe and well led, as inadequate. We rated caring as good and effective and responsive as requires improvement.

Three core services were rated as inadequate: urgent and emergency care, children and young people and outpatients and diagnostic imaging. Three services were rated as requires improvement: medical care, surgery and maternity and gynaecology. Two services, which showed improvements since the last inspection, were rated as good: critical care and end of life care.

Our key findings were as follows:

  • Risks identified by the service were not being assessed, monitored and mitigated via effective, comprehensive risk registers. 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, security and access to the children’s ward, paediatric nurse competent in the children’s ED 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.
  • There was not a holistic approach to the monitoring of safety and performance data, supported and informed by effective, ongoing clinical audits. Actions plans had not always been developed to address areas of risk or poor performance and those that were in place were not always effectively monitored.
  • The hospital had serious concerns around the accuracy and quality of its referral to treatment (RTT) data and reported position, with the correction of this being a hospital priority. The hospital was working on a plan of data improvement including education, training, changes to systems and process and validation of patient pathways. Some patients also experienced long delays waiting for treatment, specifically for urology, maxillofacial and ear, nose and throat (ENT). Patients and stakeholders were not involved in service development. In some cases, waits were in excess of 52 weeks. The service did not have the capacity to meet the needs of patients and ran additional clinics to manage waiting lists. There were long waiting lists for the majority of specialities, including medical oncology. The services’ own figures from October 2016 showed that 69% of patients were seen within 18 weeks against the national standard of 92%. The hospital was not nationally reporting referral to treatment time (RTT) performance at the time of inspection due to historical problems with the validity of data.
  • The hospital had taken action to minimise the delays in diagnostics and imaging reporting by outsourcing their radiology reporting. At the time of inspection, there were 11,733 images awaiting a radiology report. These were classified as non-urgent images.
  • Complaints were not always handled in a timely manner in almost all services.
  • Services risk registers were not comprehensive and any of the risks did not have sufficient assurance that mitigating actions were being monitored. Ward dashboards referred to some local risks but these were not systematically escalated to the service risk register.
  • There was a lack of capacity in the leadership team to consistently embed learning from incidents and audits throughout services to drive improvements. There had not been sufficient improvement in areas of concerns highlighted during our February 2016 inspection.
  • There were not enough registrars and junior doctors to cover the medical wards out of hours 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 and handover was focused on medical care wards. Working to seven day working in the service was variable.
  • There were inadequate numbers of nursing and medical staff to meet the needs of patient’s in adults and children’s ED. There were not effective processes in place to ensure that all staff were competent to carry out the roles they were tasked within the ED. The coronary care unit had nurse staffing numbers that were below the recommended number stipulated by the British Cardiovascular Society. There was inadequate medical staffing cover in the children and young people’s service. The maternity service did not always have sufficient staff, of an appropriate skill mix, to enable the effective delivery of care and treatment. There were times the consultant obstetrician was not present on the labour ward as they would be covering obstetrics and gynaecology and undertaking elective caesarean section lists. The critical care outreach team was not fully established to provide the necessary support and education to the rest of the hospital. The neonatal unit did not always operate in accordance with the required staffing levels. The paediatric outpatient department was not always staffed by registered children’s nurses. Nursing staff in both fracture and ophthalmology clinics treated children but did not have level three safeguarding training in line with national recommendations. The trust took action to address this after the inspection.
  • The children’s waiting area did not provide adequate space for patients waiting to be seen and staff in the children’s ED were not able to observe patients waiting at all times in line with guidance. The ED did not have safe and adequate facilities or processes in place to manage patients who presented with mental health illness and were a significant risk to themselves and others.
  • Staff were not always completing safeguarding processes in line with hospital policy and had not received the appropriate level of training. In the ED, staff did not always follow safeguarding processes and safeguarding training levels did not meet the hospital’s target or national recommendations. Risks to patients had not been actioned. Only 37% of nursing staff and 29% of medical staff had completed safeguarding level three training at the time of the inspection. Not all staff had completed the required level of children’s safeguarding training.
  • The hospital did not have a baby abduction policy; it had a flowchart for staff to follow in an event of an abduction. The trust took actions to address this after our inspection. The environment on Skylark ward was not safe, particularly for patients who may be at risk of self-harm or suicide. The trust took actions to address this once we had raised it as an urgent concern.
  • The ED was not consistently meeting national targets for service delivery but it had shown improvements in the last three months with performance better that the England average. From July 2016 to October 2016, the average performance against the target was 88%. There were a substantial number of delayed ambulance handovers. This meant that patients were not always receiving an initial clinical assessment in a timely manner and ambulance crews were not made available to respond to 999 calls.
  • Nurses on medical care wards 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. There were NEWS charts which showed dates and times that were not clearly stated and some were not legible.
  • 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 from avoidable harm. Confidential information was not always kept in accordance with the Data Protection Act 1998.
  • Medicine storage was not always in line with the national guidance in outpatient areas. For example, fridge temperatures were not checked regularly in some outpatient areas. Expired medication was found in the cardiac unit. Patient’s medical notes were not always stored securely in some outpatient areas. 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 in medical care. The hospital had produced poor results in two national audits that the hospital 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: the hospital was worse for 13 out of 15 indicators. There were mixed patient outcomes in surgery and not always an action plan to ensure improvements. Examples included the hip fracture audit and the bowel cancer audit.
  • 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. Discharges were sometimes delayed due to patients having to wait for ongoing care packages.
  • All staff were passionate about providing high quality patient care. Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
  • Generally, staff understood their responsibility to report incidents both internally and externally. Feedback received was variable. Learning from incidents was not always effectively embedded throughout services.
  • Most areas of the hospital were visibly clean and were cleaned regularly. Generally, effective infection control procedures were in place.
  • Despite significant staffing pressures, generally patients’ needs were met at the time of the inspection in most areas. Actual staffing levels were comparable to the planned levels for most of the wards we visited.
  • Pain of individual patients were assessed and managed appropriately. Patients’ nutritional and hydration needs were generally appropriately assessed and the food and fluid charts were well maintained.
  • 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.
  • Local leaders within services 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.
  • Most 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 clear processes and procedures in place regarding the completion of the Five Steps to Safer Surgery checklist. 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. The hospital had received the United Nations Children's Fund (UNICEF) Baby Friendly Initiative full accreditation for its maternity department.
  • 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.

We saw several areas of outstanding practice including:

  • The hospital had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • Sixty volunteers supported the chaplaincy service through a programme of daily and weekly visits to wards and clinical departments. Volunteers attended a 10 week training programme, which included awareness sessions on end of life care, dementia, and hearing and visual impairment.
  • There was a well-embedded play worker team, funding was sourced through donations from local businesses as well as fund raising activities. This was used to pay for new equipment as well as weekly visits from a music therapist, pet therapist and magician. The unit had modern toys and facilities for the children including a new projector, which projected moving images onto the floor, which entertained children under the supervision of a play worker.
  • The hospital had launched a “Joint School” education session for hip and knee replacement patients. The aim was to give patients a clear indication of what to expect from their operation and what was expected form them by the hospital.
  • The hospital had launched a new laser operation to support patients who required treatment for benign enlargement of the prostate by using a light laser to reduce the size of the prostate. This process had reduced the surgical time and the length of stay was no more than one day.

However, there were also areas of poor practice where the hospital needs to make improvements.

Importantly, the hospital must take action:

  • Ensure that there are sufficient numbers of nursing and medical staff in adults and children’s ED to meet the demands of the population and ensure safe care is delivered. To ensure that staff working in children’s emergency department (ED) have the correct skills, competence and support to care for children.
  • Ensure there is a sufficient number of medical registrars and junior doctors to cover out of hours and weekend shifts at all times across medical care wards. To ensure there is the required level of consultant obstetrician presence on the delivery suite.
  • To ensure care and treatment are provided in a safe way for service users by following the British Cardiovascular Society guidance on nurse staffing numbers in the Coronary Care Unit. Ensure there is a sufficient number of nurses working in the Coronary Care Unit at all times.
  • To ensure a qualified children’s nurse works in the outpatient department in accordance with Royal College of Nursing guidance, ‘Defining staffing levels for children and young people’s services’ which states that, ‘a minimum of one registered children’s nurse must be available at all times to assist, supervise, support and chaperone children’.
  • To ensure that suitably qualified staff in accordance with the agreed numbers set by the hospital and taking into account national policy are employed to cover each shift. In the children’s and young people service, there must be suitable numbers of staff trained in Advanced Paediatric Life Support and / or European Paediatric Life Support.
  • Ensure that there are effective systems in place to prioritise, assess and treat all patients attending the ED. Ensure that there are effective processes in place to measure time to initial clinical assessment for ambulance handovers and self-presenting patients.
  • To review the streaming competency framework and ensure that staff in this position have the necessary skills to identify a deteriorating or seriously ill patient in adult and children’s ED. To ensure that all staff in outpatients who have direct contact and assess and treat children have the appropriate level of paediatric competencies to provide safe care and treatment.
  • To ensure the security of the paediatric ward and Rowan ward at all times and review security system on the postnatal ward to minimise the risk of visitors accessing the ward without being challenged.
  • Ensure staff in medical care follow the hospital’s medication policy in the safe prescribing, cancelling, handling, storage, recording and administration of medicines. Ensure staff follow the hospital’s medication procedure for obtaining medicines for patients out of hours. The disposal of controlled drug ampules which have only been partially administered to patients must be recorded in the controlled drug register in the children’s and young people service. To ensure that all medications are stored in outpatients areas in line with hospital policy and national guidelines.
  • Ensure that the safeguarding children and vulnerable adult policies include all relevant information, specifically, details about female genital mutilation, child sexual exploitation as well as the referrals process for vulnerable adults. Ensure that all staff are trained to the required level of safeguarding children’s training and adhere to hospital safeguarding policies.
  • To ensure all staff have the required statutory and mandatory training and effective systems are in place to monitor this. To ensure that staff in the radiology department are up-to-date on basic life support training. To ensure that radiation dose awareness in plain film by the radiographers is in line with national standards.
  • To ensure staff in ED and medical care have had sufficient training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
  • To ensure there are processes and procedures for staff in surgery to adhere to the Food Safety Act 1990 and the Food Hygiene (England) Regulations 2006 (Temperature Control Schedule 4 EU Regulation No.852/2004).
  • To ensure that theatre staff comply with the Standards and Recommendations for Safe Perioperative Practice 2011 by the Association of Perioperative Practice or the hospital’s operating theatre policy and the theatre standard operating procedure regarding the wearing of cover gowns and footwear when leaving and entering the theatre area.
  • To ensure staff are aware of the escalation policy including triggers for escalation in ED and medical care and that these process and reviewed and monitored. Ensure National Early Warning Score (NEWS) charts are filled in clearly, accurately and legibly.
  • Ensure that patients’ records are completed with appropriate information to understand their care plans. Ensure all patients have person-centred care plans that are well maintained and reflect appropriately patients’ changing needs and treatment.
  • Ensure all confidential patient information in medical care, surgery and gynaecology and outpatients and diagnostics are stored in accordance with the Data Protection Act 1998.
  • To monitor patients’ referral to treatment times, and assess and monitor the risk to patients on the waiting list in surgery, children and young people’s service and outpatients and diagnostic services.
  • To develop an effective programme of cyclical audits to measure performance with evidence-based protocols and guidance in the ED. To establish a system for continuous monitoring of action plans developed in response to local and national audits. To ensure all clinical guidelines are up to date and reviewed in a timely manner in the maternity and gynaecology service. To ensure the local maternity dashboard meets RCOG good practice No.7 Maternity dashboard, clinical performance and governance scorecard standards.
  • To ensure complaints are handled in line with hospital policy and effective systems are in place to monitor this.
  • To ensure all staff are supported to recognise and escalate potential risks to the safety and quality of care and treatment for all patients and to ensure effective systems are in place to assess, mitigate and monitor these risks. The hospital should ensure that the risk registers are accurate and reflective of risks in services.
  • To review the incident reporting processes in children’s and young people service to ensure all incidents are reported and investigated and that actions agreed correlate to the concerns identified, are acted on and lessons learned are shared accordingly. Ensure ligature audits are undertaken and acted upon in the children’s and young people’s service.

In addition the hospital should take action to improve:

  • To review the environment in reception area in ED so that patients’ privacy and confidentiality can be respected.
  • To monitor the dedicated mental health room so that it meets national recommendations and poses minimum risks to patients and staff.
  • Review ways to improve the ‘whole system approach’ to managing overcrowding in the ED.
  • To provide training to staff in dementia awareness, learning disabilities and complex needs in ED.
  • Review staff training and awareness of major incident policy and equipment.
  • To monitor that equipment in ED is properly maintained and checks for resuscitation equipment are completed in line with trust policy.
  • Consider ways to meet the standards in the intercollegiate document ‘Standards for children and young people in emergency care settings, 2012’.
  • To review the function and use of the emergency decisions unit to ensure that the eligibility criteria are being adhered to.
  • To review medical cover for the Discharge Lounge.
  • To continue to work to recruit full time staff in an effort to reduce the reliance on agency staff in medical care.
  • To monitor that fabric chairs and privacy curtains within the breast pre-assessment clinic have the date of cleaning identified.
  • To monitor that the processes and procedures in place to manage the medicines stored in all clinical rooms which exceed the required temperature.
  • To support all staff to understand the trust’s vision and strategy so that it is embedded within the service.
  • To review systems and processes that are in place to ensure the cleanliness of surgical wards.
  • To review pharmacy provision to meet the needs of the ICU and be in line with national guidance.
  • Review systems for staff in ICU to provide level three safeguarding children’s training.
  • To review the provision of the outreach service to allow effective utilisation of this service.
  • To review processes so that patients are discharged from the ICU within four hours of the decision to discharge to improve the access and flow of patients within the critical care unit.
  • To review processes so that the hospital meets the needs of patient requiring admission to ICU at all times.
  • To review the data collecting methods to monitor the length of time patients are nursed in recovery whilst either waiting for a bed in ICU or following discharge from ICU.
  • To record ambient room temperatures where fluids are stored that requires this, taking action when required.
  • Steps should be taken to improve multidisciplinary working within the department between medical staff, nursing staff and allied healthcare professionals.
  • To review seven day services in medical are and critical care to ensure patient needs are met.
  • To review assessment and screening of delirium for patients cared for in the ICU.
  • To review systems for recording essential checks on equipment, including resuscitation equipment in critical care.
  • To review facilities so women’s privacy and dignity is always protected on the delivery suite.
  • To review staffing in maternity so that sufficient staff to ensure midwife-to-birth ratio is at the national average of 1:28.
  • To review the current practice where women who were having a termination due to abnormalities were cared for on the delivery suite in rooms next to women delivering healthy babies and Gynaecology and obstetrics patients and women attending for these appointments shared the same waiting room.
  • Monitor processes for patients who present with mental health needs are suitably risk assessed when admitted to the children and young people’s service to ensure care and support provided meets their needs and that staff are competent to manage difficult behaviours, including restraint.
  • Monitor staff training in mental health needs of patients and in the use of tracheostomy in the children and young people’s service.
  • A comprehensive clinical audit plan should be developed, completed and monitored in the children’s and young people service. Policies which are out of date should be reviewed and revised.
  • A dashboard should be developed in the children’s and young people service to report on and monitor operational performance data each month. Business plans should be developed which consider accurate operational activity data and performance. Objectives should be clearly defined and supported with effective action plans.
  • To review the provision of a face-to-face specialist palliative care service, aiming to achieve as Monday to Sunday service, including bank holidays.
  • To review the data collected for patients so that the hospital can assess the number of referrals for patients with or without cancer.
  • To review the collection of data in order to assess the percentage of patients who were discharged within 24 hours to their preferred location.
  • To review the processes to in the mortuary so that medicines for coroner’s inquests are recorded on receipt and transfer to pharmacy for disposal.
  • To consider increasing the education and training provision in the SPCT in line with national guidance.
  • To monitor the safety of patients who wait over 40 weeks for non-urgent outpatient appointments.
  • To review how clinic waiting times and clinic delays are appropriately displayed and communicated to waiting patients.
  • To review facilities so that consultation rooms in all outpatient areas can accommodate wheelchair users when needed.
  • To review and monitor all patients on waiting lists to ensure effective prioritisation systems are in place to identify and minimise patient harm.
  • Review how the standard operating procedure for managing outpatient clinics cancelled within six weeks is implemented and embedded.

Due to level of concerns found across a number of services and because the quality of health care provided required significant improvement, we served the trust with a warning notice under Section 29A of the Health and Social Care Act 2008.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 February 2016

During an inspection to make sure that the improvements required had been made

Kettering General Hospital is an established 576 bed general hospital, which provides healthcare services to North Northamptonshire, South Leicestershire and Rutland. The trust provides a comprehensive range of specialist, acute, obstetrics and community-based services. The trust also provides regional cardiology services to the wider Northamptonshire and surrounding areas.

The Care Quality Commission (CQC) previously carried out a comprehensive inspection between the 2 and 4 September 2014 which found that overall, the trust had a rating of 'requires improvement'.

We carried out a focused inspection on 10 February 2016 due to information of concern regarding the hospital’s emergency department (ED) and also the use of escalation areas. These escalation areas are reported in the medical care section of this report. These are clinical areas in the hospital not normally used for caring for patients overnight however are opened to accommodate patients due to high demand for beds and patient flow pressures across the hospital. Concerns had been raised regarding the quality and safety of patients being cared for in the corridor area of the ED and also in some of the escalation areas being used at times of peak demand for beds in the hospital. During the past year, attendances at the ED had risen by 6%. The inspection was conducted during the evening of one of the days of the junior doctors’ strikes which had run from 8am on 10 February 2016 to 8am the next day.

Our key findings were as follows:

  • Staff were caring and considerate towards patients and their families during our inspection.
  • Patients who required prioritisation of treatment in the emergency department (ED) were not always identified in a timely way, leading to delays in care. We escalated this immediately to the executive on call, who took immediate actions to address this on the day of the visit and the trust then took a series of actions following the visit to put systems in place to maintain oversight of this concern.
  • Patient records lacked sufficient detail to ensure all aspects of their care was clear. Risk assessments, including skin damage assessments, were not always completed and there was a lack of recording of the care and treatment given whilst patients were within the ED.
  • Patient records within the paediatric area of ED were not always stored securely and were accessible to anyone who entered.
  • Staffing within the paediatric ED was not always sufficient to ensure a paediatric trained nurse was present to care for children. We escalated this immediately to the executive on call, who took immediate action to ensure a qualified nurse was present in the paediatric ED whenever it was open. Following the inspection, the trust put in place a series of actions to address this concern.
  • The entrance to the paediatric ED was not restricted and could be accessed by all hospital staff, patients and the public. We escalated this immediately to the executive on call, who took immediate action to ensure a qualified nurse was present in the paediatric ED whenever it was open. Following the inspection, the trust put in place a series of actions to address this concern.
  • Patients’ privacy and dignity was not always respected whilst being cared for in the corridor of the ED.
  • The department was not meeting the national performance measure to admit, transfer or discharge 95% of patients within four hours, with performance consistently below the national average since October 2014.
  • There was a lack of effective risk management oversight governing the use of the corridor area in the adult ED, with a lack of clear policies and effective risk assessments for this area being used to provide care and treatment for patients. During our inspection, the trust took immediate actions to ensure the safety of patients in ED and immediately following the inspection provided a detailed action plan to deliver a programme of actions designed to sustain and embed the required improvements.
  • Escalation areas in medical care areas and wards were being used at peak times of demand for beds to facilitate patient flow through the hospital.
  • Nurse staffing levels and skill mix had been managed to meet the needs of the patients in these escalation areas. Extra nurses were booked for each shift to manage patients in escalation areas.
  • Clinical operations managers reviewed every patient in an escalation area at the start of each night shift to ensure the placement was appropriate.
  • Patients in escalation areas were reviewed by a consultant-delivered ward round, at least once every 24 hours, seven days a week.
  • Emergency equipment, including equipment used for resuscitation was checked daily in escalation areas.
  • Assessments for patients in escalation areas were generally comprehensive, covering all patients’ health needs.
  • Patients’ pain was assessed and reviewed regularly. Appropriate pain relief was given as prescribed when required.
  • The trust had been working with Commissioners and external providers to determine new ways of working to reduce demands upon the trust. At the time of the inspection these measures had not yet delivered improvements.
  • Numbers of patients with a delayed transfer of care had remained high over the past two months, however, the number of patients outlying on other speciality wards had reduced in the past two months, due to change in bed management processes.
  • Generally, effective systems were in place regarding the use of escalation areas in the hospital and senior staff had an effective oversight of the risks to patient safety.
  • Most staff had an understanding of the escalation area usage and admission criteria. They understood the need to move staff to meet patient needs, but some staff felt under pressure due to this.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure effective systems are in place to monitor and address risks to the safety and quality of patient care in the ED.
  • Ensure that all patients presenting to ED receive appropriate and timely assessments of needs and that effective care and treatment is provided in a timely way.
  • Review nurse staffing within the paediatric ED to ensure a paediatric trained nurse is present to care for children.

In addition the trust should:

  • Ensure patient records including risk assessments in ED contain sufficient detail to ensure all aspects of their care is clear.
  • Ensure all records in the paediatric ED are always stored securely.
  • Ensure patients’ privacy and dignity is respected whilst being cared for in all areas of the ED.
  • Review and monitor the security and access to the paediatric area to ensure risks of unauthorised entry are addressed.
  • Ensure effective systems are in place to monitor the risks to the quality and safety of patient care in the ED and fully embedded throughout the whole staff team to ensure effective oversight and management of risks.
  • Ensure data is collected and monitored regarding patients transferred under the ‘Early Flow Discharge policy’ to maintain an oversight of potential risks.
  • Review the storage patients’ records in escalation areas to ensure they are stored securely.
  • Ensure medicine fridge temperatures are checked regularly in all escalation areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2-4 September 2014, Unannounced inspections on 9 and 13 September 2014

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 2 and 4 September 2014. We carried out this comprehensive inspection because the Kettering General Hospital NHS Foundation Trust had been identified as potentially high risk and was scored band 1 (the highest) on the Care Quality Commission’s (CQC) Intelligent Monitoring system in July 2014.

The trust was inspected by the CQC in January 2014, and was subsequently issued with compliance actions in respect of Regulation 22 (staffing) and Regulation 13 (medicines) due to the serious failings identified on the Deene Floor. The trust reported that in respect of Regulation 13 they returned to compliance by March 2014, and in respect of Regulation 22 they returned to compliance by end of August 2014. This was reassessed at this inspection.

The trust remains non-compliant with the compliance action issued on medicines. This is because we found significant issues in respect of the storage, prescription and administration of medicines within a number of areas within the hospital.

The comprehensive inspections result in a hospital being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall, the trust has a rating of 'requires improvement'.

Our key findings were as follows:

  • The trust encouraged staff to learn from incidents that occurred, to improve the care received by patients.
  • The new management team had plans in place to deal with some of issues we found, and had already addressed some of the issues highlighted in previous CQC reports.
  • The trust had used complaints in a positive way to enhance the care received by patients.
  • Many staff felt empowered to make or suggest changes to improve care.
  • The trust had reduced usage of agency cover in the A&E department by half during the previous year.
  • The trust was not following Intensive Care Society Guidelines on the nursing staffing in critical care.
  • The trust had a shortfall of permanent clinical staff, which at times led to poor care being given. The trust have employed temporary staff to mitigate this risk.
  • Poor environment meant that potentially infection control practices could not be effective. We also found poor documentation in relation to infection control.
  • Equipment and facilities particularly in the theatre department and in Maternity were old, and required some improvements.

We saw several areas of outstanding practice, including:

  • Excellent multidisciplinary working was noted across the trust, ensuring that patients received appropriate and timely care.
  • Staff described a supportive response in the trust, where learning from incidents and staff issues was seen as important to improve safety and quality of patient care.
  • The practice in maternity of sharing 'hot' topics at handover ensured that all staff were aware of these issues.
  • The caring and responsive approach to bereaved families by staff in the mortuary, including support with viewings, and support with funeral arrangements, was outstanding. Staff in this service went beyond the call of duty to support families, particularly those bereaved of children and babies, during difficult times.

However, there were also areas of poor practice, where the trust needs to make improvements.

Importantly, the trust must:

  • Review staffing levels in the surgery and critical care units. This should include the use of junior doctors overnight within surgery.
  • Review the environments in maternity and outpatients, to ensure that infection control measures, and privacy and dignity issues, can be addressed.
  • Ensure that best practice guidelines from ‘The Safe and Secure Handling of Medicines: A Team Approach’, published by the Royal Pharmaceutical Society, are implemented to improve the safety and efficacy of medications.
  • Ensure that 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms are completed appropriately.

In addition the trust should:

  • Take action to ensure that staff in the A&E department are aware of current risks and actions to be taken in relation to communicable diseases, such as Ebola.
  • Ensure that the checking of resuscitation equipment in the A&E department, and across the trust, occurs as per policy.
  • Review the usage of storage facilities throughout the hospital, but especially in A&E and maternity.
  • Ensure that patients’ medical records are stored in a way that maintains patient confidentiality within the A&E department.
  • Review the availability and uptake of training on caring for patients living with dementia, to improve the service to patients living with dementia.
  • Ensure that staff receive appropriate appraisals, in order that they remain competent to carry out their roles.
  • Review the consent procedures for emergency patients.
  • Review the end of life service, to ensure that patients requiring this service receive care at an appropriate time.
  • Improve record keeping throughout the trust, but especially in medical areas, to ensure that it reflects the needs of individual patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 28, 29 January 2014

During an inspection to make sure that the improvements required had been made

Our inspection of 25 and 26 September 2013 found that there was not sufficient numbers of qualified, skilled and experienced staff to meet people’s needs. During this visit we looked at staffing numbers and skill mix on 16 wards and departments. The trust had taken action to increase the numbers of qualified nurses employed. There were 25 qualified nurses completing induction training during our visit. There were 33 nursing vacancies remaining.

The impact of the recruitment exercise had yet to be felt on the wards and department because the new recruits were still on induction training. Many staff told us about the nurse staffing shortages and the impact that they felt this had on patient care. The trust had put in a management system known as the safe staffing matrix. This meant that staff where moved to wards and departments where any shortage was assessed as having a negative impact on patient care. Senior managers held bed meetings three times a day and assessed each ward and department. Staff were moved accordingly. This process was risk assessed but we saw that this process did sometimes have an impact on the skill mix in some wards and departments and on staff morale. The use of agency and bank staff remained high and this was exacerbated by a temporary increase in beds to address winter pressures.

We spoke with a number of patients in all 16 wards and departments we visited. On the whole patients were complimentary about the staff and about the care, treatment and support they received. Some patients told us they were kept waiting because of staffing shortages and felt that the quality of care provided by agency or bank staff was not of the same standard as that provided by staff employed by the trust. One patient told us, “Overall I have had a positive experience. You can tell when bank nurses are on as they can’t find things and we have to wait longer. If you need help urgently at staff changeover it’s very difficult to get help”. Another patient told us they found the staff polite and friendly. They said “whenever I’ve needed water; I shouted out to the nurse, they came”. A patient told us they heard health care assistants complaining that they were very busy and did not get a break. Another patient said “The nurses and health care assistants this morning have been lovely, very respectful”

When we visited the surgical wards we found there were a number of errors on the medication administration records. The trust took immediate action to address this.

Inspection carried out on 25, 26 September 2013

During an inspection to make sure that the improvements required had been made

We spoke with patients and to visitors in all the wards and departments we visited.The majority of people were complimentary about the care and treatment they received. In the accident and emergency department a patient said "they can't do enough for you". Some patients and relatives on HC Pretty wards A and B said that staff were too busy. We saw that staff were very busy. We also saw examples of staff responding to patients appropriately and with respect and kindness. The trusts new nursing process documentation was being used in all the wards and departments we visited. In the majority of cases this documentation was being used effectively. Assessments were carried out for the risk of pressure ulcers. Where risk was identified appropriate action was taken to manage it in the majority of cases. The accident and emergency (A&E) department had been reconfigured so that children attending the department could be seen and treated in dedicated areas. Safeguarding procedures had improved since our last visit. All children who attended A&E had their records reviewed to ensure that the possibility of abuse was identified and appropriate referrals made. The number of staff who had attended mandatory training had increased since our last visit. Training for staff in dementia care had also increased. There were a number of trained nurse vacancies throughout the trust but in particular in the medical directorate. The trust were aware of this shortfall and were taking action to address this.

Inspection carried out on 17, 18, 19 June 2013

During an inspection to make sure that the improvements required had been made

We went to 16 wards and departments. We spoke with a number of patients. Overall, patients we spoke with were happy with the care and treatment they received. One patient commented “the nurses and the doctors are all top draw”. Another said that “staff are friendly and courteous and communication is good. I have confidence in the staff”. One patient told us that English was not their first language and that “staff take time to explain things clearly”. Some people felt they had waited for a long time in the Accident and Emergency (A&E) department. The trust had recently introduced a new system and documentation for the assessment, planning and delivery of care. We found that in most wards or departments we visited this was working well and patients had their individual needs met. However, on some wards this was not the case and some patients were not sufficiently well protected from the risk of receiving care or treatment that was inappropriate or unsafe. We found that staff knowledge about the management of pressure ulcers and about dementia was varied and there were inconsistencies in their approach. This meant that the trust was not sufficiently protecting some patients’ welfare and safety. The facilities for children in the A&E department did not meet expected standards. Procedures for identifying children’s safeguarding concerns in A&E were not robust. The trust had made considerable improvements to infection control practices since our last visit.

Inspection carried out on 7, 8, 11 March 2013

During an inspection in response to concerns

We inspected Kettering General Hospital 7, 8 and 11 March 2013. We carried out this inspection because we received information of concern about urgent care pathways at the trust and about infection control. We went to 10 wards or departments. We used specialist advisors for infection control, accident and emergency and governance. We spoke with patients and staff in all the wards and departments we visited. Some of the comments we received from patients included " staff were very attentive ". The staff were brilliant ". " The ward is very clean and is constantly being cleaned". "I have been here for a month, its been exemplary".

Staff we spoke with felt supported by their managers and told us they were always approachable and accessible. The majority of staff felt they had received all the training and support they required. Some staff told us they did not always have time to attend training.

Some patients experienced long delays (over 10 hours) in the accident and emergency department waiting for a bed to become available on a ward. Some patients experienced discomfort waiting in the department.

Staff did not always follow policy and procedure for the adminstration of medicines, or for the assessment of risk.

Inspection carried out on 10, 11 October 2012

During a routine inspection

We inspected Kettering General Hospital 10 and 11 October 2012. We went to 11 wards including two maternity wards and the emergency department. We used a specialist advisor to inspect maternity services. We spoke with a number of patients who told us they were happy with the care and treatment that they had received. They told us they did not have to wait to be seen by a doctor or nurse when they first came into hospital. Patients told us all staff were polite and helpful and treated them with respect. Staff maintained their privacy and dignity and explained their care treatment options to them carefully.

Some of the comments we received from patients included '’the triage nurse was much better at listening than the GP’’ and ‘’they were very good’’ and ''the staff have been brilliant''.

Staff we spoke with felt supported by their managers and told us they were always approachable and accessible. Staff felt that morale was increasing and this was partly due to the increased staffing levels they had been promised. Staff were not receiving routine clinical supervision and many had not received training about caring for people with dementia or about the Mental Capacity Act. We asked the providers to take action about this.

The delivery of care was not always sufficiently planned and did not always take into account the individual needs of patients or ensure their care and welfare. We asked the provider to take action about this.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 16 November 2011

During a routine inspection

We visited wards throughout the hospital over two and a half days. The wards we visited included those that specialised in medical, surgical, and orthopaedic treatments. We also visited the accident and emergency department, outpatients departments, and a ward for children.

Patients told us that staff were invariably polite, friendly, and despite often being very busy the nurses and healthcare assistants responded in a timely way to requests for assistance.

We were told that people felt safe on the wards because security was taken seriously by staff and there were practical precautionary measures in place, such as electronically locked doors that could only be opened from the outside by someone who had been issued with an authorised ‘swipe card’.

We observed some instances where patients could have been treated with more consideration when they were still awaiting treatment. We also found that some visitors were unhappy that information they had shared with staff, and which had been relevant to the care of their relative, had not always been effectively passed on to the next shift of staff arriving for duty.

The majority of patients we spoke with, however, had no complaints about the way they had been treated or cared for and praised the staff for their “good work."

Inspection carried out on 22, 23 March 2011

During a themed inspection looking at Dignity and Nutrition

On the two wards we visited people told us that they got the care, attention, and information they needed to make their stay in hospital as pleasant as it could be, given their circumstances. They said the ward staff were ‘kind’ and that they felt safe knowing that the nurses were attentive.

Example comments included:

• “I am well treated here. They never leave me feeling embarrassed or frightened.”

• “Staff take the time to explain what is happening. If I am not sure about anything I only need to ask.”

They told us that staff are very aware of protecting people’s dignity in communal ward bays.

People said they were never left feeling embarrassed or in discomfort. They also told us that people who needed help always got it and were not left unattended.

People told us they felt reassured when they were encouraged to ask questions about their treatment or what was happening on the ward and that the medical staff would take the time to explain their options in a way they could understand.

They told us they get enough to eat and drink and that it came as a welcome surprise to most of them that the meals and snacks available to them were enjoyable. They also told us they had not expected there to be so much choice available to them at mealtimes.

Example comments included:

• “The choice of food here is really good. There is always something on the menu you fancy…”

• “You can even order snacks if you feel peckish. I could not believe that when they first told me.”