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Kent & Canterbury 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 two core services as requires improvement and one as not enough information to rate.

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 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 and gynaecology

Not sufficient evidence to rate

Updated 21 December 2016

We have also included our findings of the services at Kent and Canterbury Hospital in the William Harvey Hospital location report due to the limited number of maternity services at this location. Births do not take place at Kent and Canterbury Hospital with mothers going to either the William Harvey Hospital in Ashford, or the Queen Elizabeth the Queen Mother Hospital in Margate. Kent and Canterbury Hospital has a midwife led unit providing pre and postnatal services including education classes and breast feeding support.

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2016

We found the medical services at the hospital required improvement because;

  • Although the trust had recruited overseas nurses, there remained staffing shortages on the wards. 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.
  • There was insufficient numbers of junior grade doctors and consultants across medical services at Kent and Canterbury Hospital. This meant consultants and junior staff were under pressure to deliver a safe and effective service, particularly out of hours and at night.
  • 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. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.
  • We found 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. Waiting times are set out in the NHS Constitution; in addition, there are waiting times performance targets measures, which are monitored by NHS England.
  • The trust was not meeting the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% national standard and the England average for six of the eight specialties from June 2015 to May 2016.
  • Although the trust had put measures in place to promote positive behaviour and eliminate bullying, staff still reported incidents of inappropriate behaviour from colleagues.

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.
  • Management prioritised staff training, which meant staff had timely access to training in order to provide safe care and treatment for patients.
  • There were systems in place to maintain a clean and therapeutic environment. Staff effectively managed infection control and appropriately maintained the environment.
  • 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.
  • Patients were supported through consultant led care and effective delivery of care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.
  • Overall Staff treated patients with kindness and compassion.
  • The trust had plans in place to ensure that medical services across the county were sustainable and fit for purpose. The trust was engaging with all stakeholders to implement any changes. The trust had taken action to address the delays to the patient pathway, such as rapid access clinics, rapid discharge team and outsourcing diagnostic investigations.
  • Staff provided good provision of care for patients living with dementia and patients’ different needs were taken into account. Staff admitted the majority of patients to the correct bed for their speciality and did not move beds or wards for the entirety of their stay.
  • The trust had a clear corporate vision and strategy. The trust reflected staff engagement when developing the strategy for medical services. Clinicians, staff and stakeholders’ opinions were taken into consideration.
  • 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. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.

 

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)

Not sufficient evidence to rate

Updated 5 September 2018

The Kent and Canterbury Emergency Care Centre has three separate areas, a Level 3 minor injury unit (including a four-bed paediatric unit), vascular and urological emergency unit and a resus unit.

The minor injuries unit (MIU) provides treatment for minor illness and injury to children over one year old and adults.

The vascular and urology emergency unit provides care to people of all ages with urgent vascular or urological conditions.

The resus area had three bays, two for adults and one for children. This unit was primarily used for vascular and urology emergency patients. These patients are treated in the resus then transferred within the hospital if they can be treated at Kent and Canterbury.

The resus unit is sometimes used for self-referred patients who need to be transferred to the emergency departments at William Harvey Hospital or Queen Elizabeth the Queen Mother Hospital due to their condition. In these cases, patients are transferred to the other hospital by emergency ambulance, but treated in resus area until the ambulance arrives.

Urgent and emergency services were last inspected in 2016 when overall, we rated the service as requires improvement. Our inspection was unannounced and we inspected all five key questions.

We have performed a focused review of the emergency services at Kent and Canterbury hospital. This report summarises our findings. However, there is insufficient information to rate this service.

Surgery

Requires improvement

Updated 5 September 2018

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

  • The environment which surgical services were provided did not always suit the purpose. Patients in the second stage of recovery after an ophthalmic operation were placed in the waiting area with a screen to separate them from other patients and visitors. This meant that their privacy was compromised. We raised this on site and the trust took action to address our concerns.
  • Referral to treatment times (RTT) were generally below the England average from January 2017 to December 2017. For example, 63% of urology patients were treated within 18 weeks compared with the England average of 77%.
  • The overall theatre utilisation between May 2017 and May 2018 was 50%. This was lower than the trust target of 80% which meant that there was poor use of staffing resources and decreased efficiency within theatres.
  • Staff were not aware of the trust’s vision and strategy. Some staff felt concerns they raised were not addressed by local leaders.
  • It was unclear how many risks were on the risk register and what issues they referred to.
  • Patients undergoing elective and non-elective surgery had a higher than expected risk of readmission.
  • Theatre staff were rostered to work extended hours which included on call cover. Staff were not having the 11 hours of rest between shifts. This breached the European working time directive (EWTD).

However;

  • Surgical services were consultant led. Junior doctors told us they received sufficient support and supervision from consultants.
  • Staff completed patient care records legibly and signed and dated all entries.
  • Patients were always assessed, treated and cared for in line with professional guidance. Staff completed risk assessments for clinical risks including falls, pressure ulcers and venous thromboembolism (VTE).
  • Staff understood the impact of the care they provided. We observed staff speaking and treating patients with respect and dignity. Staff explained to patients how to look after themselves and also gave written information for patients to refer to in their own time.

Intensive/critical care

Good

Updated 18 November 2015

Patients were cared for in a clean and safe environment and staff showed good awareness of reducing the risk of infection. On the day of our inspection staff were very busy but we witnessed a well-co-ordinated team and a good standard of patient care and safety.

We found the care delivered in the unit reflected best practice and national guidance. There were systems in place to measure patient outcomes and the quality of the service provided. Care needs were risk assessed and the unit could demonstrate a track record of delivering harm free care.

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. Staff had access to PPE (Personal Protective Equipment) and was observed using it in line with trust policy.

The unit could demonstrate delivering care that reflected national guidance and took into account the latest research. The care delivered was assessed by continuously audited to ensure a high standard and outcomes that were in line with the England average when comparted to other critical care units.

Patient had their dignity respected and their human rights protected whilst in the unit. Appropriate systems were in place to report and action safeguarding and DoLS (Deprivation of Liberty) concerns. We saw evidence that demonstrate that patients and their loved ones had their individual preferences taken into account when planning care and were possible, were involved in planning their care.

Patients and relatives spoke positively about their experience of care and treatment. Staff showed good communication practices and used this to ensure patients with complex needs received timely and expert treatment. There was a positive drive to increase the use of the Confusion Assessment Method for the ICU (CAM-ICU) for patients at risk of delirium.

Medical records were fit for purpose, kept confidential and stored appropriately. There were systems in place to ensure the safe storage, handling and administration of medication.

There was evidence that staff implemented learning from incidents and that training for staff helped them to continually improve patient care. The conversations we had with staff and the data we reviewed demonstrated a healthy culture in the department towards incident reporting. Regular Mortality and Morbidity (M&M) meetings were in place to monitor mortality on the unit.

We found sufficient numbers of skilled staff who had the appropriate skills needed to care for critically ill patients. The unit had a robust competency bases induction and ongoing learning and development programme for all staff.

Patients were looked after by a multi-disciplinary team that included appropriate consultant input. Leadership and educational support on the unit was found to be strong. Feedback received from staff about their line managers and culture in the unit was very positive and complimentary.

There was an appropriate major incident plan in place. Staff were able to tell inspectors of their roles and processes to follow should a major incident occur.

Services for children & young people

Good

Updated 18 November 2015

Kent and Canterbury hospital (KCH) children’s assessment unit (CAU) staff understood their responsibilities to raise concerns and report incidents and were fully supported by the trust when they did so. The children’s and young people’s service had systems in place to ensure that incidents were reported and investigated appropriately. Children and young people’s safety performance showed a good track record and steady improvements. Processes were in place for lessons to be learned and these were communicated widely to support improvement in other areas as well as services that were directly affected.

The trust was using the Kent safeguarding children’s board procedures; but had not produced a trust safeguarding children policy. Staff worked effectively with others to implement protection plans. There was active and appropriate engagement in local safeguarding procedures and effective working with other relevant organisations.

The children’s assessment unit (CAU) had been designed and built with children in mind. The ward areas provided a safe environment for children and families which were effective for cleaning and maintenance.

Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times.

Risks to children and young people were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies . Staff recognised and responded appropriately to changes in risks to children and young 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.

Feedback from children, young people and their families who use the service was consistently positive about the way staff at CAU treated people. The Dolphin ward friends and family test (FFT) results were consistently favourable.

There was a strong, visible person-centred culture. Staff we spoke with were motivated and inspired to offer care that was kind, and promoted children, young people and their families’ dignity.

Relationships between staff patients and their families were caring and supportive. Staff took patients and their families’ personal, cultural, and social needs into account.

Patients and their families were active partners in their care. Staff were fully committed to working in partnership with children, young people and their families. Staff always empowered patients and their families to have a voice and to realise their potential. Patients’ preferences and needs were always reflected in how care was delivered.

Children, young people and their families’ social needs were highly valued and embedded in their care and treatment. Patients’ needs were met through the way services at the CAU were organised and delivered.

Children and young people’s services were planned and delivered in a way that met the needs of the local population. The importance of flexibility, choice and continuity of care was reflected in the services provided.

The needs of different children and young people were taken into account when planning and delivering services. Patients care and treatment was coordinated with other services and other providers.

Reasonable adjustments were made and actions were taken to remove barriers when children and their carers found it hard to use or access services.

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 for children and young people’s services as the trust had not made a final decision about the future strategy for the service.

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 was taking action to address them. However, face to face monitoring at KCH CAU 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.

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. Safe innovation was being supported and staff had objectives focused on improving the culture of the trust.

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:

  • 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.
  • 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:
  • Care records for patients on the ‘care of the dying patient and their family plan’ were seen to be completed appropriately.
  • Anticipatory medicines ‘just in case’ patients at the end of life experienced symptoms were available.
  • Records of mental capacity assessments relating to decisions regarding ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) were not always completed on the trust form. However, records indicated that decisions were made in the patient’s best interest and there was evidence that the two stage capacity test had been recorded.
  • Syringe drivers were accessible and the administration of medicines via the pump was monitored in line with trust policy.
  • 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 were treated with kindness, respect, and compassion, and that they were 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. All patients were seen within 48 hours of referral, 98% of patients were seen within 24 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 Kent and Canterbury Hospital to improve end of life care.
  • 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.