You are here

Provider: East Kent Hospitals University NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 September 2018

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

We rated safe, effective, responsive and well-led as requires improvement, and caring as good. We rated ten of the trust’s 11 services as requires improvement and one as good.

Inspection areas

Safe

Requires improvement

Updated 5 September 2018

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

  • Training compliance for medical staff was worse than the trust target of 85%, in the services we inspected.
  • Training compliance in all core services we inspected had not achieved target for staff compliance in safeguarding children level three and safeguarding adult’s level two.
  • During the night the children’s areas of the Queen Elizabeth the Queen Mother Hospital and William Harvey Hospital emergency departments were closed. This meant children shared waiting areas with adults. There was no audio or visual separation between children and adult patients. There were no facilities available for the distraction of the distressed child in line with the Royal College of Emergency Medicine (RCEM): Emergency Department Care (2017) Quality standard 43.
  • There was a risk staff may not have recognised or responded appropriately to signs of deteriorating health or medical emergencies due to inconsistent practice in taking observations.
  • The arrangements for storing medicines did not always keep people safe. During our inspection, we saw opportunities for unauthorised people to access a variety of medicines.
  • Daily fridge temperature monitoring across the core services we inspected was inconsistent. Staff did not always take fridge temperatures. When they did take fridge temperatures, they were sometimes taken incorrectly and when temperatures were outside of the expected range, staff did not always escalate concerns in line with guidance. Some staff we spoke to, who were responsible for checking the temperatures, did not understand how to take the temperature correctly, why they were taking fridge temperatures or the impact of temperatures that were out of range. This meant the trust did not have assurance medicines were stored in line with manufacturer’s guidelines and would therefore be effective.
  • The trust had not updated sepsis guidelines to reflect separate assessment by age group. Sepsis is a life-threatening blood infection. Although staff told us changes were in progress, we did not see any documents to evidence this.
  • Some areas we reviewed during the inspection were visibly unclean.
  • Equipment and the environment were sometimes old and dated. Staff in the surgery department had raised incident reports about broken equipment, but these incidents were closed and not always actioned. This meant staff used equipment which was faulty or unsuitable for its purpose.
  • The trust was unable to provide us with results from hand hygiene audits when requested. This meant they were not assured staff cleaned their hands effectively and in line with national guidelines. Since our inspection we have seen evidence which demonstrated effective hand hygiene audits had been implemented, although the trust had not submitted the results previously.
  • Staffing rates in some departments we inspected were below the planned staffing levels. We saw one department with unfunded beds, this meant the number of patients in the department had increased but funding to provide staff for those patients had not increased. In some instances, the hospital had not been able to recruit permanent staff or find bank or agency staff to fill in for uncovered shifts. This meant senior staff had to cover or there were not adequate numbers of staff to provide necessary care.
  • Bank and locum staff provided a significant portion of nursing and health care assistant cover, this resulted in a large gap in skill mix as the day to day nursing care varied significantly.

However,

  • Staff we spoke with understood their responsibilities to safeguarding both adults and children, despite low training compliance levels.
  • There were processes and pathways to escalate and care for patients with suspected sepsis in a timely fashion. Staff managed suspected or confirmed cases of sepsis effectively using the ‘Sepsis 6’ care bundle. Audit findings showed improved compliance in relation to the screening and management of patients with sepsis.
  • In some core services, we saw mandatory training had improved to meet the trust targets.

Staff understood their responsibilities to raise concerns and report incidents, even when the patient sustained low or no harm. The trust investigated serious incidents and staff complied with duty of candour requirements.

Effective

Requires improvement

Updated 5 September 2018

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

  • The trust performed some audits but they did not always perform scheduled audits. The trust did not always learn from audit outcomes or apply learning. This meant the trust was missing the opportunity to use audit information to implement meaningful change.
  • When staff identified learning from audit results and the organisation did not always implement changes or changes were sometimes delayed or stalled. We requested the action plans that had been created in response to the Royal College of Emergency Medicine audit results. The plans we received were incomplete. We did not see evidence in meeting minutes that action plans were shared or discussed. The plans did not always show they had a divisional sign off and although most actions had a completion date, it was unclear if these actions had been accomplished by their completion date. Many of the action plans were brief and limited. We did not see evidence that any of the actions were effective as audits were not repeated
  • Audit results from national audits varied. Although there were areas where the trust performed similar to the national average, there were audits across the core services where the trust did not meet national standards.
  • Staff still did not always receive timely and effective appraisals. Appraisal rates changed every month but generally the trust did not meet its target for appraisals. We reviewed the most recent staff survey which showed poor staff satisfaction regarding the effectiveness of their appraisals.

However,

  • In the 2016/17 severe sepsis and septic shock audit, staff took 92% of patients’ observations on arrival. This was better than the UK average of 69%.
  • Staff we spoke with understood the importance of patients receiving sufficient nutrition and hydration. Dietitians within the hospital’s clinical decision unit, supported patient nutrition and hydration. Staff could refer patients could if there were concerns about their weight and calorie intake.
  • There were processes to make sure pain relief medicines were effective for patients.
  • The trust supported national priorities to improve the population’s health. Staff supported patients to manage their own health. We also saw information for patients on how to find emotional support and guidance.
  • Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. Staff we spoke with could describe their responsibilities to ensure patients consented when they had the capacity to do so.
  • In some individual departments, appraisal numbers had improved and met or exceeded the trust targets.

Caring

Good

Updated 5 September 2018

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

  • Staff provided emotional support to patients to minimise their distress and generally cared for patients with compassion.
  • Across most core services, staff tried to ensure patients privacy and dignity for instance using discreet symbols to communicate personal or sensitive information about medical history, disabilities or end of life status.
  • Staff involved patients and those close to them in decisions about their care and treatment. Medical staff provided clear information to their patients and families verbally and in writing across most of the core services.
  • Staff spoke to patients, both adults and children, in a way that they could understand. Staff told us about how they worked to communicate clearly with patients who had communication difficulties.

However:

  • There was no privacy and very little confidentiality for some patients waiting for and recovering from care.
  • Feedback from patients regarding the care they received was mixed.
  • People’s emotional, and social needs were not always addressed or reflected in their care, treatment and support.

Responsive

Requires improvement

Updated 5 September 2018

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

  • The trust remained under significant pressure to meet the needs of their patients. It did not have a clinical strategy, despite working with the Clinical Commissioning Groups (CCGs) and Sustainability and Transformation Partnership (STP) on this for some time. This meant the trust was not making some improvements or changes as they were waiting for the overall clinical strategy.
  • The Royal College of Emergency Medicine standard recommends that the time patients should not wait more than one hour from the time of arrival to receiving treatment. The trust did not meet the standard for ten months over the 12-month period from February 2017 to January 2018.
  • The Department of Health’s standard for emergency departments states 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. The trust did not meet the standard from February 2017 to January 2018.Performance ranged between 70% and 80%.
  • Flow through the emergency department was delayed due to low availability of beds in other departments. When patients were waiting for inpatient beds they were often waiting in the clinical decision unit or in the over flow corridor area. Although the department could discharge to ambulatory care, the unit was often too full to do so.
  • Across the surgery services Referral to Treatment Times (RTT) for admitted pathways were worse than the England average.
  • The hospital was not always responsive to the needs of children. A significant number of children could not access the area of the emergency departments, and nurses with paediatric competencies did not always treat patients in either the surgery or emergency departments. This was not in line with national guidance.
  • There was little evidence of the learning applied to practice within the service from complaints.

However,

  • The trust held bed meetings twice daily which ensured capacity was planned and discussed.
  • The trust used technology to support patient access to care and treatment. There were screens in the waiting areas displaying estimated wait times and patients could access this information before they arrived on the trust website or through a mobile app.
  • Staff took account of patients’ individual needs. The service took action to meet the needs of different patient groups so they could access the service on an equal basis to others. This included the needs of patients living with dementia, patients with learning disabilities, bariatric patients (those with a high body mass index) and patients unable to speak English.

Well-led

Requires improvement

Updated 5 September 2018

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • The trust had not sufficiently embedded systems and processes to support the leadership to be able to drive improvement at the time of the inspection.
  • A focus of transformation was the new clinical strategy. The trust had been working on the clinical strategy with the Clinical Commissioning Groups (CCGs) and Sustainability and Transformation Partnership (STP) to develop the plans in line with regional needs for several years. This strategy had not yet been agreed. As a result, the board had suspended some decisions, which would affect governance and running of the trust until the strategy was in place. This impacted on many aspects of running the trust including investment, staffing and culture.
  • The 2017 staff survey highlighted issues of concern. Board members recognised the need to focus on and improve the culture of the organisation and was developing processes to support staff and promote their positive well-being.
  • The trust did not have effective structures, processes and systems of accountability to support the leadership’s delivery of the strategy and high quality, sustainable services.
  • The trust did not have a system or process to ensure it learned from mistakes, shared that learning or implemented changed based on it. For instance, lessons from incidents were not always identified. When it was identified, it was not always used to inform change or change was not fully implemented.
  • Proactive risk identification and management was limited. Processes were not always adhered to and much risk management was reactive, risks were not always anticipated and it was not always clear that risks were escalated to the board.
  • The trusts did not always use information and data effectively to monitor and improve the quality of care.
  • Mandatory training numbers were low across core services and staff did not always feel they had time to complete mandatory and non-mandatory training.
  • Staff provided a mixed picture about the visibility of the senior leadership team across the trust. Some staff members felt senior leadership was visible and approachable others said they would not know the senior leadership team if they saw them.
  • Staff reported they did not always feel engaged and listened too. Some staff members told us they received too many e-mails and did not have time to read them. Some reflected they were disengaged and did not read communications, while others reported that they did not feedback to senior leadership because they did not feel they had been listened to historically.

However,

  • We found the senior leadership team had the capability and integrity to ensure strategy could be delivered and address risks to performance.
  • The trust was on a ‘transformation journey’. It aimed to build on the improvements, which had raised the trust out of special measures in 2017. The trust had a transformation board, which was to oversee the transformation of the trust from ward to board.
  • The transformation board was directly accountable to the Board of Directors and was on the agenda of each board meeting.
  • The trust had six priorities for its transformation. These were: Getting to Good, Higher Standards for Patients, Healthy finances, A great place to work, Delivering our Future, Right Skills Right Time Right Place.
  • These six work streams were used to develop change in the trust and were used in the board notes to justify and explain changes as well as being the structure used to communicate with staff and the public about change. The Trust included sustainability in its strategic and operational planning. The Sustainable Development Unit (SDU) and the regional network supported this.
  • The trust had seen some improvements to culture since being put into quality special measures.
  • The organisation had processes to manage current and future performance. There were systems and processes to assess, prevent, deter, manage and mitigate risk, although they were not always used effectively.
  • The trust managed data so that it was safe. It used an information management system developed as part of an NHS and private collaboration.
  • The communications and engagement strategy focused on engagement with public and patients, staff, governors, members, partner organisations and other stakeholders. There was a cooperative relationship between the engagement and communications team and the board. The engagement and communications team supported trust strategies, for instance the Council of Governors membership engagement strategy, Quality Strategy, People Strategy, Research and innovation strategy and the Trust’s charity.
  • The trust was proactive in encouraging some kinds of learning and development. For instance, it had an active research department and encouraged quality improvement.