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Inspection Summary


Overall summary & rating

Good

Updated 4 October 2018

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

We rated effective, caring responsive and well-led as good. We rated safe requires improvement overall.

In urgent and emergency care we rated safe, responsive and well-led as requires improvement and caring and effective as good. We rated the service as requires improvement overall.

In critical care we rated safety, responsive and effective as good and caring and well-led as outstanding. We rated the service as good overall.

In medicine we rated safe as requires improvement and effective, caring, responsive and well led as good. We rated the service as good overall.

In children and young people’s services we rated safe, effective, caring, responsive and well-led as good, and the service as good overall.

We did not inspect all core services. The previous rating for those services we did not inspect were taken into account when working out the overall trust ratings for this inspection

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately and could discuss the processes involved.

The service used safety monitoring results well and participated in the national safety thermometer scheme. Staff collected safety information and shared it with staff, patients and visitors. The trust used information to improve the service.

The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Standards of hygiene and infection rates were monitored to identify any risks and infection rates were low.

Staff kept appropriate records of patients’ care and treatment. Multi-disciplinary, electronic records were clear, up-to-date and available to all staff providing care.

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. Specialist teams support ward staff and patients in vulnerable circumstances.

The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Recruitment, especially of nursing staff was a major challenge to the trust. However, there were systems, including the use of a flexible workforce that ensured there was a match between staff on duty and patients’ needs.

The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance through programmes of audit.

The trust made sure staff were competent for their roles. There was a programme of mandatory training and staff had opportunities to develop their skills and gain experience and qualifications to help them do their jobs effectively.

Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Electronic records were used effectively and there were electronic systems to ensure patients’ conditions were monitored

Staff cared for patients with compassion. Feedback from patients and our observations confirmed that staff treated them well and with kindness and respected their privacy. In critical care there were examples of staff making exceptional efforts to deliver a caring service.

Staff involved patients and those close to them in decisions about their care and treatment. Patients said they were given sufficient information and support to make decisions about their care and treatment

Staff provided emotional support to patients to minimise their distress, and patients could access a member of a multi-faith chaplaincy team to discuss spiritual matters.

The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with other healthcare organisations and patient groups to identify and meet local needs.

Generally, people could access the service when they needed it. Waiting times from referral to treatment met government standards and arrangements to admit, treat and discharge patients were in line with good practice. However, waiting times for assessment and treatment or admission in emergency care did not meet government and professional standards.

The service took account of patients’ individual needs. There were specialist teams to support those with additional needs, for example those living with dementia or those in vulnerable circumstances.

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. However, the trust acknowledged there were issues with the timeliness of complaints responses and sometimes in the quality of the response. An action plan was in progress at the time of inspection to address these issues.

Generally, the trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care and promoted a positive culture focussed on the needs of patients. The organisational values were embedded and staff could give examples of how they guided them in their work.

The trust 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 trust had recently reset its overall strategy, mission and strategic objectives; these were well understood by staff.

Staff had been engaged in setting the trust’s recently revised vison, mission statement and strategic objectives. These and the existing trust values, were well understood and embedded in staff’s work.

The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Staff were involved in quality improvement projects and research activity.

The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Patients were involved in the production of pathways of care and other initiatives. There were arrangements for staff to register concerns or to highlight areas of exceptional practice or achievement.

However:

Medicines were not always stored in a way that ensured their effectiveness although patients were prescribed and given medicines well. Patients received the right medication at the right dose at the right time.

The service had suitable premises and equipment but did not always look after them well. We found issues relating to fire safety, waste management, storage of substances hazardous to health and emergency equipment being checked to ensure it was ready for immediate use.

Departmental managers did not always identify safety hazards and manage them.

The service provided mandatory training in key skills to all staff but completion rates were variable and often did not meet the trust own targets.

Inspection areas

Safe

Requires improvement

Updated 4 October 2018

Effective

Good

Updated 4 October 2018

Caring

Good

Updated 4 October 2018

Responsive

Good

Updated 4 October 2018

Well-led

Good

Updated 4 October 2018

Checks on specific services

Critical care

Outstanding

Updated 4 October 2018

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

  • Following our inspection in 2014, there had been improvements to the critical care unit. These improvements contributed to the safety of patients.
  • There were effective systems in place to protect patients from harm and a good incident reporting culture.
  • The critical care outreach team provided effective support to the general wards with the management of deteriorating patients and preventing admissions to ICU.
  • Patients received effective, evidence-based care and patient outcomes were within the expected range. There was an extensive audit and research programme and an investment in finding new ways to improve patient outcomes.
  • Appropriately qualified staff cared for patients. There were effective training programmes for both nursing and medical staff. The percentage of nursing staff with post registration qualification in critical care met the recommended guidelines.
  • There was a strong culture of multidisciplinary working on the unit.
  • There was an embedded culture of supporting patients and their families during and after admission to critical care. The service was committed to engaging with patients and their relatives and tailored care to suit individual needs.

Outpatients and diagnostic imaging

Good

Updated 10 March 2015

We found that a safe environment for patients was maintained and that the required safety checks were being completed and recorded. The outpatient waiting areas and clinic rooms were clean and hygienic.

Patients attending the outpatient clinics were positive about their treatments and consultations and the professionalism of the staff.

Clinical staff were caring and compassionate in their approach to patients. Staff were treated with respect.

The trust was taking action and implementing changes to respond to an increased demand in some clinic services. Some additional clinics were being run and action was being taken to improve the patient experience with regards to appointment booking.

There were consistent processes to monitor the performance of the different clinic services and identify risks and ongoing concerns. There was an ongoing transformation plan for the outpatient service that was being implemented with the engagement of staff.

Urgent and emergency services

Requires improvement

Updated 4 October 2018

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

  • The service did not always control infection risks well as there were ineffective systems in place to protect patients from cross infection. Staff did not clean their hands at the right time, did not wear personal protective equipment, such as gloves and aprons, correctly, or manage linen in line with policy. There was a lack of adequate isolation facilities within the emergency department. Waste was not segregated in line with guidance. We found inappropriate items in all of the different waste containers
  • The service had suitable premises and equipment but did not a look after them well. Equipment used in the event of an emergency was not checked consistently to ensure it was present, and in working order. Fire exits were blocked; fire doors were not fit for purpose, and would be ineffective at protecting patients and staff from fire and smoke.
  • Staff did not always keep appropriate records of patients’ care and treatment. Casualty care records we looked at varied in quality and completeness. We found two set of notes where we could not read the writing.
  • The service provided mandatory training in key skills but not everyone completed it. Mandatory training was below the trust target of 90%, for all staff groups.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. The department took part in both national and local auditing. However local audits did not reflect, or limited improvements were seen despite non-compliances being identified.
  • Patient indefinable information was not kept secure. Patients’ information including full name, date of birth and other information was on display to other patients and visitors to the department.
  • Staff did not always give patients food and drink to meet their needs and improve their health. Patients were not routinely offered a choice of food to meet both dietary and cultural requirements. This meant, that patients with dietary requirements or choices, such as lactose intolerance or being a vegetarian were not offered a choice of food.
  • Pain was manged well, but the assessment and recording of patient’s level of pain on arrival at the emergency department was variable. Waiting times from treatment and arrangements to admit, treat and discharge patients were not in line with good practice. The service did not meet the Department of Health’s standard for emergency departments, which is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the emergency department The service did not meet the Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival in the department to receiving treatment should be no more than one hour.

However:

  • Equipment was visibly clean and had been checked for electrical safety. There was a programme of planned preventative maintenance
  • The service managed patient safety incidents well. Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff. There were effective systems in place to report incidents. Incidents were monitored and reviewed and staff gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations and were confident in applying the practical elements of the legislation

  • The service provided care and treatment based on national guidance and evidence of its effectiveness Staff had access to up to date evidenced based guidance from organisations such as the National Institute for Health and Care Excellence and the Royal College of Emergency Medicine. There was effective multidisciplinary team working within the service and with other agencies. The service also participated in national audits.
  • Staff knew the trust’s vision and strategy, and told us how they made sure they put these into their practice.
  • Patients were treated with dignity and respect. Staff introduced themselves to patients and asked what they would like to be called.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed that they felt involved in decision-making and medical and nursing staff shared enough information to support their decision-making; we observed that staff asked if what they said had been understood by the patient and if there were further questions the patients, relatives or carers had.

Medical care (including older people’s care)

Updated 9 January 2018

As this was a focussed inspection we did not re-rate this service.

We found some areas where the trust was in breach of the regulations and must take action.

We had concerns about fire safety and the blocking of fire exits with equipment.

Medicines were not always stored securely and emergency equipment was not always checked or serviced to ensure it was ready for immediate use.

We found other areas where the trust should take action.

Mandatory training levels were below trust targets and staff found it difficult to access training. Safety performance information was not readily available to staff and patients.

However, we also found areas of good practice.

Generally patients received care that met their needs. There were sufficient nursing staff; although there was high usage of temporary staff, there were arrangements to ensure they were inducted to the ward areas where they worked.

There were robust arrangements for the prevention and management of pressure ulcers and safety thermometer performance was in line with national averages.

Staff helped patients to eat and drink and to take their medicines. Patient records were generally completed in line with professional standards, although there were some omissions. Patients reported being treated with kindness and that their privacy and dignity was maintained.

Managers responded promptly to area of concern we raised at the time of our inspection.

Maternity and gynaecology

Good

Updated 10 March 2015

We found that the maternity and gynaecology services provided at Ashford and St Peter’s were good overall and improving; there was a sense of pride in the service and optimism for the future. Midwives and doctors collaborated well to achieve the best outcomes for women and their families.

Feedback from women using the services was good, received through the NHS Friends and Family Test.

The midwife-to-birth ratio was 1:31 which was just outside the recommended ratio of 1:29. Many of the managers worked as supernumery and in clinical capacity and there was a flexible system for the deployment of staff to deal with peaks in activity.

The recent opening of the Abbey Birth Centre which had enhanced the service by ensuring that women were cared for in the areas most appropriate to their needs.

There was a new, engaging and participative leadership style with clear standards for safety and quality and a greater empowerment of midwives to make decisions, as appropriate, and provide a normalised childbirth experience.

Introduction of the Perinatal Institute Growth Assessment Protocol had led to some duplication of postnatal records and gaps in information.

We found a considerable number of staff had been impacted by what had been acknowledged as inappropriate leadership behaviours. The current leadership team had developed a vision and were working on an action plan following the external review which focused on quality and team work.

Medical care (including older people’s care)

Good

Updated 4 October 2018

Our rating of this service stayed the same. 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.
  • The service controlled infection risk well. They used control measures to prevent the spread of infection. Cleaning was of a good standard and staff used recognised methods to control the risk of infection such as good handwashing practice.
  • The service had suitable premises and equipment which were well looked after. Equipment was serviced and maintained in line with manufacturer’s instructions.
  • The service assessed and mitigated risks to patients. Staff carried out a range of risk assessments for patients and acted on these. There were systems that ensured the early detection of patients whose condition was deteriorating.
  • Staff kept appropriate records of patients’ care and treatment. These met professional guidance. A multi professional integrated pathway was used to which all professionals involved in a patient’s care contributed.
  • When things went wrong, staff apologised and gave patients honest information and suitable support. Staff were aware of the duty of candour and we saw examples of its use.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff could access policies that were based on best practice and there were systems to ensure new guidance was reviewed.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Patients’ nutritional needs were assessed using a recognised tool.

  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service made sure staff were competent for their roles. New staff had an induction programme and all staff had appraisals at least annually.
  • Staff of different kinds worked together as a team to benefit patients. Patient’s had access to the full range of health professions and we observed them working collaboratively.
  • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. There was an electronic records system all staff could readily access which included all patient records and test results.
  • Staff understood their responsibilities in relation to the Mental Capacity Act (2005). They supported people to make decisions and when people lacked capacity acted in their best interests.
  • Staff cared for patients with compassion. Staff involved patients and those close to them in decisions about their care and treatment and the patients’ emotional wellbeing was at the centre of all care provided. We observed staff delivering care with kindness and they supported patients emotionally. The feedback received from patients was positive.
  • The service planned and provided services in a way that met the needs of local people and patients could access the service when they needed it. There were systems to gain the views of patients when planning services.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. We saw examples of complaints outcomes leading to changes in practice.
  • The medical division had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The leadership team were described by staff as visible and approachable. Staff told us they felt supported and valued. Staff felt able to make comments and raise concerns about the service, confident they would be heard and there would be no recriminations.
  • The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

  • The service provided mandatory training in key skills to all staff but not all eligible staff had completed it. Trust data showed that the acute medical unit 59% of eligible staff were not up to date with their mandatory training.
  • The trust was not compliant with Control of Substances Hazardous to Health Regulations (COSHH). In all ward areas chlorine tablets were stored in the sluice which was unlocked. We found chlorine tablets, which are subject to COSHH regulations were not securely stored.
  • Waste was not managed in line with national guidance as clinical and domestic waste were not appropriately segregated by staff.
  • Medicines were not always stored in line with manufacturer’s and national guidance. The fridge temperatures were medicines were stored were not always checked and staff did not escalate concerns when fridge temperatures were outside recommended ranges. We found stock was not checked and there were out of date medicines on the wards
  • Fire prevention and management of the environment did not adequately minimise risks. Fire doors had not been maintained as fit for purpose.
  • The discharge lounge remained a mixed sex area with patients of both sex sharing a toilet which did not ensure the privacy and dignity of the patients was always maintained.
  • Computer terminals were not always locked when not in use and confidential information could be accessed by unauthorised people.

Surgery

Good

Updated 10 March 2015

While care was seen to be caring and compassionate across all areas, improvement was required to make the service safe.

Staff were encouraged to report any incidents on the trust’s computer system. Where incidents had been repeated, it would suggest learning from these had not taken place.

Compliance with the WHO surgical safety checklist was not meeting the trust target.

There was a high number of qualified nurse vacancies across the division. Staff told us they were working extra bank (overtime) hours to cover, as well as using agency staff.

Storage on some wards for patient notes was not secure and this meant visitors to the hospital could have had access to these confidential records.

The trust participated in local and national audits, for example, the hip fracture audit. There was good multidisciplinary working within the units and wards.

Patients and their relatives felt the care patients received was very good. Patients told us the staff respected their privacy and dignity.

The trust was not meeting the 18-week referral-to-treatment time (RTT) target for general surgery and trauma and orthopaedics.

A new urology unit had recently been opened to make the assessment of patients quicker and to provide their treatment at one location.

Staff told us they were aware of the trust’s visions and values and they were very passionate about patients receiving good care. Staff on the wards told us they felt supported and listened to by their divisional management team. However, some staff in theatres told us they did not feel supported by or listened to by the divisional management team.

Services for children & young people

Good

Updated 4 October 2018

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

  • Staff fully understood how to protect patients from abuse and the service worked well with other agencies to do so. The safeguarding team were visible on the children’s wards both days of our inspection and staff told us they came to the wards every morning to assist with any safeguarding issues.
  • Risks to people who used the services were assessed, monitored and managed on a day-to- day basis. We saw comprehensive risk assessments carried out on admission. This included background information on the child’s previous admissions and if they were known to social services or under any protection plan.
  • Although medical staffing was on the risk register, the division were maintaining safe staffing levels. Nurse staffing levels were often achieved by using bank and agency nurses. However, the department had a robust induction and competencies check and tried where ever possible to use regular agency to mitigate the risk.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service. The department also had a separate children and young people specific safety thermometer.
  • Pain assessments on children and young people had greatly improved, with pain assessment forming part of the paediatric early warning systems (PEWS) chart.
  • The service 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 involved patients and those close to them in decisions about their care and treatment.
  • The play therapy team were available seven days a week. They came to the wards to work with patients around anxiety and distress, and helped to prepare them for procedures.
  • Patients’ needs were considered at all stages of paediatric care. There had been a marked improvement to the care of children or adolescents suffering with mental ill health since our last inspection.
  • People could access the service when they needed it. There were good links with local GPs who could call the paediatric registrar (who held a bleep) for telephone advice, or could directly contact the consultant in charge. The service has helped to reduce referral to hospital and improved patient experience.
  • Staff universally felt supported by their managers and each other. We saw a collaborative team who worked together to ensure they were delivering the best care to their patients.
  • The senior staff we spoke to understood the challenges and could identify what changes were needed to address them. An example of this is the planned paediatric assessment unit to help with the flow and staffing of the department.

However:

  • We found chipped skirting boards and peeling paint in bathrooms, this could be an infection control risk as these areas could not be cleaned effectively. We also found some light dust in high areas, such as above beds, and on television brackets, suggesting these areas may need to be cleaned more often.
  • We found an un-locked sluice which contained cleaning products and waste in the incorrect bin. This could mean patients could access the harmful cleaning products.
  • The department did not have a dedicated pharmacist. The ward was visited each day by a pharmacist or pharmacy technician. However, we found for one ward had not been visited by a pharmacist for over two days to clinically check the medicine charts or carry out medicines reconciliation.
  • Some leaflets needed to be reviewed to ensure they contained up-to-date information.

There was no formal care passport for patients with complex needs. This was not in line with recently recommended National Confidential Enquiry into Patient Outcomes.

End of life care

Good

Updated 10 March 2015

The specialist palliative care team were accessible, visible and supportive of all areas in the trust. Team working with all wards and departments was evident to promote safe and effective end of life care. Staff throughout the trust valued the skills and support of the specialist palliative care team. The review of patients took place within multidisciplinary meetings to promote coordinated, safe and effective care. Care records demonstrated that potential problems for patients were identified and planned for in advance. The team were piloting and reviewing a person-centred care plan to be used to improve the safe and effective delivery of care in line with current best practice.

Staff throughout the trust were caring and treated end of life patients and their relatives with dignity and respect. Staff made every possible effort to ensure that patients and relatives had everything they needed to be comfortable and accommodated. The close working relationship between the nursing and medical staff, chaplaincy, bereavement, mortuary services and porter services was evident to support patients and relatives.