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The Tunbridge Wells Hospital at Pembury Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 February 2015

Tunbridge Wells Hospital, Pembury, 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.

We carried out an announced inspection of Tunbridge Wells 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 each of the eight core services required at least some improvement with the exception of the critical care service which we rated as inadequate with significant improvement required in this core service.

The hospital requires improvement in ensuring that it provides safe and effective care which is caring and responsive to the needs of patients. The hospital requires improvement to ensure that it is being well-led.

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.
  • The hospital was found to be visibly clean. Infection rates across the hospital were noted to be falling when compared to previous years. There was however, some localised poor performance of hand hygiene practices.
  • Performance for surgical site infection rates for those undergoing total hop replacements was worse than the national benchmark standard.
  • Medicines management required improvement in some areas including, but not limited to the provisions for the storage and administration of medicines.
  • Medical cover within the Intensive Care unit was not consistent with national core standards.
  • 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 and the children’s and young people’s service, its use was inconsistent.
  • Nursing levels were generally found to be good. This was not always the case for the children’s and young person’s service, which had a nursing establishment based on historical activity. However, every mother in active labour could expect to receive 1:1 support from a qualified midwife.
  • Patient records were not always found to be kept securely, nor were they always well organised or accessible.

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. However, 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 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.
  • Maternity services scored better than the national average in the Friends and Family test. Responses to the friends and family test for patients undergoing surgery was varied, however, it was noted that overall, the hospital scored better than the national average.
  • 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 provision of interpreting services across the hospital was poor.
  • 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. However, 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:

  • On Ward 20 there was a focus on dementia care. Staff had bid and won funds from the Dementia Challenge fund to create a Dementia Café for use by people living with dementia, their friends and families. This area was designed using current guidance to be dementia friendly and was equipped to meet the special needs of people living with dementia.

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

Importantly, the trust must:

  • Ensure that care and treatment provided to service users has due regard to their cultural and linguistic background and any disability they may have. This should include ensuring that patients have access to translator services are required.

  • Ensure that people who use the service are protected against the risks associated with unsafe or unsuitable premises.
  • Improve the environment in the Intensive Care Unit with regards to toilet/shower facilities for patients.

  • Have adequate intensivist consultant cover at all times to ensure cover is consistent with national core standards
  • Ensure patients are not delayed more than 4 hours once a decision has been made to admit or discharge them to or from the intensive care unit (ICU).
  • Ensure that where possible, patients are not discharged from the ICU during the night.
  • Ensure outreach service meets current guidelines. (NCEPOD (2011)
  • Ensure that level 3 intensive care patients are observed in line with their needs.
  • Make arrangements to ensure that contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.
  • Make suitable arrangements to ensure the dignity and privacy of patients accommodated in the Clinical Decisions Unit.
  • Ensure that patient records are maintained, include appropriate information relating to individual care needs, and are fit for purpose.
  • Review the process for incident reporting to ensure that staff are aware of and act in accordance with the trust quality and risk policy.
  • Review the clinical governance strategy within children’s services to ensure there is engagement and involvement with the surgical directorate.
  • Review the arrangement for the management and administration of topical anaesthetics
  • Review the children’s directorate risk register to ensure that risks are recorded and resolved in a timely manner.
  • Review the current PEWS system to ensure that it has been appropriately validated, is supported by a robust escalation protocol and is fit for purpose. Its use must be standardised across the children’s directorate (excluding neonates).

In addition the trust should:

  • 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 or learning disabilities.
  • Ensure the protocol for monitoring patients at risk is embedded and used effectively to make sure patients are escalated in a timely manner if their condition deteriorates.
  • Ensure that all medical staff in the ED have completed training in safeguarding children at the level appropriate to their grade.
  • Make appropriate arrangements for recording and storing patients’ own medicines in the CDU to minimise the risk of medicine misuse.
  • Respond to the outcome of their own audits and CEM audits to improve outcomes for patients using the service.
  • Review the arrangements for meeting the needs of patients presenting with mental ill health so they are seen in a timely manner.
  • Review the management of patient flow in the ED to improve the number of patients who are treated and admitted or discharged within timescales which meet national targets.
  • Review the systems in place in the ED for developing, implementing and reviewing plans on quality, risk and improvement.
  • Review the way complaints are managed in the ED to improve the response time for closing complaints.
  • Ensure there is strategic oversight and plan for driving improvement.
  • Review the quality of root cause analysis investigations and action plans following a serious incident or complaint and improve systems for the dissemination of learning from incidents and complaints.
  • On the Medical Assessment unit the trust should ensure that point of care blood glucose monitoring equipment is checked. It should also consider how this checking should be managed to be integrated as part of an overall policy that forms part of a pathology quality assurance system.
  • Develop systems to ensure the competence of medical staff is assessed for key procedures.
  • Develop systems to ensure that medicines are stored at temperatures that keep them in optimal condition.
  • Ensure that patients’ clinical records are stored securely in ward areas.
  • Review the ways in which staff can refer to current clinical guidance to ensure that it is easily accessible and from a reputable source.
  • Review current nil-by-mouth guidance to ensure that it is consistent with national standards; patient information leaflets should be standardised and reflect national guidance.
  • Review the process for the management of patients presenting with febrile neutropenia to ensure they are managed in a timely and effective manner.
  • Standardise the post-operative management and guidance of children undergoing urology surgery.
  • Review the process for the hand-over of pre-operative children to ensure they have support from a health care professional with whom the child and family are familiar with.
  • Ensure that all staff introduce themselves and wear name badges at appropriate times.
  • Review the location of the vending machine currently located between Hedgehog ward and the Woodlands Unit.
  • Review the managerial oversight of staff working in children’s outpatients.
  • Review the current clinic provision to ensure that women who have recently miscarried or who are under review for ante-natal complications are seen in a separate area to children who are also awaiting their appointment.
  • Review the facilities and admission process for elective surgical patients.
  • Monitor the transfers between sites, for both clinical and non-clinical reasons. The monitoring process should include the age of the patients transferring and the time they arrived after transfer.
  • Have clarity about the definition of what constitutes an Serious Incident Requiring Investigation (SIRI) or Never Event in relation to the retained swabs.
  • Ensure policies that have not been reviewed and impact on current evidenced-based knowledge/care are updated.
  • Address staffing levels and recruitment on the gynaecology ward/unit
  • Ensure appropriate reporting and recording of incidents on the trust system on the gynaecology ward.
  • Implement actions for the findings of the gynaecology ward audit undertaken in June 2014.

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

Requires improvement

Updated 3 February 2015

The maternity services at Tunbridge Wells Hospital were well planned and organised. There were systems in place that ensured that safety was a priority. Women and their babies were treated in a well-equipped environment.

Women’s care and treatment followed national evidenced-based guidelines. Staff involved women who use the service as partners in their own care and in making decisions, with support where needed. Risks were effectively assessed and managed, there was a process for reporting incidents and any areas of learning were shared with staff in the maternity service.

However, the gynaecology service did not mirror the same robust approach to the recording of incidents on the electronic recording system. The maternity service demonstrated the trusts vision, being proud of the service they offered to women.

Investigations and internal reviews to look at interpersonal relationships within obstetrics and gynaecology consultants needed to be commissioned and completed and the findings fed-back to staff in order that longstanding cultural and behavioural issues amongst staff groups could be resolved.

Medical care (including older people’s care)

Requires improvement

Updated 3 February 2015

Overall, medical care services required improvement.

Staff provided kind, compassionate care that preserved patients’ dignity. Patients were supported emotionally and received enough information to be involved in their care and treatment. Staff felt supported by their leaders and managers to provide high quality care and there was a culture that was focussed on meeting the needs of individual patients and their families. Service leaders at all levels had systems in place so they knew how well they were doing and were aware of the service needs.

However; Policies in relation to the checking of blood glucose monitors were not being followed and the temperature of storage of medicines was not robust. Patient records were not always stored securely.

Current clinical guidance was not always easily accessible for staff. Staff sometimes used inappropriate source of guidance that led to ineffective care. National audits showed patients with stroke or diabetes were receiving below average quality care.

Medical care services were not responsive to people’s needs as there was insufficient capacity in the service to meet demand. Arrangements for the provision of translation services required improvement.

Urgent and emergency services (A&E)

Requires improvement

Updated 3 February 2015

There was a multidisciplinary collaborative approach to care and treatment that involved a range of health and social care professionals. There was adequate access to both medical and clinical leads to support a seven day service. Medical and nursing staff had good access to education to develop their skills and competencies.

The ED provided a caring and compassionate service. Staff treated patients with respect and kept patients, their relatives and carers well-informed and involved in the decisions and plans of care. Staff respected patients’ choices and preferences and were supportive of their cultures, faith and background.

However the protocol for monitoring patients at risk was not used effectively and the department did not have enough medical staff trained at the appropriate levels for safeguarding children, which increased the risk of oversight for vulnerable children attending the ED.

There was no protocol for managing patients’ own medicines in the CDU, which increases the risk of misuse of medicines.

Security staff were trained in control and restraint under their Security Industry Authority (SIA) licences only and had not completed patient specific training courses to improve their awareness when they supervised patients presenting with challenging behaviours, including patients with mental ill health and dementia needs.

Patient flow was poor and waiting times were above the national average due to capacity.

Male and female patients were accommodated in the CDU overnight and shared bathroom facilities, which compromised the privacy and dignity of patients and did not meet the standard for mixed sex accommodation.

The department was failing to meet their target for closing complaints within an agreed response date.

Surgery

Requires improvement

Updated 3 February 2015

Patients found the staff to be caring but improvements are required to ensure the service is safe, effective, and responsive. Improvements are required in the well led domain.

Whilst most people admitted to Tunbridge Wells Hospital were happy with the quality of care they received and patient outcomes were, generally, in line with national averages, there remained significant shortfalls in the way services were provided.

The Surgical Assessment Unit provided real benefits to patients and increased the effectiveness of surgical services at the Trust.

The operating theatre department was well managed and demonstrated improving efficiency and effectiveness. Patients received safe peri-operative care and all appropriate measures were taken to ensure optimal outcomes for during and immediately after their operation.

Where there were patients that were complimentary about the care they received there were others who reported negative experiences with the level of care they received.

The Trust had good resuscitation provision and staff understanding of the safeguarding policies was good. However, the level of falls seen and the impact of these on patient wellbeing were unacceptable. Falls prevention work was ongoing but had not been embedded in the surgical patient pathways.

Record keeping was poor; individual patient’s records were disorganised and incomplete.

Risk assessment and care planning for patients was not always adequate.

The Trust had reduced the number of hospital acquired infections and the latest recorded level showed performance below the national benchmark but there was still work to be done improving compliance with hand hygiene policies as this was well below the target of 100%.

Team working within the surgical directorate meant patients were not admitted under a named consultant and were frequently passed between teams. This resulted in a lack of continuity of care, indecisiveness over the plan of care and mixed messages to the patients.

High bed occupancy levels led to ineffectiveness in the service provision. Operations were frequently cancelled, patients experienced unexpected delays and were cared for in unsuitable environments.

Surgical patients were cared for on non-specialist wards and received sub-optimal care; this was of particular concern for patients with spinal problems. It also resulted in frequent transfers between sites for non-clinical reasons. There were concerns about ‘out of hours transfers’ and The Trust was unaware how frequently patients were being transferred between sites for non-clinical reasons.

There was a lack of access to a translation service with staff relying on relatives, sign language and staff who spoke another language.

Leadership was very variable. Some staff felt supported whilst others felt disempowered and “Cut adrift”. Where we saw good leadership it was at a local ward or department level and reliant on the personalities and managerial skills of the individual. There was no sense that the staff working directly with patients understood what was happening at board level; the reverse was also true with little sense that the executive team and board really understood what was happening operationally across the Trust.

There was little evidence of effective trust wide learning from incidents and complaints.

Intensive/critical care

Inadequate

Updated 3 February 2015

Staff were caring but improvements were required to make the service safe, effective, responsive and well led.

There were no apparent admission guidelines in use to show the criteria for admission to the ICU and we observed a lack of direct supervision of Level 3 patients.

Medicines management systems were safe.

The unit was clean however patients that were being source isolated because of an infection had their room doors left open.

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 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. For example, at weekends, there was only one ICU Consultant led ward round per day and the consultants were often more than 30 minutes away as they were shared between the Trust’s two ICUs.

Staff cared for patients in a compassionate manner 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 due to lack of ward beds, and in many instances were discharged home directly from ICU. There were inadequate facilities for these patients. The patients were all in single rooms but there were no en-suite facilities or separate male/female toilet or bathroom facilities.

Improvements were required to the leadership of the ITU to ensure that national best practice guidelines were followed.

Services for children & young people

Requires improvement

Updated 3 February 2015

There was a collaborative approach to ensuring the nursing and medical needs of children were met. However, the relationship, engagement and management of children requiring surgical intervention required significant improvement. The children’s directorate lacked any formal governance framework which incorporated the surgical directorate; this led to some surgical patients not being offered pre-assessment appointments, the post-operative management of patients was inconsistent and written information was neither age specific or appropriate.

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

Performance against national audits was varied. The NNU performed well when compared nationally and although the NNU did not always meet national benchmark standards, action plans had been generated to improve services. However, children admitted for suspected febrile neutropenia could not always expect to receive antibiotics within an hour of arrival.

Parents and children were generally complimentary about the care and treatment provided. However, there were mixed reviews about the attitudes and behaviours of some surgical teams.

Where children and/or parents/carers had cause to complain, these complaints had been acknowledged, investigated and action plans generated to help improve services for the future.

The children’s directorate lacked a formal vision or strategy and some staff were unaware of the trust’s values. Day to day leadership within the directorate was good although the visibility of some senior managers needed to be improved. Whilst the directorate operated a risk register, we found this to be heavily underutilised. Whilst directorate leaders were aware of the issues which posed a potential risk to the operational effectiveness of the service, these risks were not always escalated to the trust board, nor were there any robust action plans in place to resolve the issues.

End of life care

Requires improvement

Updated 3 February 2015

The SPCT were available five days a week for face to face contact and a local hospice provided telephone out-of-hours and weekend cover. Medicines were provided in line with guidelines for EoLC, but DNACPR forms were not consistently completed in accordance with trust policy. There were no standardised processes for completing mental capacity assessments.

The SPCT provided four study days per year for trained nurses And 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.This was delivered by the palliative care consultant and the trust clinical ethicist. Palliative care link nurses were present on the wards we visited but training had reduced recently due to staff shortages in the SPCT. Leadership of the specialist palliative care team was good and quality and patient experience was seen as a priority.

All patients requiring EoLC were referred to the SPCT, but often no input was required by the team. Referrals to the team supported audit processes within the trust. There was a multidisciplinary team (MDT) approach to facilitate the rapid discharge of patients to their preferred place of care.

Patients were cared for with dignity and respect and received compassionate 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 that they had been treated with dignity and their privacy protected. They spoke highly of the staff in outpatients and radiology. They found staff polite and caring. However, many patients complained to us about the waiting times in the outpatient clinics.

Staff were reporting incidents and these were discussed at the clinical governance meetings within the directorates. There were systems 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 their national targets and consistently performed higher than the national average in regard to radiology waiting times. There had been a backlog in reporting CT and MRI scans for several months but there was evidence at the visit that these were reaching resolution. There was an ongoing backlog in clinic letters being sent out that was not resolved. There was risk to patients receiving delayed or inappropriate treatment and considerable stress caused to the staff.

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