Maidstone Hospital

Maidstone Hospital is part of Maidstone and Tunbridge Wells NHS Trust and provides acute services to a population of approximately 500,000 living in the south of west Kent and parts of north-east Sussex.

Maidstone and Tunbridge Wells NHS Trust employs around 4,710 whole time equivalent members of staff with approximately 1,200 staff working at Maidstone Hospital.

We carried out an announced inspection of Maidstone hospital between 14 and 16 October 2014. We also undertook two unannounced visits of the hospital on 23 and 28 October 2014.

Overall, this hospital requires improvement. We found that maternity and gynaecology services were good. Urgent and emergency care, medicine, surgery, services for children and young people, outpatients and diagnostic imaging and those patients requiring end of life care required some improvement to ensure a good service was provided to patients. We found that critical care services was inadequate and significant improvement is required in this core service.

We rated this hospital as good for caring for patients. However, the hospital requires improvement in ensuring that it provides safe and effective care which is responsive to the needs of patients. The hospital requires significant improvement to ensure that it is being well-led as we found the current arrangements to be inadequate.

Our key findings were as follows:

Safe:

• The concept of learning from incidents varied from service to service. Whilst some departments had grasped the important role that incident reporting and investigation had in improving patient safety, this ethos was not replicated throughout the hospital.
• The anaesthetic department utilised an independent incident reporting tool which fell outside the auspices of the trust’s quality and risk strategy; there was a lack of robust oversight of this reporting tool into the overarching trust-wide governance structure.
• Medicines management required improvement in some areas including, but not limited to the storage and administration of medicines.
• Some junior medical staff were not aware of their statutory duty of candour; this had been recognised as an area of risk by the trust and there was a plan in place to heighten staff awareness.
• Medical cover within the Intensive Care unit was not consistent with national core standards.
• We identified that the trust had failed to adhere to national standards and guidance regarding water safety; specifically this related to lapses in the trusts governance of legionella testing. We have warned the trust and have asked for timely improvements to be made in this area.
• The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied. The use of early warning systems was embedded within the medicines directorate, whilst in A&E, its use was inconsistent.

Effective:

• The use of national clinical guidelines was evident throughout the majority of services. The Specialist Palliative Care Team had introduced an end of life pathway to replace the existing Liverpool Care Pathway.

• There was lack of clinical guidelines within the ICU setting and staff were not routinely using national guidance for the care and treatment of critically ill patients.

• The A&E generally performed poorly with regards to the management of patients presenting to the department in severe pain with fractured neck of femur injuries. However, post-operative patients reported that their pain was well managed on the wards.

• The pre-operative management of children and adults was not consistent with national guidance. There were inconsistencies in the advice patients were offered with regards to nil-by-mouth times, with some patients experiencing excessively long fasting periods.

• Whilst staff were afforded training in understanding the concepts of, and the application of the Mental Capacity Act (MCA), we found that staff were not routinely implementing the MCA policy into their practice.

Caring:

• Staff were caring and compassionate and treated patients with dignity and respect.
• Patients considered that they had been given sufficient information and counselling by qualified healthcare professionals to enable them to make informed decisions about their care and treatment.

Responsive:

• Patient flow across the hospital was poor. Patients deemed fit to be discharged from intensive care units frequently experienced significant delays in being transferred to a ward and elective surgical patients were cancelled due to a lack of available beds.
• The accident and emergency department consistently met the national target of ensuring that patients were admitted, transferred or discharged within four hours. However, patients could expect to experience delays of 60 minutes or more before receiving treatment within the A&E.
• The provision of interpreting services across the hospital was poor.
• There was an insufficient number of single rooms at Maidstone hospital to meet people’s needs.
• Capacity issues within the hospital led to a high proportion of medical “outliers”. The result of this included patients being moved from ward to ward on more than one occasion, alongside late night transfers.
• All medical specialities were meeting national standards for referral-to-treatment times, including all national cancer care waiting time standards. However, some surgical patients were experiencing delays of more than 18 weeks from referral to treatment. The hospital had responded to this by introducing additional surgical lists on Saturday mornings.

Well-led:

• The hospital values “Pride” were known by some staff, but not all. The majority of directorates lacked a clear vision or strategy which led some staff to being frustrated. Whilst staff were keen to develop clinical services, initiatives were hampered by financial restraints and cost improvement plans which were not aligned with quality governance measures.
• The ability of the senior directorate management teams to effectively lead their respective service was varied. Whilst the directorates of medicine, maternity and end of life were rated to be well-led, the same could not be said for the remaining five services.
• The application of clinical governance was varied, with some services lacking any formal, robust oversight.
• Staff engagement was varied throughout the eight core services; some staff spoke positively whilst others reported examples of departmental silo working, favouritism and poor visibility amongst the senior management team.
• Risk registers were poorly applied in some clinical areas which led to some risks not being escalated to the executive board. Where risks were escalated, there was evidence that the trust was taking action to try and resolve issues.

We saw several areas of outstanding practice including:

• The Maidstone Birth Centre had developed, designed and produced the Maidstone birth couch, which was used by women in labour.

• On Mercer Ward, the role of dementia care worker had been created to focus on the needs of people with dementia and their families. An activities room had been designed, furnished and equipped to meet the specific needs of people with dementia, and was widely used. This project was the subject of an article published in the professional nursing literature.

• The breast care service provided very good care from before the initial diagnosis of cancer through to completion of treatment. Good support and holistic care was provided to patients requiring breast surgery.

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

The trust must:

• Make arrangements to ensure contracted security staff have appropriate knowledge and skills to work safely with vulnerable patients with a range of physical and mental ill health needs.
• Ensure that intensivist consultant cover is adequate.
• Ensure that sufficient numbers of ward rounds take place in the intensive care unit (ICU) to ensure the department complies with national standards.
• Ensure that once a decision to admit or discharge a patient to or from the ICU is taken, this takes place within four hours.
• Ensure that discharges from the ICU to other wards do not take place at night.
• Ensure that the governance structure within the ICU supports a framework to ensure clinical improvements using a multidisciplinary approach.
• Review the existing management arrangements for the Riverbank Unit to ensure that the unit operates effectively and efficiently.
• Take action to ensure that medical and nursing records are accurate, complete and fit for purpose.
• Ensure that staff and patients have access to a competent and independent translator when necessary.
• Ensure that the water supply is tested for pathogens and that appropriate systems are in place for monitoring water quality and water safety.
• Take action to ensure that all patient clinic letters are sent out in a timely manner.

The trust should:

• Arrange for the safe storage of medicines so that unauthorised access is restricted.
• Make sure that medical staff complete training in safeguarding children at the level appropriate to their grade and job role.
• Make sure that a sufficient number of consultants are in post to provide the necessary cover for the ED.
• Ensure that up-to-date clinical guidelines are readily available to all staff.
• Review the arrangements for meeting the needs of patients presenting with mental health conditions, so they are seen in a timely manner.
• Review the way complaints are managed in the ED to improve the response time for closing complaints.
• Review the governance arrangements for nursing staff in the ED to ensure effective leadership and devolution of responsibilities.
• Review the current provisions of the ICU outreach service, to ensure that the service operates both day and night, in line with National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommendations.
• Ensure that medical care services comply with its infection prevention and control policies.
• Develop robust arrangements to ensure that agency staff have the necessary competency before administering intravenous medicines in medical care services.
• Develop systems within the directorate of speciality and elderly medicine to ensure that the competence of medical staff for key procedures is assessed.
• Ensure that systems are in place to ensure that the system of digital locks used to secure medicines storage keys can be accessed only by authorised people.
• Develop systems to ensure that medicines are stored at temperatures that are in line with manufacturers’ recommendations.
• Ensure within medical care services that patients’ clinical records used in ward areas are stored securely.
• Ensure that the directorate of speciality and elderly medicine further monitors and embeds a robust system of medical handover that ensures patients’ safe care and treatment.
• Review the ways in which staff working in medical care services can access current clinical guidance to ensure it is easily accessible for them to refer to.
• Review the way in which in medical care services it authorises and manages urgent applications under the Deprivation of Liberty Safeguards.
• Ensure that patients have access to appropriate interpreting services when required.
• Ensure that the directorate of speciality and elderly medicine reviews its capacity in medical care services to ensure capacity is sufficient to meet demand, including the provision of single rooms.
• Consider reviewing the processes for the capturing information to help the service better understand and measure its overall clinical effectiveness.
• Review the current arrangements for the providing elective day case surgical services to ensure parity of services across the hospital campus.
• Ensure that the provider reviews the quality of root cause analysis investigations and action plans following a serious incident or complaint and improves systems for disseminating learning from incidents and complaints.
• Ensure that the provider monitors transfers between sites for both clinical and non-clinical reasons. The monitoring process should include the age of the patients transferred and the time they arrived after transfer.
• Consider collating performance information on individual consultants. Where exceptions are identified, these should be investigated and recorded.
• Provide written information in a format that is accessible to people with learning difficulties.
• Reduce delays for clinics and reduce patient waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals