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William Harvey Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 September 2018

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

We rated safe, effective, responsive and well-led as requires improvement, and caring as good. We rated three of four core services as requires improvement and one as good.

Inspection areas

Safe

Requires improvement

Updated 5 September 2018

Effective

Requires improvement

Updated 5 September 2018

Caring

Good

Updated 5 September 2018

Responsive

Requires improvement

Updated 5 September 2018

Well-led

Requires improvement

Updated 5 September 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, through structured audit and review the department was able to evidence improvements in health records management, call centre management, referral to treatment (RTT) processes, increased opening hours, clinic capacity and improved patient experience.

Although there was still improvement required in referral to treatment pathways the outpatients department and trust demonstrated a commitment to continuing to improve the service long term.

As a part of the strategy the trust had pulled its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.

Maternity

Requires improvement

Updated 5 September 2018

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

  • Training compliance for medical staff was much worse than the trust target of 85%. This meant that not all medical staff received the mandatory training required to undertake their rolls.
  • Safeguarding training amongst the medical staff was worse than the trust’s target of 85%. Of the 28 medical staff eligible for level two and three training there was a compliance rate of 64%.
  • Despite the staff achieving a 88% compliance rate with mental capacity training, the staff we talked with showed a varied understanding of mental capacity and deprivation of liberty safeguards. This meant that not all staff were aware of their individual responsibilities. This was also identified at our last inspection.
  • Data supplied by the trust showed very poor compliance rates of 57% with the World Health Organisation Safer Surgery check list. This meant that this safety standard was not being applied in practice to safeguard patients from practices known to reduce preventable maternal and new-born deaths around the time of childbirth.
  • The midwife to birth ratio at the time of the inspection was 1:30. This was worse the national benchmark of 1:28. We noted this risk was reported on the trust risk register which identified compliance with one to one staffing in labour between 90-95% at the William Harvey Site. This meant that the trust was failing to ensure one to one care was provided to all mothers in line with best practice. However, the trust had recruited 5 staff who were due to commence work just after the inspection which brought the ratio back to an acceptable level to provide appropriate individualised care to patients in labour.
  • We were concerned about the security of the entry system to Folkestone ward. There was a risk of tailgating and the distance and visibility of the entry point from the main desk area did not support staff to be vigilant.
  • During the inspection we identified a high caesarean section and third degree tear rates which was rate worse than the England average.
  • The maternity unit environment was generally cramped, lacking suitable storage facilities and in need of modernisation. There was a general lack of responsiveness to staff when they raised concerns with the estate and facilities service. This meant when things fell into disrepair, they were not fixed in a timely way which affected patient satisfaction and frustrated staff.
  • Managers identified the need for further improvement to feedback from lower level incidents and cross-site learning and staff engagement as an area for continued improvement.
  • There was a lack of a mature and proactive audit and quality assurance systems to monitor quality outcomes, benchmark against national standards and drive service improvement. This meant the provider was missing an opportunity to regularly assess and monitor the service provided. However, we recognise that this concern had been identified by the senior leadership team and Maternity Faculty and this was being addressed.

However:

  • The feedback we received from many patients was consistently positive, very complimentary of the staff, and the service they received.
  • The service had sourced sponsorship from a baby wrap sling company who helpfully provided the unit with wraps for all mothers who undergo a caesarean section. Mothers wore the wrap to theatre and their baby was placed in the wrap immediately after birth. This meant that babies born were less likely to have a sudden drop in temperature and provided an immediate and invaluable skin to skin contact to aid bonding.
  • Staff felt recent changes had been very positive and had driven the major culture shift. Examples of the contributing factors included the new ‘hands on’ and ‘approachable’ senior leadership team, work undertaken by the Maternity Faculty which was providing a multidisciplinary, ‘no blame’ and candid approach to education which had a positive effect on the wider team dynamics.
  • The care provided reflected best practice and national guidelines, patients received care and treatment that was standardised and evidenced based.
  • Nursing and midwifery staff protected patients from the risk of inappropriate or unsafe care because there were systems to ensure that incidents were identified, reported, investigated and learned from to prevent recurrence.
  • Patients were protected from the risk of health acquired infections during their admission because staff followed national and best practice guidance.
  • The faculty of multi-professional learning in maternity provided training that exceeded that of other maternity units. The teaching programme was aligned to the service incident reporting tool, risk register and staff need. This unique approach to providing training meant that the unit was actively addressing clinical risk, preventing recurrence and ensuring all staff had the competency they needed to carry out their roles in line with national guidance and best practice guidelines.
  • There were systems and processes to ensure comments and complaints were responded to, learned from and used to improve the service.
  • There was a notable and positive shift in the culture of the department. For example, staff told us ‘it felt different’ and ‘things were getting better’.
  • The new leadership team was having a positive impact on the quality of leadership and support provided to staff. There was an air of optimism and excitement in the department, which appeared to be driven by happier staff, who felt involved, and were encouraged and supported to innovate and deliver a better service.

Maternity and gynaecology

Requires improvement

Updated 21 December 2016

We rated this service as requires improvement because:

  • Lack of staffing affected many areas of service planning and the care and treatment of women including; not meeting national safe staffing guidelines, therefore 1 in 5 women did not receive 1:1 care in labour; staff did not have the time to attend risk meetings or complete incident forms.
  • The physical environment was not conducive to the safe care and treatment of women. The bereavement suite on Folkestone ward did not meet department of health standards. Some areas of the department were intolerably hot, although there had been some improvements on the delivery suite since our last inspection.
  • Hospital management did not ensure robust governance, for example, hospital data of the number of surgical abortions was incorrect as figures included women who had miscarried and had a surgical evacuation.
  • On our previous inspection, we found there was an ingrained bullying culture within women’s services. This had since improved, however the culture of the service needed more input to support the improvement journey. For example, innovation hubs had increased in popularity, however there was still a lot of disengagement amongst staff and at the time of inspection there was no audit of the hubs to monitor benefits.

However;

  • Staff were supportive of one another and worked well as a multidisciplinary team. Staff provided a caring, empathetic environment for women during their pregnancy and labour.
  • Care and treatment was evidence based and patient outcomes were in line with other trusts in England.

On this inspection we have maintained a rating of requires improvement.

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2016

We found the medical services at the William Harvey Hospital required improvement because;

  • There were insufficient numbers of junior grade doctors and consultants across medical services at the William Harvey Hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service particularly out of hours and at night.

  • We found there were nursing shortages across the medical services. The situation had improved due to the use of agency and bank staff. Although the trust had recruited overseas nurses, there remained staffing shortages on the wards. The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day basis. This meant, even when there appeared to be sufficient numbers of staff on duty according the rota, the acuity and complexity of the patients meant that nursing staff were under pressure to deliver an acceptable level of care.

  • Staff did not always complete care records in accordance with best practice guidance from the Royal Colleges. We found gaps and omissions in the sample of records we reviewed. The trust did not have a robust system in place to audit, monitor and review care records to ensure they always gave a complete picture of the assessments and interventions undertaken.

  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.

  • We found the hospital was not yet offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.

  • The hospital had improved the number of bed moves patients had during their stay. However, a fifth of all medical patients moved wards more than once during their stay. This meant the hospital transferred some patients several times before they had a bed on the right ward, which put additional pressures on receiving wards.

However;

  • The trust had a robust system for managing untoward incidents. Staff were encouraged to report incidents and there were processes in place to investigate and learn from adverse events. The hospital measured and monitored incidents and avoidable patient harm and used the information to inform priorities and develop strategies for reducing harm.
  • The trust prioritised staff training, which meant staff had access to training in order to provide safe care and treatment for patients.
  • Medical care was evidence based and adhered to national and best practice guidance. Management routinely monitored that care was of good quality and adhered to national guidance to improve quality and patient outcomes.

  • Consultants led on patient care and there were arrangements for supporting the delivery of treatment and care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.
  • Staff treated patients with kindness and compassion.
  • The trusts average length of stay for both elective and non-elective stays were better than the England average for the majority of medical specialities.
  • There was good provision of care for those living with dementia and learning difficulties. There were support mechanisms and information available to take individual patients needs into account.
  • The trust had clear corporate vision and strategy. The trust reflected the opinions of clinicians, staff and stakeholders’ when developing the strategy for medical services. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.
  • The trust had clearly defined local and trust wide governance systems. There was well-established ward to board governance, with cross directorate working, developing standard practices and promoting effective leadership. The trust acknowledged they were on an improvement journey and involved all staff in moving the action plan forward.

At our last inspection, we rated the service as Requires improvement. On this inspection we have maintained a rating of requires improvement but have seen improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Urgent and emergency services (A&E)

Requires improvement

Updated 5 September 2018

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

  • The service did not ensure mandatory training in key skills was completed by all staff. Training compliance for medical staff was worse than the trust target of 85%, in all six training modules.

  • Staff did not always have up to date training on how to recognise and report abuse. William Harvey Hospital had not achieved target for staff compliance in safeguarding children level three and safeguarding adults level two.
  • The approach to assessing and managing the risks to children at night was focused on clinical risks but did not take a holistic view of children’s needs.
  • There was a risk that staff may not have recognised or responded appropriately to signs of deteriorating health or medical emergencies.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep children safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staffing levels in the paediatric emergency department at William Harvey Hospital were not sufficient to keep the paediatric department open 24 hours a day.
  • The service did not always store medicines well. During our inspection we saw several opportunities for unauthorised people to access a variety of medicines.

  • William Harvey Hospital did not meet the audit standards in five out of six of their most recent Royal College of Emergency Medicine audits.

  • The service monitored the effectiveness of care and treatment but did not always use the findings to improve them. Actions from audit results were often delayed and slow to complete.
  • The service did not always make sure staff were competent for their roles. Staff did not always receive timely and effective appraisals.
  • Staff did not always care for patients with compassion. People’s emotional, and social needs were not always reflected in their care, treatment and support.
  • Staff did not always understand the need to make sure that people’s privacy and dignity was maintained. While this may not have been intentional, it resulted in patients not feeling valued or respected.
  • Complaint themes and trends showed a quarter of complaints related to subjects that impacted care and compassion.
  • The most recent staff survey showed that most staff did not respond positively to ‘Care of patients/service users is organisation's top priority’ (53%) and ‘If friend/relative needed treatment would be happy with standard of care provided by organisation’ (59%), both were poor compared to the benchmark average.

  • The department remained under significant pressure to meet the needs of their patients. Flow through the emergency department was significantly held up due to low availability of beds in other departments. When patients were waiting for inpatient beds they were often waiting in the clinical decision unit or in the over flow corridor area. Although the department could discharge to ambulatory care, the unit was often too full to do so.
  • There was little evidence of the learning applied to practice within the service from complaints.
  • The service did not always take account of patients’ individual needs. Patients had little privacy when discussing their illnesses or injuries when talking with the meet and greet nurse. Although there was a private room on request, this was not routinely offered.
  • People could not always access the service when they needed it. Waiting times from treatment and arrangements to admit, treat and discharge patients were often slow and delayed.
  • Senior leaders were not visible and approachable at every level. Staff we spoke with did not consistently know who their leaders were or how to gain access to them.
  • Managers across the department did not always promote a positive culture that supported and valued staff. Staff satisfaction was poor. Staff we spoke with said they felt unsupported and undervalued by their immediate leaders and felt senior leaders did not understand the pressures they were facing.
  • The department did not used a systematic approach to continually improve the quality of its services. Clinical and internal audit processes were inconsistent in their implementation and impact. We were not assured that local audits were always taking place.
  • The trust did not have effective systems for identifying risks, planning to eliminate or reduce them. The organisation did not react sufficiently to risks identified through internal processes, but often relied on external parties to identify key risks before they started to be addressed.
  • The trust had not made sufficient improvement since the last inspection. The trust had failed to ensure national safeguarding training requirements were fulfilled.
  • Where changes were made, the impact on the quality and sustainability of care was not monitored.

However:

  • Staff understood how to protect patients from abuse. All staff we spoke with knew who the safeguarding lead was and understood their responsibilities to safeguarding both adults and children.
  • Since our last inspection a doctor had been allocated to the paediatric area and the department had a consultant with a sub specialty in children.
  • The trust responded immediately to CQC concerns about paediatric care in the department at night. They implemented a short term plan to address concerns raised and were due to implement a more permanent plan approximately six weeks after the inspection.
  • In the 2016/17 severe sepsis and septic shock audit, 92% of patients’ observations were taken on arrival, this was better than the UK average of 69%.
  • We saw pathways created to promote early treatment and improve patient outcomes in line with best practice guidance.
  • We saw health care assistants engaging with patients in a compassionate manner.
  • The outcome of complaints was explained appropriately to complainants. The responses addressed and answered all concerns raised by the complainants and offered a sincere apology.
  • Senior leadership teams understood what the challenges were and acted to address them.
  • Candour, openness, honesty, transparency and challenges to poor practice were the norm.
  • Mortality and morbidity meetings were held weekly. Staff presented a case and the team discussed and identified learning.
  • The department held weekly teaching sessions that all staff were welcome to attend.

Surgery

Good

Updated 5 September 2018

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

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. There was an open and transparent culture of incident reporting and investigation. Incidents were recorded on electronic systems that incorporated fail-safes about aspects such as duty of candour. Managers investigated incidents and shared lessons learned with staff to continuously improve patient safety.
  • All the areas we inspected were visibly clean and tidy. The service controlled infection risks very well. Staff kept themselves, equipment and the premises clean and used effective control measures to prevent the spread of infection.
  • The service maintained suitable premises and sufficient equipment to support safe care and treatment.
  • 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. Nursing staff turnover and vacancy rates were close to trust averages and where bank or agency staff were used, the trust had sufficient controls in pace to manage risk. Medical staff turnover and vacancy rates were below trust averages.
  • Records were clear, up-to-date and available to all staff providing care. The service used safety monitoring results well. Staff collected safety thermometer information, such as rates of falls, pressure ulcers and catheter-acquired urinary tract infections and shared it with staff, patients and visitors.
  • The service provided care and treatment based on national guidance and best practice. The service carried out audits to check staff followed internal policies and guidance.
  • Patients had good outcomes following surgery. Results from national audits showed the service performed well, with patient outcomes close to the same as other NHS acute hospitals nationally.
  • The service made sure staff were competent for their roles. Managers appraised staff performance, and we saw evidence of meaningful appraisals. Competency records we reviewed provided assurances staff had the skills they needed to do their jobs.
  • Staff of different kinds worked very well together as a team to benefit patients. We saw positive examples of multidisciplinary working between different staff groups.
  • Staff obtained patient consent and understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion, kindness and respect. Feedback from patients confirmed that staff treated them well and were involved with their families in decisions about their care and treatment.
  • Managers promoted a positive culture that supported and valued staff. Staff spoke positively about the culture and described good working relationships with colleagues and managers.
  • The service acted to actively engage with staff and seek their views through focus groups and other forums.

However:

  • Referral to treatment times (RTT) for admitted pathways for surgery were worse than the England average. In December 2017, 57% of patients were treated within 18 weeks, which was worse than the England average of 72%.
  • While we saw improvement in mandatory training rates in nursing and other staff groups, compliance rates for medical staff was 67% on average and medical staff did not meet the trust target of 85% of training for any mandatory training course. This meant that medical staff might not have the most up to date information about these critical areas.
  • We saw a similar trend in safeguarding training. Nursing staff compliance rates exceeded the trust target while medical staff training rates were 28%, appreciably below the 85% trust training target.

Intensive/critical care

Good

Updated 18 November 2015

We found the service delivered at the William Harvey Critical Care unit (CCU) to be safe, effective, caring, responsive and well led.

However, we continue to recognise a concern with delayed discharges from the unit which may suggest problems with patient flow elsewhere in the hospital. Capacity in the unit was also a concern, given the 100% occupancy rates despite the additional two unfunded beds in operation. The location of these beds was not desirable but staff had taken reasonable steps to minimise the risk to patients and staff. We also noted a robust strategy and vision in the unit, but were uncertain about whether it reflected the trust vision. We acknowledge a recent change to the trust leadership, and the on-going financial challenges, which presented an obstacle to achieving the plan. We recognised the frustrations of staff in terms of the stagnant situation in which they find themselves due to the environmental and financial restraints. The CCU did not always manage to achieve the national recommendation of ensuring a supernumerary shift leader for all shifts. However, we acknowledge that there has been a significant improvement in supernumerary management cover since our last inspection. A standardised approach to inotropic infusion concentrations (modifies the force of muscle contractions) and meeting national guidance for the x-ray checking of Nasogastric (NG) tubes had been implemented across all three sites.

We found effective systems in place to ensure safe care. The care delivery was continuously monitored and assessed to ensure a high quality care for the patients using the service. There was a positive culture towards reporting and learning from adverse events, and a refreshingly positive emphasis put on avoiding recurrence.

The care delivered reflected best practice and national guidance. Needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. There were appropriate measures in place to ensure that patients were protected from the risk of acquiring hospital acquired infections, and staff were observed to follow trust infection control guidance.

Patients and their loved ones had their dignity and human rights respected and protected. The unit provided an ample and varied supply of information for relatives, and actively encouraged their feedback and comments. If a complaint was raised the service learned from the feedback given, and ensured that people felt listened to.

The relatives we talked with during the inspection were very complimentary about the service their loved ones had received, and the caring and approachable attitude of the staff. Relatives were also involved in the planning of care and told us that they had access to sufficient information about their loved ones’ condition. Patients had their right to consent to care respected and, where possible, formal consent was obtained. Staff were found to make reasonable adjustments to reflect the needs of their patients. The service provided a person centred bereavement service for families.

There were suitable arrangements in place for dealing with foreseeable emergencies. Patients had their health needs risk assessed and balanced with safety, and had their rights and preferences taken into consideration. We noted effective systems to ensure patients’ nutritional and pain needs were addressed and managed. Medication management reflected national and trust guidance.

The CCU had appropriate numbers of staff with the required skills to meet people's individual care needs. Staff were subject to competency-based learning and assessments, and were provided with support to learn, develop and progress professionally.

A multidisciplinary approach to care was noted, as was the provision of a seven day service. There was a consultant-led ward round twice daily which meant that patients conditions and progress were continuously monitored. There were effective systems in place to ensure that deteriorating patients had their care needs reviewed in a timely manner. This was also true of patients who were in ward areas as they had their conditions reviewed by the outreach team using an electronic monitoring system.

There was strong leadership in the CCU and staff expressed feeling valued and listened to. They voiced satisfaction with the local unit management and the support provided to them. Numerous steps had been put in place to address the culture concerns raised in the last inspection. Staff told us these measures had a positive impact on morale and on their working environment.

Services for children & young people

Requires improvement

Updated 18 November 2015

Performance showed a track record and steady improvements in safety. However, information about safety was not always comprehensive. The trust was using the Kent safeguarding children’s board (KSCB) safeguarding procedures. These were not trust specific. The trust had not produced an East Kent University NHS Foundation Trust (EKUNFT) children and young people’s safeguarding policy.

Padua ward, NICU and SCBU provided safe and comfortable environments for children. However, the waiting area in the WHH fracture clinic was not child friendly. The fracture clinic had a children’s bay in the clinic which staff had decorated in child friendly décor. However, there was no designated waiting area for children and their families; waiting room conditions were cramped and overcrowded.

Gap analysis had been conducted to identify staff that needed up-to-date training in children and young people’s safeguarding to an appropriate level. The training was being rolled out across the trust.

There was an increased risk that people could be harmed, due to medicines not being secure in children’s ward areas and adult medicines being placed on top of a children’s resuscitation trolley in the outpatients department. On Padua ward medicines fridge temperature had a number of omissions. A number of patient group directions (PGD’s) were out of date.

Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately. There were effective handovers and shift changes, to ensure staff could manage risks to people who use services.

Risks to people who use services were assessed, monitored and managed on a day-to-day basis. These include signs of deteriorating health, medical emergencies or behaviour that challenges. People were involved in managing risks and risk assessments were person-centred, proportionate and reviewed regularly.

Staff recognised and responded appropriately to changes in risks to people who use services.

Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Children and young people had good outcomes because they received effective care and treatment that met their needs. People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Padua ward had a practice development nurse who monitored staff practice to ensure consistency.

Children and young people had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. The expected outcomes were identified and care and treatment was regularly reviewed and updated.

There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services and service accreditation. The trust had achieved level 1 UNICEF Baby Friendly accreditation for supporting breastfeeding and parent infant relationships by working with public services to improve standards of care.

Staff were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. Staff were supported to deliver effective care and treatment through supervision and appraisal processes.

When people received care from a range of different staff, teams or services, this was coordinated. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of children and young people’s needs.

When children and young people were due to move between services their needs were assessed early, with the involvement of all necessary staff, teams and services; discharge and transition plans took account of patients individual needs, circumstances, on-going care arrangements and expected outcomes. Children and young people were discharged at an appropriate time and when all necessary care arrangements were in place.

Staff could generally access the information they needed to assess, plan and deliver care to people in a timely way.

Consent to care and treatment was obtained in line with legislation and guidance. Children and young people were supported to make decisions. Processes for seeking consent were appropriate.

Feedback from children, young people and families who used the service was mostly positive about the way staff treated people. Children and young people were treated with dignity, respect and kindness during interactions with staff and relationships with staff were positive.

Children, young people and their families were involved and encouraged to be partners in their care and in making decisions, with any support they needed. Staff spent time talking to children, young people and their parents. Children and young people were communicated with in a way they could understand. Children, young people and their families understood their care, treatment and condition. Parents told us staff worked with them to plan care and share decision-making about care and treatment.

Staff responded compassionately when patient’s needed help. Staff took appropriate steps on the ward to ensure patient’s privacy and confidentiality was respected.

Staff helped children, young people and their families to cope emotionally with their care and treatment. Patient’s social needs were understood. Children and young people were supported to maintain and develop their relationships with those close to them, their social networks and community. Parents were facilitated to stay on the ward over night or in accommodation specifically provided for parents.

Children and young people’s needs were met through the way services were organised and delivered. The importance of flexibility, choice and continuity of care was reflected in service provision. The needs of different patients were taken into account when planning and delivering care and treatment. Care and treatment was coordinated with other services and other providers.

Children and young people could access the right care at the right time. Access to care was managed to take account of patients’ needs, including those with urgent needs.

The appointments system was easy to use and supported people to make appointments.

Waiting times, delays and cancellations were minimal and managed appropriately. Services ran on time. Patients were kept informed of any disruption to their care or treatment.

It was easy for people to complain or raise concerns and they were treated compassionately when they did so. Complaints and concerns were always taken seriously, responded to in a timely way and listened to. Improvements were made to the quality of care as a result of complaints and concerns.

The values for children and young people’s services had been developed with elements such as compassion, dignity and equality. However, there was no long-term vision or strategy in place for children and young people’s services. The trust had conducted a recent strategic review of children and young people’s services, and concluded that the proposed strategy of children and young people’s services operating from one site was not viable. At the time of our inspection there was no decision pending on what the vision or strategy would be for children and young people’s services.

Children and young people’s staff were unaware of the trust’s strategic goals as the trust had not made a final decision about the future strategy for children and young people’s services.

The board and other levels of governance within the organization had undergone changes in the past 12 months. The chief nurse and director of quality had been instated as the children and young people’s services lead. The service’s structures, processes and systems of accountability were set out and understood by staff.

There was an effective process in place to identify, understand, monitor and address current and future risks. Performance issues were escalated to the relevant committees and the board through clear structures and processes. Clinical and internal audit processes were in place.

The leadership was knowledgeable about quality issues and understood what the challenges to children and young people’s services were, and took action to address them. However, monitoring at WHH was a challenge due to the matron being based in Maidstone.

Leaders at every level prioritised safe, high quality, compassionate care and promoted equality and diversity. The culture change programme encouraged cooperative, supportive relationships among staff so that they felt respected, valued and supported. However, staff reported that ward managers for children and young people’s services had been overlooked for administrative support.

There was evidence that the leadership had introduced processes that would actively shape the culture through effective engagement with staff, people who use services and their representatives and stakeholders. Senior leaders encouraged a culture of collective responsibility between teams and services. But, these processes were not embedded.

The children’s and young people’s service was proactively engaging with and involving all staff to ensure that the voices of staff were heard and acted on. The leadership actively promoted staff empowerment to drive improvement and a culture where the benefit of raising concerns was valued.

Senior leaders focus was on continuous learning and improvement at all levels of the organisation. Safe innovation was being supported and staff had objectives focused on improvements.

End of life care

Requires improvement

Updated 5 September 2018

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

  • Information was not always available for staff to deliver safe care and treatment to patients at the end of life. Care records for patients on the ‘care of the dying patient and their family plan’ were seen to be inconsistently completed or not used appropriately for patients at the end of life.
  • Anticipatory prescribing for medicines ‘just in case’ patients at the end of life experienced common symptoms was not always in line with trust guidance.
  • Lessons were not always learned and improvements made when things went wrong. There were no examples of reported or recorded incidents relating to the care of patients at the end of life, however there was evidence of incidents relating to the mortuary and anticipatory prescribing.
  • Records of mental capacity assessments relating to decisions regarding ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) were not maintained.
  • Staff did not always have the skills, knowledge and experience to deliver effective care, support and treatment. A range of end of life care training was available but not all link nurses on the wards had completed the mandatory training for the role.
  • The palliative care service was not available face to face seven days a week.
  • Patients were not always identified who were in need of extra support. For example, there was no framework in place for identifying patients in the last year of life or those with an uncertain recovery who were at risk of dying. There was no framework for advance care planning.
  • Capacity issues within the mortuary led to processes for storing the deceased that did not ensure that people’s dignity was respected during care after death. We were told that the practice of storing two bodies in the space meant for one had occurred during busy periods, particularly during the winter months.
  • The trust did not record the percentage of patients who were discharged to their preferred place of care at the end of life. Discussions about preferred place of care were not consistently held in advance of the last days of life.
  • There was no organisation specific end of life care strategy or aligned action plans.
  • Processes for managing risks, issues and performance were not always effective. Risks were not always identified and recorded on the risk register or adequately mitigated.
  • Governance structures were in place; however their effectiveness was impacted by a lack of structured action planning and prioritising.
  • There were quality assurance processes evident, for example, in relation to audit and surveys. However, improvement plans were not detailed, structured or timely.

However:

  • Syringe drivers were accessible and the administration of medicines via the pump was appropriately monitored.
  • Anticipatory medicines ‘just in case’ patients at the end of life experienced symptoms were available.
  • People’s needs were assessed and care and treatment delivered in line with evidence based guidance to achieve effective outcomes.
  • People’s nutrition and hydration and pain management needs were identified and met in relation to national guidance for caring for people in the last days and hours of life.
  • People’s care and treatment outcomes were monitored through trust participation in the national end of life care audit there was evidence of improvement over time and trust participation in relevant quality improvement initiatives.
  • The learning needs of staff had been identified and there was a range of training initiatives aimed at engaging generalist staff in improving patient care for those at the end of life.
  • The service ensured that people are treated with kindness, respect, and compassion, and that they are given emotional support when needed. Staff were committed to ensuring the patient experience at the end of life was as positive as possible.
  • People could access care in a timely way. Ninety eight percent of patients were seen within 72 hours of referral.
  • Spiritual support services were available to patients of different religions and beliefs, including for those patients with no particular faith.
  • Leaders were visible and approachable. The end of life care board was made up of a range of senior staff including executive directors, matrons, consultants, hospice staff and members of the specialist palliative care team.
  • An end of life care working group had been established at William Harvey Hospital to improve end of life care, although comprehensive action plans were not in place.
  • There were governance structures and culture to support end of life care, with clear leadership at executive and senior staffing levels and an end of life care board responsible for decision making.
  • People’s views were gathered through a bereavement survey across the trust. This provided feedback to staff on the experience of relatives.
  • There was some evidence of innovation, in particular with the development of a nationally recognised compassion symbol in collaboration with the local hospice.