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Maidstone Hospital Requires improvement

Reports


Inspection carried out on 18 October 2017

During a routine inspection

A summary of services at this hospital appears in the overall summary above.

Inspection carried out on 30th June 2015

During a routine inspection

At the inspection carried out 14th – 16th October 2014, we found Maidstone and Tunbridge Wells NHS Trust had failed to comply with Health and Social Care Act 2008 with respect to the monitoring and prevention of infection. This was specifically in relation to the arrangements for ensuring the quality and safety of its water supply at Maidstone Hospital. We took regulatory action and we served a warning notice on 16 November 2014.

We carried out a review at Maidstone Hospital on the 30th June 2015 to see if the improvements specified in the warning notice had been met, and to establish if the trust was compliant with the relevant regulations.

Our key findings were as follows:

  • The trust had implemented suitable arrangements to ensure the quality and safety of its water supply thus minimising the risks of infection to patients, staff and visitors.
  • Whilst some actions remain not fully completed, systems and processes have been put in place to ensure compliance with government guidance and Regulation 12 of The Health and Social Care Act 2008.

We saw an area of outstanding practice:

  • The development of the estates dashboard as a system for collating all required tasks for all systems across the trust was an outstanding piece of work. The links with relevant guidance, legislation and external portals enabled staff learning and support as well as ensuring that the systems were safely monitored to a set programme.

However, the trust needs to continue to make improvements.

The trust should:

  • Maintain progress in line with their action plan.
  • Collate information to give the trust board assurance that improvements are made and sustained and that all relevant guidance and regulations are met.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14-16 October 2014

During a routine inspection

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 carried out on 12 February 2014

During an inspection in response to concerns

When we visited Maidstone Hospital our inspection team consisted of 3 Compliance Inspectors, a hospital governance specialist, a Consultant Surgeon, a Pathology specialist, and two experts by experience.

All the patients that we spoke with were positive about the care they had received before and following surgery. However, some patients told us they were not happy about the number of cancellations and delays they felt that they had experienced whilst awaiting surgery.

We found that patients had not always had an opportunity to speak with their surgeon prior to their surgery. We also found that some patients were not asked for their consent until they were on a trolley waiting to go into the operating theatre. This meant that although patients had consented to surgery, they may not have had sufficient time or information to have made an informed choice.

We found that patients had not always received safe care either before or after their surgery. This meant that risks to patient’s health, safety and welfare could be compromised because safe practices were not always followed.

We found that patients did not always receive care from appropriately qualified staff. We found that arrangements were not in place for patients to receive on-going care from their consultant. Children receiving care at Maidstone Hospital did not always have access to staff trained in paediatric medicine. The paediatric resuscitation team did not routinely contain a paediatrician out of hours.

We found the provider did not have adequate processes in place to assess or monitor the quality of the service. This meant that risks to patient’s health, welfare and safety were not being managed appropriately.

Within this inspection report we have made some references to a report about the trust written by the Royal College of Surgeons (RCS). This report was commissioned by the trust following the deaths of 5 patients who had had similar surgeries. The trust was reviewed by the RCS in October 2013, and received the report from the review in December 2013.

Inspection carried out on 28 September 2012

During a routine inspection

Patients felt that they had been consulted and informed about their treatment. One patient said, “They explain the treatment and what’s happening, but most of all I like that they speak to me like an adult”. Patients said that they had consented to the medical interventions. They said that options and risks had been discussed with them.

One patient said, “… wonderful. The nursing staff really talk to you they don’t just do the tasks. I couldn’t wish for better. It’s a good ward, good people and well run. I’m more than happy with it”.

Patients told us that on most occasions the call bells were answered quickly.

Patients felt that care they received helped them to regain confidence where, for example, they had experienced a fall.

Inspection carried out on 1 August 2012

During a themed inspection looking at Dignity and Nutrition

Patients told us what it was like to receive treatment in the hospital and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people receiving treatment in hospitals are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by two CQC inspectors joined by an Expert by Experience (people who have experience of using services and who can provide that perspective) and a practising professional.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of patients who could not talk with us.

All of the 12 patients with whom we spoke gave us generally positive feedback about the hospital. They said, “The staff are very kind”, “The doctors are approachable”, “It is a very good hospital and I’ve been in a few, I can’t praise it enough” and “It’s very clean throughout, I think they’re obsessed with cleaning”.

A carer (relative) speaking about a patient’s discharge arrangements said, “I’m very pleased that at last extra care has been arranged that will help her and her family. No-one else outside the hospital has told her that she could have this help in the past”.

Inspection carried out on 11, 12 May 2011

During an inspection in response to concerns

We spoke to people using the services and staff in each of the areas that we visited. People who use the service generally felt that they were looked after well and that staff were attentive and caring.

Comments from patients about their experience included “the attention is very good, the place is nice compared to others”, “I am satisfied with the care”, “It’s great I am satisfied” and “Superb. Satisfied with everything including the food”. “Nurses are lovely, everyone has been really nice”.

People told us that their privacy was on the whole maintained, but one person said “the nurses always pull the curtains when they are doing anything for privacy; they are very good at that, but the doctors usually just pull them open and walk in”.

Overall people stated that the level of cleanliness was very good and that the wards were swept and cleaned on a regular basis. People had seen that beds and equipment were cleaned between uses. Most people said that hand cleaning was carried out by staff in advance of any care being provided.

Comments included “as clean as it can be”. “Cleaners are always cleaning and staff clean up spillages and doctors wash their hands”. “The bathrooms are perfect”. “They mop everyday I see people cleaning and they frequently wash their hands and wipe down the beds and chairs”. “It’s very clean”. “Brilliant cleanliness, very fastidious, nothing is slapdash”.