You are here

Kent & Canterbury Hospital Requires improvement

Reports


Inspection carried out on 5th,6th 7th September 2016 and unannounced 21st September 2016

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

The Kent and Canterbury Hospital (K&C) is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT). EKUHFT provides local services primarily for the people

living in Kent. The Trust serves a population of approximately 759,000 and employs approximately 6,779 whole time equivalent staff.

The Kent and Canterbury Hospital is an acute hospital providing a range of elective and emergency services including an Urgent care (UCC). Thishospital provides a central base for many specialistservices in East Kent such as renal, vascular,interventional radiology, urology, dermatology, neurology and haemophilia services.

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.

We rated The Kent and Canterbury Hospital as Requires Improvement overall

Safe

We rated The Kent and Canterbury Hospital as Requiring improvement for safe because:

  • 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.

 

  • The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day-basis.

 

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

  • We found there were nursing shortages across the hospital.

 

  • 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.

However

  • Staff reported incidents and adverse events that were investigated through robust quality and clinical governance systems. Lessons arising from these events were learned and improvements had been made when needed.

 

  • Staff followed cleanliness and infection control procedures. Potential infection risks during the building works were anticipated and appropriate responses implemented and measured

Effective

We rated The Kent and Canterbury Hospital as Requiring improvement for effective because:

  • Documents and records supporting the learning needs of staff were not always competed and there were gaps in the records of training achieved.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision

  • Appraisial rates across the hospital needed to be improved.

 

  • 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

  • We saw good examples of multidisciplinary working between doctors, nurses, ENPs and other healthcare professionals, including colleagues from the other emergency departments.
  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • Comfort rounds had been performed and audited. These provided good assurance that pain assessments had been performed, analgesia administered.

 

Caring

We rated The Kent and Canterbury Hospital as Good for caring because:

  • Staff treated patients with kindness and compassion.
  • 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.

  • Staff we observed were consistently respectful towards patients and mindful of their privacy and dignity.

 

Responsive

We rated The Kent and Canterbury Hospital as Requiring improvement for responsive because:

  • 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.

  • 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.

  • Admission criteria for the UCC appears to be an ongoing issue of confusion to some parts of the local community, as evidenced by inappropriate ‘walk in’ patients arriving at the department.

However

  • There was an average of 17 60-minute breaches in ambulance handover times per month over the last four months. This represented 2.2% of the total number of patient handovers and was better than the regional average of 3%.
  • 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 Kent and Canterbury Hospital as Requiring improvement for well led because:

  • 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
  • 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 had only recently been realised and as a result had yet to fully address the issues relating to these services.
  • Although there were measures in place to promote positive behaviour and eliminate bullying, staff still reported incidents of poor behaviour from colleagues.

However

  • The hospital had well-documented and publicised vision and values. Their vision was to provide ‘Great healthcare from great people’, with the mission statement ‘together we care: Improving health and lives’. These were readily available for staff, patients and the public on the trust’s internet pages, posters around the hospitals and on the trust’s internal intranet.

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.

Importantly, the trust must:

  • Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.

  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.

  • 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 generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

 

  • Take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.

Action the hospital should take to improve

  • Ensure the administration of pain relief medication is provided to patients in a timely manner in the urgent care unit and minor injury unit.

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

Inspection carried out on 13-17 July 2015

During a routine inspection

The Kent and Canterbury Hospital (K&C) is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT). The Trust provides local services primarily for the people living in Kent.

EKUHFT serves a population of approximately 759,000 and employs approximately 6,779 whole time equivalent staff.

The Kent and Canterbury Hospital is a 287 bedded acute hospital providing a range of elective and emergency services including an Emergency Care Centre (ECC). This hospital provides a central base for many specialist services in East Kent such as renal, vascular, interventional radiology, urology, dermatology, neurology and haemophilia services

Following our last inspection of the Trust in March 2014 when we found many of the services provided to be inadequate, EKUHFT was placed into special measures by the Foundation Trust regulator Monitor. This announced inspection was undertaken to monitor and 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.

Our key findings were as follows:

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:

  • The trust must review its nursing establishments to ensure that numbers of registered nurses meets national guidance, and the needs of patients at all times, including throughout the night.

  • The trust must review the medical establishments to ensure that the numbers of doctors is sufficient to meet the needs of patients at all times, including through the night and at weekends.
  • The trust must clarify name and service provided in the ECC and provided protocols for the ambulance service about what patients can be admitted.
  • The trust must review its arrangements to ensure they can be assured that medicines and intravenous fluids are stored safely and securely.
  • The trust must review its arrangements for ensuring that resuscitation equipment is available and ready for use at all time.
  • The trust must ensure that training for staff on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards is available for staff providing care to patients a cognitive impairment.
  • The trust must ensure that suitable arrangements are made for patients with mental health issues whilst awaiting assessment.

In addition the trust should:

  • The trust should review its medical bed capacity to ensure that the majority of patients are cared for in the correct speciality bed for the duration of their hospital admission. It should also review its arrangements for the management of patients outlying in non-speciality beds to ensure the quality and safety of their care is not compromised.
  • The trust should review the processes in place that provide assurance that equipment shared between patients is clean and ready for use.
  • The trust should review the pharmacy service and how staff shortages are impacting on patient’s timely discharge.
  • The trust should review its care planning arrangements for summarising and recording the individual needs of patients when individual risks have been identified.
  • The trust should review pain management tools to assist patients living with a disability or dementia.
  • The trust should ensure that all confidential patient records are fit for purpose and securely stored in clinical areas to minimise the risk of unauthorised access.
  • The trust should consider the support available to people living with learning disabilities is provided when they are patients, and to its staff to ensure they can meet individual needs.
  • 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.
  • Consider how the environment in which surgical services are provided would be suitably maintained.
  • Improve theatre utilisation.
  • Ensure that staff are afforded the opportunity to have their performance formally reviewed.
  • Ensure staff in surgical areas complete all the required mandatory training.
  • Ensure that patient risk assessments were completed and acted upon.
  • The trust should consider standardising inotropic infusions to avoid the risk of potential drug errors when staff engage in cross site working.
  • 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 6, 19 and 20 March 2014

During a routine inspection

We inspected services at Kent & Canterbury (K&C) Hospital, including the Emergency Care Centre, Medicine, Surgery, Critical Care, Children’s services, Outpatients and End of Life Care.

The hospital’s A&E department closed in 2005 and was replaced by an Emergency Care Centre and an Urgent Care Centre. The hospital has 287 beds in total.

We spoke with a number of patients, relatives and staff while inspecting the hospital and we also held a listening event in Canterbury on 4 March 2014. We spoke with around 25 people at this event, who came to share their views on this and the other hospitals managed by the trust.

We undertook unannounced visits to Kent &Canterbury Hospital on 19 and 20 March 2014.

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 services 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 CQC’s Intelligent Monitoring system.

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

Our key findings were as follows:

We observed areas of good practice, including:

  • The critical care unit promoted the use of patient diaries to support patients with memory loss and poor recollection.
  • Patients being cared for on medical wards gave positive feedback about the care they received.

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 that, at a board level, there is an identified lead with the responsibility for services for children and young people.
  • Ensure all staff are up to date with mandatory training.
  • Protect patients by means of an effective system for reporting 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 that staff refer to when providing care and treatment 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 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 undertaken.
  • 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 take place in all areas.
  • Ensure that staff in children’s services audit their practice against national standards.
  • Implement regular emergency drills for staff, and ensure relevant policies are up to date.
  • 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.
  • Ensure that procedures for documenting the involvement of patients, relatives and the multidisciplinary team in ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNA CPR) forms are followed at all times. All forms must be signed by a senior health professional.
  • Ensure that patients are not experiencing unnecessary waits for follow-up appointments with outpatients clinics, and when waiting in outpatients to be seen, that they are not delayed.
  • Ensure there is adequate administrative support for the outpatients department.
  • Assess and mitigate the risk to patients from the high number of cancelled outpatient appointments and the delay in follow-up care.

In addition the trust should:

  • Take all appropriate steps to inform potential service users in the local community of the remit of the Emergency Care Centre.
  • Ensure appropriate signage to reflect that the hospital provides an Emergency Care Centre and not an Accident and Emergency department.
  • Consider national guidance is reflected in medication policies.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13 March 2013

During a routine inspection

This inspection included visits to the following wards: Mount/McMaster, Harbledown, Invicta and Marlowe. We observed and talked with 30 patients and 11 relatives on the wards and spoke to 14 staff, including ward managers and junior doctors. Around half the patients we spoke with had reduced mental capacity, for example dementia or confusion, and needed additional support to understand their treatments and care in the hospital.

People told us the staff explained their treatment to them and gave them enough time to make a decision. One patient on Invicta ward told us “Doctors explain what they are about to do with my treatment, so I always know what’s going on”. All the staff we spoke to were aware of their responsibilities to support people to make decisions about their care and treatment. Some of the relatives told us that discharge planning was an area that needed some improvement as there was confusion about whether patients were ready to be discharged and what arrangements had been made for post discharge support.

The wards were very busy and active. Harbledown and Mount/McMaster had extra beds because of winter pressures such as seasonal infections. Staff, patients and visitors commented on how busy the staff were and some said they were short staffed but all the comments about the staff and the care were positive. Patients and relatives said the staff were friendly. One patient commented, "We have a laugh together which makes it more friendly."

Inspection carried out on 22 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

Patients on Treble ward and Cathedral Day unit said their care and treatment had been well coordinated and everything had been explained well by the staff.

They said that they had been informed of their diagnosis and had been consulted about the treatment and rehabilitation support they needed.

On Treble ward patients had discussed their preferred routines with staff and that they were well supported to do everyday things such as to wash, get dressed and use the bathroom. On Cathedral Day unit patients had discussed their preferred routines with staff and they said that they were helped with practical tasks during their short stays.

Patients on Treble ward said that there was a choice of meals and that they had enough to eat. On Cathedral Day unit, patients said that there was always drinks available.

Patients said that Treble ward and Cathedral Day unit were orderly, neat and clean.

Inspection carried out on 19 July 2011

During an inspection in response to concerns

This Responsive Review of Compliance was completed because we had received concerning information in relation to Kingston Ward about the quality of treatment and care, nutrition and hydration and infection control.

Patients said that they had been consulted about their medical options and that they received the medical treatment and rehabilitation support they needed.

They said that they discussed their preferred routines with staff and that they were well supported to do everyday things such as to wash, get dressed and use the bathroom.

Patients said that there was a choice of meals and that they had enough to eat.

Patients said that the ward was orderly, neat and clean.