You are here

Provider: East Kent Hospitals University NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 16 - 17 May 2018

During a routine inspection

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.


CQC inspections of services

Inspection carried out on September 5th - 7th 2016

During an inspection to make sure that the improvements required had been made

East Kent Hospitals University NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 750,000 across Dover, Canterbury, Thanet, Shepway and Ashford. The trust operates from three acute sites; William Harvey Hospital (WHH)Ashford, Queen Elizabeth the Queen Mother (QEQM) Hospital Margate and Kent and Canterbury Hospital. In addition local services including outpatients and diagnostics are provided from the Buckland Hospital Dover and The Royal Victoria Hospital, Folkestone.

The trust has over 1000 beds including 27 critical care beds and 67 children's beds. The trust receives over 200,000 emergency attendances , 94,000 inpatient spells and 727,000 outpatient attendances. There are 138,000 day case attendances. All core services are provided at both William Harvey Hospital and QEQM Hospital whilst at Kent and Canterbury Hospital there are no maternity beds and a minor injuries unit with an emergency care centre rather than a full emergency department service.

We carried out an announced inspection between 6th and 8th September 2016.

This is the third inspection of this trust. The first in March 2014 led to an overall rating of inadequate and as a consequence the trust was placed into special measures by Monitor. A supporting performance management structure has been placed around the trust including the placement of a Monitor director of improvement. Following our second inspection in July 2015 the trust showed significant signs of improvement and an overall rating of requires improvement applied. We also made the recommendation that the trust remained in special measures as leadership was not substantive and a number of service improvements were not fully embedded in practice.

This inspection was specifically designed to test the requirement for the continued application of special measures to the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection. The remaining services were not inspected as they had indicated strong improvement at our last inspection and our information review indicated that the level of service seen at our last inspection had been sustained.

Following this inspection we have re-rated the services inspected. For the other services we have maintained the ratings from the July 2015 inspection. We have aggregated the ratings to provide an updated overall rating for the trust of requires improvement.

Caring was rated as good and safe, effective, responsive and well led were all found to require improvement. We found that William Harvey Hospital, QEQM Hospital and Kent and Canterbury Hospitals as individual locations also all require improvement.

It is important to read the detail of this report. Whilst the overall trust rating has not changed from the inspection of July 2015 this report indicates a number of areas in which further significant improvement has been obtained, notably there are no longer any elements of the report that are rated inadequate.

Our key findings were as follows:

SAFE

  • There are delays in the transfer of patients from ambulances into the emergency department.
  • Completion of patients medical records was not comprehensive and consistent.
  • Staffing levels in medicine and maternity have continued to impact on the quality of patient care and experience.
  • Planned preventative maintenance of medical equipment, although improved, remained behind plan.
  • Issues around consistency of incident reporting in the emergency medicine departments had been addressed.
  • Access to cardiotacography CTG equipment in maternity services had been improved.
  • The assessment of patient risk had improved in the emergency care and maternity settings.
  • The ratings for safety had improved in all emergency care departments including a movement from inadequate to requires improvement in the ED at William Harvey Hospital

EFFECTIVE

  • Although deficiencies in audit results were addressed through action plans, the actions and timescales for completion were not always clearly defined.
  • The results for stroke and diabetes were worse than the England average for Kent and Canterbury Hospital, and in the case of stroke indicating a deteriorating trend.
  • The trust had not successfully attained the required standard for a number of the components of the NCDAH.
  • Although the end of life care pathway had been significantly improved it was in the early stages of implementation.
  • National and local audit was being undertaken in all services inspected. Audit was followed up by the completion of action plans to address deficiencies.
  • The trust had implemented documentation and training to replace the Liverpool Care Pathway.
  • The trust had improved its rate of sepsis screening.

CARING

  • All services inspected were rated as good. The culture of compassionate care that was reported at our last inspection had been maintained and was supported by feedback and our observations during this inspection.
  • Discussions with patients and carers indicated confidence in the level of involvement they have in their or their relatives care.
  • Issues relating to the emergency department reported following our last inspection had been resolved by the impact of improved leadership.
  • Patient surveys supported the observations of the inspection team.

RESPONSIVE

  • Access targets for emergency care, referral to treatment and cancer were not being attained.
  • Patients continue to be moved between wards to address capacity issues and patients are placed in beds within unsuitable specialty wards.
  • Patients on an end of life care pathway do not receive rapid discharge to support achieving their preferred place of death. The trust does not measure attaining preferred place of death.
  • Improvements in availability and use of data for bed management purposes, facilities and support to dementia patients and overall engagement with CCG's in planning of services have improved

WELL LED

  • Changes in leadership in end of life care and maternity services had only recently been realised and as a result had yet to fully address the issues relating to these services.
  • Despite improvement, the national staff survey stillreports a high number of indicators that are in the worst 20% nationally.
  • Changes in performance and risk management remain relatively new and have yet to become fully embedded.
  • The trust board and executive are at full establishment and staff acknowledge greater visibility and clarity of direction within the organisation
  • The culture of the organisation continues on a trajectory of improvement with a continued reduction in bullying and harassment.
  • Staff at all levels are contributing to the improvement programme and as a result a momentum of improvement is apparent within the organisation

We saw several areas of outstanding practice including:

  • Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.

  • Ensure the number of staff appraisals increase to meet the trust target. So that the hospital can assure itself that staff performance and development is being monitored and managed.

  • Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.

  • Ensure that all staff have attended mandatory training and address gaps in training records that make it difficult to determine if training meets hospital policy requirements.

  • Ensure generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.

  • Take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Ensure there are sufficient numbers of midwives to meet national safe staffing guidelines of 1:1 care in labour.

  • Ensure maternity data is correctly collated and monitored to ensure that the department’s governance is robust.

  • Ensure there are adequate maintenance arrangements in place for all of the medical devices in clinical use in accordance with MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • Ensure that mental capacity assessments are in place for vulnerable adults who lacked capacity.

There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13th-17th July 2015

During a routine inspection

East Kent Hospitals University NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 750,000 across Dover, Canterbury, Thanet, Shepway and Ashford. The trust operates from three acute sites; William Harvey Hospital (WHH)Ashford, Queen Elizabeth the Queen Mother (QEQM) Hospital Margate and Kent and Canterbury Hospital. In addition local services including outpatients and diagnostics are provided from the Buckland Hospital Dover and The Royal Victoria Hospital, Folkestone.

The trust has over 1000 beds including 27 critical care beds and 67 children's beds. The trust receives over 200,000 emergency attendances , 94,000 inpatient spells and 727,000 outpatient attendances. There are 138,000 day case attendances. All core services are provided at both William Harvey Hospital and QEQM Hospital whilst at Kent and Canterbury Hospital there are no maternity beds and a minor injuries unit with an emergency care centre rather than a full emergency department service.

The trust provides services to a population that has lower than England average black Asian and ethnic minority representation  and only Thanet has levels of deprivation below the England average. However, Dover, Thanet and Shepway are all below the national average for child poverty.

We carried out an announced inspection between 13th and 17th July 2015. We also undertook unannounced visits to the trust on the 29th of July.

This is the second inspection of this trust. The first in March 2014 led to an overall rating of inadequate and as a consequence the trust was placed into special measures by Monitor. A supporting performance management structure has been placed around the trust including the placement of a Monitor director of improvement.

Overall this trust requires improvement. Whilst caring was rated as good, safe, responsive and well led were all found to require improvement and effective was found to be inadequate. We found that William Harvey Hospital, QEQM Hospital and Kent and Canterbury Hospitals as individual locations also all require improvement. Both Buckland Hospital and Royal Victoria Hospital were rated as good.

Our key findings were as follows:

SAFE

  • There has been significant improvement in the culture and processes surrounding the reporting of incidents although we found practice within the emergency departments that was inconsistent with trust policies.
  • Infection control policies and procedures were in place and adhered to and the environment was clean. We did find that the escalation ward at QEQM was not fit for purpose and that appropriate fire safety planning and processes were not in place in some areas.
  • Equipment was largely available as required by the staff but there was inconsistent practice in the identification of equipment that had been cleaned and was ready to use.
  • Despite recruitment challenges staffing levels had improved. However, the increased use of agency and locum staff requires diligence to ensure that competency levels are identified and workloads are not excessive.
  • The standard procedures for the placement of nasogastric tubes requires clarification with a supporting communication and training package to ensure consistent safe practice across all locations within the trust.

EFFECTIVE

  • Although national audit performance was largely adequate we are concerned about the deteriorating performance in the emergency department in some audits without the development of action plans. The trust had also not made appropriate provision for the end of life care pathway and had not completed the 2015 national care of the dying audit.
  • Best practice protocols and policies were in place and accessible via information technology, although we identified occasions where printed copies in use but were out of date.
  • Staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards could be improved.
  • Corporate induction, local induction, appraisal and supervision along with specialist nurses provided a suitable framework for maintaining a competent workforce.

CARING

  • Care was largely compassionate and afforded patients and carers dignity and privacy although there was a shortage of private areas to support confidential discussions.
  • Patients and carers were kept informed and engaged regarding care plans and emotional support was well provided to patients and staff.

RESPONSIVE

  • Service planning is required to address the congested emergency pathway and in maternity services to appropriately manage the demand for beds.
  • Facilities and support for dementia patients and patients with mental health needs are not at the level required.
  • The trust has a well developed approach to the management of learning from complaints.

WELL LED

  • A suitable board structure is in place which is underpinned by a governance structure that has been revised following external review.
  • Despite some inconsistencies in risk assessment at directorate level, risks are reviewed regularly and escalated through the governance structure. The board understands it's three key risks.
  • Improvements in culture and staff engagement have been identified, however there remains pockets of behaviour and practice that do not support the continued improvement aspiration of the trust.
  • Some departments do not have clear sight of strategy, however the development of, and engagement with, the trust clinical strategy will facilitate resolving this.

We saw several areas of outstanding practice including:

  • The outpatient improvement plan had significantly improved the service for patients. This transformational change has been well structured and designed to deliver improvements in access, notes availability and overall patient experience. It's success is an example of outstanding nurse leadership.
  • The trust had introduced an innovation and improvement hub where staff could meet and discuss improvement initiatives and this is generating ideas, enthusiasm and heightened staff engagement.
  • The pre-operative joint clinic for patients is recognised as enhancing patient outcomes.
  • The care pathway for patients discharged with ridged cervical collar in place is acknowledged for contributing to on-going care to individuals.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Make arrangements for the replacement of the Liverpool Care Pathway and ensure that appropriate national audit is undertaken.
  • Ensure that where deficiencies in audits are identified that clear action plans are developed that are subsequently managed within the trust governance framework.
  • Ensure that there are sufficient numbers of suitably qualified, skilled, and experienced staff available to deliver safe patient care in a timely manner.
  • Ensure that the environment and facilities in which patients are cared for must be safe, well maintained, fit for purpose and meet with current best practice standards.
  • There must be sufficient equipment in place to enable the safe delivery of care and treatment, that the equipment is regularly maintained and fit for purpose to reduce the risk to patients and staff.
  • The trust must ensure the hospital has sufficient capacity to cope with the number of women in labour and new born babies on a day to day basis.
  • There must be robust systems in place to monitor the safe management of medicines to ensure that national guidelines are reviewed appropriately and their implementation monitored.
  • Ensure that there are clear trust wide protocols for the placement of nasogastric tubes.
  • Ensure that medicines and intravenous fluids are stored safely and securely.
  • Ensure that suitable arrangements are made for patients with mental health issues whilst awaiting assessment.

In addition, the trust should:

  • Clarify emergency care services provided at Kent and Canterbury and provide clear protocols for the ambulance service about what patients can be admitted.
  • Review the training provided to clinical staff on the Mental Capacity Act and DoLS to ensure all staff understand the relevance of this in relation to their work.
  • Ensure that all staff undertake required training in safety related subjects.
  • Continue to improve referral to treatment times across all specialities to ensure that patients are treated in an acceptable timeframe following referral to the service.
  • Standardise inotropic infusions to avoid the risk of potential drug errors when staff engage in cross site working.
  • Develop a formal vision and strategy for women’s health services to enable the development of a modern maternity service which is woman centred, underpinned by a sound evidence base and benchmarked against best practice standards.
  • Review the routine administrative burden on maternity staff at weekends and out of hours should be reduced in order to free midwifery staff to look after patients.
  • Encourage the reporting of non-clinical incidents in order that action can be taken to protect patients from avoidable harm.
  • Ensure that the electronic system for allocating NHS numbers to new born babies should be functioning, in order to avoid the risk of babies missing screening tests through a manual process with insufficient printers available.
  • Ensure there is a robust system in place to measure, monitor and analyse common causes of harm to women during pregnancy and childbirth.
  • Review its medical bed capacity to ensure that the majority of patients are cared for in the correct speciality bed for the duration of their hospital admission. It should also review its arrangements for the management of patients outlying in non-speciality beds to ensure the quality and safety of their care is not compromised.
  • Review the processes in place that provide assurance that equipment shared between patients is clean and ready for use.
  • Review the pharmacy service and how staff shortages are impacting on patient’s timely discharge.
  • Review its care planning arrangements for summarising and recording the individual needs of patients when individual risks have been identified.
  • Review pain management tools to assist patients living with a disability or dementia.
  • Ensure that all confidential patient records are fit for purpose and securely stored in clinical areas to minimise the risk of unauthorised access.
  • Consider the support available to people living with learning disabilities is provided when they are patients, and to its staff to ensure they can meet individual needs.
  • Continue to improve referral to treatment times across all specialities to ensure that patients are treated in an acceptable timeframe following referral to the service.
  • Consider how the environment in which surgical services are provided would be suitably maintained.
  • Ensure that staff are afforded the opportunity to have their performance formally reviewed.
  • Ensure staff in all areas complete all the required mandatory training.
  • Ensure that patient risk assessments were completed and acted upon.
  • Consider how it may improve the environment in the day surgical unit.
  • Consider how it may move forward with the implementation of the dementia care work to bring it to fruition.
  • Continue to work with commissioners to ensure there is adequate funding and resources for the End of Life service.

Significant progress has been made over the last six months following the appointment  of new executive team members, in particular in terms of staff and stakeholder engagement. However, the team is still very new and further improvement in quality and safety is still required across multiple services before they can be considered good. I am therefore recommending that the trust should remain in special measures. CQC will re-inspect key aspects of care within the next six months to make a further determination on this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4, 5, 6, 7, 19 and 20 March 2014

During a routine inspection

The trust is a group of hospitals providing acute, specialist and community services to a population of 759,000 across all of East Kent. The trust has a total of 1,173 beds in its three acute hospitals: 476 at William Harvey Hospital based in Ashford; 410 at Queen Elizabeth The Queen Mother Hospital based in Margate and 287 at Kent & Canterbury Hospital based in Canterbury. It also has two community hospitals – Buckland which is based in Dover and Royal Victoria which is based in Folkestone. The trust directly employs over 7,000 staff.

The trust has a stable long-standing board with only one of the seven executive directors having been recently appointed in 2013. It became a foundation trust in March 2009. It was a teaching trust and has been a university hospital trust since 2007.

We inspected the three acute hospitals from 4 to 7 March 2014. We also carried out an unannounced inspection on 19 and 20 March 2014.

At Kent and Canterbury Hospital in Canterbury the Accident & Emergency department closed in 2005 and was replaced by an Emergency Care Centre (ECC) and a Minor Injuries Unit (MIU). We inspected the ECC and MIU, as well as both A&E departments at the other two hospitals. We also inspected the two maternity units at Queen Elizabeth The Queen Mother and William Harvey Hospitals.

We wrote to the trust in January 2014 to request information in advance of our inspection, but we did not receive this within the required time frame and received it one week before the inspection.

Before and during our inspection we heard from patients, relatives, senior managers, and other staff about some key issues that were having an impact on the service provided at these hospitals. We also held three listening events in Canterbury, Margate and Ashford.

An issue that dominated discussions was the trust’s recent proposal to centralise surgical services to the Kent & Canterbury site. The staff we spoke with did not feel consulted in this decision and did not support the decision made by the board on 14 February 2014. Clinical staff raised detailed concerns with CQC and with executives in the trust.

We carried out this inspection because the East Kent trust had been identified as medium risk on CQC’s Intelligent Monitoring system.

Our key findings were as follows:

Headline findings

This trust was rated as inadequate for providing safe care; requires improvement for providing effective care; good for providing caring services, requires improvement for responsive care and inadequate for being well-led. We rated this trust as inadequate overall.

Key findings

  • There was a concerning divide between senior management and frontline staff.
  • The governance assurance process and the papers received by the Board did not reflect our findings on the ground.
  • The staff survey illustrated cultural issues within the organisation that had been inherent for a number of years. It reflected behaviours such as bullying and harassment. The staff engagement score was amongst the worst 20% when compared with similar trusts.
  • Staff have contacted us directly on numerous occasions, prior to, during and since the inspection to raise serious concerns about the care being delivered and the culture of the organisation.
  • The number of staff who would recommend the hospital as a both a place to work or to be treated is significantly less than the England average.
  • Risk to patients was not always identified across the organisation and when it was identified it was not consistently acted on or addressed in a timely manner.
  • Throughout the trust there was a number of individual clinical services that were poorly led.
  • There were insufficient numbers of appropriately trained staff across the three sites and in different areas of the trust. Specific staffing concerns were in the emergency departments, on wards at night and in areas across the trust where children were being treated.
  • Staff were referring to a trust major incident plan that was out of date; the staff we spoke with were not trained and had not participated in a practice exercises, given the location of this trust and its proximity to the channel tunnel this is a significant concern.
  • We had concerns in relation to the accuracy of the documentation of waiting times in the A&E department.
  • An incident reporting system was in place, but patient safety incidents were not always identified and reported, and the staff use of the system varied considerably across the trust.
  • Policies and procedures for children outside of the neonatal unit did not reflect to National Institute for Health and Care Excellence (NICE) quality standards and other best practice guidance for paediatrics.
  • Children’s care outside of recognised children’s areas (such as the children’s ward, the neonatal unit and the children’s centre) fell below expected standards. Equipment in areas where children were being treated was identified as being out of date and not safe.
  • There was a lack of evidence-based policies and procedures relating to safety practices across the three sites, and a number of out of date policies across the trust.
  • In the areas we visited we saw limited evidence of how clinical audit was used to provide and improve patient care.
  • We saw examples where audits had not been undertaken effectively and provided false assurance.
  • We found examples of poorly maintained buildings and equipment. In some cases equipment was not adequately maintained and was out of date and unsafe.
  • Patients had excessively long waits for follow-up appointments and then, when attending the outpatients department, they also experienced considerable delays waiting to be seen.
  • Communication following the withdrawal of the Liverpool Care Pathway had been poor and resulted in confusion and misunderstanding about alternative tools to support patients at the end of their life.
  • The complaints process was not clear or easy to access. The trust applied its own interpretation of the regulations and had two categories of complaints. A high a number of complaints were referred to the Ombudsman, and there were 16 open cases as of December 2013.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.