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Provider: Dartford and Gravesham NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 March 2018

Our rating of the trust stayed the same. We rated it as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 28 March 2018

Our rating of safe went down. We rated it as requires improvement because:

  • Overall the safety domain in urgent care, surgery, medicine and maternity was rated as required improvement. This meant that improvements were needed to safeguard patients from the risk of receiving unsafe care.
  • Patients were not protected from the risk of healthcare acquired infections because national and trust guidance was not being consistently adhered to.
  • There was a lack of robust infection control compliance monitoring. Trust quality monitoring data was not consistent with our inspection findings. Clinical areas were not always clean and infection prevention methods were not consistently used.
  • Emergency equipment was not consistently checked in line with trust policy.
  • Staffing in maternity was unsafe due to the midwife to birth ratio of 1:36 which is not in line with Birth-Rate Plus staff guidance.
  • In urgent and emergency care we found insufficient safeguarding processes which did not protect vulnerable adults or children from the risk of abuse.
  • Systems and processes to prevent recurrence from patient safety incidents were not effective because there was a lack of learning at departmental or trust wide level.
  • The standard of record keeping lacked consistency and varied greatly across the trust.
  • Records were not always stored securely or kept confidential.
  • In urgent and emergency care and surgery compliance with Mental Capacity Act Training was poor. This meant staff may not have awareness if patients lacked mental capacity to make decisions; or understand best interests decisions or awareness of the Mental Capacity Act 2005

Effective

Requires improvement

Updated 28 March 2018

Our rating of effective went down. We rated it as requires improvement because:

  • Surgery, medicine and urgent care were rated as requires improvement for the effective domain. The maternity core service was rated as good.
  • In medicine, consultants did not always work in a shift pattern that promoted continuity of care. This had led to delayed discharges and patients being reviewed twice unnecessarily.
  • In medicine, urgent care and surgery trust performance in the national audit programme showed varied performance when benchmarked against other trusts.
  • The medical directorate did not routinely undertake clinical supervision to ensure staff competencies were up to date.
  • In urgent care Mental Capacity and Deprivation of Liberty safeguards was not widely understood by staff.
  • Staff in theatres did not have the required knowledge, training and skills to care for children.
  • In surgery, there was not a process which ensured staff had the necessary skills and competence to perform their role within theatres. Ongoing competence was not reviewed and therefore not assured.

Caring

Good

Updated 28 March 2018

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

  • We observed patients being treated with compassion, by kind and professional staff who put patients at the heart of the service they delivered.
  • Patients were treated with dignity and were involved in planning and making decisions about their care.
  • Emotional support was provided to patients, and their relatives.
  • Patients told us the care they received met their individual needs and respected their wishes.
  • The feedback we received from patients and their loved ones showed high levels of satisfaction with the services.

Responsive

Requires improvement

Updated 28 March 2018

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

  • Access and flow throughout the trust presented as a daily operational challenge.
  • In urgent care and medicine, patients did not always have their individual care needs taken into consideration.
  • There was a notable increase in medical outliers in medical care.
  • In surgery relatives, staff and the internet were used to translate for patients who did not speak English. The use of family, friends or unqualified interpreters is strongly discouraged in national and international guidance and is not considered good practice. The trust had translation services available however staff said they avoided using them when they could to reduce cost.
  • In surgery systems and processes to learn and improve from complaints was not effective.
  • Overall, we found the service provided by the maternity service was responsive to individual needs and was rated as Good.

Well-led

Requires improvement

Updated 28 March 2018

Our rating of well-led went down. We rated it as requires improvement because:

  • There was a lack of clarity regarding the structure amongst executive teams, middle managers and staff. From an accountability perspective a lack of understanding of structure leaves the organisation vulnerable.
  • We found that the board was not always assured of safety and quality through its governance structures. Although there was a governance structure in place inspection findings showed that it was not effective.
  • Although the trust had an overarching strategy there was no current nursing or quality strategy, but plans were in place to refresh this following our inspection.
  • The trust had identified a gap in oversight and told us there was a need for a Head of Nursing role within directorate management teams in order to strengthen nursing leadership and governance processes.
  • Key nursing metrics did not form part of the performance reporting framework, but these were being developed at ward level.
  • We were not assured that there was a consistent and embedded approach to learning from incidents. We found pockets of learning were demonstrated but that this learning had not been shared trust wide. We also found that staff were not always following the trust policy and reporting relevant incidents.
  • The trust had a patient engagement strategy plan in place but at the time of inspection this had not been embedded into practice.

However:

  • The leaders had the skills, knowledge, experience and integrity to lead the trust. The trust board members we met were a group of individuals with a wide range of experience, knowledge and skills, although most relatively new to their posts.
  • The trust had a clear vision and set of values with quality and sustainability as the top priorities.
  • The trust’s strategy, vision and values underpinned a culture which was patient centred. The leadership culture in the trust was described by the Chief Executive Officer as ‘very focussed on getting it right for the patient’, and ‘friendly organisation where people felt free to express ideas and concerns’.
  • Most staff reported feeling supported, respected and valued. Staff felt able to raise concerns without fear of retribution. The trust had appointed a Freedom to Speak-up Guardian and had a number of routes to enable staff to raise concerns.
  • The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans. The trust had been working with both the South East London and Kent and Medway sustainability and transformation plans.
  • External organisations had recognised the trust’s improvement work. Individual staff and teams received awards for improvements made and shared learning. The trust worked with Guy's and St Thomas' National Health Service Foundation Trust with their Vanguard initiative.