The Tunbridge Wells Hospital at Pembury

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