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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

Reports


Inspection carried out on 14 May to 13 June 2019

During a routine inspection

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.


CQC inspections of services

Inspection carried out on 7 Nov to 7 Dec 2017

During a routine inspection

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

Inspection carried out on 5 and 6 December 2013

During a routine inspection

Darent Valley Hospital offers a comprehensive range of acute hospital-based services to around 270,000 people in Dartford, Gravesham, Swanley and Bexley. The hospital opened in September 2000. The hospital building is run as part of a private finance initiative. This means the building is owned by The Hospital Company (Dartford) Limited, a private sector company, and the trust leases the building. Darent Valley Hospital now has around 463 inpatient beds and specialties that include day-care surgery, general surgery, trauma, orthopaedics, cardiology, maternity and general medicine. The hospital has a team of around 2,000 staff.

Dartford and Gravesham NHS Trust was selected as part of the Chief Inspectors of Hospitals’ first new inspections as a trust considered to be in the middle ground between low and high risk of poor care. This inspection focused on Darent Valley Hospital.

Dartford and Gravesham NHS Trust is registered for the following regulated activities to be provided at Darent Valley Hospital:

  • Diagnostic and screening procedures
  • Maternity and midwifery services
  • Surgical procedures
  • Termination of pregnancies
  • Transport services, triage and medical advice provided remotely
  • Treatment of disease, disorder or injury.

Since the trust registered with the Care Quality Commission (CQC) in 2010, Darent Valley Hospital has been inspected four times. At the last inspection in November 2012 the trust was found to be compliant with all regulations inspected.

Our inspection team included CQC inspectors and analysts, doctors, nurses, patient ‘Experts by Experience’ and senior NHS managers. Experts by Experience have personal experience of using or caring for someone who uses this type of service. The team spent two days visiting the hospital, and two further unannounced visits were conducted the following week. One of these included an evening/night time visit.

Maternity, outpatients, children’s services and end of life care were found to be good. In all services across the hospital, most staff were committed to the trust and said it was a supportive environment to work. Patients were generally positive about their experience and the care they received.

The trust faced challenges after the recent collapse of merger plans, and it had not yet developed an alternative vision for the organisation. There were a number of examples of good practice and examples of shared learning in the hospital, although in some cases the changes in practice in response to learning from serious incidents took up to 12 months to implement. The main challenge was the demand on the accident and emergency (A&E) department and the rise in emergency admissions. A significant causal factor had been the recent reduction of acute services in the immediate vicinity. The trust was managing issues on a day by day basis but not solving the key underlying problems, in particular bed management/capacity and inappropriate attendance at A&E. It is acknowledged that the trust cannot solve these problems on its own, as they will require a whole healthcare community approach.

The trust had taken action in some areas where staffing issues had been identified. This had included increased nursing staff levels on some wards, an increase in the number of porters in the pharmacy department and the recruitment of additional midwives. In A&E there were insufficient numbers of nurses qualified in the care of children and a high use of locum middle grade doctors, which had the potential to impact on patients’ safety.

Patients’ dignity was being compromised by the continued use of mixed sex wards and facilities in the Clinical Decision Unit where staff told us they always have mixed sex accommodation and the Medical Assessment Unit, which we observed as a mixed sex ward. This also occurred in the intensive care area when patients no longer required intensive care. Patients’ right to privacy was being compromised by personal information being on display in open areas, for example on computer screens in the A&E and confidential information being discussed in public areas such as corridors. The area in the operating theatre where people were received into the department also compromised patients’ privacy and dignity, as it was an open area. Since April 2011, the hospital’s bed occupancy rate had consistently been above the national average of 86.5%, rising as high as 96.1% for the period of April to June 2013. This was impacting on patient safety through the use of additional beds in areas not designed or equipped for this purpose.

In some areas, the trust was considering and implementing national guidelines, but in A&E we found guidance was not always being followed, for example with the management of children’s pain. Also some of the guidance that was available was not the most current such as resuscitation guidelines. Staff told us that the trust was a supportive environment in which to work and that training was available, though its own training records showed that attendance at the trust’s mandatory training was below its expected level. This was as low as 66% in some areas compared to the trust’s target of 85%. There was a system in place to monitor attendance at the trust’s mandatory safety training and follow up non-attendance, but this was ineffective in some cases. There were 285 members of staff whose training was out of date and were not booked to attend a session.

Overall, we found a culture where staff were positive, engaged and very loyal to the organisation. The staff and management were open and transparent about the challenges they faced.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.