You are here

Maidstone Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 February 2015

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

Inspection areas

Safe

Requires improvement

Updated 3 February 2015

Effective

Requires improvement

Updated 3 February 2015

Caring

Good

Updated 3 February 2015

Responsive

Requires improvement

Updated 3 February 2015

Well-led

Inadequate

Updated 3 February 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 3 February 2015

Systems were in place to ensure that safety was a priority for maternity and gynaecology services. Women and their babies were treated in a well-equipped environment. National evidenced-based best practice, professional standards and expert guidance were routinely used to ensure that mothers’ needs were assessed and care delivered that was safe and effective.

Feedback from people who used the maternity service was positive about how staff treated them. Women who wanted to give birth at the Maidstone Birth Centre (MBC) were assessed to ensure they were suitable for a low-risk-environment birth. Staff were engaged with innovative practices; they were making changes that had a direct impact on women and improved their experiences.

Medical care (including older people’s care)

Requires improvement

Updated 3 February 2015

Policies related to MRSA were not being followed by staff, and aspects of medicines management needed strengthening. Patients’ records were not always stored securely, and systems for handover between medical teams were not robust. Services were not always effective, because current clinical guidance was not easily accessible for staff to follow, and national audits showed that patients with stroke or diabetes were receiving below average quality care. Systems for authorising the deprivation of people’s liberty were not robust.

Medical care services were not as responsive as needed. Capacity in the service was insufficient to meet demand. Arrangements for the provision of translation services also required improvement.

Staff provided care in a compassionate and kind way that preserved patients’ dignity. Patients felt supported psychologically and involved in their care and treatment. Staff felt supported by their leaders and managers to provide high quality care. We observed a culture focused on meeting the needs of individual patients and their families. Service leaders at all levels had systems to assess how well they were doing and were aware of any challenges they faced.

Urgent and emergency services (A&E)

Requires improvement

Updated 3 February 2015

Learning outcomes from a recent never event were not implemented in the department. The arrangements for the storage of medicines did not restrict unauthorised access. The department did not have enough medical staff trained at the appropriate levels for safeguarding children. An insufficient number of consultants were in post to provide the necessary cover for the department.

Security staff were trained in control and restraint under their Security Industry Authority licences only and had not completed patient-specific training courses to improve their awareness when they supervised patients presenting with behaviours that were challenging, including patients with mental ill health and dementia. Clinical guidelines available in the department were out of date, and no action had been taken to review the department’s deteriorating performance against College of Emergency Medicine audits.

Patients were left waiting for treatment for longer than the expected national average, and the department was failing to meet its target for closing complaints by an agreed response date. There was a lack of strategic oversight and planning for driving improvement in the department. Nursing leadership was uncoordinated, and nursing staff did not consider themselves involved in governance.

Overall, staff provided a caring and compassionate service. We observed staff treating patients with respect. Patients and their relatives and carers told us that they felt well-informed and involved in decisions and plans of care.

Surgery

Updated 8 October 2015

We found that there were now arrangements to ensure the quality and safety of the water supply in surgery.

Intensive/critical care

Inadequate

Updated 3 February 2015

Significant improvements were required to ensure the safety of patients in critical care. No admission guidelines were in use to show the benefits of, and criteria for, admission to the ICU. Improvements were required to ensure that all incidents were reported through the same trust-wide system and were acted on promptly.

Although the ICU was obtaining mostly good quality outcomes, there was some lack of compliance with national guidelines.

Governance systems were inadequate; for example at mortality and morbidity meetings, not all deaths were discussed, and there was no record of the meetings that had taken place. Improvements were also required to the leadership of the ITU to ensure that the national best practice guidelines were followed, for example the core standards for intensive care units (2013).

Infection control and medicines management systems were found to be safe. Staff cared for patients in a compassionate manner and treated them with dignity and respect. Both patients and their relatives were very satisfied with the care provided. However, patients who were ready to be discharged to a ward environment were often delayed for up to a week because of a lack of ward beds, breaching same-sex accommodation, and in many instances were discharged home directly from the ICU.

There were inadequate facilities for patients who were fit to be transferred to wards; for example, there were no separate male/female toilet or bathroom facilities.

Services for children & young people

Requires improvement

Updated 3 February 2015

The children’s and young people’s service at Maidstone Hospital requires improvement to ensure that children receive appropriate, evidence-based and effective care.

We found that nursing staff provided compassionate and empathic care both to children and their families. The environment in which children were cared for was appropriate; however there was insufficient evidence to determine whether regular cleaning audits were carried out to ensure the unit was being appropriately cleaned. There were some inconsistencies in the frequency with which medical and electrical devices were serviced. We also found that although medicines were stored appropriately on the ward, we had concerns about the chain of custody of controlled drugs; this was attributed to the informal nature with which keys to the controlled drug cupboard were stored at night and over the weekends, when the Riverbank Unit (children’s day assessment and day-case ward) was closed.

The directorate used a combination of National Institute for Health and Care Excellence (NICE) and royal colleges’ guidelines to determine the treatment it provided. However, there were discrepancies in the pre-operative management of children undergoing surgery with regards to nil-by-mouth guidance.

We could not fully determine the overall effectiveness of the service; this was because of the limited evidence and limited audit activity undertaken by the children’s directorate that was specifically related to the Riverbank Unit. From the information collated, we identified that the department was not always performing in line with national standards; this was especially true for the management of children with diabetes.

The children’s directorate lacked a formal vision or strategy, and some staff were unaware of the trust’s values. The overall leadership of the Riverbank Unit was poor. There was little in terms of consistent management oversight of the unit. There was limited evidence to demonstrate that incident reporting was an embedded practice within the unit, with only eight incidents being reported over a six-month period. Although the directorate’s senior management team was aware of issues such as contractual issues with third party transport providers, these had not been listed as issues that posed operational risks to the effectiveness of the service.

End of life care

Requires improvement

Updated 3 February 2015

The specialist palliative care team (SPCT) was available five days a week for face-to-face contact, and the hospice provided telephone out-of-hours and weekend cover. Medicines were provided in line with guidelines for end of life care. ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms were not consistently completed in accordance with trust policy, and there were no standardised processes for completing mental capacity assessments.

The SPCT provided four study days per year for trained nurses, and trust staff were able access palliative care study days provided by the hospice in the Weald. Medical end of life training was delivered as part of the doctors’ formal education programme. Leadership of the SPCT was good; quality and patient experience were seen as priorities.

All patients requiring end of life care were referred to the SPCT. However, often no specialist input was required by the team. Patients were cared for with dignity and respect and received compassionate care. There was a multidisciplinary team approach to facilitate the rapid discharge of patients to their preferred place of care. Relatives of patients receiving end of life care were provided with free car parking.

Outpatients

Requires improvement

Updated 3 February 2015

All the patients we spoke with told us they had been treated with dignity and their privacy protected. They spoke highly of the staff in outpatients and radiology. Patients found staff polite and caring. However, many patients complained to us about waiting times in outpatient clinics.

Staff were reporting incidents, and these were discussed at the clinical governance meetings within the directorates. Systems were in place to reduce the risk and spread of infection. Medicines were stored and administered safely. The department held its own training records, which were up to date and demonstrated that most staff had attended mandatory training.

The trust had met its national targets and consistently performed higher than the national average with regard to radiology waiting times. There had been a backlog in reporting computerised tomography (CT) and magnetic resonance imaging (MRI) scans for several months, but there was evidence at the visit that these were being resolved. An ongoing backlog in clinic letters being sent out had not been resolved. There was a risk of patients receiving delayed or inappropriate treatment, and considerable stress caused to staff.

Staff demonstrated a commitment to patient-centred care, and we found many examples of such care and attention to patients’ conditions and preferences.