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Provider: Kingston Hospital NHS Foundation Trust Outstanding

On 30 August 2018, we published a report on how well Kingston Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Outstanding

Updated 30 August 2018

Our rating of the trust improved. We rated it as outstanding because:

  • At location level, we rated safe, effective, responsive and well-led as good and caring as outstanding. We rated all of the trust’s eight services as good. In rating the trust, we took into account the current ratings of the five services not inspected this time.

  • We rated well-led for the trust overall as outstanding.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website www.cqc.org.uk/provider/RAX/reports

Inspection areas

Safe

Good

Updated 30 August 2018

Our rating of safe improved. We rated it as good because:

  • The design and layout of the emergency department (ED) had changed considerably since our last inspection. There was a new entrance area, waiting area, streaming cubicles, urgent treatment centre and majors waiting area. The resuscitation area had expanded to include two more bays and the major’s area expanded by five cubicles.
  • Mandatory training was well organised and staff were released from their normal duties to attend or complete them.
  • Safeguarding systems, processes and practices protected people from abuse, neglect and breaches of their dignity and respect.
  • Staffing numbers in nursing had improved since our last inspection. The trust planned and reviewed staffing levels and skill mix so that people received safe care and treatment. Where there were staff vacancies, there were processes in place to avoid any negative impact on patients.
  • Staff understood their responsibilities to raise and record safety incidents, concerns and near misses. Lessons were learnt and improvement was made when things went wrong.
  • There were good standards of infection prevent and control. All areas we inspected were visibly clean and staff adhered to bare below the elbow protocols.

However:

  • Medical staffing was not at establishment in the ED. We saw that half of the middle grade doctor posts were vacant.
  • The trust did not use any specific tools or rating scales for triaging mental health patients.
  • Not all outpatient services had suitable premises. For example, fracture and orthopaedic clinic was located at the far end of the main outpatient department with long convoluted corridors, and there were not sufficient seating arrangements to reflect the nature of the patients seen at that clinic.

Effective

Good

Updated 30 August 2018

Our rating of effective improved. We rated it as good because:

  • Care and treatment were delivered based on evidence-based guidelines, national guidance and best practice.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff development opportunities and systems for appraisals were commented on favourably by staff.
  • Patients nutrition and hydration needs were assessed and met. All patients had been offered food or drink unless they were nil by mouth, in which case they had intravenous fluids administered.
  • Patient’s pain levels were assessed and managed appropriately.
  • There was effective multi-disciplinary working across the services we inspected.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

However:

  • The trust was not meeting the 100% target in Royal College of Emergency Medicine (RCEM) audits. It was below the national average in moderate and acute asthma, vital signs in children, and procedural sedation in adults.
  • On medical wards, staff did not have access to some diagnostic scans seven days a week. If these were required during the night or over the weekend on an emergency basis, a consultant referral was needed.
  • Discharge summaries were not completed for all patients, preventing GPs from following up on patient care after discharge.

Caring

Outstanding

Updated 30 August 2018

  • Staff treated patients with dignity, kindness and compassion.
  • Staff took the time to interact with patients and those close to them in a respectful and considerate way.
  • Staff treated patients as partners in their care. Staff took the time to ensure patients and their families understood treatment plans and answered questions to explain what was going to happen next to provide reassurance.
  • Patients’ individual preferences and needs were always reflected in how care was delivered.
  • Staff maintained patients’ privacy at all times.
  • Staff helped patients and those close to them to cope emotionally with their care and treatment.
  • In the emergency department (ED), volunteers spoke with patients and relatives, and the department made use of a therapy dog, which helped attend to people’s emotional needs.
  • ED staff went to the canteen and obtained cooked breakfasts for patients and their relatives who had been in the department overnight, and this was embedded in practice.
  • Patients provided us with positive feedback about their care during our inspection.
  • Friends and families provided us with other positive examples of care. It was clear that staff placed a lot of emphasis on making sure patients were well cared for and building a positive relationship with them.
  • Staff showed determination and creativity to overcome obstacles to delivering care for vulnerable patients and those with additional needs. For example, in the outpatient department, quiet waiting areas for patients living with dementia and a learning disability were provided, despite the lack of space.
  • In the ED, patients with confusion were cared for in a caring and compassionate way in dementia friendly cubicles, which were designed by the staff specifically for patients.
  • Staff were compassionate and understanding towards people attending the ED due to their mental health.

Responsive

Good

Updated 30 August 2018

  • In the ED, five dementia friendly majors’ cubicles were designed by the staff to create a calming environment. Staff also designed two new resuscitation bays which included annexes so relatives could be close to the critically unwell patients and did not have to leave the area to go to the family room.
  • The ED consistently met the RCEM arrival to treatment 60-minute standard.
  • The trust had placed significant emphasis on meeting the needs of people living with dementia and had a series of arrangements in place to care for and improve the experience of those patients at the hospital.
  • From December 2016 to November 2017 the trust’s referral to treatment time (RTT) for non-admitted pathways had been consistently better than the England average. The trust had robust plans for clinical validation of patients in the tracking access issue and robust plans for recovery of waiting list backlogs and RTT indicators.
  • The trust performed better than the 93% operational standard for people being seen within two weeks of an urgent GP referral. Trust performance was consistently better than both the standard and the England average.
  • The trust was performing better than the 93% operational standard for people being seen within two weeks of an urgent GP referral for suspected cancer.
  • Staff had telephone access to language interpreters if they were required and interpreters could attend appointments when booked in advance. Staff could also access sign language interpreters.

However:

  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED. The trust was not meeting this four-hour standard, but was better than the England average.
  • From December 2016 to November 2017, the average length of stay for medical elective patients at Kingston Hospital was 7.8 days, which was higher than the England average of 5.8 days.
  • The trust took an average of 30 days to investigate and close complaints. This was not in line with their complaints policy, which stated complaints should be should be closed in less than 25 days.

Well-led

Outstanding

Updated 30 August 2018

  • The leadership in the ED had significantly improved since our last inspection. There was clear and strong clinical leadership in the department.
  • Services had a clear vision and set of values, with quality and sustainability as the top priorities. The vision for services were in line with the trust’s overall vision for the organisation.
  • All levels of governance and management functioned effectively.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Staff felt supported, respected and valued by the organisation.
  • Staff were confident that any issues in performance and behaviour would be addressed appropriately by senior leaders. Staff told us they were encouraged to be open and honest.
  • Services gathered people’s views and experiences, and acted on them to shape and improve the service and culture. Leaders and staff strived for continuous learning, improvement and innovation.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

However:

  • In the ED, incomplete documentation, closing incidents and below average mandatory training rates had been on the department’s risk register for up to six years, and remained as issues.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 30 August 2018

Combined rating