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William Harvey Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 July 2020

William Harvey Hospital is operated by East Kent Hospitals University NHS Foundation Trust. The trust became an NHS foundation trust in 2009. It has five hospitals serving the local population of around 695,000 people across Dover, Canterbury, Thanet, Shepway and Ashford.

The trust has 1,111 inpatient beds across 54 wards. This includes 31 critical care beds, 48 children's beds and 49 day-case beds. Each year the trust receives over 200,000 emergency attendances, 158,000 inpatient spells and one million outpatient attendances. Both William Harvey Hospital in Ashford and Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate provide all core services while Kent and Canterbury Hospital in Canterbury does not have maternity beds and has a minor injuries unit with an emergency care centre rather than a full emergency department.

NHS Improvement (NHSI) put the trust in financial special measures in March 2017 because it was forecast to be in significant financial deficit and was not meeting its control total (the trust’s year-end target against its budget). The trust was still in financial special measures at the time of the inspection.

We inspected urgent and emergency care services at William Harvey Hospital using our focused inspection methodology. However, we inspected all areas that we would inspect on a comprehensive inspection. We carried out an announced inspection on 3 and 4 March 2020.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

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

  • The service did not always have enough staff to care for patients and keep them safe. Staff did not always manage safety well. The service did not always control infection risk well. Staff did not always assess risks to patients, act on them, or keep good care records. They did not always manage medicines well. The service did not always manage safety incidents well or learn lessons from them.

  • Staff did not always follow department policy. The service did not always provide patients with pain relief when they needed it. Managers did not always monitor the effectiveness of the service.

  • The service did not always plan care to meet the needs of local people or take account of patients’ individual needs. They did not always make it easy for people to give feedback. People could not always access the service when they needed it and did sometimes have to wait too long for treatment.

  • Staff did not understand the service’s vision. Some staff were not clear about their role or accountabilities. Some staff were committed to continual improvement of services.

    However:

  • The service had made improvement to the paediatric emergency department services since our last inspection.

  • Most staff had the training in key skills. Staff understood how to protect patients from abuse.

  • Most staff provided evidenced based care and treatment and gave patients enough to eat and drink. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. The service engaged well with patients and the community to plan and manage services.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should take action either because it was not doing something required by a regulation, but it would be disproportionate to find a breach of the regulation overall, to help the service improve. We also issued the provider with two requirement notices that affected urgent and emergency services. These requirement notices tell the trust to produce a plan, within 28 days, for how it will comply with regulation 12 (safe care and treatment) and regulation 17 (good governance). Details are at the end of the report.

Inspection areas

Safe

Inadequate

Updated 7 October 2020

Effective

Requires improvement

Updated 7 October 2020

Caring

Good

Updated 7 October 2020

Responsive

Requires improvement

Updated 7 October 2020

Well-led

Requires improvement

Updated 7 October 2020

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 7 October 2020

We did not change the overall rating for medical care at this inspection. We did a focused inspection on infection prevention and control within safe. However, we took enforcement as result of our concerns at the trust, so this limits the rating of safe to inadequate, so this key question has been rerated. 

We undertook an announced focused inspection of medical care on 11 August 2020. We spoke with 23 members of staff on site including domestic staff, physiotherapist, administrative staff, nurses, doctors and ward managers. We also invited trust staff to call our National Customer Service Centre to provide feedback about their experiences during the pandemic. We observed infection prevention and control practices and reviewed three sets of patient records.

The trust had identified two streams for patients during the pandemic to minimise the risk of spreading the infection. The blue stream was for patients with confirmed or suspected Covid-19. The red stream was for patients who had tested negative for Covid-19 and had no symptoms. At William Harvey hospital, there were three designated medical wards in the blue stream and one outbreak ward at the time of our inspection. We visited the following wards:

  • Suspected ward where patients had Covid-19 symptoms and were awaiting their test results
  • Covid-19 ward where patients have tested positive for Covid-19
  • Non Covid-19 ward where patients do not have Covid-19 and do not have any symptoms of Covid-19
  • Outbreak ward where there was an outbreak of Covid-19 and subsequently the ward was closed to new admissions

At the time of our inspection, the national guidance which was in place was Public Health England’s ‘Covid-19 infection prevention and control’ dated 18 June 2020. We are aware there have been updates to this guidance, however these updates have not been considered in this report as they were not in place at the time of this inspection.

 

Services for children & young people

Inadequate

Updated 28 February 2019

Staff did not always report incidents and when they did the investigation was insufficient. There were frequent staff shortages which increased the risk of harm to children. There was poor oversight of medicines management and infection control. Staff missed opportunities to identify deteriorating patients.

There were minimal performance indicators for the trust to demonstrate their performance against national standards. Staff did not have sufficient training to enable them to provide safe care for children with mental health conditions or learning disabilities. The service did not always provide evidence based care. The dignity and privacy of children was not always prioritised. The

services were planned and delivered without consideration of people’s needs.

Governance and risk management processes were ineffective and where risks were identified, inadequate action was taken.

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.

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.

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.

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.

Urgent and emergency services

Inadequate

Updated 7 October 2020

We did not change the overall rating for urgent and emergency services at this inspection. We did a focused inspection on infection prevention and control within safe. However, we took enforcement action as result of our concerns at the trust, so this limits the rating of safe to inadequate, so this key question has been rerated.

We carried out an announced focused inspection of urgent and emergency services on 11 August 2020. We spoke with 19 members of staff on site including domestic staff, administrative staff, nurses, doctors and managers. We also invited trust staff to call our National Customer Service Centre to provide feedback about their experiences during the pandemic. We observed infection prevention and control practices and reviewed four sets of patient records.

The trust identified two streams for patients during the pandemic to minimise the risk of spreading the infection. The blue stream was for patients with confirmed or suspected Covid-19. The red stream was for patients who tested negative for Covid-19 and had no symptoms. At William Harvey hospital, there was a designated respiratory area which formed the blue stream in the emergency department. We visited the designated ‘blue’ and ‘red’ areas within the emergency department during this inspection.

At the time of our inspection, the national guidance which was in place was Public Health England’s ‘Covid-19 infection prevention and control’ dated 18 June 2020. We are aware there have been updates to this guidance, however these updates have not been considered in this report as they were not in place at the time of this inspection.

Maternity

Requires improvement

Updated 28 May 2020