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William Harvey Hospital Requires improvement

Reports


Inspection carried out on 24 October to 25 October 2018

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

We inspected services for children and young people at the William Harvey Hospital on 24 and 25 October 2018. The inspection visit on 24 October was unannounced and began at approximately 8.30pm.

This responsive inspection was undertaken because we had received concerning information from members of the public and staff about the Emergency department and children’s inpatient wards. We had also identified concerns about the care of children during our May 2018 inspection when we inspected the emergency department and operating theatres but did not review services for children and young people as a separate core service.

As part of this inspection, we reviewed the care and treatment of children and young people from birth to 18 years in the two acute hospital sites with children’s inpatient units. Some outpatient services for children are provided at the Kent and Canterbury Hospital site and from Buckland Hospital in Dover, but there are no inpatient services there. We did not inspect clinics or community services as the inspection was focused on the areas of concern.

We rated the children and young people’s services at William Harvey Hospital as Inadequate overall. We fed back our immediate concerns to the chief executive officer, the director of nursing and quality, the medical director and the quality improvement programme lead.

The services for children and young people were not safe.

  • Staff do not recognise concerns, incidents or near misses. When concerns were raised or things went wrong, the approach to reviewing and investigating causes was insufficient or too slow. There was little evidence of learning from events or action taken to improve safety.
  • Frequent staff shortages increased risks to children and young people who used the services.
  • There were inconsistent infection, prevention and control practice.
  • Medical records were not stored securely.
  • There was poor oversight of medicines management.
  • Staff did not have assurance all equipment was clean, fit for purpose and ready for patient use.
  • Staff did not assess, monitor or manage risks to people who use the services. Opportunities to prevent or minimise harm were missed.

The services for children and young people were not effective.

  • Clinical audits were not being completed within the scheduled timeframes which meant there were no current performance indicators for the trust against national standards.
  • There was confusion amongst staff on how to access policies and guidelines.
  • There were gaps in the seven-day service provision that meant children had to be treated in adult environments by adult staff.
  • The compliance rates for appraisals were worse than the trust target.
  • Staff had limited training in the management of children with mental health needs.
  • Ward rounds were not multidisciplinary which was a missed opportunity to plan and co-ordinate patient care and treatment.
  • Fasting times before surgery did not follow current best practice and put the needs of the service before the needs of the children.
  • There was no recognition of the psychological needs of children and young people in the operating theatre environment.
  • Pain thresholds were not assessed in a timely manner.

Improvements were needed in the care and compassion shown to children and families.

  • People were not always treated with kindness or respect.
  • Staff did not see people’s privacy and dignity as a priority.
  • There was an inadequate psychology service for children with diabetes.
  • There was poor provision of paediatric mental health advice and assessment.

The services for children and young people were not responsive.

  • Minimal effort was made to understand the needs of the local population. The services were planned and delivered without consideration of people’s needs.
  • The provision of service to meet the needs of children with mental health or learning disabilities was insufficient.
  • The facilities and premises used do not meet people’s needs.
  • Children and their families were frequently and consistently unable to access services in a timely way for an initial assessment, diagnosis or treatment. They experienced unacceptable waits for some services.
  • Staff did not understand the pathway for children within the emergency department.
  • There was little evidence to show concerns and complaints led to improvements in the quality of care.
  • Lack of children services 24 hours a day led to children being cared for in adult designated areas within the emergency department.

The services for children and young people were not well led.

  • The services did not have a clear vision or strategy.
  • Continuous improvement, and learning from when things go wrong was not evident across all areas.
  • Governance and risk management processes were ineffective and provided false assurance to the board.
  • Significant issues that threaten the delivery of safe and effective care were not identified or adequate action to manage them was not always taken.
  • There was little evidence of innovation or service development. There was minimal evidence of learning and reflective practice and the impact of service changes on the quality of care is not understood.
  • The NHS Staff Survey results for 2017 showed that overall the trust was in the worst 20% of trusts nationally for staff engagement. The results had worsened for many key findings since 2016.

We saw several areas of good practice including:

  • Staff interacted well with babies and used different methods of distraction to keep them calm.
  • Children and young people services did consistently well in the friends and family test.
  • Staff had a clear understanding of their safeguarding role and responsibilities and there was an effective system to provide prompt child protection medicals when needed.
  • The trust had a flagging system for children with learning disabilities so patients arriving in accident and emergency departments would be identifiable.
  • Staff had a sound understanding of the need for informed consent to be obtained before providing care or treatment.
  • There was good teamwork amongst staff and staff strived to support their peers.

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

Importantly, the trust must:

  • Provide suitable accommodation for children and young people with mental health problems.
  • Review their booking and triage processes to ensure all staff are clear about the pathway children take through the emergency department and to minimise the time before they are assessed by a qualified children’s nurse.
  • Ensure that equipment checks required by trust policies are carried-out.
  • Ensure the safe management of medicines.
  • Ensure that clinicians are aware and follow trust policy and national guidance on the safe management of deteriorating children, sepsis identification and management.
  • Ensure that children wait in the children’s waiting area at all times. They must not be exposed to volatile behaviour, inappropriate television programmes and unpleasant sights and sounds in the adult waiting area.
  • Review the care of children aged 16 years to 19 years and ensure that their needs are fully considered.
  • Ensure submission of data to national audit programmes to allow benchmarking against other children’s services and to drive improvements.
  • Ensure that they adhere to a local audit plan and use the results to drive service improvements.
  • Carry out a learning needs analysis for nursing staff working with children and young people to assist in identifying what training is necessary and where there are gaps in staff skills and knowledge.
  • Ensure that staff are provided with the necessary training and support to ensure they can carry out their work competently.
  • Ensure compliance with the Health and Social Care Act 2008: code of practice on the prevention and control of infections. To include ensuring there are appropriate isolation facilities in the children’s emergency department for children with communicable diseases.
  • Review their policy and usual practice on pre-operative fasting for children to ensure it is aligned to national guidance.
  • Ensure that up to date policies and protocols are available to staff.
  • Ensure that the needs of children and young people presenting in mental health crisis are considered and met.
  • Ensure the views of children and young people are taken into consideration to aid service provision and make sure the care and treatment meets their needs and reflects their preferences.
  • Ensure that there are no breaches of the four-hour admission to treatment target for children attending the emergency department.
  • Develop a clear vision for children’s services that is recognised and shared by all staff caring for children and young people.
  • Ensure that data and information provided to the board is an accurate reflection of the services being provided to avoid the risk of false assurance.
  • Undertake an assurance review of their children’s service to identify gaps in their assurance and governance processes.
  • Ensure that there is clear, accountable leadership of services for all children from birth to 18 years (and beyond 18 years for looked after children and children in need).

In addition, the trust should:

  • Provide staff with training in the care of children and young people with autism and learning disabilities.
  • Ensure that the pathway for providing care when a child dies is known and understood by all staff likely to be affected.
  • Provide all staff including senior leaders with training in equality and diversity.
  • Consider providing customer service training for reception staff in the emergency department.

Professor Edward Baker

Inspector of Hospitals

Inspection carried out on 16 - 17 May 2018

During a routine inspection

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 carried out on 5th,6th 7th September 2016

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

The William Harvey Hospital (WHH) in Ashford, Kent is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT).

The William Harvey Hospital (WHH) is an acute 476 bedded hospital providing a range of emergency and elective services and comprehensive trauma, orthopaedic, obstetrics, general surgery and paediatric and neonatal intensive care services. The hospital has a specialist cardiology unit undertaking angiography, angioplasty, an analytical robotics laboratory that reports all East Kent’s General Practitioner (GP) activity and a robotic pharmacy facility. A single Head and Neck Unit for East Kent has recently been established and includes centralised maxillofacial services with all specialist head and neck cancer surgery co-located on the site.

Following our last inspection of the Trust in August 2015, we carried out an announced inspection between 5th and 7th September 2016, and an unannounced insection on 21st September 2016.

This is the third inspection of this hospital. This inspection was specifically designed to test the

requirement for the continued application of special measures to the trust. Prior to inspection we risk

assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection.

Overall we rated the William Harvey Hospital as Requires improvement

Safe

We rated The William Harvey Hospital as Requiring improvement for safe because:

  • Whilst 86% of patients were triaged within 15 minutes, only 34% had a clinician first assessment within one hour and only 17% a decision to admit within two hours. Attendance by a specialist within 30 minutes following referral was only achieved 35% of the time.

  • Ambulance handover figures for WHH showed an average of 168 occasions per month (July – October 2016) when vehicles were delayed beyond 60 minutes. This represented 7.8% of the total number of patient handovers and was worse than the regional average of 3%. During this period, WHH was consistently in the bottom four of 17 hospitals in the region.
  • There was a shortage of junior grade doctors and consultants across the medical services at the 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.
  • On medical wards staffing numbers have been increased and the trust monitors safe staffing levels. However, there was a lack clarity amongst staff about the acuity based tool ( to assess appropriate staffing for the complexity of patients cared for ) and leaves staff convinced that there is still insufficient staff on duty for many shifts.

  • In Maternity, a lack of staffing affected many areas of service planning and the care and treatment of women. This included not meeting national safe staffing guidelines, meaning 1 in 5 women did not receive 1:1 care in labour.

  • We found poor records management in some areas. Staff did not always complete care records according to the best practice guidance.

  • 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 did not have adequate maintenance arrangements in place for the 483 medical devices used in maternity and gynaecology.

However

  • We saw robust systems in place for reporting and learning from incidents both locally and trust-wide.

  • Ward and departmental staff wore clean uniforms and observed the trust’s ‘bare below the elbows’ policy. Personal protective equipment (PPE) was available for use by staff in all clinical areas.

  • The hospital was clean and met infection control standards.

Effective

We rated The William Harvey Hospital as requiring improvement for effective because:

  • Some documents and records supporting the learning needs of staff were not always completed and there were gaps in the records of training achieved.

  • Staff annual appraisals rates were worse than last year.

  • 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 diabetes services.

  • There was poor compliance in the use of the end of life documentation across the wards we visited which was reflected in the May 2016 documentation audit undertaken by the SPC team.

However

  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • We saw good examples of multidisciplinary working between all staff grades and specialities.

Caring

We rated The William Harvey Hospital as Good for care because:

  • Staff treated patients with kindness and compassion.

  • Staff responded compassionately when women in Maternity and Gynaecology needed help and supported them to meet their basic personal needs as and when required. Privacy and confidentiality was respected at all times.
  • Patients and relatives we spoke with were complimentary about the nursing and medical staff.
  • Patients were given appropriate information and support regarding their care or treatment and understood the choices available to them.
  • Responsive

We rated The William Harvey Hospital as requires improvement for responsive because:

  • Performance indicators such as patients being seen within four hours in A&E remained below trust target and national averages.

  • Delayed discharges remained a concern.

  • The hospital was not 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.
  • Maternity staff had diverted women to another hospital on 28 times between January 2015 and June 2016 due capacity issues.

However

  • The trust employed specialist nurses to support the ward staff. This included dementia nurses and learning difficulty link nurses who provided support, training and had developed resource files for staff to reference. Wards also had ‘champions’ who acted as additional resources to promote best practice.

Well Led

We rated The William Harvey Hospital as requires improvement for responsive because:

  • No separate risk register was available for palliative /end of life care. A separate risk register would allow the risks to this patient group be discussed regularly at the end of life board, and allow plans to be made to alleviate any identified risks.

  • Changes in leadership in end of life care and maternity services had only recently been realised and as a result had yet to fully address the issues relating to these services.

  • In some areas risk management and quality measurement were not always dealt with appropriately or in a timely way. Risks and issues described by staff did not correspond to those
  • Where changes were made, appropriate processes were not always followed and the impact was not fully monitored in maternity and gynaecology services

However

  • Overall, the leadership, governance and culture within the ED was good and we saw examples of good practice regarding visibility of supervisors, comfort rounds and communication. Staff were supported by their managers and were actively encouraged to contribute to the development of the services.

We saw several areas of outstanding practice including:

  • Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.

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

Action the hospital MUST take to improve

  • Ensure the number of staff appraisals increase to meet the trust target. So that the hospital can assure itself that staff performance and development is being monitored and managed.
  • Ensure that all staff have attended mandatory training and address gaps in training records that make it difficult to determine if training meets hospital policy requirements.
  • Ensure that the trust audit programme is completed and that following audits action plans are submitted in a timely manner and these are fully implemented. To have assurance that best practice is being followed.
  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.
  • Ensure there are adequate maintenance arrangements in place for all of the medical devices in clinical use in accordance with MHRA (Medicines & Healthcare products Regulatory Agency) guidance.
  • Ensure maternity data is correctly collated and monitored to ensure that the department’s governance is robust.
  • Ensure that mental capacity assessments are in place for vulnerable adults who lacked capacity.
  • Ensure generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

Action the hospital SHOULD take to improve.

  • Ensure there are sufficient numbers of junior grade doctors and consultants across medical services to deliver a safe and effective service particularly out of hours and at night.

  • Reduce the number of bed moves for medical patients.
  • Ensure the bereavement suite on Folkestone ward meets the Department of Health Standards.
  • Review the physical environment within maternity services to ensure it meets the needs of the patients. Specifically temperature control
  • Ensure that the fast track discharge process is fully implemented for end of life patients to be discharged to their preferred place of care within a short time frame.

There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13th - 17th July 2015

During a routine inspection

The William Harvey Hospital (WHH) in Ashford, Kent is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT).

The William Harvey Hospital (WHH) is an acute 476 bedded hospital providing a range of emergency and elective services and comprehensive trauma, orthopaedic, obstetrics, general surgery and paediatric and neonatal Intensive care services. The hospital has a specialist cardiology unit undertaking angiography, angioplasty, an analytical robotics laboratory that reports all East Kent’s General Practitioner (GP) activity and a robotic pharmacy facility. A single Head and Neck Unit for East Kent has recently been established and includes centralised maxillofacial services with all specialist head and neck cancer surgery co-located on the site.  

Following our last inspection of the Trust in March 2014 when we found many of the services the Trust provided to be inadequate, EKUHFT was placed into special measures by the Foundation Trust regulator Monitor. This announced inspection was undertaken to assess what progress the Trust had made in addressing our concerns.

We carried out an announced inspection of EKUHFT between 13- 17 July 2015. We also undertook unannounced visits the following week on 29 July 2015.

At this inspection although we found the hospital overall to require improvement we noted there had been improvements made in the majority of services we inspected, particularly in the emergency department, surgical services, children’s services and outpatients.

Our key findings were as follows:

Safe

  • At the last inspection we told the Trust they must ensure there were sufficient numbers of suitably qualified, skilled, and experienced staff available to deliver safe patient care in a timely manner. At this inspection we found that although staffing overall had improved through a sustained recruitment initiative and the use of agency and bank staff, recruitment continued to be a problem for the hospital. The numbers, skills and qualifications of staff did not always reflect the needs of patients.
  • We continued to have concerns that the environment and facilities in which patients were cared for were not always safe, well maintained, fit for purpose or met with current best practice standards. For example there was only one obstetric theatre, the temperature on the labour ward was excessively high causing mothers and staff to feel ill, in the fracture clinic there was no designated waiting area for children and their families, the waiting room conditions were cramped and overcrowded; there were carpets in clinical areas and we found taps that did not work.
  • Access to and availability of equipment had improved since our last inspection through the implementation of an equipment library. However there areas in the hospital where appropriate equipment was not readily available. In the maternity department there was a shortage of basic medical equipment from medical devices such as resuscitation equipment, fetal monitoring equipment and cardiotocography (CTG) devices to broken printers, photocopiers, air-conditioning units and electric fans.
  • Although the Trust had revised the adverse incident and serious incident policy and had trained more staff in incident investigation and Root Cause Analysis, patients were not always protected from inappropriate or unsafe care because staff were not always reporting incidents. Where incidents were reported there was good evidence that learning was shared and actions taken to prevent reoccurrence.
  • There was evidence of poor record keeping. In the emergency department we saw records that were not held securely. Where daily audits of records were taking place, there had been no action taken to address the shortfalls.
  • The management of medicines did not always meet best practice guidance. We saw medicines not kept secure and fridge and room temperatures not always being recorded. We found a number of patient group directions (PGD’s) were out of date.
  • Staff were aware of the policies for infection prevention and control and adhered to them. The majority of clinical areas we visited were visibly clean and tidy.
  • We found that attendance at mandatory training had improved along with the system for recording and monitoring attendance although the mandatory training targets and agreed actions had not been achieved. Induction was given to all newly recruited nurses and medical staff, including agency nurses.
  • Junior doctors told us they felt well supported by the senior medical staff and received regular training.
  • The recording of patient assessments and the documentation and monitoring of patients’ treatment, needs and observations had improved since our last inspection. Patient observations were undertaken electronically and regular audits were undertaken to check that information was recorded appropriately.

Effective

  • Most of the services we inspected provided effective care.
  • National guidance was used to inform the care and treatment of patients and services participated in national and local audits.
  • Patients generally had good outcomes because they received effective care and treatment that met their needs.
  • Patients’ care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • We found there was an effective model of care being used in the emergency department to facilitate prompt treatment of patients on the stroke pathway.
  • We spoke with practice development nurses who monitored staff practice and competencies to ensure consistency.
  • At the last inspection we found that the paper and electronic policies, procedures and guidance that staff referred to when providing care and treatment to patients were out of date. The Trust had undertaken a major review of the Trusts policies and procedures and apart from the emergency department and medication policies, the majority were now current and reflected best practice.
  • We found that although the wards and consultants offered a seven day service they were not always supported by other services. This limited the responsiveness and effectiveness of the service the hospital was able to offer and on occasions delayed discharge. For example there was no access to therapy staff, dieticians or speech and language therapists (SALT) at weekends on the stroke ward. Pharmacy services only available until midday at weekends, which impeded timely discharge for patients who were unable to obtain their discharge medication.
  • We found that patients were always asked for their consent before any intervention and this was always appropriately recorded.
  • There was good multidisciplinary working throughout the hospital.
  • We observed that patients’ nutritional needs were met. They were served a choice of foods and that therapeutic diets were managed well. Dietary supplements were given to people when prescribed.
  • In general patients received timely effective pain relief.

Caring

  • Patients and relatives we spoke with during the inspection were very complimentary about the service they 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 relative’s condition.
  • We saw caring and compassionate care being delivered throughout the hospital but in particular we observed staff in the critical care and outpatients and diagnostic and imaging department treating patients, relatives and visitors with respect and thoughtfulness.

Responsive

  • We found that the hospital did not always have sufficient capacity to meet the needs of the patients admitted.
  • This meant that patients were often moved between wards during their stay, they were admitted to non-specialty beds where their own doctors were difficult to contact and consultant reviews less likely to occur. Women in labour often had to travel considerable distances to access maternity care when in labour because there was lack of capacity at their nearest hospital. In the emergency department patients were subject to overcrowding with no processes for requesting additional staff or diverting patients to other emergency departments. The lack of capacity had negative implications for the safe care and treatment patients.
  • The wards must be supported in providing a full seven day service by appropriate numbers of support services such as radiology, physiotherapy and pharmacy.
  • Patient flow through the hospital was limited by the availability of beds, caused by delayed discharges. In turn delayed discharges associated with provision of on-going support, rehabilitation and delays in take home medication, adversely impacted on the hospital’s bed capacity. The discharge of patients was not managed in a timely manner, especially at weekends. This was raised as a concern at the last inspection.
  • We also found that support for people with an acute medical condition or emergency care needs but who also had mental health needs was variable.
  • Surgical referral to treatment times were not being met over consecutive months for surgical specialties. Theatres were not always effectively utilised and this affected performance.
  • Improvements were needed for the day-care environment, as this did not provide sufficient privacy.
  • Arrangements were in place to support people with disabilities and cognitive impairments, such as dementia. Translation services were available and information in alternative languages could be provided on request.
  • The complaints process was understood by staff and patients had access to information to support them in raising concerns. Where complaints were raised, these were investigated and responded to. Where improvements were identified, these were communicated to staff through a range of methods.

Well Led

  • The Trust had implemented a Special Measures Action plan following our last inspection. The action plan identified where issues had been raised during inspection and outlined actions to be taken by the Trust along with an agreed timescale. This action plan had been RAG rated on delivery of objectives.
  • We found that the Trust had taken action to refocus its vision and mission strategy. However many of the leadership, organisational and developmental changes were in their infancy and had not had time to deliver the necessary changes to the patient experience.
  • Work was in progress to develop the directorate strategic aims and principles. Although there was now a clear direction of focus in many of the services, others such as the End of Life team and midwifery unit lacked a clear strategy and strategic direction.
  • We had concerns that the reduced resources for the End of Life team meant that the planned improvements were unsustainable and could not be implemented on current resources.
  • Some services such as the midwifery service had been through a period of instability of leadership which led to a great deal of staff dissatisfaction and unrest. Although progress was being made to stabilise the midwifery service with appointments to a number of interim, acting and substantive posts, a number of staff remained unhappy.
  • We received positive feedback about the changes instigated by the interim chief executive. Staff told us that the change in culture was ‘seeping through every area of the hospital’. They told us that there was ‘positivity in the air which is very exciting’ and that 'management' was slowly becoming more visible and approachable to front line staff. They told us they felt more valued as an employee and encouraged to be better. Staff told us that they felt there were now shared goals and although things were far from perfect there was some direction at last.
  • Governance arrangements throughout the hospital had been strengthened and were starting to provide more robust information to staff at all levels and to the Trust Board.

We saw areas of outstanding practice including:

  • The Nurse leadership in outpatients was outstanding with staff inspired to provide a good service to patients. The main outpatient’s matron provided knowledgeable and inspirational support to staff whilst working hard to maintain and improve the service.

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

Importantly, the trust must:

  • There must be sufficient numbers of suitably qualified, skilled, and experienced midwifery staff available to deliver safe patient care in a timely manner.
  • The environment and facilities in which patients are cared for must be safe, well maintained, fit for purpose and meet with current best practice standards.
  • The trust must ensure that all taps in clinical rooms are working effectively.
  • The trust should ensure that clinical areas are not carpeted. Where clinical areas are carpeted they must be managed with effective risk assessment and cleaning regimes.
  • There must be sufficient equipment in place to enable the safe delivery of care and treatment, that the equipment is regularly maintained and fit for purpose to reduce the risk to patients and staff.
  • The trust must ensure the hospital has sufficient capacity to cope with the number of women in labour and new born babies on a day to day basis.
  • The wards must be supported in providing a full seven day service by appropriate numbers of support services such as radiology, physiotherapy and pharmacy.
  • There must be robust systems in place to monitor the safe management of medicines to ensure that national guidelines are reviewed appropriately and their implementation monitored.

In addition the trust should:

  • Review the training provided to clinical staff on the Mental Capacity Act and DoLS to ensure all staff understand the relevance of this in relation to their work.
  • The trust should ensure that surgical staff undertake required training in safety related subjects.
  • The trust should continue to improve referral to treatment times across all specialities to ensure that patients are treated in an acceptable timeframe following referral to the service.
  • Standardising inotropic infusions to avoid the risk of potential drug errors when staff engage in cross site working.
  • There should be a formal vision and strategy for women’s health services to enable the development of a modern maternity service which is woman centred, underpinned by a sound evidence base and benchmarked against best practice standards.
  • Methods of maintaining the stability of leadership within the maternity department should be established.
  • The routine administrative burden on maternity staff at weekends and out of hours should be reduced in order to free midwifery staff to look after patients.
  • Staff should be encouraged to report non-clinical incidents in order that action can be taken to protect patients from avoidable harm.
  • The electronic system for allocating NHS numbers to new born babies should be functioning, in order to avoid the risk of babies missing screening tests through a manual process with insufficient printers available.
  • There should be a robust system in place to measure, monitor and analyse common causes of harm to women during pregnancy and childbirth.
  • The trust should continue to improve Referral to Treatment times across all specialities to ensure that patients are treated in an acceptable timeframe following referral to the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5, 7, 19, 20 March 2014

During a routine inspection

William Harvey Hospital (WHH) is one of five hospitals that form the East Kent Hospitals University NHS Foundation Trust, which is one of the largest hospital trusts in England. The trust provides services to the whole of East Kent, which has a population of around 759,000 people.

William Harvey Hospital had approximately 476 inpatient beds. It provided accident and emergency (A&E) services, outpatient services and a range of other specialties. We spoke to more than 75 patients, 18 relatives, and 120 staff while visiting the wards and departments in the hospital. We also held a listening event on 5 March 2014 where we spoke with around 25 people who came to share their views on this and the other hospitals managed by the trust. We undertook unannounced visits to WHH on 19 and 20 March 2014 when we inspected A&E, ward areas and spoke with the estates department.

Before and during our inspection we heard from patients, relatives, senior managers, and other staff about some key issues that were having an impact on the service provided at this hospital.

An issue which dominated many discussions was the trust’s recent proposal to centralise surgical services to this site. The staff we spoke with did not feel consulted in this decision and did not support the decision made by the Board on 14 February 2014. Clinical staff raised detailed concerns with the Care Quality Commission (CQC) and with executives within the trust.

This inspection was undertaken because the East Kent trust had been identified as potentially high risk by the CQC’s intelligent monitoring system.

Overall this hospital was rated as good for caring, requires improvement for effective, inadequate for being responsive to patients’ needs and being well led, and inadequate for safety. We therefore rated this hospital as inadequate overall.

Our key findings were as follows:

  • We saw that staff in all areas of the hospital were caring and responsive to patients’ needs.
  • We found that there were not always enough appropriately skilled staff, which placed patients at risk of receiving inappropriate care.
  • The records of patients’ waiting times in A&E were not an accurate reflection of the time patients waited.
  • The trust’s major incident policy was up to date however staff referred to the out of date policy and there had been mock major incident practice event.
  • Children’s needs were not always being appropriately met at this hospital.
  • Most patients on medical wards received care according to national guidelines.
  • Clostridium difficile (C Diff) and Meticillin-resistant staphylococcus aureas (MRSA) for the trust were within expected statistical limits.
  • Some equipment was not maintained in accordance with manufacturers’ guidance and therefore may not be fit for use.
  • There was not enough staff to provide a safe service to women during their pregnancy. The midwife to birth ratio was up to beyond 1:33. This was above the national recommended ratio of midwives to births of 1:28.
  • Risk management and clinical governance relating to the care of children was not managed effectively. Areas identified as serious concerns had not been addressed for long periods.
  • Some clinics were routinely overbooked because the number of appointment slots did not always reflect patients’ needs. Patients could therefore experience long waiting times, although they were kept informed about the expected length of delay. Patients who required follow-up appointments often had these appointments cancelled, moved to a later date and often there was a significant delay in patients receiving a follow-up appointments.

We saw an area of good practice:

  • The critical care unit monitored its performance and data from Intensive Care National Audit and Research Centre (ICNARC) and showed that patient outcomes were good.

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

Importantly, the trust must:

  • Ensure that there are always sufficient numbers of suitably qualified, skilled, and experienced staff to deliver safe patient care in a timely manner.
  • Ensure that appropriately trained paediatric staff are provided in all areas of the hospital where children are treated to ensure they receive a safe level of care and treatment.
  • Ensure all staff are up to date with mandatory training.
  • Protect patients by means of an effective system for the reporting of all incidents and never events of inappropriate or unsafe care, in line with current best practice and demonstrate learning from this.
  • Ensure that paper and electronic policies, procedures and guidance referred to by staff in the care and treatment they provide to patients are up to date and reflect current best practice.
  • Ensure that the assessment and monitoring of patients’ treatment, needs, and observations are routinely documented to ensure they receive consistent and safe delivery of care and treatment.
  • Ensure that the environment in which patients are cared for is well maintained and fit for purpose.
  • Ensure that equipment used in the delivery of care and treatment to patients is available, regularly maintained and fit for purpose, and that audits for tracking the use of equipment are completed appropriately to reduce the risk to patients.
  • Ensure that cleaning schedules are in place in all areas of the hospital, personal protective equipment for staff is in good supply and that in-depth cleaning audits are undertaken in all areas.
  • Implement regular emergency drills for staff.
  • Make clear to staff the arrangements in place for the care of patients at the end of life to ensure the patient is protected against the risk of receiving inappropriate or unsafe care.
  • Review the provision of end of life care to ensure a coordinated approach.

In addition the trust should:

  • Ensure that patients are informed of the reasons why their appointments are cancelled.
  • Ensure that letters to patients’ GPs are provided within the timescales established by the trust.
  • Aim to reduce the number of transfers between wards experienced by patients.
  • Review discharge arrangements for patients to reduce the risk of re-admissions.
  • Ensure that strategies are developed and implemented, and that staff are fully aware of them in relation to escalation, emergencies, and dealing with patient capacity issues.
  • Ensure that patients’ privacy and dignity is maintained at all times.
  • Manage patient documentation better to minimise risk of breaches to patient confidentiality.
  • Introduce a policy to make clear the timescales for changing bed curtains.
  • Ensure handwash and hand gel dispensers are kept topped up, as we found some that were empty or half full.
  • Review the layout of the A&E majors area to provide improved visibility of patients from the nurses’ station.
  • Promote the Friends and Family Test (FFT) around the hospital to improve participation.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 29 November 2012

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

This inspection included visits to the following wards: Cambridge K, L and M1, the Clinical Decisions Unit (Male and Female) and Richard Stevens Stroke Unit. We observed and talked with eight patients on the wards and spoke to 14 staff of different levels, including ward managers and junior Drs. We focused on patients in the wards who had reduced mental capacity and needed additional support to understand their treatments and care in the hospital, for example people who had dementia or learning disabilities. Patients told us that they felt well supported by the staff and we observed polite, unrushed interactions between patients and staff when people were being helped to make a decision.

All the staff we spoke to were aware of their responsibilities to support people to make decisions about their care and treatment, if they had reduced capacity and had direct access to the guidance and policies to follow. The trust had increased the level of training and support provided so that staff were able to obtain further advice if needed.

Inspection carried out on 31 May 2012

During a routine inspection

We spoke with eight patients on Cambridge J, five patients on Cambridge K, three patients and two visitors on Cambridge M1. On Kings A2 we talked with nine patients, on Kings C1 we talked with four patients and two relatives, and on Kings D1 we talked with four patients.

Everyone said that their privacy and dignity was protected and promoted. People said staff always pulled the curtain around their bed before any treatment. On Cambridge J a person said. ‘They treat me with respect here’. On Cambridge K a person said, "They always pull the curtain around and knock on the toilet and shower doors". On Cambridge M1 a person commented, "Staff speak loudly and clearly enough. Always draw the curtains. They come quickly and they don’t rush me if I need to use the commode". On Kings C1 a person said "Yes, staff always speak with kindness and care. Always pull curtains etc". On Kings A2 a person said, "Yes, curtains always drawn and they help with the toilet." On Kings D1 a person commented, "Yes staff are always respectful. They always pull curtains but often forget to pull them back again!"

People said they had been given sufficient information to make a decision and consent to their care and treatment.

Relatives of people who had dementia or confusion commented, "there is a lack of awareness of advanced dementia." They were referring to staff asking the person questions and not being aware of when the person had capacity or not.

People spoke very positively about the care and treatment they had received. On Cambridge J a person said, ‘This ward is top dog, I have no complaints at all. They don’t rush me and they keep me informed, they show me my records and results’. On Cambridge K people said, ‘They have been brilliant, nothing has been too much trouble’. On Kings A2 people said they were given the information they needed about their care and treatment. On Kings C1 one of the relatives said that the staff communicated with them because they were the next of kin and they had been given good information, "The risks and benefits were explained before surgery."

Some people on Cambridge M1 said that they were not given enough information about their care and treatment because staff did not have the time to speak to them. However, despite saying that the staff were busy, one person said, "The care I have always received at William Harvey Hospital is world class and I've never felt unsafe here. There have been hospitals in the UK where I have felt unsafe but not here."

On all the wards people said they were satisfied with the food provided. One person said, "The food is brilliant and I am looked after well... you can have extra if you want it." Another person said, "The food is served hot, I have no complaints about the food. There is a choice and I am given time, I am never rushed." People said that there was a good range of choices of food. One person commented, "The food is pretty good. There are three choices. The last two mornings I have had a cooked breakfast."

People said the food was good but it was not always hot. People also commented that by the time they got "…the ice-cream it had turned to liquid."

People said they were impressed with the standard of hygiene and cleanliness in the wards. They said that the wards were clean and that they saw cleaners come everyday and the care staff cleaned too. They commented "…cleaning staff come round two or three times a day cleaning." "The sheets are changed every day, the ward is very clean." There was only one negative comment and that was on Cambridge M1 and again related to there not being enough staff to carry out tasks in a timely way.

A person on Kings A2 said, "Staff are straightaway your friend when you come in. There are plenty of them too." They said staff were available to help when they needed assistance. One comment was "…yes they are, sometimes have to wait a little, they are run off their feet." One person on Cambridge J commented, "The staff are pretty good." "Sometimes they rush, but usually they are good."

People we spoke to said that their call bells were answered quickly apart from people on Cambridge M1.

On Cambridge M1 people were concerned about the lack of staff. They said this had meant that some people had to wait for assistance.

People said, "The staff are very nice, very pleasant". "The nurses are happy, I do not know how they manage it and stay happy as they are very busy".

People said they felt confident in the staff who were supporting them.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

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

Inspection carried out on 15 September 2011

During a routine inspection

People told us that they “were not given a lot of information prior to or soon after admission to the ward”. They said that “The nursing care has been very good”, and that “Nurses were so patient”.

They also said that sometimes care staff can be rushed, and perhaps there should be more care staff on the ward. We spoke with two people who both told us that care staff treated them with kindness and respect at all times, and that they felt safe on the ward.

Everyone we spoke to on Bethersden ward said that they were satisfied with their care and treatment. People told us that even though the staff appeared busy, they always had time to talk to patients and ask how they were.

People said that they felt safe and that their privacy and dignity was respected. People said that they were kept informed about their care and treatment and had been given choices and options of treatment when available.