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Provider: Dartford and Gravesham NHS Trust Good

On 22 August 2019, we published a report on how well Dartford and Gravesham NHS 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

Good

Updated 22 August 2019

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

  • Effective, caring, responsive and well led were good.
  • Safe was rated as requires improvement overall.
  • Services had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

  • The trust managed patient safety incidents well. Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support in line with the duty of candour.

  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. The trust had a programme of internal audits and participated in national audits and research projects. Trust policies and clinical guidelines reflected national guidance from the National Institute for Health and Care Excellence and other national bodies.

  • There was effective multidisciplinary working to improve patient care.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with commissioners, local authorities and other partner organisations.

  • The service treated concerns and complaints seriously. Complaints were investigated, the trust was candid with complainants and they learned lessons from their complaint investigation findings.

  • The trust had an effective system for identifying strategic risks or planning to eliminate or reduce those risks. Robust arrangements were in place for identifying, recording and managing risks, issues and mitigating actions. The trust board had sight of the most significant risks.

  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The workforce strategy reinforced the trust’s values with the core message ‘Our Family, Caring for Yours’. The development of the trust’s values involved focus groups with over 300 staff involved. Staff developed the values and they were aligned to the core knowledge and skills framework, national leadership standards and codes of professional conduct.

However:

  • The urgent and emergency care service did not mirror the general findings of the hospitals services. The leadership of the service did not have sufficient oversight of the quality and safety of the service provided.
  • While the trust had controlled infection risk well and there had been a significant improvement in practice, we observed poor practice in relation to the use of personal protective equipment and that several staff were not ‘bare below the elbow’ in the emergency department.
  • In urgent and emergency care, patients did not always receive treatment within agreed time frames and national targets.
  • In urgent and emergency care, staff treated patients with compassion and kindness. However, because of the constraints of the physical environment, it was not always possible for staff to respect patients’ privacy and dignity and maintain their confidentiality.
  • The average length of stay for non-elective surgery at the trust was worse than the England average and showed little improvement since our last inspection.
  • There was poor compliance to safeguarding adults training for nursing and medical staff.
  • There was no Mental Capacity Act specific training at the time of the reporting period. The trust advised that a new course was introduced on 1 April 2019.
Inspection areas

Safe

Requires improvement

Updated 22 August 2019

Our rating of safe stayed the same. We rated it as requires improvement because:

  • While the trust had controlled infection risk well and there had been a significant improvement in practice, we observed poor practice in relation to the use of personal protective equipment and that several staff were not ‘bare below the elbow’ in the emergency department.
  • There was poor compliance to safeguarding adults training for nursing and medical staff.
  • While the trust generally safeguarded patients from the risk of abuse, some staff in the emergency department did not always recognise when adults and children may be at risk of abuse. Although staff in the department did know how to respond to the risk when it was recognised.
  • We found that temperature monitoring of medicines storage areas was not always consistently undertaken. Plans were in place to utilise a remote temperature monitoring system, with an estimated completion date of December 2019.

However:

  • Services had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Generally, staff knew how to recognise and report abuse and they knew how to apply it. There was a dedicated safeguarding team to support staff and patients. This team liaised with partner organisations to safeguard children and adults in vulnerable circumstances.

  • The trust followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.

  • Staff kept detailed records of patients’ care and treatment. Generally, records were clear, up-to-date and easily available to all staff providing care. Staff always had access to accurate and comprehensive information on patients’ care and treatment.

  • The trust managed patient safety incidents well. Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support in line with the duty of candour.

  • Generally, the trust had suitable premises and equipment and looked after them well.

  • Medicines reconciliation was consistently above the national target of 70% at 24-hours post admission. This is an important measure of medicines safety.
  • Records were accessible to staff and stored securely, however in the emergency department, records were not always clear and up-to-date.

Effective

Good

Updated 22 August 2019

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

  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. The trust had a programme of internal audits and participated in national audits and research projects. Trust policies and clinical guidelines reflected national guidance from the National Institute for Health and Care Excellence and other national bodies.

  • Staff assessed and monitored patients regularly to see if they were in pain. Staff used specialised assessment tools for those who could not tell staff about their comfort. The patients we spoke with said that they were given adequate pain relief.

  • The trust made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide for support and development.

  • There was effective multidisciplinary working to improve patient care.

  • Staff ensured patients understood their treatment and gained consent before starting it. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

  • The trust managed the application of deprivation of liberty safeguards (DoLS) in patient’s best interests. The local authority did not have capacity to give statutory authorisation to every application the trust made, but the trust had a working agreement with the local authority to protect patients subject to DoLS.

However:

  • The urgent and emergency care service failed to meet any of the national standards in the 2016/17 Royal College of Emergency Medicine moderate and acute severe asthma audit. The department only met three of the 13 indicators within the 2016/17 severe sepsis and septic shock audit.
  • The trust could not demonstrate that effective local audit was used for the urgent and emergency care service, to act on national audit results.
  • For the surgery service, although staff understood best practice in obtaining consent, the practical application of the Mental Capacity Act varied.

Caring

Good

Updated 22 August 2019

Our rating of caring stayed the same. We rated it as good because:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to patients to minimise their distress. Patients had access to specialist teams to meet their needs.

  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and families were given choices and information to help them make their decisions.

However:

  • In urgent and emergency care, the environment made it difficult to always respect patients’ privacy and dignity and maintain confidentiality.

Responsive

Good

Updated 22 August 2019

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

  • The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with commissioners, local authorities and other partner organisations.

  • Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.

  • Services took account of patients’ individual needs. Services were accessible to those with a wide range of disabilities or special needs, including those with mobility, sensory or cognitive challenges. There were arrangements to meet patients’ cultural needs.

  • The trust sought patient feedback to make improvements to services. Developments of new services within the trust were based on identification of needs through consultation with community health leadership such as, the clinical commissioning group, Healthwatch and other voluntary sector groups.

  • The trust treated concerns and complaints seriously. Complaints were investigated, the trust was candid with complainants and they learned lessons from their complaint investigation findings.

  • Staff used a translation service when patients did not speak English. Managers made sure patients and carers could get help from interpreters or signers when needed.

However:

  • In urgent and emergency care, patients did not always receive treatment within agreed time frames and national targets.
  • There was often a delay in obtaining a specialist inpatient bed for children requiring acute mental health care.
  • The average length of stay for non-elective surgery at the trust was worse than the England average and showed little improvement since our last inspection.
  • The trust did not always meet its own standards of timeliness when responding to complaints.

Well-led

Good

Updated 22 August 2019

Our rating of well-led improved. We rated it as good because:

  • Managers in the trust had the right skills and abilities to run a service providing high-quality care.

  • The trust had an effective system for identifying strategic risks or planning to eliminate or reduce those risks. Robust arrangements were in place for identifying, recording and managing risks, issues and mitigating actions. The trust board had sight of the most significant risks.

  • Generally, leaders operated effective governance processes, throughout the trust and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

  • Staff generally felt supported, respected and valued and felt proud to work at the trust.

  • The trust had a strategy and vision for what it wanted to achieve and workable plans to turn it into action. The trust’s 2014 to 2020 strategy was to deliver outstanding care, local specialist services and a hospital without walls.

  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The workforce strategy reinforced the trust’s values with the core message ‘Our Family, Caring for Yours’. The development of the trust’s values involved focus groups with over 300 staff involved. Staff developed the values and they were aligned to the core knowledge and skills framework, national leadership standards and codes of professional conduct.

  • The trust had systems so it could learn from deaths, complaints or safety incidents.

However:

  • The urgent and emergency care service did not mirror the general findings of the hospitals services. The leadership of the service did not have sufficient oversight of the quality and safety of the service provided.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 22 August 2019

Combined rating