Kettering General Hospital NHS Foundation Trust

Evidence appendix Rothwell Road Date of inspection visit: Kettering 05 to 07 February 2019 and 12 to 14 Northamptonshire March 2019 NN16 8UZ Date of publication: Tel: 01536492000 22 May 2019 www.kgh.nhs.uk This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust

Acute hospital sites at the trust

A list of the acute hospitals at Kettering General Hospital NHS Foundation Trust is below.

Name of acute Details of any specialist services provided Address hospital site at the site • Assessment or medical treatment for persons detained under the 1983 Act • Diagnostic and screening procedures • Family planning services Kettering General Rothwell Road, • Maternity and midwifery services Hospital Kettering, NN16 8UZ • Services for everyone • Surgical procedures • Termination of pregnancies • Treatment of disease, disorder or injury

Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 275,280 in north Northamptonshire, South Leicestershire and Rutland. There are approximately 541 inpatient beds and over 3,400 whole time equivalent staff are employed. Kettering General Hospital is one of the largest employers in Northamptonshire.

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All acute services are provided at Kettering Hospital with outpatients’ services also being provided at Nene Park, Corby Diagnostic Centre, and Isebrook Hospital. The findings in this report do not reflect the site we did not inspect, Isebrook outpatients.

The trust ended the financial year 2017/18 with a deficit of £34.7m (£33.6m after excluding the impact of non-performance technical adjustments – impairments, donated asset movements and loss on disposal of assets). The financial plan agreed with the regulator was a total deficit of £19.9m. This excluded sustainability and transformation funding as the trust rejected its control total. In 2017/8 the hospital had: • 87,497 patients per year, 240 patients per day in A&E; • 267,000 outpatients each year; • 741 outpatient clinics per week • 40,000 inpatients; • 41,500 day case patients; • 3,500 births. This was the fourth inspection of the trust which included ratings and the second inspection of the trust using a new methodology, whereby we inspected core services, and included an inspection of the well-led element of the trust overall and took place form 5 February 2019 to 14 March 2019. The first inspection took place in September 2014, when it was rated as requires improvement overall. The hospital was inspected again in October 2016. The overall rating for the trust was ‘inadequate’ with two of the five key questions we ask, safe and well-led, being ‘inadequate’. Effective and responsive were rated as ’requires improvement’. The trust, and every service level, was rated ‘good’ for care. The service was placed into special measures. The third inspection took place from 7 November to 1 December 2017, which was announced. Our rating of the trust improved. We rated it as requires improvement because: Caring was rated as good in all areas inspected. Safe, effective, responsive and well led were rated requires improvement, and leadership at the trust level overall was rated as requires improvement. However, the trust was not removed from special measures. Is this organisation well-led?

Leadership The trust had managers at most levels with the right skills and abilities to run the service. There was a mix of experience within the executive directors with some new to the executive role and others with considerable experience.

In order to assess if the organisation was well-led, we interviewed the members of the board, both the executive and non-executive directors, and held focus groups with a range of senior staff across the hospital. We met and talked with a wide range of staff to ask their views on the leadership and governance of the trust. Over the previous 12 months, we had observed board meetings and serious incident panel meetings. We looked at a range of performance and quality reports, audits and action plans, board meeting minutes and papers, annual reports, investigations, and received feedback from patients, staff, and stakeholders.

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The trust board had the appropriate range of skills, knowledge and experience to perform its role. Although some were new to the board and trust, they reported a high level of support, gave very positive messages with regards to improvements and future opportunities. The capacity of the executive team had increased and the leaders had the skills and experience required. Teamwork was much more apparent than at previous inspections. Additionally, all the board members told us that over the past year, since the substantive chief executive had been in post, there had been a period of stability; they had been able to stand back and assess their impact as board. They had all, through a series of board development sessions and subsequent reflection, realised that they had become too involved in operational issues within the trust. As a result of this, they had focussed on the work of the committees who reported to them, so that their work was more accurate, better presented, timely and succinct. Reports were presented to the board ‘by exception.’ This had allowed the board to leave operational issues to the divisional teams, so that they could be more strategic.

Board Members

Since our last comprehensive inspection, there had been some changes to the trust board. The board comprised a chief executive officer (CEO), who was appointed in April 2018.This was their first CEO post.

There were seven other executive directors as detailed below:

• Interim deputy chief executive, joined the trust in June 2018. • Chief operating officer, joined the trust September 2018. • Medical director, was appointed in June 2010. • Director of nursing and quality, appointed October 2014. • Director of human resources and organisation development, joined the trust in June 2014. • Director of finance and contracting, was appointed in June 2017. • Director of integrated governance, joined the trust in July 2018. The chair had been in post since August 2017 and was supported by six non-executives (NEDs) and one associate non-executive director. The NEDs had a range of experience and skills, including senior positions business and in health and social care.

Of the executive board members at the trust, 0.0% were British Minority Ethnic (BME) and 50.0% were female.

Of the non-executive board members 12.5% were BME and 37.5% were female.

Staff group BME % Female % Executive directors 0.0% 50.0% Non-executive directors 12.5% 37.5% All board members 6.3% 43.8%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

There was a council of governors in place who spoke positively of the relationships since the arrival of the chair and chief executive officer. When senior leadership vacancies arose the recruitment team reviewed capacity and capability needs. Additionally, the trust reviewed leadership capacity and capability on an ongoing basis.

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Leadership development opportunities were available, including opportunities for staff below team manager level. We were assured there was an accountability framework in place which defined responsibility from ward to board through a clinical directorate and divisional structure. There was a programme of board visits to the wards, which was recorded. Staff reported leaders were visible and all were described as approachable, individual board members made visits to wards and departments on all the trust’s sites.

In the 2018 staff survey 79.3% of respondents said they knew who the senior managers were, while this was below (worse) than the national average 83.4% it was an 4.3% improvement on 2017 response. 41.4% of staff said communication between senior management and staff was effective. This was above (better) than the national average (40.8%) and a 9% improvement from the previous year. 35.4% of responds said senior managers try to involve staff in important decisions, this was 1.6% above (better) than the national average and a trust improvement of 9.2% from the 2017 result. A formal leadership strategy, development programme, succession planning and talent management had been developed but not yet implemented or therefore embedded. The board recognised this needed further development throughout the trust. It was however, recognised that development had taken place with key individuals.

The trust’s organisational structure comprised three clinical divisions; medical, surgical and family health. This organisational structure had been in place since late 2017. The medicine division included urgent and emergency care, nephrology, cardiology, diabetes rheumatology, adult medicine, respiratory, dermatology, neurology, radiology and stroke. The surgery division included gastroenterology theatres, trauma and orthopaedics, head and neck, general surgery, urology, colorectal and anaesthesia. The family health division included, obstetricians and gynaecology, midwifery, paediatrics, pathology, haematology, oncology, cancer services, outpatients and therapies. Each division had a chief of division role. The medicine division had a head of nursing for medicine and urgent care. Surgery also had a head of nursing in post. The trust leadership team had knowledge of current priorities and challenges and took action to address them. Staff at all levels were clear about their roles, responsibilities and what they were accountable. The organisational structure was embedded. All staff were clear on which division they worked within and who their divisional leaders were. The directorate management team was accountable to the divisional leadership team for all aspects of directorate performance and the divisional management teams were accountable to the executive for all aspects of divisional performance through quality and performance meetings. Fit and Proper Persons The trust processes generally ensured that the board were fit and proper for their role. However, two of the board members files did not contain all of the recruitment documents. NHS trusts are required to carry out checks to ensure directors have the qualifications, competence, skills, experience and character required to carry out their role (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Regulation 5 Fit and proper persons:

20171116 900885 Post-inspection Evidence appendix template v3 Page 4 directors). This regulation ensures that directors of NHS providers are of good character and have the right qualifications and experience to carry out this important role. We reviewed 15 personnel files and found that ten files were fully complete. All files contained evidence of disclosure and barring service (DBS) checks, employment history and fit and proper person checks. These included insolvency, companies house and removed charity trustee searches. An annual declaration was made by non-executive directors and executive directors to confirm that there was nothing that would affect their fitness as a director of the trust. We saw completed declarations in all the files that we checked. Following the inspection, we sort further information from the trust which provided some further assurance, however, for two of the board members complete records of the interview process were not available. Vision and strategy There was a clear vision and strategy developed with the involvement of staff. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. This included active involvement in sustainability and transformation plans.

However, although the integrated performance report was organised around the trust’s four objectives and there were a number of plans to review the progress against these objectives, these were not yet consolidated into clearly articulated quantifiable and measurable plans.

The challenges to achieving the strategy were understood. The trust vision was “to provide safe high-quality care to our communities” The trust operated within the framework of their CARE values which were developed through consultation and engagement with staff across the organisation. The CARE values were: • ‘Compassion: means we take the time to be empathetic and open; treating each other and our patients as individuals that matter. • Accountable: means taking responsibility and ownership, individually and collectively, for our decisions and action. • Respectful: means we value the experience and contribution of others; respecting others’ thoughts, feeling, beliefs and behaviours. • Engaging: means asking for and listening to the opinions of others and facilitating an open environment for dialogue.’

(Source: Kettering General Hospital website)

The care values supported the trust’s strategic objectives: • To provide high quality care to individuals, communities and the population we serve. • To be strong and effective partner in the wider health and social care community • To maintain a fulfilling and developmental working environment for our staff • To be a clinical and financially sustainable organisation.

(Source: Kettering General Hospital website)

Non-executive directors knew and understood the trust’s overall vision and their role in achieving them. A number of staff at different levels had been involved in the development of the vision and values

Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy, especially where there were plans to change services. Staff engagement events

20171116 900885 Post-inspection Evidence appendix template v3 Page 5 included divisional and departmental sessions specifically designed to engage staff in the strategy. Leaders had the view that strategic objectives would only be delivered if staff were well-engaged.

The trust’s vision was aligned to local proposals in the wider health and social care economy to plan services to meet the needs of the local population. The vision and strategy were developed following engagement with staff, patients, members of the public from the local area and stakeholders. Staff knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. The trust embedded its vision, values and strategy in corporate information received by staff. In the 2018 staff survey 34.0% of staff said the values of the organisation were discussed as part of the appraisal process. This was below (worse) the national average of 35.1% but an 4.7% increase in trust response from 2017.

The leadership team regularly monitored and reviewed progress on delivering the strategy and local plans.

Board members were actively involved in the Northamptonshire Sustainability and Transformation Plan (STP.) All were working collaboratively with the organisations within the Northamptonshire footprint, which included another acute and a mental health and community trust. Up until the recent past, the two acute trusts within Northamptonshire were working very separately, however, there were plans underway to consider which trust offered the best service in some particular specialities, so that resources could be shared in an effort to offer a more clinically effective service to patients.

The trust had a strategy for meeting the needs of patients with a mental health, learning disability, autism or dementia diagnosis. Processes were in place to care for patients admitted with acute mental health conditions. A mental health triage tool had been introduced and had been updated when patients were transferred between the emergency department and Middleton Assessment Unit. Processes were in place to request one to one nurse care as well as support from security. A 24-hour seven-day mental health liaison service could be accessed to assess patients and support nursing and medical staff in managing patient care and risks. Mental health training had recently been provided to staff by the local mental health trust. Dementia training was provided to staff with a target to reach compliance of 85% by April 2019. Some wards had specialist roles who provided experiential learning. A registered mental health nurse was recruited on Naseby wards due to the number of patients living with dementia. The nurse provided training to staff in supporting patients living with dementia and other mental health conditions. The “about me” booklet was in use throughout clinical areas for patients living with dementia. They included information about patients’ likes and dislikes, eating and drinking preferences, special requirements and personal information such as what the patient enjoyed doing in their spare time and information about their family and pets. Communication requirements and preferences were documented. Staff attended external multidisciplinary meeting to improve patient pathways. For example, a matron from the medical division attended regular mental health interface meetings to improve pathways for mental health patients who were inpatients.

There were processes in place for monitoring patients with Deprivation of Liberty Safeguards or required mental capacity act assessments. We observed board rounds and staff handovers where a patients’ mental health and capacity needs were discussed.

The service identified and met the communication needs of people with a disability or sensory loss. Patients were assessed on admission by nurses and records highlighted any communication needs. 20171116 900885 Post-inspection Evidence appendix template v3 Page 6

There were specific admission checklists and discharge planning tools for patients living with a learning disability. Patients living with a disability were easily identified on a database and in the patient record. A learning disability checklist was in place to ensure staff had fully assessed all care and communication needs. Communication passports were in place to help staff understand the patients’ needs and ensure equity of treatment and care. A learning disability worker was based in the hospital, and visited patients identified with a learning disability to offer support to patients and staff.

Booklets were in use for patients with a learning disability, “help me in hospital”. Similar to the, “this is me” booklets and were used to inform care when patients found it difficult or were unable to communicate their needs.

Culture The executive team and managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on the trust’s shared values. There was a clear culture of collective responsibility across the organisation.

We spoke with different groups of staff including consultants, nurses, clinical and directorate leads, and support staff. We also held several focus group sessions that all staff were invited to attend. Staff were welcoming, friendly and helpful. Staff cared about the services they provided patients and were proud to work at the trust. Senior leaders demonstrated compassion and values of the organisation. They were committed to high quality care. They displayed a culture of being open and honest and willing to learn. Staff generally felt respected, supported and valued. Most staff we spoke with during the inspection process felt positive and proud about working for the trust and their team. The trust recognised staff success by staff awards and through feedback. In the 2018 NHS Staff Survey, 35.0% of respondents said senior managers acted on staff feedback. This was above (better) than the national average of 32.4% and a 10.4% improvement of the trust response the previous year.

In the 2018 NHS Staff Survey, the trust scored better than average in support from immediate manager however the trust scored below average in three areas, equality, diversity and inclusion, health and wellbeing and safe environment, bullying. (Source: NHS Staff Survey 2018)

Staff knew how to use the whistle blowing process. There was an up to date policy that set out the procedures for staff and managers in relation to raising a concern at work (whistle blowing). Staff knew how to report a problem.

In the 2018 staff survey, 70.3% said they felt secure raising concerns about unsafe clinical practice. This was above (better) than the national average 69.2% and a 2.4% increase from the previous year. 56.8% of staff said they were confident that the organisation would address their concern, which was the same as the national average and 7.7% increase from the previous year.

Freedom to Speak Up Guardian

The trust had a freedom to speak up guardian (FTSUG) and provided them with sufficient resources and support to help staff to raise concerns. FTSUGs are the result of a recommendation from Sir Robert Francis’ 2015 Freedom to Speak Up Report. NHS Improvement, supported by the National Guardian’s Office, require all trusts to have a freedom to speak up guardian in place, a speaking up culture supported by the board, underpinned by appropriate systems and processes. Freedom to speak up (FTSU) is a safe channel through which staff can raise concerns to the trust’s FSUG and where the guardian will monitor the trust’s response, feedback to staff and see

20171116 900885 Post-inspection Evidence appendix template v3 Page 7 that appropriate changes are made. Since the last inspection, more resources had been provided to support the team. A part time FTSU officer (25 hours) and a part time administrator and seven champions were now part of the team. Additional resources meant there was FTSU representatives arranging drop in sessions across the trust, and presenting at the trust inductions.

Whilst staff did not always know who the trust’s FTSUG was, by name, they were clear about the role of the FTSUG and how to access them. The handling of concerns raised by staff met with best practice. Staff felt able to raise concerns without fear of retribution. The trust took appropriate learning and action as a result of concerns raised. Governance arrangements were in place. The revised ‘Speaking Up’ policy was issued in September 2018 and reflected improvements made to strengthen the trust’s arrangements. The FTSUG and non-executive lead met monthly, with the lead executive and chief executive to review concerns or investigations. Board reporting took place and a board input to the NHS Improvement Francis report self-assessment toolkit took place in December 2018. Trust update reports were presented to the board on a six-monthly basis.

There were posters around the hospitals to let staff know how they could contact the FTSUG, as well as information on the intranet. The CEO actively promoted the FTSG role. There had been an increase in contacts to the team in the last three years. In 2017 and 2018 eight contacts had been made each year but at the time of inspection, March 2019, there had been 30 contacts in the year to date.

The trust worked appropriately with trade unions. The trust had a positive, collaborative working relationship with the staff side and recognised the vital role they played in the organisation. ‘Staff side’ was made up of representatives from recognised trade unions. The staff side felt there was a new stability at board level which was open, welcoming and transparent. The board were working to remove any blame culture and took appropriate learning and action as a result of concerns raised. Concerns and investigations were being dealt with in a timely manner.

Managers addressed poor staff performance where needed. The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

The culture encouraged openness and honesty at all levels within the organisation, including with people who use services. The trust applied duty of candour regulation appropriately. The trust had policies and procedures in place to support a culture of openness and transparency, and ensured that all staff follow them. We reviewed a number of incidents and complaints at random, duty of candour, if appropriate had been applied in a timely manner. Staff awareness of the regulation was well-embedded in areas that we visited. Patients who had suffered moderate or severe harm received an apology. The senior clinician involved at the time of the incident was responsible for duty of candour, all contacts to patient or relatives were undertaken by the consultant or matron level. While duty of candour, according to the regulation, did not apply for patient suffering minimal harm, there was an expectation at a local level of being open and honest. Staff were expected to give an apology.

Staff had the opportunity to discuss their learning and career development needs at appraisal. This included agency and locum staff and volunteers. The trust wide appraisal rate was at 84% in January 2019.

Staff had access to support for their own physical and emotional health needs through occupational health.

Staff Diversity Equality and diversity was promoted within the organisation. Staff felt equality and diversity were promoted in their day to day work and when looking at opportunities for career progression. The percentage of staff with protected characteristics was more diverse than in the local community.

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There was an action plan in in place, dated 2017/18. It had not been updated since the 2017 staff survey and it was not clear if staff groups had been involved in its development. The action plan showed the following arrangements to effect improvement: • Equality impact assessment programme (checking the effects of policies / services / change on staff belonging to protected groups.) • Departmental/directorate team meetings. • Chief executive’s drop-in sessions and weekly message to staff. • Leadership briefings for senior managers. • Promotion of CARE values. • Harassment, bullying and abuse campaigns (for example, Random Acts of Kindness.) • Minority ethnic equality network (supporting identification and addressing of issues.) • InfoScribe; staff engagement events based on the trust’s CARE values • Interactive theatre Programme examining relationship behaviours (positive and negative.)

It was not clear when the action plan had been updated. There were no dates when actions should be completed by, progress, or the owners of each action.

Teams had positive relationships, worked well together and addressed any conflict appropriately. A positive culture was developing noting improving results in the staff survey. In the 2018 NHS Staff Survey, of the ten themes within the survey the trust scored better than average in four areas: o Support from immediate manager o Quality of appraisal o Quality of care o Safe environment – violence

KGH scored below average in three areas o Equality, diversity and inclusion o Health and well being o Safe environment – bullying

In questions relating specifically to staff motivation, the trust showed improved scores across all three areas and was above average when compared with other NHS trusts. 63.1% of staff said they looked forward to going to work (NHS average 59.3%) and 77.2% said they were enthusiastic about their job (NHS average 74.8%)

Staff responded more positively in relation to their ability to contribute to improvements at work with scores across all three areas increased on last year.

Staff also reflect the safety improvements made and embedded across the organisation with some dramatic improvements in scores across all six question areas, for example; • My organisation takes action to ensure [errors, near misses or incidents] do not happen again – increased by 8% to 69.7%. • We are given feedback about changes made…… - increased by 8.7% to 57.7% • I am confident my organisation would address my concern – increased by 7.7% to 56.8% However, the trust was still either just below or equal to the average score in these specific question areas indicating further work required to build upon the progress that has been made. (Note: at an aggregated level score is equal to the average) The proportion of staff who would recommend KGH as a place to work or receive treatment had improved: • 73.9% of respondents agreed that KGH places care of patients as its top priority (65.3% last year.)

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• 60.5% of staff would recommend KGH as a place of work compared with 48.8% last year. • 64.4% of staff were happy with the standard of care provided compared with 55% last year.

NHS Staff Survey 2018 results – summary scores The following illustration shows how Kettering General NHS Trust compares with other similar providers on ten key themes from the survey. Possible scores range from one to ten – a higher score indicates a better result.

The trust had similar scores compared to the average for other acute trusts across all themes in the staff survey.

(Source: NHS Staff Survey 2018)

The data is compared against the trust based on the trust 2017 responses and the 39 acute trusts surveyed by Quality Health. The overall response rate for the trust was 45% against an average of 44%. A high number of these responses were completed electronically. However, this was an improvement on the previous three years, where the response rates were 32%, 27% and 25% respectively.

• Engagement score was 'much lower.' • Bullying and harassment was 'higher.’ • Recommendation rates were 'much lower.' • Communication was 'much lower.’

There were eight new questions for 2018 so overall comparison data against last year was not possible; however, for individual questions against comparator the trust was:

• Higher in four.

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• The same in three. • Lower in one question.

With regards to recommending the organisation, the score had improved to 61% of staff surveyed feeling positive in 2018 (compared with a comparator average of 60%), increasing from 50% in 2017. Detailed information on bullying and harassment and communication was not available at the time of the report.

We saw 81.9% of staff said in the 2018 NHS staff survey they were satisfied with the quality of care they give to patients/service users. This was 1.8% above the national average and an improvement of 3.9% from last year. 69.2%of staff said they were able to deliver the care they aspired to, which was 2.3% above (better) than the national average and 6.9% increase from 2017.

In the 2018 NHS staff survey, 8.6% of staff said, in the last 12 months they had personally experienced discrimination at work from manager / team leader or other colleagues. This was the same as 2017 results, but above (worse) the national average of 7.7%. When asked if relationships at work were strained, 42.6% agreed which was similar to the national average of 42.9%. 15.5% said in the last 12 months how many times have they personally experienced harassment, bullying or abuse at work from managers. This was above (worse) than the national average of 13.7%. 21.7% said in the last 12 months how many times have they personally experienced harassment, bullying or abuse at work from other colleagues This was above (worse) than the national average of 20%. 40.4% of respondents said the last time they had experienced harassment, bullying or abuse at work, did they or a colleague had report it. This was 3.8 below (worse) than the national average and 1.9% decline from the previous year.

Staff Diversity

The trust provided the following breakdowns of medical and dental and nursing and midwifery staff by ethnic group.

Medical and dental Nursing and Ethnic group staff midwifery staff (%) (%) White – British/Irish/Any other white background 30.3% 74.1% BME - British 50.8% 20.8% BME - Non-British 16.0% 3.9% not stated 2.9% 1.3%

(Source: Routine Provider Information Request (RPIR) – Diversity tab)

There was a clear focus on equality and diversity for staff, with networks groups in place for protected groups and an executive lead for each one. Examples included: • Brexit group – to support staff from Europe. • Feedback taken into consideration to provide disabled parking for staff on ground floor of the ‘new’ car park. • Muslim staff supported during Ramadan. There was recognition that the board was not diverse but that it had been difficult to address this through the recruitment process.

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Workforce race equality standard (WRES) The executive lead for equality and diversity was the director of human resources (HR) and organisational development. (OD) The trust had an equality and diversity manager who reported to the deputy director of HR and OD. There was a diversion and inclusion policy in place, which was fin date and fit for purpose. It included goals and outcomes of the NHS Equality Delivery System (EDS2.) This is a system that helps NHS organisations improve the services they provide for their local communities and provide better working environments, free of discrimination, for those who work in the NHS, while meeting the requirements of the Equality Act 2010.

Equality impact assessments were carried out against core trust policies. These identified if there was likely to be any impact on any of the protected characteristics, such as age, gender, race and sexual orientation, and to mitigate the likely impact. The latest WRES report from 2017, had an action plan for 2017/18 attached. The report showed that the trust was more diverse with regards to BME staff than the local population. However, in some disciplines BME staff were more heavily represented, for example medical staff, whereas in other disciplines there was under representation. The action plan demonstrated that there were executive champions for each of the hospital’s protected characteristics networks and evidence of progress in response to WRES.

From 6 April 2017, employers in Great Britain with more than 250 staff were required by law to publish their gender pay gap information, covering pay and bonuses. They were also required to publish this information on their website and via the designated government website. In accordance with the Equality Act 2010 (Gender Pay Gap Information Regulations 2017), the trust had undertaken a gender pay gap review as of 31 March 2017. The report demonstrated that on average, men were more likely to earn about 60 pence per hour more than women. The trust acknowledged where improvements could be made, for example, that there could be greater female representation in its senior medical roles. It was stated in the action plan that the trust would reassess their recruitment and selection policy and process for internal and external candidates to avoid any potential bias.

The scores presented below are questions relating to bullying and harassment from the NHS staff survey, they are question 15b and key findings 25, 26 and 21 split between white, black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard.

Your Average Your Trust in (median) for trust in 2018 acute trusts 2017 KF25 Percentage of staff White 27% 28% 29% experiencing harassment, BME 32% 30% 29% bullying or abuse from patients, relatives or the public in last 12 months KF26 Percentage of staff White 27% 26% 28% experiencing harassment, BME 34% 29% 26% bullying or abuse from staff in last 12 months KF21 Percentage of staff believing White 87% 87% 86% that the organisation provides BME 75% 72% 73% equal opportunities for career progression or promotion Q15b In the last 12 months have White 7% 7% 8%

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you personally experienced BME 16% 15% 13% discrimination at work from manager/team leader or other colleagues

(Source: NHS Staff Survey 2018)

In the 2018 NHS staff survey, 84.8% of respondents said the trust acted fairly with regards to career progression / promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age. This was 0.9 above (better than the national average and a 0.8% improvement of the previous year.

Friends and Family test

The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the facilities they have used, giving the opportunity to feedback on their experiences of care and treatment.

The trust scored about the same as the England average for recommending the trust as a place to receive care from October 2017 to September 2018.

(Source: Friends and Family Test)

Sickness absence rates

The trust’s sickness absence levels from August 2017 to July 2018 were similar to the England average.

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(Source: NHS Digital)

Sickness and absence figures were not outliers compared to other similar organisations nationally. The trust wide sickness absence rate was at 4.66% in January 2019, with year to date at 4.4% which was just above (worse) the trust target of 4% but similar to the national average.

General Medical Council – National Training Scheme Survey

In the 2018 General Medical Council Survey the trust performed better than expected for no indicators, worse than expected for one indicator (educational supervision) and the same as expected for the remaining 12 indicators.

Survey area RAG Overall satisfaction Clinical Supervision Clinical Supervision out of hours Handover Induction Adequate Experience Supportive environment Work Load Educational Supervision Feedback Local Teaching Regional Teaching Study Leave

(Source: General Medical Council National Training Scheme Survey)

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The trust was supported by a dedicated group of volunteers they stated the trust has been in the ‘doldrums’ but felt it was coming out. The refurbishments that had been carried out had improved morale, as had the changes to car parking. They believed the attitude of staff was now more positive.

Governance The systems and process to support effective governance were developing. There was a clarity about the role of the board and of committees, with recent work having been undertaken to reduce duplication. However, governance processes from ward to committee were not yet fully developed although there were plans to achieve this. Since the last inspection, the trust had redesigned its assurance, risk and governance processes to include a more timely ‘integrated governance report’ to the board’s committees of quality and safety, organisational development, and finance performance and resources. These elements were brought back together for a single reporting process to board which integrated escalation from the committees into the board within one single report.

The trust had a governance committee structure, which had been put into place a few months before the inspection. This included a new scheme of delegation, committee structure and reporting frequency. It had been recognised by the incoming director of governance that prior to this the framework was not fit for purpose. The second stage of the overhaul of the governance framework was about to start following the inspection. The board met every other month. In the intervening months, board members attended board development sessions, this included support so that the board got to know each other better, work to reduce their operational involvement and scrutiny of operational papers from committees and developing a more strategic oversight. The training within these development sessions had been delivered at some pace and was timely and appropriate. The effectiveness of the levels of governance and management functioned effectively and interacted with each other appropriately.

There were five committees that supported the board function: • Performance, finance and resource committee. • Audit committee. • Integrated governance committee. • Quality and safety committee. • Organisational development committee.

All committees were chaired by a NED, who then reported into the board. All committees had a routine cycle of meetings. Their roles and responsibilities were clear and provided the board with appropriate assurance. There were no gaps in reporting lines between committees. Non- executive and executive directors were clear about their areas of responsibility. The accountability of each committee and individual’s roles at all levels was clear.

The trust operational structure had been reorganised into three clinical divisions. The restructure had been implemented to improve board to ward accountability, enhanced divisional ownership and responsibility for delivery.

Since our last inspection in November 2017, the trust had developed structures, systems and processes in place to support the delivery of its strategy. This included sub-board committees, divisional committees, team meetings and senior managers. Leaders had reviewed these structures.

Papers for board meetings and other committees were of a reasonable standard and although

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brief, contained appropriate information. The reason for brevity was that much business was delegated to the committees that reported to the board. Only issues that required escalation and items for assurance were taken to the board. This was in line with the decision to make the board a more strategic, rather than operational group.

A clear framework set out the structure of ward/service team, division and senior trust meetings. Managers used meetings to share essential information such as learning from incidents and complaints and to take action as needed. Divisional managers had access to a range of information to support them with their management role. This included information on the performance of the service, staffing and patient care. All team managers had access to a performance dashboard which showed their specific departments performance of the service, including team staffing and patient care indicators. Sharing of information was consistent and governance processes was starting to become embedded. For example, information was shared at team meetings. All tiers of management had monthly meetings including a sisters’ and matrons’ forums. Key risks were identified through quality ward dashboards. For example, pressure ulcers and falls were recorded consistently as agenda items in all team meetings. A daily safety huddle attended by ward sisters and managers across medical care had effective oversight of day to day risks including staffing and safeguarding. The meeting was used to gather feedback from all areas and escalate any concerns to senior managers.

While there were governance arrangements in place in relation to Mental Health Act administration and compliance. There was inconsistency in documenting and recording decisions. Not all medical staff were compliant with mental health act or DoLS training.

The governance framework addressed the need to meet people’s mental health needs. Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They could explain how they acted in patients’ best interests when they were unable to make decisions for themselves; however, we found some inconsistencies in the completion of documentation of patients who were being cared for under the MCA or DoLS. Medical staff were not complaint with mandatory mental capacity training targets.

The trust was working with third party providers effectively to promote good mental health patient care. A partnership arrangement was in place for the provision of psychiatric liaison services with appropriate governance arrangements.

Medicines management was integrated into the trust governance structure with clinicians chairing the main medicines committees and the chief pharmacist making a comprehensive quarterly report to the trust governance committee. • A comprehensive medicines management report was sent quarterly to the integrated governance committee. This included a commentary in changes in performance. • The management of medical gases was included in medicines safety committee to increase clinical overview. Gases training was included at induction for staff. • Medicines safety, medicines management and drug and therapeutics committees were all chaired by clinicians. • Pharmacy staff delivered training for junior doctors within the clinical induction programme. Staff were expected to complete an eLearning refresher training on medicines.

The trust had recognised that it was not fully compliant with the Delegated Regulation to the Falsified Medicines Directive (FMD) 2011/62/EU and had added this to their corporate risk register. This was published on the 9 February 2016, and was due to be implemented by February 2019. This new regulation requires manufacturers to place safety features on all medicines and contribute financially to the establishment of an IT verification system that will allow the assessment of the authenticity of a medicine at the time of supply to the patient.

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Falsified medicines include those medicines with little or no active ingredients, the wrong active ingredients, fake or tampered packaging, and those where products and/or packaging have been stolen for re-use or re-sale. However, because the coded packs have not started to work their way into the supply chain to date, the trust was unable to fully implement the directive. (Source: Trust Board Assurance Framework – 29 October 2018)

Management of risk, issues and performance The trust board had sight of the most significant risks and mitigating actions were clear. Staff had access to the risk register either at a team or division level and were able to effectively escalate concerns as needed. The trust had commissioned an internal audit review of the risk management strategy. This had not been completed at the time of the inspection.

The trust aimed to achieve the following five risk management ambitions: • To support greater devolution of decision making and accountability for management of risk throughout the organisation from the trust board to point of delivery. (Ward to board). • To promote a risk culture of monitoring and improvement that supports our quality strategy 2018-21 aim of consolidating risk management; ensuring that risks to the delivery of the trust’s objectives are identified and addressed within a ‘risk literate’ organisation. • To refine processes, systems and policies throughout the trust which are in place to support effective risk management and ensure these are integral to activities in the trust. • To support patients, carers and stakeholders through reduction of risks to services delivery and improved service provision. • To support the trust board in being able to receive and provide assurance that the trust has a clear line of sight of all risks across the organisation.

The ambitions were underpinned by the principles of the trust’s approach to risk management that is proportionate, aligned, comprehensive, embedded and dynamic. The board members we spoke with could provide examples of how poor performance was being improved. Poorer performing areas and identified risks were mitigated in a timely manner. There was an effective process in place to deal with reported incidents. This included those that were open and overdue. Incidents were reported through the electronic report system. Most staff we spoke with during the inspection were confident in how to report an incident using the electronic system. However, there was some confusion in how agency staff could report incidents, from informing another member of staff and to submitting themselves and confusion on how they received feedback. There was a system of ongoing training and support for all levels of staff, including managers, who were responsible for handling incidents. In the 2018 NHS staff survey, 89.4% of respondents said the organisation encouraged staff to report errors, near misses or incidents. This was 1.4% above (better) than the national average and a 1.5% improvement from last year. 69.7% of responds said when errors, near misses or incidents were reported, the organisation took action to ensure that they did not happen again. This was similar to the national average (69.9) but an 8% improvement on the year before. Serious incidents were the subject of a panel that met weekly, the serious incident review group (SIRG). This panel was chaired by either the medical director, the director of nursing, or the deputy director of nursing. The composition of SIRG changed depending on the type of the incident. We reviewed a number of incidents at random. All those that we saw contained relevant

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documentation, statements and had been thoroughly investigated and closed in a timely manner. Duty of candour if appropriate, had been applied and the serious incidents that we reviewed had evidence of contact with the patient or nominated relative, this included meeting with key staff where further explanations were given, if needed.

There were risk registers in place across all levels of the organisation.

• Ward/service risk register The assessed risks within the service delivery area that needed managing within the level of tolerance that the ward/service had determined was acceptable. • Directorate/specialty risk register The assessed risks across a group of wards/services that were part of the directorate/specialty that were assessed or informed by escalation from wards/services or groups of similar risks. • Divisional risk register The assessed risks for the division that include escalated risks from wards and directorates/specialties. • Corporate risk register (CRR) The CRR brought together all significant risks (scoring 15 and above) from across the organisation which impacted on the delivery of the trust’s operational activities. It was used to ensure appropriate action was taken to effectively manage each risk. The CRR was informed by divisional and local risk registers. Additionally, it was utilised to consider risks across the organisation to the trust’s operational objectives.

Staff concerns matched those on the risk register. Robust arrangements were in place for identifying, recording and managing risks, issues and mitigating actions. Recorded risks were aligned with what staff said were on their ‘worry list’.

It was reported in January 2019, all cancer waiting time standards had been achieved between April 2018 and February 2019. (Source: Board Pack February 2019)

The trust had no 52 week breaches, this meant there were no patients waiting over 52 weeks for their treatment on the admitted and non-admitted referral to treatment (RTT) pathways. This was an improvement from the last inspection where we had reported the trust had 182 patients waiting. The trust still had in place a prioritisation system for carrying out harm reviews for those patients waiting more than 52 weeks on incomplete RTT pathways for high-risk specialties. There was also oversight on the potential deterioration of patients waiting over 18 weeks. Staff communicated with patient’s GPs to find out about potential harm. Procedures were in place to prioritise patients whilst waiting on RTT pathways.

The trust had identified 126,000 referrals that were open on their patient administration system, but did not have a future appointment booked (sometimes referred to as ‘lost to follow up’). There were a number of reasons this had happened, for example, duplication of referrals, no appointment needed, inappropriate pathway identified and not ‘closing clocks.’ The clock stops on the date that a clinical decision is made and communicated with the patient. Work was underway to validate and cleanse historical referral data. Over 60% (86,000) of those referrals had been identified for ‘batch’ closure. The operations management group had developed, tested and approved five different set of criteria for closing the 86,000 referrals in line with NHS Improvement guidelines. The lead for this piece of work told us there was 40,000 remaining referrals that required manual validation at the time of our inspection. We were told this

20171116 900885 Post-inspection Evidence appendix template v3 Page 18 work would be completed by the end of March 2019. No patients to date had been required urgent referral or treatment The trust had responded to audit results on safe and secure storage of medicines by introducing new posts; quality assurance (QA) technicians to support wards and departments. The effectiveness of the new posts was monitored through audit. An example of an improved process was the colour coded storage temperature recording books, which gave a visual prompt to staff recording temperatures outside the recommended range for medicines. Electronic keys had been introduced throughout the trust, allowing authorised staff only access to medicines storage areas and recording their identity. The trust used the junior doctor administrative assistants to transcribe discharge letters, audit results had shown an increase in errors and additional training had been put in place.

• Quality assurance (QA) technician roles had been introduced – responding to department medicines management issues. Medicines safe and secure audits had shown some improvements. These improvements had been limited during Q2 to Q3 but as the QA technicians were new, it was expected their impact would not be seen until Q4 onwards. • New processes had been introduced, for example, new storage temperature recording books, that had been colour coded to indicate excursions outside recommended temperatures. • ‘Mind the gap’ campaign to reduce omitted doses of critical medicines. • Abloy keys (High security and wear resistant) were used throughout trust. • Medicines management technicians funded by directorates included providing support to the discharge lounge. • Pharmacist checking discharge letters in response to audit findings of reduced accuracy. Discharge letters were produced by junior doctor administration assistants, who had been trained to undertake this task. The minutes of the medicines safety committee showed both audit results and risks were discussed in July 2018, with an action plan developed. We saw from the minutes of the September 2018 meeting, there had been further discussion and a follow up audit planned for February 2019. • Corporate risk register demonstrated the risks and mitigations in place with regards to prescribing, administration, storage and dispensing. • Pharmacy risk register was in place. • There had been a focus on antimicrobial stewardship. The trust had met a CQUIN; reducing use of Teicoplanin and Carbopenems. • The use of medicines safety thermometer was regularly reviewed at the medicines safety committee meetings.

The governance team regularly reviewed the systems within medicines. Senior management committees and the board reviewed performance reports. Leaders regularly reviewed and improved the processes to manage current and future performance.

Board Assurance Framework (BAF) The board assurance framework (BAF) was fit for purpose and the director of governance, with the support of the board, intended to improve it further as part of integrated governance. Overall, we were assured that the board understood its governance strengths and weaknesses and had a plan in place to address shortfalls.

The trust provided their board assurance framework, which detailed four strategic objectives within each and accompanying risks.

The BAF brought together in one place all relevant information with regards to organisational risks against the trust’s strategic objectives. The BAF was informed by the significant operational risks, in addition to considering further external risks to delivery of the trust’s strategic objectives. It was 20171116 900885 Post-inspection Evidence appendix template v3 Page 19 fit for purpose. The board used it, at every meeting, as an essential tool to provide them with assurance that key controls were in place, to manage the risks to the achieving strategic objectives.

During quarter one of 2018/19 the board agreed the revised format of the risk registers and regularly reviewed the board assurance framework (BAF) or corporate risk register (CRR) either at board meetings or at executive management group. Although risk registers were established throughout all levels of the organisation and this revised format was intended to enhance risk maturity further. The revised format of the BAF and CRR detailed what assurances there were for management of risks, together with gaps in assurances that further informed any actions required. This revised format was being rolled out across the organisation for both divisional risk registers and directorate/service level risks registers. The director of governance had plans to improve it further as part of integrated governance.

The trust was planning to use the 5x5 matrix introduced by the National Patient Safety Agency (2008). This is a guide developed for the purpose of assisting NHS risk managers in implementing an integrated system of risk assessment.

The trust had systems in place to identify learning from incidents, complaints and safeguarding alerts and make improvements.

The safeguarding leads demonstrated they had the skills, knowledge and integrity they required and staff knew who the leads were. They were described as approachable and accessible. The annual safeguarding report for the period April 2017 to March 2018 was presented to the board in April 2018 following review, comment and sign-off at relevant meetings and committees. The report showed that the trust was committed to protecting children, young people and vulnerable adults. It also outlined their priorities for the following period such as education, supervision and support, strategic direction, governance, structure and capacity and interagency working. The safeguarding team were in the process of developing a strategy for safeguarding excellence over the coming three years, 2019 to 2022. The strategy was due to be brought to the board in April 2019. This took the form of four separate objectives for the hospital, which each had milestones and performance indicators. A drive towards organisational competence, a culture of awareness and commitment and the development of individual safeguarding expertise was at the heart of the strategy. Integral to the strategy was a plan to establish a safeguarding academy at the hospital, with a remit encompassing both children’s and adult work, which would provide a centre of excellence in safeguarding development for staff. This had been planned in partnership with the trust’s learning and development department. Formal accreditation of the scheme by a university was anticipated. Finances Overview Whilst the trust was financially challenged the board had a clear understanding of the financial position. There was an appropriate level of operational and financial experience and expertise across both the NEDs and executives with sufficient board time spent reviewing the trust’s finances.

The board’s understanding of the financial position of the trust had significantly improved over the last 18 months. Prior to this improvement, the trust had a history of not meeting its financial plans, failing to properly scrutinise its underlying financial position, not fully understanding the financial implications of some of its decisions and was overly focused on its short-term financial position. A series of executive and non-executive board changes during 2017 and 2017/18 led to an improvement in the board’s financial insight and the quality of the financial information. As a result, the trust’s financial decision-making abilities had significantly improved. However, despite this, the trust did not deliver its 2017/18 financial plan. This was predominantly due to the operational and 20171116 900885 Post-inspection Evidence appendix template v3 Page 20 financial consequences of medical vacancies, use of locums and poor planning with regards to estates. There had been a backlog of maintenance that had not been carried out. For example, repair of damaged and worn flooring and decoration to repair walls. Since the new chief executive and estates director had come into post, significant improvement had been made with progressing these outstanding repairs.

The board had an appropriate level of operational and financial experience and expertise across both the NEDs and executives. Sufficient board time was spent reviewing the trust’s finances and there was also a separate monthly performance, finance, and resources committee (PFR).

The director of finance and contracting was appointed in July 2017. Prior to this appointment they had been the trust’s transformation director and was appropriately qualified in terms of professional skills and qualifications. In addition, the director of finance and contracting had a good operational understanding.

There had been some changes to the structure and composition of the whole finance team. Each clinical division had a finance partner who supported divisions to develop and deliver financial plans. Clinical divisions reported on delivery of financial improvement through confirm and challenge sessions with the chief executive and director of performance and finance.

The trust had a clear and improved process for short-term financial planning, which considered both internal and external influencing factors and interlinked with the trust’s overall strategy.

NHS Improvement’s ‘Model Hospital’ benchmarking tool was being used as an opportunity to use nursing staff more efficiently, particularly band 3s and 5s. Additionally consideration was being given to estates and IT, in an effort to strip costs from external contracts. The trust is part of the Northamptonshire Sustainability and Transformation Partnership (STP). System-wide initiatives were being developed that will lead to patients, within the STP footprint, receiving more joined-up and innovative services, which have made effective uses of the resources available. An example of this was a strengthening partnership with another Northamptonshire acute trust to share services and develop centres of expertise across the county.

Relationships between NEDs leading on financial areas (audit committee and PFR chairs) and the director of finance and contracts were appropriate, supportive and challenging. Board members we interviewed had a consistent view of the financial position of the NHS trust, with a shared understanding of the reasons for the trust’s under-performance against plan during 2017/18.

The audit and PFR committees had clear roles and responsibilities, and provided the board with appropriate assurance. Internal audits were determined by the audit committee on an annual cycle based on key risks. Audit committee meetings included the review of internal controls, the review of risk management processes (including the risk register) and the review of financial controls.

A good level of financial information was available at board level and this included a summary of the financial position shown on a dashboard and a summary of exception reports.

Divisions were involved in the 2018/19 budget setting process. The 2018/19 CIP plans were informed by benchmarking against the NHS Improvement’s Model Hospital data.

For 2018/19, the NHS trust agreed its control total of £15.2 million deficit but was not on track to deliver it. The forecast position as at February 2019 was £32.2 million deficit before PSF (13.2% of turnover). Whilst this indicates an improvement in the reported position compared to the previous year, non-recurrent measures have contributed to the improvement and the underlying deficit position is expected to further deteriorate in 2018/19. The key drivers for the adverse variance remain agency costs, commissioner fines, funding of temporary capacity, and slippage against the cost improvement plans.

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We interviewed the director of finance who was aware of the size of the financial challenge for the trust to deliver its financial plan and reduce the size of its deficit in 2018/19.

Historical data Projections Previous Last Financial This Financial Financial metrics Financial Year Year (2017/18) Year (2018/19) (2016/17) Income £234.5m £228.1m £249.3m Surplus (deficit) (£24.7m) (£33.6m) (£18.7m) Full Costs £260m £262.7m £268.1m Budget (or budget (£6.4m) (£19.9m) (£7.8m) deficit)

(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

In relation to infection control the trust had no MRSA bacteraemia for the last four years and was below trajectory for Clostridium Difficile. E Coli had been an issue and work was ongoing across the whole health economy to address. The infection control team were disappointed with the outcome of a review by NHS Improvement last year which rated the trust as red for infection control. As a result, they had made considerable changes and now moved to green. The team confirmed they were involved in the development of refurbishments that were taking place across the trust.

Trust corporate risk register

The trust provided a document detailing their 12 highest profile risks. Each of these had a current risk score of 15 or higher.

Date risk Risk score Risk level Last review ID Description opened (current) (target) date Risk of not meeting NHSi Not CRR002 plan for £10.8m ceiling for 16 6 Not indicated indicated agency staff spend. Not Risk that the organisation Not indicated indicated will not achieve the Seven Trust may not be able to CRR004 16 6 achieve 1 of the 4 regulatory clinical standards for 7 day service by 2020 Not Lack of systematic Not indicated indicated CRR006 understanding of procedural 15 3 documents that need review Not Not indicated CRR007 Failure to deliver RTT 16 3 indicated Not Failure by Trust to be fully Not indicated CRR008 16 4 indicated compliant with GDPR Not Threat to IT systems from Not indicated indicated CRR009 Cyber security and malware 16 8 attacks Not Increased safeguarding Not indicated indicated CRR010 referrals relating to Trusts 15 3 discharge process Not Performance and sustained Not indicated CRR011 20 12 indicated patient flow through the

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Emergency Department Not No Uninterruptable Power Not indicated indicated CRR012 Supply to X-ray equipment 15 5 in Cath Labs 1 & 2 Not Risk of Trust not meeting Not indicated indicated the requirements of the CRR013 15 3 Falsified Medicines Directive Not Risk to processing of Not indicated indicated Safeguarding concerns due CRR014 16 4 to financial challenges at Northants County Council

(Source: Trust Corporate Risk Register)

Information management Although the trust collected, analysed, and used information to support its activities the information systems in place were not fit for twenty first century care. Some IT systems did not interface with each other and were not fit for purpose. There was a reliance on manual systems to support the provision of performance information. Senior leaders were aware of these challenges and had commissioned external reviews to provide assurance on the quality of the data. There was a plan for digital transformation. The trust used a wide number of information systems across the organisation, which captured and recorded relevant clinical and demographic data about patients along their pathway. There were clinical systems and non-clinical systems in place that captured information, for example, incident reporting. This directly contributed to improving the quality of care for patients. However, staff told us that the systems were slow, they did not always interface with each other and some were not fit for purpose. An executive and non-executive led information technology away day was held to develop the digital strategy. The strategy aimed to bring greater efficiencies in providing patient care, and said: “By 2020 the trust aims to deliver digital services and infrastructure that enables seamless care for patients, with less delays, and giving them more control over their own health service interactions. It also aims to empower staff with the best ways of analysing data so that we can carry out evidence-based improvements to care, better manage pressures on the organisation, and save staff time by moving towards paperless working.” A digital hospital board as a committee reporting into the main board was approved in November 2018. A digital roadmap had been developed. A digital roadmap is a high-level document that outlines what goal a business wants to achieve, identifying initiatives that can help it get there. There were three core activities to delivery of the strategy: • Selecting a new electronic patient record (EPR) partner; • Developing the right capacity and capability to deliver the strategy; • Establishing the right governance and delivery architecture. Clinical engagement through clinical chief information officers (CCIOs). The board were aware that failure to deliver the digital strategy would impact the quality and effectiveness of clinical care and financial sustainability. The digital hospital board were responsible to oversee strategic aspects of the trust’s digital, technology and information agenda which included: • Execute their vision for 2020 to deliver digital services that: o Empowered patients, putting them at the centre of their care.

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o Enabled passionate staff to provide the best possible services and achieve world class health outcomes. o Utilise data and information in a collaborative way across the trust and with strategic partners. • Ensure projects underpinning the five key workstreams in the digital roadmap were delivered. • Create a joined up digital approach across the hospital, working closely with all staff across the trust. There were regular updates and reporting on the digital strategy to the digital hospital board. The trust had a confirmed start date (April 2019) for the holder of the newly created post of chief digital and information officer (CDIO)

Leaders used meeting agendas to address quality and sustainability sufficiently at all levels across the trust. Staff said they had access to all necessary information and were encouraged to challenge its reliability.

The trust was aware of its performance through the use of KPIs and other metrics. This data fed into a board assurance framework.

Team managers had access to a range of information to support them with their management role. This included information on the performance of the service, staffing and patient care. All team managers had access to a performance dashboard which showed their specific departments performance of the service, staffing and patient care.

The trust had a Caldicott Guardian, a senior information risk officer and a clinical information risk officer. A Caldicott Guardian is a senior person responsible for protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing. The Caldicott Guardian was the trust’s deputy medical director.

The trust used a paper prescription and administration chart, and the ward pharmacy team used paper systems to identify which patients they should see. An electronic prescribing and medicines administration system had been ordered for implementation across most areas during 2020. Paper systems were in use to prioritise patients for ward teams. Pharmacy technicians assessed lower risk patients. The chief pharmacist was the controlled drugs accountable officer. There had been a new process introduced to improve audit trail for ward receipts. Junior doctors had access to summary care records limited by smart card capable computers.

The information governance (IG) toolkit annual assessment is a requirement for NHS trusts. At the time of inspection, the trust was in the process of completing the IG toolkit and planned to submit its results to NHS Digital. The IG Toolkit has been replaced by the new Data Security and Protection Toolkit from April 2018, with completion required by March 2019. This was part of the trust’s GDPR plan. At the time of our inspection, information governance training compliance was 89%. This met the trust target of 85%.

Engagement The trust engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The trust worked with providers and commissioners, to support transformation of the health and social care system and understand the needs of people within Northamptonshire.

The trust board engaged with the public through formal routes, for example, patient stories at the board meeting, and informally through conversations with patients in public areas such as the trust’s on-site coffee shop. The chief executive carried out a weekly walk around across the site. 20171116 900885 Post-inspection Evidence appendix template v3 Page 24

Patients were encouraged to offer real time feedback on services through text messages. People’s views and experiences were gathered and acted on to shape and improve the services and culture.

There was a communications strategy in place. The trust website had been reviewed and refreshed, to make it easy to navigate and could be translated easily, by using a drop down box, into over 100 other languages.

There was a quarterly newsletter, ‘kgh together,’ reporting a number of hospital and staff news items including: reflections from the CEO, fundraising initiatives, opening or upgrades of new departments, events and good news stories.

Staff were actively engaged and their views were reflected in the planning and delivery of services and in shaping culture. The trust started an initiative called, ‘let’s ask the organisation,’ Staff actively participated in the 2018 NHS Staff Survey, where 45% of KGH staff took part. This was an improvement in engagement against the previous year when 35.5% of staff responded and an almost 20% improvement on three years ago when in 2015 only 26.6% of staff took part.

The trust had published a document; ‘Nursing and Midwifery Achievements in 2018, and included: presentation of projects arising from the sisters’ leadership development leadership development programme, an article on the simulation training suite, another demonstrating continuous cultural improvement and quality improvement. The document was bright, lively, easy to read and contained many photographs.

The trust had widened its engagement with local organisations through the ‘Dragons Den’ initiative.

The trust and Young Healthwatch north won ‘team of the year’ award at the patient experience network national awards 2018 in March 2019. Members of Young Healthwatch had carried out a visit to children’s services at the trust in April 2018 from which they documented their findings and produced a report which was then acted on by the hospital. The report recommended improvements, which the hospital has made, to children’s services including: • Improving signs to direct people to children’s services – for example colourful footprints on the floor signposting the paediatric area in A&E. • Adding more colour to paediatric areas to make them more child friendly. • Having more books and games available for children in waiting areas in children’s A&E and outpatients. • Using brightly coloured fun staff name badges so that it is clear and children can better understand who they are talking to.

The chief executive (CEO) held routine staff drop-in sessions as well as hosting Link-Listeners, a forum for Band 5 to band 1 staff to engage directly with the CEO on matters related to their work.

A patient experience strategy had been approved but at the time no associated delivery plan had been developed. The implementation of the strategy was to be monitored through the patient steering group.

The trust had invested in electronic tablets devices at strategic locations in the hospital such as the main entrance, the emergency department and main outpatients. The aim was to increase the volume of feedback but despite media support this increase was yet to be seen. It was envisaged that both the content and method of feedback would be reviewed.

The trust offered public governors training on appointment. They were actively involved in holding the trust publicly accountable for the services it provides.

Senior pharmacists such as the antimicrobial and homecare pharmacists were supported to 20171116 900885 Post-inspection Evidence appendix template v3 Page 25 contribute to national medicines optimisation projects. Patient engagement was a key theme in the medicines strategy but not this had not progressed. At the time of inspection, there was no patient representative on the medicines safety committee.

Learning, continuous improvement and innovation Although there was a lack of a structured methodology for continuous improvement, it was one of the pledges in the quality strategy with investment planned to further develop the approach to continuous quality improvement. Staff had time and support to consider opportunities for improvements and innovation and this had led to positive changes.

The staff were encouraged to share ideas for improving patient care and experience. In the 2018 NHS staff survey 72.3% of staff said there were frequent opportunities for me to show initiative in their role, this was the similar to the national average (72.5%) 75.3% of staff said they were able to make suggestions to improve the work of their team/department. This was above (better) than the national average (74.5%). 55.5% of staff said they were able to make improvements happen in my area of work, while this was below the national average of 56.1% it was a 4.8% on last year.

The trust had introduced an innovative approach to trying to resolve issues and support long stay patients who no longer required acute hospital care. Where the trust identified trends in patient flow they changed practice to help to reduce unnecessary time spent in a hospital bed. It was in response to a Multi-Agency Discharge Event (MADE) event. MADE brought together the local health system to: support improved patient flow across the system, recognise and unblock delays, challenge, improve and simplify complex discharge processes.

Every Wednesday, the long stay team went to each ward and assess certain patients. They visited medical patients who had been in hospital for over 21 days and surgical patients whose stay had been over seven days. The team comprised of nurses, therapists, doctors who established if the patient needed an acute hospital bed, if not, the reasons for them continuing to occupy one. The team tried to solve any obstructions with regards to effective, safe and swift discharge, by ensuring the patient was on correct pathway and not accepting delays.

As a direct result of this work, the trust had achieved a reduction in bed stays for patients, meaning less time in hospital. In April 2018, there were 198 patients whose hospital stay was over 21 days and 406 whose stay was over seven days. In December this had reduced to 107 for over 21 days and 277 for over seven days. At the time of inspection, patients staying over 21 days had fallen to below 100. It was very rare for there to be any patients staying in hospital for over 100 days. Staff said the approach meant there were robust and clear actions for patients and this had influenced flow through the hospital and discharge timeliness, had changed ward culture and role modelled good practice. Staff saw actions related to discharge planning were followed through. Staff were supported to deal with patient and family challenges, which they said made them feel more confident. This meant some complex patients had been supported to go home or be discharged to somewhere suitable for their needs, that may not have happened before.

As a result of the process, the trust had identified trends in patient journeys to help to reduce unnecessary time spent in a hospital bed. For example, the trust had developed different pathways, to suit particular needs. One included a delirium pathway, to enable the patient to be discharged to an appropriate setting. This pathway helped to manage patients who were medically fit but had developed delirium due to an extended stay and prevented them being ‘stranded’ in hospital due to delirium.

Ideas to improve efficiency and cost improvement were encouraged from staff within all divisions. For the 2018/19 financial year, the trust held a one million pound ‘incentive pot’, which was used to reward divisions when staff designed efficiency schemes. However, some of the divisional leads

20171116 900885 Post-inspection Evidence appendix template v3 Page 26 we spoke with raised concerns that any innovations that were not expected to deliver in-year savings were not given appropriate consideration by the executive team and were refused implementation.

Staff were encouraged to make suggestions for improvement and gave examples of ideas which had been implemented, for example: • The garden between Lamport and Twywell wards, for patients with dementia. • An appeal for members of the public to send postcards from holiday destinations, with messages about the weather, eating fish chips and ‘wish you were here; for patients with dementia. • A bereavement garden, particularly for those whose baby had died at or soon after birth.

The trust worked with a range of funders to encourage broader investment in health research. This included work with a number of charities and the life sciences industry to help patients gain earlier access to effective treatments. Current studies included several surrounding cardiac research.

There was a ‘Nursing Leadership Development Programme for Sisters’ which took place over the course of 2018. 64% of Sisters in Medicine, 75% of Sisters in Maternity had attended. This programme was facilitated by an independent consultant in health and life sciences in 2018, and was overseen by the deputy director of nursing within the trust.

The pharmacy department continued to recruit and develop staff through the use of innovative roles. One pharmacist had a post held jointly with the trust and a GP surgery. A respiratory ward had a dedicated pharmacist to improve medicines optimisation by seeing patients daily where necessary and providing continuous support to the clinical team. There was a pharmacist-led diabetic foot clinic. The trust operated the “Royal Blackburn” model where there was one pharmacist allocated to each ward. Pharmacy technicians who had undergone specific training, were able to undertake routine medicine rounds, thus relieving the nursing staff of this task.

During 2018 the trust held a ‘Dragon’s Den’ event where an external investment approval panel made up of local business leaders assessed business investment ideas put forward by staff. The event was open to all staff and twenty credible investment and improvement opportunities were identified through this process.

It resulted in five key areas of the hospital benefiting from just under £100,000 in investment. The event, which saw 10 teams pitch their ideas for improving patient care and experience to a panel of five Dragons from the local business community and a voting audience, saw around 150 people attend and was open to members of the public. Pitches ranged from silicone scrotums to enable staff to teach men how to check for testicular cancer, right through to a proposal to secure specialist data analyst support to develop an artificial intelligence algorithm to predict and schedule hip and knee replacement operations with the aim of moving from “just in case” to “just in time”. Other ideas included a patient buggy scheme to help less able patients and visitors move across the hospital site; an audit ‘app’ that would free up staff who spend time preparing audit reports to care for patients; the creation of a cancer support information hub; and a virtual learning ward to bring non-medical staff into the healthcare profession to train and work their way up which in turn can help address staffing issues. There was also an initiative to get patients out of pyjamas and up and dressed each day, boosting their mental health and reducing the risk of muscle loss; a request for new thoracoscopy equipment to drain lung fluid and capture images of the lung less invasively, this has led to a reduction in the length of stay of five days per patient and a £60,000 saving; and a proposal from the hospital’s urology team to train and support community staff in catheter removal which would enable more patients to remain at home rather than come into hospital for the service. A case was also put forward for AIRVO devices for patients needing additional oxygen which would replace traditional oxygen masks and work out cheaper per machine, last longer and were more comfortable for patients as they cover less of the face. Money was awarded to the following innovations: 20171116 900885 Post-inspection Evidence appendix template v3 Page 27

• Thoracoscopy equipment – £24,000 • Out of pyjamas - £5,000 • Virtual training ward - £35,000 • Silicone scrotum - £675 • AIRVO - £15,000 • Patient buggy - £20,000

There was recognition of the other four pitches which were not chosen and the 15 proposals that did not get to pitch which have been supported with transformation resource to deliver additional benefits for patients.

The trust’s learning from deaths process had been established and was part of overall scrutiny of mortality. Effective systems were in place to identify and learn from unanticipated deaths. In the previous 12 months the trust had not received any Regulation 28; ‘Prevention of Future Deaths Reports’ nor any recommendations made by the coroner’s court that had resulted in action plans in the last 12 months. Mortality The Summary Hospital Mortality Indicators (SHMI) was as expected with a value of 1.09 (compared to 1.0 for England) and 1,745 deaths compared to an expected 1,602 deaths for the period from July 2017 to June 2018. (Source: Acute Insight March 2019)

Hospital Standardised Mortality Ratio (HSMR) for October 2017 to September 2018 (January 2019 Report) was 106.7 and was in the ‘higher than expected’ range. This is the third time in six months the trust’s HSMR level has been outside of the ‘as expected’ band. The mortality review team and deputy medical director had completed an analysis on the ‘higher than expected’ HSMR (including continuous alerts).

Within the HSMR: -108.0 'higher than expected,' there were three outlying groups: skin and subcutaneous tissue infections, fractured neck of femur and pneumonia. The latter two were new alerts. HSMR for November 2017 to October 2018 (February 2019 Report) was 108.0 and was in the ‘higher than expected’ range. This is the fourth time in seven months the trust’s HSMR level has been outside of the ‘as expected’ band. The mortality review team and deputy medical director were completing analysis on the ‘higher than expected’ HSMR (including continuous alerts) and feedback was expected to be provided in February 2019. (Source: Board pack final February 2019) Learning from deaths A CQC review in December 2016, 'learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England,’ found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care. In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. Each acute trust must produce an annual summary report of the actions that it has taken to learn from patient deaths over the previous year. In 2017/18 Kettering General Hospital implemented a range of initiatives to improve the way in which patient deaths were reviewed, analysed and the learnings shared.

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There was a learning from deaths policy in place which was due to expire in March 2019. The policy contained up to date and relevant information with one exception; there was no refences in the policy or in the appendices on engagement with families and carers in reviews and investigations of deaths. The trust collected and published a mortality dashboard on a quarterly basis, specified information related to inpatient deaths which included the following: • The total number of the trust’s in-patient deaths. • Deaths subject to case record review, termed Structured Judgement Review (SJR.) • Deaths judged more likely than not to have been due to issues associated with the care given or potentially avoidable. • Details on themes identified and recommendations for action • Details of any mortality alerts and response. • Each specialty/departmental held monthly mortality review meetings. Appropriate cases, according to criteria described in the trust’s ‘learning from deaths’ policy, were referred for structured judgement review (SJR) The trust had a dedicated team who ensured that deaths fulfilling the criteria for further review, including those deaths where lessons may be learnt, were referred for SJR. The SJR review is a validated Royal College of Physicians methodology and there were 14 clinicians trained to do the initial screening representing all clinical divisions and 6 trained SJR reviewers. All deaths had an initial screening which scored their potential avoidability and depending on the score, they had an SJR completed by a qualified reviewer. All SJRs were scored between one and six. One was ‘definitely avoidable’ and six was ‘definitely not avoidable’. Any reviews scoring between one and four automatically went to an SJR panel review. This multidisciplinary panel determined the potential avoidability of the death. All deaths and their learning were discussed at clinical divisional mortality and morbidity meetings. Agreed actions were followed up within the division and monitored quarterly by the mortality manager. The total number of the deaths of inpatients was 286 in quarter 2, 2018/2019, and 138 (48%) were reviewed and 15 of these were escalated to SJR and all learning was escalated to mortality and morbidity leads. We reviewed ten SJRs and found that a clear method of reviewing and investigating death had been set up. Deaths of people with a learning disability were reviewed and investigated to the same standard as other deaths. However, there was no evidence of carer and family involvement in all cases reviewed. We raised this with the lead for mortality who was aware that this was not currently in place. This was something they were going to introduce alongside a newly appointed role of medical examiner. The trust had a good process for learning from deaths and was meeting national guidance (National guidance on learning from deaths, March 2017). The lead for mortality shared examples of changes that had been made following implementation of actions after identifying a theme. For example, there had been a rise in deaths due to sepsis in 2017, specifically from the early stages of admission. The sepsis lead spent some time working with the teams in these areas and in 2018 there was a decrease in the number of patients who died due to sepsis within the trust. The mortality team also highlighted positive feedback when learning from deaths. These were highlighted on the quarterly dashboard report and communicated directly to the relevant divisions or departments. 58% of quarter two’s reviews had been rated as good care, of which 23% had positive learning points. Emails regarding positive feedback were circulated to each speciality lead

20171116 900885 Post-inspection Evidence appendix template v3 Page 29 and shared with the teams. There was also a patient safety lesson learnt forum, every six weeks which was a platform to share lessons learned from deaths with clinical staff. One piece of learning identified from December 2018 was the compliance with the consent policy in patients who lacked capacity. Complaints process overview Although systems were in place to manage complaints, these were not responded to in a timely manner The trust had a clear process in place for dealing with complaints and concerns raised. The director of nursing and quality was the executive lead for managing complaints with support from the patient advisory and liaison service (PALS) and complaints team.

There was a complaints policy in place, which was in date. However, it was due to expire in June 2019 and had a review date of March 2019. At the time of inspection, a new policy was available in draft form. It had been updated based on the service changes. It was due to be presented at the patient experience and involvement steering group in early April 2019, and quality governance steering group prior to ratification at the operational management group.

The complaints policy provided a clear process for dealing with complaints: • Complaints could be made in person, by telephone and in writing by letter or email. Most complaints (90%) were acknowledged within three working days. • Once a complaint was received, the complaints/case manager contacted the complainant to confirm issues to be investigated, they made the offer to deal with the complaint either as a PALS concern or formal complaint. They also offered a meeting if appropriate. • The complainant was contacted by letter (an acknowledgement letter) to confirm the specific concerns to be investigated and where necessary seek consent. • The complaint, along with the key lines of enquiry was then sent to the appropriate divisional director to nominate a lead investigator to complete the investigation and response letter. A timeframe was given to provide the patient experience team with the proposed draft response. Complaints against medical staff, although investigated and resolved at the time, were raised during appraisals. • The division provided a full written response letter providing an explanation to each issue as stated in the acknowledgement letter and will also identify areas of learning and actions/improvements taken as a result of the complaint. • The case manager ensured the draft response covered all the issues and contains action/learning points, if applicable, and forwarded this to the complaints manager for a quality check. • Once approved the response letter will be sent to the appropriate executive for signing. • Once signed the patient experience team sent out the letter, updated the electronic record, sent a scanned copy of the signed response letter to the division for their records and closed the file.

Staff we spoke with were aware of the complaints procedure. Information for patients and relatives about how to complain was available and accessible. Posters and leaflets about how to make a complaint were available throughout the trust. Additionally, the trust’s website contained information on making a complaint. All complaints and concerns were recorded on the trust’s electronic risk management system, to enable the identification of common themes and ensure learning was shared in response to complaints received.

The divisions used a standard template available on the risk management system to produce a formulated response, which was submitted to the complaints team two weeks prior to being sent to the complainant. For each response, an action plan was created to ensure steps were taken to resolve or reduce the chance of reoccurrence and lessons are learned.

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The divisions provided a review of their complaints on a monthly basis to the quality and safety committee which was chaired by the director of nursing and quality and reported in to the board. Complaint monitoring was reported to the board monthly in the quality dash board. The dash board reported on complaints acknowledged within the regulated three days and complaints response performance (working days).

A review of the complaints process had been undertaken during November 2018. As a result of this there had been a significant improvement in the three day acknowledgement target, which had increased to 100% in December 2018 from 70% in November 2018. The target for completing complaint responses was 35 days. However, the average number of days this had been taking was 90 days in December 2018. In the same month, the number of complaints that had been closed, was 18, compared to 36 in November 2018. (Source: Board minutes, February 2019)

In January 2019, 96% of complaints were acknowledged within three days and 91% year to date, which was below the target of 100% set by the trust.

Exception reporting at the February 2019 quality and safety committees stated in January 2019, the trust average number of working days to close a complaint rose to 112 against the target of 35, which compared to 90 in December 2018. The increased number of average days in January 2019 rose, due to a large number of complaints being closed compared to previous months, and of these the majority of complaints closed were the oldest of the open complaints. This had resulted in a reduction of the backlog of complaints but also reflected temporarily on the average days taken. 68 complaints were closed, compared to 18 in December 2018. This demonstrated progress in clearing the backlog of overdue complaints as of the 68 complaints closed 64 were over the trust’s 35 working day target. The executive management group approved the recommendations of the complaints review with new processes and resourcing commencing 1 March 2019. Additional resources were being sourced to support the complaints team and the management of complaints within the divisions. Whilst improvements had been seen, as detailed above, it was too early to see if these would be sustained.

If complaints were also serious incidents (SI), they were dealt with by the SI team. The complaints team engaged with the SI team, contacted the patient and collated the SI and complaint responses.

The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.

Target Question In days performance What is your internal target for responding to complaints? 3 days 90% What is your target for completing a complaint 35 days 90% If you have a slightly longer target for complex complaints N/A N/A please indicate what that is here Number of complaints resolved without formal process in the 1,401 N/A last 12 months?

(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)

Number of complaints made to the trust

The trust received 417 complaints from October 2017 to September 2018. The surgery core service received the most complaints with 128.

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complaints total Surgery 128 30.7% Medical care (including older people's care) 93 22.3% Urgent and emergency services 56 13.4% Outpatients 52 12.5% Diagnostics 26 6.2% Other / not specified 23 5.5% Maternity 16 3.8% Gynaecology 14 3.4% Services for children and young people 8 1.9% Critical care 1 0.2%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

The director of nursing and quality was the signatory on all response letters. We saw that letters were sympathetic and thorough. If the complainant was dissatisfied with the trust’s response, the complaint was returned to the division and reviewed. The trust endeavoured to resolve the issues raised by writing a further letter and/or offering a meeting with the relevant clinicians. There was a process in place to ensure duty of candour had been applied, where appropriate. We checked a sample of complaints and saw that it had been applied in all cases.

In the 2018 staff survey, 69.6% of staff felt the organisation acted on concerns raised by patients/relatives. While this was below (worse) than the national average of 72.6% it was a 5.9% increase from the previous year.

Compliments

From October 2017 to September 2018, the trust received a total of 251 compliments. A breakdown by core service can be seen in the table below:

Core service Number of compliments Percentage of total Urgent and emergency services 66 26.3% Surgery 54 21.5% Medical care (including older 35 13.9% people's care) Maternity 26 10.4% Outpatients 22 8.8% Gynaecology 19 7.6% Services for children and young 12 4.8% people Diagnostics 9 3.6% Other / not specified 6 2.4% Critical care 2 0.8%

(Source: Routine Provider Information Request (RPIR) – Compliments)

Accreditations NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

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The table below shows which of the trust’s services have been awarded an accreditation.

Accreditation scheme name Service accredited Clinical Pathology Accreditation and it's successor Medical Diagnostic Imaging Laboratories ISO 15189 Joint Advisory Group on Endoscopy (JAG) Surgery

(Source: Routine Provider Information Request (RPIR) – Accreditations tab).

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Acute services

Urgent and emergency care

Facts and data about this service The emergency department (ED) at Kettering General Hospital provides a 24 hour, seven day a week service for a population of approximately 320,000 people across North Northamptonshire and South Leicestershire. The population demographics show that 20% are aged under 16 years, 64% are aged 16-64 years, and around 16% of the population served are over 65 years of age. The main ED consists of 20 bays for patients within majors which were separated into two areas, one with 13 bays and one with seven, nine treatment areas for patients within minors, resuscitation spaces for up to five patients and six areas in the emergency decisions unit (EDU). The department has its own children’s ED with a separate waiting area, three cubicles, and an assessment area. Patients present to the department either by walking into the reception area or arriving by ambulance through a dedicated ambulance-only entrance. Patients who transport themselves to the department report to the reception area where they are assessed and streamed to either the minors or the major’s areas. We inspected the following areas on the Kettering General Hospital site: • Accident and Emergency. • Emergency Decision Unit. Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team: • spoke with seven adult patients and two patients under the age of 18 years who were using the service. We also spoke with three relatives, and three parents with their children in the department. • spoke with the managers, matrons, and clinical leads for the department. • spoke with 15 other staff members; including doctors, nurses and support staff. • observed handover and bed meetings as well as department ‘huddles’. • reviewed 25 patient records to assess the care and treatment provided. • reviewed a further 25 records relating to patient flow, time to initial assessment, triage, treatment and total time spent in the department.

Details of emergency departments and other urgent and emergency care services

• Kettering General Hospital emergency department

This department includes emergency care provision for both minors and majors attendances. It

20171116 900885 Post-inspection Evidence appendix template v3 Page 34 runs 24 hours per day, 365 days per year.

The service also has an ambulatory care unit and emergency decisions unit.

(Source: Routine Provider Information Request (RPIR) – Sites tab)

Activity and patient throughput

Total number of urgent and emergency care attendances at Kettering General Hospital NHS Foundation Trust compared to all acute trusts in England, August 2017 to July 2018

From August 2017 to July 2018 there were 87,909 attendances at the trust’s urgent and emergency care services as indicated in the chart above.

(Source: Hospital Episode Statistics)

Urgent and emergency care attendances resulting in an admission

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The percentage of A&E attendances at this trust that resulted in an admission remained similar in 2016/17 compared to 2017/18. In both years, the proportions were higher than the England average.

(Source: NHS England)

Urgent and emergency care attendances by patients being discharged, or transferred to another department August 2017 to July 2018

* Discharged includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment

(Source: Hospital Episode Statistics)

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm.

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*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training The service provided mandatory training in key skills to all staff. However, not all nursing staff had completed mandatory training, for example medicines management and sepsis. Medicines management was 74% and sepsis training was 61%, these did not meet the trust target of 85%. The trust had a programme of mandatory training that all staff had to complete. Mandatory training included subjects such as, fire safety, infection control, information governance, manual handling, equality and diversity, and conflict resolution. Courses for mandatory training were accessed online and via face-to-face teaching sessions. The trust had a rolling training mandatory year. Mandatory training completion rates The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for qualified nursing staff in urgent and emergency care is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) NEWS2 2 2 100% 85% Yes Conflict Resolution 105 108 97% 85% Yes Equality, Dignity & Respect 102 108 94% 85% Yes MCA Awareness 102 108 94% 85% Yes Prevent Health Wrap 98 108 91% 85% Yes Information Governance 96 108 89% 85% Yes Basic Life Support (Adult) 96 108 89% 85% Yes Fire Safety 95 108 88% 85% Yes Manual Handling Patient 95 108 88% 85% Yes Infection Control 93 108 86% 85% Yes Health and Safety & Risk Management 91 108 84% 85% No Medicines Management 80 108 74% 85% No Sepsis 66 108 61% 85% No Paediatric Basic Life Support 102 108 94% 85% Yes

In urgent and emergency care the 85% target was met for 11 of the 14 mandatory training modules for which qualified nursing staff were eligible. Data shown in the table showed that only two members of staff had completed NEWS2 training. This was incorrect data; all registered nurses and health care assistants had received training.

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Training compliance by medical staff had improved since the last inspection in 2017. The 85% target was met for the ten of the 12 mandatory training modules, for which medical staff were eligible. The two subjects that were below compliance were just under at 84%. A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for medical staff in urgent and emergency care is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Equality, Dignity & Respect 36 37 97% 85% Yes Prevent Health Wrap 34 37 92% 85% Yes Health and Safety & Risk Management 34 37 92% 85% Yes MCA Awareness 34 37 92% 85% Yes Information Governance 34 37 92% 85% Yes Fire Safety 33 37 89% 85% Yes Conflict Resolution 33 37 89% 85% Yes Infection Control 33 37 89% 85% Yes Medicines Management 32 37 86% 85% Yes Basic Life Support (Adult) 32 37 86% 85% Yes Sepsis 31 37 84% 85% No Manual Handling Patient 31 37 84% 85% No

In urgent and emergency care the 85% target was met for ten of the 12 mandatory training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) This data showed us that on each shift there were staff with the right paediatric life support training competencies. Paediatric basic life support training compliance for nursing staff showed that 94% of nursing staff had completed this course at the time of our inspection. National standards set by the Royal College of Paediatrics and Child Health, recommend that paediatric nurses are trained in emergency paediatric life support (EPLS). The data showed that eight out of 15 nurses held this qualification. This was an improvement from the previous inspection in 2017, where only three nurses held this qualification. The service was challenged with the availability of this course being delivered locally. The plan was for one nurse per month to attend this training externally from February 2019. All of the consultants apart from one, had completed EPLS training. However, the one consultant was booked on the course in February 2019. This was an improvement since the last inspection in 2017, where only 60% of the doctors had completed it. This meant that on each shift there was at least one member of staff that held this qualification. Paediatric immediate life support (PILS) had been completed by 86% of nursing staff.

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Advanced life support (ALS) had been completed by all advanced clinical practitioners, 86% of medical staff and in addition 11 of the nursing staff. All other nursing staff were compliant in immediate life support (ILS). Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. There was a clear system and process in place for identifying and managing patients at risk of abuse. Nursing staff we spoke with were able to explain the process of safeguarding a patient and provided us with specific examples of when they would do this. Staff were aware of how to contact the safeguarding lead. The trust set a target of 85% for completion of safeguarding training. All safeguarding training modules were above the trust target of 85% in the nursing and medical staff groups, apart from safeguarding level 3 for medical staff. Safeguarding training completion rates Trust level A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for qualified nursing staff in urgent and emergency care is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Adults - Level 2 106 108 98% 85% Yes Safeguarding Children Level 2 105 108 97% 85% Yes

In urgent and emergency care the 85% target was met for both of the safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for medical staff in urgent and emergency care is shown below: eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 35 37 95% 85% Yes Safeguarding Adults - Level 2 34 37 92% 85% Yes

In urgent and emergency care the 85% target was met for both of the safeguarding training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) The percentage of medical staff trained in safeguarding adults level 2 was 92%, safeguarding children level 2 was 95% and in addition to the table, safeguarding children level 3 was 72% with 18 of 25 required staff having completed the training. The clinical director for the service told us that the doctors were booked onto the next available courses.

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The percentage of nursing staff trained in safeguarding adults level 2 was 98%, safeguarding children level 2 was 97% and safeguarding level 3 was 89%. All children who presented to ED were seen and treated in the paediatric emergency department. All the paediatric nurses and doctors that worked within the department had safeguarding level 3 training. This met the intercollegiate standards for children and young people, that states, in emergency care settings doctors and nurses who assess children should have received the more advanced level three safeguarding training. Safeguarding level 3 training figures were not included in the tables above, this was collated during the inspection. Across the adult and paediatric ED, there was a clear system and process in place for identifying and managing patients at risk from abuse. This was in line with the trust’s policy for safeguarding adults and children. Nursing, medical and administrative staff we spoke with were able to explain the process of safeguarding a patient and provide us with specific examples of when they would do this. There was clear guidance on recognising signs of specific abuse on display in both the adult and children’s ED. This included whom to contact internally and externally with concerns. We saw information in relation to female genital mutilation in line with the World Health Organisation guidelines. There was specific guidance for caring for patients who presented with non-accidental injuries in children and adults. We reviewed the policy for safeguarding children in the children’s emergency department. The policy was clear on when patients would be highlighted on medical records or assessed as a safeguarding concern. Medical and nursing staff we spoke with knew how to identify and flag safeguarding for multiple attendances and concerns and at what point this would occur. They were aware of the policy and would refer to it before making a decision. The medical and nursing staff followed the local safeguarding children’s board (LSCB) county wide guidelines on bruising in non-mobile babies and children. This document was available, with other LSCB guidance on the trust’s safeguarding intranet page. Staff receiving level 2 safeguarding children training were trained around the protocol for bruising in non-mobile babies and children and how to respond to this. The trust’s safeguarding children policy stated how it was staff’s responsibility to identify child protection/safeguarding issues during their daily contact with children and how to refer to safeguarding services. This is a recommendation in National Institute of Health and Care Excellence (NICE) Clinical Guideline (CG) 89 titled ‘Child maltreatment: when to suspect maltreatment in under 18s. The majority of staff we spoke with were aware of their mandatory duty to report all cases of female genital mutilation (FGM) to the safeguarding lead and the Department of Health. Staff reported cases using an interagency referral form, and placed an appropriate alert on the electronic system. Cases were also reported through the safeguarding steering group on a monthly basis for discussion and shared learning. FGM and child sexual exploitation (CSE) were included in level two safeguarding training. Staff received a safeguarding learning booklet after their annual update. This booklet included questions for staff to complete about FGM and CSE. Cleanliness, infection control and hygiene There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained. This had improved since our last inspection. The department was visibly clean and we saw support staff cleaning the department on a regular basis. We saw cleaning schedules that were used each day for each area of the department. Staff

20171116 900885 Post-inspection Evidence appendix template v3 Page 40 told us there was a rapid cleaning team available if rooms needed deep cleaning between patients with potentially infectious illnesses. We observed patient trolleys and other patient equipment being cleaned between patient use. There were hand hygiene stations in all the cubicles within the department and wall mounted hand sanitiser dispensers in all corridors and main entrance. We saw all staff used correct hand hygiene techniques after patient care or when moving around the department. We saw staff actively encouraged patients, relatives and visiting staff to use the hand sanitisers. Staff complied with the trust’s policies for infection prevention and control. ‘Arms bare below the elbow’ policies were adhered to and staff wore minimal jewellery in line with the trust infection control policy. Personal protective equipment such as gloves and disposable aprons were used in accordance with the trust’s infection prevention policy. Waste was segregated and stored correctly in line with national guidance. We observed domestic staff regularly changed waste bags to ensure they did not overflow. We observed barrier nursing in the major’s area, which was compliant to the trust’s infection prevention and control policy. Barrier nursing is a specific set of infection control measures, utilised to minimise the risk of germs spreading to staff or patients. The disposal of sharps, waste and hand hygiene techniques had all improved since the last inspection, where minor concerns were found. The service undertook hand hygiene audits monthly. The results of these audits showed a compliance rate of 95% and 100% for November and December 2018, which met the trust target of 95%. The audit included observation of hand hygiene, and the cleanliness of commodes and equipment in the department. Infection control training was mandatory and completed by 86% of nursing staff and 89% of medical staff. This was compliant with the trust target of 85%. Environment and equipment The design, maintenance, and use of facilities and premises did not always meet patients’ needs. The paediatric emergency department was too small to now accommodate the numbers of children attendances. There were no systems in place to prevent queueing patients overhearing conversations between reception and streaming staff at the reception desk. Since the previous inspection in November 2017, the reception and booking in area had been redesigned and moved to a different part of the department. Staff could now visibly see the waiting room and the old reception room had been turned into a security office, where security staff were present 24 hours a day, seven days a week. However, despite the changes, patient’s confidentiality could still be breached, due to patients having to give details of why they were attending the department, at the booking in desk. Efforts had been made to mitigate the situation. A ‘privacy screen’ had been put up around this area, but patients sat in the waiting area, were still able to overhear. We informed the senior management team and they immediately removed the seats that were located opposite this desk. They had ordered equipment, such as barriers and coloured tape for the floor, to keep other patients that were waiting to book in a suitable distance away from desk. This was due to be delivered the week of our inspection. We checked this on our well led inspection and there was no additional equipment present. The paediatric emergency department did not fully meet the requirements of the ‘Standards for Children and Young People in Emergency Care Settings 2012’ (RCPH), NHS Estates Health Building Note (HBN) 22: Accident and Emergency Facilities for Adults and Children and HBN 23: Hospital Accommodation for Children and Young People. 20171116 900885 Post-inspection Evidence appendix template v3 Page 41

The guidance states there should be one or more child-friendly clinical cubicles or trolley spaces per 5,000 annual child attendances, and children should be provided with waiting and treatment areas that are audio-visually separated from the potential stress caused by adult patients. The PED was audio-visually separate from adults; however, it was now too small to accommodate the number of children attendances. With almost 20,000 attendances per year being for children, the trust was unable to meet this in the current environment. This meant that the corridor outside the PED was used for waiting children and their parents/carers, which was within the main adult area. We returned to the department in the evening and saw this corridor was full of waiting children and their parents/carers. The trust had tried to rectify this after the last inspection, by building an ‘overflow’ waiting area within the main waiting room. However, this could not be used as it was not visually separated from adults. The PED did not have a cubicle with a door for consultations where privacy and confidentiality was paramount, or to isolate children/babies with a risk of infection. They mitigated against this, by using one of the minor’s rooms, which was located in the main ED. The department also did not have appropriate areas suitable for breastfeeding and nappy changing. We were assured that staff were vigilant and risk assessed the children that were waiting in the corridor. The senior management team recognised the environment was not suitable for the growing needs of the population. This was on their risk register and they had invited local members of parliament to visit the department for their input, this was still in discussion. The risks associated with the environment of the children’s emergency department were recognised by the service. The staff and department leads informed us that they had a few ideas of how to redesign the PED, but they could not tell us when this would start. The resuscitation equipment was checked daily. We checked four resuscitation trolleys during the inspection and found checks had been completed, where equipment was missing this was rectified in a timely manner. We broke the seal of one trolley and found this was stocked in line with Resuscitation Council guidelines. The blood glucose boxes and anaphylaxis boxes were found to be secure, checked regularly and all items were in date. There was a resuscitation trolley in the PED to support a deteriorating child. There was a designated children’s bay in the resuscitation area. This was stocked with the appropriate equipment of all sizes and was checked daily. We reviewed a selection of equipment in the adult and PED as well as emergency decisions unit (EDU). All equipment was in good condition and had service dates. There was a designated room for seeing patients who required a mental health assessment. This had recently been re-furbished so that it met the Psychiatric Liaison Accreditation Network quality standard requirements. At the time of the inspection the service did not have a designated relatives room, that could be used for relatives\carers to wait whilst the patient was in the resuscitation area, or to have sensitive conversations in. The senior leaders for the service told us that they had a plan for an area to be refurbished into a relative’s room. In the meantime, they used a private staff room. Clinical waste and specimens were appropriately labelled and segregated. They were stored safely and disposed of according to hospital policy.

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There was an x-ray department next to the ED, which supported patient flow. Patients in the resuscitation area had direct access straight to the x-ray and computerised tomography (CT) department. Assessing and responding to patient risk Risks to patients were not always assessed appropriately. For example, patients that self- presented to the department did not always receive a timely initial assessment or observations. Nursing risk assessments and safety checklists were not routinely completed. However, patients that arrived by ambulance were assessed immediately. A key concern identified during our last inspection in 2017 was that the service was not performing observations on self-presenting patients within 15 minutes. This was recognised as a patient safety risk. At the current inspection, we were still not assured the trust were performing initial observations on self-presenting patients (minors) within 15 minutes of arrival. Once booked in, the patient would have an initial assessment with a senior nurse. This was done at the reception desk. The patient would then wait in the waiting room to be called through to a room to have the appropriate observations taken. While the initial assessment involved taking details of the patient, including symptoms and medical history, the assessment did not include the undertaking of an initial set of observations. Staff were using the ‘Manchester Triage System’ to categorise patients. The system showed each patient was assigned a category using the triage tool. However, we could not be assured how accurate the categorisation of each patient was if observations had not been undertaken at this stage. Nursing staff were classing ‘streaming’ as triage, with observations being undertaken a period of time after streaming, which did not meet the 15 minute requirement. We observed a sample of nine patients, four did not receive full initial assessment within 15 minutes. However, patients only missed the 15 minutes by an average of ten minutes. The service provided us with their spot check audit on 15 minute observations. They audited 20 sets of records that showed that the average time from arrival to first set of observations was 16 minutes. Patients that arrived by ambulance were assessed immediately by the nurse in charge and taken into the ambulance streaming area. Patients would then see a nurse and have a full initial assessment. A doctor was always present in this area and we saw that they would often be with the nurse whilst this assessment was being carried out. If any urgent tests were needed, for example, blood tests or electrocardiograms (ECG) they would be done at this stage. The patient would then be streamed to the appropriate area. During the inspection we observed all patients arriving by ambulance being fully assessed within 15 minutes. The EDU was staffed by two senior nurses and a doctor. This area was used for patients who were waiting blood results, inpatient beds and social care assessments. There were criteria for admission on the EDU, which staff were aware of. All the patients we observed in the EDU met the safe criteria for admission. Since the last inspection there was an extra major’s area, called ‘majors 2’. This was a seven bedded area and was used during busy periods. This had increased the number of major’s cubicles from 13, to 20. This meant that ambulances arriving could be offloaded in a timely manner and the use of the corridor had decreased. During the three day inspection we only observed three ambulance crews in the corridor. The patients were there for approximately five

20171116 900885 Post-inspection Evidence appendix template v3 Page 43 minutes before moving to the streaming area. While they were in the corridor they had a full initial assessment carried out in a way that protected their privacy and dignity. The emergency department had an escalation policy in place. They also carried out regular ‘huddles’. This was where the nurse in charge and consultants would meet to review all patients in the department, and see how many ambulances were on the way in. This assisted them to safely manage the department. The department had commissioning for quality and innovation indicators in place (CQUIN) for the improvement of sepsis management. The audits for this showed that the ED staff were screening and treating the majority of patients, but improvements were still required. From July to September 2018, the service screened 84% of patients with suspected sepsis, and 69% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. The screening had improved since the last inspection in 2017, where only 32% of patients were screened. From October to December 2018, the service screened 85% of patients, and 87% of patients prescribed antibiotics for red flag sepsis, were administered these within one hour. This was an improvement and they had met the CQUIN target. We were able to review four patients with sepsis during the inspection, and all four had received appropriate screening with treatment administered at the correct times. National early warning scores (NEWS2) were used to assess the seriousness of a patient’s condition. This was a quick and systematic way of identifying patients who were at risk of deteriorating. Clinical observations such as blood pressure, temperature, heart rate and respirations were recorded and contributed to a total score. Once a certain score was reached, a clear escalation of treatment was commenced. We reviewed 12 charts that had patients’ vital signs recorded on them. Of the 12 charts we reviewed, all NEWS2 had been calculated correctly in the correct time intervals and escalated to medical staff where necessary. The patients NEWS was written on a whiteboard in each bay. This gave the nurse in charge and the head of nursing an at a glance view of the patient’s condition and level of risk within the department. There was a patient safety checklist that was aimed at reminding nursing staff to undertake hourly safety checks of all patients in the major treatment area. The list included a variety of checks, which included but were not limited to; vital signs measured, identification wristband on patient, suspected sepsis (infection) screening, blood tests and pain score. This document had only been introduced in December 2018 by the new senior leadership team. However, not all patients had one completed in a timely manner, or not completed at all during their time spent in the department. We looked at ten sets of notes and only five had the safety checklist in place. The mental health risk assessment tool was used during the course of the inspection and we observed its use in four patient cases. The tool identified the risks to the patient, and others, and informed staff of what measures to put in place to keep the patient and others safe. This was an improvement from the last inspection in 2017. The assessment tool identified that when a patient was at significant risk that one to one nursing should be considered and provided. We found that not all nursing risk assessments were completed, for example, skin and falls assessments. This was a risk, especially for patients who were admitted with a fall or were frail with an increased risk of skin damage. The patients however, were visible by the nursing staff and were on appropriate pressure relieving mattresses. The nursing staff told us they had calculated the skin assessment in their heads.

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Emergency Department Survey 2016

The trust scored about the same as other trusts for all of the five Emergency Department Survey questions relevant to safety.

Question Score RAG Q5. Once you arrived at the hospital, 8.1 About the same as other how long did you wait with the trusts ambulance crew before your care was handed over to the emergency department staff? Q8. How long did you wait before you 6.4 About the same as other first spoke to a nurse or doctor? trusts Q9. Sometimes, people will first talk to a 6.9 About the same as other nurse or doctor and be examined later. trusts From the time you arrived, how long did you wait before being examined by a doctor or nurse? Q33. In your opinion, how clean was the 8.8 About the same as other emergency department? trusts Q34. While you were in the emergency 9.7 About the same as other department, did you feel threatened by trusts other patients or visitors?

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Median time from arrival to initial assessment (emergency ambulance cases only)

The median time from arrival to initial assessment was higher than the England median in 11 months over the 12 month period from October 2017 to September 2018.

Ambulance – Time to initial assessment from October 2017 to September 2018 at Kettering General Hospital NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

Percentage of ambulance journeys with turnaround times over 30 minutes

From November 2017 to October 2018 there was a stable trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes.

Ambulance: Number of journeys with turnaround times over 30 minutes – Kettering General Hospital

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Ambulance: Percentage of journeys with turnaround times over 30 minutes – Kettering General Hospital

(Source: National Ambulance Information Group)

Number of black breaches for this trust

A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. From October 2017 to September 2018, the trust reported 1353 “black breaches”. Higher volumes were reported across the winter months.

(Source: Routine Provider Information Request (RPIR)

Reasons for these breaches was: • Insufficient discharges in the main hospital, often occurring late in the day, resulting in poor flow and capacity within the ED. Along with • Peak attendances across all streams, resulting in delays in ambulance handover times.

Staff within the department were very aware of the need to offload patients and release the ambulance crews as soon as possible and were observed to try and meet this during the inspection. We did not observe any ambulance crews waiting over 60 minutes. 20171116 900885 Post-inspection Evidence appendix template v3 Page 46

Nurse staffing There were enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Each area of the emergency department had appropriate levels of staffing. However, the service leads had not yet carried out a staffing review, using an evidence based tool. The trust reported the following qualified nursing staff numbers from for the period September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Number in Post Ward / Team WTE Staff (September 2017 to October 2018) Accident & Emergency Nursing 55.4 61.0 Advanced Clinical Practitioner 13.3 17.0 Ambulatory Care Unit 17.1 19.0 Emergency Care Practitioners 1.6 2.0 Minor Injuries Unit 6.3 10.0 Grand Total 93.7 109.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 12.0% for registered nurses in urgent and emergency care. This was higher than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

At the time of our inspection this had reduced due to new recruits commencing employment.

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 8.7% for registered nurses in urgent and emergency care. This was lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 2.6% for qualified nursing staff in urgent and emergency care. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

From October 2017 to September 2018, the trust reported that 32% of shifts requiring registered nurses in urgent and emergency care, were filled by bank staff and 50% of shifts were filled by agency staff.

(Source: Routine Provider Information Request (RPIR) – Bank and Agency tab)

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We observed agency staff working in the department during the inspection who were familiar with the service. The bank and agency staff on duty during the inspection were either employed by the trust (bank) or long-term agency staff familiar with the clinical environment. All had received a local induction and competency checks prior to undertaking treatment, for example, the administration of medicines Medical staffing There were enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. There were seven full time equivalent consultants employed. The service also employed associate specialists who worked at consultant level bringing the number covering the on-call rota to ten. Three consultants we spoke with felt this was manageable and safe. The numbers of staff available to support the on-call rota had improved since the last inspection. There was one consultant within the emergency department who was also paediatric trained and one who had a subspecialist interest in paediatrics. Paediatric support was also provided by the children’s ward when required. The consultant rota met the 16 hours of cover recommended by the Royal College of Emergency Medicine (RCEM). Consultant hours daily were between 8am and 12 midnight, Monday to Friday and then 8am to 4pm and 4pm to midnight on Saturday and Sunday. After these hours, consultants were available through an on-call rota. The trust reported the following medical staffing numbers from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Ward / Team WTE Staff Number in Post (September 2017 to October 2018) Urgent Care (1010) 35.5 37.0 Grand Total 35.5 37.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 0.2% for medical staff in urgent and emergency care. This was lower than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 3.9% for medical staff in urgent and emergency care. This was lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 1.3% for medical staff in urgent and emergency care. This was lower than the trust target of 4%.

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(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage

From October 2017 to September 2018, the trust reported that 69% of shifts requiring medical staff in urgent and emergency care were filled by bank staff and 22% of shifts were filled by locum staff.

(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

The use of locum doctors had reduced since the last inspection, but remained high. The service provided a document, which demonstrated a planned trajectory for continued reduction in the use of locums as new recruits joined the team.

The locums used were mostly long-term locums who were familiar with the staff, and the department. All had received a local induction and competencies check.

Staffing skill mix

As of July 2018, the proportion of consultant staff reported to be working at the trust were lower than the England average and the proportion of junior (foundation year 1-2) staff was lower also.

Staffing skill mix for the 33 whole time equivalent staff working in urgent and emergency care at Kettering General Hospital NHS Foundation Trust. This England Trust average Consultant 21% 29% Middle career^ 52% 15% Registrar group~ 24% 32% Junior* 3% 24%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (SpR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Records Records of patients care and treatment were not kept up to date and did not contain all the information required. For example, records did not always contain nursing risk assessments. Medical staff did not always record the time they had seen the patient or document their role and speciality. Patients’ records were stored appropriately. This was an improvement from the last inspection.

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We reviewed 25 sets of patient records. We found that most doctors recorded detailed and logical accounts of their examinations, diagnoses and investigations. However, doctors did not always record the time they had seen a patient or referred a patient. It was often difficult to identify the identity of the doctor or their seniority. Patient risk assessments were not always completed. Nursing staff completed a nursing assessment booklet. We reviewed 14 nursing assessment booklets and found ten had not been fully completed. We found moving and handling, skin integrity and falls assessment had not been completed. This was significant for three elderly patients who were admitted following a fall that resulted in an injury, who had not had a skin or falls assessment completed despite being in the department for several hours. This was raised with the senior management team at the time of inspection and staff then completed these appropriately. We also saw five patients who were receiving intravenous fluids did not have fluid balance charts completed. We saw evidence in prescription charts where antimicrobials were prescribed of clinical indication, dose and treatment duration documented. Medicines There were effective systems in place regarding the storage and handling of medicines. The service followed best practice when prescribing, giving and recording medicines. Patients received the right medication at the right dose at the right time. We checked a sample of medicines, including emergency medicines. These were in date and stored at the correct temperature. Nursing staff had access to the medicines cupboard using an electronic key system. This enabled pharmacy staff to audit who had accessed the cupboards. Fridge temperatures for medicines requiring refrigeration were checked daily to ensure those medicines were stored correctly. Fridge temperatures observed were within the expected range. The emergency department did not have a commissioned full-time pharmacist, the service had recently introduced clinical pharmacy input. This meant a pharmacist visited the department each morning, to liaise with and support staff with medicines. There was a business case in progress for a seven-day pharmacy service for ED that would include a grade 8 pharmacist and a medicines management technician. Medicines were available out of hours and staff knew how to obtain them if needed. Additional medicines were available and staff knew where to locate them. We observed an example of the nursing staff in the resuscitation area obtaining additional anaesthetic medicines to support the anaesthetist during a medical emergency. Any known allergies or sensitivities to medicines were recorded on all medicine charts seen. This information is important to prevent the potential of a medicine being given in error and causing harm. Patients with known allergies wore a separate wristband alerting staff that they had a medication allergy. Checks were in place to ensure emergency medicines were available and safe to be used as well as being protected from tampering. This included IV medicines being stored in tamper proof bags that were checked prior to opening. We observed that prescriptions were checked and signed by two nurses prior to the administration of medicines in all witnessed cases during the inspection.

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Resuscitation trolleys containing medicines and equipment were accessible if needed in an emergency situation. Daily checks were in place to ensure emergency medicines were available and safe to be used. Controlled drugs which required special storage and recording were stored following good guidance procedures including twice daily checks by two nurses. Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. There was an electronic reporting system in place to allow staff to report incidents. All staff we spoke with knew how to access the system and their responsibilities to report incidents. Staff told us they were provided with feedback after reporting an incident and that learning from incidents was shared across all areas via staff meetings, huddles, emails and notices. Managers and matrons felt there was a good incident reporting culture across the service and that staff could identify near misses along with incidents. The emergency department reported 1,151 incidents from February 2018 to January 2019. A breakdown of incidents in categories is shown below:

Incident Category Total Pressure Ulcers 692 PU (Cat. 2) present on admission 412 PU (Cat. 3) present on admission 124 PU (Cat. 4) present on admission 62 Clinical Care & Treatment (Policy & Procedure) 197 Delay In Treatment 55 Failure to Follow Policy/Protocol/Guidelines 33 Cardiac Arrest Calls (2222) 20 Medical Records / Patient Information (Records/Documentation/Tests/Results) 86 Medical Records or Documentation Misfiled/Missing/Unavailable 53 Wrong/Incorrect Documentation, Details & Results and/or for wrong patient 17 Patient wristband missing / incomplete 8 Access/Appointment/Admission/Transfer or Discharge 78 Admission - Patient Admitted to Inappropriate Clinical Environment 32 Transfer - In-Patient Transfer Problems (communication, delays) 18 Appointment - Failure in Referral Process 8 Medication (non-controlled drugs) 67 Administration - Wrong Dose 11 Administration - Drugs Given at Wrong Time 7 Administration - Drugs Omitted 7 Infrastructure (Accommodation/Availability/Capacity/Staffing) 50 Staffing - Lack of Suitably Trained/Skilled Staff 12 Accommodation - Clinical Environment Unsafe/Not Fit for Purpose 7 Staffing - Activity-to-Staff Ratio 7 Patient Fall 48 Fall (Unwitnessed) 16 Fall (Found on floor) (unwitnessed) 8 20171116 900885 Post-inspection Evidence appendix template v3 Page 51

Fall (Slip or Trip to the floor (witnessed)) 5 Patient Accident / Injury / Health Issue 30 Skin Tear 7 Cannula not removed post discharge 5 Patient Injury - Unknown Cause 4 Violence & Aggression 29 Aggressive / Agitated Behaviour - by Patient 10 Assault (attempted) - Patient to Staff 10 Assault (contact made) - Patient to Staff 6 Blood Transfusion 27 Traceability 16 Failure - Follow Protocol/Policy 5 Incorrect - No Prescription or incorrect prescription for Blood 2 Environment 27 Unsuitable / Unsafe Condition (building structure) 22 Unsuitable / Unsafe Condition (Temperature too hot / cold, access to fluids) 5 Information Governance & Confidentiality 27 Confidentiality - Breach of Patient's Confidentiality or Information Disclosed in Error 15 Lost/Found/Missing/Stolen paperwork, devices, hardware & ID badges 6 Confidentiality - Breach of Staff Records/Information or Unauthorised Access/Disclosure 3 Verbal Abuse 20 Verbal Abuse Staff to Staff (Non-Racial) 9 Verbal Abuse Patient to Staff (Racial) 5 Verbal Abuse Patient to Staff (Non-Racial) 3 Security Incidents 19 Equipment (other) 17 Equipment (Medical or Electronic only) 13 Paediatrics 13 Sharps Incident 12 Employee Accident / Injury 10 Radiology related 9 Medication (controlled drugs) 8 Self Harming Behaviour 7 Communication or Consent 6 Healthcare Associated Infection & Infection Control 6 Delay in Radiology Reporting 3 I.T. Systems / Data Protection / Software 3 Privacy and Dignity 3 Visitor Accident / Injury 3 Fire 1 Theatre/Surgery Incidents 1

Evidence of learning from incidents was disseminated through the local governance meetings, team meetings and the head of nursing would feedback any learning at the morning handovers. From November 2014, NHS providers were required to comply with the Duty of Candour Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person. The service could demonstrate where duty of candour had been applied following incidents. This was monitored through the divisional governance meetings. All staff we spoke with about incidents were able to explain what duty of candour was and when it would be needed and what the thresholds for application of the trust policy were. Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

From November 2017 to October 2018, the trust reported no incidents classified as never events for urgent and emergency care.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS England from November 2017 to October 2018.

These were VTE (venous thromboembolism), a diagnostic incident including delay (including failure to act on test results) and a treatment delay.

(Source: Strategic Executive Information System (STEIS))

We reviewed the route cause analysis for the three serious incidents. We found they had been investigated in an open, honest and thorough way by clinical experts not directly involved in the incident. All contributing factors were considered and measures were identified to help prevent a repeat of similar incidents with recommendations given. For example, a discharge checklist was formulated and an ‘exit observation’ standard operating procedure for all patients who have a NEWS of three and above. This ensured that these patients had a repeat set of observation and if the NEWS score remained at three or above they would be seen by a doctor and the discharge delayed. Safety thermometer The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.

Data collection takes place one day each month. A suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of the suggested data collection date.

Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and three new urinary tract infections in patients with a catheter from October 2017 to October 2018 within urgent and emergency care.

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Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Kettering General Hospital NHS Foundation Trust

1 Total CUTIs (3)

1 Catheter acquired urinary tract infection level 3 only

(Source: NHS Digital - Safety Thermometer)

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. An emergency department (ED) consultant was the lead for clinical audits. An audit plan had been produced which had involved working with other services to audit current practice. For example, internal audits had been completed for upper gastrointestinal bleeding, management of patients on non-invasive ventilation and renal colic patients. We saw documents that showed prescribing staff in the ED used the hospital’s adult antimicrobial guidelines when prescribing antibiotics. We reviewed the policies and pathways for the admission of patients with fractures and chest pain. We saw that these were written in line with the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines. We saw up to date national guidance, such as NICE guidelines were used for paediatric procedures. Staff had access to these in folders and through the trust’s internal website. However, three paediatric policies were out of date. A senior nurse told us these had not been reviewed due to staff absences and had a plan for this to be carried out in March 2019. There was a clear protocol for staff to follow for the management of sepsis. The department used the ‘sepsis six’ interventions to treat patients. ‘Sepsis six’ is the name given to a bundle of medical therapies designed to reduce the mortality of patients with sepsis. Bundles were also available for neutropenic sepsis and fractured neck of femur. These pathways were clear and detailed; however, records completion was a concern, due to assessment bundles not being consistently completed. The service had reported good outcomes for patients in a recent national audit. Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. The service made adjustments for patients’ religious, cultural and other preferences. However, patients receiving intravenous fluids did not have fluid balance charts completed. Risk assessments on patients were undertaken where required if there was a risk of malnutrition. An initial assessment would be undertaken in the department and a referral sent to the dieticians.

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Comprehensive risk assessments of malnutrition risks were undertaken if a decision was taken to admit the patient to the hospital. This would be undertaken by the department in the event of the patient being in the department whilst waiting for a bed on a ward. Weight loss, food intake and malnutrition was assessed on children who were seen in the children’s emergency department. We examined the records of two babies that showed weight was considered during their initial assessment for risks associated with weight loss. Following the assessment of a patient, intravenous fluids were prescribed, administered and recorded when clinically indicated. However, we saw that no monitoring of a patient’s fluid balance was documented on patients who were receiving intravenous fluids. Emergency Department Survey 2016

In the CQC Emergency Department Survey, the trust scored 7.6 for the question “Were you able to get suitable food or drinks when you were in the emergency department?” This was about the same as other trusts.

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Pain relief Patients pain was not always managed effectively. For example, patients did not have their pain re-assessed following the administration of pain relief or throughout their stay in the emergency department. When the department was busy, pain relief was not always administered in a timely manner. However, initial pain assessments were completed on arrival and pain relief was provided. Throughout the inspection, we observed staff asking patients if they were in any pain and providing pain relief where required. When the department was busy pain relief was not always administered in a timely way. Nurses were able to administer simple pain relief under a patient group direction, which permitted suitably trained staff to supply prescription-only medicines to groups of patients, without asking a doctor to write a prescription. Patient records showed that patients’ pain levels were assessed and recorded using pain scores. We observed nursing staff administering rapid pain relief when they assessed patients who had walked into the department and those who had arrived by ambulance. However, pain scores were not re-assessed at regular intervals to ensure that pain relief had been effective. Emergency Department Survey 2016

In the CQC Emergency Department Survey, the trust scored 6.3 for the question “How many minutes after you requested pain relief medication did it take before you got it?” This was about the same as other trusts.

The trust scored 7.7 for the question “Do you think the hospital staff did everything they could to help control your pain?” This was about the same as other trusts.

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Patient outcomes

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The emergency department failed to meet any of the national standards for the Royal College of Emergency Medicine (RCEM) asthma, severe sepsis and the consultant sign off audits. However, whilst outcomes of care did not meet national standards, they were being monitored and the service used the findings from audits to improve patient outcomes. The service took part in all national audits in 2018/19. The local audit programme for the main emergency department and the children’s emergency department was based on the RCEM standards of care. The services were in the process of completing a large number of local audits to reflect the main service activity. The audits undertaken were based on the RCEM standards, as well as local medical audits. We were provided with local medical and nursing audits undertaken within the last 12 months. The medical audits included, pain in children, fractured neck of femur and procedural sedation clinical audits. The nursing audits included, matron spot checks, NEWS2 audits, mental health audit and nurse sensitive indicator (NSI) audit. The NSI audit looked at indicators such as, pressure tissue damage, falls, safeguarding, medications and the deteriorating patient. The results of the NSI for December 2018, ranged from 100% of patient receiving antibiotics within an hour for sepsis, to 63% of patients receiving a pain score. This was similar to the records we looked at during the inspection. In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma audit, Kettering General Hospital emergency department failed to meet any of the national standards.

The department was in the upper UK quartile for two standards:

• Standard 1a (fundamental): O2 should be given on arrival to maintain saturations 94-98%. This department: 32.1%; UK: 19%.

• Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given within 10 minutes of arrival at the emergency department. This department: 40.7%; UK: 25%.

The department was in the lower UK quartile for one standard:

• Standard 4 (fundamental): Add nebulised Ipratropium Bromide if there is a poor response to nebulised β2 agonist bronchodilator therapy. This department: 67.7%; UK: 77%.

The department’s results for the remaining five standards were all within the middle 50% of results.

(Source: Royal College of Emergency Medicine)

In the 2016/17 Consultant sign-off audit, Kettering General Hospital emergency department failed to meet any of the national standards.

The department was in the upper UK quartile for two standards:

• Standard 3 (fundamental): Consultant reviewed: patients making an unscheduled return to the emergency department with the same condition within 72 hours of discharge. This department: 25.7%; UK: 12%.

• Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years and over. This department: 21.7%; UK: 10%.

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The department was in the lower UK quartile for no standards.

The department’s results for the remaining two standards were all within the middle 50% of results.

(Source: Royal College of Emergency Medicine)

In the 2016/17 Severe sepsis and septic shock audit, Kettering General Hospital emergency department failed to meet any of the national standards.

The department was in the upper UK quartile for two standards:

• Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement, temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary blood glucose recorded on arrival. This department: 94.1%; UK: 69.1%.

• Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or involvement of critical care medic (including the outreach team or equivalent) before leaving the emergency department. This department: 76.5%; UK: 64.6%.

The department was in the lower UK quartile for no standards.

The department’s results for the remaining six standards were all within the middle 50% of results.

(Source: Royal College of Emergency Medicine)

They were given recommendations from the RCEM and we saw evidence of action plans in completing these.

From October 2017 to September 2018, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and about the same as the England average.

Unplanned re-attendance rate within seven days - Kettering General Hospital NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

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Competent staff The service had processes in place to ensure staff were competent for their roles. However, staff did not always receive an appraisal. For example, only 80% of nursing staff and 78.6% of medical staff had received an appraisal, this did not meet the trust target of 85%. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. As of September 2018, 63.5% of required staff across the trust’s urgent and emergency care services received an appraisal compared to the trust target of 85%. The breakdown by staff group can be seen in the table below:

Individuals Staff who Completion Met Staff group received an rate Target required Yes / No appraisal Allied Health Professionals 7 6 86% 85% Yes Additional Clinical Services 35 27 77% 85% No Administrative and Clerical 9 6 67% 85% No Nursing and Midwifery Registered 97 55 80% 85% No

(Source: Routine Provider Information Request (RPIR) - Appraisal tab)

The appraisal rate for the medical staff within the ED as of January 2019 was, 78.6%, this meant that 22 out of the 28 doctors had received an up-to-date appraisal. The remaining six were due theirs in the next three months.

Since September 2018 the department had a new senior leadership team. They had been working on increasing the appraisals for nursing staff and administrative staff and all staff we spoke with during the inspection had received an appraisal. We did not have updated data to show this.

Since the last inspection in 2017, the paediatric emergency department (PED) was now staffed with at least one registered children’s nurse. All adult registered nurses received a bespoke paediatric training package which included competencies they had to complete before they could work in the PED, alongside a registered children’s nurse. There was a paediatric trained consultant and another with a subspecialist interest. The staff had access to, and were supported by the paediatric team from the ward when needed.

Newly qualified nurses were given a period of supernumerary time working alongside a peer mentor and had a formal training programme. We spoke with one student nurse, who was about to qualify and had chosen to start their career within this emergency department. They had already been given their mentors and their induction programme for the next six months and spoke highly of their mentor and the induction process.

All doctors had a clinical supervisor; they planned regular meetings and completed their portfolio. One of the consultants was the named clinical educator and had an in-depth training and teaching plan for all doctors.

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Clinical supervision was delivered face to face and via an online portal. The consultants had education supervision written in their individual job plans. There was an educational lead for each speciality and an educational committee.

At 8am and 9am, there was ‘breakfast’ training for doctors in the clinical simulation suite. Feedback was positive and was well attended.

In May 2018, the mental health quality improvement (MHQI) project was developed with the aim of improving care to mental health patients and training for ED staff. Collaborative working with a local NHS acute trust had enabled clearer communications between trusts and effective working. It had also allowed for the implementation of a rolling training programme for staff to enhance their mental health and alcohol dependency knowledge whilst understanding the legislation underpinning practice. The first training day commenced 24 September 2018 and was ongoing until October 2019. At the time of our inspection, 78 members of the non-clinical and nursing team had completed this training, however, none of the medical staff had as yet, however, we were assured by the managers that all staff would by October 2019.

During our inspection we saw nursing staff being asked to go and be part of this training, as they were adding extra sessions at certain times of day to ensure all staff could take part. Multidisciplinary working Staff of different disciplines worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. There was very positive engagement and working with the acute medical team, surgical team and the emergency department. When the department called for a review or referral, the team would attend swiftly. We observed effective multidisciplinary working during a cardiac arrest call. Staff communicated well, understood their roles, and worked together to provide the best outcome for the patient. The service worked well with the local mental health trust. The department were supported when referrals were made and responded to in a timely manner. The department worked well with the paediatric service who provided support to the children’s emergency department, we observed referrals were responded to swiftly when specialist input was required. We spoke with three members of the ambulance service who reported that they had good relationships with the team and since the ambulance streaming process had started, they were able to handover patients in a timely manner. Seven-day services The main ED and paediatric ED were open seven days per week, 24 hours per day and had appropriate consultant cover. Patients could access emergency diagnostic imaging services at all times, in line with the NHS Services Seven Days a Week Priority Clinical Standards. The department had access to radiology support 24 hours each day, with rapid access to computerised tomography (CT) scanning when indicated. The ED had access to on-site pharmacy support Monday to Friday from 8.30am to 6pm and Saturday 9am to 1pm. Outside of these hours staff had access to an on-call pharmacist who was available to provide support. The ED had access to an emergency and trauma theatre as per national guidance 24 hours a day, seven days a week.

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Health promotion Staff were committed to supporting people to live healthier lives. The service promoted alternative options to attending the emergency department. The service recognised that a number of patients who self-presented in the department could attend an alternative service for their treatment. Through the trust website, and in leaflets and posters displayed, alternative options available were explained and promoted instead of attending the ED for minor ailments. The information included what conditions a patient should visit a pharmacy or GP for. We saw numerous posters around the ED and in the paediatric ED, for example advice on antibiotics. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care and gained consent appropriately.

This was an improvement from the last inspection in 2017. The knowledge of medical staff with MCA was a recognised risk on the risk register in 2017/18. However, during this inspection, nursing and medical staff we spoke with understood their role in assessing mental capacity.

We saw in patients’ medical records that their mental capacity had been considered and documented where appropriate.

Nursing and medical staff understood their responsibilities with consent, especially regarding patients under the age of 16 years old.

Staff received training on breakaway techniques and restraint. The department worked with a specialist in this area. Data provided by the trust showed that 63% of staff had received this training.

The trust reported that from October 2017 to September 2018, Mental Capacity Act (MCA) training was completed by 93% of staff in urgent and emergency care compared to the trust target of 85%. Deprivation of liberty safeguards was included in the MCA training.

(Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training tab)

Is the service caring?

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

We saw several examples of patients treated with compassion, dignity and respect. Staff spoke in a respectful but friendly manner and maintained patients’ confidentiality. We observed one nurse comforting a distressed patient by giving them a hug. Other staff showed patience and tolerance with patients who were agitated, confused or distressed.

We observed several examples of staff asking for the patient’s consent before entering their cubicle area, respecting their dignity. The department staff adopted the use of the “Hello, my

20171116 900885 Post-inspection Evidence appendix template v3 Page 60 name is” approach when introducing themselves to patients.

Nurses and healthcare assistants showed understanding and a non-judgmental attitude when talking about patients with mental health needs, patients living with a learning disability or dementia.

We spoke with seven adult patients and one patient under the age of 18 years who were using the service. We also spoke with three relatives, and three parents with their children in the department. All patients reported that they were receiving good care in the service and praised the staff for their approach and the treatment provided.

Reception staff greeted people reassuringly and with courtesy. However, privacy was sometimes compromised. Reception and nursing staff told us that some patients complained about having to give private information which could be overhead by other patients waiting behind them. We shared this information with the leadership team and they told us of mitigating actions that were being put in place, some with immediate effect.

The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was about the same as the England average in December 2017 and January 2018. In the months from February 2018 to August 2018, data was suppressed as less than five responses were received by the trust. The trust performed better than the England average in September 2018 and October 2018, but dropped below the England average in November 2018.

A&E Friends and Family Test performance - Kettering General Hospital NHS Foundation Trust

(Source: NHS England Friends and Family Test)

Emotional support Staff provided emotional support to patients to minimise their distress. Staff understood the need for emotional support within the emergency department setting.

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Patients and their families told us they were kept informed of all care and treatment due to be carried out. We observed nurses talking to a patient who was seriously ill. They explained what was happening in simple terms so that treatment and investigations were less alarming. Staff we spoke with demonstrated understanding of how to provide emotional support to patients with mental health needs and those in crisis. They also understood how mental health challenges could manifest themselves and how they could tailor care and treatment to the patient’s needs. Staff understood the impact that a patient’s diagnosis could have on their wellbeing and on those close to them, both emotionally and socially. Nursing staff we spoke with told us that they received formal debriefs after particular events in the department such as the death of a child or a traumatic incident. This was an improvement since the last inspection in 2017. Straight after the event, the lead consultant carried out a debrief and discussed any concerns, what went well and any other information that staff needed. The head of nursing would then meet with any staff afterwards for support if they remained distressed. The head of nursing gave an example of where they were giving this support to a member of staff at the time of inspection. Staff could also access counselling services through occupational health. Patients and staff had access to the chaplaincy service who offered support to patients and staff seven days per week. In addition, there were multi-faith options available and non-religious ministers who also supported the department. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives felt informed about their care and treatment and were able to ask medical and nursing staff questions before making decisions about their care. Staff made sure patients and relatives understood the assessments being done and the likely diagnosis and treatment plan. Patients and relatives were given opportunities to ask questions and staff gave them time to do this. We observed nurses introducing themselves and explaining what was about to happen before providing care. They wore name badges which clearly stated their name and role. This helped to ensure that patients were aware of the professionals involved in their care. The trust scored about the same as other trusts for all of the 24 Emergency Department Survey questions relevant to the caring domain.

Question Trust 2016 2016 RAG 4.1 About the Q10. Were you told how long you would have to wait same as to be examined? other trusts 8.5 About the Q12. Did you have enough time to discuss your same as health or medical problem with the doctor or nurse? other trusts 8.1 About the Q13. While you were in the emergency department, same as did a doctor or nurse explain your condition and other treatment in a way you could understand? trusts Q14. Did the doctors and nurses listen to what you 8.6 About the had to say? same as

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Question Trust 2016 2016 RAG other trusts 8.8 About the Q16. Did you have confidence and trust in the same as doctors and nurses examining and treating you? other trusts 8.9 About the Q17. Did doctors or nurses talk to each other about same as you as if you weren't there? other trusts 8.0 About the Q18. If your family or someone else close to you same as wanted to talk to a doctor, did they have enough other opportunity to do so? trusts 8.5 About the Q19. While you were in the emergency department, same as how much information about your condition or other treatment was given to you? trusts 8.2 About the Q21. If you needed attention, were you able to get a same as member of medical or nursing staff to help you? other trusts Q22. Sometimes in a hospital, a member of staff will 8.9 About the say one thing and another will say something quite same as different. Did this happen to you in the emergency other department? trusts 8.0 About the Q23. Were you involved as much as you wanted to same as be in decisions about your care and treatment? other trusts 9.1 About the Q44. Overall, did you feel you were treated with same as respect and dignity while you were in the emergency other department? trusts 7.3 About the Q15. If you had any anxieties or fears about your same as condition or treatment, did a doctor or nurse discuss other them with you? trusts 7.3 About the Q24. If you were feeling distressed while you were in same as the emergency department, did a member of staff other help to reassure you? trusts 8.2 About the Q26. Did a member of staff explain why you needed same as these test(s) in a way you could understand? other trusts 8.2 About the Q27. Before you left the emergency department, did same as you get the results of your tests? other trusts 8.8 About the Q28. Did a member of staff explain the results of the same as tests in a way you could understand? other trusts

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Question Trust 2016 2016 RAG 9.1 About the Q38. Did a member of staff explain the purpose of same as the medications you were to take at home in a way other you could understand? trusts 4.6 About the Q39. Did a member of staff tell you about medication same as side effects to watch out for? other trusts 5.6 About the Q40. Did a member of staff tell you when you could same as resume your usual activities, such as when to go other back to work or drive a car? trusts 5.2 About the Q41. Did hospital staff take your family or home same as situation into account when you were leaving the other emergency department? trusts 6.4 About the Q42. Did a member of staff tell you about what same as danger signals regarding your illness or treatment to other watch for after you went home? trusts 7.7 About the Q43. Did hospital staff tell you who to contact if you same as were worried about your condition or treatment after other you left the emergency department? trusts 8.2 About the same as Q45. Overall... (please circle a number) other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

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Is the service responsive?

Service delivery to meet the needs of local people The service was unable to plan and provide services in a way that met the needs of local children. This was because the paediatric area was now too small for the population they served. However, services for adults were mostly planned and provided in a way that met their needs. The emergency department (ED) was originally built to treat 30,000 patients per year and now saw in excess of 80,000 per year. The service had increased the footprint of the department by adding an additional major’s area known as ‘majors 1’. Since the last inspection a further area for major’s patients had been utilised, this was known as ‘majors 2’. This had helped to improve the flow and experience for patients. The main waiting area at the last inspection was shared with the fracture clinic. This had changed and the area was now solely for ED patients. This provided more space for patients and relatives to wait. The service now had a refurbished minor’s area because the fracture clinic had relocated. This improved the flow for this stream of patients. The paediatric area could not always accommodate waiting children and their parents, carers or guardians. This was being discussed at corporate level to decide the best plan for this area. The emergency decision unit was an area of older clinic rooms within the ED. This area was not ideal for patients who were waiting to receive final tests or treatment. It was also challenging to locate and we observed many people trying to find it but had to ask for assistance due to signage not being sufficient. There were agreements in place to work cohesively with other trusts to ensure responsive care. This included a local trauma trust, and the mental health trust. Meeting people’s individual needs The service took account of patients’ individual needs. Food and drink was available to those who were in the ED for any length of time. There were regular time slots for care ‘rounding’ which included offering patient’s drinks. This was when health care assistants would go around the department two hourly to offer food and drink and see if patients needed help with their toileting needs. Food and drink was also available to relatives who were waiting in the department. There was awareness in the ED for meeting the needs of patients living with dementia or a learning disability. The trust employed a specialist nurse from a national dementia charity, who worked with staff in the department when looking after patients living with dementia. We were also given an example of a patient with severe dementia who arrived in the department by ambulance. The specialist dementia nurse was informed and the patient was taken to an appropriate area, seen by a senior doctor and was treated and discharged back to the nursing home within an hour. Staff that we spoke with had received training in responding to the needs of people living with dementia. They described the care needed in a knowledgeable and sympathetic fashion. They knew, for example, that patients living with dementia should be cared for in a quiet part of the department in a low stimulus environment. The ED had a clear process for the support of those living with a learning disability coming through the service. In the event a patient with known learning disabilities attended the

20171116 900885 Post-inspection Evidence appendix template v3 Page 65 department, the service would contact the learning disabilities specialist nurse. Nursing staff told us that they responded quickly and could give us examples of when they had contacted them.

The mental health liaison team provided training to all staff within the department. This was an improvement since the last inspection in 2017. Knowledge and awareness had increased and nursing staff we spoke with knew how to support and interact with patients presenting with mental health concerns.

Support workers from a nationwide charity for older people had started to work in the department seven days a week. They supported patients with filling in forms, spoke with patients, provided refreshments, engaged in activities with patients living with dementia, sourced mobility aids and helped make arrangements to get patients home once discharged. ED staff said they were a great resource and really helped with the older patients and relatives.

Patients had access to leaflets in the waiting area providing information on a variety of health conditions. Further leaflets in other languages were also available. Leaflets were available for children and adults in the children’s ED. Information for children was provided in an easy read format to help them understand their condition. Staff had access to translation services, via a telephone service, when there was a need to communicate with a patient whose first language was not English.

The trust scored about the same as other trusts for all three of the Emergency Department Survey questions relevant to the responsive domain.

Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your 6.7 About the same as condition with the receptionist? other trusts Q11. Overall, how long did your visit to the emergency 7.4 About the same as department last? other trusts Q20. Were you given enough privacy when being 9.4 About the same as examined or treated? other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Access and flow Patients could not always access care and treatment in a timely way. Whilst waiting times for treatment and admission had improved in recent months the percentage of patients admitted, transferred or discharged within four hours of arrival in the emergency department and total length of time patients were in the department was higher than the national average.

The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the ED.

On review of the performance data information provided for November 2018 to January 2019, it was determined that 33.5% of all breaches of the national four-hour standard recorded were linked to bed capacity, and 37.5% linked to emergency department performance. For example, patients who had been waiting more than 120 minutes to be seen and treated often meant they would not meet the standard of being admitted, transferred or discharged within four hours of arrival.

The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet the standard for nine months over the 12 month period from October 2017 to September 2018.

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From October 2017 to September 2018 performance against this standard showed improvement towards both the standard and England average performance. This was due to the new ambulance streaming process and minor’s area.

Median time from arrival to treatment from October 2017 to September 2018 at Kettering General Hospital NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.

From November 2017 to October 2018 the trust failed to meet the standard and consistently performed worse than the England average.

Four hour target performance - Kettering General Hospital NHS Foundation Trust

(Source: NHS England - A&E Waiting times)

From November 2017 to October 2018 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was generally worse than the England average.

From November 2017 to October 2018 performance against the four hour metric showed signs of improvement. In the most recent three months (August 2018 to October 2018 it performed better than the England average.

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Percentage of patients waiting more than four hours from the decision to admit until being admitted - Kettering General Hospital NHS Foundation Trust

(Source: NHS England - A&E SitReps).

Over the 12 months from November 2017 to October 2018, no patients waited more than 12 hours from the decision to admit until being admitted.

Month Number of patients waiting Number of patients waiting more than four hours to more than 12 hours to admission admission November 2017 502 0 December 2017 848 0 January 2018 1122 0 February 2018 1053 0 March 2018 981 0 April 2018 518 0 May 2018 422 0 June 2018 441 0 July 2018 481 0 August 2018 99 0 September 2018 239 0 October 2018 153 0

(Source: NHS England - A&E Waiting times)

During the inspection we saw no patients waiting for more than 12 hours after their decision to admit. However, there were three patients who had been in the department for more than eight hours. The three patients were on the appropriate pressure relieving mattresses and had beds allocated on the wards.

We reviewed patient’s medical records whom had been referred to a speciality and could see that they were seen in a timely manner. This helped with admitting patients into the hospital once they had a decision to admit.

From October 2017 to September 2018 the monthly percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment was better than the

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England average.

From December 2017 to September 2018, the trust reported that there were no patients that left the urgent and emergency service without being seen. We queried this data with the trust and was informed this data was inaccurate. We were given data from January 2018 to December 2018 that showed that 2.3% of patients left the department before being seen for treatment, this was better than the England average.

Percentage of patient that left the trust’s urgent and emergency care services without being seen - Kettering General Hospital NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

From November 2017 to October 2018 the trust’s monthly median total time in A&E for all patients was consistently higher than the England average.

Median total time in A&E per patient - Kettering General Hospital NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

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We observed staff who were very focused and dedicated to improving flow through the majors department. Daily huddles with the senior leadership team facilitated flow and communication with the site bed management team, who were seen regularly in the department. We observed an operational bed meeting during the inspection. During these meetings, flow, capacity, staffing concerns and operational challenges for escalation were discussed though this was not consistent between meetings. At each meeting, the ED was discussed, and concerns were escalated where required. Staff in the department told us that patient flow had improved since the creation of the ‘majors 2’ area and the ambulance streaming area. However, there were still delays due to capacity of beds within the main hospital. The main booking in desk had been moved to a more appropriate area of the department. However, we observed patients booking in with the receptionist, sitting back in the waiting area, then being called back to the desk to speak with the streaming nurse, then sitting back in the waiting area, then being called through into one of the triage/minor’s cubicles to have a set of observations and other tests such as blood tests or an electrocardiogram. The patient would then go back to the waiting area and wait to be called through to see a doctor. This did not show effective use of the streaming/triage service. At the last inspection we had concerns about the timeliness of triage, when patients were getting a full initial assessment and the booking in desk being by the entrance with no privacy. As a result, the main booking in desk had been moved to a more appropriate area of the department. However, the flow of patients in this area did not work well. We observed patients booking in with the receptionist then sitting back in the waiting area. The streaming nurse would then call the patient back to the desk to have a face to face conversation about the patient’s concern. Following this the patient would return back to sit in the waiting area. Here they would wait again before being called through into one of the triage/minor’s cubicles to have a set of observations and other tests such as blood tests or an electrocardiogram. The patient would then return to the waiting area and wait to be called through to see a doctor. This did not show effective use of the streaming/triage service. A GP worked specifically in the minor injuries/urgent care unit in the adult ED. Patients could be seen by the GP reducing the demand on the main department. There was also emergency nurse practitioners and advanced clinical practitioners with medical prescribing, working in minors and the main ED at all times. This pathway worked well. The service worked well with the local mental health trust. The department were supported when referrals were made and response times, when referrals were made, were kept to a minimum.

Learning from complaints and concerns The service treated concerns and complaints seriously. They investigated them and learned lessons from the investigations. Lessons learnt were shared with all staff through governance meetings. However, complaints were not always responded to in a timely manner. From October 2017 to September 2018, there were 56 complaints about urgent and emergency care services. The trust took an average of 66.6 working days to investigate and close complaints. This was not in line with their complaints policy, which stated complaints should be closed within 35 days.

The most commonly received complaints were in relation to nursing staff this included appending

20171116 900885 Post-inspection Evidence appendix template v3 Page 70 to basic needs, for example hygiene and nutrition. Ten complaints about care and treatment had been received from October 2017 to September 2018.

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

We discussed with the senior leadership team (SLT), the reasons that complaint investigation was not meeting the complaints policy target. There were staff shortages within the complaints department, which had led to delays in the complaints team responding to complainants. Members of the SLT told us, since they commenced their roles in November and December 2018, they found 26 complaints that had not been investigated by the previous management team, these led to a delay in the response times. The matron had since met face to face with all the complainants and now 14 investigations were outstanding. Staff that were named in complaints also attended the face to face meetings where appropriate. This made an impact on staff in a positive way, rather than just reading about the complaint in a letter. Replies to complaints reviewed were courteous and displayed an understanding of how the complainant felt.

The head of nursing attended departmental nursing handovers each day and shared any learning from complaints in this forum when they arose.

From October 2017 to September 2018, there were 66 compliments in urgent and emergency care. Examples of these ranged from, praise to the kind and caring nursing and medical staff and receiving timely treatment.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led?

Leadership The emergency department (ED) had a new senior leadership team, with the right skills and abilities to run a service. They were committed to providing high-quality, sustainable care. However, due to the infancy of the ED senior leadership team, changes and improvements were yet to be embedded. The emergency department (ED) was part of the medicine division. The division was led by a chief of division, divisional director and a head of nursing for urgent care. For the ED there was a clinical lead, matron and general manager and a nurse consultant. The clinical director for urgent care was also a consultant within the ED. The head of nursing, matron and deputy divisional director were all new in post, commencing in November 2018 and January 2019. The clinical director had worked in the department for nine years, but had gained the director’s position in 2018. The new senior leadership team (SLT) had agreed six priority areas which they were focusing on for implementing and delivering change. These included, ambulance streaming, daily huddles, senior leadership weekly team meetings, flow coordinator role, national early warning score compliance and a training needs analysis. They had support from the chief executive and chief operating officer, who were also new to the trust. The ED SLT met with the chief executive every six weeks and the chief operating officer every week. Improvement plans and data reviewed showed that the new SLT were making progress in line with what they had set out to achieve. However, due to their short time in their roles in ED, some changes and improvements were yet to be embedded. For example, a flow coordinator. This was

20171116 900885 Post-inspection Evidence appendix template v3 Page 71 being trialled at the time of inspection. The aims of this role were to improve patient experience as a result of optimised flow through the department, ensure patients were seen efficiently in the right area and breaches reduced and support clinical staff in decisions relating to capacity and appropriate patient transfers. Nursing and medical staff told us that the SLT were visible and approachable, as was the chief executive and other members of the executive board. The matron and the head of nursing were visible throughout the department during our inspection. The staff told us management visibility had improved from the previous local leaders. Staff felt supported clinically and nursing staff told us that there was now more focus on patient care and safety. At the last inspection, there was a lack of operational support within the ED. This had now changed with the recruitment of a deputy divisional director. The divisional director had operational management oversight of the department and worked closely with the chief operating officer. Medical staff we spoke with, spoke highly of the clinical lead and director for ED. We found the SLT to be exceptionally knowledgeable about their department, their roles, and the challenges within the service. The clinical lead and director had excellent insight into where the challenges were and were working hard, and with tenacity to make a difference. We observed a positive improvement in the way the department was managed since our last inspection. The SLT told us there was a challenge with changing the culture within the whole staff team, which would take time to change. However, they told us that they were starting to see small positive changes, especially within the nursing team. The SLT had commenced a coaching and human factor training course for staff, with external professionals delivering this training. Leaders also had access to a nationally recognised leadership course and protected time for training. Vision and strategy The service had a vision for what it wanted to achieve and workable plans to turn it into action. It had been developed with involvement from staff, patients, and key groups representing the local community. The trust had a clear set of values, with quality and sustainability as the top priorities. Staff were aware of the values of the trust and these were visually displayed on posters throughout the department. The service was included in the Northamptonshire Urgent and Emergency Care Strategy 2016- 2021. Which was developed and agreed by local health and social care leaders. The planning process was associated with the development of the Northamptonshire sustainability and transformation plan (STP). The strategy objectives were: • Objective 1- help people remain well for longer and provide better self-care support. • Objective 2- help people with urgent care needs get the right advice in the right place, first time. • Objective 3- highly responsive, effective and personalised services. • Objective 4- ensure people with serious or life-threatening needs are treated in centres with the right facilities and expertise.

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• Objective 5- connect urgent and emergency care services so the system becomes more than the sum of its parts. The trustwide strategy included the performance of the ED, and there was a focus to improve flow and time spent in the department. This was evident with an improvement in the overall performance of the department on seeing patients within four hours. There was a quality improvement plan for the service, this had been updated in February 2019. This highlighted four areas of concern and a thorough action plan for each area. For example, physical capacity and ambulance handover process were highlighted as problem areas. The SLT had increased the minor’s area capacity, and the ambulance handover process had improved to include, prompt, effective streaming at the front door and had embedded an ambulance standard operating procedure for this. This was audited monthly. There were actions that were still ongoing, such as, aligning the trust’s electronic clinical system with the ambulance’s system to gain more accurate data. Culture Managers across the service were starting to promote a positive culture that supported and valued staff. They were creating a sense of common purpose based on shared values. We saw positive joint working between senior medical and nursing staff. We observed effective communication between all members of the ED team. Senior doctors and nurses discussed patients at the twice daily “board rounds”, these were a summary discussion of the patient journey and what was required that day for it to progress. They identified and resolved any waits or delays in the patient’s stay. This enhanced patient experience and reduces the risk factors associated with a prolonged stay in hospital (SAFER patient flow bundle: board rounds NHS Improvement 2017). The senior leadership team had a daily ‘huddle’ in the mornings. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. Effective safety huddles involve agreed actions, are informed by visual feedback of data and provide the opportunity to celebrate success in reducing harm (Safety Huddles NHS Improvement 2019). Members of the leadership team, each expressed the same views on issues such as dealing with a crowded department, responding to complaints and incidents and working with different services. Clinical and non-clinical staff told us that, overall, they enjoyed working in the service and felt supported by the new SLT. They were able to express any concerns they may have had and felt they were given opportunity to make changes in the department. The culture regarding duty of candour was positive, and where incidents were recognised to have caused harm, ‘being open’ meetings took place. Where an incident met the requirement of the duty of candour, we saw evidence that the regulatory requirements of these were met. Staff we spoke with about duty of candour understood its meaning and had received relevant training. Part of the SLTs focus, was the need to ensure high quality appraisals and career development plans for staff. The matron had commenced work on this, by starting with a training needs analysis (TNA) and the development of a ‘skills portfolio’ for staff to work towards. They were also developing a training package for each staff group. A TNA is the process of identifying the gap between employee training and needs for training. The skills portfolio was made up of samples of work that demonstrate staff’s knowledge, skills and abilities and competence. It provides a record of their career to date, detailing achievements, skills, qualities and qualifications (Developing your portfolio, Health Careers -NHS Careers)

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There was culture of staff safety. There were appropriate security arrangements to keep staff and others safe and protected from violence. We observed rapid and effective responses from security officers. We were told that all security staff were trained annually in conflict management and physical intervention. Security staff were due to be permanently based within the department, with their own office that could oversee the waiting area. This had not commenced during the time of our inspection. Governance The service had started using a systematic approach to continually improve the quality of its services and safeguard high standards of care. Whilst they had a framework in place for governance, mortality and morbidity meetings were not minuted. At our last inspection in 2017, we found that clinical governance arrangements lacked detail, that governance meetings were poorly attended and that information was not shared with all staff. During this inspection, we found a well-structured governance system in place with the production of information about the department’s clinical quality performance. This was discussed at monthly governance meetings and used to demonstrate effectiveness and progress. Minutes of meetings, we reviewed, showed meetings were well attended by the multi-disciplinary team. Items such as quality indicators, risks, incidents, complaints, compliments and plans for audits and training were discussed. Quality indicators included items such as, patient documentation, recording of observations, nursing risk assessments and hand hygiene. These were monitored by the head of nursing and matron Mortality and morbidity review processes were well established in the service and were mostly effective. Meetings were scheduled to be held monthly; however, because this was an academic process for learning, these were not formally minuted. The SLT told us that going forward, mortality and morbidity would be on the agenda in their clinical governance meetings. Management of risk, issues and performance The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected, these systems were mostly effective. The department maintained a risk register, which defined the severity and likelihood of risks in the department causing harm to patients or staff, risks to the service, operational risks and quality risks. The services top risks were: • Potential for the current nurse and support worker vacancies in the ED to negatively impact on the quality of patient care and experience including non-compliance with key performance indicators e.g. time to be seen, observations. • Recognition of impact on staff experience. • Challenges in providing timely care. • Mandatory training compliance. • Patients having to wait for prolonged periods in the emergency decisions unit, due to the lack of bed capacity within the main hospital. Actions included: • Recruit to posts. To be achieved by June 2019. • Embed standard operating procedure on ED processes. To be achieved by July 2019.

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Current mitigating actions that were in place, were: • Ongoing management of skill mix, nursing rotas, utilisation of bank and agency staff and continual recruitment process. • Quality Matron in post to support education, training and development. • Cross cover as part of skill mix with staff in Urgent Care wards. • Coaching support provided through leadership development and human factors coaches. • Recruitment of a clinical support worker to maintain cleaning and stock control. • The use of emergency nurse practitioners and advanced clinical practitioners to support other activities within the department. • Review undertaken with support from daily safety huddle. • Additional staffing agreed on temporary basis to cover corridor. • Practice development nurses based in the department for the next 4 weeks whilst recruitment plans enacted. • Cross county work to relieve bed pressures and facilitate flow in the ED. • Surges in capacity managed through implementation of internal escalation protocol. • 6 weekly roster planning. The risk register was due for review in March 2019. At the last inspection in 2017, we were not assured that the service was reporting all incidents, no learning was shared following serious incidents and not all risks on their register were sufficiently detailed. On the current inspection, we observed there had been improvements made in each of these areas of concern: • A risk escalation was in place. • Staff survey was conducted, which confirmed that staff understood how to report and raise incidents. • Risks that were due for review were electronically flagged to the risk owners so that they could provide an update of the mitigating actions that were being implemented and the current status of that risk. • All risks on the register had been reviewed, updated and were continuously monitored. • Risks were now raised through the divisional governance meetings and to the risk management steering group and were reported to the quality safety committee. • Staff received a bi monthly newsletter including key themes arising from serious incidents and trends with key risks. Since the new SLT had been recruited, the matron found that the staff were not using an emergency care safety checklist. This was now implemented within the department. However, we found that this was not fully embedded within the nursing team and was not always completed. An emergency care safety checklist is a simple time-based framework that outlines clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to improve patient satisfaction and reduce risks.

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At the last inspection, the service needed to ensure that sepsis treatment was provided in accordance with best practice from the Royal College of Emergency Medicine. On the current inspection visit, we found improvements had been implemented including: • The adult sepsis screening and immediate action tool was now incorporated in the ED medical records. • In addition to mandatory sepsis training, additional training and drop in sessions were provided to support all clinical staff to increase compliance from 65%. • An advanced clinical practitioner with medical prescribing worked in the ambulance streaming area, to prescribe antibiotics. As well a doctor in this area. • Deterioration in sepsis performance was escalated via the sepsis working group to the ED clinical director and lead. As a result of these actions, treatment performance had increased to 90% of ‘red flag’ patients receiving their antibiotics within an hour in January 2019. Service performance was a priority for the service and for the executive members of the trust. Performance was reported on monthly at board meetings and was also discussed externally with commissioners.

Information management The service did not have effective arrangements in place to ensure information and data used to monitor, manage and report on performance was accurate. For example, times recorded for initial assessment and streaming. Whilst managers had plans to improve the accuracy of performance data, these were not fully embedded yet. However, electronic systems were secure with security safeguards in place. Service performance measures were reported on and monitored at local governance meetings, and at executive board meetings. These indicators included time to treatment, four-hour performance and 12 hours performance. The patient record system was predominantly paper based. The data inputted for time of initial assessment for ‘walk-in’ patients was not always recorded accurately. The streaming time was also recorded as the triage time, however, patients had not received a full triage at this point. Initial assessment involved taking details of the patient, including symptoms and medical history, the assessment did not include the undertaking of an initial set of observations. We could not be assured how accurate the categorisation of each patient was if observations had not been undertaken at this stage. Nursing staff classed ‘streaming’ as triage, with observations being undertaken a period of time after streaming, which did not meet the 15 minute requirement. Staff had access to the information they needed to undertake their roles effectively. They had access to patients’ records and the results of diagnostic tests via a secure computer system controlled by confidential, individual card access. Policies and procedures were available and accessible via the trusts intranet facility. Engagement Patient engagement was previously limited. There were no innovative methods considered for promoting the importance of patient feedback. No attempt had been made to increase

20171116 900885 Post-inspection Evidence appendix template v3 Page 76 response rates. However, since the decline in response rates in November 2018 the service had introduced electronic tablets for feedback. The service engaged with staff to plan and manage appropriate services. They collaborated with partner organisations where possible. Patients could give feedback through comment cards, and the friends and family test. However, their response rate was poor, showing only five responses from February 2018 to August 2018, and dropping below the England average again in November 2018. Since November 2018, posters were now displayed throughout the ED asking for their comments in an effort to improve the service. Also, there were electronic tablets situated by the main entrance for patients/relatives and carers to complete a friends and family survey when leaving. However, during the inspection we did not see these used regularly and no staff signposted patients to use these. We had no recent data to see if this innovation was improving response rates yet. Staff were involved in the planning and delivery of services. Staff we spoke to had been asked about the planning and redesign of the reception, waiting area and new minor’s unit. The trust worked with stakeholders and commissioners to improve engagement with the public. This included joined up working within commissioners to promote alternative options to patients to help avoid unnecessary attendances to the emergency department. The service also supported national flu campaigns, and displayed posters promoting flu jabs and self care with influenza. The SLT had recently invited the community’s local MP to have a tour of the department and for them to show the challenges they were faced with due to the nature of the environment, especially the paediatric ED. The service demonstrated that despite a challenging financial position, they were able to obtain internal investment to improve the quality of care. This included the increase of nurse staffing, increase in doctors’ training, and the opening of the additional space within the department. The leads for the service were positive future investment in the service would be provided if funding was required. Learning, continuous improvement and innovation The new senior leadership team were committed to improving services. There was evidence of learning from good practice and from incident and complaint investigations. They promoted training, and innovation. However, this was still in its infancy. There was little evidence of any other innovations or research since the previous inspection. The ambulance streaming model that was planned and implemented by the new SLT, was having a positive impact on reducing avoidable admissions. There was continuous monitoring and feedback at all levels involved. New pathways had been developed and continuous learning was still ongoing during our inspection. The junior and senior doctors working in ED had an education programme. The service was also part of the regional teaching program and had regular sessions with doctors across the East Midlands. The clinical educator held training, such as interactive simulations. The clinical educator constantly evaluated their needs and expectations. The clinical educator analysed the feedback to improve the teaching quality. They supervised the personal plan development of the doctors and encouraged them to participate in courses and conferences. To ensure doctors could attend, they changed the rota and arranged extra staff. This meant all medical staff could rotate and attended teaching sessions throughout their shifts.

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Doctors spoke highly of their teaching and training opportunities within this service. The General Medical Council gave positive feedback. The nursing structure within the service was innovative with a range of nursing skills on offer to support patient needs. This included a nurse consultant and advanced clinical practitioners, as well as paramedics supporting the teams in resuscitation. This range of skills provided a good support system for high quality effective care. There was little evidence of any other innovations or research since the previous inspection.

Medical care (including older people’s care)

Facts and data about this service

The medical care service at Kettering General Hospital provides care and treatment in 289 medical inpatient beds located in several wards including: the endoscopy day-case unit, the cardiac centre, Oakley ward and the coronary care unit, the ambulatory day care unit, the medical admission unit (Middleton assessment unit), Clifford ward (medical short stay), elderly care (Naseby A and B wards), haematology (Lilford ward), respiratory (Harrowden A and C wards), endocrinology (HC Pretty A and B wards), general medicine (Poplar and Cranford wards) and Twywell and Lamport ward (intermediate care).

The service provides care and treatment for cardiology, clinical haematology and immunology, endocrinology, gastroenterology, general medicine, geriatric medicine, medical oncology, nephrology and respiratory medicine. Since our last inspection, all stroke services were provided by another hospital nearby.

(Source: Routine Provider Information Request AC1 - Acute context)

The trust had 42,773 medical admissions from June 2017 to May 2018. Emergency admissions accounted for 18,714 (43.8%), 577 (1.3%) were elective, and the remaining 23,482 (54.9%) were day case.

Admissions for the top three medical specialties were:

• General medicine – 14,300. • Gastroenterology – 10,195. • Cardiology – 5,009.

(Source: Hospital Episode Statistics)

The medical care service was last inspected in October 2016. We rated caring and responsive as good, and safe, effective and well led as requires improvement. Requires improvement was the overall rating.

We carried out our short notice inspection on the 5, 6, 7 and 18 of February 2019. During our inspection, we visited:

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• Middleton assessment unit • Naseby A and B wards • Twywell and Lamport wards • Harrowden A and B wards • HC Pretty Wards • Lilford Ward • Cranford Ward • Endoscopy suite • Barnwell C ward • Deene Acute Surgical Unit (DASU)

We spoke with eight patients and relatives, and 45 members of staff, including registered nursing staff, healthcare assistants, administrative staff, medical staff, pharmacists, ward sisters, matrons, senior managers and agency staff. We reviewed 35 patient records and observed care being delivered.

The inspection team consisted of a lead inspector, an assistant inspector, two mental health inspectors, a specialist pharmacy inspector, and two specialist advisors, including a registered nurse and a consultant.

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm.

*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training

Mandatory training was provided for staff. The service met the trust set target of 85% for completion in the majority of mandatory training modules. However, Mental Capacity Act awareness, medicines management and basic life support training rates were below the trust target for medical staff.

There was clear guidance for staff which outlined what mandatory training was required for the roles undertaken. Staff received mandatory training through face-to-face sessions and e-learning modules. Staff understood their responsibility to complete mandatory training. An 85% target was set for completion of mandatory training and managers regularly monitored training compliance. Staff told us they sometimes had difficulty completing training due to workload and capacity.

Mandatory training completion rates

The trust set a target of 85% for completion of mandatory training.

Nursing staff

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for qualified nursing staff in medical care is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)

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Conflict Resolution 242 262 92% 85% Yes NEWS2 12 13 92% 85% Yes Prevent Health Wrap 241 262 92% 85% Yes Infection Control 247 270 91% 85% Yes Equality, Dignity & Respect 245 270 91% 85% Yes Information Governance 242 270 90% 85% Yes Fire Safety 236 270 87% 85% Yes Health and Safety & Risk Management 235 270 87% 85% Yes Manual Handling Patient 228 262 87% 85% Yes MCA Awareness 216 262 82% 85% No Basic Life Support (Adult) 215 262 82% 85% No Medicines Management 203 255 80% 85% No Sepsis 198 262 76% 85% No

The 85% target was met for nine of the 13 mandatory training modules for which qualified nursing staff were eligible. Up to date mandatory training data for February 2019 demonstrated nursing staff were compliant with all 13 mandatory training modules.

Medical staff

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for medical staff in medical care was:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Equality, Dignity & Respect 80 94 85% 85% Yes Information Governance 79 94 84% 85% No Conflict Resolution 79 94 84% 85% No Prevent Health Wrap 78 94 83% 85% No Manual Handling Patient 72 94 77% 85% No Fire Safety 72 94 77% 85% No Health and Safety & Risk Management 71 94 76% 85% No Infection Control 71 94 76% 85% No MCA Awareness 68 94 72% 85% No Medicines Management 67 94 71% 85% No Sepsis 61 94 65% 85% No Basic Life Support (Adult) 61 94 65% 85% No

(Source: Routine Provider Information Request (RPIR) – Training tab)

The 85% target was met for one of the 12 mandatory training modules for which medical staff were eligible. Following inspection, the trust provided us with updated mandatory training figures as of 1 February 2019 which demonstrated improvements in compliance. Medical staff were compliant with eight out of 12 mandatory training modules.

Completion Trust Met Name of course rate Target (Yes/No) Equality, Dignity & Respect 91% 85% Yes Information Governance 88% 85% Yes Conflict Resolution 99% 85% Yes Prevent Health Wrap 76% 85% No

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Manual Handling Patient 99% 85% Yes Fire Safety 98% 85% Yes Health and Safety & Risk Management 91% 85% Yes Infection Control 97% 85% Yes MCA Awareness 56% 85% No Medicines Management 71% 85% No Sepsis 85% 85% Yes Basic Life Support (Adult) 75% 85% No

(Source: data request 39)

Updated mandatory training figures on 1 February 2019, showed the trust target of 85% was also not met by support staff in key skills such basic life support, Mental Capacity Act (MCA) awareness, medicines management and sepsis.

Staff could monitor their own training compliance. An electronic staff record system recorded mandatory training and highlighted to staff what needed doing and when. Ward sisters and managers used this information to monitor when staff training was due and to confirm training modules completed.

Matrons and ward sisters had oversight of training compliance rates. Ward sisters received monthly reports from the learning and development department which identified compliance against core mandatory training topics for individual staff members. Training compliance information was available to staff and we saw it was discussed in ward meetings.

Mandatory training for new staff was incorporated into the induction, and mandatory training compliance was reviewed as part of annual appraisals.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

The trust had a policy and procedure in place to safeguard children and vulnerable adults at risk of abuse which had been reviewed and was up to date. Policies were available to staff on the intranet and staff knew how to access them when required. Safeguarding procedures were clearly displayed on ward notice boards. Mental Capacity Act (MCA) and Deprivation of Liberty Safeguard (DoLS) information posters were on display to staff, patients and visitors. Staff rooms displayed information about MCA and DoLS, demonstrating the process for completing assessments and onward referral.

Nursing staff were aware of the signs of abuse and told us they would report any concerns to the person in charge of the shift or the ward sister. Staff were aware how to make a safeguarding referral and would seek support from the safeguarding leads if necessary. Staff told us they completed incident forms for all safeguarding incidents. We did not see a completed form during the inspection.

Senior staff and ward sisters confirmed they completed referrals direct to the safeguarding team and the local authority. From December 2017 to December 2018, the medical division made 33 adult safeguarding referrals. Referrals made were for reasons such as neglect, for example, pressure ulcers upon admission from care homes. Ward sisters could provide examples of how they had followed the process when making a referral.

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We observed two board rounds on Naseby ward and Harrowden ward. Safeguarding concerns were discussed with the multidisciplinary team, including doctors, nurses, therapy staff and discharge co-ordinators. Daily safety huddles were attended by matrons and ward sisters. Safeguarding was on the agenda and attendees provided oversight of patients who were under DoLS. Staff told us safeguarding incidents and lessons learnt were discussed at these meetings.

Safeguarding training completion rates

The trust set a target of 85% for completion of safeguarding training.

Nursing staff

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 for qualified nursing staff in medical care is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 244 262 93% 85% Yes Safeguarding Adults - Level 2 243 262 93% 85% Yes

Data provided to us by the trust showed from October 2017 to September 2018, nursing staff met the trust standard of 85% for both level two safeguarding children and adults.

Medical staff

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 for medical staff is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 79 94 84% 85% No Safeguarding Adults - Level 2 79 94 84% 85% No

(Source: Routine Provider Information Request (RPIR) – Training tab)

The 85% target was almost met for both safeguarding training modules for which medical staff were eligible. Up to date safeguarding training data as of 1 February 2019 demonstrated medical staff were compliant with safeguarding training for both adults (89%) and children (89%).

Ward sisters had oversight of training compliance and this was reviewed as part of the compliance dashboard by matrons and divisional leads. The learning and development team monitored compliance and provided the division with up to date figures of overall compliance. The safeguarding steering group had oversight of training.

Cleanliness, infection control and hygiene Whilst the service mostly controlled infection risks well, some staff did not use appropriate control measures to prevent the spread of infection. We observed both nursing and medical staff not adhering to appropriate hand hygiene practice.

We saw hand hygiene was not routinely completed by approximately half of staff we observed. We observed 16 occasions where staff displayed effective hand hygiene practices. However, we identified 18 missed opportunities for hand hygiene practice between patients over the course of the inspection. We observed some nursing and medical staff moving from one clinical area to another without washing their hands or using hand sanitising gel provided. For example, we saw healthcare assistants providing care with personal protective equipment (PPE); however, they did 20171116 900885 Post-inspection Evidence appendix template v3 Page 82 not wash their hands or use hand sanitising gel afterwards. We observed staff undertaking patient observations within a bay in Middleton Assessment Unit (MAU) not washing their hands or using hand sanitising gel before and after patient contact.

While most wards displayed compliance with monthly hand hygiene practice audits, the data showed some wards did not complete regular monthly audits. For example, Naseby A, the discharge lounge, Clifford ward and ambulatory care only completed two hand hygiene audits over a six-month period from August 2018 to January 2019. Results of hand hygiene audits from August 2018 to January 2019 showed variable compliance with hand hygiene practice. However, some wards demonstrated 100% compliance, for example, Harrowden A and C, the cardiac centre and HC Pretty A and B.

Hand sanitising foam dispensers were readily available throughout clinical areas. ‘Stop, hand sanitising’ posters were situated at the entrance to each ward. These posters prompted staff and visitors to maintain effective hand hygiene to prevent the spread of infection. Lever operated taps were in place at most hand wash basins, with liquid soap dispensers and paper hand-towels nearby. This was in line with Health Building Note (HBN) 00-09.

Standards of cleanliness and hygiene were generally well maintained, and all areas we inspected were visibly clean and generally tidy. Equipment was dated with “I am clean” stickers. This enabled staff to instantly recognise when equipment was last cleaned. We saw housekeeping staff completing various tasks throughout the course of the inspection. Cleaning schedules were clearly displayed in all ward areas. Patients told us they were happy with the cleanliness of the wards and public areas.

Cleaning audits were carried out across the service. A target of 95% compliance was set for most areas. An audit from October 2018 to January 2019 indicated overall 96% compliance. The discharge lounge (93%), endoscopy (93%) and MAU (94%) had not quite met the target set.

There were no cases of hospital acquired MRSA reported. The national target for MRSA bacteraemia is zero and the trust reported zero cases since May 2015. The service reported 13 cases of hospital acquired C. Difficile from February 2018 to January 2019. We saw when a bacteraemia was identified, the service completed a ‘root cause analysis’ report to identify how the incident had occurred and ensured lessons were learnt. Staff told us the infection control team facilitated a diarrhoea roadshow to promote good hygiene and prevention of hospital acquired infections. We saw a poster promoting the roadshow with a list of wards and the number of days since the last C. Difficile incident.

Side rooms were available for patients who required isolation due to clinical conditions. We saw there was appropriate signage to encourage staff and visitors to wear PPE or speak to the nurse in charge for information before entering the rooms. Most side rooms had toilet facilities. Staff told us deep cleans were arranged following the discharge of patients from side rooms.

Waste was appropriately segregated in clinical areas with separate colour coded arrangements for general waste, clinical waste and sharps (needles). Bins were clearly marked, pedal operated and within safe fill limits. Date of opening was filled in on all sharps bins across all medical wards. We observed these bins were not overfilled and there were risk assessments in place for needle stick injuries. Spill kits were readily available which allowed staff to safely collect and dispose of bodily fluids including blood and urine.

We saw processes in place which ensured the decontamination of endoscopic equipment was adhered to. The endoscopes were cleaned and then transported directly to a dedicated decontamination area. All endoscopes had bar codes on them which enabled the scopes to be traceable. Once cleaned, endoscopes were transferred to a clean area and placed in sterile, seven-day storage cabinets. Staff working in the decontamination area wore appropriate disposable gowns, face-shields and hair nets.

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Patients with known communicable infections were treated at the end of endoscopy lists to enable additional time for deep cleaning of the environment prior to the next patient. The decontamination procedures and equipment in the department destroyed infections such as MRSA and E-coli.

The trust had up to date policies in place to manage effective infection control and hygiene processes. Staff demonstrated how they could access the policies on the trust’s electronic system. Up to date training figures as of 1 February 2019 showed the trust target of 85% was met for infection prevention level two for both medical and nursing staff.

Environment and equipment The service did not always have suitable premises. Equipment was available but was not always checked to ensure it was safe to use.

During the inspection, staff told us patients with acute mental health conditions were admitted to the Middleton Assessment Unit (MAU), whilst awaiting a bed in a mental health ward. Staff reported three recent incidents of patients attempting to hurt themselves or others whilst in MAU. The MAU had three observation beds near the nurses’ station and four multiple bedded areas where patients could not be directly observed. Staff said it was not always possible to place a mental health patient at risk of self-harm in an observation bed, due to the demand for these beds for other acutely unwell patients. We also observed several ligature risks throughout the ward such as oxygen tubing, toilet light cords and bed rails. We raised these concerns with staff and requested plans to mitigate risks. Following the inspection, we were provided with a ligature risk assessment. This included effective plans to identify and mitigate ligature risks. It provided assurance that processes were in place to risk assess patients and the environment prior to a transfer of a patient at risk of self-harm or suicide.

The design, maintenance and use of facilities and premises were generally suitable for purpose on most wards. The estates department was responsible for the provision and maintenance of the environment and equipment. Medical wards were located across four floors in the main building and in a smaller building on site, where Naseby A, Naseby B, Lamport and Twywell wards were situated. Wards generally consisted of multiple bedded bays, usually containing six beds and two isolation rooms. All wards we visited had card activated security access. There was an intercom linked to reception for visitors to be let in and out.

Wards generally had adequate space and storage; environment risk assessments were in place and monitored through monthly audits. There was sufficient equipment to maintain safe and effective care. Most equipment seen had been electronically tested; stickers on equipment confirmed this had been completed in a timely way. However, we did see some equipment, for example, scales and a thermometer on HC Pretty ward had not been safety tested by the specified date on the equipment. During our inspection, we did not see any bariatric equipment in clinical areas. For example, there were no large size commodes for patients. However, staff told us bariatric equipment was available upon request from the handling and moving department.

Resuscitation trolleys containing medicines and equipment required in an emergency were accessible on all wards we visited. They were safely secured with tamper proof seals. Resuscitation trolleys were mostly checked daily and weekly to ensure they were stocked, equipment was in working order and medicines were up to date. However, weekly checks of the resuscitation trolley were not consistently completed in the discharge lounge or in MAU. We saw four gaps in checks for MAU and three in the discharge lounge in January 2019. The endoscopy unit had just purchased a second resuscitation trolley based on recommendations from a recent Joint Advisory Group for Endoscopy (JAG) assessment. The JAG accreditation scheme is a patient-centred and workforce-focused scheme based on the principle of independent assessment against recognised standards. The scheme was developed for all endoscopy services and providers across the UK in the NHS and independent sector.

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Endoscopy staff monitored the decontamination system daily and weekly, ensuring there was sufficient clean equipment to meet the demands of the service. We saw water sampling was completed regularly and the service provided us with water sampling data from July 2018 to January 2019. This included a report on actions taken to resolve any legionella (a collective term used for diseases caused by legionella bacteria) and pseudomonas (a common bacterium found in soil and water which can cause chest and wound infections) detection. This demonstrated the trust regularly retested following positive detections and had actions plans in place to maintain equipment.

During the inspection, the endoscopy department was undergoing a refurbishment. The ward manager told us the department was being designed around JAG requirements and to allow for improved single sex segregation. We observed four procedure rooms in the department with three in use. The matron told us the fourth room would be opening soon to increase capacity.

Assessing and responding to patient risk Risk assessments were provided, however these were not always completed or monitored to identify risks or prevent a deterioration in a clinical condition.

During our inspection in October 2016, we found patients were exposed to the risk of receiving inappropriate care and treatment due to poorly written and incomplete care plans. During this inspection, we found completion of risk assessments was inconsistent and quality of care planning was variable.

The service provided staff with assessment and care bundles based on nationally recognised assessment frameworks. Nursing staff were expected to complete them for patients on admission and repeated at regular intervals according to the patients’ clinical condition or the risks identified. This included a falls risk assessment tool and the Malnutrition Universal Risk Assessment (MUST). However, they were not always completed in line with the trust policy. We reviewed a total of 35 patient records and found:

• 13 out of 35 falls risk assessments had not been fully completed. Of those completed, lying and standing blood pressure had not been recorded daily in the assessment documentation as outlined in the trust policy. 14 patients were identified as being at risk of falls; however, we only saw a falls care bundle in eight records. • Two pressure ulcer risk assessments were not completed and ten were partially completed out of 35 records reviewed. • 24 out of 35 records reviewed did not have a pain assessment completed.

We saw falls risk assessments were completed as part of the nursing assessment document. Where a box was ticked indicating a risk, a falls care bundle should be completed. Nurse sensitive indicator (NSI) audits were completed monthly to review compliance with falls assessments. Audits indicated from January to December 2018, an average of 93% of patients had a falls risk assessment completed against a target of 100%. It also indicated an average of 87% of patients had a fully completed falls care plan against a target of 100%. We reviewed four serious incident reports from November 2017 to July 2018 relating to patient falls. All four incidents indicated issues around the quality of falls risk assessments and use of the falls care bundle. Therefore, we could not be assured falls assessments were adequately documented with appropriate mitigations in place to reduce the risk of falls.

The level of patient falls was monitored by the service. There had been 355 falls recorded from January to December 2018. Six resulted in moderate harm, four severe harm and one resulting in a patient death.

A falls action plan was implemented in April 2018 and the service participated in the NHS Improvement (NHSi) falls prevention collaborative. There was a falls and prevention policy in place and had been reviewed. Staff we spoke to knew about the policy and knew how to access it. 20171116 900885 Post-inspection Evidence appendix template v3 Page 85

During this inspection, we saw the service had strategies in place to reduce the risk of falls such as: • Cohorting bays were in place across all wards. Cohorting bays allowed more than one person deemed at risk of falls to be nursed in the same bay with a staff member present at all times. For example, Naseby A ward used this and implemented a tagging system so staff members would have to identify another staff member to cover the bay before leaving. • Slip socks were provided to patients to reduce the risk of falls and these were available across the wards we visited. • Yellow stickers were designed to stick in medical records where a patient was high risk or had a recent fall, to alert other staff and medical staff. This was used well in MAU; however, we did not see this across all medical wards. • Display boards with falls information for patients, staff and visitors were visible. For example, HC Pretty ward had a display board at the ward entrance with useful contacts and a poster outlining 12 steps to reduce the risk of falls. • Yellow falls wrist bands were available to alert staff a patient may be a risk of falls; however, we did not see these being consistently used. • Falls alert magnets were used on patient information boards to alert staff. However, this was not a consistent method used on all wards. • Low beds were used for patients at risk of falling out of bed.

There were processes in place to assess and review risk of pressure ulcers as part of the nursing care bundle, however they were not always fully completed. The assessment included a review of the skin condition, completion of a body map and an assessment of the correct use of equipment such as mattresses in use. SSKIN (Surface, Skin, Keep, Incontinence/moisture, Nutrition/hydration) assessment and care plans were for patients at risk of pressure ulcers, to document plans to prevent and treat pressure ulcers. Nurse sensitive indicator (NSI) audits showed Harrowden wards demonstrated an average of 100% compliance from August 2018 to January 2019 with care planning. However, most wards did not consistently achieve the 100% compliance target. For example, Cranford ward was on average 71% complaint, Lamport male ward 79%, MAU 84% and Poplar ward 83%.

The trust had noticed an increase in avoidable category two pressure ulcers from July to September 2018. A review concluded they were avoidable due to the lack of compliance with SSKIN and nursing documentation. Therefore, we could not be assured pressure ulcer assessment and care plans were personalised and appropriate mitigations were documented to reduce the risk of developing and treating a pressure ulcer in hospital.

Processes were in place to care for patients admitted with acute mental health conditions. Following an incident involving a high-risk patient, a card activated door had been installed on MAU. A mental health triage tool had been introduced and had been updated when patients were transferred between the emergency department and MAU. Processes were in place to request one to one nurse care as well as support from security. A 24-hour seven-day mental health liaison service could be accessed to assess patients and support nursing and medical staff in managing patient care and risks. Mental health training had recently been provided to staff by the local mental health trust.

During our inspection of medical care in October 2016, we found deteriorating patients were not always managed effectively. Nurses had not always followed the escalation process for high-risk patients by informing a doctor when a patient’s National Early Warning Score (NEWS) score was raised or when the patients’ oxygen saturation showed a downward trend. NEWS was used to identify deteriorating patients in accordance with the National Institute for Health and Care Excellence (NICE); Clinical Guidance (CG) 50: ‘Acutely ill adults in hospital: recognising and responding to deterioration’ (2007). During this inspection we found improvements had been made and there were processes in place to identify, monitor and manage a deteriorating patient.

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The NEWS 2 updated guidance was implemented across medical services in August 2018 to align nationally with the ‘track and trigger’ system. The system calculated the NEWS score for each patient and automatically calculated when the next set of observations were due. There were clear directions for actions to take when patients’ scores increased, indicating a deterioration. We reviewed 22 NEWS charts in patient records across multiple wards and found NEWS was recorded appropriately and escalated where required. Actions taken were documented in the nursing records. Monthly nurse sensitive indicators (NSI) were completed by ward sisters and matrons across the medical division. We reviewed outcomes from these audits from January to September 2018. Audits demonstrated across all medical wards, an average of 96% of NEWS were appropriately escalated in line with the trust policy, against a target of 98%.

There were systems in place for identifying and tracking patients at risk of sepsis. Sepsis is a serious complication of an infection. The sepsis screening tool was incorporated into the patient track system which prompted nursing staff to complete a sepsis screen. We reviewed eight patients’ records that indicated possible sepsis. We found seven of these cases evidenced sepsis screening in place, however one case did not have all the necessary paperwork completed. The trust participated in the NHS CQUIN for sepsis screening and treatment. Following the inspection, the trust sent us the quarter three 2018/2019 CQUIN report. The report showed 85% of patients who met the criteria for sepsis screening in quarter three were screened for sepsis. Furthermore, 67% of patients prescribed antibiotics for new red flag sepsis were administered these within one hour as outlined in sepsis protocols.

The trust had a sepsis lead nurse and implemented initiatives to improve identification and treatment of patients with suspected sepsis. For example, sepsis stars were given to staff who performed well in identification of sepsis and league tables were implemented to reflect the number of sepsis forms completed. Sepsis was a standing agenda on the daily safety huddle. Data provided by the trust following our inspection indicated 86% of staff had completed NEWS 2 training. Further data indicated sepsis training compliance had improved with 85% of medical staff and 86% of nursing staff completing sepsis training. Sepsis boxes were available on wards, located in the resuscitation trolleys. They were available to support the timely management of patients with sepsis.

Patients requiring non-invasive ventilation (NIV) (a system that supports the patient’s breathing without the need for intubation or a tracheostomy), were mostly managed on Harrowden A, a respiratory ward. Pathways were in place to safely monitor patients requiring NIV. Patients requiring NIV in MAU were assessed by the respiratory outreach team. NIV was started by the outreach team and monitored by MAU staff. During the inspection, we found all patients on NIV had regular observations, NIV specific charts were in place and were closely monitored, in line with the NIV pathway.

During this inspection, 34 patients were being cared for in another speciality such as surgical wards. Medical patients were admitted to non-medical wards due to lack of beds on medical wards or to free up beds whilst they were waiting to be discharged. Systems were in place for identifying these patients to ensure they were regularly reviewed and treated by the medical teams. Patients’ were discussed during the daily safety huddle and there was a medical outlier team that reviewed patients. Managers told us medical patients on non-medical wards were normally medically fit and awaiting a social care package, before being discharged. During the inspection we visited two surgical wards; Barnwell C and Deene Acute Surgical Unit (DASU) and reviewed four medical patient records. The documentation showed patients were reviewed daily by a doctor and consultant. On DASU, there was a full time medical doctor specifically to manage these patients.

We observed a handover between night and day staff on HC Pretty ward and found it was structured and methodical. A whole team handover occurred in a staff room and covered staff training, current performance, staffing issues and ward based risks. Staff discussed outstanding tasks, those patients requiring further review and those at risk of deterioration. This included

20171116 900885 Post-inspection Evidence appendix template v3 Page 87 information about patients’ high risk of falls, infection control risks and those with do not attempt resuscitation (DNACPR) orders in place. We noted staff identified patients with special support needs, for example, patients living with dementia and patients who were on time critical medicines.

Intentional care rounding was completed by healthcare assistants (HCAs) on the medical wards. Intentional care rounding is a structured process with staff carrying out regular checks with individual patients at set intervals. For example, we observed HCAs visiting patients to check call bells and drinks were within reach and asked if the patient was comfortable or in any pain.

Nurse staffing The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Whilst there were contingencies in place to manage staffing levels, the vacancy rate was significantly higher than the trusts average vacancy rate.

There were systems and processes in place to assess, plan and review staffing levels, including staff skill mix. A staffing tool was used to calculate the number of nurses and health care assistants required for each shift based on the acuity (level of care a patient requires) and needs of the patients. The staffing tool was in line with NICE staffing guidance.

During our previous inspection in October 2016, we found medical wards relied on agency nurses to make up the numbers per shift. During this inspection, we observed a high proportion of staff were bank or agency staff. For week commencing 4 February 2019, 42% of trained nursing staff shifts were filled with agency and bank staff.

Actual Nursing Staffing

The trust reported their staffing numbers below from September 2017 to October 2018. The trust did not report a planned staffing figure to provide a fill rate. (Whole Time Equivalent – WTE)

WTE Number in Post (September 2017 to October Ward / Team Staff 2018) Cardiac Centre 20.4 22.0 Cardiac Outreach 6.8 7.0 Cardiac Rehab 4.0 4.0 Cardiac Research 0.6 1.0 Cardiology 1.5 2.0 Care of The Elderly Management 1.0 1.0 Clifford Ward 13.8 15.0 Cranford Ward Medicine 13.7 14.0 Day Case Unit Ward 12.5 15.0 Discharge Lounge 1.8 2.0 General Medicine Management 9.0 9.0 Geriatric Medicine 4.0 4.0 Harrowden A Ward 20.5 22.0 Harrowden C Ward 14.8 16.0 HC Pretty Wards 12.5 14.0 Heart Failure Team 3.3 4.0 Lilford Ward 12.5 13.0 Middleton Assessment Unit 18.7 20.0 Naseby Ward 18.2 19.0 Oakley Ward 31.8 37.0 Poplar Medicine Ward 9.8 11.0

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Respiratory 3.0 3.0 Rocket Demand Management Team 5.5 6.0 Stroke 1.0 1.0 Twywell & Lamport Wards 7.4 8.0 Grand Total 248.1 270.0

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Staffing was managed using e-rostering and safer care. Shortfalls were managed using bank and agency nurses. Staffing was discussed at daily safety huddles, chaired by the head of nursing for medical care and representatives from each ward including matrons and ward sisters. During the inspection we attended a safety huddle. All wards reported on their staffing levels and skill mix. An assessment was made on the level of risk using a traffic light risk scoring system. This enabled managers to move staff across wards to ensure those with red staffing levels were safe. Any shifts where staffing was compromised were ‘red flagged’ and reported on the incident reporting system. Staffing levels were reported and discussed monthly at the organisational development committee and bi-annually a full establishment paper was reported to the board.

The planned levels of staff and the actual levels were displayed on each ward/unit and updated daily. We reviewed these during the inspection and discussed the staffing levels with the nurses in charge. Nurse staffing levels during the inspection were below planned levels on numerous wards across the medical care division. For example, on 5 February, Naseby ward was down one trained nurse on both the early and late shift and a healthcare assistant (HCA) on the late shift. MAU was down one trained nurse and HCA on both the early and late shift. Although required staffing levels did not always meet the actual staffing levels, we saw the ward sister had re-structured the ward to ensure staffing levels met the needs of the patients. For example, we saw this in place during the inspection whereby the ward sister worked clinically on MAU and Naseby ward. We also observed staff being redeployed where shortages were identified to mitigate risk to patient safety and care.

Newly qualified or international nurses were not counted in the actual numbers and remained supernumerary for a minimum of two weeks and dependent upon level of training required. We spoke to a newly appointed international nurse who confirmed they were on restricted duties for a period before passing an assessment.

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 27.9% in medical care. This is worse than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Vacancy levels in medical care were significantly higher than the overall trust rate. The service had an active recruitment plan for 2019/2020 in place. The service had signed up for cohort four of the NHS improvement (NHSi) retention collaborative to support them to improve their recruitment and retention processes. Senior staff confirmed they maintained a focus on recruitment and retention activities across the medical service. This included advertising, trust recruitment events, Saturday recruitment events, attending job fairs and international recruitment. Wards and departments with high vacancy rates such as Lamport and Twywell, Poplar and Clifford wards had specific recruitment plans in place.

Following the inspection, we requested up to date staffing figures. The service establishment for registered nurses was 309.99 whole time equivalent (WTE). This included nurses at all grades, including band five, six and seven. As of February 2019, the vacancy rate was 19.3%, consisting of 59.96 WTE trained nurses. This showed the service had been actively recruiting and the

20171116 900885 Post-inspection Evidence appendix template v3 Page 89 vacancy rate had reduced.

Turnover rates

From October 2017 to September 2018, the service reported a turnover rate of 9.4% in medical care. This is lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the service reported a sickness rate of 4.3% in medical care. This was about the same as the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

From October 2017 to September 2018, the service reported 26% of qualified nursing staff hours within medical care which required cover were filled by bank staff, while 58% were filled by agency staff. In addition, 16% of qualified nursing staff hours were not filled by bank or agency staff to cover staff absence. Managers told us where necessary, ward sisters worked clinically on wards to mitigate the risk to patient safety.

Over the same period, the trust reported 71% of unqualified nursing staff hours in its medical services which required cover were filled by bank staff, while 2% were filled by agency staff. In addition, 27% of unqualified nursing staff hours were not filled by either bank or agency staff to cover staff absence.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)

The service had processes in place for new and agency staff to have a ward orientation and induction to the ward. This included fire safety, area of specialism, emergency and escalation processes. Most wards had a nurse in charge book to record agency staff who had completed an orientation and induction. Staff told us this was reviewed every three months.

During our previous inspection of medical care services in October 2016, we found the coronary care unit (CCU) had nurse staffing numbers were below the recommended number stipulated by the British Cardiovascular Society. During this inspection we found there were systems in place to ensure the correct patient to nurse ratio was in place in areas such as CCU and respiratory wards.

During our inspection, we observed agency staff working in isolation in the discharge lounge overnight. The discharge lounge was being used as an escalation area over night for patients medically fit and awaiting discharge the following day. There were five patients in the discharge lounge overnight, however the unit could accept up to seven patients. This was staffed by two registered agency nurses. Staff told us they rarely had contact from management whilst on duty in the discharge lounge. One nurse we spoke to had been blocked booked for another area and was familiar with the hospital processes; however, did raise concerns about being unable to access incident reporting systems. During the inspection we were unable to confirm whether inductions and orientations had been completed for agency staff on duty in these areas. However, following the inspection, the trust advised us they would be introducing a nurse in charge book to ensure they were monitoring this.

Medical staffing

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The service did not have enough medical staff with the right qualification, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment most of the time.

The trust reported their staffing numbers below for the period from September 2017 to October 2018. The trust did not report a planned staffing figure to provide a fill rate.

Ward / Team WTE Staff Number in Post (September 2017 to October 2018) Acute Medicine 22.0 22.0 Cardiology 28.0 28.0 Diabetes / Endocrinology 9.6 10.0 Geriatric Medicine 11.0 11.0 Respiratory 15.4 16.0 Stroke 7.0 7.0 Grand Total 93.0 94.0

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 20.0% in medical care. This is worse than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Vacancy and turnover rates were significantly higher than the trust average in medical care and significantly higher than rates at our previous inspection in 2016 (10% vacancy). However, the trust mitigated against this by using locums and agency staff. Following the inspection, the trust provided us with a list of vacant posts and recruitment plans for those posts.

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 17.2% in medical care. This is higher than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 1.5% in medical care. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage

From October 2017 to September 2018, the trust reported 68% of medical staff hours which required cover were filed by bank staff and 24% were filled by locum staff. In addition, 8% were not filled by bank or agency staff to cover staff absence.

(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab).

Staffing skill mix

In July 2018, the proportion of consultant staff reported to be working at the trust was about the

20171116 900885 Post-inspection Evidence appendix template v3 Page 91 same as the England average and the proportion of junior (foundation year 1-2) staff was lower.

Staffing skill mix for the 109 whole time equivalent staff working in medical care at Kettering General Hospital NHS Foundation Trust This England Trust average Consultant 43% 42% Middle career^ 5% 6% Registrar group~ 33% 27% Junior* 18% 25%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

Source: NHS Digital - Workforce Statistics - Medical (1 July to 31 July 2018).

During our previous inspection in October 2016, we found there were not enough registrars and junior doctors to cover the medical wards out of hours, especially between 5pm to 9pm (Monday to Friday) and at weekends. This exposed patients to delays in receiving appropriate care and treatment.

During this inspection we saw out of hours were covered by two specialist registrars (SpR) and two senior house officers. The night shift started at 9pm and finished at 9.30am the following day. One of the senior house officers was allocated to MAU and the other the rest of the medical wards. They were supported by a junior doctor to cover all medical patients on wards. During the week, an additional senior house officer worked from 5pm to 1am the following day. The night team responded to emergencies as well as follow up on patients identified through the day as a priority. Bleep holders were trained in advanced life support (ALS).

We requested the medical staff rotas from November 2018 to March 2019 and saw the service was reliant on agency staff to cover the medical care on call rota. Most vacant shifts were covered by agency, however we identified 16 out of 20 SpR shifts for the month of February for out of hours (specifically 5pm to 9.30pm) during Monday to Friday were unfilled, meaning there was only one SpR on call across all medical wards during this time.

We spoke to a doctor on call overnight based in Middleton Assessment Unit (MAU) who felt out of hours medical cover had improved and was sufficient. The doctor felt there was good support mechanisms in place and an outreach team supported doctors with clinical tasks such as cannulation.

There was a consultant on call at weekends who was responsible for the assessment and care of all new admissions. Patients on wards, were not routinely reviewed by their designated consultant at weekends, and were managed by the SPR. Patients who deteriorated were referred to the on- call consultant for urgent review.

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The coronary care unit had a daily consultant walk around, seven days a week. An on-call consultant was available 24 hours seven days a week. There was an on-call registrar during the evening, overnight and at weekends.

Unexpected absences were managed by the on-call consultant, who looked at whether roles could be re-allocated within the on-call team. For example, the medical on call team could move doctors to cover any gaps. This was discussed at the handover meeting. The service could access a 24- hour medical staffing service to arrange cover out of hours.

During our previous inspection in October 2016, we found the discharge lounge had no medical staff assigned to review patients if necessary. During this inspection, we were advised there was a senior house officer responsible for the discharge lounge although there was not a doctor based within the department. When patients were in the discharge lounge they were the responsibility of their admitting consultant or the on-call team out of hours.

Daily board rounds were embedded into practice across the medical care service to improve handovers of care. We observed two doctor’s board rounds which included a review of each patient, the formulation of a management plan and possible discharge arrangements. Both had a good skill mix of doctors, nursing, therapy and discharge staff. We noted there was good rapport between professionals and a good level of understanding of each case discussed.

Doctors told us there was no electronic handover system and electronic list of priority patients to alert them to problems out of hours and at weekends in the medical wards. Doctors fed back an electronic system would be safer so they could easily identify patients. However, mitigations were in place: regular medical handover meetings took place to handover patients from each ward to on call medical staff.

All medical staff we spoke with said they received a good level of support from their consultants who were approachable and able to be contacted at any time. They said they could attend the weekly teaching sessions and grand rounds. Grand rounds are medical education sessions where medical staff present medical conditions or incidents to an audience to share learning and practice. Some consultants facilitated early morning teaching sessions.

Records

Records were not always stored securely. Staff kept appropriate records of patients’ care and treatment. However, risks assessment and care planning documentation was not always completed.

During our previous inspection on October 2016, we found patients’ medical notes were mainly kept in lockable trolleys which were not locked when not in use and in some wards, they were kept on open shelves in the bays. This meant confidential information was not always kept in accordance with the Data Protection Act 1998.

Patient records were found in two different locations which included; a paper based nursing care folder and a medical records folder. Nursing and medical paper records were stored securely in lockable trolleys and when not in use, were mostly closed and locked. However, we did see one trolley left open and unattended on Harrowden C ward and one on Middleton Assessment unit (MAU). On HC Pretty ward, the nursing care folders were situation on a shelf within the patients’ bays. This contained personal patient information regarding nursing care provided and clinical observations. Whilst we did see improvements, we could not be assured confidential information was always kept in accordance with the Data Protection Act 1998.

We reviewed a total of 35 sets of nursing and medical records and found these to be mostly in good order. Staff kept records of patients’ care and treatment. Records were clear, up-to-date and

20171116 900885 Post-inspection Evidence appendix template v3 Page 93 easily available to all staff providing care. Records were signed and dated by nursing and medical staff.

Managers regularly audited nursing records using the nurse sensitive indicator tool (NSI). For example, ward sisters checked compliance with recording of NEWS2 completion, safeguarding and nutritional wellbeing. Audits demonstrated variable compliance with documentation. NSI outcomes evidenced compliance with NEWS2 documentation, however overall poor compliance with fluid balance and stool chart recording. Risk assessment and care plan reviews were not always completed. For example, we reviewed 12 completed Malnutrition Universal Screening Tool (MUST) assessments and found five out of 12 had been regularly reviewed in line with policy.

There were processes in place when patients moved between wards, services and organisation. This included referral, discharge and transfer documentation. Patient transfer checklists were in place for patients transferring between wards and departments. We saw all the information needed for their ongoing care was shared appropriately. The service had introduced a discharge checklist to improve the quality of discharges. For example, to ensure cannulas were removed and take-home medications were checked and accounted for.

Ward information boards were in place across all wards with patient information. These boards were used by medical and nursing staff to do daily board rounds on some wards. Information boards contained different levels of patient information. For example, Naseby A board was used effectively as part of the board round to track patient progress and highlight conditions and risks. However, the board held a lot of personal patient information, including patient names and was in full view of the ward. This was raised with the trust during our inspection and the hospital told us they removed all personal patient information from the board. Other wards we visited had boards with minimal information including a pictorial system for flagging patient risks. For example, a falls hazard symbol was used to alert staff to a patient at risk of falls. Staff felt this approach was a quick way of identifying important information and relevant risks, however, this approach was not consistently used across all wards we visited.

Medicines

The service did not always follow best practice when prescribing and recording medicines. However, the service did store and give medicines in line with best practice.

During our previous inspection of medical care services in October 2016, we found:

• Entries on prescription charts had been cancelled without being signed and dated. • Patients had not always been assessed for needing prophylactic medicine to combat venous thromboembolisms (VTEs) • Patient weights were not always recorded on the prescription chart. This could lead to incorrect prescribing of some medicines. • Medicine reconciliations had not always been done.

During this inspection we were not assured improvements had been made since our inspection in 2016. We found:

• 10 out of 14 medicine charts reviewed had cancellations of medicines. However, they were not signed and dated. We also noticed four out of 14 medication charts had a dose omission with no clear reason why. We raised this with nursing staff who did not know the reason for the omission. • VTE risk was assessed as part of the medical assessment upon admission. We reviewed 35 patient records indicating 31 had a VTE assessment completed within the medical assessment documentation. However, only five out of 14 medicine charts had a VTE recorded on the prescription chart. We did however see evidence in all 14 medicine charts,

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where VTE medications had been prescribed. Whilst we were assured VTE assessments had been completed, we were not assured medicine documentation had adequate information to safely prescribe. • A patients’ weight was recorded in 11 out of 14 records.

However, we did see improvements in the number of patients receiving medicines reconciliation. We reviewed 14 medicine charts and 13 had evidence of medicines reconciliation being completed. Furthermore, the medicines safety thermometer for quarter three 2018/2019, showed 71% of patients received medicines reconciliation within 24 hours of admission. This was about the same as the national average.

Staff ordered, dispensed and disposed of medicines safely and securely. Medicines were supplied by the onsite trust pharmacy who topped up ward medicine stocks weekly. Medicines were stored securely in locked cabinets and fridges within locked clinical treatment rooms.

Medicines used for internal use and external use were stored separately. All intravenous fluids were stored safely behind locked doors and only accessible to appropriate staff. Medicines for patients awaiting discharge were placed in clearly labelled and identifiable bags. All to take away (TTA) medicines were stored in locked cupboards in clinical rooms. The service implemented a new key locking system across all wards to improve medicine security and accountability. All nursing staff had a key which could track medicine cupboards opened, when and by whom.

Medicines stored on the resuscitation trolley were checked weekly. We inspected the medicines in three resuscitation trolleys. All medications were accounted for, regularly checked and in date.

Eight medicine rooms were checked during the inspection. Medicine rooms were clean, tidy and medicines were clearly labelled and in date. Medicine storage rooms had suitable preparation facilities for all types of medicines for example; controlled drugs and antibiotics. Medicines that needed to be stored below a certain temperature were stored in locked fridges. Since the last inspection a colour coded record book had been introduced which helped staff identify when a temperature was out of range, providing guidance on what action they should take. Staff understood the importance of monitoring the fridge and medicine room temperatures. Fridge and room temperatures were recorded regularly in all eight medicine rooms we inspected. We noted two dates in January 2019 in the discharge lounge indicated amber for room temperature. This was appropriately recorded and monitored.

Patients prescribed medicines were stored in locked bedside lockers. Registered nurses had a key to dispense medicine to patients. Staff told us this reduced the risk of medicine errors and reduced the time taken to do medicine rounds as all medicines were in bedside lockers.

Controlled drugs (CDs) are medicines such as morphine which are controlled under the misuse of drugs legislation. We saw all CDs were checked daily by two nurses in accordance with guidance. We noted one CD check missed in January 2019 in MAU, however there were no discrepancies identified. Weekly checks were also in place and recorded in the CD drug book. The nurse sensitive indicator (NSI) audits completed by ward sisters demonstrated consistent compliance of daily CD stock checks.

Staff had access to the pharmacy which was open Monday to Friday from 8.30am to 7pm. It was open 9am to 1pm on Saturdays and bank holidays. An emergency duty pharmacist (plus technical support) was on site from 1pm to 4pm. Outside of opening hours the emergency duty pharmacist could be contacted through the hospital switchboard.

Ward based pharmacists monitored the prescribing of medicines, including checking any known allergies, raising any omissions with medical staff. The pharmacist undertook clinical checks on patients’ medicines to ensure safe prescribing with any intervention recorded or discussed directly

20171116 900885 Post-inspection Evidence appendix template v3 Page 95 with the prescriber. Pharmacists were available to provide advice and support to staff and patients as needed.

Pharmacists or pharmacy technicians were based on each ward. For example, Harrowden A had a dedicated pharmacist able to amend doses in line with weight changes, switch intravenous (IV) to oral antibiotics and check discharge letters. Members of the pharmacy team had their own room on MAU so pharmacists and technicians were available to talk to clinicians, nursing staff and patients as needed. An advanced pharmacist who was an independent prescriber could support with clinical tasks such as clerking and post falls reviews.

Medical wards received monthly medicines performance data and was displayed on ward performance boards. The performance data was shared with ward sisters at a monthly sisters’ forum and this was then cascaded to staff. Ward sisters we spoke to were aware of the ward medicines performance but staff such as band five nurses we spoke to and health care assistants were not aware of this. A pharmacy matters briefing was sent to managers with medicines updates. For example, in October 2018, there was an update in the medicines code and in November 2018, an update on the supply on the supply of pre-filled insulin pens. During the inspection, we observed a morning handover where learning around insulin administration was shared.

The pharmacy team undertook quarterly audits with any identified issues fed back directly to each ward for learning. We saw the medicines assurance report from July to September 2018. The report reviewed the performance of the trust and individual wards against the standards required for the safe, secure storage and use of medicines. The report was presented to the sisters’ forum and we saw actions for implementation of new initiatives and improvements. For example, there were actions relating to the implementation of tracking keys to open medicine storage cupboards.

Incidents

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately, however we were not assured temporary staff were reporting incidents. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

The service had processes in place to prevent harm to patients. Staff understood their responsibilities to raise concerns, to record safety incidents and how to report them internally and externally. The hospital used an electronic online system for reporting incidents. Most staff knew how to access the system and their responsibilities to report incidents and felt confident to do so. All staff could give examples of when they had or would report an incident. Staff told us they were provided with feedback after reporting an incident and learning from incidents was shared across areas through staff meetings.

However, during this inspection, concerns were raised by several staff members including managers and agency staff, that agency staff did not have access to the incident reporting system. Feedback from matrons indicated agency staff needed to use their personal email address as they did not have a trust email address to receive feedback. However, agency staff we spoke with said they were unable to use their personal email addresses due to concerns with data protection. Agency staff told us they had to rely on other staff members to report incidents for them. We were therefore not assured there was a clear process in place that was understood by all staff; this meant there were potentially missed opportunities for shared learning from incidents.

The service had an incident reporting policy and procedure in place to guide staff in the process of reporting incidents. The service recorded 3963 incidents from 1 January 2018 to 31 December 2018 across medical services. Incidents were categorised in to subjects and levels of harm. There had been 38 deaths (not related to patient safety incident), 10 cases of severe harm, 41 cases of

20171116 900885 Post-inspection Evidence appendix template v3 Page 96 moderate harm, 996 cases of low harm, 2089 cases where there was no harm, and 788 near misses. The incident log included a description, immediate action taken, action taken as a result of an investigation, and lessons learned.

(Data requests 275)

The service had several methods to ensure lessons were shared and disseminated the learning from incidents. Examples included:

• Matron and sisters’ forums. • Medical care division daily safety huddles. • Trust notifications: learning outcome posters and medication safety bulletins. • Monthly lessons learnt forums for learning from serious incidents. • Learning outcome posters and learning briefings. • Monthly ward meetings and shift handovers. • Monthly morbidity and mortality review meetings.

Managers told us they shared lessons learnt with staff through ward meetings. We reviewed several meeting minutes of wards and found evidence lessons learnt were shared with staff. Learning outcome briefings were issued trust wide to inform staff when incidents occurred and shared lessons learnt. For example, we observed evidence of shared learning from a fall related serious incident resulting in a patient death. There was also evidence of medicine related incidents and learning being shared, for example, medicines being left in a locker following a patient discharge. We saw evidence of the incident being discussed in Harrowden A team meeting in December 2018. Staff could recall the incidents and talk through learning from them and changes in practice. For example, medicine checks being incorporated into the discharge and transfer checklist.

Never Events

From November 2017 to October 2018, the trust reported no incidents classified as never events for medical care.

Never Events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each Never Event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a Never Event.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the service reported seven serious incidents (SIs) in medical care which met the reporting criteria set by NHS England from November 2017 to October 2018. The incidents reported were:

• Four incidents relating to slips, trips and fall. • One medication incident. • One venous thrombosis embolism incident. • One diagnostic incident, including delay in meeting SI criteria (including failure to act on test results).

The most common type of incident reported were slips/trips/falls meeting SI criteria with four incidents (57% of total incidents).

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(Source: Strategic Executive Information System (STEIS))

Serious incidents were reviewed at the trusts serious incident review group (SIRG). Action plans and lessons learnt were reviewed at SIRG.

The service demonstrated they had processes in place to improve performance following incidents and this was shared with staff. The trust carried out a root cause analysis (RCA) in relation to serious incidents and identified preventative actions. Ward sisters told us they had been involved in completing RCA investigations linked to pressure ulcers and falls. Action plans were in place, for example, the service had falls and pressure ulcer action plans in place which were regularly reviewed and updated.

Where unexpected or potentially avoidable deaths occurred in the service they were reviewed monthly at ward based and directorate based mortality and morbidity (M&M) meetings. Mortality outliers were reviewed monthly in the quality and safety committee. Learning themes and actions were discussed at M&M meetings. Patient deaths were investigated and records were reviewed to look at causes of death and the care provided. Medical staff told us these meetings were an opportunity to share learning and develop practice.

When things went wrong, staff apologised and gave patients, their family or carers, honest information and suitable support. Duty of candour (DoC) is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person, under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff knew their responsibilities regarding DoC and knew what the trigger for application of DoC was. Local arrangements were in place to ensure patients were kept informed of incidents and any investigations and their outcomes. Information regarding DoC was available to staff on the trust intranet. Staff provided examples of situations when an incident had occurred, how they had informed the patient and their relatives of the incident, made an apology and explained what investigation and actions had resulted from the incident. We saw evidence in SI reports of DoC being applied.

Safety thermometer

The service used safety monitoring results well.

Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.

Data from the Patient Safety Thermometer showed the trust reported 57 new pressure ulcers, 16 falls with harm and 49 new urinary tract infections in patients with a catheter from October 2017 to October 2018 for medical services.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Kettering General Hospital NHS Foundation Trust 1

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Total Pressure ulcers (57)

2 Total Falls (16)

3 Total CUTIs (49)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only

Source: NHS Digital - Safety Thermometer

We saw data on display on information boards across the medical service. For example, these included the number of falls, pressure ulcers, infection prevention and complaints as well as medicines performance. Information boards included information on staffing levels and the name of the nurse in charge. Performance boards were updated monthly by managers and staff we spoke with were aware of the ward key performance areas.

Staff told us there had been a focus on reducing pressure ulcers and falls within the trust. They said they completed a root cause analysis (RCA) to look at the care provided when patients developed a pressure ulcer and ways in which they could be prevented.

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. However, we were not assured care plans were personalised.

Patient’s physical, mental health and social needs were holistically assessed, and their care, treatment and support was delivered in line with legislation, standards and evidence-based guidance. This included the National Institute for Health and Care Excellence (NICE). During our inspection in 2016, we found nursing care plans were not always person centred. During the inspection on 18 February 2019, we reviewed 13 care plans in the nursing assessment document. We found three out of the ten were fully completed and ten were only partially completed. Those partially completed lacked personalised information about the patients care. For example, we

20171116 900885 Post-inspection Evidence appendix template v3 Page 99 found lack of detail around nutritional needs and specific detail about patients requiring repositioning.

Trust policies were up to date and assessed to ensure they did not discriminate based on race, nationality, gender, religion or belief, sexual orientation or age. Staff we spoke with knew how to access policies relevant to their specialty area and knew who was responsible for providing their national clinical guidance. Staff were aware of these policies and gave us examples of how they followed guidance when delivering care and treatment for patients. The service was compliant with NICE guidance CG 50 Acute Illness, Recognising and Responding to the deteriorating patient in all clinical areas.

The service had performance measures, which were reported and monitored. These included, key nurse sensitive indicators, medication indicators, referral to treatment times, and FFT (friends and family test) results. The data from these was used to drive forward changes in practice.

We saw a Nurse Sensitive Indicator (NSI) audit schedule was in place to ensure all staff complied with policy and procedures to maintain patient safety. This included areas such as falls prevention, pressure tissue damage, infection control, deteriorating patients, safeguarding, nutrition, and medicines incidents. Ward sisters audited against the indicators monthly and dashboards were produced. Ward quality dashboards contained data performance in relation to several metrics including falls, pressure tissue damage, infection prevention and medicines. Outcomes were visible across all departments and nursing staff were aware of how to access their current ward performance results.

Patients’ clinical conditions and outcomes were assessed using nationally recognised assessment tools and audits. For example, the National Early Warning Scores (NEWS) 2 for monitoring clinical observations, the falls risk assessment tool and the universal malnutrition-screening tool (MUST). The service introduced quality audits, to ensure these assessments were completed appropriately and improvements in completion were made.

Endoscopic procedures, for example, diagnostic upper and lower gastrointestinal endoscopies were carried out in line with professional guidance. The endoscopy pathway included a World Health Organisation (WHO): five steps to safer surgery checklist, promoting a methodical approach to patient safety during invasive procedures.

We saw evidence of patients’ needs being assessed and treatment delivered in line with legislation, standards and evidence-based guidance. For example, the endoscopy service followed NICE professional guidance for endoscopic procedures and the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) procedures.

Care pathways were in place for the management of patients admitted with specific conditions. Pathway included dementia, sepsis and Non-Invasive Ventilation (NIV). We saw assessment documents enabled key information to be captured and suggested treatments to be administered according to clinical findings. For example, with a suspected sepsis, staff were reminded to obtain blood samples and administer oxygen therapy.

The trust had implemented a sepsis improvement plan for 2018/19. This included the execution of sepsis screening tools which provided clear management strategies for patients who trigger for sepsis. These were aligned with the requirements for NICE and the Commissioning for Quality and Innovation (CQUIN) for 2017/19. CQUIN is a framework which supports improvements in the quality of services and the creation of new, improved patterns of care. As part of the improvement plan the service introduced sepsis stars for staff who demonstrated good practice and the sepsis lead monitored cases of sepsis.

In line with best practice, ward staff were supported to care for patients with presenting mental health conditions through the provision of mental health liaison staff employed by the nearby

20171116 900885 Post-inspection Evidence appendix template v3 Page 100 mental health trust. The mental health liaison service worked 24 hours a day, seven days a week with patients of all ages who required mental health input. Nursing staff could contact the team for support. Staff in the Middleton Assessment Unit (MAU) told us they regularly seek support and guidance in caring for patients with a mental health condition. We saw evidence of patients who had been seen by all staff documented in patient records.

Nutrition and hydration Nutrition and hydration risk assessment and care plans were generally in place; however, they were not always reviewed in line with trust policy. Staff gave patients enough food and drink to meet their needs and improve their health. The service used special feeding and hydration techniques when necessary. The service catered for patients’ religious, cultural and other preferences.

Nutrition and hydration needs were assessed using the Malnutrition Universal Screening Tool (MUST). This was in line with NICE guidance QS15 Statement 10: “Physical and psychological needs” 2012). During our inspection we found 29 of the 35 patient records reviewed contained a MUST assessment. During our inspection on 18 February, we looked at 12 MUST assessments and found five were reviewed following the initial assessment. We were therefore not assured the MUST assessments were being regularly reviewed for all patients. The trust nurse sensitive indicators (NSI) showed most wards did not re-assess the MUST at a minimum once a week. HC Pretty A and B wards and Naseby B wards were mostly compliant whereas Cranford ward was below compliance each month with an average of 73% from August 2018 to January 2019.

We saw completed fluid balance charts to monitor patients’ fluid intake. However, nurses told us they were not completed for all patients, only those where there were concerns with fluid intake and those on IV fluids. Patients had jugs of water within reach on their bedside tables. We observed these were mostly filled. However, one patient told us their water was topped up rather than replaced with fresh water. Intravenous fluids were also prescribed and recorded appropriately.

Referrals were made to dietitians where concerns were identified about the amount patients were eating or their weight. We saw dietitian entries in patient medical records outlining plans for nutrition and advise to medical and nursing staff.

The service made dietary adjustments for patients for religious, cultural, personal choice or medical reasons when required. One patient we spoke to told us there was adequate gluten free options available to meet their dietary needs.

Patients who had endoscopy procedures, were provided with food and drinks following procedures requiring fasting. The endoscopy service screened patients with diabetes to ensure they were at the beginning of a list and provided with food following the procedure.

Wards protected patient mealtimes to ensure patients could eat their meals without interruption. Family members were encouraged to attend at mealtimes if the patient required assistance with eating so they could provide extra support.

Pain relief We did not see evidence patients pain was assessed and monitored regularly. However, patients told us they were regularly asked about levels of pain and pain management.

The patient records we reviewed, did not show nursing staff assessed patients’ pain regularly for each patient. Staff told us following the implementation on NEWS2 in August 2018, there was no place to record pain during routine observations, therefore they did not document pain assessment and reviews. We reviewed 35 patient records and found 11 had a pain assessment documented within the patient record. Following the inspection, we were informed a pain assessment proforma should be completed for all patients to assess their level of pain which incorporated a care plan for

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those patients experiencing pain. However, during the inspection, not all staff we spoke with were aware of the pain assessment document, therefore we could not be assured pain was being adequately assessed and monitored.

Most patients we spoke with, did not have problems with pain, and all patients told us they were asked about pain during routine interactions. One patient we spoke with said they received pain relief in a timely manner when they requested it.

We observed a board round on Naseby ward and morning handover on HC Pretty ward. Both demonstrated pain management was discussed as part of the board round and patient handover process.

Patient outcomes The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

The service participated in quality improvement initiatives such as local and national clinical audits, benchmarking, accreditation schemes, and research. For example, the endoscopy service took part in JAG (Joint Advisory Group) accreditation in November 2018, however, the service was not accredited. The JAG report highlighted recommendations for the service to address. We saw an action plan to address the areas identified which included for example; improvement with patient flow through the department. The JAG accreditation scheme is a patient-centred and workforce- focused scheme based on the principle of independent assessment against recognised standards. The scheme was developed for all endoscopy services and providers across the UK in the NHS and independent sector.

The service had commissioning for quality and innovation indicators (CQUIN) in place for the improvement of sepsis management. The audits showed that medical care staff were screening and treating the majority of patients within the recommended timescales, but improvements were still required. From September to December 2018, an average of 85% of patients received a sepsis screen within an hour which was below the 90% national standard. Furthermore, an average of 67% of patients prescribed antibiotics for red flag sepsis were administered these within one hour as outlined in the sepsis protocol. Sepsis management training was provided to all staff and quality improvement measures had been put in place, such as the introduction of NEWS2 (national early warning signs) in August 2018, in line with national guidance.

Relative risk of readmission

From July 2017 to June 2018, patients at Kettering General Hospital had a lower than expected risk of readmission for elective admissions when compared to the England average.

• Patients in medical oncology had a lower than expected risk of readmission for elective admissions • Patients in gastroenterology had a lower than expected risk of readmission for elective admissions • Patients in general medicine had a higher than expected risk of readmission for elective admissions

Elective Admissions - Kettering General Hospital

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Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

From July 2017 to June 2018, patients at Kettering General Hospital had a higher than expected risk of readmission for non-elective.

• Patients in general medicine had a higher than expected risk of readmission for non-elective admissions • Patients in respiratory medicine had a higher than expected risk of readmission for non-elective admissions • Patients in cardiology had a lower than expected risk of readmission for non-elective admissions.

Non-Elective Admissions - Kettering General Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

Data from October 2018 showed the rate of emergency readmissions for chronic obstructive pulmonary disease (COPD) and bronchiectasis was 119 from April 2017 to March 2018, compared to a national average of 100. This meant the trust was worse than comparators. However, data in January 2019 showed an improvement; with an emergency readmission rate of 112 from July 2017 to June 2018. The service had initiatives in place to reduce the need for admissions for conditions such as COPD and provide timely access to treatment. For example, the service had introduced rapid access COPD clinics to assess and treat patients at risk of admission where access to a consultant could mitigate this.

Sentinel Stroke National Audit Programme (SSNAP)

The trust does not take part in the quarterly Sentinel Stroke National Audit programme. Since our previous inspection in October 2018, the trust no longer provides a stroke service or stroke services. All services are provided at another local NHS hospital.

Lung Cancer Audit

The trust participated in the 2017 Lung cancer audit and the proportion of patients seen by a Cancer Nurse Specialist was 94.0%, which met the audit minimum standard of 90%. The 2016

20171116 900885 Post-inspection Evidence appendix template v3 Page 103 figure was 79.2%.

The proportion of patients with histologically confirmed Non-Small Cell Lung Cancer (NSCLC) receiving surgery was 21.9%. This is within the expected range. The 2016 figure was significantly better than the national level.

The proportion of fit patients with advanced (NSCLC) receiving Systemic Anti-Cancer Treatment was 65.6%. This is within the expected range. The 2016 figure was not significantly different to the national level.

The proportion of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy was 64.0%. This is within the expected range. The 2016 figure was significantly worse than the national level.

The one-year relative survival rate for the trust in 2017 is 34.5%. This is within the expected range. The 2016 figure was not significantly different to the national level.

(Source: National Lung Cancer Audit)

The service had an action place in place to improve and demonstrated improvement in performance. Learning from the audit was shared with relevant staff.

National Audit of Inpatient Falls 2017

The crude proportion of patients who had a vision assessment (if applicable) was 57%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients who had a lying and standing blood pressure assessment (if applicable) was 28%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients assessed for the presence or absence of delirium (if applicable) was 24%. This did not meet the national aspirational standard of 100%.

The crude proportion of patients with a call bell in reach (if applicable) was 86%. This did not meet the national aspirational standard of 100%.

(Source: Royal College of Physicians)

The audit highlighted areas for improvement and an action plan included improved training for ward staff on falls prevention and documentation. The falls working group maintained oversight of the progress of the action plans.

Competent staff

The service generally made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

Processes were in place to induct new staff and ensure they were competent to fulfil their roles. Staff told us they received a comprehensive induction which included both a trust wide and local induction. The local induction included orientation to the area and support to complete local competencies. We spoke with two nurses undertaking a transition programme, after training in other countries. They told us they received support in undertaking examinations and competencies required, to allow them to be registered as nurses in the United Kingdom. They were positive about the support they received from staff and managers within their area. Transitional nurses underwent a period of restricted duties whist undergoing an induction.

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A competency framework was in place for both health care workers and trained nursing staff. Wards and departments had varied processes for monitoring competency compliance. Middleton Assessment Unit (MAU) had a spreadsheet in place to record when training sessions were due, for example blood transfusion competency training. Endoscopy had a whiteboard containing all competencies and a record of who had completed them and when. However, not all wards had effective systems in place to monitor staff training needs and competency sign offs. For example, Poplar ward action plan identified the ward did not have evidence of competency monitoring.

Specialist wards had competencies requiring sign off before providing specialist treatment. For example, nurses in respiratory, completed respiratory training including non-invasive ventilation (NIV) training. NIV was also provided to patients on MAU; the ward advised us 50% of their nursing staff were trained to manage patients having NIV. MAU was supported by the critical care outreach team to safely assess and manage patients undergoing NIV. The trust held a regular training day for NIV, as part of a respiratory study day. Training sessions were fully booked to the end of 2019.

Role specific training was provided in addition to mandatory training. For example, blood transfusion training was provided to eligible nursing staff bi-yearly. In February 2019, the service introduced a process to deactivate staff access to blood dispensers for those staff who had not completed their training to ensure they were up to date with training before giving blood to patients.

Training was sought from a local mental health trust by managers to improve management of patients who were living with a mental health condition. Staff told us they had the skills to sensitively manage any difficult behaviours patients may display, and they would request support from senior nurses, doctors or security staff if a situation placed staff or a patient at risk.

Dementia training was provided to staff with a target of 85%. However overall compliance was 60%. The service informed us they had set a target to reach compliance by April 2019. Some wards had specialist roles who provided experiential learning. A registered mental health nurse was recruited on Naseby wards due to the level of patients living with dementia. The nurse provided training to staff in supporting patients living with dementia and other mental health conditions.

A leadership development programme was in place for managers including ward sisters. Following the inspection, the trust provided training figures which showed 64% of sisters in medical care attended the nursing development leadership programme during 2018.

Medical staff told us they had a thorough induction. Teaching sessions were weekly, including acute simulation sessions. Consultants provided training on wards for junior doctors across the hospital and all doctors said they felt supported by consultants. Local mortality and morbidity meetings supported shared learning and doctors were encouraged to attend grand rounds.

Medical and nursing staff told us they had sufficient support to undertake revalidation. Revalidation is a process by which doctors and nurses can demonstrate they have undertaken continuing professional development and maintained their competence to practice safely. Compliance with revalidation for medical and nursing staff was 100%.

There were processes in place to provide a local induction and ward orientation to agency staff, however, they were not always documented. We did not see evidence of ward orientations being completed for agency staff. For example, there was no record agency staff working in isolation in the discharge lounge overnight, had an induction and orientation. Following the inspection, we requested evidence of induction and orientation checklists for staff who worked in the discharge lounge overnight from 1 January to 7 February 2019. The trust was unable to provide us with this evidence for these staff members. The trust advised us they would introduce a system to record

20171116 900885 Post-inspection Evidence appendix template v3 Page 105 all induction sign offs for agency staff aligned with other wards.

Volunteers were recruited across medical wards and were trained and supported for the roles they undertook.

Appraisal rates

As of September 2018, 88% of staff within urgent and medical care at the trust received an appraisal compared to a trust target of 85%.

Individuals required Appraisals Completi Staff group (YTD) complete (YTD) on rate Allied Health Professionals 2 2 100% Add Prof Scientific and Technic 6 6 100% Administrative and Clerical 32 31 97% Nursing and Midwifery Registered 51 47 92% Additional Clinical Services 21 18 86% Medical and Dental 35 26 74% Grand Total 147 130 88%

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Staff we spoke to during the inspection, all had a recent appraisal and told us during the appraisal they discussed their development and training needs. Staff also told us they discussed mandatory training compliance and lead roles.

Multidisciplinary working Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

We observed effective multi-disciplinary working. Therapy staff were based on some wards and staff communicated well with each other. Pharmacists were present on medical wards daily.

We observed effective multidisciplinary attendance at daily board rounds. Board rounds were used to facilitate multi-disciplinary communication and effective care planning. A board round we attended on Naseby ward had representation from medical staff, nurses, physiotherapists and occupational therapist and discharge co-ordinators. Each patient was discussed in terms of the plans for their care and discharge planning.

We saw evidence in patient records, of the involvement of dietitians, physiotherapists, occupational therapists, speech and language therapists, pharmacists and specialist nurses in addition to medical staff and ward nurses. Specialist nurses such as tissue viability nurses and diabetic podiatrists attended wards to provide care to patients and advice to staff.

Elderly care wards demonstrated good working relationships with the frailty team, admiral nurses and activity co-ordinators based on wards. Admiral nurses provided specialist support to patients and families living with dementia. There were regular entries in care records by the “dementia and delirium team”. We saw frailty assessments in place and evidence patients were regularly seen by the frailty team. This showed advice and support had been given to staff.

Staff regularly communicated with ongoing placements, such as care homes in preparation for discharge. Discharge co-ordinators were based on wards, supporting nursing staff in organising care packages and communicating directly with community services.

The service attended external multidisciplinary meeting to improve patient pathways. For example, a matron advised us they attended regular mental health interface meetings to improve pathways 20171116 900885 Post-inspection Evidence appendix template v3 Page 106 for mental health patients who were inpatients. As a result, training had been provided to staff across medical wards including Middleton Assessment Unit (MAU) to improve their skills in supporting patients with acute mental health conditions.

Seven-day services Relevant staff, teams and services were available seven days per week for assessing, planning and delivering patients’ care and treatment.

Only newly admitted patients and those patients who required a medical review were routinely seen at weekends by a consultant. Patients who required a review at the weekend, including those who were fit for discharge or who had deteriorated, were highlighted to the on-call team for inclusion at a weekend ward round.

A seven-day lead nurse rota was in place on all medical wards to support the service and ensure staffing oversight. Matrons were also available seven days per week.

Therapy staff worked across the service Monday to Friday and were ward based. At the weekend there was an on-call service.

There was seven-day access to the pharmacy department and an out of hour’s system to obtain medicines was available. An emergency duty pharmacist could be contacted via the hospital switchboard.

Access to routine diagnostic imaging and endoscopy was available Monday to Friday, with on call referral for emergencies. Endoscopy occasionally operated a weekend service dependent on staff availability.

A liaison service delivered by a local partnership trust provided acute mental health assessments for inpatients who required mental health input. The team were based in the emergency department seven days a week.

Health promotion The service supported people to live healthier lives and care was planned holistically using health assessments where appropriate.

A range of information leaflets were provided for patients, in a variety of formats. These included locally produced leaflets provided by national organisations and charities. We did not see any of these available in other languages or easy read format. Leaflets were provided to patients undergoing endoscopic procedures. Two patients we spoke to told us they received a good level of information about the procedures, what to expect and post care.

Display boards across medical wards provided awareness and information about pressure care, reducing the risk of falls, mouthcare, dementia awareness and local service information.

We also observed some health promotion information was displayed on the wards. For example, the respiratory ward had leaflets encouraging people to stop smoking and other wards had information about healthy eating. Information leaflets and posters were also available about dementia, support for carers, discharge from hospital, sepsis and a range of other topics.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They could explain how they acted in patients’ best interests when they were unable to make decisions for themselves; however, we found some inconsistencies in the completion of documentation of patients who were under the MCA or DoLS. Medical staff were not complaint with mandatory mental capacity training targets.

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The service had policies in place regarding consent and the Mental Capacity Act 2005 (MCA). Staff could access these through the intranet. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to make decisions, any made on their behalf must be in their best interests and be as least restrictive as possible.

Staff we spoke to were aware of the requirement to complete a mental capacity assessment and to act in the patients’ best interests when they were unable to make a specific decision for themselves. They described how they involved their relatives and other professionals in the decision-making process.

We saw evidence of mental capacity assessments and best interest decisions, in relation to “do not attempt cardio-pulmonary resuscitation” (DNACPR) orders, when patients could not be involved in the decision-making process. We reviewed 11 patients records who were DNACPR and found nine had fully completed DNACPR and mental capacity documentation. There was also evidence of consent and feedback from family and carers documented. However, we found two did not have the necessary documentation completed and recorded in the patient record. One did not have a mental capacity assessment and one record referenced a patient had Deprivation of Liberty Safeguards (DoLS) in place, however, we could not find evidence of this being obtained. Deprivation of Liberty Safeguards (DoLS) protect patients who are subject to restrictions to deprive them of their liberty and are unable to make decisions when they are in hospital and care homes.

We found mental capacity assessments had been undertaken for other patients who were unable to make their own decisions and decisions were taken in their best interests. For example, a patient with a dementia diagnosis. We reviewed seven patient records and found all had appropriate risk assessments in place in relation to their mental health. Mental capacity assessments were in place for six of these patients and one was not in place. This was escalated to the service. We found evidence of dementia screening where required.

We saw only two dementia care bundles in place, therefore we were not assured dementia care plans were being used for all patients living with dementia. However, we did find evidence “this is me” documents were in place, and relatives or carers had been involved with completing these where possible. We saw one patient had a behavioural chart in place, for when they displayed behaviours that challenged staff.

There were processes in place for monitoring patients with DoLS or required MCA assessments. We observed board rounds and staff handovers where a patients’ mental health and capacity needs were discussed. Where it was identified an assessment was required, this was discussed and actioned. The daily safety huddle had oversight of MCA and DoLS patients. The service was aware of the number of patients they had on a DoLS and discussed this in relation to staffing levels.

Senior staff told us they worked closely with the local mental health provider to support the management of patients detained under the Mental Health Act (MHA). Senior staff attended a bi- monthly interface meeting with other local trusts and mental health services. An acute liaison mental health service (ALMHS) provided 24-hour service to the hospital to assess patients acutely unwell presenting to the emergency department. They were also able to see patients in acute admission wards.

We saw staff obtained consent for medical procedures and documented this. For example, we reviewed five patient records who were undergoing an endoscopy procedure and found consent was obtained and recorded for all patients. We observed staff interactions with patients across various medical wards and noted staff asking a patient for permission before undertaking a

20171116 900885 Post-inspection Evidence appendix template v3 Page 108 procedure. For example, staff completing patient observations, asked for the patients consent to undertake observations.

Some staff had received mental health training from a local mental health trust. This had started recently, and was set to continue. Examples of subjects included diagnosis, and sections under the Mental Health Act, and how this would apply to practice. On Naseby ward, one of the nurses was a registered mental health nurse, who worked as part of the multi-disciplinary team. Part of this role, was to educate staff around mental health, such as dementia. Staff told us this was particularly useful for the team, in relation to completion of Mental Health Act documentation.

Mental Capacity Act and Deprivation of Liberty training completion

The trust reported from October 2017 to September 2018, Mental Capacity Act (MCA) training was completed by 77% of staff in medical care compared to the trust target of 85%. MCA training included Deprivation of Liberty Safeguards (DoLS) training.

(Source: Routine Provider Information Request (RPIR) – Training tab)

Following inspection, the trust provided us with updated training figures as of 1 February 2019 which demonstrated overall 81% compliance, against a target of 85%. For nursing staff alone, 90% compliance was achieved, however, medical staff were significantly below the service target at 56%. Therefore, we found no improvements in compliance with medical staff since our previous inspection in October 2016.

Is the service caring?

Compassionate care

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

We observed staff to be caring and compassionate with patients and their relatives. We observed positive and supportive interactions between patients and staff. Patients told us the staff were kind towards them and “couldn’t do enough for them”.

Staff promoted privacy, and patients were treated with dignity and respect. Cubicle curtains were drawn and single room doors were closed during patient care to protect the privacy and dignity of patients.

We observed staff spending time with patients, and interacted with them during tasks and clinical interventions. We saw staff talking with patients, explaining what was happening and what actions were being taken or planned. Staff responded compassionately to pain, discomfort, and emotional distress in a timely and appropriate way. We saw staff asked permission before entering side rooms and cubicles or when the curtains were drawn.

We observed letters and cards of thanks from relatives on display on noticeboards across all wards. Feedback cards from patients included comments, “staff at all levels displayed a genuine, professional attitude; some staff clearly went that extra mile to provide genuine patient care”.

During the inspection a board round we observed on Naseby ward, took place within the nurses’ station by the main reception area. Each patients’ condition and treatment was discussed and a white board highlighted patients’ names. There was a potential for this information to be both overheard and seen by other patients and visitors. This was brought to the attention of senior staff to review the feedback.

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Friends and Family test performance

The Friends and Family Test (FFT) was introduced in 2012 and is a national initiative designed to measure patient’s experience, by asking whether patients would recommend the service to their family and friends. The FFT response rate for medical care at the trust was 33% from October 2017 to September 2018. This was higher than the England average of 25%.

Friends and family test – Medical care wards response (% recommended)

Re Ann Total Percentage recommended3 Ward sp. ual Resp name Rat perf 1,2 e Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Jun- Jul- Aug- Sep- 1 17 17 17 18 18 18 18 -18 18 18 18 18 Cardiac 47 99 100 100 100 100 100 98 100 99 centre 1,252 % % 99% % % % 98% % % 99% % 99% % % 29 98 100 89 85 92 MAU 682 % % 92% 90% 90% % 87% % 95% 93% % 97% 96% % CCU / 40 100 100 100 92 100 100 99 Oakley 681 % 98% % % % 99% % 99% 98% % % 98% % 22 88 100 100 100 100 91 100 100 96 Clifford 333 % % % % % % 97% % 95% 80% % % 98% % Harrowd 24 100 90 93 en A 214 % 89% 95% 95% 69% % 95% 88% % 97% 94% % 25 100 100 100 100 100 100 100 100 97 Lilford 139 % % % % % % 92% % % % 86% 87% % Naseby 41 67 73 A & B 118 % % 60% 82% 83% 65% % Pretty A 22 100 100 94 100 100 96 & B 112 % 92% % % % 91% % 96% % % Harrowd 29 100 100 100 91 91 94 en C 109 % % % % % % 90% % Cranfor 21 100 100 100 100 85 100 93 100 86 d 103 % % 91% % % 91% % % % % 69% % %

Highest score to lowest score 50 Key 100% % 0%

1 The total responses exclude all responses in months where there were less than five responses at a ward

2 Sorted by total response. 3 The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.

(Source: NHS England Friends and Family Test)

Clifford ward, Cranford ward, Harrowden A ward and Pretty wards were slightly below the national average for response rates. Naseby wards and Cranford ward had the lowest recommendation rate and the cardiac centre, Oakley ward and Lilford ward had the highest recommendation rate.

Emotional support Staff provided emotional support to patients to minimise their distress.

Clinical nurse specialists were available for advice and support in several specialties including respiratory services, cancer services and for cardiac patients. Staff could refer patients for additional support if necessary. Medical and nursing staff could refer patients for mental health

20171116 900885 Post-inspection Evidence appendix template v3 Page 110 assessments if they were concerned about mental health conditions. Interactions were not rushed and patients were given sufficient time to speak to staff about any concerns.

Throughout the inspection, we saw distressed patients were spoken to kindly. Patients who were confused were given clear details of the time and place, and offered reassurance of safety. A cohort bay system was used to provide constant nurse care to patients who were confused. We observed positive interactions from staff in cohort bays, enabling staff and patients to build a rapport. Activity co-ordinators were based on some wards, providing stimulation and distraction to patients to minimise their distress.

Patients’ spiritual needs were considered irrespective of any religious affiliation or belief. The chaplaincy service supported spiritual care across the services and ensured the delivery of spiritual, pastoral and religious care was adequate and appropriate.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment.

We saw patients and relatives were greeted with friendly responses when they asked for assistance or information. For example, we saw relatives speaking to ward administrators and nursing staff requesting information, which was always responded to positively.

Patients told us they were involved in their care and provided with information about their treatment and care plans. Patients described conversations with the doctors and consultants, they had been able to ask questions and had been told how their illness or injury might improve or progress. We saw evidence in patients records of communication with family and carers, including them in patients care where appropriate. We saw evidence of communication with concerned others in decisions about a patients’ capacity.

We saw staff providing support and information to concerned others. Staff took time to update family members about a patients’ treatment and care. When staff were busy, they communicated this to concerned others who wanted to talk to them and we observed staff went back to them as soon as they were available.

Staff used the “this is me” passport, which outlined the communication needs of patients, communication aids such as symbols were available to ensure patients could understand and be involved in their care and treatment. The service had learning disability team based at the hospital to support patients admitted who lived with a learning disability. They also supported staff to ensure all relevant paperwork was completed and patients were involved in decisions about their care.

The chaplaincy service was available to provide spiritual and pastoral care when asked by the patient/families and medical and nursing staff. The team offered support, prayers or a listening service to people who may find it helpful to talk about their anxieties.

Is the service responsive?

Service delivery to meet the needs of local people

The service planned and provided services in a way that met the needs of local people.

The service worked collaboratively with local social services to facilitate timely and appropriate discharges for those patients requiring complex social care packages in the community. The service attended meetings with the local authority and other statutory providers to prevent avoidable admissions to hospital and review discharge pathways to improve bed capacity.

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The frailty assessment team aimed to improve care and reduce the length of stay and readmission rates for elderly patients with complex medical needs. Frailty assessments were completed for patients referred and we saw evidence of the frailty team having regular contact with patients to support their care and discharge needs. The frailty team displayed information around the hospital to promote their service.

The hospital had an ambulatory care service which opened seven days a week from 8am to 8.30pm. Patients were admitted to the service by different routes including the emergency department, wards and GPs. The service aimed to expedite care through the emergency department and reduce the number of patients being admitted to medical wards. Staff worked closely with community teams to ensure an overall plan of care was in place for each patient. Treatments included those for deep vein thrombosis, cellulitis and pleural disease and aimed to meet the needs of local people by enabling them to stay in their own homes.

The service worked well with a local mental health trust in embedding a pathway to care and manage patients living with a mental health condition awaiting a mental health placement. The service attended regular meetings with local providers and had a mental health liaison service, based in the emergency department to ensure patients’ needs were being met.

Meeting people’s individual needs

The service generally took account of patients’ individual needs.

During the inspection, we noticed there were no shower facilities for patients to meet their personal care needs who were staying overnight in the discharge lounge. However, the service fed back to us following the inspection that patients were provided with a wash bowl at the bedside if they requested. Patients transferring overnight to the discharge lounge, moved to the area in the evening and were discharged the following day.

Services were delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances. The service identified and met the communication needs of people with a disability or sensory loss. Patients were assessed on admission by nurses and records highlighted any communication needs. There were specific admission checklists and discharge planning tools for patients living with a learning disability.

Disability status information was taken at admission and recorded. Patients living with a disability were easily identified on a database and in the patient record. A learning disability checklist was in place to ensure staff had fully assessed all care and communication needs. Communication passports were in place to help staff understand the patients’ needs and ensure equity of treatment and care. A learning disability worker was based in the hospital, and visited patients identified with a learning disability to offer support to patients and staff.

We saw a variety of communication aids used across the medical division including a “hospital communication book”. This was a ring bound book to help staff make sure people who have difficulties understanding or communicating get equal service in hospital. It provided advice and guidance to staff as well as non-verbal score cards and pictures containing key needs, such as thirsty, pain and toilet. Communication aids were used predominantly for patients who could not communicate. Staff told us relatives or carers were encouraged to attend the hospital as often as they liked. This promoted a feeling of normality and enabled patients to communicate their needs.

A logo was used to identify patients living with dementia. Staff could access specialist dementia nurses who gave expert practical, clinical and emotional support to families of patients living with dementia. Naseby wards had a large number of patients living with dementia and had recruited an

20171116 900885 Post-inspection Evidence appendix template v3 Page 112 activity co-ordinator to work with patients. Activity co-ordinators organised activities for patients and helped nursing staff keep patients occupied and stimulated during their hospital stay.

The “about me” booklet was in use throughout clinical areas for patients living with dementia and we observed “help me in hospital” booklets in use for patients with a learning disability. They included information about patients’ likes and dislikes, eating and drinking preferences, special requirements and personal information such as what the patient enjoyed doing in their spare time and information about their family and pets. Communication requirements and preferences were documented. Booklets were used to inform care when patients found it difficult or were unable to communicate their needs.

The service worked with patients, relatives and carers from ethnic minority communities who experienced difficulties in communicating in the English language. The trust had access to translation service and British sign language services. Staff knew how to access the translation services and we saw posters on display with clear guidance and contact telephone numbers.

A dedicated discharge team worked on wards to ensure the needs of patients being discharged with complex needs were being met. Discharge co-ordinators supported nursing staff with discharging patients and following up social care requirements following discharge.

Specialist nurses were in place to support patients with specialist care needs in the community. For example, a pleural nurse had recently been recruited to support patients with complex respiratory conditions whilst in hospital and followed them up in the community. Lead nurses were effective in arranging for ambulatory care post discharge to avoid further hospital admissions. We saw examples of patients with mental health conditions who were seen by the mental health liaison service. Patients were offered appointments and then referred into community services where appropriate.

Wards had long periods of time when they were open to visitors. Flexibility of visiting was offered for patients with complex care needs.

Access and flow

Most people, could access the service when they needed to; there were delays at times in admitting patients from the acute areas to appropriate inpatient medical wards.

The service had an assessment unit (Middleton assessment unit) and a short stay ward (Clifford ward) for patients to transfer from the emergency department. This helped to divert patients from the emergency department to provide a streamlined service. Most medical patients were admitted through MAU, with a large proportion transferred from the urgent and emergency care department (ED) following an initial assessment by a medical consultant. Patients were usually admitted for further investigations or awaiting results to determine if a hospital admission was necessary. Patients were either discharged or admitted to a ward.

The average length of stay on MAU from April 2018 and January 2019 was 1.1 days and Clifford ward 1.2 days. Target timescales for transferring to other specialist wards such as respiratory or endocrinology, was 48 hours. On average from April 2018 to January 2019, 86% of patients on MAU and 87% on the short stay ward were transferred within the target timescales.

The medical division closely monitored demand and capacity to improve performance. The service had oversight of external pressures and worked closely with the wider health system including commissioners and key stakeholders to reduce acute bed occupancy and improve flow. The trust had a transformation programme to improve pathways so patients were being managed in the right clinical setting. At the time of our inspection, a winter plan was in place to manage additional stress on the service due to winter pressures.

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The service had systems in place to improve access to timely treatment. For example, an eight- bedded ambulatory care unit provided a rapid access clinic to avoid unnecessary admissions for patients who could be treated as outpatients and managed there. This helped reduce the number of patients going to the emergency department and receiving timely treatment. `Specialist outreach such as respiratory and cardiac teams provided assessment to decide the most appropriate treatment pathway. Identifying them early to commence treatment and identify the most suitable ward if admission was required.

The frailty and intermediate care team worked together to assist patients, who had packages of care in place, return home. In a follow up inspection on 18 February 2019, we reviewed ten patient records and saw evidence in eight records the patient was assessed by the frailty team. This demonstrated a proactive approach to managing complex and vulnerable patients.

A clinical site team was responsible for managing hospital capacity including: emergency admissions, non-emergency planned admissions, transfers within the hospital, repatriations to and from other hospitals, transfers to other acute hospitals, and transfers to community and rehabilitation hospitals. A daily safety huddle and site meetings were held with key staff members such as the discharge team, matrons and ward sisters. Site meetings provided oversight of capacity, planned discharges, patients in escalation areas, location of outliers and demand for acute beds. We attended a safety huddle during our inspection. The meeting was well attended by ward sisters as well as the discharge team, pharmacy, housekeeping, safeguarding and estates. Capacity was discussed and ward sisters fed back potential discharges and capacity levels. Requests were made for managers to escalate any barriers to discharge, such medications and discharge letter delays.

Referral to treatment (percentage within 18 weeks) - admitted performance

From October 2017 to September 2017 the trust’s referral to treatment time (RTT) for admitted pathways for medical care were better than the England average.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) – by specialty

Five specialties were above the England average for admitted RTT (percentage within 18 weeks).

Specialty grouping Result England average Geriatric Medicine 100.0% 96.9% Neurology 100.0% 90.9% Rheumatology 100.0% 94.9%

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Gastroenterology 93.9% 93.6% Cardiology 92.9% 81.6%

(Source: NHS England)

The hospital achieved its referral to treatment times of fewer than 18 weeks for patients waiting for medical procedures or interventions in all specialties, except in dermatology, general medicine and thoracic medicine. The endoscopy unit was not meeting targets for patients to be seen within six weeks. From December 2018 to February 2019, an average of 95% of patients were offered appointments within six weeks. Urgent patients offered an appointment within two weeks was 98% over the same period. During the inspection, the service was undergoing refurbishment to increase the number of endoscopy rooms and enable more appointments to be offered. The service had an action plan to reduce their waiting times including additional theatre lists at the weekends and recruitment of staff to enable the service to open an additional endoscopy room.

Patient moving wards per admission

From October 2017 to September 2018, 84% of individuals did not move wards during their admission, and 16% moved once or more across the trust. This data was supplied by the trust at trust wide level and not core service identifiable. This was similar to the previous year.

(Source: Routine Provider Information Request (RPIR) – Ward moves tab)

Patient moving wards at night

The majority of moves in medical care were for patients moving from MAU to wards that could accommodate their medical needs. For example, patients admitted to MAU with respiratory conditions were mostly transferred to Harrowden C ward, a specialist respiratory ward. Patients were also moved because of a changing speciality or during times of peak demand. All patients for transfer to a speciality ward were risk assessed to ensure their condition was stable and staff had the appropriate skills to manage their condition. The responsibility of the patient remained with the admitting speciality team and consultant.

Staff informed us care was taken to only move patients for non-medical reasons when unavoidable and in mitigation of potential clinical risk to another patient.

From October 2017 to September 2018, there were 1,064 patients moving wards at night within medical care. 872 (82% of the total patients) of these moves took place on Clifford Ward and MAU. Data provided to us following the inspection, indicated 6% of patients were moved overnight. Data demonstrated a steady reduction over the year of patients moving at night from 8% in October 2017 and 4% in September 2018.

(Source: Routine Provider Information Request (RPIR) – Moves at night tab)

The number of patients waiting for discharge impacted on patient flow through the hospital. The service had 97% bed occupancy which was higher than the national average. High bed occupancy can be associated with regular bed shortages, periodic bed crises, and increased health care acquired infections. During periods of pressure and high demand, areas were opened in the hospital called escalation areas. Escalation areas were used during the winter period as temporary overnight wards for patients medically fit and awaiting a care package in the community prior to discharge. For example, the discharge lounge was opened overnight as an escalation area. During busier periods this enabled the service to increase bed capacity for acutely unwell patients so they could be admitted to a bed most suitable for their care.

The discharge planning process on every ward started on admission and each patient had a

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discharge planning document. Each of the medical wards undertook daily, morning multi- disciplinary board rounds where updates to patients’ medical conditions and plans for discharge were communicated.

A discharge team was established within the hospital to facilitate discharges. The team consisted of a head of service, senior sister and discharge co-ordinators. The service supported ward staff in dealing with complex discharges. Discharge co-ordinators were based on wards to support nursing staff, attend board rounds and facilitate discharge. During the inspection we observed effective communication between nurses and discharge co-ordinators in arranging a complex discharge.

Monthly safer discharge meetings were held. Meetings were attended by the deputy director of nursing and quality, head of discharge, medicines assurance and safety lead, clinical sisters, head of nursing, matrons and safeguarding practitioners. The meeting had oversight of issues relating to discharges including incidents, complaints and safeguarding concerns. We reviewed meeting minutes dated 15 January 2019. Staff were asked to share ward based discharge issues, lessons learnt from incidents were discussed and the discharge action plan was discussed. There was an action to amend the wording on a ‘are you leaving hospital poster’ and for posters to be printed and displayed on wards and departments.

The service used Red2Green day methodology to manage patient flow and expedite discharges. Red2Green bed days was a visual management system to assist in the identification of wasted time in a patient’s journey. A red day was when a patient received little or no value-adding acute care, and a green day was when a patient received value-adding acute care that progressed them closer to discharge. We observed this being used during a consultant led multi-disciplinary board round. Staff worked towards reducing red days and increasing green days, thereby reducing length of stay and improving patient flow and safety. Green and red days were displayed on white boards on some medical wards. We observed a board round in place on two wards during our inspection, both were task orientated and multi-disciplinary.

Average length of stay

From August 2017 to July 2018 the average length of stay for medical elective patients at Kettering General Hospital was 5.2 days, which is lower than England average of 6.0 days.

Average length of stay for elective specialties:

• Average length of stay for elective patients in cardiology is lower than the England average. • Average length of stay for elective patients in general medicine is similar to the England average. • Average length of stay for elective patients in clinical haematology is higher than the England average.

Elective Average Length of Stay - Kettering General Hospital

Note: Top three specialties for specific site based on count of activity.

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From August 2017 to July 2018 the average length of stay for medical non-elective patients, the average length of stay was 7.7 days, which is higher than England average of 6.3 days.

Average length of stay for non-elective specialties:

• Average length of stay for non-elective patients in general medicine is higher than the England average. • Average length of stay for non-elective patients in respiratory medicine is higher than the England average. • Average length of stay for non-elective patients in cardiology is lower than the England average.

Non-Elective Average Length of Stay - Kettering General Hospital

Note: Top three specialties for specific site based on count of activity.

(Source: Hospital Episode Statistics)

Staff told us the main cause of discharge delays concerned patients waiting for social care placements or packages of care. Furthermore, delays in transport and delays with the preparation of medications to take away (TTAs) requested from pharmacy were a common cause. The service demonstrated insight into the delays in discharge and implemented strategies to improve this such as:

• A discharge prescribing action plan was endorsed in October 2018. Ward based pharmacists and technicians were available to improve the timeliness of medications to check they were correct before being discharged. A pharmacy technician was based within the discharge lounge. • Discharge co-ordinators were based on wards to support nursing staff arranging social care packages and to confirm equipment was in place. Co-ordinators liaised with care homes to ensure communication channels were open. • A discharge checklist was in place to prompt staff to check and confirm TTAs were ready, cannulas were removed, family had been informed and transport had been booked. • Joint meetings with system partners aimed to improve communication around social care packages for patients following discharge.

Long stay Wednesday was an initiative implemented in August 2018 to reduce the number of complex patients with extended hospital stays. The service implemented the NHS improvement guide in reducing the number of long hospital stays for stranded and super stranded patients. Stranded patients were identified as patients in hospital for more than seven days and super stranded patients in hospital for 21 or more days. Long stay Wednesday used a multi-disciplinary team (MDT) approach, using a set of questions aiding enquiry and planning. There was a clear focus of solving discharge challenges on the day. The discharge and management team took the

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MDT to the ward where the patient was identified to explore options and increase opportunities for discharge.

(Source: Supplementary information – medical care)

The service saw a reduction in the number of stranded and super stranded patients since implementing long stay Wednesday. Data provided to us by the service indicated 54 fewer beds had been used in December 2018 in comparison to December 2017. Monthly delayed transfer of care (DTOC) data was provided to us indicating a reduction in the number of bed days lost to delayed transfer of care. In April 2018, 29.1 beds were lost in comparison to 11.8 in January 2019. The service set targets to reduce bed days lost to 21 by January 2019, demonstrating achievement of these targets.

During the first day of our inspection, 34 medical patients were located on non-medical wards such as surgical wards. These patients were monitored at site meetings and safety huddles, and moved to the most appropriate area when a bed became available. However, nursing staff told us most patients were medically stable or medically fit and often awaiting a discharge plan. There was a patient transfer checklist in patients’ notes for those who were transferred within the hospital. We saw a checklist had been completed appropriately which ensured the transfer was safe and the patient’s care continued with minimal interruption and risk. We saw all medical patients on non- medical wards were reviewed daily by a doctor and consultant. A medical doctor was placed on Barnwell wards (surgical ward) full time to oversee the care for medical patients.

Learning from complaints and concerns The service investigated complaints and learned lessons from the results, which were shared with all staff. However, complaints were not always responded to in a timely manner.

From October 2017 to September 2018, there were 93 complaints about medical care. The service took an average of 76.4 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be closed within 35 days. The service had improved complaint investigation timescales for new complaints, however still had a backlog of previous complaints which they were investigating.

The most commonly received complaints (21) were in relation to the care and treatment received from nursing staff (basic needs, hygiene and nutrition), followed by complaints (15) surrounding the attitudes and behaviour of nursing staff.

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(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust

From October 2017 to September 2018, there were 35 compliments within medical care.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

Compliments

During the inspection, we saw compliments on display within the wards. Examples of feedback included “the nurses, doctors and care staff have gone out of their way to make an extremely difficult time for us, as comfortable as possible” and “I’ve been very well looked after” and “the nurses can’t do enough for you.”

The trust had an up-to-date complaints policy in place. Staff we spoke were aware of the complaints procedure and informed us they tried to resolve any patient concerns immediately to prevent the concerns escalating to a complaint. Matrons were accessible to deal with patient and visitor complaints and told us they met with complainants to resolve concerns raised where possible.

Alternatively, staff directed patients and visitors to PALS (Patient Liaison and Advice Service). Information was displayed regarding how patients could provide feedback and details of PALS. Staff understood the principles of duty of candour and could describe them.

Senior management including matrons had oversight of complaints within the service. Feedback from complaints was shared with staff through a variety of means such team meetings, the leadership forum, patient safety lessons learnt meetings and in the patient experience report. The service had daily safety huddles and matron briefings where complaints were discussed and lessons learnt shared. Matrons invited complainants to feedback their experiences at team meetings to improve staff learning and understanding of the impact on patients and their families. We saw evidence of complaints being investigated, lessons being learnt and communicated to staff. For example, there had been actions to address concerns with discharge processes and these were discussed in team meetings.

Literature and posters were displayed within the ward areas, advising patients and their relatives how they could raise a concern or complaint, either formally or informally. Notice boards on the wards included ‘You said’ ‘We did’, in response to patient comments, however they were not always up to date. For example, we noticed this was not up to date on Twywell and Naseby wards.

Is the service well-led?

Leadership

The service generally had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

The medical care division was led by a chief of medicine, divisional director and a head of nursing for medical care. The head of nursing was visible in clinical areas and chaired a daily safety huddle. The post of clinical director for the division was vacant, however, speciality leads within the division were covering this post temporarily.

There was clear management structure at a local level; staff were aware of their divisional

20171116 900885 Post-inspection Evidence appendix template v3 Page 119 leaders and they were approachable. Medical staff reported to the medical lead. Matrons reported to the head of nursing and senior nursing staff, in turn, reported to the matrons. We met with some ward sisters and registered nurses during the inspection and found they were organised and demonstrated supportive leadership. They were knowledgeable about the wards performance against the trust priorities and the areas for improvement.

The trust provided a leadership development programmes for ward sisters to improve their leadership on the ward. Staff who had completed the course told us they found it helped develop their leadership skills and understanding of how other divisions work.

Staff knew the medical and nursing lead for their area. Seven matrons worked across the medical division and worked in close collaboration to support the delivery of safe and excellent patient care across the hospital. Matrons worked closely with other matrons across the divisions. Matrons were visible on the wards; ward sisters said they were supported by the matrons. A matron of the day was a key point of contact for staff should a concern arise.

All staff we spoke with were aware of the whistleblowing policy and many staff told us they would escalate concerns or challenge colleagues if patient safety was compromised.

Vision and strategy The service had a vision based on the trusts overall vision for what it wanted to achieve; workable plans to turn it into action developed with involvement from staff and patients. During our previous inspection in October 2016, we found, not all staff were fully aware of the services plans to remodel the beds in the service, which was designed to improve patient flow. Some staff described it as a ‘stop, start’ process with delays in the reconfiguration of beds and wards. Staff were not generally aware of the timescales for this reconfiguration. During this inspection, staff fed back they had a better understanding of planned changes ahead and were updated through team meetings. Staff told us they had opportunities to feedback directly to senior management.

Staff within medical care could talk about the CARE values and we saw these values were used to share learning following incidents and complaints. The CARE values underpinned the strategic objectives. Staff and patients within medical care were involved, along with other divisions, in the development of strategic objectives. Over the course of summer 2018 there had been a period of staff engagement, in the development of short and medium-term objectives that supported the delivery of the trust’s long term strategic objectives. The trust quality strategy incorporated plans for development within medical care. The strategy laid out six pledges to deliver quality improvements to benefit patients and staff.

Culture Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Both medical and nursing staff reported a positive culture. Staff felt supported by their colleagues and matrons in their individual areas. They said they were proud to work within the trust. We saw positive and supportive interactions between matrons and ward sisters. Medical staff told us they have a good team working ethic. Doctors of all grades told us they felt supported by their peers and supervisors and working at the trust was a good learning experience. Staff told us they enjoyed caring for their patients and we observed good interaction during the inspection. Most staff felt valued and supported to deliver care to the best of their ability. All staff commented the service had made significant improvements in quality and the senior management team were visible and approachable. All staff talked about an open and transparent culture within the service. Service leaders spoke highly of staff on wards and how hard they had worked and adapted to the winter pressures.

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The trust had a freedom to speak up guardian. However, most staff spoken with were unaware of who the freedom to speak up guardian was but knew of their role and said they would go on the trust intranet to obtain their contact details.

Some ward staff expressed a sense of unfairness when asked to move from their regular ward to support another ward that was short of staff. Nursing staff told us they preferred their own ward because they knew the team. However, all staff understood the reasons for moving and the importance of patient safety. Senior staff reviewed all ward moves during safety huddles, demonstrating fairness in moving staff. All decisions were based on patient safety.

Governance The service did not always use a systematic approach to continually improve the quality of its services, safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

Whilst frameworks were in place to provide oversight of quality and safety performance, we were not assured the service was sufficiently effective in maintaining standards consistently. For example, in ensuring medical staff compliance with mandatory training. Furthermore, the audit framework and action plans to improve the service were not always effective in ensuring patient risk assessments, such as pain, pressure ulcer and falls assessments were completed in line with policies and procedures.

Clinical and divisional directors attended monthly directorate meetings where senior managers discussed performance, risk, governance and human resources. Arrangements supported the cascading of information from board to ward level.

The service had a system in place to enable the monitoring of performance. Clinical governance indicators, including nurse sensitive indicators, were compiled each month into a comprehensive integrated governance report, presented to the monthly integrated governance committee.

We found the sharing of information was consistent and governance processes were embedded. For example, team meetings were in place across all wards. All tiers of management had monthly meetings including a sister’s forum and matron’s forum. Key risks were identified through quality ward dashboards. For example, pressure ulcers and falls were recorded consistently as agenda items in all team meetings. A daily safety huddle attended by ward sisters and managers across medical care had effective oversight of day to day risks including staffing and safeguarding. The meeting was used to gather feedback from all areas and escalate any concerns to senior management.

Senior staff attended various meetings regularly including the lessons learned forum, matrons’ forums, sisters’ forums, risk management meetings and quality meetings to discuss clinical practice and to improve patient care and experience. We saw these meetings were used to discuss wider governance issues and shared learning from incidents or complaints. Medical care risks were reported on the divisional risk register. This was regularly reviewed at governance meetings.

The service introduced a ward accreditation scheme. Wards were assessed against a set of quality standards expected on a ward. Wards worked towards a bronze, silver and gold level of accreditation. This was an effective quality marker for managers. These were in place across most medical wards with actions plans to improve. We saw evidence of these being reviewed in ward meetings.

Management of risk, issues and performance The service did not always have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

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During our previous inspection in October 2016, we found risks identified by the service were not being assessed, monitored and mitigated using an effective, comprehensive risk register. Risks were not recognised by the service, including the failure to escalate deteriorating patients, poor junior doctor cover for medical wards, and the poor completion and storage of patients’ records. During this inspection we found improvements had been made. Medical staffing including nursing and medical staff was incorporated into the risk register. We also observed deteriorating patients and storage of records was included on the risk register.

Whilst the trust had systems in place to record incidents, we were not assured there was an effective and understood process in place for agency staff to report all incidents. This meant the service was potentially not able to collect and analyse all information relating to incidents.

Risks we identified during the inspection linked to safety of patients living with a mental health condition were included on the risk register. We also saw that risks related to poor compliance with nurse sensitive indicators (NSI) were on the risk register. Whilst the service had a system in place for identifying and recording risks on local and service risk registers, we were not assured that the risks were always adequately managed. For example, in addressing non-compliance with nurse sensitive indicators relating to patient risk and patient care.

We saw the risks were regularly reviewed and mitigations were in place. The service demonstrated staff were involved in compiling risk registers and there was a person responsible for each risk. Staff could tell us their local risks and we saw evidence in ward meetings of the risk register being discussed. The divisional risk register input into the corporate risk register. These were monitored and reviewed at the risk management steering group and quality and safety committee. This demonstrated effective ward to board information sharing.

Staff completed audits in line with the service NSI audit schedule. Any compliance issues were addressed through team meetings and action plans devised to identify how compliance would be achieved. Whilst action plans were in place, we saw poor compliance with pain assessments, falls assessments and pressure ulcer assessments. There were monthly staff meetings to share learning from incidents and complaints and compliments. Where specific actions were required they were fed back at daily handovers and safety meetings.

Seasonal demands and risks were addressed in winter planning meetings. These meetings involved all the medical matrons and managers. A strategy had been proposed to manage the potential increase in demand for inpatient beds during the winter season. Risk assessments were in place to support seasonal demands such as the use of escalation areas.

Information management The service generally collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

Senior staff told us they had access to the information they needed to monitor performance to ensure there was a sustained or improvement to standards of care. Information included performance in relation to quality, performance as well as finance. All managers and ward sisters we spoke with were aware of the areas to improve their wards performance.

Staff and managers confirmed a secure login was required that was unique to the individual before they could access confidential information. We saw information governance training was provided to all staff and the performance statistics monitored.

Important information such as safety alerts, minutes of meetings and key messages were displayed on notice boards in staff areas to help keep staff up to date and aware of issues. Staff had access to the information they needed to undertake their roles effectively. Policies and procedures were available and accessible on the trusts intranet facility. 20171116 900885 Post-inspection Evidence appendix template v3 Page 122

There were sufficient computers available to enable staff to access the system when they needed to. Computers were available in all the areas we visited. All staff had secure, personal login details and had access to email and all hospital IT systems.

Engagement

The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. During our previous inspection in October 2016, we found, staff felt they were not always listened to and there had been few changes about staffing issues raised. During this inspection, staff told us they felt listened to by senior management. Staff told us the culture had changed over the past few months and senior management were more approachable. The service was transparent, collaborative and open with all relevant stakeholders about performance considering the needs of the population to design improvements. The service engaged staff through several mechanisms, some examples are: • The CEO weekly brief, • Link Listener events have been re-established and feedback is provided to participants. • ‘Ask Simon’ access to the CEO on the trust intranet site. • Promotion of Speaking Up/Raise a concern.

The service website outlined opportunities to contact the trust and express opinions and supplied information on the services and hospitals. Feedback was also obtained on the trust social media accounts and reviews on NHS Choices.

There were display boards highlighting relevant information such as the vision and strategy and key members of the management team to identify them to staff and public. The website also provided key contacts on specific wards so patients could directly contact individuals.

The chief executive officer (CEO) was visible and had attended medical wards on many occasions, providing opportunities for staff to feed back. The CEO facilitated drop in sessions for staff and ‘dragons den’ events. This was where staff could ‘pitch an idea’ to the CEO direct. Staff provided examples of where the CEO had been proactive in responding to concerns raised. All staff told us the CEO was approachable and had seen improvements since being in post.

The service collaborated effectively with the wider health system, to promote coordinated, person- centred care. For example, the service worked with local partners to improve the rates of successful discharges and improve the experience for patients with mental health conditions.

Learning, continuous improvement and innovation

The service was committed to improving its services by learning from when things go well and when they go wrong. However, the service had not made significant improvements in medical care following our previous inspection in October 2016.

During this inspection we found the following areas had improved since our previous 2016 inspection: • Improvements in the identification and escalation of deteriorating patients. • Nursing staff compliance with mandatory training. • Identification, assessment and monitoring of risks.

However, we found the following areas remained a concern/hadn’t been fully embedded: • Ensuring medical staff compliance with key mandatory training modules. • Ensuring care plans were personalised.

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• Ensuring all risk assessments were completed and reviewed in line with policy and procedure. • Ensuring medication cancellations on prescription cards were signed and dated.

The endoscopy service had not achieved JAG accreditation in November 2018. However, we saw an action plan to improve the service and work towards reaccreditation. The endoscopy service was undergoing renovations during the inspection to improve patient flow in the department, increase capacity and offer wider services.

The service showed improvements in engagement with staff. Staff spoke positively about local and divisional management and said they were supportive and had an open-door policy. Most staff told us the service had improved since the previous inspection and staff spoke highly of the new CEO. We also saw evidence communication had improved from ward to board.

The service had embedded improvements in medication security by implementing an electronic locking system to improve medication security and accountability.

Maternity

Facts and data about this service

Kettering General Hospital NHS Foundation Trust provides maternity services to women living in Kettering and the surrounding areas. The maternity service has 51 inpatient beds across one site. The delivery suite has 17 beds; nine delivery rooms, two high dependency beds, four triage beds and two induction of labour beds. 36 beds are within the antenatal and postnatal ward (Rowan). The hospitals maternity services are available across both hospital and community settings.

The maternity service is part of the family health division. The maternity service at Kettering General Hospital (KGH) offers a consultant and midwifery led delivery suite for low and high risk births, a water birth suite with two birthing pools, community based ante-natal clinics and an antenatal and postnatal ward area. The delivery suite also has a two bedded high dependency observation bay for women who need higher levels of care and observation than those provided on the general maternity ward. The service has a bereavement suite. There are two dedicated theatres with dedicated theatre teams. The hospital has an early pregnancy assessment unit (EPAU) for women who experience problems before 20 weeks pregnancy and a fetal health unit where women can be assessed by a midwife and, or, a doctor without having to be admitted to hospital. The maternity service also offers specialist antenatal clinics for women with medical conditions such as diabetes who require obstetric review and plans of care during their pregnancy.

Women who have a straightforward pregnancy can choose to have their baby at home or in the delivery suite using the low risk birthing pool rooms.

The maternity service employs community midwives who provide care for women and their babies both during the antenatal and postnatal period and provide a home birthing service. From September 2017 to September 2018 the service reported that 85 (2.6%) of babies were born at home. This was above the national average of 2.3%. The number of home births had fallen from the previous year when there were 116 home births. The community midwives were aligned to GP practices and children’s centres.

(Source: Trust Provider Information Request – Acute sites)

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During the inspection we spoke to 32 members of staff including matrons, midwives, maternity support workers, specialist midwives, theatre staff, junior doctors and consultants, and nine women and their families. We reviewed seven patient records and seven prescription charts.

From July 2017 to June 2018 there were 3,197 deliveries at the trust.

A comparison from the number of deliveries at the trust and the national totals during this period is shown below.

Number of babies delivered at Kettering General Hospital NHS Foundation Trust – Comparison with other trusts in England.

A profile of all deliveries and gestation periods from April 2017 to March 2018 can be seen in the tables below.

Profile of all deliveries (April 2017 to March 2018)

KETTERING GENERAL HOSPITAL England NHS FOUNDATION TRUST

Deliveries (n) Deliveries (%) Deliveries (%) Single or multiple births Single 3,095 98.6% 98.6% Multiple 45 1.4% 1.4% Mother’s age Under 20 145 4.6% 3.1%

20-34 2,489 79.3% 74.9%

35-39 403 12.8% 18.1% 40+ 103 3.3% 4.0% Total number of deliveries Total 3,140 596,828

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Source: Hospital Episode Statistics, April 2017 to March 2018

Notes: A single birth includes any delivery where there is no indication of a multiple birth. This table does not include deliveries where delivery method is ‘other' or 'unrecorded'.

(Source: Hospital Episodes Statistics (HES) – Provided by CQC Outliers team)

The number of deliveries at the trust by quarter for the last two years can be seen in the graph below.

Number of deliveries at Kettering General Hospital NHS Foundation Trust by quarter.

SOURCE: Hospital Episode Statistics - HES Deliveries (July 2017 - June 2018)

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training Although the service provided mandatory training in key skills to all staff they did not ensure all staff completed it. Mandatory training compliance was variable and did not meet the trust target of 85% in all topics. The service received monthly reports which identified compliance against core mandatory topics reported to the board. Reports were also sent to managers which identified individuals who needed to update their training. Mandatory training figures for maternity showed that midwifery staff were just below the trust target of 85% for medicines management, equality and diversity training, basic life support and sepsis. Medical staff had not met the 85% target for mental capacity

20171116 900885 Post-inspection Evidence appendix template v3 Page 126 awareness (MCA) or medicines management. This meant that not all staff were fully compliant with all mandatory training. During our last inspection in November 2017 we found that compliance with mandatory training was poor. Medical staffing compliance with mandatory training did not meet the trust target of 85% for all training modules. At this inspection we found that mandatory training compliance figures for both midwifery and medical staff had improved. Basic life support (adults and paediatrics) was now included in the top 10 reported mandatory training courses to improve oversight of compliance. Training schedules were displayed across maternity the services. Managers said that they had worked hard to increase mandatory training rates and had improved processes to manage this. Following our inspection, we requested action plans for how the service was ensuring that all staff were compliant with the outstanding mandatory training. Evidence was provided that every non-compliant staff member had training scheduled by 18 March 2019. Staff said they received monthly updates regarding their compliance and one to one support was available if required. Staff confirmed mandatory training was covered during their annual appraisals. Staff told us that an overview of lessons learnt from incidents had also been included at the beginning of all mandatory training sessions.

A dedicated practice development team had full oversight of the training compliance figures within the service. Their main role was to support staff to complete their mandatory training, develop specific training packages, design competence assessment tools and identify learning needs through analysing incident and complaint themes. The team also sent regular email reminders to maternity staff when their training needed completion or was overdue.

The service held mandatory specific education days each year in addition to the trust mandatory training days. This included a specific day for all midwives and a multidisciplinary obstetric “skills and drills” training day. The maternity mandatory study day covered training on antenatal screening, midwifery advocacy, the” Better Births” programme which included smoking cessation, water births, diabetes in pregnancy, customised growth charts (Grow), carbon monoxide testing, bereavement and perinatal mental health. From September 2017 to September 2018 98% of midwives had attended this training.

The multidisciplinary obstetric “skills and drills” training day was in line with the Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth recommendations. Skills and drills are the accepted format by which healthcare professionals gain and maintain the skills to manage a range of obstetric emergencies. These include shoulder dystocia, vaginal breach birth, postpartum haemorrhage, sepsis and maternal and neonatal resuscitation. From September 2017 to September 2018 98% of midwives were compliant. However, staff in maternity theatres told us that they did not participate in the skills and drills training. Following our inspection, we requested information from the service about the specific maternity training that was provided for theatre staff. Managers told us that PROMPT (Practical Multi-Professional Training) had been implemented on the maternity skills and drills study days in 2018. Human factors training had also been incorporated into the study day so that staff developed a knowledge of the effects of teamwork. Managers and practice educators were introducing maternity safety education and training for all maternity staff to include health care assistants (HCA’s), maternity support workers (MSW’s), midwives, doctors, anaesthetists and theatre staff.

From January 2019 all HCA’s, MSW’s and allied health professionals (AHP’s) were booked onto skills and drills training alongside all levels of obstetric doctors, obstetric anaesthetists, obstetric theatre staff and all grades of midwives. Training would include simulation stations, based on obstetric emergencies and would include multidisciplinary training. Scenarios were to be based on previous serious investigations, common incident themes, new guidance updates and changes to current practice. Live drills in the maternity unit to promote MDT Training were also planned and would include all staff depending on the scenario including paediatric staff.

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Scenarios that started on labour ward, involved theatre and the neonatal unit (NNU) were to be included.

Medical staff and midwives were required to complete mandatory annual cardiotogography (CTG) training. Staff were also required to attend a minimum of one CTG meeting per year. These meetings were held once a week and included individual case reviews. Multidisciplinary CTG case review training had been added to the skills and drills training day to enable all staff to attend.

Mandatory training completion rates

The trust set a target of 85% for completion of mandatory training.

Trust level

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for qualified nursing staff in maternity is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) NEWS2 1 1 100% 85% Yes Prevent Health Wrap 148 151 98% 85% Yes Manual Handling Patient 146 151 97% 85% Yes MCA Awareness 146 151 97% 85% Yes Fire Safety 142 151 94% 85% Yes Information Governance 140 151 93% 85% Yes Health and Safety & Risk Management 138 151 91% 85% Yes Conflict Resolution 136 150 91% 85% Yes Infection Control 135 151 89% 85% Yes Newborn Basic Life Support 128 148 86% 85% Yes Medicines Management 84 100 84% 85% No Equality, Dignity & Respect 126 151 83% 85% No Basic Life Support (Adult) 125 151 83% 85% No Sepsis 4 5 80% 85% No

In maternity the 85% target was met for ten of the 14 mandatory training modules for which qualified nursing staff were eligible.

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for medical staff in maternity is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Paediatric Basic Life Support 2 2 100% 85% Yes Sepsis 3 3 100% 85% Yes NEWS2 3 3 100% 85% Yes Infection Control 28 29 97% 85% Yes Prevent Health Wrap 27 28 96% 85% Yes Basic Life Support (Adult) 26 27 96% 85% Yes Equality, Dignity & Respect 27 29 93% 85% Yes Information Governance 26 29 90% 85% Yes

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Manual Handling Patient 25 28 89% 85% Yes Health and Safety & Risk Management 25 29 86% 85% Yes Fire Safety 25 29 86% 85% Yes Newborn Basic Life Support 24 28 86% 85% Yes Conflict Resolution 24 28 86% 85% Yes MCA Awareness 22 28 79% 85% No Medicines Management 15 20 75% 85% No

In maternity the 85% target was met for 13 of the 15 mandatory training modules for which medical staff were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. There were clear systems, processes, and practices in place to ensure that women and babies were kept safe from avoidable abuse. There was a dedicated team of midwives who provided support, care, and treatment to women who were deemed to be in vulnerable circumstances. The midwifery safeguarding lead post was vacant at the time of our inspection. This was recorded on the risk register. A new midwifery safeguarding lead was due to commence in post in March 2019. The midwifery safeguarding post was being covered by the perinatal mental health midwife and support was available from the wider safeguarding team. There was also a rotational midwifery post between the hospital and community midwifery to enhance safeguarding arrangements. The safeguarding team liaised with other professionals and agencies for example social workers, health visitors, the police and independent domestic violence advisors (IDVA’s) and attended multi agency risk assessment conferences (MARAC) and child protection conferences. The Safeguarding Intercollegiate Document (March 2014) states that: “Any clinician who is responsible for planning or assessing the needs of children who may be vulnerable or at risk of harm, require level 3 safeguarding training”. This included clinicians whether a doctor, nurse or allied health professional. Therefore, level 3 safeguarding training was the expected level for people caring and assessing the needs of children (and young people). Midwifery and medical staff were meeting the trust standard of 85% for levels one, two and three safeguarding training for children and adults. This was an improvement from our last inspection in September 2017 when medical staff were just below the trust target of 85% for level three safeguarding training. Staff were aware of the different types of abuse and the procedure for reporting a concern. This included their mandatory reporting responsibilities for female genital mutilation (FGM). Appropriate arrangements were in place to ensure patients were kept safe from avoidable harm. The trust had safeguarding policies and procedures available to staff on the trust intranet including out of hours contact details for hospital staff. The trust safeguarding policies reflected relevant legislation and local requirements for safeguarding. We saw that staff followed the correct procedures to raise and investigate a safeguarding concern during our inspection. A red flag alert was placed on the trust IT systems if safeguarding information was made available to the service or if FGM was identified. This meant that all staff were aware of any safeguarding issues and enabled staff to consider the FGM history in the context of the current presentation. 20171116 900885 Post-inspection Evidence appendix template v3 Page 129

Any cases of FGM were reported through the safeguarding steering group (SSG) on a monthly basis for investigation, discussion and the identification of trends and themes. The safeguarding team within midwifery led on FGM and other safeguarding concerns, supported by the corporate safeguarding team. The electronic maternity IT system had been revised to improve record keeping. More mandatory fields had been added. These included routine domestic abuse questions and the production of reports to inform safeguarding audits and service provision. This meant that appropriate safeguards could be put in place for families. Safeguarding alerts were placed on electronic systems to ensure robust information sharing systems were in place. The trust reported in the annual safeguarding report April 2017 to March 2018, that safeguarding activity remained a high priority and often involved complex and challenging cases. There were 364 maternity services safeguarding referrals and 61 Early Help Assessments (EHA) had been completed for families identified as requiring additional support. Monthly maternity activity reports were reported through the SSG and demonstrated increased safeguarding activity. The reporting period identified that staff had been dealing with emerging national safeguarding issues such as child sexual exploitation (CSE), female genital mutilation (FGM) and domestic abuse. The top five reasons for referral to social care were around mental health issues, domestic abuse, children and siblings who were previously known to social care, drug abuse and housing difficulties. There had been changes in the multi-agency safeguarding hub (MASH) referral system in the past year which had proved challenging in relation to tracking and monitoring referrals as staff were unable to save and print their referral. The MASH process was being reviewed between the local council and partner agencies. All MASH referrals were being sent as paper copies. This was recorded on the risk register. The service was putting processes in place to ensure that referrals were followed up. These included making referrals to the local authority by telephone and paper copies, the process was being monitored and reviewed by the safeguarding team until the end of March 2019 when further discussion was to take place with the local authority. Maternity teams had been informed of the process changes through emails and team meetings. Safeguarding training was provided on staff induction. There were three yearly refreshers for levels two and three. Safeguarding training included FGM, CSE, PREVENT, which is part of the Government’s counter-terrorism strategy, domestic abuse as well as any bespoke sessions that were required where specific safeguarding issues had arisen. This included “Signs of Safety” which is a strengths based, safety-organised approach to child protection casework. The aim is for partnership working with other agencies and parents to help practitioners in social care to risk assess and safety plan in child protection cases. Due to a rise in CSE within the area training events had taken place to raise awareness, this had resulted in an increase in referrals to social care. The trust safeguarding adult programme included training at levels one and two, mental capacity act and deprivation of liberty (MCA/DoLs) training. These were updated to reflect local and national changes including domestic abuse, female genital mutilation, modern slavery, sexual exploitation and trafficking. Entry to the maternity unit was protected by swipe care access and buzzers to ensure the safety of babies. We observed staff were vigilant when relatives wanted to gain entry and answered buzzers promptly. There was a closed circuit television (CCTV) system to identify visitors. All visitors were required to sign a visitor’s book and wear a visitors’ sticker label so that they were easily identified. We saw that staff monitored this system. A baby tagging system was in place and every baby had an identity tag applied to each ankle shortly after birth, which contained the baby’s name, date of birth and the mother’s name. The

20171116 900885 Post-inspection Evidence appendix template v3 Page 130 service had an up-to-date abduction policy and measures and controls were in place to minimise the risk of a baby being abducted from the unit. Staff described the actions that would be taken in the event of a baby being abducted. The service had carried out simulations of an abduction of a baby to test the effectiveness of controls. We saw that there were posters and information throughout the department about safeguarding issues, including FGM, CSE and domestic abuse, which contained relevant support contact details. The service had set up a health visitor and midwifery forum with partner agencies. This provided a multi-agency forum to share safeguarding information with regard to vulnerable families. This helped to ensure there was effective handover between agencies and acted as a point of contact between the community services and the safeguarding team at the hospital, ensuring streamlined processes. Early Help Champions had been developed to try and ensure families were offered and accepted support and assistance to try and prevent safeguarding and child protection issues developing. This had resulted in an increase in the number of early help offers, and data was captured where early help was declined. Safeguarding processes were audited to identify risks and priorities and included maternal mental health pathway compliance and a documentation audit. As a result, further education had been introduced in a variety of topics including strengthening domestic abuse risk assessment processes, embedding learning from serious case reviews and encouraging attendance at lessons learned events following significant events. Safeguarding training completion rates

The trust set a target of 85% for completion of safeguarding training.

Trust level

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for qualified nursing staff in maternity is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 3 3 100% 85% Yes Safeguarding Children Level 3 144 148 97% 85% Yes Safeguarding Adults - Level 2 142 151 94% 85% Yes

In maternity the 85% target was met for all of the three safeguarding training modules for which qualified nursing staff were eligible.

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for medical staff in maternity is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 11 11 100% 85% Yes Safeguarding Children Level 3 17 17 100% 85% Yes Safeguarding Adults - Level 2 24 28 86% 85% Yes

In maternity the 85% target was met for all of the three safeguarding training modules for which

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(Source: Routine Provider Information Request (RPIR) – Training tab)

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. The service controlled infection risk well. Most areas of the maternity services were visibly clean and clutter free. We saw however, that in the theatre area boxes of intravenous infusions were stacked high which meant that staff were unable to clean the floor and there was evidence of cobwebs between the boxes. There had been no incidents of MRSA bacteraemia or Clostridium difficile from October 2017 to September 2018. Dispensers of hand sanitising gel or foam were available at entrances to each department and within clinical areas. We observed staff adhering to good hand hygiene practices. In the period August 2018 to January 2019 results of hand hygiene audits within maternity services scored 100% consistently with the exception of September 2018 when there was no submission from labour ward. Results were displayed on patient safety boards and posters promoting hand hygiene were visible to staff. There was a written prompt at the entrance to the wards which reminded staff, visitors and women to decontaminate their hands prior to entry. We observed staff complied with trust policies for infection prevention and control. This included wearing the correct personal protective equipment (PPE), such as gloves and aprons. We observed that staff adhered to the trust uniform policy and were ‘arms bare below the elbow’. Cleaning schedules were clearly displayed in all ward and department areas. Waste was appropriately segregated in clinical areas with separate colour coded arrangements for general waste, clinical waste and sharps (needles). Bins were clearly marked and were pedal operated and within safe fill limits. New plastic pedal bins had been provided within the departments. We saw dated “I am clean” stickers on equipment. A review of cleaning audits requested for the maternity unit from November 2018 to February 2019 demonstrated that all areas achieved an average of 96.99% to 100%. There were three exceptions in December 2018 when the results fell just below the risk levels which had been identified, no explanation was provided for this. At the time of the inspection staff were fully compliant with infection prevention and control training and exceeded the trust target of 85%. The staff flu vaccination programme was part of a national and local campaign and vaccination was encouraged in all staff groups. The annual infection prevention and control report for 2017 identified that 66.32% of staff were vaccinated against a target of 70%. Side rooms were available on delivery suite and Rowan ward which could be used to admit women with a known or suspected infection. Staff described what they would do if a woman required isolation due to infection. Two surgical site infections in women undergoing caesarean sections were reported from October 2017 to December 2017. This represented a 1.1% infection rate with 183 caesarean sections taking place within this time. Managers had undertaken an internal review following this. The Caesarean section operation is not a mandatory requirement of the Public Health England, categories of surgical site infection surveillance therefore there was no national data to benchmark this against.

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Women were offered screening for infectious diseases, such as rubella and hepatitis B. Women were also offered flu and whooping cough vaccination in pregnancy, in line with national recommendations. Women who had opted for an elective caesarean section were screened in accordance with the trust protocol, (Detection and Management of MRSA) which was based on latest national guidance: Implementation of modified admission MRSA screening guidance for NHS (2014) Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI). Any woman who fitted the risk based category, or had a previous positive result were screened. All women received decolonisation as required by the protocol. There were processes in place for cleaning the birthing pools. Each birthing pool was cleaned and flushed daily and following every patient use. Cleaning schedules seen confirmed this.

Environment and equipment The service had suitable premises and equipment and looked after them well. Equipment was checked at regular intervals to ensure it was safe to use. The design, maintenance and use of facilities and premises were suitable for purpose. Access to the delivery suite and wards was by swipe cards or an intercom buzzer system to gain both entry and exit from the wards. There were also security cameras at the entrances to clinical areas with screens displaying images from the cameras at the midwives work station. This meant that staff could identify visitors and ensure women and their babies were kept safe. There was no designated low-risk birthing unit in the maternity service. This was recorded on the risk register. However, the delivery suite contained equipment to promote normal vaginal deliveries and mobility during labour. This included birthing balls, floor mats, and access to mood music. There were also two birthing pools, which were clean and well maintained. Both rooms contained an evacuation net in order to support the evacuation of a woman from the pool in an emergency. The maternity staff we spoke with knew the birthing pool cleaning and evacuation procedures. The maternity service had access to two dedicated obstetric theatres, however one theatre had insufficient ventilation and therefore was not suitable for all emergencies. This meant that women who were booked for an elective caesarean section may have to wait to go to theatre whilst an emergency caesarean section took place. This was recorded on the risk register. However, a gynaecology theatre was also available for use in the event of an emergency. Staff liaised with the theatre team at the maternity safety huddle and regularly throughout the day to assess and plan activity. The estates department had completed a ventilation survey and maintenance work had been carried out to improve ventilation to theatre standard. The obstetric theatres, delivery suite and neonatal intensive care unit (NICU) were all situated on the ground floor, which enabled timely transfer when required. CTG machines were available for women who required continuous electronic fetal heart monitoring. A CTG machine is used to record both the fetal heart rate and uterine contractions during pregnancy and labour. Its purpose is to monitor fetal wellbeing and allow early detection of fetal distress. Telemetry (wireless) CTG machines, which enabled women to be mobile, were available on the delivery suite. We saw that the CTG machines were checked daily. A fetal blood gas analyser was available on delivery suite in line with national recommendations.

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All equipment across the maternity service had been electrically tested; we saw stickers on equipment which confirmed this had been completed in a timely way. Staff said equipment repairs were undertaken promptly and equipment failures immediately addressed. This meant that risks to mothers and babies from unsuitable equipment was reduced. Staff confirmed that they always had sufficient equipment. Adult resuscitation equipment was available on the delivery suite, Rowan ward, theatres and outpatient areas. Resuscitation trolleys were checked daily to ensure they were stocked, equipment was in working order and medicines were up to date. All trolleys were tamper evident and were checked daily. We found some out of date equipment in the obstetric theatre and delivery suite including sterile gloves, two expired blood bottles and suction tubing. This was raised with staff and immediately removed. There were five resuscitaires (used to support new born babies who may need resuscitation after delivery) on the delivery suite and two in theatre. This meant that there may not be sufficient resuscitaires available if needed. This was not recorded on the risk register. We raised this with managers during our inspection and were informed that staff had always had sufficient resuscitaires available. Four new resuscitaires had been ordered to replace old models. This was recorded on the risk register. On review of resuscitaire checks we found that there were two checking processes in place. We raised this with managers who identified that there had been two separate checking processes for resuscitaires which had contributed to an oversight of the assurance process. Actions had been taken to revise the checking process to ensure that there was clear oversight and assurance that the checks had occurred. We saw that there was compliance with daily checks. Managers told us that all of the anaesthetic machines had been replaced in the last two years. The new equipment had an automatic self checking and self calibration system. This meant that anaesthetic machines could not be used without going through an automated daily check which occurred when they were switched on. All anaesthetic machines were turned off at night which meant they would self test when next turned on. Managers had taken guidance from the manufacturers who had advised that carrying out additional manual tests might result in damage to the machinery. The policy for checking anaesthetic machines no longer reflected the checking process and managers planned to review the documentation and process relating to the checking of anaesthetic machines. Rowan ward did not have piped oxygen or suction in three of the bays, however portable oxygen and suction equipment was available and safely stored. This was recorded on the risk register. During the last inspection women experiencing a miscarriage before 20 weeks gestation were not all cared for in a single room. The service was asked to review the environment. The service had sought advice from the still born and neonatal death charity (SANDS) and ARC, a national charity that support parents if there are any foetal abnormalities. Women were counselled and given the choice to have care provided on the delivery suite or gynaecology ward. Staff told us that they would try to place women in rooms at the end of the delivery suite to maintain their privacy and dignity. An estates work application remained in place to create a single room on the gynaecology ward. Community staff were provided with mobile phones. This enabled them to be contacted easily during their community visits and ensured they were able to escalate any situations when they did not feel safe to colleagues or the police. The trust had a lone worker policy. The team of midwives who provided care to vulnerable women never conducted a visit alone to a woman’s house if they did not previously know her. Visits were

20171116 900885 Post-inspection Evidence appendix template v3 Page 134 completed by two members of community staff until they determined whether it was safe for them to visit alone. Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. At the initial antenatal booking appointment, community staff were responsible for carrying out full risk assessments of women. These included medical, mental health and social assessments and referral as necessary. Other assessments included tobacco and drug use and family and obstetric history. The findings from risk assessments were used to help women choose their preferred place of delivery, recommend further investigations, and inform plans of care. This included whether a woman required midwife or consultant-led care. Midwives continued to complete risk assessments throughout the entire antenatal, intrapartum and postnatal period. We reviewed seven risk assessments in both women’s electronic and paper notes and these were all completed. Women with high-risk pregnancies, for example, due to a multiple pregnancy, diabetes, pre-eclampsia and obstetric cholestasis, were regularly monitored and reviewed by an obstetrician. In the seven medical records we reviewed, venous thromboembolism (VTE) assessments (used to determine a patients’ risk of developing a blood clot) were completed in line with national recommendations (RCOG, ‘Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium’: Green-top Guideline No 37a, April 2015). Treatment to prevent blood clots was prescribed and administered in accordance with trust policy. The electronic record system automatically prompted staff when a VTE assessment needed completion. Audits of VTE results were undertaken monthly. We saw that VTE was discussed at maternity team meetings and staff were reminded to complete all elements of the risk assessment. Community midwives completed risk assessments for women wishing to have a home birth. This included an easement of the woman’s home, mobility and any social care involvement. Managers monitored the number of women attending for their booking appointment by 10+6 weeks gestation and 12+6 weeks gestation. Women seen and assessed before the end of the twelfth week of pregnancy have been proven to have better outcomes than those seen later in pregnancy. Information provided by the trust demonstrated that out of a total number of 4641 bookings, 3514 (75%) of women attended for their antenatal booking appointment by 10+6 weeks and 4114 (88.6%) by 12+6 weeks. Women were routinely asked about their baby’s movements at each antenatal contact. Written information regarding fetal movements was given to women at their initial ante natal appointment and if they experienced episodes of reduced fetal movements. This was in line with national guidance (NHS England ‘Saving Babies’ Lives: A care bundle for reducing stillbirth’, 2016. Women were advised to contact the fetal assessment unit, or Rowan ward at night or on Sundays if they had any concerns about their baby’s movements. The Saving Babies’ Lives care bundle also included the use of customised fetal growth charts to help identify babies who were not growing as expected, routine symphysis-fundal height measurements from 24 weeks gestation and counselling about smoking cessation. A referral to a stop smoking service was offered to women identified as smokers. We saw that carbon monoxide monitoring was undertaken at each antenatal contact. If babies were not growing as expected women were offered additional antenatal scans. Women attended the antenatal assessment area in the fetal health unit for regular cardiotocography (CTG) monitoring. CTG monitoring was undertaken when clinically indicated as per NICE “Intrapartum

20171116 900885 Post-inspection Evidence appendix template v3 Page 135 care for healthy women and babies” CG 190 (last updated 2017). The service used the “fresh eyes” approach to CTG monitoring which is a technical means of recording the foetal heartbeat and uterine contractions during pregnancy and is widely used to assess foetal wellbeing. This meant a second midwife checked the interpretation and classification of the CTG recording of fetal heart and uterine contractions during labour. This ensured the CTG trace was correctly interpreted and appropriate actions were taken when indicated. This was in line with national guidance (NHS England ‘Saving Babies’ Lives’: A care bundle for reducing stillbirth’, 2016. Fresh eye reviews were generally carried out hourly and non-reassuring and pathological CTG traces were appropriately escalated. We saw that midwives had followed this approach in the seven records we reviewed. Weekly multidisciplinary CTG meetings were held to review CTG’s and develop learning and expertise. However, the service did not have any central CTG monitoring which meant that any areas of concern were not seen centrally by all staff. This was not recorded on the risk register. Maternity staff used the modified early obstetric warning score (MEOWS) assessment to detect signs of deterioration. This included a pain score and a full set of vital signs (heart rate, respiratory rate, temperature, blood pressure, oxygen saturations and fluid balance). Staff plotted the observations against pre-determined parameters. There were clear actions to take when the MEOWS increased and indicated a woman was deteriorating. The maternity service monitored compliance with MEOWS documentation and escalation. The audit report from November 2018 to January 2019 demonstrated 100% compliance with the correct calculation and escalation of the MEOWS score. During our inspection we saw that MEOWS had been escalated appropriately. A community MEOWs tool had been developed in partnership with the sepsis leads in the trust. Training had been received by all community staff and the tool was launched in October 2018. There had been one referral and transfer to hospital where the tool had supported the decisions made. This meant that the correct use and escalation of the tool had resulted in appropriate and timely treatment for a woman and her baby. Maternity staff used neonatal observation charts to record a baby’s vital signs (heart rate, respiratory rate and temperature) when they identified that, the baby was at risk of clinical deterioration following birth. This included babies born before 37 weeks gestation, those suffering from jaundice and babies of mothers with gestational diabetes. There was a clear pathway for the management of sepsis. Staff described the signs of sepsis and what treatment should be initiated in line with national and local guidance. Staff received annual training on the recognition, escalation and management of sepsis during their maternity training updates. We saw that the “sepsis six” pathway had been completed in women’s notes and escalated immediately to medical staff. Sepsis six is the name given to a bundle of medical therapies designed to reduce the mortality of patients with sepsis. It consists of three diagnostic and three therapeutic steps to be delivered within one hour of the initial diagnosis. The delivery suite and Rowan ward had a ‘sepsis’ box which contained all the necessary equipment for the monitoring and treatment of sepsis in an emergency. At the last inspection in November 2017 the service was not auditing the identification and treatment for sepsis to assure themselves that women and babes were having rapid, effective treatment according to national guidelines. During this inspection we saw that compliance with the use of the sepsis screening and immediate action tool for all women with a new MEOWS of three or more within the delivery suite and Rowan ward was being audited. The number of women with red flags for sepsis was monitored on the monthly maternity dashboard and was being audited against the NICE sepsis quality standards 1-4 [QS161]. Audits reviewed from March 2018 to January 2019 indicated that compliance with the

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MEOWS score was 90-100%. 100% of women who required antibiotic therapy within one hour received it. There was a designated triage (emergency assessment) unit which provided 24-hour assessment, review and ongoing care planning for women over 20 weeks gestation and postnatal women up to 10 days post delivery. Women could telephone for advice or present to the triage unit if they had any concerns or health issues such as pain, reduced fetal movements or vaginal bleeding. The maternity service had a daily safety huddle which was attended by the multidisciplinary team. This included the midwives in charge of the delivery suite, Rowan ward, the fetal health unit, the obstetric consultant, registrar and senior house officer, the anaesthetic registrar, theatre staff and the nurse in charge of the neonatal unit. We observed a huddle during our inspection. The huddle was well organised, staff discussed high risk women, the numbers of elective admissions and discharges and staffing levels. The coordinator liaised with members of the multidisciplinary team throughout the day to ensure that all staff had oversight of the acuity level of the department. A further 5pm huddle had been introduced to improve patient safety and assessment. However, this had only started on the week of our inspection so was not yet embedded in practice. Following two serious incidents in the management of labour, managers had introduced processes to reduce the risks. These included encouraging staff to have full oversight of a woman in labour and consider a holistic view. We saw that changes had been made to the white board in the delivery suite where a woman’s progress in labour was clearly documented so that all staff were aware of any changes. The maternity service used an adapted version of the World Health Organisation’s (WHO) surgical safety checklist. This was in accordance with national recommendations (NPSA ‘Patient safety alert: WHO surgical safety checklist’, January 2009). The checklist was used for women having a caesarean section or other surgical procedure relating to childbirth, for example, a manual removal of the placenta. We observed staff correctly carrying out the WHO checklist and this was embedded in practice. Completion of the checklist was audited. The compliance rate from October to December 2018 was 100%. The audits were observational and non observational. Managers could therefore be assured that the team worked well together to keep women safe from avoidable harm. The delivery suite had a two bedded high dependency area for women who needed higher levels of observation, care and treatment. Staff in the high dependency area could access support from the critical care outreach team. The outreach team was available out of hours, to provide extra clinical support for deteriorating women. However, at the time of inspection, it was not yet available 24 hours a day, seven days a week. Any woman who required central venous access or further care and treatment was transferred to the intensive care unit. The practice development team held live “skills and drills” scenarios for all members of the multidisciplinary team. The “skills and drills” annual sessions were also multidisciplinary. This meant that in the event of an emergency, staff were familiar with processes. There were up-to-date policies in place for transfer arrangements to ensure women and /or their babies received care and treatment in the most appropriate location. These included transfer from homebirth to hospital, transfer from the emergency department to delivery suite and transfer to another hospital. Standard operating procedures were in place with the ambulance service for attendance at emergencies, such as babies born unexpectedly at home. Since our last inspection in November 2017 managers had implemented changes to improve oversight of risks within the service. The dashboard exception report was now co-written by the delivery suite lead consultant and midwifery matron and included actions and reflections on the 20171116 900885 Post-inspection Evidence appendix template v3 Page 137 reds flag areas. These were discussed at the governance meetings. Minutes of meetings we reviewed confirmed this. The service had a central alerting system (CAS). This was a web-based cascading system for issuing alerts, important public health messages and other safety critical information and guidance. This meant that staff were aware of any safety information that needed escalating. Midwifery and nurse staffing The service 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. The maternity service planned and reviewed staffing levels and skill mix so that levels were in line with relevant tools and guidance. The service used the “Birthrate Plus” midwifery workforce planning tool which is recommended by the Department of Health, endorsed by the Royal College of Midwives (RCM) and incorporated within the standards issued by the NHS Litigation Authority. The tool calculated the level of midwifery staff needed based on the trust’s activity, case mix and demographics. Managers had introduced a birthrate and acuity tool since the last inspection in November 2017 for use on the delivery suite. This aimed to improve the capacity and flow and reduce risk to improve patient safety. Staff told us that this had been effective. Daily staffing levels were published outside the wards and departments in line with NHS England requirements and the National Quality Board (NQB) recommendations. Duty rotas were planned six weeks in advance and were updated both electronically and on paper. Daily staffing was assessed and managed by the matron and head of midwifery. We saw that staffing levels were discussed at the daily safety huddle meetings and actions were taken to deploy staff if necessary. Staffing levels met the planned levels on most shifts. The delivery suite co-ordinator was supernumerary and co-ordinated the activity for each shift. The service had an escalation policy to follow if staffing levels fell below the agreed levels. This included ensuring that bank shifts were filled and deploying midwives from other areas to support delivery suite or the ward. One band seven specialist midwife was available each day to cover escalation shifts and would be called upon as necessary. Ward managers who were supernumerary would also be called upon to work clinically. The on call community midwives were asked to support the unit when needed. A system was in place to re-organise their case loads should they be called out for a home birth at night. Staff told us that there was an electronic message sent out to staff offering bank shifts. Staff confirmed that shifts were filled. There was a maternity manager on call 24 hours a day, seven days a week who was available for additional support and advice. During our inspection managers told us that they did not use agency staff within the department. They relied on bank, specialist midwives and managerial midwives to provide cover. All bank staff were existing or previous staff and were known to the rest of the team. This meant that staff were confident in working with them. Managers monitored the number of additional shifts that staff worked to ensure that they did not exceed the European working time directive. Managers would have formal discussions with staff who worked regular additional shifts and took sick leave. The maternity service monitored the midwifery staffing to birth ratios on a monthly basis and these were reported on the maternity dashboard. From September 2017 to September 2018 the service complied with the recommendations of a midwife to birth ratio of 1:28 for 11 out of 12 months. For one month the ratio was 1:29.

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Following our inspection, we requested information about the compliance and provision of one to one care for women in established labour as this was not recorded on the maternity dashboard. Maternity handovers took place at the change of each shift. We observed nursing handover on the delivery suite and Rowan ward which were detailed and effective. Appropriate information was shared and discussed. There was effective use of the whiteboard which identified specific risks, admissions, discharges, safeguarding concerns and staff allocation. Handovers were confidential and took place in an office area. We saw that specific one to one handovers of a woman and her babies care and treatment took place away from the bedside to maintain confidentiality. Planned vs actual

The trust has reported their staffing numbers below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Number in Post Ward / Team WTE Staff (September 2017 to October 2018) Ante-Natal Newborn Screening 3.6 4.0 Community Midwifery 42.8 51.0 Foetal Health Unit 6.6 8.0 Kettering Midwifery 61.8 74.0 Maternity Management 5.0 5.0 Obstetrics & Gynaecology Specialist Posts 8.4 10.0 Grand Total 128.2 152.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 9.3% in maternity. This is higher than the trust target of 7%

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 5.3% in maternity. This is lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 2.9% in maternity. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

From October 2017 to September 2018, the trust reported that agency staff were used to provide 93% of required cover in maternity. This left 7% of hours unfilled.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

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Medical staffing The service 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. Medical staffing levels and skill mix were planned in advance and were in accordance with relevant guidelines to ensure women and babies received safe care and treatment. The service provided 60 hours of consultant obstetric cover on the delivery suite per week. This was in line with Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour (RCOG, 2007), which recommends that units with between 2500 and 5000 births a year should provide at least 60 hours a week of consultant presence. On-call arrangements worked well and staff told us they did not have any concerns about contacting the on-call team when needed. There were four multidisciplinary ward rounds each day on the delivery suite and a consultant-led ward round of Rowan wards each day, seven days a week. We observed a morning handover on the delivery suite, which included structured discussions about all maternity patients and overnight deliveries and appropriate guidance was provided for junior medical staff. Data provided by the service had reported improved staffing within the department for consultant roles. Since the last inspection in November 2017 the service had recruited one new consultant with a further interview being held in March 2019. Managers told us that the service did not use medical agency staff but would use locum medical staff who had previously worked within the department. This meant that medical staff were familiar with the processes and environment. Consultants told us that they would also “act down” to provide medical cover if necessary. An obstetric consultant provided on site cover from 8am to 7pm Monday to Friday. At the weekends a consultant provided cover from 9am to 12pm. After 7pm on weekdays and 12pm on weekends as consultant was on call from home for emergencies and support. Medical staff confirmed that they were able to access support when required. There was dedicated anaesthetic cover available on the delivery suite 24 hours a day, seven days a week. Middle grade anaesthetists provided this. From 8am to 6pm Monday to Friday a consultant anaesthetist covered the maternity service. Planned vs actual

The trust have reported their staffing numbers below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Number in Post Ward / Team WTE Staff (September 2017 to October 2018) Obstetrics & Gynaecology Medical Staffing 29.0 29.0 Grand Total 29.0 29.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 6.0% in maternity. This is about the same as the trust target of 7.0%

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(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 11.5% in maternity. This is about the same as the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) - Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 1.1% in maternity. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage

From October 2017 to September 2018, the trust reported that bank staff for used to supply 89% of required cover. This left 11% of hours unfilled.

(Source: Routine Provider Information Request (RPIR) – Medical agency locum tab)

Staffing skill mix

In July 2018, the proportion of consultant staff reported to be working at the trust was lower than the England average and the proportion of junior (foundation year 1-2) staff was about the same.

Staffing skill mix for the 33.8 whole time equivalent staff working in maternity at Kettering General Hospital NHS Foundation Trust. This England Trust average Consultant 30% 41% Middle career^ 15% 9% Registrar group~ 47% 43% Junior* 9% 6%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Records

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Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. The maternity service used an electronic record system for antenatal and postnatal care, and standardised maternity notes, developed by the perinatal institute, for intrapartum care. The electronic record system enabled timely access to diagnostic and screening results. We observed that paper notes were stored away from public view in lockable trolleys. Community midwives had access to hand held electronic records. Community midwives told us that they had occasional issues with connectivity to the live electronic record system in women’s houses and children centres. In these situations, community staff needed to revert to paper records until they had access to the live system to input their findings. This meant there could be delays in information being submitted. Women carried a copy of their antenatal screening results and ultrasound scan findings. This ensured community midwives always had access to this information. This was in line with national recommendations (NICE ‘Antenatal care for uncomplicated pregnancies’: CG62, (last updated January 2017); NICE ‘Antenatal care’: QS 22, (last updated April 2016). We reviewed seven sets of records, both electronic and paper. The electronic record could be “flagged” if there was any cause for concern, for example if there were safeguarding concerns. This meant that all staff were aware of any specific issues for women or babies. All records reviewed contained previous and current clinical and obstetric information, and completed risk assessments with details of actions taken. Regular clinical assessments, such as blood pressure and urinalysis, were also evident in all patient records reviewed. However, there was some loose paper within the paper records. This meant that there was a risk of information being lost which could compromise patient confidentiality. Medical records included care plans and referrals to specialist services when indicated. For example, the haematology obstetric clinic (HOBS). Managers undertook monthly audits of ten records on the content and standard of recordings made by midwives. Audits of records from November 2018 to January 2019 demonstrated that actions were taken if there were omissions to the records such as not including previous health issues. Actions taken included speaking with individual staff, the departmental manager and providing feedback to staff at ward meetings. Mothers were given the national personal child health record (often called the ‘red book’), before they were discharged home. The red book is a national standard health and development record used to monitor the child’s health and development during the first four years of life. Discharge summaries were sent to health visitors. Electronic discharge letters had recently been introduced and were automatically sent to the GP. The summary included information about the woman’s pregnancy, labour and postnatal care, any medications they had been prescribed and any ongoing risks and/or follow-up care needed. On post natal discharge from the unit women were given written information and relevant contact details in case they needed extra support. Medicines The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication, at the right dose, at the right time. Medicines (including controlled drugs) were stored securely and there were appropriate disposal facilities. A controlled drug (CD) register was used to record the details of CDs received and administered as well as CDs that had been disposed of. Some prescription medicines are controlled under the Misuse of Drugs legislation (and subsequent amendments). These medicines

20171116 900885 Post-inspection Evidence appendix template v3 Page 142 are called controlled medicines or controlled drugs. Stricter legal controls apply to controlled medicines to prevent them being misused, being obtained illegally and causing harm. All clinical rooms were accessible by key pad entry only. This meant that unauthorised personnel were restricted from entering these areas. A new key locking system had been introduced to the service to improve medication security and staff accountability. All midwifery staff had their own key to access medicine cupboards. Maternity support workers (MSW’s) had keys with restricted access, this meant that they could only access fridges and cupboards that were relevant to their role for example the baby milk fridge. If staff forgot their key there were systems in place for them to have a spare key for a span of duty, this had to be signed for at the beginning of a shift and returned and signed for at the end of a shift. Medicines and equipment for use in emergencies were stored in tamper proof boxes and were checked regularly. Medicines were stored securely in all the areas we visited. However, we saw that in the delivery suite there were injectable water and sodium chloride ampoules that were left on a side worktop in the treatment room. Medicines that needed to be kept below a certain temperature were stored in locked fridges. We sampled ambient and fridge temperatures to ensure medicines stored kept patients safe from avoidable harm. The fridge temperature records for delivery suite and the antenatal ward were within the recommended range, were clearly documented and there were no omissions on the documented checklists. Staff were able to describe the actions they would take if the fridge temperatures were out of range. Ambient room temperatures were recorded and there were notices in the clinical areas describing actions to take if the temperatures were out of range. This was an improvement on our last inspection, in November 2017 when some ambient room temperatures were out of range for several days and had not been reported by staff. Medicines room and medicine storage audits provided for February 2019 demonstrated compliance with monitoring room temperatures which were within range. Medicine room audits were undertaken by pharmacy staff, it was unclear who undertook the medicine storage audits. We reviewed seven prescription charts and saw that they were legible, allergies and weight were documented and medicines were given as prescribed. However, there was limited evidence of a pharmacy review to ensure that medicines were prescribed and discontinued appropriately. Medicine incidents were reported through the electronic incident reporting system. Midwives may supply and administer pain-relieving medicines without a prescription under a national system known as midwives’ exemptions. The practice development team completed competency assessments on newly qualified midwives before they were allowed to administer any medication alone. We saw that there was a separate record chart for medicines prescribed under midwives’ exemptions. This record chart was attached to the main prescription chart as required by trust policy. This was an improvement from our last inspection in November 2017 when the record chart was not attached to the main prescription chart and there was a risk that a medication may be given twice. There were local microbiology protocols for the administration of antibiotics. Of the seven prescription charts reviewed only two women were prescribed antibiotics. One of these has not been reviewed. On call community staff midwives carried equipment for facilitating a home birth. This included emergency equipment such as oxygen and pain relief medication such as nitrous oxide (gas and air). Community staff told us that they only carried medication if they were on call. Maternity staff checked their medication packs on a weekly basis to ensure medications were in date. If a woman thought she would need a controlled drug during a home delivery she had to get a prescription 20171116 900885 Post-inspection Evidence appendix template v3 Page 143 from her GP beforehand. Following our inspection, we requested further information about the processes for pharmacy to review and check community medications for home deliveries. Data provided showed there was daily monitoring of drugs and an audit to demonstrate that storage of medication was secure. Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. The service used an electronic incident reporting system. Staff understood their responsibilities to report incidents and patients were informed when things went wrong. Incidents were reported and investigated and were subject to review by matrons and senior managers in maternity services. However, not all staff who investigated incidents had undergone root cause analysis (RCA) training. If staff had not received training they worked with a trained or experience investigator as identified in the trust policy. An internal course was available and staff investigating incidents who were not trained were supported by someone who was. Evidence of decisions and discussions at safety and team meetings were consistent and learning outcomes were recorded in the minutes of team meetings and in the maternity service newsletter. Learning was also shared through monthly lessons learnt forums for learning from serious incidents, bulletins on outcomes from serious incident investigations and medication safety bulletins. We saw briefing papers for learning from internal investigations and saw that clear information was provided to staff identifying the situation, actions taken and lessons learned. Action plans to implement learning actions were also in place. Staff were given feedback about incidents in emails and face to face if they were involved. Staff told us that an overview of lessons learnt from incidents was included at the beginning of all mandatory training sessions. Staff were confident in the use of the system and said they always reported incidents. Since June 2018 all ward staff had access to the electronic incident dashboard that related to their ward. This meant that they could see the outcomes, action plans and learning relating to their clinical area. The service had a maternity quality lead midwife who supported staff to understand serious incidents. Learning from serious incidents was incorporated into “skills drills” so that staff were trained in managing the scenarios. The service had processes in place to review incidents. Serious incident review group meetings were held. Monthly perinatal and maternal mortality and morbidity meetings were attended by clinicians from across the women and children’s division. Minutes indicated a full discussion of cases took place and learning points were identified. For example, serious incidents, themes, stillbirths and neonatal deaths were discussed. Lessons were learned and actions were taken to improve the outcome of care for women and their babies. The maternity service reported all premature births between 22+0 and 23+6 weeks gestational age who did not survive the neonatal period. This was in line with national recommendations (MBRRACE-UK, 2015). The maternity service had reported 776 incidents from January 2018 to December 2018. Six hundred and twelve of the incidents reported incurred no harm, whilst 96 “near misses” were reported. Three incurred moderate harm, and three resulted in patient death, two of which were not as a result of a patient safety incident. One moderate incident was investigated through the incident reporting system. Serious incidents were reviewed at the serious incident review group (SIRG). We saw that women and their families were offered the opportunity to ask questions as part of the investigation. During our last inspection in November 2017 we found that the service

20171116 900885 Post-inspection Evidence appendix template v3 Page 144 did not manage incidents well. Incidents were not always appropriately reported and investigated as serious incidents when the threshold was met. During this inspection we saw that incidents were overseen by senior staff. We reviewed three incidents and found that thorough investigations had been completed including the application of “duty of candour”. The maternity service had applied duty of candour 10 times from October 2017 to September 2018. Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify parents (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person, under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Medical and nursing staff understood their responsibilities regarding the duty of candour regulation and were aware of the trigger for application of duty of candour for moderate harm and above. All staff received training in duty of candour at induction which included the principles and how to apply them. The patient safety team monitored investigations and ensured duty of candour compliance was evidenced. Compliance was currently 100%. Compliance reports are provided through the governance structure in the trust and detailed in patient safety quarterly reports. Incidents were discussed at the monthly women’s and children’s services divisional governance meetings and monthly risk forum meetings. At our previous inspection in November 2017 there was poor medical attendance. We reviewed minutes for meetings in October and November 2018 and saw that there was good medical staff attendance. Minutes showed that incidents were discussed. We saw evidence of learning from incidents. For example, women had not received their dating scans in an appropriate timescale and so were unable to have specific scans for Downs syndrome. The service had employed additional sonographers to ensure that women were able to have scans between 10 to 14 weeks of pregnancy. Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

From November 2017 to October 2018, the trust reported no incidents which were classified as never events for maternity.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in maternity which met the reporting criteria set by NHS England from November 2017 to October 2018.

(Source: Strategic Executive Information System (STEIS))

Safety thermometer The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.

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Safety information was collected on the maternity dashboard and shared with staff, women and visitors. This information was discussed at team meetings and in monthly meetings. Data sets were collected and recorded on the maternity dashboard, for example post partum haemorrhage, perineal trauma, caesarean section and infection rates. Staff were aware of the main risks for the service. For example, a higher than level of caesarean sections, for the period April 2017 to March 2018 the rate was 34.9% which was higher than the previous year which was 31.7%. In November 2018 the overall caesarean section rate was 40.2% which place the service in the top quintile for caesarean sections. The maternity safety thermometer is a national system that was designed to support improvements in patient care and experience. The thermometer records the proportion of mothers who have experienced harm free care. It also records harm associated with maternity, such as perineal trauma, abdominal trauma, postpartum haemorrhage, infection and women’s psychological perception of safety. It should be in use for postpartum care. The trust’s maternity dashboard was in line with the RCOG ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’ (2007). We reviewed the maternity dashboard and found there was monitoring of key areas, for example, staffing levels, induction of labour and caesarean section rates, and the number of unexpected neonatal term admissions to NICU. Is the service effective? Add headings, text, graphs and diagrams

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Local and national audits were completed and actions were taken to improve care and treatment when indicated. The service had processes in place to monitor that evidenced based practice and National Institute for Health and Care Excellence (NICE) guidance was followed. NICE compliance was monitored through quality dash boards which were discussed at clinical governance meetings at speciality and divisional level and quality governance steering group at corporate level. Perinatal mortality and morbidity meetings, patient safety lessons learned forum also provided platforms for sharing evidence based practice and learning from cases. Staff were able to access policies through the trust’s intranet. The service allocated authors to review policies and ensure that they were up to date. Authors also considered guidance from other professional bodies such as the Royal colleges. However, we saw that processes were not always robust. For example, policies for review would be allocated three months before the review date but if the author had left this was not identified until this time. This meant that there could be a delay in reviewing policies while a new author was identified and staff potentially following out of date guidance. Following our inspection, we requested data from the service as to the number of policies or guidelines due for review. There were ten guidelines which had expired in February 2019. Policies were reviewed and ratified at the monthly scrutiny committee. Prior to this meeting, the author of the policy shared the draft document with the scrutiny committee members via email. The members reviewed the guideline and suggested changes. This process ensured there was adequate medical input and scrutiny in the development of policies, as medical staff were often not available to attend the meetings. Review of minutes identified that all out of date policies and actions to be taken were identified.

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The service participated in local and national audits and had an audit schedule for 2018/19. Evidence was collated to monitor and improve care and treatment. The clinical audit schedule for 2018/19 included national audits for example, the maternal, newborn and infant clinical outcome review programme (MBRRACE-UK) which is responsible for national surveillance of all maternal, perinatal and infant deaths in UK, the national maternity and perinatal audit (NMPA) which monitors the provision of high-quality information about NHS maternity and neonatal services and the saving babies lives care bundle. Local audit included the identification and treatment of sepsis in maternity patients and compliance with the implementation of the new maternity early obstetric warning scoring system score (MEOWS), the measurement of surgical site infection post caesarean section and documentation audits. Results for local monthly audits were identified on ward notice boards and included hand hygiene, venous thromboembolism (VTE) assessment and pain scores being fully documented. This was an improvement from the last inspection in November 2017 when the local audit programme was limited. The service had introduced the latest version of the national early warning score (NEWS 2) in August 2018. The adult sepsis screening and immediate action tool (sepsis six) was updated and integrated into a NEWS 2 booklet to ensure that it was readily available to staff when a patient deteriorated. The sepsis six is the name given to a bundle of medical therapies designed to reduce mortality in patients with sepsis. The service had an up to date sepsis guideline. Antenatal, intrapartum and postnatal care was provided in line with NICE quality standards and guidelines. Policies and patient records we reviewed reflected this. For example, women were cared for in accordance with NICE “Postnatal care”: QS 37, (last updated June 2015). This included the care and support that every woman, their baby and partner should expect to receive during the postnatal period. We observed staff supporting women with infant feeding. Women at risk of gestational diabetes were referred for a glucose tolerance test in the antenatal clinic. Combined consultant led endocrine and obstetric clinics were available for women with diabetes. This was in line with NICE “diabetes in pregnancy: management from preconception to the postnatal period”: NG3 (last updated August 2015). Maternity staff reviewed cardiotocography (CTG) traces using the “fresh eyes” review process. The “fresh eyes” system required a second midwife to review the foetal heart trace and contractions to ensure the trace was correctly interpreted and managed appropriately. These reviews were documented and escalated in line with NICE “Intrapartum care for healthy women and babies”, CG190, (last updated February 2017). The service had implemented the “Saving Babies Lives” care bundle (NHS England 2016) and was designed to reduce still births. This included the use of customised foetal growth charts to identify babies who were not growing as expected and routine symphysis-fundal height measurements from 24 weeks gestation. Women were asked about their smoking status during their antenatal booking appointment. Women were monitored routinely for carbon monoxide (CO) levels, if they smoked, at each ante natal appointment. This was in line with NICE “Smoking: acute, maternity and mental health services” PH 48 (November 2013). The service was participating in the national bereavement care pathway pilot and provided support for families suffering a loss. This included offering post loss appointments with the consultant obstetrician, counselling support, and involving families in the development of this service. Nutrition and hydration

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Women’s and babies’ nutrition and hydration needs were identified, monitored and met. There was access to an infant feeding specialist to assist women and babies when needed. Women received support and advice for feeding their babies, including positioning and attachment, hand expression and preparing infant formula. Women told us how ‘supportive and helpful’ staff were. They told us they were never pressurised to breastfeed and they were assisted with feeding their babies whatever method they chose. Breastfeeding initiation rates were monitored, however this was not recorded on the maternity dashboard. Breastfeeding initiation rates were 60% which was below the national average of 81%. This had fallen from the last inspection in November 2017 when the initiation rate was 88%. Midwives were actively promoting skin to skin contact on the ward and in theatre to increase breastfeeding initiation rates. Breastfeeding was also discussed at ante natal classes. Breastfeeding information was widely displayed throughout the service. The service had a specialist infant feeding midwife who provided education and support to women and staff and attended local neonatal forums. Women told us that they felt fully supported in feeding their babies and in their choice of breast or formula feeding. The maternity service had achieved the United Nations Children’s Fund (UNICEF) Baby Friendly full accreditation and was re-accredited in 2018. This is the top award from UNICEF to accredit organisations that have established and implemented very high standards of care for all pregnant women and new mothers. It meant that the organisation was committed to supporting mothers to initiate breastfeeding and encouraged them to exclusively breastfeed for the first six months while at the same time also supporting parents who chose to bottle feed. Expressed breast milk was labelled and stored safely in a specialist milk fridge. The milk fridge was locked and in a locked room. This was only accessible by key pad access. This was an improvement from our inspection in November 2017 when there was no key pad access to the room. This meant that the milk could not be tampered with. Fridge temperatures were monitored daily and in range. Staff described the actions they would take if the temperatures were out of range. There was a range of formula milk for women who wanted to formula feed their babies. This was stored in a locked room with disposable sterile teats and could only be accessed by staff. The service had a kitchen where women could make themselves a snack or access a drink 24 hours a day, seven days a week. The service had protected meal times and a range of menus were available. Meals met cultural and nutritional needs and included for example, gluten free, vegetarian, vegan, halal and kosha options. Women were advised about pre-operative fasting if they were to undergo an elective caesarean section. If their surgery was delayed they would be advised if they were able to have drinks of water or anything to eat so that they did not go without food for long periods of time.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. Pain was assessed and managed well on an individual basis and was regularly monitored by midwifery and nursing staff. Pain levels were routinely assessed during the completion of patient observations and were recorded on observation charts.

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Maternity staff provided pregnant women with evidenced-based information about the availability and provision of different types of analgesia, in line with national recommendations (OAA/AAGBI ‘Guidelines for Obstetric Anaesthetic Services’, 2013). For example, midwives provided information and advice on pain relief options during their antenatal parent craft classes. Pharmacology methods of pain relief were readily available and included nitrous oxide (gas and air), opioids (such as pethidine and oral morphine) and epidural anaesthesia, which were available 24-hours a day. Non-pharmacological methods of pain relief were also available. The delivery suite had two birthing pools that were available for women to use in labour and/or birth. The number of women who used these were not recorded on the maternity dashboard. The maternity service audited the time from women requesting an epidural to the time the anaesthetist attended. National recommendations (OAA/AAGBI ‘Guidelines for Obstetric Anaesthetic Services’, 2013) recommend the length of time should not normally exceed 30 minutes. Data provided by the service for September 2018 indicated that there were 45 epidurals performed during September 2018. Of these 27 (60%) were audited with the average response time being 10 minutes. Of these, 81.5% (22 out of 27) women had a response within 30 minutes and two had a response within 60 minutes. Reasons provided for the two epidurals being delayed were due to the anaesthetist being busy with other patients. This meant that the service was able to determine whether women received pain relief in a timely way. This was an improvement from our previous inspection in November 2017 when the time from requesting to receiving an epidural was not audited. However, this audit was not documented on the audit schedule for 2018/19. All staff we asked told us anaesthetists responded promptly to requests for epidurals. Women we asked did not have any concerns with timeliness of pain relief. Midwives told us regular analgesia was prescribed for post-operative women, including opioids, paracetamol and non-steroidal anti- inflammatory drugs (NSAIDs). Women were routinely given local anaesthetic prior to perineal suturing, unless contraindicated. This was in line with national recommendations (NICE ‘Intrapartum care for healthy women and babies’: CG 190, last updated February 2017). Women, who had undergone surgery including caesarean section, were given pain relief for use at home when discharged. Women that we spoke to throughout the inspection told us that they had received effective pain relief and were advised to ask for more if necessary. Community midwives told us that if women required opioids for a home delivery they had to arrange a prescription from their GP. This would be kept at home and administered by the community midwives as required. Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. The audit programme for the service for 2018/2019 had 48 audits documented. These included the maternal, newborn and infant clinical outcome review programme (MBRRACE audit), elective caesarean section, skin to skin contact at delivery, and an induction of labour audit. Six of the audits identified on the audit programme were overdue. During the last inspection in November 2017 the management of the audit programme was not effective. During this inspection we saw that the audit programme was more robust. We saw that the modified early warning scores (MEOWS) audits had been added to the audit programme. However, the audit programme did not include all of the audits that were undertaken. For example, hand hygiene audits and the time from women requesting an epidural to the time the anaesthetist attended were not on the audit schedule although these were undertaken. This meant that the

20171116 900885 Post-inspection Evidence appendix template v3 Page 149 audit team did not have full oversight of all of the audits completed within the maternity service, their results and whether improvements to practice had been fully implemented. Managers maintained a monthly maternity indicator summary (dashboard), which reported on the birth activity, workforce and obstetric and neonatal outcomes such as normal vaginal births, instrumental and caesarean section deliveries, third and fourth degree tears and intrauterine deaths. The dashboard tracked monthly performance against locally agreed thresholds and national targets where available. A traffic light system using red, amber and green (RAG) ratings was used to flag most of the performance against agreed thresholds. We saw exceptions, (red flags) reported on the maternity dashboard which identified areas that required action in order to maintain safety and restore quality. Actions and reflections on the red flags were discussed at governance meetings. The dashboard exception report was co-written by the delivery suite lead consultant and the midwifery matron. The maternity dashboard review from December 2017 to December 2018 identified the top trigger areas as the caesarean section rate, both elective and emergency, failed instrumental deliveries and post partum haemorrhage. The emergency caesarean section rate was red flagged for the whole 12 month period. The elective caesarean section rate was red flagged for four of the twelve months and scored amber for two months. National audit data demonstrated that the service had a higher than average rate of caesarean sections. From April 2017 to March 2018 the combined rate of elective and emergency caesarean sections was 34.9% which had increased from 31.7% in the equivalent period the previous year. This was measured against a target of 29.9%. This placed the service in the top quintile for caesarean sections. In November 2018 the overall caesarean section rate reached 40.2%. Managers had developed an action plan to reduce the number of caesarean sections. The action plan was discussed at the clinical audit meeting. Minutes seen for the clinical audit meeting in June 2018 confirmed this. An audit had been undertaken which identified the following themes: o To increase the number of referrals to the Choices clinic, (a clinic to assess birthing options) o Develop processes to ensure that women received the patient information leaflet (PIL) and ensure that maternal requests for elective caesarean sections were discussed with a second professional o Increase consultant involvement in decision making. Following the audit managers introduced a proforma to ensure that women received the PIL, were referred to the Choices clinic and that their request for caesarean section had been discussed with a second professional. Managers planned to continue to identify the reasons for caesarean section in the monthly exception report which accompanied the maternity dashboard. Data provided by the service identified that: o grade one caesarean sections, (one that is done if there is an immediate threat to the baby's or mother's life) were lower than expected and accounted for 16% of all emergency sections o Some of the increase was attributable to maternal requests; 16% of all grade four caesarean sections were as a result of maternal choice alone. A grade four caesarean section is an elective delivery planned to suit the woman and the hospital.

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o Of the 23 requests for caesarean section due to previous caesarean section (46% of the overall elective caesarean rate), only two had been identified as missed opportunities for referral to the Choices clinic There had been an increase in referrals to the Choices clinic, compared to audit data from February to May 2017 when only 55% of women requesting caesarean section were seen in the Choices clinic (n=80 cases). Managers reported that of all the women seen, there was documented evidence that a discussion had occurred about choice of modes of birth. Success rates, risks and individualised care had been discussed either at the Choices or Consultant clinic. Additionally, a multidisciplinary team (MDT) team of leaders from delivery suite had attended a labour leaders’ workshop which had a focused project on reducing caesarean section rates. MDT training in birth trauma resolution and personalised care was planned for 2019. Managers had reviewed practice following publication of a Royal College of Obstetricians and Gynaecologists (RCOG) statement letter about offering women choice. It was identified that not all requests for caesarean section had been subject to dual consultation. Managers had sought legal advice which stated that it should be ensured that women were given adequate choice. Managers also reported that an NHSi critical friend review was planned to begin at the end of January 2019. (It was not confirmed that this had started.) Managers would assess any recommendations and consider implementing new plans. These would first be discussed at directorate and divisional governance meetings. According to the maternity dashboard, from December 2017 to December 2018, the service did not meet the agreed threshold of 11 major post partum haemorrhages (the loss of more than 1000mls of blood within 24 hours of the birth of a baby) for seven of the twelve months. The highest number of incidents was reported in July 2018 when there were 22 post partum haemorrhages. At our previous inspection in November 2017 the threshold was not met for five of the twelve months. We requested information from the service about their plans to address this. Data had been submitted to the national maternal and perinatal audit (NMPA) audit but was in the incorrect format. Managers had addressed this to ensure subsequent submissions were presented correctly. The maternity safety improvement plan 2016-2020 provided details to improve safety through multidisciplinary training, audit and learning from serious incidents but did not specifically address post partum haemorrhage as an issue. Therefore, we could not be assured that sufficient priority was given to this issue. Following our inspection managers told us that they planned to review their metrics to ensure consistency with peer organisations and national benchmarks. Additionally, metrics were to be reviewed at a monthly patient safety advisory group, monthly maternity safety meetings and reported bi annually to the quality and safety committee. National Neonatal Audit Programme

In the 2017 National Neonatal Audit, Kettering General Hospital performance in the two measures relevant to maternity services was as follows:

• Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any dose of antenatal steroids?

There were 86 eligible cases identified for inclusion, 87.5% of mothers were given a complete or incomplete course of antenatal steroids.

This was within the expected range when compared to the national aggregate where 86.1% of mothers were given at least one dose of antenatal steroids.

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The hospital met the audit’s recommended standard of 85% for this measure.

• Are mothers who deliver babies below 30 weeks gestation given magnesium sulphate in the 24 hours prior to delivery?

There were 17 eligible cases identified for inclusion, 29.4% of mothers were given magnesium sulphate in the 24 hours prior to delivery.

This was lower than the national aggregate of 43.5%, and put the hospital in the middle 50% of all units.

(Source: National Neonatal Audit Programme, Royal College of Paediatrics and Child Health)

Standardised Caesarean section rates and modes of delivery

From April 2017 to March 2018 the total number of caesarean sections was higher than expected. The standardised caesarean section rates for elective sections were higher than expected and rates for emergency sections higher than expected. Staff told us that the women requesting elective caesarean sections were referred to the Choices clinic so that they could discuss the options available for delivery. Staff said that they respected women’s individual choices, however, second reviews were undertaken when elective caesarean sections were requested. Managers audited all elective and emergency caesarean sections by consultant obstetrician.

Standardised caesarean section rate (April 2017 to March 2018) KETTERING GENERAL HOSPITAL NHS FOUNDATION England Type of TRUST caesarean Caesarean Caesareans Caesarean Standardised RAG rate (n) rate Ratio Elective Higher than 12.4% 459 14.6% 127.8 (z=2.3) caesareans expected Emergency Higher than 15.9% 640 20.4% 130.2 (z=2.1) caesareans expected Higher than Total caesareans 28.3% 1,099 35.0% 129.2 (z=3.7) expected Source: Hospital Episode Statistics, April 2017 to March 2018

Notes: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries. Delivery methods are derived from the primary procedure code within a delivery episode.

In relation to other modes of delivery from April 2017 to March 2018 the table below shows the proportions of deliveries recorded by method in comparison to the England average:

Proportions of deliveries by recorded delivery method (April 2017 to March 2018) KETTERING GENERAL HOSPITAL England NHS FOUNDATION TRUST Delivery method Deliveries (n) Deliveries (%) Deliveries (%)

Total caesarean sections1 1,099 35.0% 28.3%

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Instrumental deliveries2 270 8.6% 12.4% Non-interventional deliveries3 1,771 56.4% 59.3% 100% Total deliveries 3,140 100% (n=596,828) Source: Hospital Episode Statistics, April 2017 to March 2018

Notes: This table does not include deliveries where delivery method is ‘other' or 'unrecorded'. 1Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Includes breech and vaginal (non-assisted) deliveries

Total caesarean sections delivery rates were higher than the England average.

(Source: Hospital Episodes Statistics (HES) – provided by CQC Outliers team)

Maternity active outlier alerts

As of December 2018, the trust reported no active maternity outliers.

(Source: Hospital Evidence Statistics (HES) – provided by CQC Outliers team)

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK Audit)

The trust took part in the 2017 MBRRACE audit and their stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) was 4.91.

This is up to 10% higher than the average for the comparator group rate of 4.79.

(Source: MBRRACE UK)

Data for the 2018 was being compiled for return, however the perinatal mortality rates collated from January 2018 to December 2018 identified the adjusted perinatal mortality rate was 3.95. This was an improvement on 2017. Data obtained from the bereavement midwives records, using the electronic record and MBRRACE - UK documentation identified the perinatal rate from January 2018 to December 2018.

Year Total Stillbirths Compassionate Late Neonatal NND Births Induction foetal death >24 loss 22- (NND) weeks 23+6 < 24 weeks 2018 3290 11 3 5 4 6 2017 3470 16 3 2 9 9 2016 3672 14 2 4 1 8 All late fetal losses from 22 weeks gestation, stillbirths and all neonatal deaths cases were reviewed monthly at a perinatal multidisciplinary meeting. Minutes of meetings seen confirmed this. The service had implemented the “Saving Babies Lives” care bundle (NHS England 2016). This had been implemented into the Maternity Safety Plan in 2017. The service was auditing the elements of the “Saving Babies Lives” care bundle, this included reducing smoking in pregnancy, surveillance and risk assessment for fetal growth restriction, raising awareness of reduced fetal movements and held monthly skills and drills sessions for the effective foetal cardiotocograph (CTG) interpretation and use of auscultation during labour. Policies were in place and learning was shared with staff through regular learning from investigations newsletters.

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Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. There were systems and processes in place to ensure that staff had the necessary qualifications, skills, knowledge and competencies to do their jobs. The service enabled staff to take on new responsibilities on a continual basis. Trust induction programmes included mandatory training and competency based ward skills. New staff were inducted to the clinical areas. Student midwives spoke highly of their mentors and felt well supported. Newly qualified midwives were supported through preceptorship programmes and received a supernumerary period in each of the clinical areas. They rotated to work on the delivery suites, foetal medicine, and Rowan ward. Newly qualified midwives completed competencies to enable them to become proficient in a variety of skills. This included venepuncture, cannulation and perineal skin suturing. Midwives may supply and administer pain-relieving medicines without a prescription under a national system known as midwives’ exemptions. The practice development team completed competency assessments on newly qualified midwives before they were allowed to administer any medication alone. There was a clinical supervision policy which was in date which contained supervision documentation. Clinical supervision was provided in a variety of ways, either in group or one to one sessions. Ward sisters and matrons were invited to monthly forums where they could share learning on a number of key practice or professional issues. Heads of nursing and midwifery met with the director of nursing and quality bi monthly to provide opportunities to explore professional situations. Midwives received formal clinical supervision and robust systems were in place to record and monitor supervision. The role of the supervisor of midwives (SoM) was discontinued in April 2017 following changes to legislation. The trust had implemented a model of midwifery advocacy supervision with professional midwifery advocates. There were nine professional midwifery advocates (PMA’s) and more were being recruited to undertake the course. PMA’s provided care and support to midwives and multi-disciplinary teams. Staff development and leadership opportunities were available for all staff. This included supporting midwives to progress to the next band, developing specialist midwifery roles for example, perinatal bereavement midwives and specialist infant feeding midwife. Opportunities were available for midwives to attend a variety of clinical and managerial courses. These included high dependency, sonography, new born physical examination (NIPE), root cause analysis (RCA) for the investigation of incidents and leadership courses. Leadership programmes were open to all staff. Attendance was identified through role profiles or the appraisal and development process. The service did not have a leadership and talent management strategy. The trust delivered a variety of leadership courses to support the development of skills across the workforce roles in partnership with NHS Elect, the NHS Leadership academy and the Kings Fund. During the last year there had been a focus on programmes that supported wider leadership skills and organisational change. These included the impact of personal leadership styles, developing confidence to manage, promoting personal and team resilience and personal effectiveness. A leadership and development programme was accessed by all the newly qualified professional staff as part of their preceptorship programme, alongside staff completing the essential leadership skills programme. The nursing sisters’ leadership programme was in place to promote excellent ward leadership.

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Early help champions had been developed to try and ensure families were offered and accepted support and assistance to try and prevent safeguarding and child protection issues developing. This had resulted in an increase in the number of early help offers, and data was captured where early help was declined. The service had an up to date temporary staffing policy. Temporary staff had an induction to the clinical areas and evidence of competencies were confirmed by the nurse in charge for midwifery and midwifery support workers Consultants were responsible for ensuring that if locums had not previously worked at the hospital their curriculum vita was reviewed and approved. All trainee doctors had educational supervisors. The supervisors met with their supervisee on regular occasions. Junior doctors told us that they felt well supported and had received excellent teaching. One junior doctor had extended their placement because they felt the training and development opportunities were good. Antimicrobial stewardship training was included in the doctor and clinical induction programmes, the preceptor nurses and the nurse development programme. The service had implemented mandatory annual CTG competency assessments for all practising midwives and obstetricians. This was in line with national recommendations (NHS England “Saving Babies Lives”: A care bundle for reducing still births) 2016. This meant failure to achieve adequate mandatory training would mean staff may lack the required knowledge to successfully assess foetal well being using CTG equipment. There were weekly CTG sessions and annual midwifery training days included CTG training. Appraisal rates

As of September 2018, 93% of staff within maternity care at the trust received an appraisal compared to a trust target of 85%.

Appraisals Individuals complete Completion Staff group required (YTD) (YTD) rate Additional Clinical Services 13 13 100% Administrative and Clerical 1 1 100% Nursing and Midwifery Registered 55 50 91% Grand Total 69 64 93%

Staff told us that they were up to date with their appraisals and that they found the process to be beneficial and gave them an opportunity to discuss their individual training needs and the requirements of the department. Multidisciplinary working Maternity services were committed to working collaboratively. Medical staff, midwives, anaesthetists and other health care professionals supported each other to provide good care. Staff in all areas of the maternity service told us they worked closely together to make sure women received person-centred and effective care. This included working with healthcare professionals outside the trust and patient records we reviewed corroborated this. Community staff reported good relations and communications with other professionals and/or agencies. They described effective multidisciplinary working between health visitors, GPs and social services. Staff

20171116 900885 Post-inspection Evidence appendix template v3 Page 155 confirmed they were advised when a woman had suffered a pregnancy loss or had safeguarding concerns. A multidisciplinary handover took place twice daily on the delivery suite and included an overview of maternity patients. We observed good interactions between medical staff and midwives on the delivery suite during multidisciplinary handovers. Meeting minutes confirmed regular multidisciplinary meetings were held and were well attended. These included perinatal morbidity and mortality meetings and speciality quality meetings. At our previous inspection in 2017 medical staff attendance at governance meetings was infrequent. Midwifery staff told us there was good communication with the neonatal unit. The delivery suite coordinator would inform the neonatal unit of the acuity within the maternity service, including potential admissions to the neonatal unit. For example, women who had been admitted in pre-term labour, and when an emergency caesarean section was performed. During our inspection we saw that acuity levels within the whole maternity service were discussed. Women referred for a caesarean section, were reviewed to assess if they were suitable for a vaginal birth. If the women agreed with the multidisciplinary team’s recommendation, they were offered an appointment at the birth options clinic. Women with multiple pregnancies were cared for by a multidisciplinary team which included foetal medicine specialist obstetricians. Women who needed higher levels of care were referred to neighbouring trusts with tertiary foetal medicines centres. Multidisciplinary cardiotocography (CTG) case reviews took place weekly to facilitate discussion and learning. These were attended by all grades of staff. Multidisciplinary specialist medical clinics were held, for example diabetic clinics which were attended by the specialist diabetic midwife, consultant obstetrician and consultant endocrinologist. Specialist mental health clinics were also held with a psychiatrist and obstetrician. The service had links with other maternity services within the local maternity system (LMS) to work collaboratively to improve the care for women and their babies. Seven-day services Women had access to midwifery, obstetric and anaesthetic support seven days a week. Arrangements were in place to keep women and their babies safe out of hours. Access to medical support was available seven days a week throughout the service. Consultant obstetricians and anaesthetist cover was provided seven days per week with on-call arrangements out of hours. Local diagnostic services were available daily with out of hour’s facilities for emergency procedures such as x-ray, computerised tomography (CT), ultrasound sonography and pathology out of hours. Phlebotomy and physiotherapy services were provided seven days a week but offered variable hours. Women were able to report to the hospital in an emergency by telephoning the triage midwives. The service had an early pregnancy unit where women were assessed if they experienced any early pregnancy complications. This service was available from Monday to Friday from 8.30 am to 4.30 pm and on Saturdays from 9 am to 2pm. A late pregnancy and fetal medicine service was provided in the foetal health unit from Monday to Friday 7am to 7pm and from 8am to 4pm on Saturdays. Out of these hours, women could call the delivery suite for advice. Community midwives were on call over a 24-hour period to facilitate home births. Antenatal and postnatal services were available to community-based mothers in emergencies. The pharmacy department provided clinical pharmacy services to the department and was open from Monday to Friday 8.30 am to 6.30 pm, Saturdays and bank holidays 9am to 12.30. An 20171116 900885 Post-inspection Evidence appendix template v3 Page 156 emergency duty pharmacist and pharmacy technician were available from 12.30 to 4.00 on bank holidays and Saturdays. The pharmacy was closed on Sundays, however an emergency dispensing service was offered with a duty pharmacist available. Staff told us that they did not have regular pharmacy support except to top up medications. The chaplaincy service was available 24 hours a day, seven days a week. Health promotion Women who used the maternity service were supported to live healthier lives and manage their own health, care and wellbeing. In 2018, the hospital was re-accredited with the Unicef baby friendly initiative stage three. In 2018 the hospital was re-accredited with the UNICEF baby friendly level three award. This is the top award accredited to organisations by UNICEF. This meant that the trust was committed to supporting and promoting mothers to initiate breastfeeding and educate staff about infant feeding. Women and babies were offered a comprehensive immunisation programme which included influenza (flu), pertussis (whooping cough) and BCG vaccinations in line with national recommendations. Women were routinely asked about smoking at their booking visit and their carbon monoxide (CO) levels were monitored. Women who smoked had their carbon monoxide levels routinely monitored throughout their pregnancy. The maternity service supported women who wanted to reach a healthier weight during their pregnancy. The service worked with colleagues to in dietetics and the community to provide national and physical activity guidance for women. The trust website contained a wide range of information to support women and their babies. For example, parent education courses and breast feeding support. Midwives and maternity support workers (MSW’s) held a daily discharge session for all women and their families who were being discharged. This session included staff discussing the demands of new parenthood, safe sleeping and caring for their babies. They also demonstrated bathing a baby. In December 2018 the service hosted a bi annual pregnancy and baby roadshow. The roadshow helped parents to be to prepare for parenthood and provide new and updated information. People were able to learn about water births, home and hospital births and support groups that were available after their baby was born. The day was facilitated by the trust’s maternity advocates and supported by health visitors, physiotherapists and the infant feeding co-ordinator. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards 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. Patients’ consent was obtained in line with hospital policy and statutory requirements. Staff received specific training in the relevant consent and decision-making requirements relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Staff understood their responsibilities in relation to consent and we saw consent was undertaken in line with the trust consent policy. We observed midwifery staff asking for consent before they provided care or treatment, for example, taking clinical observations or giving medication. All women we spoke with told us staff always asked permission before providing care.

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Medical staff informed women of about the risks and benefits of obstetric procedures, such as emergency caesarean sections. Written consent was obtained from women prior to surgery and we saw evidence of this in the maternity records we reviewed Post mortem examinations were offered in all cases of still birth and neonatal death to enhance future pregnancy counselling. Consultants or registrars gained consent for all post mortem examinations. Mental Capacity Act and Deprivation of Liberty training completion

The trust reported that from October 2017 to September 2018, Mental Capacity Act (MCA) training was completed by 91% of staff in maternity services compared to the trust target of 85%. Staff we spoke with confirmed they had received MCA and DoLS training and understood their responsibilities to ensure patients were protected. Staff had access to specialist midwives and nurses that had particular expertise in dealing with women in vulnerable circumstances, such as those with learning disabilities and mental health concerns.

The trust did not report on Deprivation of Liberty Safeguards training.

Is the service caring?

Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Most women, their birthing partners and families told us they were very happy with the care and support they received and feedback was consistently positive throughout the inspection. Staff were very kind and caring towards patients on all interactions we observed. Most women and those close to them were very happy with the care and support they received and feedback was consistently positive throughout the inspection. One woman and their partner told us that it had been a “really positive experience” and they were very happy with the hospital overall. Another woman and her partner told us that the care “had been really good” and she had been well looked after. One woman said that the midwives had made the environment individualised to her needs, that she felt listened to throughout and was given the name of a midwifery lead to escalate any concerns to if necessary. However, one family felt that they had received conflicting information and were unhappy with the attitude of some staff, but felt that the night staff had “been fantastic.” All staff we spoke with were passionate about their roles and were committed to making sure women and their babies received the best patient-centred care. We observed all staff respecting the privacy and dignity of women at all times during the inspection. We observed staff knocking on doors, politely asking before opening curtains and waiting to be invited into rooms and cubicles in all areas. However, there were no curtains behind the doors in the rooms on the labour suite or clear identification that the room was in use. This meant that women’s privacy and dignity could be compromised if they were in labour. We saw constant positive interactions by staff that were kind and caring to both parents and their families. Thank you cards were displayed throughout the unit and comments were positive about the care and treatment that women and their families had received.

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If a woman had suffered a previous pregnancy loss a teardrop sticker was attached to her notes as an identifier. This ensured that all health care professionals were aware of the woman’s obstetric history. These stickers were electronically available on the electronic notes system. The service received feedback from women and their families in a variety of forms. This included the Care Quality Commission (CQC) survey, feedback provided to the clinical commissioning group, NHS choices and the NHS friends and family test. Feedback provided to the CCG during a visit in May 2018 was positive. Women and their families had reported that care had been of a high quality. For example, one family reported that they felt listened to, felt at ease and were provided with clear information throughout their delivery and postnatally. The maternity “Listen to Me” campaign which encouraged staff to listen to women’s concerns and enable them to debrief had been successful and feedback had been positive, was now being piloted in other departments with a view to implement across the organisation. Women were allocated to a midwife who was separate from the midwife who cared for her, if she had any concerns she could raise this with the second midwife. Women told us that they knew who to contact if they wanted to speak with anyone about their care and treatment. Friends and Family test performance

Friends and family test performance (antenatal), Kettering General Hospital NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (antenatal) performance (% recommended) was generally similar to the England average.

Friends and family test performance (birth), Kettering General Hospital NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (birth) performance (% recommended) was generally similar to the England average.

Friends and family test performance (postnatal ward), Kettering General Hospital NHS Foundation Trust

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From September 2017 to September 2018, the trust’s maternity Friends and Family Test (postnatal ward) performance (% recommended) was generally similar to the England average.

Friends and family test performance (postnatal community), Kettering General Hospital NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (postnatal community) performance (% recommended) was generally similar to the England average.

Note: due to a low number of responses the data for September 2018 was suppressed and this is the reason for the drop in the chart above.

(Source: NHS England Friends and Family Test)

CQC Survey of women’s experiences of maternity services 2018

The trust performed similar to other trusts for all 19 questions in the CQC maternity survey 2018.

Area Question Score RAG Labour and At the very start of your labour, did you feel that you About the birth were given appropriate advice and support when 8.8 same you contacted a midwife or the hospital? During your labour, were you able to move around About the and choose the position that made you most 8.0 same comfortable? Did you have skin to skin contact (baby naked, About the directly on your chest or tummy) with your baby 9.0 same shortly after the birth?

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If your partner or someone else close to you was About the involved in your care during labour and birth, were 9.8 same they able to be involved as much as they wanted? Staff during Did the staff treating and examining you introduce About the 8.9 labour and themselves? same birth Were you and/or your partner or a companion left About the alone by midwives or doctors at a time when it 7.5 same worried you? If you raised a concern during labour and birth, did About the 8.7 you feel that it was taken seriously? same If attention was needed during labour and birth, did About the a staff member help you within a reasonable 8.5 same amount of time Thinking about your care during labour and birth, About the were you spoken to in a way you could 9.6 same understand? Thinking about your care during labour and birth, About the were you involved enough in decisions about your 8.9 same care? Thinking about your care during labour and birth, About the 9.2 were you treated with respect and dignity? same Did you have confidence and trust in the staff About the 9.0 caring for you during your labour and birth? same Care in Looking back, do you feel that the length of your About the 7.0 hospital stay in hospital after the birth was appropriate? same after the Looking back, was there a delay in being About the birth 5.7 discharged from hospital? same Thinking about response time, if attention was About the needed after the birth, did a member of staff help 7.3 same within a reasonable amount of time? Thinking about the care you received in hospital About the after the birth of your baby, were you given the 7.8 same information or explanations you needed? Thinking about the care you received in hospital About the after the birth of your baby, were you treated with 8.8 same kindness and understanding? Thinking about your stay in hospital, was your About the partner who was involved in your care able to stay 7.0 same with you as much as you wanted? Thinking about your stay in hospital, how clean was About the 8.7 the hospital room or ward you were in? same

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(Source: CQC Survey of Women’s Experiences of Maternity Services 2018)

Results from the latest CQC survey indicated that 93% of women were treated with respect & dignity. Emotional support Staff provided emotional support to patients to minimise their distress. Women’s emotional and social needs were as important to staff as women’s physical needs, and there was ongoing support for bereaved women and their families. Staff demonstrated an awareness and understanding of women with complex needs and when to provide them with additional support to minimise the potential of them becoming anxious or distressed. Maternity staff followed the bereavement policies and guidelines to support mothers and their family in the event of a pregnancy loss, such as miscarriage, still birth or neonatal death. The service had a specialist bereavement midwife and a dedicated assistant practitioner who supported families from their initial loss throughout their time in hospital and return home. A consultant offered a post loss appointment with families to provide additional support. The service was part of the national bereavement pathway pilot work led by a multi-agency group of baby-loss charities and professional bodies to improve bereavement care and was developing a “Rainbow clinic” for families who had suffered the loss of a baby. This included families suffering the loss of a baby through miscarriage, termination for foetal anomaly, stillbirth, neonatal death or sudden and unexpected infant death up to 12 months. The pathway was due to commence in April 2019. Staff signposted women and their families to national and local advisory groups when required such as the stillbirth and neonatal deaths charity (Sands) The service had a bereavement room on the delivery suite and had developed a garden which was attached to the room. The garden had been completed since the last inspection in November 2017. Memory boxes were provided for early and term babies. Midwives supported families to collect keepsakes such as photographs and imprints of babies’ hands and feet after they had suffered a loss. Women suffering an early loss were provided with “care bags” of essential items. A perinatal mental health midwife had been appointed in November 2018 and worked collaboratively with an obstetrician, perinatal psychiatrist and community psychiatric nurses (CPN’s). Midwives could refer women with perinatal mental health issues to the service. The perinatal mental health midwife supported midwives to identify and support women with perinatal mental health issues. Staff could also refer to the mental health crisis team if more specialist support and intervention was needed. The service offered a maternity advocacy service which was provided by senior midwives from Monday to Friday 9am to 1pm. Women who required additional support could be referred to the advocacy service. Advocates offered a listening service to women who wanted to talk about any midwifery issues and provided feedback to the woman’s named midwife. If additional support was required women could be referred to other appropriate services for example, early help, a service to provide support for families, individuals and their children, the multiagency safeguarding hub (MASH) and the perinatal mental health service. A joint perinatal pathway had been developed with a neighbouring trust to support the mental health needs of women. Further support was available from the mental health (psychiatric liaison) team. Staff told us that they could access the service easily.

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There was a chaplaincy service which provided pastoral, spiritual and religious care for staff, women and their families. The chaplaincy service included chaplains and volunteers. The chaplaincy service included Christian chaplains, and multi faith groups of local people. These included representatives with Bahá’í, Buddhist, Christian, Hindu, Jewish, Muslim, Sikh, Spiritualist and Humanist beliefs. General advice about faiths and customs, for example around birth and dying, was available from the Chaplains, who were available twenty four hours, seven days a week. There was also a link on the Chaplaincy pages of the trust website. Understanding and involvement of patients and those close to them Staff involved women and those close to them in decisions about their care and treatment. They provided women and their partners the opportunity to ask questions and raise concerns throughout the care pathway. Women were involved in the choice of birth location at booking and throughout the antenatal period. This was important for the women who had a complicated pregnancy, for example those who had diabetes, hypertension (high blood pressure), or were at risk of pre-term birth. Women and relatives, we spoke with told us they felt involved in their care and their babies care and received the information they needed to understand their treatment. Women said they were supported by midwives and doctors to make informed decisions and the choices open to them and were given options of where to have and when to have their baby safely. Women told us they were encouraged to ask questions and raise concerns and said they were given the opportunity to speak with staff and were kept informed about what was happening regularly. All partners said they felt involved in the care and treatment of their partner and felt able to ask questions. Partners were allowed to stay on the ward with women at night to provide support. However, they had to read and sign a visitors’ charter. This provided guidance which included keeping noise to a minimum and ensuring that the privacy of other women was respected. Staff told us that they would ask visitors to leave if they did not adhere to the charter. Birthing partners accompanied women into theatre for caesarean sections carried out under regional anaesthesia (epidural and/or spinal). Birthing partners could sit beside women and support them throughout the procedure. This helped alleviate anxiety and distress for the women.

Is the service responsive? Service delivery to meet the needs of local people The maternity service planned and delivered services in a way that met the needs of the local people. The importance of choice and continuity of care was reflected in future maternity care provision. The service worked closely with commissioners, the local authority, clinical networks and other stakeholders to plan delivery of care and treatment for the local population. The service worked closely with local stakeholders and neighbouring trusts to establish the local maternity system (LMS) to improve the maternal and neonatal safety across the clinical network. This collaborative working ensured future planning covered recommendations laid out in “Better Births” (NHS England 2016), the “Maternal and Neonatal Health Safety collaborative (NHS Improvement 2017). Managers told us that the priority of the LMS was to align services and processes across the district. Priorities included reducing the numbers of elective caesarean

20171116 900885 Post-inspection Evidence appendix template v3 Page 163 sections and streamlining community teams into smaller teams to ensure greater continuity of care for women throughout their pregnancy. Continuity of care was ensured for women whilst in hospital and on discharge. We saw multidisciplinary, team and midwife to midwife handover meetings. We saw good use of the situation, background, assessment, recommendation (SBAR) methodology at all handovers we attended. This meant that all staff were aware of specific details regarding the health and social care of the women and babies they cared for, actions taken or referrals and actions to be undertaken. Processes were in place to inform community services for example GP’s and health visitors about the care and treatment of women and babies. A named midwife and/or consultant cared for women throughout their pregnancy. This was confirmed from the maternity records we reviewed and the women we spoke with. This was in line with national guidance, National Institute for Health and Care Excellence (NICE) “Antenatal care” (April 2016). Community midwives were based at the local GP surgery or in children’s centres. This ensured that women had ease of access to their community midwife. There was no midwife led unit (MLU) at the hospital, this was recorded on the risk register. This meant that some women chose to deliver their babies at another centre. Managers planned to introduce a midwifery led unit. A new build was planned and managers hoped that building may commence within 12 to 18 months. Women were given a choice about where they gave birth. Midwifery led models of care were offered to women. Consideration was given to any potential risks. Home births were facilitated or women could deliver in the delivery suite. The option of a water birth was available for those who met the criteria. The service provided community based, consultant led ante-natal clinics across the district. This included Kettering, Corby and Wellingborough. These clinics enabled women to access clinics nearer to home. A joint clinic for women with mental health issues was held with the consultant psychiatrist and consultant obstetrician. A clinic was also available for vulnerable women. Each community team had a vulnerable women’s lead midwife. Midwives referred women who met the criteria to the family nurse partnership (FNP) service. This is an enhanced visiting service which provides additional support for vulnerable women and their babies both ante and postnatally. Specialist clinics were available for women as necessary. For example, a specialist clinic was held at the hospital for women who required additional ultrasound scans because of concerns raised during routine scans. This meant that women could attend a local clinic rather than travelling to a clinic in a tertiary centre. Partners were able to stay overnight on the delivery suite, this had been introduced as a result of patient feedback. However, all partners who stayed overnight had to sign a “visitor charter” to ensure that they were aware of the limited facilities and the behaviours that were expected. Representatives from the service attended the local Maternity Voices Partnership (MVP) meetings which were held every two months. The MVP provided a forum for service users, healthcare professionals and the clinical commissioning group to work in partnership to plan, monitor and improve maternity service provision in the local area. The service planned to develop a maternity website to provide information on birth choices and option availability.

Meeting people’s individual needs

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The maternity service took account of women’s individual needs, including those who were in vulnerable circumstances or had complex needs. Bereavement care provision was in place to support families from their initial loss, throughout their time in hospital and return home. The maternity service had arrangements to support women in vulnerable circumstances, such as those with learning disabilities, substance misuse and teenagers. These were managed by specialist midwives and /or consultants and included a joint endocrinology and obstetric clinic for women with diabetes, perinatal mental health clinic and a fetal medicine clinic. There was a variety of specialist lead midwives in post including a bereavement midwife, infant feeding specialist, perinatal mental health, safeguarding, diabetes, sonographers and a clinical quality and safety midwife. The maternity service provided individualised care and support to vulnerable women in the antenatal and postnatal period. A joint perinatal mental health pathway had been commenced and a perinatal mental health midwife had been appointed in response to recommendations of “Better Births”. This provided an integrated approach and collaborative working with the perinatal mental health team in the community. Women with mental health issues were referred to the service by both community and hospital based midwives. Support was also available for midwives in the care of women with mental health issues. The team worked closely with GPs, health visiting teams, the community perinatal team, children’s social services and women’s counselling services to support women and their babies. The team was able to access local support groups, for example, local women’s centres and postnatal support illness groups. Midwives had started a weekly group for antenatal women in early pregnancy with a history of present or previous mental health concerns. Women could continue to attend until 12 weeks postnatally. This was in response to the NHS England “Five year Forward View for Mental health”. Midwives could refer vulnerable young women, who met the criteria, to the family nurse partnership (FNP) in the antenatal period. These women were offered additional antenatal and post natal support. If women and their families required additional social support midwives who had received education in completing early help assessments could provide additional support in collaboration with the safeguarding team and the local authority. This may include facilitating support to access services for example housing or financial support. Patient information posters were displayed throughout the maternity department. For example, supporting women in labour, the benefits of skin to skin contact for mother and baby, breastfeeding information including correct positioning and attachment, and advice from 20 weeks for women experiencing adverse symptoms in pregnancy. A reduced fetal movement leaflet was given to women and they were encouraged to contact the hospital if they had any concerns. Women and staff told us that skin to skin contact had been encouraged following a normal vaginal delivery and elective caesarean sections. A midwifery advocate service was available to support women who required additional support or advocacy. For example, they could provide professional mediation in situations where women had complex care needs, undertake listening sessions for women who had undergone an emergency procedure or to support women with their choices. Women told us that they had been informed about the service. The service had processes in place to support women with a learning disability. This included a “flagging” system in the electronic records, a specific learning disability pathway and a “passport” that highlighted women’s’ specific communication needs. A midwife from the vulnerable

20171116 900885 Post-inspection Evidence appendix template v3 Page 165 community team also met with women and their families antenatally. This ensured that any appropriate equipment that was required to support the woman during labour was available. Staff could access bariatric equipment when necessary. Staff told us that specific equipment was easy to acquire. A diabetes specialist midwife supported women with diabetes, both pre-existing and gestational diabetes. There was a diabetes care pathway to offer both individualised and group care. Weekly group education sessions were held to provide women with insight into their condition. Women were reviewed throughout their pregnancy to ensure they were receiving optimal care for their needs. Written information and contact details were also provided. There was a birth options clinic called “Choices”. This was for women who had undergone a previous caesarean section or traumatic birth to be able to explore the birth choices for their current pregnancy. The fetal health unit shared the same waiting area as the early pregnancy assessment unit (EPAU). This meant that women who were experiencing a miscarriage were sharing the same area as women whose pregnancies were more advanced. Staff told us that they tried to maintain women’s privacy as much as possible, options were available for women to be taken to the gynaecology ward. A bereavement specialist midwife provided care and support for parents and education for staff. There was a counselling room in the foetal health unit which was used for sensitive conversations to occur in privacy. It was also used for families who had received bad news or were distressed. There was a dedicated room for bereaved families which was accessed through the delivery suite. This meant that women were cared for in a room next to women delivering health babies. This had been raised at the previous inspection in November 2017. Since the last inspection a bereavement garden had been developed which was attached to the bereavement room. Parents could also access the room from the garden. Memory boxes were made up for bereaved parents. These included photographs, and hand and foot prints. Rainbow bags were provided for families where women had given birth to a baby following a previous stillbirth or neonatal death, these included items for the newborn baby such as a sleepsuit and a blanket. At 34 weeks a maternity support worker (MSW) offered all women and their families a pre-birth educational session. These sessions included information about safe sleeping, optimum room temperature and infant feeding. They also ensured the environment was suitable for the baby. Midwives and maternity support workers held a daily group session with new parents and relatives before mothers and babies were discharged from the ward. Topics discussed in the session included safe sleeping, responsive feeding and sterilisation of equipment. Healthcare assistants demonstrated how to bath a baby. A translation service was available for those whose first language was not English and services for those who had difficulties with hearing. Translation services were available face to face or telephone service. Telephone interpretation was available 24 hours per day, seven days a week. Interpreting services were available in all languages. Sign language interpreters were also available. Written information could be translated into all languages. Easy read, large print, braille, audio and picture based translation was provided upon request. The service also offered type talk and had a bank of staff volunteers who spoke a second language to assist with interpreting in an emergency until an interpreter could be sourced either on the telephone or face to face. Staff said that it was easy to access interpreters.

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Additional services were available for any women with disabilities or sensory impairments. These included tactile sign communication for example sign writing on the individual and picture based material could be provided on request. Plans were in place for a British sign language video relay to be introduced. Women on Rowan ward and the delivery suite were able to have drinks and snacks when they wanted them. The inpatient areas had communal areas, where women and relatives could help themselves to tea, coffee and water. Women who had recently given birth were offered toast and cereal. A water fountain was available in the outpatient clinics. Access and flow People could access the service when they needed it. Women could access the maternity service via their GP, local children’s centre or by contacting the community midwife directly. Community postnatal care was arranged as part of the discharge process from hospital and an electronic discharge letter was automatically sent to the women’s GP. NICE guidance recommends that women should ideally be able to access antenatal care by 10 weeks gestation. The service did not record this data on the maternity dashboard. Information provided by the service after the inspection reported that from December 2017 to December 2018 of 4641 antenatal bookings, 4,114 women were booked into antenatal clinics by 12 weeks and six days gestation. Of these, 3,514 of women were booked by 10 weeks and six days gestation. During the last inspection in November 2017 the service had had a historical problem with providing women with a dating scan within the appropriate time range. This meant that they could not always receive the recommended method of screening for Downs syndrome which was the combined test (a blood test and ultrasound scan). Managers had addressed this. Sonography staffing had improved with two new sonographers recruited and another two being trained. A new scanning room had been also been developed and capital had been agreed for another ultrasound machine. Women were able to get their dating scans in a time appropriate manner. The service was not able to provide access to scanning services on a Sunday for early pregnancy patients. The service was participating in a national audit to establish whether there was a clinical demand for weekend scan services. However medical staff were able to scan women if necessary out of hours. Women were medically reviewed on a regular basis whilst diagnostic results were awaited. The service did not have a transitional care unit. This meant that babies had to go to the neonatal unit for more specialist care such as intravenous drug therapy. Managers told us that they were working with the neonatal team to reduce the number of admissions to the neonatal unit. Competencies were being developed for staff on Rowan ward so that they could second check intravenous drug therapy to babies, this would mean that babies would not need to be transferred. The service now recorded delays in antenatal clinics. A pro-forma template was used to document when the clinic delays reached 40 minutes, one hour and two hours. There was also a white board, which midwifery staff updated with clinic waiting times. Clinic staff informed the women and reception when there were delays. Women we spoke with in the outpatient areas told us they were kept well informed about any delays to their appointment time. The midwife led early pregnancy assessment unit (EPAU) offered appointments between 8.30am and 4.30pm Monday to Saturday. Referral was made through the woman’s GP, community midwife or by attending the emergency department. Women could not self-refer to the EPAU.

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Midwives working in the EPAU were sonographer trained. This meant women did not have to wait for ultrasound scans to be carried out by medical staff. The fetal health unit was open Monday to Friday from 7am to 7.30pm, and 8.30am to 4.30pm on a Saturday, to see women with antenatal complications. Referrals for investigation and treatment were accepted from women themselves, GPs, community midwives and the emergency department. The service operated a 24-hour a day triage service on the delivery suite. This meant that women with urgent health issues, such as pain, vaginal bleeding, or suspected broken waters, could be reviewed. Elective caesarean section lists took place five times a week, Monday to Friday. A maximum of three caesarean sections would be scheduled on a list. The maternity service had access to two dedicated obstetric theatres, however one theatre had insufficient ventilation and therefore was not suitable for all emergencies. This meant that women who were booked for an elective caesarean section may have to wait to go to theatre whilst an emergency caesarean section took place. This was not recorded on the risk register. Following our inspection, we requested the action plan to address this. Emergency caesarean sections took priority over elective caesarean sections. Elective patients were made aware of any possible delays. Staff liaised at the maternity safety huddle with the theatre team and regularly throughout the day to assess and plan activity so that women were informed of any delay. Staff on Rowan ward completed a daily discharge talk at 12pm that was attended by all the women being discharged that day. The talk included information about safe sleeping and birth registration and a baby birth demonstration. The group discharge talk meant staff did not have to repeat the information multiple times a day. A frenulotomy service (a surgical procedure to correct tongue-tie, a condition that restricts the tongue’s range of motion) was available for babies. This service was run by a consultant who tried to see babies with tongue-tie prior to them being discharged. If this was not possible, the baby was given an outpatient appointment. Closure of the maternity unit

The maternity service had not closed the unit on any occasions from December 2017 to December 2018. There was an escalation guideline to support staff during peaks in activity.

Bed Occupancy

From quarter one 2017/18 to quarter two 2018/19 the bed occupancy levels for maternity were generally higher than the England average.

The chart below shows the occupancy levels compared to the England average over the period.

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(Source: NHS England)

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. However, complaints were not responded to in a timely manner. The service had a complaints review service. Complaints were fully reviewed and investigated. Formal complaints were handled confidentially with a regular update for the complainant. The outcome of the complaint was always explained to the individual after the investigation was completed and a meeting to discuss the investigation was offered to the woman and her family. All staff spoken with knew how to deal with people’s concerns and stated that they were supported in dealing with concerns straight away before they developed into more significant complaints. This was through the implementation of the ‘listen to me campaign’. The ‘listen to me’ campaign ensured women felt listened to during their stay on the delivery suite and Rowan ward. Each woman was allocated a midwife separate to the midwife caring for her. If the woman had any concerns in relation to her care, she could raise these issues with this individual. Senior managers told us this campaign helped to reduce the number of formal complaints raised. For example, the service recently purchased ‘soft-close bins’ following complaints about noise on the delivery suite raised through this campaign Complaints were discussed at meetings which included the clinical governance, team meetings, the patient experience steering group meeting and the skills and drills and the maternity study days. Minutes of meetings and study day agendas confirmed this. Summary of complaints

From October 2017 to September 2018 there were 16 complaints about maternity. The trust took an average of 61.5 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be closed within 35 days. Six of the 16 complaints received were in relation to the attitude and behaviour of the midwifery staff, this 20171116 900885 Post-inspection Evidence appendix template v3 Page 169 formed the largest proportion of complaints received.

(Source: Routine Provider Information Request (RPIR) – Complaints tab) The service was working to improve the response time to complainants to ensure a response within 35 working days. Managers reported that they had seen a reduction in complaints received. Further themes from complaints included poor communication and delays in receiving results. Managers had made improvements to address these concerns. For example, all telephone calls to the maternity suite from women seeking advice were logged on the electronic workflow system. Staff were reminded to provide women and their families with clear communications about care and treatment and to access test results following every patient contact to ensure prompt follow up of results. Staff were reminded of the “listen to me campaign” which enabled any woman's concerns to be escalated quickly.

Number of compliments made to the trust

From October 2017 to September 2018, there were 26 compliments within maternity.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

There were no open Parliamentary Health Service Ombudsman (PHSO) complaints at the time of our inspection. There was guidance on how to make a complaint in clinical areas for those using the service, this included leaflets about the listen to me campaign and the trust’s patient advisory liaison service (PALS). Information on how to complain was also published on the trust website. Is the service well-led?

Leadership Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. The maternity service was under the women’s and children services division. The divisional structure was reconfigured in December 2017. The trust had four clinical divisions. Divisions were responsible for the delivery of clinical services. The maternity service was part of the family health division. The senior management team for maternity consisted of; a head of midwifery, who was new in post, two midwifery matrons, a patient safety lead, a service manager, antimicrobial champion and a clinical director who was a consultant obstetrician. The safeguarding lead post was vacant but had been recruited to. This was recorded on the risk register. The service also had a non executive director (NED) allocated to them. The NED had been appointed since the last inspection in November 2017. We saw that there was a monthly programme of executive and non- executive visits to clinical areas. This meant that there was greater involvement with the trust board. We met with the senior management team who demonstrated an awareness of the service’s performance and the challenges they faced. Medical and midwifery leads worked together to improve service provision. The head of midwifery reported regularly to the trust board, presenting the maternity safety improvement plan and attending trust board meetings. Ward, unit and community managers demonstrated clear and strong midwifery leadership at a local level. Some managers were new in post and were provided with developmental leadership

20171116 900885 Post-inspection Evidence appendix template v3 Page 170 opportunities. For example, there were a leadership course that managers attended for their development. Ward managers told us they felt supported by the senior management team. All staff told us that the head of midwifery and senior midwives were visible, supportive and had an open door policy. We saw that lead midwives attended the clinical area to support staff, discuss activity and any issues that had occurred. The matrons for each clinical area confirmed that the lead midwives had a detailed knowledge of the pressure the areas faced and took prompt action to address any problems. Staff told us that they found their line managers supportive and accessible. Medical leadership had improved since the inspection in November 2017. New consultants had been recruited to the department and were proactive in the development of the service. For example, there was a focus on collaborative working, safety projects and the maternity safety plan. There were consultant leads for specific services, such as diabetes, audit, and the delivery suite. Junior medical staff told us that they felt well supported and received excellent training. One junior doctor had extended their placement because of the support and education received. The delivery suite was coordinated by an experienced band 7 midwife who was supernumerary to the staffing numbers required for the provision of one-to-one care in labour. Vision and strategy The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The vision and strategy for the maternity service was closely aligned with the trust strategy. The service vision was to develop the maternity service and was referred to by senior managers as a “direction”. The focus was to improve the safety culture and improve job satisfaction. This included: o Implementing the modified early obstetric warning score (MEOWS) in the community o Recruiting a perinatal mental health midwife o Introducing designated perinatal clinics o Sharing work widely and increasing the profile of the service o Implementing team development training o Introducing learning from experience exercises o Public engagement work o Increasing funding for maternity staff training and development Collaborative working with commissioners, the local authority, clinical networks, and other stakeholders ensured future planning of the maternity service covered recommendations from national guidance. For example, the maternity service was implementing the ‘Maternity Safety Improvement Plan, 2016 to 2020’ to respond to the recommendations laid out ‘Better Births’ (NHS England, 2016) and ‘Safer Maternity Care’ (Department of Health, 2016). The plan linked with the Northamptonshire’s sustainability and transformation plan 2016-2021. Progress against delivering the maternity safety improvement plan was regularly monitored and reviewed. The maternity service did not have a midwife-led birthing unit (MLU) at the hospital. This was recorded on the risk register. The head of midwifery told us that there was senior executive support to build a four bedded MLU, which would be attached to the delivery suite. At the time of

20171116 900885 Post-inspection Evidence appendix template v3 Page 171 the inspection, feasibility studies were being completed to investigate the options available to the service to create a MLU. At the last inspection, in November 2018, feasibility studies were being undertaken for the development of a MLU. Staff in all areas we visited emphasised their commitment to providing safe care and to improving women’s experience of care. They demonstrated they understood the trust vision to provide high quality care to communities and its values of compassionate, accountable, respectful, and engaging. These values were clearly displayed throughout the service on noticeboards. Culture Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff of all roles and levels of seniority talked with pride about the focus on providing the best possible care for women and their babies. It was evident that staff cared about the services they provided. Junior medical and midwifery staff felt well supported, respected, and valued by their managers, the senior team and consultants, and community staff told us they felt part of the overall maternity service. We observed positive interactions and working relationships between consultants and midwives. Staff told us that the head of midwifery and the two midwifery matrons had an ‘open-door’ policy and encouraged staff to voice any concerns. All staff we spoke with told us that they found senior managers and ward managers to be approachable, visible and that they had an open door policy. Individual staff told us how they had been supported by their managers during stressful or difficult times. Staff also spoke of the support they received from their peers and through the supportive mechanisms in the department for example the preceptorship programme. All managers told they were proud of their staff, their hard work, team working and support for each other. During a clinical commissioning group (CCG) visit in May 2018, staff reported a blameless culture with learning being a shared responsibility. Staff in all areas described a supportive and friendly team. Staff were proud of their work in individual teams and in the wider maternity services. The culture regarding duty of candour was positive. Where incidents were recognised to have caused harm and met the requirement for duty of candour, we saw evidence that this regulatory requirement was met. Staff we spoke with about duty of candour also understood its meaning. The trust had appointed a freedom to speak up guardian. Staff were actively encouraged to raise any concerns through the freedom to speak up process. Most staff we spoke to were aware of the role that but were not all able to name them. Staff told us that they would raise any concerns with their local manager, the head of midwifery or the midwifery matrons. They all had an ‘open-door’ policy and encouraged staff to voice any concerns. Governance The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Monthly clinical governance meetings were held by the service, which discussed service performance, incidents, complaints, clinical audit outcomes, and guidelines. We reviewed the

20171116 900885 Post-inspection Evidence appendix template v3 Page 172 minutes of these meetings from November 2018 to January 2019, and found they were detailed and contained copies of relevant reports, action plans, and lessons learned. During the last inspection in November 2017 medical staff engagement with clinical governance and risk meetings was poor with inadequate medical staff representation. During this inspection we saw that medical representation was consistent and that governance meetings were now multidisciplinary. Managers told us that this was embedded in practice. Monthly ward and department meetings took place, we reviewed minutes from October 2018 to January 2019 and saw that there was discussion of incidents, complaints, audit results, risks and learning. Staff confirmed that they could access minutes of meetings and were also informed through monthly newsletters, emails and at staff handovers. The governance structure within the trust was being improved. An integrated governance report had been introduced to provide an escalation route for issues to pass from ward to board. The governance structure of the groups was also being reviewed to improve reporting into board committees. There were a variety of committees within the maternity department. These included a perinatal multidisciplinary forum, shared serious incident reviews, an incident open forum, and benchmarking of the Each Baby Counts Report. The maternity service used a clinical dashboard to monitor activity and clinical outcomes. The trust’s maternity dashboard was now in line with the RCOG ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’, (2007). The dashboard tracked monthly performance against locally agreed standards. The dashboard was discussed at the clinical governance meeting. The maternity dashboard was reviewed at the delivery suite forum and obstetric and gynaecology governance meeting each month. The parameters for each of the indicators were agreed through both forums based on national statistics published by the RCOG/MBRRACE and an agreed local variance. During the previous inspection in November 2017 the service was not auditing the clinical indications identified on the dashboard. We saw that audits were being completed and actions taken to address issues. For example, there was an action plan in place to reduce the number of elective caesarean sections. Trust policies were reviewed and ratified at the service’s monthly scrutiny group (policy review group). Prior to this meeting, the author of the policy shared the draft document with the scrutiny committee members via email. The members reviewed the guideline and suggested changes. This process ensured there was adequate medical input and scrutiny in the development of policies, as medical staff were often not available to attend the meetings. The author was informed three months before the policy was due for renewal. However, if the author had left the organisation a new author had to be identified. This led to a delay in policies being updated and staff potentially following out of date guidance. There were 10 policies which were due for renewal during our inspection. Review of minutes identified that all out of date policies and actions to be taken were identified. Each area had their own key performance measures, which were reported monthly and discussed at the speciality governance meetings. These included the Friends and Family Test (FFT) results, the number of complaints and incidents, staffing and infection prevention and control. Medical staff told us they attended regular half day clinical governance meetings every month which included progress on clinical audit programmes, risks attributed to the maternity service, education and infection control and prevention issues. Information from governance meetings was cascaded to staff via emails, staff handovers and safety briefings. Information was recorded on safety boards in ward and department areas to ensure that staff that had missed a safety briefing were able to receive feedback. There were patient safety and ward and unit newsletters which included safety messages, incidents and learning opportunities.

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Management of risk, issues and performance The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The family health division had a divisional risk register which identified key risks and was reviewed monthly at the obstetrics and gynaecology directorate meetings. Maternity services had its own risk register which identified each risk with a description of the mitigation and assurances in place and the nominated risk owner. Risks included staffing shortfalls, lack of privacy and dignity in the delivery suite due to lack of curtains, the management of elective and emergency caesarean sections, and the lack of a midwifery led unit. Not all risks were recorded on the risk register. For example, the lack of a transitional care unit, paper referrals were currently sent to the multi agency safeguarding hub (MASH) following changes in the MASH process, the limited number of resuscitaires in the department and lack of a central Cardiotocography (CTG) monitoring system were not on the risk register. The service had investigated the incidents in the period December 2017 to December 2018 in line with national and trust requirements. We reviewed all of the root cause analysis reports which demonstrated clear actions and changes to practice. Patients received care and treatment according to national guidelines and the service had a comprehensive audit programme to ensure practice was current and based on sound evidence. The service was able to demonstrate quality outcomes as evidenced by MMBRACE and NNAP and where shortfalls were identified actions were taken to address them. There were monthly staff meetings to share learning from incidents and complaints and compliments. Where specific actions were required they were fed back at daily handovers and safety meetings. Midwifery staff confirmed that the quality matron distributed a monthly ‘spotlight on quality’ newsletter. We reviewed copies of the October 2018 to January 2019 newsletter and saw they included analysis of recent complaints and incidents, information about risk and any other necessary information updates. The maternity service monitored perinatal morbidity and mortality via the incident reporting system. The service also held monthly perinatal mortality and morbidity meetings to discuss stillbirths and neonatal deaths, other adverse events, and review the care provided. Minutes of meetings held from November 2017 to January 2019 showed stillbirths and neonatal deaths were discussed, lessons were learned, recommendations were made and actions were taken to improve patient outcomes were indicated. These meetings were very well attended by members of the neonatal, obstetric and midwifery team. The maternity service completed a daily safety huddle whereby midwives-in-charge of clinical areas and medical staff communicated risk and key information. This ensured senior staff from each area maintained an effective oversight of the daily risks of the service. During the last inspection in November 2017 there was poor escalation and management of the ambient room temperature levels in treatment rooms on Rowan ward. During this inspection we saw that temperature recordings were made and that there were notices in clinical areas to remind staff of the actions to take in the event of temperatures being out of range. Information management The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Some national audits were used by the service to ensure the service continuously improved patient care and were decided by national guidance, patterns of incidents and clinical data

20171116 900885 Post-inspection Evidence appendix template v3 Page 174 outcomes. The service submitted data to external bodies as required, such as the National Neonatal Audit Programme and MBBRACE-UK. This enabled the service to benchmark performance against other providers and national outcomes. During the last inspection in November 2017 the management of their local audit programme was not effective. The audit leads did not have oversight over what audits were being completed within the service. During this inspection we saw that there was greater oversight of local audit and audits had been added to the audit programme. For example, the service now audited compliance with the modified early obstetric warning score (MEOWS). Results of other local audits such as hand hygiene, record keeping and cleaning were clearly displayed in all clinical areas. During our inspection, we saw the arrangements in place to ensure confidentiality of maternity patient records were robust. We found trolleys where patient records were stored were locked in all areas we visited. Computer terminals were also locked when not in use to prevent unauthorised persons from accessing confidential information. However, the service was using both electronic and paper systems. For example, the records of a woman in labour were documented on paper whilst all other records were electronic. This meant that all records of a woman’s care and treatment could not be clearly followed. Some paper records were loose within the record which meant that there was a risk of confidential information being lost. The trust was undertaking a review of its electronic patient record (EPR) and the system used for the management and care of patients. A development programme was in progress. The maternity service had clear performance measures, which were documented on the maternity dashboard. The data for the dashboard was presented in a format to enable it to be used to challenge and drive forward changes to practice, for example, the dashboard had locally set targets to allow the service to benchmark themselves against national targets. The dashboard performance was regularly reviewed by senior staff Engagement The service engaged well with women, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The service contributed to the CQC’s national maternity survey as well as the national friends and family test (FFT) survey. Information about the Patient Advice and Liaison Service (PALS) was available in all clinical areas, and internet feedback was gathered through the NHS Choices website. Staff distributed FFT feedback forms regularly to ensure they captured women’s comments and concerns. We were provided evidence that issues raised through these surveys were acted upon by the service. For example, an outside space had been requested for bereaved families. This had been implemented and was now in use. Community midwives held regular focus groups for women to attend during their pregnancy. These were generally held at local children’s centres and provided an opportunity for women to discuss and feedback the care they were receiving. Staff engaged and worked collaboratively with local groups and other members of the local maternity network. For example, healthwatch maternity, the national childbirth trust (NCT) a local doula group and the maternity voices partnership (MVP). Staff were working with the MVP around the induction of labour process. The MVP held meetings every two months and provided a forum for service users, healthcare professionals and the clinical commissioning group to plan, monitor and improve maternity service provision in the local area. Representatives from the midwifery team at Kettering General Hospital also attended the MVP forums.

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Regular newsletters, emails, notices in staff areas and “hot topics” ensured that ongoing staff engagement took place. This included a “you said, we did” notice board in the handover room on delivery suite. The service offered a midwifery advocates service. Midwifery advocates were experienced midwives who were available to provide mothers who required some additional support to achieve a positive birth experience. Midwives who were undertaking the advocacy role were available on a rotational basis every day from 9am to 1pm to listen to women’s experiences and provide support as necessary. Midwifery advocates were also available to support midwives in the care they provided to mothers. Women who were in agreement could have their story written up and shared with staff to ensure learning and development. A midwifery advocates roadshow had been held to advertise the programme and had had over 100 attendees. The bereavement service held a coffee morning during baby loss awareness week in October 2018. This was for bereaved families who had used the service. Positive feedback was reported as it had helped families to identify that they were not the “only ones”. Midwives had introduced a ‘Whose Shoes’ workshop for local parents and providers of maternity service to improve the quality of the service. Improvements would be based on the experiences of women and their families. The “Listen to Me Campaign” offered women the opportunity to speak with a midwife about any concerns they had about their care. If they felt, they were not listened to by their midwife women were offered the opportunity to speak with a “listen to me” campaigner who would be a senior midwife available to discuss any concerns in relation to care offered Women told us that they were aware of this campaign. The chief executive officer (CEO) held routine staff drop-in sessions as well as hosting link- listeners. This was a forum for band 5 staff and below to engage directly with the CEO on matters related to their work. Staff engagement was being increased through a number of mechanisms, including the CEO weekly brief and link listener events. Feedback was provided to participants. Violence and aggression feedback was strong in the staff survey and feedback and additional support for staff was being implemented, before, during and after any potential situation. Staff were encouraged to speak to senior staff or the freedom to speak up guardian with any concerns. We saw effective team working across all clinical areas. There was a positive and collaborative relationship with external partners and stake holders to build a shared understanding of challenges within maternity and the needs of the local population, and delivery of services to meet those needs. The service was working collaboratively with service users, neighbouring trusts and commissioners via the LMS to ensure national recommendations for maternity care were implemented across the region. Learning, continuous improvement and innovation The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. Staff spoke positively about local and divisional management and said that they were supportive and had an open door policy. The hospital had been re-accredited in 2018 to the United Nations Children’s Fund (UNICEF) Baby Friendly initiative. This remained at level three which is the highest level to be achieved. PROMPT training was implemented to the maternity skills and drills study days in 2018

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A perinatal mental health specialist midwife had been appointed and was working collaboratively with consultant obstetricians and psychiatrists Staff at all levels demonstrated a commitment to multidisciplinary working. A new consultant had been appointed, with a further post to be interviewed for. This meant that there were no consultant vacancies. The service was acting as a pilot site for national bereavement care. A pathway was commencing in April 2019. A bereavement garden had been developed and was now being used by families. The service was engaging with women, their families and stakeholders through a variety of events to offer new and updated information, provide support and opportunities to discuss any concerns. There was an ongoing educational programme for all staff.

At this inspection we found the following improvements since the last inspection in November 2017: • Additional sonographers had been employed and more were being trained which ensured that women received scans within appropriate time scales • The maternity dashboard was being continually developed and monitored • The audit programme both local and national was more robust • Complaints and incidents were being investigated thoroughly • Mandatory training compliance had improved • The staffing in maternity consistently met the nationally recommended midwife-to-birth ratio of 1:28 • An action plan was in place to address the high caesarean section rate • The service had a non-executive director with responsibility for the maternity service. However, there were areas where they had not been any changes since our inspection in November 2017. These included: • Not all clinical guidelines were up to date. However, the service had a robust system for ensuring guidelines were reviewed and scrutinised in a timely manner and all overdue guidelines were either awaiting upload to the trust’s intranet or additional amendments. Outpatients

Facts and data about this service

Kettering General Hospital NHS Trust provides its main outpatients services at Kettering General Hospital. It also has four satellite locations where outpatient services are provided at Prospect House, Nene Park outpatients’ clinic, Nuffield centre and Isebrook outpatients’ clinic. These satellite services are managed by the same team who oversee main outpatients. Each year the hospital facilitates over 300,000 outpatient appointments. On average there are 627 outpatient clinics per week. There was a separate childrens’ main outpatient department which is reported on under children and young people core service, however some children were seen in the adult outpatient clinics dependant on specialty including ENT, fracture clinic, dermatology and ophthalmology.

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There are consultant and nurse-led outpatient clinics across a range of specialities, which are provided in the outpatients’ department. Outpatient clinics are held from Monday to Friday from 8am until 6pm. Some ad hoc Saturday, Sunday and evening appointments were provided, dependant on specialty.

Total number of first and follow up appointments compared to England

The trust had 327,023 first and follow up outpatient appointments from August 2017 to July 2018. The graph below represents how this compares to other trusts.

(Source: Hospital Episode Statistics - HES Outpatients)

Number of appointments by site

The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from August 2017 to July 2018.

Site Name Number of spells Kettering General Hospital 283,301 East Northants Outpatient Department (Nene Park Outpatients, Irthlingborough) 35,725 Nuffield Diagnostic Centre 19,418 Isebrook Hospital 9,040 Kettering General Hospital NHS Foundation Trust 1,288

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This Trust 350,678 England 107,320,812

(Source: Hospital Episode Statistics)

Type of appointments

The chart below shows the percentage breakdown of the type of outpatient appointments from August 2017 to July 2018.

Number of appointments at Kettering General Hospital NHS Foundation Trust from August 2017 to July 2018 by site and type of appointment:

(Source: Hospital Episode Statistics)

Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Mandatory training Mandatory training in key skills were provided to all staff and most nursing staff completed it. However, medical staff compliance with mandatory training was low for some training modules. There was no clear action plan in place to address this. Staff received face-to-face, online and practical training sessions. An electronic system was used by staff to monitor compliance and to book onto training classes, and access electronic learning. Training compliance rates were displayed in most areas we visited. Mandatory training modules included infection prevention and control, basic life support, information governance, fire safety, manual handling, and medicine management. Nursing staff told us they were encouraged by their line managers to attend training sessions and were given time to complete online training modules. Medical and nursing staff who saw adults and children also completed paediatric immediate life support (PILS). During our inspection, there were enough staff trained to ensure one PILS trained member of staff was on duty during clinics seeing children.

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Mandatory training completion rates

The trust set a target of 85% for completion of mandatory training.

Trust level

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for registered nursing staff in outpatients is shown below:

Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) NEWS2 2 2 100% 85% Yes Prevent Health Wrap 104 105 99% 85% Yes Conflict Resolution 103 106 97% 85% Yes Equality, Dignity & Respect 102 106 96% 85% Yes Health and Safety & Risk Management 101 106 95% 85% Yes Information Governance 100 106 94% 85% Yes Infection Control 100 106 94% 85% Yes Fire Safety 98 106 92% 85% Yes MCA Awareness 95 105 90% 85% Yes Manual Handling Patient 89 106 84% 85% No Basic Life Support (Adult) 85 106 80% 85% No Paediatric Basic Life Support 29 39 74% 85% No Medicines Management 67 100 67% 85% No Sepsis 21 33 64% 85% No

In outpatients the 85% target was met for nine of the 14 mandatory training modules for which registered nursing staff were eligible.

During our inspection, we reviewed up to date data which showed compliance had improved. We requested further data from the trust for nursing and additional clinical services staff which showed that in February 2019, all mandatory training courses above exceeded the trust target of 85%:

Completion Trust Met Name of course rate Target (Yes/No) NEWS2 100% 85% Yes Prevent Health Wrap 97% 85% Yes Conflict Resolution 94% 85% Yes Equality, Dignity & Respect 92% 85% Yes Health and Safety & Risk Management 95% 85% Yes Information Governance 95% 85% Yes Infection Control 95% 85% Yes Fire Safety 95% 85% Yes MCA Awareness 90% 85% Yes Manual Handling Patient 97% 85% Yes Basic Life Support (Adult) 86% 85% Yes Paediatric Basic Life Support 86% 85% Yes Medicines Management 87% 85% Yes Sepsis 93% 85% Yes

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(Source: Additional data requests – Summary of outpatient training compliance DR231)

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for medical staff in outpatients is shown below:

Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Prevent Health Wrap 16 17 94% 85% Yes Information Governance 14 17 82% 85% No Conflict Resolution 11 17 65% 85% No Equality, Dignity & Respect 11 17 65% 85% No Infection Control 11 17 65% 85% No Manual Handling Patient 10 17 59% 85% No Health and Safety & Risk Management 10 17 59% 85% No Fire Safety 10 17 59% 85% No Basic Life Support (Adult) 10 17 59% 85% No Sepsis 9 17 53% 85% No MCA Awareness 9 17 53% 85% No Medicines Management 8 17 47% 85% No

In outpatients the 85% target was met for one of the 12 mandatory training modules for which medical staff were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

We raised the low compliance amongst medical staff with the divisional management team who were aware of the issue. They told us they had plans to ensure medical staff knew that mandatory training must be completed. We requested the action plan to address low compliance, however this was not provided. During our inspection, we reviewed up to date data which showed compliance had improved. We requested further data from the trust for medical staff which showed that in February 2019, most mandatory training courses above exceeded the trust target of 85%:

Completion Trust Met Name of course rate Target (Yes/No) Prevent Health Wrap 94% 85% Yes Information Governance 88% 85% Yes Conflict Resolution 99% 85% Yes Equality, Dignity & Respect 92% 85% Yes Infection Control 97% 85% Yes Manual Handling Patient 98% 85% Yes Health and Safety & Risk Management 88% 85% Yes Fire Safety 97% 85% Yes Basic Life Support (Adult) 77% 85% No Sepsis 82% 85% No MCA Awareness 62% 85% No Medicines Management 47% 85% No

(Source: Additional data requests – Medical compliance for mandatory training DR230)

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Safeguarding Staff understood how to protect patients from abuse and were aware of the requirement to work well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Most staff had the appropriate level of safeguarding training for the services they delivered. Appropriate arrangements were in place to ensure patients were kept safe from avoidable harm. The hospital had safeguarding policies and procedures available to staff on the trust’s intranet, including out of hours contact details for hospital staff. Nursing and medical staff were able to explain safeguarding arrangements, and when they were required to report issues to protect the safety of vulnerable patients. We observed information about safeguarding was displayed on noticeboards within most clinical areas. This included information about different types of abuse and how to raise a concern. Safeguarding referral forms were accessible online through the trust’s intranet and staff knew where to find them. Most staff we spoke with knew the name of the safeguarding lead was and all staff we spoke with knew how to contact them. Safeguarding training completion rates

The trust set a target of 85% for completion of safeguarding training.

Trust level

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for registered nursing staff in outpatients is shown below:

Eligible Completion Trust Met Name of course Staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 66 67 99% 85% Yes Safeguarding Adults - Level 2 103 106 97% 85% Yes

In outpatients the 85% target was met for both of the safeguarding training modules for which registered nursing staff were eligible.

During our inspection, data showed that 83% of nursing staff had received level three safeguarding children training. This was slightly below the trust target of 85% and was also below the 86% compliance level we saw during our last inspection. The ‘Intercollegiate document on safeguarding children and young people’ (March 2014), recommends that all nursing and medical staff who have direct contact with children and young people should attain level three safeguarding training. All outpatient areas that saw children had a registered nurse (child branch) to facilitate care and treatment delivered to children. Nursing staff told us that they had access to children’s nurses from the children’s outpatient department on the occasions when there was not a registered children’s nurse on shift. There was collaborative partnership working with the children’s safeguarding lead who had implemented a new paediatric liaison referral process. We observed a nurse following the guidance to ensure a referral was made appropriately for a child who had not attended two appointments.

There was a monthly safeguarding report which tracked training compliance, children’s appointments and any safeguarding issues and identified themes. Actions in response to the November 2018 safeguarding report included the lead nurse for children’s safeguarding delivered specialised learning sessions for the appointment centre staff. This was to ensure that key messages were embedded and to instil professional curiosity.

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Female genital mutilation (FGM) and child sexual exploitation (CSE) training was included in level two safeguarding training. Concerns were reported using the interagency referral form, and an appropriate alert placed on the trust IT systems. Cases were also reported through the trust’s safeguarding steering group on a monthly basis, for interrogation and discussion, identifying trends and themes if possible. All staff we spoke with in the gynaecology outpatient clinic had a good knowledge about FGM and CSE and could explain potential signs and what they would do in terms of reporting, in line with policy. Nursing staff in the gynaecology outpatient clinic told us they had received formal training and received regular updates as their speciality was relevant to both these issues.

The trust delivered PREVENT training; 94% of staff had completed this. PREVENT is one of the arms of the government’s anti-terrorism strategy. It addresses the need for staff to raise their concerns about individuals being drawn towards radicalisation.

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for medical staff in outpatients is shown below:

Eligible Completion Trust Met Name of course Staff trained staff rate Target (Yes/No) Safeguarding Children Level 2 11 17 65% 85% No Safeguarding Adults - Level 2 11 17 65% 85% No

(Source: Routine Provider Information Request (RPIR) – Training tab)

In outpatients the 85% target was met for none of the two safeguarding training modules for which medical staff were eligible. However, during our inspection, data we reviewed showed that compliance had improved. February 2019 data showed:

Completion Trust Met Name of course rate Target (Yes/No) Safeguarding Children - Level 2 94% 85% Yes Safeguarding Adults - Level 2 93% 85% Yes Safeguarding Children - Level 3 69% 85% No

(Source: Additional data requests – Medical safeguarding compliance DR232)

Cleanliness, infection control and hygiene Infection risk was controlled well in most areas. Staff collected safety information and shared it with staff, patients and visitors. They used control measures to prevent the spread of infection and all staff we observed followed the trust’s infection prevention and control policy. During the November 2017 inspection, we found that cleanliness, infection control and hygiene was mostly controlled well. However, we found that some areas had equipment and boxes stored on store room floors which increased the risk of contamination. During this inspection we found that this had been rectified. Staff had received training about infection, prevention and control (IPC) during both their initial induction and annual mandatory training. We saw that 94% of nursing staff had completed their IPC training which exceeded the trust target of 85%. However, only 65% of medical staff across the outpatient services had completed their IPC training, which did not meet the trust target.

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Whilst some areas of outpatient services remained dated in appearance, the environment and equipment were visibly clean. Standards of cleanliness were maintained across the outpatient areas, with reliable systems in place to protect and prevent people from healthcare associated infections. Data provided by the trust confirmed that there had been no reported cases of hospital acquired MRSA (antibiotic resistant bacteria) or Clostridium difficile (C. difficile) (bacteria that can infect the bowel and cause diarrhoea) in the previous 12 months. Audits were carried out monthly in relation to hand hygiene and environmental cleanliness. Hand hygiene audits generally showed compliance of 100% in most areas from August 2018 to December 2018.

Aug-18 Sep-18 Oct-18 Nov-18 Dec-18

Observations% Return Rate Observations% Return Rate Observations% Return Rate Observations% Return Rate Observations% Return Rate

Observations Average Score % ObservationsScore Average % ObservationsScore Average % ObservationsScore Average % ObservationsScore Average Department % ObservationsScore Average Corby OPD 100 100 100 100 100 100 100 100 0 0 Fetal Health Unit 100 100 100 100 100 100 100 100 100 100 Frank Radcliffe 100 100 92 100 100 100 100 100 0 0 Isebrook OPD 100 100 100 100 100 73 100 100 100 100 Kettering OPD 100 100 100 100 100 100 100 100 100 100 Nene Park OPD 100 47 100 100 100 100 100 100 100 100 Rockingham Unit OPD Obs & Gynae 100 100 100 100 100 100 100 100 100 100 Jubilee Wing - Dermatology Unit 100 100 100 100 0 0 0 0 0 0 Breast Clinic - Outpatients 86 73 100 33 100 80 100 100 100 100 ENT Outpatients 100 100 100 100 98 100 100 100 100 100 Pre Op Assessment 100 100 100 100 100 100 100 100 100 100 ENT OPD 100 100 100 100 98 100 100 100 100 100 Max Fax Unit 100 100 100 100 100 100 100 100 100 100 Rheumatology OP 100 100 100 100 100 100 100 100 100 100 Spencer Ward Opthalmology OPD 100 100 100 100 100 67 100 67 100 67

The lack of data in relation to the dermatology unit was due to the relocation of the service to Prospect House. Audit results viewed on inspection showed compliance was 100%. (Data source: Additional data request - Hand Hygiene DR5)

From July 2018 to December 2018, environmental cleanliness compliance ranged from 62% to 100%. Overall combined compliance across the six months was 94%. Most areas achieved over 95% monthly. Main outpatient department (OPD), however, showed a deteriorating level of compliance ranging from 92% in July 2018, to 62% in December 2018.

Area/Month July 2018 August September October November December 2018 2018 2018 2018 2018 Max Fax 97% 96% 90% 94% 97% 98% Pre-op 100% 99% 97% 100% 98% 97%

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Breast - 97% 97% 95% 98% 98% ENT - - - No % No % No % calculated calculated calculated Corby - 98% 98% 98% 98% 98% Isebrook - 98% 92% 96% 97% 98% Main OPD 92% - 74% 74% - 62% Nene Park 99% 100% 98% 96% 95% - (Data source: DR5 Environmental Audits)

The clinical and domestic staff within main OPD were aware of the issues in relation to low environmental audit compliance. Staff explained that there was only a short time in which the department could be cleaned, due to it being used by an out of hours GP service. Audit results had been discussed with staff at daily huddles and monthly matrons’ meetings. The sister said daily checks of the areas were being completed. Staff had engaged with the NHS Improvement (NHSI) infection prevention lead who was working with them to improve compliance. There had been an investment in new equipment, the introduction of a cleaning forum and new cleaning schedules. During our inspection we found the main OPD area to be visibly clean. Managers felt confident to raise environmental cleaning issues with the out of hours GP service staff.

We reviewed environmental cleaning schedules throughout all outpatient areas we visited. Cleaning and safety checklists reviewed were completed daily, including in the main OPD. Domestic staff and nursing staff understood their responsibilities for keeping areas clean and knew how to record what tasks had been undertaken. We saw that all schedules were up to date and had been signed by domestic staff at the necessary points of cleaning. We reviewed two room cleaning schedules which were also complete.

We observed each item of equipment was cleaned after patient use. However, we saw clean equipment was not always labelled with 'I am clean' stickers. We raised this with nurses and healthcare assistants who told us they knew the equipment they were using was clean because they had personally cleaned it. However, there was no formal process being consistently followed. This meant there was a risk that staff did not always know the items were clean and ready for use.

We saw that staff followed the trust’s policy regarding infection prevention and control. This included staff being ‘bare below the elbows of the arms’, adhering to uniform guidelines and hand washing between patient contact and clinical tasks. We observed personal protective equipment (PPE) such as gloves and aprons being used appropriately. PPE was available in sufficient quantities in all areas visited. Hand washing facilities and sanitising gel was available and we observed staff and volunteers using these regularly. Hand sanitiser was also available at the entrance to all areas, including temporary clinical areas such as the fracture clinic, where it was available in bottles as opposed to dispensers on the walls. During our inspection, we observed staff washing their hands before and after patient contact. Patients we spoke with also confirmed staff washed their hands and used gloves and aprons.

Precautions were taken in outpatients for patients with either known or suspected communicable diseases, for example, infectious diarrhoea, tuberculosis, or seasonal flu, although there were still no designated waiting areas for these patients. Nursing staff informed us that these patients were seen at the end of the clinic, in a separate treatment room if required, which was deep cleaned after use. Most staff, including healthcare assistants (HCAs), were aware of isolation protocols.

Decontamination of reusable medical devices was managed in line with national guidance such as the DH Health Technical Memorandum (HTM) on decontamination. Staff in the ENT clinic followed 20171116 900885 Post-inspection Evidence appendix template v3 Page 185 guidance on the management and decontamination of naso-endoscopes. Nursing staff were knowledgeable about the process and we saw evidence that they had their competencies regularly reviewed and signed off.

At the Nuffield diagnostic centre, Corby, patients were frequently exposed to the dirty utility room. This was routinely used as a thoroughfare to the treatment room where patients had their minor procedures performed, despite there being an alternative entrance and exit that could be used. This was not good practice. We raised this with the senior nurse during our inspection who recognised this was a poor patient experience and understood the potential risks involved. The senior nurse told us that action would be taken to ensure the alternative entrance and exit would be used.

Environment and equipment The environment was clean and organised. Most areas had appropriate facilities for the care and treatment provided. However, premises or facilities were not always suitable for their intended use. Some areas were overcrowded, such as ophthalmology and the temporary fracture clinic. Mitigating actions were in place to address overcrowding where possible and we saw long term refurbishment plans and relocation plans to address these issues. During our previous inspection in November 2017, we found that waiting areas throughout the outpatient services were not always suitable for the volume of patients attending. On this inspection we did not observe any overcrowding in the main OPD waiting areas. Each zone had enough seating for patients and their relatives who were waiting for their appointment. However, the ophthalmology clinic and fracture clinic was overcrowded on occasions, throughout the course of our inspection.

During our last inspection in November 2017, we found that the fracture clinic had a poor environment and staff felt that this impacted on the patient care they delivered. During this inspection, a new fracture clinic with a larger dedicated waiting room, consulting rooms and a plaster room was being built and was close to completion. Whilst it was not yet ready for use, the new plaster room had moved locations to a dedicated area which senior nurses told us had ventilation and four trolleys for applying and removing plaster casts. This was in line with the Health Technical Memorandum 03-01 ‘Ventilation in healthcare premises’. The temporary fracture clinic in use at the time of our inspection had been reduced in size due to ongoing building work in the new fracture clinic. We reviewed plans for the new fracture clinic and were assured that the overcrowding issue observed on inspection would be resolved when the new clinic was open, as it had a larger dedicated waiting area in a purpose-built unit. Signs indicating where patients could wait, when the clinic area was busy were displayed.

During our last inspection in November 2017, we found that the ophthalmology clinic was extremely confined and patients were sometimes receiving treatment in the corridor, for example, instillation of eye drops and visual acuity tests. This was similar to our findings during this inspection. However, privacy screens had been put up to protect patients’ privacy and dignity when drops were administered. There were plans, with definitive timeframes in place, to move the ophthalmology service to another area of the hospital. This was to resolve issues with the lack of space to care for and treat patients and was an improvement since our last inspection. Staff told us the service would relocate to a larger area by December 2019.

The ear, nose and throat (ENT) outpatient area had suitable facilities to carry out examinations and provide treatment. Staff in the ENT clinic said that a bigger space would be beneficial. Changes were being made to the environment, for example, moving the reception desk, to provide

20171116 900885 Post-inspection Evidence appendix template v3 Page 186 more space. Some clinics, such as ENT, had a separate children’s waiting areas which was an improvement since the previous inspection. These waiting areas had toys suitable for children.

The main OPD environment did not always protect patients’ privacy and dignity. We observed that conversations between medical staff and patients could be heard in adjacent consulting rooms. This was on the divisional risk register. We reviewed estate plans for the main OPD and it was evident that service managers recognised the importance of including sound proofed rooms in the new estate plans. In the meantime, staff were mindful of this. The OPD team allocated clinicians to alternate rooms, when space allowed, to minimise overhearing of conversations. Radios were also playing in waiting areas to minimise level of noise heard from consulting rooms.

During our last inspection in November 2017, we reported that patient-led assessments of the care environment (PLACE) had been undertaken. The overall observation was that there was a poor state of repair in some of the older areas. This was on the departmental risk register. It had been recognised that the environment was poor and access for wheelchair users was restricted. Not all clinic areas were accessible for patient trolleys and wheelchairs. Estate plans reviewed on our inspection addressed these issues. We reviewed 2018 PLACE audits which showed the department had scored 91% for cleanliness, 67% for privacy, 93% for appearance, 71% for suitability for patients living with dementia, and 79% for patients living with a disability. Information submitted by the trust showed they had taken a number of actions in response to the PLACE audit. Actions included improving the privacy, dignity, and appearance of the department through the outpatient refurbishment programme. There was also a programme underway to improve signage for patients living with dementia. Maintenance requests had been fulfilled at the time of our inspection in response to the concerns around appearance.

Healthwatch Northamptonshire performed a walkaround of the ear, nose and throat (ENT) outpatient department in July 2018. Their overall findings were red, amber green rated and were found to be mostly positive and the department only had four amber recommendations. These included the suggestion of a fan, as the waiting room was very warm, to ensure staff all wore their ID badges and they suggested the addition of photographs of staff on duty in the waiting areas. All recommendations had been actioned in response to the walkaround.

Disposable equipment was stored appropriately and all items inspected were found to be within their expiration date. Bariatric equipment could be accessed when required, for example larger patient beds and wheelchairs. Staff knew how to report faulty equipment and how to source a replacement for any essential items. There were resuscitation trolleys or grab bags available in all outpatient areas. They were generally accessible and had received the necessary daily and weekly checks. Equipment stored within resuscitation trolleys and grab bags was within expiration dates and in sealed packaging ready for use. Automatic external defibrillators on resuscitation trolleys and grab bags had received suitable device testing to confirm their safety for use.

There was an equipment asset list within the department which detailed electrical testing dates, services dates and anticipated replacement of medical equipment dates. We reviewed portable equipment within outpatient’s services and found all items to have received appropriate safety checks to ensure their suitability for use. A small number of pieces of equipment were coming to the end of their life, such as the flow and urodynamic machine and electrocardiogram (ECG) machine. These were listed on the divisional risk register as they had the potential to cause delays to clinics if the machines stopped working. The trust was in the process of procuring new equipment at the time of our inspection. During our inspection, we observed portable appliance testing being carried out at the Nene outpatient department.

Waste was handled appropriately with separate colour coded arrangements for general waste, clinical waste and sharps bins. Waste bins were emptied regularly and were not overfilled.

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Assessing and responding to patient risk Systems and procedures were in place to assess, monitor and manage risks to patients. There was a clinical harm review process in place to monitor and manage the risks to patients on the waiting list.

There was a system in place to monitor and manage the risk to patients on the waiting list. During the last inspection in November 2017, we saw that whilst the trust had made improvements to patients who were waiting over 52 weeks for an appointment, there were still 46 patients waiting over 52 weeks. During this inspection, we found that there were no patients waiting over 52 weeks for an appointment. This was monitored weekly by a dedicated team and fortnightly by the executive team. We saw evidence that harm reviews were also discussed by each speciality within their monthly governance meeting.

There was a process in place whereby if any clinical speciality pathway identified an increased frequency of harm or high levels of harm, then the clinical harm review (CHR) process would be extended to those patients waiting before 46 weeks. This was still happening within outpatient services. The CHRs ensured that all patients who had waited for longer than 46 weeks or longer for treatment had their clinical record reviewed to ascertain if harm had occurred. If potential harm was identified, then a level of harm was assigned (no harm, low, moderate, or severe). Patients’ notes and clinical records were reviewed by the relevant clinicians using a standardised form. The clinician determined if harm had occurred and what the level of harm was. This review of the clinical record may have meant that it was not possible to ascertain if clinical harm had occurred or what level of harm had occurred without a further review of the patient. If this was the case, then an urgent outpatient appointment was scheduled or a review of the patient took place when attending for treatment, (whichever was sooner).

We saw from our review of patients’ notes, instances where outpatient appointments had been brought forward as a matter of urgency due to the possibility of the patients suffering harm. Any patients deemed to be at risk of moderate or severe harm were reviewed by the trust’s medical director.

Risk assessments were completed for patients undergoing minor procedures in the outpatient department, including World Health Organisation (WHO) ‘Five Steps to Safer Surgery’ 2008. Patient records we reviewed contained appropriate risk assessments. Modified WHO checklists were in use for minor procedures.

There were processes in place to develop local safety standards for invasive procedures (LocSSIPS). They had been developed using the national safety standards for invasive procedures (NatSSIPS) and we observed these in practice during our inspection. For example, for tooth extractions and the removal of skin lesions.

If a patient became clinically unwell in an outpatient area, staff would monitor them and check their vital signs. Emergency assistance from on call medical staff could be requested. There were clear procedures in place for the care of patients who became unwell or patients who deteriorated while waiting at the clinic. Whilst staff told us this was rare, they could clearly articulate emergency procedures and the escalation process for unwell and deteriorating patients using the national early warning scores (NEWS2).

Nursing and support staff knew what to do if a patient deteriorated at one of the satellite clinics and a system was in place to transport unwell patients to the emergency department at Kettering General Hospital. However, there was no clinical guideline in place. We requested this but were

20171116 900885 Post-inspection Evidence appendix template v3 Page 188 presented with a clinical guideline for managing sepsis in adults. The satellite outpatient clinics called 999 when required to transfer unwell patients. If a patient had a cardiac arrest, the process was to call the on-site emergency team and dial 999. They then managed the patient using life support until an ambulance arrived. Staff we spoke with were aware of the process and what action they would take if a patient deteriorated. Resuscitation equipment was available in the outpatient areas. The senior sister and matron for outpatients told us an ambulance had been called following a patient falling on the day before our inspection. A care award had been given to the nurse who cared for the patient whilst they waited for an ambulance to admit the patient. For those who became unwell at Nuffield diagnostic centre, they were escorted to the Corby urgent care centre if they did not require an ambulance.

The department ensured that there was a fire marshal on every shift. This was documented on some clinic whiteboards. In areas where this wasn’t documented, staff were able to tell us who their fire marshal on shift was.

Information was available to help staff identify patients who may become septic. Sepsis is a serious complication of an infection. A ‘sepsis box’ was available in outpatient areas, which contained equipment, for example, kit for taking correct blood samples, intravenous fluids and sepsis guidance, so that staff could access the right equipment quickly. Patients suspected of having sepsis were transferred to the A&E department for ongoing monitoring and treatment. Staff were familiar with clinical guideline for managing sepsis in adults.

The department launched ‘Brilliant Basics’ campaign. This was put in place to ensure patient safety fundamentals were maintained and the staff focussed on what they did daily. This included patient care in clean, safe departments, maintaining equipment and the skills and knowledge in accordance with the trust’s requirements.

Staff were provided with a debrief and support from peers and senior staff after involvement in aggressive or violent incidents. However, most staff told us they had never encountered violence. Staff were given time out away from their clinical area, when they had encountered an aggressive patient.

Nurse staffing There was enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. At the time of our inspection, we observed there were enough staff with the right skill mix to meet patient needs. Nursing and healthcare assistant staffing levels were displayed in waiting areas. We observed that nursing staff data was displayed in most departments and most met planned levels during our inspection. The areas that we visited displayed the required and actual staffing numbers, these staffing levels met patient needs. Most clinics were consultant-led and were run by registered nurses supported by health care assistants. Some clinical nurse specialists led their own clinics.

There were no agreed national guidelines as to what constitutes ‘safe’ nursing staffing levels in outpatient departments, at the time of our inspection. Staffing levels and skill mix were planned based on the number of clinics and patients attending. Insufficient nurse staffing within the outpatient department was on the service risk register. They recognised that this could have an impact on the referral to treatment times and affect current activity. They had mitigated this risk

20171116 900885 Post-inspection Evidence appendix template v3 Page 189 by using bank staff to help with clinics and prepare medical records. Senior sisters worked clinically most of the time. There were 16 clinics cancelled between October 2017 and September 2018 due to staff shortages; eight of them were within thoracic medicine. The outpatients service rarely used agency staff to cover shortages.

The nurse in charge of each area was not always easily identified. Not all nurses in charge wore a red “nurse in charge” badge which meant they were not easily identifiable to staff, visitors and patients. The trust has reported their staffing numbers for outpatients below for the period from September 2017 to October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Ward / Team WTE Staff Number in Post Anti-Coagulation Service 10.7 11.0 Breast Service 10.1 14.0 Centenary Wing 16.0 18.0 Clinical Support CBU Nursing 4.0 4.0 Corby OPD 4.4 6.0 Dermatology 4.6 5.0 Head of Core Services 1.0 1.0 Isebrook OPD 2.7 3.0 Kettering General Hospital OPD 13.4 21.0 Med Records & OPD Management 2.0 2.0 Nene Park OPD 6.5 9.0 Nephrology 1.0 1.0 OMFS Outpatients 4.0 5.0 Rheumatology 4.0 6.0 Grand Total 84.4 106.0

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

From October 2017 to September 2018, the trust reported a vacancy rate of 3% over establishment in outpatients. This is better than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a staff turnover rate of 8.3% in outpatients. This is lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a staff sickness rate of 4.3% in outpatients. This was about the same as the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

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From October 2017 to September 2018, the trust reported that bank staff were used to cover 86% of unfilled shifts, with agency usage providing an additional 4%. The remaining 10% of shifts were unfilled.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

Staff group Total number of Total number of Percentage of bank hours bank hours unfilled unfilled bank hours Registered nurses 4,242 445 10.5% Nursing support staff 9,611 1,540 15% (Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

The service used a high volume of bank staff throughout their different clinic areas within the reporting period; The highest number of hours were used in Kettering General Hospital outpatient department with 1,826 hours used for registered nurses and 3,713 hours for nursing support staff.

Medical staffing Staffing levels and skill mix were planned based on the number of clinics that ran within the outpatient service. Medical staffing was provided by the specific specialities that were holding the clinics such as rheumatology, cardiology, and ear, nose, and throat (ENT). Consultants had job plans. They reviewed patients in clinics between the hours of 8am until 8pm from Monday to Friday. Locum doctors were employed by individual specialties when necessary. There was a bank and locum usage rate of 91% in outpatients.

Consultants arranged outpatient clinics directly with the outpatient department to meet the needs of their speciality. Where appropriate, consultants were supported by junior doctors in some clinics. We observed this during out inspection. No medical staff reported directly to the outpatient management team.

Ophthalmology had a higher vacancy rate than other areas. The trust had recently run a successful campaign, resulting in most vacancies being filled following advertisement. This included advertisements for consultant ophthalmologists; the most recent attracted three viable candidates. Work was ongoing to progress these through the recruitment process.

The trust had reported their staffing numbers for outpatients below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

Ward / Team WTE Staff Number in Post Breast Service 3.0 3.0 Dermatology 4.0 5.0 Nephrology 1.0 1.0 Neurology 2.9 3.0 Rheumatology 4.2 5.0 Grand Total 15.1 17.0

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 51.2% in outpatients. This is worse than the trust target of 7%.

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(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 0% in outpatients. This is lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) - Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a staff sickness rate of 2.3% in outpatients. This was lower than the trust target of 4%

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage

From October 2017 to September 2018, the trust reported that bank staff were used to cover 32% of unfilled hours and locum usage for 59%. This left an unfilled rate of 9% in outpatients.

(Source: Routine Provider Information Request (RPIR) – Medical agency locum)

Records Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to- date and available most of the time to all staff providing care. During our last inspection in November 2017, we found that confidential waste had not been managed appropriately. During this inspection, we found action had been taken to ensure these risks had been mitigated. Staff knew where and how to access confidential waste bins and we observed staff using them appropriately throughout or inspection.

Records were stored at an off-site building approximately one mile from the main hospital site. They were transported between the off-site facility, satellite services and the main site using a dedicated courier service. They were paper based and required a large volume of administrative staff to maintain them and ensure their availability. Staff found that whilst patients’ notes were accessible most of the time, they were not always available. It was reported that the majority of the time, patient records took 48 hours to arrive in the department. The process to obtain notes and their availability had been audited to understand where the issues were with non-compliant areas. The main weakness with the system was that it was paper-based and was reliant on staff members manually tracking notes using the online system. The outpatient service had developed an escalation process for unanswered notes requests, so that managers were aware that there had been issues. Following this, notes availability was re-audited and in August 2018, over 99% of records were available on time for clinics. Following our inspection, the trust provided assurance that they planned to continue regularly undertaking availability of records audits. There were plans in place to move from paper records to electronic patient records.

If a patient’s medical record was not available in time for their clinic it would be risk assessed by the clinician as to whether the appointment could go ahead. This meant some patients were seen without records, and some had their appointment cancelled. Staff told us they had tried, where time allowed, to review ahead of time the records available, but this often resulted in a healthcare

20171116 900885 Post-inspection Evidence appendix template v3 Page 192 assistant or nurse travelling around the hospital to locate them. Nursing and support staff told us consultants were becoming increasingly likely to decline to see a patient without a full set of medical records. Main outpatients had recruited extra administrative members of staff whose sole responsibility was to prepare medical records and ensure they were available for clinics. This had been funded from losing a healthcare assistant post.

The service risk register showed that there were unknown quantities and backlogs of loose notes across the trust which required filing in patients’ medical records. This had resulted in some of the patient medical records being incomplete. This had been discussed amongst managers and senior nursing staff who told us they had increased staffing levels and reiterated the importance of complete records to staff, to ensure all notes were filed appropriately.

Most records were consistent, with risk assessments and medical notes being stored in the same place throughout patient records. We reviewed 13 sets of medical records across various specialties, which were completed, mostly legibly, with entries dated and signed for. However, the time that the notes were written was not always recorded. We observed patients’ medical notes were in locked notes trolleys to ensure patients’ details were kept confidentially.

Patient outcome letters were generally dictated by doctors immediately following a patient consultation. The letters were typed and forwarded to patients and their GPs once they had been checked by a clinician. All medical staff we spoke with told us they had not experienced any difficulties with the timeliness or accuracy of the letters being typed.

Records contained relevant information about patients’ mental health and learning disability needs. The electronic patient administration system had an alert function which notified staff if a patient had an underlying diagnosis or mental health condition.

Information governance (IG) was part of the trust’s mandatory training. Staff told us they had received information governance training. At the time of our inspection, 95% of outpatients’ staff and 88% of medical staff had completed the IG training. The trust target was 85%.

Medicines Medicines were prescribed, dispensed, administered, recorded and stored in accordance with best practice. Patients received the right medication and the right dose at the right time. Arrangements for managing medicines in outpatient services were suitable to ensure people were kept safe from avoidable harm. Most patients were given a prescription to collect from the hospital pharmacy, with the exception of some items, such as eye drops, which were given to patients within the individual clinic. If a patient required long-term medicines, the consultant would send a prescribing recommendation to the GP to enable the patient’s condition to be managed jointly and effectively. All FP10 prescription pads were stored appropriately in locked cupboards and we observed that the standard operating procedure (SOP) was followed to monitor the safe use and supply of prescriptions. The FP10 is a prescription that can be issued by a GP, nurse, pharmacist prescriber, supplementary prescriber or a hospital doctor in England.

Patient group directions (PGDs) were used in the ophthalmology service to enable nurses to supply and/or administer eye drops and ointments. A PGD is a document signed by a doctor and agreed by a pharmacist, to give direction to a nurse to supply and/or administer specific

20171116 900885 Post-inspection Evidence appendix template v3 Page 193 medicines to a pre-defined group of patients using their own assessment of patient needs, without necessarily referring back to a doctor for an individual prescription. The PGDs were not readily available for us to review initially during our inspection. Nursing staff presented us with an out of date PGD, which had been signed and dated annually on the back for each year they had been reviewed. The last date recorded was within the last 12 months. We raised this with the matron for surgery during the inspection. We also raised this with the trust during a feedback session. We were told nurses were reassessed annually and a copy of the signed standards of competency (SoC) was sent to pharmacy who retained a copy of all returned SoCs. The department recorded annual assessments by signing the back of the initial PGD certificate. The trust recognised that this was not the optimal way of recording PGD compliance and therefore stopped this process with immediate effect during our inspection. We saw an action plan in relation to this and all current copies of the SoC was going to be held on file for all relevant staff. We saw evidence that all PGDs had been authorised and signed appropriately. A record was kept of all instances where a medicine was administered under a PGD within the department.

Pharmacy support was available during clinic hours. Nursing staff told us that they were accessible and happy to answer any queries. We saw in clinics that stock medicines were checked regularly by a member of the pharmacy team. Pharmacy staff reinforced medicine safety instructions and information to patients when they collected their prescriptions following their consultation.

Many of the specialist nurses also provided information and support about medicines during a patient’s consultation. In dermatology, there had been discussions about developing nurses to become non-medical prescribers.

Nursing and medical staff were aware of policies on administration of controlled drugs according to the Nursing and Midwifery Council (NMC) – ‘Standards for Medicine Management’ despite controlled drugs not routinely being used or stored in the main outpatient department.

Medicines were stored in locked cupboards and locked fridges. Temperatures were recorded daily when the department was open. We observed temperatures to be within the safe range. Staff knew what to do if temperatures were outside of the safe range. Actions included escalating to pharmacy.

There was a service whereby patients could have their medication transported to one of the satellite services from the hospital pharmacy. This meant that patients who lived far away from the hospital did not have to travel to the pharmacy for their medicines. This was particularly helpful to patients who had regular long-term medicines.

There were arrangements which ensured the safety of chemotherapy given in outpatients. There was an electronic prescribing system for chemotherapy, in line with best practice guidance. The pharmacy team based within the Centenary wing were working with a local NHS trust to improve the prescribing system. The team worked well together to make up the chemotherapy medicines on demand for patients. They were working towards the one-hour standard from when a patient was declared fit for treatment to administering the medicines. This was monitored closely and was improving. For example, in October and November 2018, 75% of patients were administered chemotherapy medicines within the hour. In December, this had improved to 80%. There were a number of initiatives the team were working through to increase the number of patients who received chemotherapy within one hour. For example, making chemotherapy in advance rather 20171116 900885 Post-inspection Evidence appendix template v3 Page 194 than on demand and exploring the option of inviting patients in the day before their appointment in preparation for their chemotherapy the next day.

The service reported 23 medication incidents that had involved nurses, within the outpatient department, since they were last inspected in December 2017. All of which were graded as near misses with the exception of one incident, which was graded as low harm. We saw evidence of learning from all medication incidents.

Incidents Patient safety incidents were managed well. Staff recognised incidents and most staff reported them appropriately. Managers investigated incidents and shared lessons learned with the team involved. When things went wrong, staff apologised and gave patients suitable support. However, lessons learned from incidents were not always shared with the wider service and other specialities.

There was an electronic reporting system in place to allow staff to report incidents. All staff we spoke with knew how to access the system and their responsibilities to report incidents. Staff told us they were provided with feedback after reporting an incident and that learning from incidents was shared across all areas via staff meetings, huddles, emails and notices. Managers and matrons felt there was a good incident reporting culture across outpatient services and that staff could identify near misses along with incidents. We did, however, see in the ophthalmology governance meeting minutes from November 2018, that staff didn’t have individual access to the reporting system. The meeting minutes provided a username and password for all staff to use. This meant that staff would not receive individual feedback from incidents and it might not always be clear who reported the incident.

There had been a total of 427 incidents reported from the outpatients’ departments during the period from 01 July 2018 to 31 December 2018. A third of the incidents (139) were due to medical records and 83 were attributed to access, appointment or transfer issues. The service identified key learning themes which included ensuring that systems were robust for the availability of medical records, monitoring the standard of filing in clinical records, early identification of clinics that were running late and ensuring patients were kept informed. We saw examples of unavailability of patient records being discussed and escalated at huddle meetings. We found that not all learning had been embedded. For example, during our inspection patients were not always kept informed of waiting times for clinics that were running late. Two nurses and two healthcare assistants across two different specialties also told us that they no longer reported the unavailability of medical records for a clinic as they felt action was not taken.

The head and neck service had not reported any incidents in the last six months. We raised this during our inspection. Following our inspection, evidence provided by the trust showed that action had been taken to ensure incidents was included on the head and neck service team meeting agendas for an area of discussion. The risk manager planned to deliver training to staff on identifying incidents and incident escalation.

Medical, nursing and support staff told us how practice had been reviewed in some areas, and learning shared as a result of incident investigations. For example, a new security process for staff had been introduced at Nene Park outpatients in response to security risks that staff had reported. The process implemented meant that staff could not leave the building alone at the end 20171116 900885 Post-inspection Evidence appendix template v3 Page 195

of their shift. They were paired up with another member of staff to ensure their safety. We also saw a change in safety practices following an incident involving a sharp blade being left on a surgical blade handle in dermatology. For example, new safety checks had been introduced when returning blade handles to the sterilisation and decontamination unit.

Staff working in outpatient settings were not always made aware of incidents in other outpatient settings. For example, incidents in the ophthalmology clinic and dermatology clinic were not shared with staff working in the main outpatient department and vice versa. Managers were aware of the lack of joined up working and shared learning across specialties. We raised this during our inspection and were told that work was underway to improve the governance across specialties that were managed within different divisions to ensure learning was shared across different specialities working within an outpatient setting.

From November 2014, all NHS providers were required to comply with the Duty of Candour, Regulation 20, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of, ‘certain notifiable safety incidents’ and provide reasonable support to that person.

Duty of candour awareness was included as part of a clinical governance presentation to all new staff in the corporate induction. Staff were aware of the duty of candour regulation. Nursing and medical staff could give us examples of where they had used this in practice or instances where they would use it. For example, we saw evidence that the duty of candour regulation had been met following a serious incident. The patient was informed of the incident, was given information about the investigation process, kept up to date, and was provided a copy of the final investigation.

Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

From November 2017 to October 2018, the trust reported no incidents classified as never events for outpatients.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported one serious incident (SIs) in outpatients which met the reporting criteria set by NHS England from November 2017 to October 2018.

The incidents reported were:

• Diagnostic incident including delay meeting SI criteria (including failure to act on test results).

(Source: Strategic Executive Information System (STEIS))

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There were arrangements in place for reviewing and investigating safety incidents, including SIs. Relevant staff, partner organisations and people who used services were involved in investigations. Lessons learned were identified to prevent a similar incident happening again. The root cause analysis reviewed during our inspection was for an SI that took place in ophthalmology. The lessons learned had been disseminated to staff. Staff in ophthalmology were knowledgeable about the SI. However, staff in other outpatient clinics were not aware of any SIs within the outpatient service. Safety thermometer The NHS Patient Safety Thermometer is a national tool used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering ‘harm free’ care. This information is intended to help staff focus their attention on reducing patient harm and improve the safety of the care they provide. Safety performance was monitored and reviewed on a monthly basis such as the number of falls. Departmental RTT performance levels and did not attend rates within each clinical area were also reported every month.

Is the service effective?

Evidence-based care and treatment Policies were aligned and referenced to national guidance, such as National Institute for Health and Care Excellence (NICE) guidelines. Staff were knowledgeable and dedicated to providing good patient care based on nationally recognised guidelines.

People's physical, mental health and social needs were holistically assessed, and their care, treatment and support was delivered in line with legislation, standards and evidence-based guidance, including National Institute for Health and Clinical Excellence (NICE) guidelines where relevant, and other expert professional bodies. Clinics were usually organised, and delivered effective assessment and treatment. There was a clear process to ensure that new NICE guidance was distributed and compliance with the guidance was assessed. NICE guidance was initially assessed by the clinical effectiveness team and then distributed to the appropriate clinical leads who completed an assessment within four weeks. This was to ensure practice was delivered in line with evidence-based, best practice. The outcomes were returned to the clinical governance department and the level of compliance and any actions required was entered onto a NICE database.

During our last inspection in November 2017, we found there were no audits registered for compliance with NICE guidelines for outpatients. During this inspection, we found there were a number of audits being undertaken to monitor compliance NICE guidance. For example, annual audits of the use of Dexamethasone for treating diabetic macula oedema and auditing the time in which patients were informed of biopsy test results.

We saw examples of how national guidance had been adapted and implemented locally. As part of the development of the rapid access chest pain service, the advanced cardiac nurse specialists used the most recent NICE guidance relating to the Chest Pain of Recent Onset (CG95) to produce their own local protocol. They adapted the NICE guidance and extended it based on the local expertise and services available at the trust. The work had taken several

20171116 900885 Post-inspection Evidence appendix template v3 Page 197 months of research and went through several layers of assurance after input from cardiologists. An ongoing database was developed to audit the work, challenge clinical decisions and help provide feedback to practitioners who worked in the clinic. They used this as a way of assuring themselves that they were working in line with best practice national guidelines. Regular meetings had been set up to continuously review the data to ensure ongoing learning.

Minor procedures performed in outpatient areas were carried out in line with professional guidance. For example, outpatient hysteroscopy (a procedure used to examine the inside of the uterus) was conducted outside of the formal operating theatre setting in an appropriately sized and staffed treatment room with dedicated toilet and changing facilities. This was in line with recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG): Best Practice in Outpatient Hysteroscopy (March 2011). A one-stop clinic had been operating for a year whereby patients were scanned and had a hysteroscopy performed when necessary.

Adapted World Health Organisation (WHO) safer surgery checklists were in place. We observed staff using the locally adapted version during minor oral surgery procedures. The maxillo-facial department completed WHO audits monthly. They audited 124 forms in October 2018 and 100% of forms were completed and 100% of brief and debriefs were completed. During our inspection, we observed the WHO checklist in the maxillo-facial service was appropriate for the procedure performed and saw it was completed in line with best practice.

Staff followed best practice for assessing and monitoring the physical health of people with severe mental illness. For example, staff had the skills to undertake appropriate health screening such as assessments for falls and dementia in the geriatric medicine outpatient clinics.

Staff in outpatients demonstrated how they could access trust policies and guidelines on the trust intranet. We observed all policies were up to date. However, some documentation and policies still had the previous interim chief executive’s name on them. For example, WHO checklist proformas. Staff were aware of trust policies and gave us examples of how they followed guidance when delivering care and treatment for patients.

Nutrition and hydration Patients attended the outpatient department for short time periods however, staff gave patients with specific needs, such as those with diabetes, enough food and drink to meet their needs. The service made adjustments for patients’ religious, cultural and other preferences. Nutrition and hydration was not routinely assessed as part of the outpatient services but staff had the skills to carry out assessments using the malnutrition universal screening tool (MUST) when required.

Glucose preparations, drinks and biscuits were available in most outpatient settings for patients with diabetes if their blood sugar was found to be low.

Water fountains were available in most areas within the department for patients whilst they were waiting. If patients were found to have long delays for their appointments, the staff contacted the kitchen and obtained a packed lunch for them.

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Patients who were receiving chemotherapy treatment were offered lunch and snacks as they were often in the department for a considerable amount of time.

Pain relief Pain was well managed when analgesia was required. Pain relief could be prescribed within the outpatient department and subsequently dispensed by the pharmacy department as required. Outpatient clinics had access to analgesia and local anaesthetic preparations in areas where patients were undergoing minor procedures. For example, ophthalmology stored paracetamol for patients who attended clinics for eye injections. The dermatology service, maxillo-facial clinic and ophthalmology clinic also had access to local anaesthesia preparations, which were used if prescribed by a doctor.

There was a pain clinic, which took referrals from GPs, consultants and other departments within the hospital. The pain service involved consultants, nurses, physiotherapists, occupational therapists, clinical psychologists, and pharmacy input to provide a complete approach to pain management. Patients were seen by a designated consultant for pain management at their initial appointment. Follow-up appointments were with specialist pain nurses unless their condition deteriorated. Outcomes of this service were monitored by patient self-assessments.

Staff asked patients to rate their pain on a scale of one to ten and that if a patient was in pain they were assessed and a one-off prescription was issued by a consultant. We observed some staff checking on patients’ pain and discomfort.

Patient outcomes Some outpatient areas monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. In the last inspection in November 2017, we found that clinical audits were not conducted within outpatient services. The service intended to create and begin an audit schedule from February 2018. During this inspection, we did not see evidence of a robust audit schedule, but we found a number of nursing and clinical audits had been undertaken.

The outpatient department were involved in a range of national audits; however, they were led by the division that the speciality of the audit sat within. Outcomes from audits were shared within speciality groups for a change of practice, process or pathways. Data was submitted to external bodies, such as the lung cancer audit. This enabled the service to benchmark performance against other providers and national outcomes. They were used as a driver for change. For example, there were initiatives in place to reduce the need for admissions for conditions such as chronic obstructive pulmonary disease (COPD) and provide timely access to treatment. For example, the service had introduced rapid access outpatient COPD clinics to assess and treat patients at risk of admission where access to a consultant could mitigate this.

Senior nurses and consultants from most specialties told us about audits that had been completed in their individual specialty. For example, gynaecology outpatient staff were aware that their colleagues in maternity had audited the notification of female genital mutilation to the multi-

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agency safeguarding hub (MASH).

The pain clinic staff had audited the satisfaction of new patients and the efficiency of patches used for pain. Audit results showed that the use of patches were a safe, effective treatment and could be used to treat neuropathic pain. Early improvements in pain management was evident when used on the most appropriate patients.

The department shared best practice with other NHS trusts. They invited them to their department to see the work that they were doing and to share learning.

Follow-up to new rate

The trust monitored the number of new and follow-up appointments and reported this externally. The follow-up to new rate, is a comparison of the number of follow-up patients seen to the number of new patients seen, to ensure all patients are seen in a timely manner and within nationally defined targets. Kettering General Hospital NHS Foundation Trust outpatients’ department follow-up to new appointments rate was higher than the England average. In satellite clinics, however, it was generally lower than the England average. This meant that patients may have had follow up appointments for longer than was clinically necessary or appropriate in a hospital setting. Additionally, these extra patients may have been utilising resources that could have been used to reduce the time that patients waited for appointments.

Where patients required a follow-up appointment they were booked at the point of departure from the clinic. When this was not possible due to capacity or patient choice, the patient was placed on an active waiting list. Follow-up lists were managed as part of the outpatient team, or within clinical areas supported by their own administrative staff. Follow-up compliance and capacity issues were raised at the weekly access and performance board meeting. Waiting list initiatives, such as holding additional weekly clinics in some specialties, assisted with reducing the timing of follow-up appointments.

From August 2017 to July 2018,

• The follow-up to new rate for Nuffield Diagnostic Centre was lower than the England average. • The follow-up to new rate for Isebrook Hospital was fluctuated from both higher and lower than the England average over the capture period. • The follow-up to new rate for Kettering General Hospital was lower than the England average. • The follow-up to new rate for East Northants Outpatient Department was lower than the England average. • The follow-up to new rate for Kettering General Hospital NHS Foundation Trust was mostly higher than the England average.

Follow-up to new rate, Kettering General Hospital NHS Foundation Trust.

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(Source: Hospital Episode Statistics)

Competent staff Staff were competent for their roles. Supervision meetings were held across most specialities to provide support and monitor the effectiveness of the service. Appraisal rates had increased to 91% since our last inspection, which now exceeded the trust target.

Staff were encouraged to develop professionally and were supported to attend internal and external training programmes. Some staff had completed specialist training to support their roles, such as nurse leadership and management courses. Five nurses in the maxillo-facial clinic had attended a radiology course and undergone diathermy training. Two members of the pharmacy team working in the cancer outpatient department had attended training for product approval and had product approval competencies. Nurses working in rheumatology had trained nurses from other specialities in administering Methotrexate. Methotrexate is a chemotherapy agent and an immune system suppressant. It is also used to treat conditions such as rheumatoid arthritis, psoriasis and Crohn’s disease.

There were regular dedicated outpatient practice development sessions and best practice events for staff working within outpatient areas. The tissue viability team, for example, held a practice development group. There were also safeguarding and transformation practice development groups that staff had attended. Practice development afternoons covered topics such as service transformation, infection control, and sepsis updates. Relevant speakers attended, for example the lead nurse for infection control, to facilitate educational sessions.

We observed there were a range of clinical nurse specialists (CNSs) and link nurses employed across the outpatient service, all who had undertaken extended training to support patients and staff. For example, Macmillan nurses, falls nurses, safeguarding nurses and clinical specialist pain nurses. nursing staff and HCAs spoke highly of CNSs and described them as approachable and knowledgeable.

Senior nursing staff informed us there was a clinical area induction routine provided to new staff; all new starters underwent a four-week supernumerary induction process. We saw completed

20171116 900885 Post-inspection Evidence appendix template v3 Page 201 induction checklists for bank and agency staff who were new to the outpatient area. This included department orientation and an introduction to frequently used IT systems.

Competency assessments were in place across all clinical areas in outpatients. We reviewed HCA competencies in main outpatients and competencies of nursing staff in both Centenary wing and ear, nose and throat (ENT). We found these to be completed and signed off. Staff told us they had their competencies assessed regularly and when required. For example, following an incident or near miss.

We observed the care provided by HCAs they were giving in clinical areas. Some HCAs were trained for specific tasks, for example taking physiological measurements. HCAs told us they received direct supervision from registered nurses. The electronic training records recorded any specialist training HCAs had undertaken and they received emails to notify them when training updates were due.

Formal clinical supervision was available for all staff by self-referral or requested by their manager. The learning and development team also delivered group supervision for staff in outpatients.

During our last inspection in November 2017, the service had recently employed a paediatric nurse within the ophthalmology department and were planning on recruiting a paediatric nurse into all outpatient clinics. On this inspection, areas that saw children had a paediatric nurse in post. When they were not on shift, staff could access a registered children’s nurse from the children’s outpatient department. Staff nurses and health care assistants had also completed their paediatric competencies. This meant that staff were competent to care for children when seen within outpatients.

Nursing staff were continuously supported with revalidation of their registration with their professional regulatory bodies.

There were nurse training associate (TA) posts across outpatient clinics. For example, in dermatology. The TAs we spoke with during our inspection told us they felt supported in their roles and were keen to develop. This was mainly because of the support they received from their colleagues and managers. They told us they felt part of a team.

All the trainee doctors (foundation, core and specialist) had an educational/clinical supervisor. They met the trainee at the start of the placement, middle of the placement and the end of the placement as a minimum. Non-training grade doctors were allocated a clinical supervisor by the clinical director, clinical lead, or educational lead for the relevant department. They had regular meetings with the clinical supervisor in a similar pattern to the training grade doctors. During our inspection, junior doctors were present in the department and were observing consultant-led clinics for learning.

Appraisal rates

As of September 2018, 91% of staff within the outpatient department at the trust received an appraisal compared to a trust target of 85%. This had improved since our last inspection where only 79% of staff had received an appraisal.

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Appraisals Individuals complete Completion Staff group required (YTD) (YTD) rate Additional Clinical Services 9 9 100% Medical and Dental 2 2 100% Administrative and Clerical 38 36 95% Nursing and Midwifery Registered 47 41 87% Add Prof Scientific and Technic 12 10 83% Grand Total 108 98 91%

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)

Staff had opportunities for development and received an annual appraisal. The trust had an electronic appraisal system accessible to all. Appraisal paperwork had objectives aligned to the trust values. Appraisal compliance for each area was noted within the bi-monthly outpatient newsletter.

Multidisciplinary working Staff from all disciplines worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Outpatient services worked with speciality teams across the trust and external providers to plan and deliver care and treatment. We saw positive examples of multidisciplinary working throughout outpatient areas. Professionals referred patients to other specialist teams when necessary, such as, psychiatrists, podiatrists, dietitians, physiotherapists, occupational therapists and speech and language therapists. All necessary staff, including those in different teams and services, were involved in assessing, planning and delivering care and treatment. There were multidisciplinary team (MDT) meetings held across the specialties to provide effective assessment and treatment. Nursing staff provided positive feedback about the advice and support provided by medical staff when required.

During our inspection, we observed medical staff teaching nursing staff of all levels about areas of interest. Staff working within dermatology outpatient clinics told us that the plastic surgeon often offered informal teaching to nurses. In the maxillo-facial clinic, nurses told us the consultants empowered nurses to develop their skills and knowledge. For example, they told us they had been learning about intraoral scanning for digital impressions.

Clinical specialist nurses worked in clinics, including respiratory, dermatology and diabetes. These staff worked closely with consultants and specialist support services to improve patient care around specific conditions. Occupational therapy (OT) staff worked within fracture clinic to provide therapy for patients who had suffered an injury. OTs told us they had good working relationships with the staff in fracture clinic and had regular communication to ensure clinic time was used effectively when hand therapy was offered.

All staff, including members of the business and administrative team, worked together to support the smooth-running of the outpatient service. Booking and clinic co-ordinators were based within the Kettering hospital site. They worked together with divisional managers and the individual

20171116 900885 Post-inspection Evidence appendix template v3 Page 203 specialties to continuously manage waiting lists for outpatient services. Throughout our inspection, the management team were regularly approached by administrative members of staff.

There was a dedicated diabetes centre, which was run by a multidisciplinary team, which included joint working with staff from another local hospital.

Seven-day services Outpatient services were provided across sites from 8am to 6pm, Monday to Friday. Some specialities were carrying out additional Saturday and evening clinics to attempt to reduce the number of patients on waiting lists but this was not a standard clinic day.

Health promotion The service supported people to live healthier lives and care was planned holistically using health assessments where appropriate. Efforts were made to promote self-care with patients and carers, and achievable and realistic goals were set to improve their health. Staff actively promoted improving the health of the local population and keeping well, such as obesity and weight management, smoking cessation, healthy eating, and diabetic care. Medical and nursing staff in outpatient services spoke about the, ‘every contact counts’ methodology that they had adopted and brief interventions to maximise health promotion opportunities.

We observed information was displayed in waiting areas to support and educate patients with managing health concerns. These included a support group for people with a lung condition; a stoma care group, and a group to support people caring for a person suffering from memory loss. FGM posters were displayed in waiting areas to raise awareness. Support groups, coffee mornings and buddy systems were highly promoted for patients who had recently been diagnosed with cancer.

Nursing and medical staff were knowledgeable about inpatient alcohol and tobacco screening audits that were taking place to prevent risky behaviours.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Patient records we reviewed contained evidence of appropriate consent, where required. Consent was obtained on the day by consultants who were carrying out the procedure, in line with legislation. Consent for care and treatment was usually managed by individual specialist departments. During our inspection, patient feedback confirmed that told us that staff had explained the risks and side effects of both minor procedures and newly prescribed medicines. Staff obtained consent to carry out procedures and examinations. The service used different consent forms, depending on the patients’ capacity to make the decision. We reviewed six consent forms and found they were completed in line with Department of Health guidance. Care and treatment was explained to patients.

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We requested a copy of the consent audits undertaken in the outpatient areas but these were not provided.

The trust reported that from October 2017 to September 2018, Mental Capacity Act (MCA) training was completed by 84% of staff in the outpatient department compared to the trust target of 85%.

The trust did not report on Deprivation of Liberty Safeguards training however this was included in the MCA training.

(Source: Routine Provider Information Request (RPIR) – Training tab)

Is the service caring?

Compassionate care Patients were treated with compassion, kindness, dignity and respect, when receiving care. Feedback from people who used the service, those who are close to them and stakeholders was positive about the way staff treated people. Staff interacted with patients and those close to them in a timely, respectful and considerate manner. All patients we spoke with were complementary of the care they had received in outpatient areas and many had used the services for a number of years. We observed caring interactions with patients whilst they were having observations taken or being assisted in the departments. Patients and their relatives told us staff friendly and helpful despite working under pressure and being very busy.

Staff understood and took into account people’s personal, cultural, social and religious needs. The reception staff told nursing or medical staff if a patient had a sensory deficit, or required an interpreter. We also observed staff identifying themselves, asking patients if they were well and if they needed help with anything when being collected from waiting areas. This was in line with National Institute for Health and Care Excellence (NICE) QS15 Statement 1, Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty. The trust obtained patient feedback via the Friends and Family Test (FFT), which allowed patient to state whether they would recommend the service and give feedback on their experiences. From June 2018 to August 2018, 96.7% of patients would recommended the outpatient department. The trust did not provide us with a response rate, however, the annual complaints and patient experience report stated that there had been a significant reduction at the end of 2017 in the number of returns from all outpatient areas.

Staff mostly ensured people’s privacy and dignity was respected. Staff conducted consultations in closed rooms, knocked on the doors prior to entering, and signs indicated if a room was in use. Staff recognised and took action in areas where the environment did not always maintain patients’ privacy and dignity. For example, the walls within the consulting rooms were thin. The staff therefore scheduled clinics, where possible, in rooms which were not adjacent to each other. They also played the radio within the waiting areas to reduce the chance of noise being heard from the consulting rooms. Soundproofing was included in reconfiguration plans.

Patients were not always able to speak to receptionists without being overheard as some seating areas were situated near to the reception desks. We observed however, that reception and

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nursing staff were aware of the need to ensure patient’s confidential and sensitive information was protected. Staff spoke discreetly with patients or waited until there were no members of the public near to the reception desk before continuing a conversation. Signs were placed next to reception desks explaining that conversations may be overheard and that a private area would be arranged if requested.

The trust’s chaperone policy set out the requirement for all patients to have access to a chaperone of the same sex if required. Nurses or healthcare assistants acted as chaperones when necessary, and we observed there were posters on display in each clinic area to inform patients they may ask for a chaperone.

Emotional support Staff provided emotional support to patients to minimise their distress. Staff throughout the department understood the need for emotional support.

We spoke with patients and relatives who all felt that their emotional wellbeing was cared for. Staff had a good awareness of patients with complex needs and those patients who may require additional support should they display difficult behaviours during their visit to outpatients.

Patients with a life changing diagnosis were offered specialist support from trained nurses as well as a physical space to address their emotional needs. This was in line with NICE QS15 Statement 2, Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills. A patient had provided feedback about a student nurse. They said “you (the student nurse) have made a difficult time in my life bearable”.

We observed relatives and carers, where appropriate, being included in conversations during clinic appointments to ensure they fully understood what steps were next in the patient’s care. There were also MacMillan nurses and resources that provided advice and support within the department.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives said they felt informed about their care and treatment and were able to ask doctors and nurses questions and were involved in making decisions. Some specialties had clinical nurse specialists available who could provide in depth knowledge and support to patients about their particular condition. One patient told us, “there is nothing we cannot ask and there appears there is nothing they do not know the answer to” when referring to a clinical nurse specialist. Another patient told us, “they always had time to speak with us and were happy to discuss our concerns and anxieties”.

Staff recognised when patients required additional support to help them understand and ask relevant questions about their care and treatment.

Staff communicated with patients in ways they could understand and information was provided appropriately. Patients and relatives said that they felt listened to and relatives and carers were

20171116 900885 Post-inspection Evidence appendix template v3 Page 206 able to escort patients if they wished. Staff had telephone access to language interpreters if they required and interpreters could attend appointments when booked in advance.

After their appointments, patients were aware of when they would receive test results or future appointment dates. Patients understood when they might need to attend the hospital for repeat investigations and further treatment. Staff communicated with patients and families in ways they could understand and patients felt they had been encouraged to make their own decisions.

Is the service responsive?

Service delivery to meet the needs of local people The outpatient’s department generally planned and provided services in a way that met the needs of local people. Some clinics were provided in other GP surgeries and community health centres to promote ease of access to appropriate services. The number of patients who did not attend (DNA) their appointment had decreased (improved) from the previous year. We saw evidence that services were planned to meet the needs of the local population. To meet the needs of the local population, clinics were provided at satellite units across Corby, Wellingborough and Irthlingborough. This meant patients could be seen closer to their home if the clinical specialty allowed. Patients could select where they were seen through the NHS ‘choose and book’ service, and could complete bookings online or via telephone. Patients seen at the hospital site could also have their medicines delivered to a satellite service nearer to their home.

Similarly, to what we found during our last inspection in 2017, most staff we spoke with advised us that they tried to help patients receive care closest to their home address. Administrative and clinic staff often reviewed patients’ addresses and checked whether a clinic was available nearer their home, at one of the satellite locations rather than travelling to Kettering General Hospital. Patients we spoke with felt this was beneficial and felt the satellite units were very beneficial, especially to elderly patients or those who could not travel easily.

Car parking facilities were available at each site. During the previous inspection in December 2017, we found that the car parking facilities were not sufficient to meet the demand. During this inspection, we found that this had improved and the multi-story car park was located directly across from the main entrance of the outpatient department. However, some patients who required a disabled access space told us they often had to use the main car parks as the disabled access spaces were full. Senior nurses told us the trust were planning to increase the number of disabled access car parking spaces due to demand.

During the last inspection in November 2017, we found that the signage was confusing within the department and providing directions took a large amount of time out of administrators’ days. On this inspection, we found further improvements to signage had been made. Voluntary staff sat at the main entrance of the outpatient department and were knowledgeable about which clinics were being delivered in which zones. Temporary waiting areas for the fracture clinic were sign- posted. The signposting in the ophthalmology clinic and the Nene Park outpatient department was very clear and met the needs of patients who had reduced vision or patients who were living with dementia. Signs for clinics in the hospital corridors were clear and arrows were used to guide patients in the right door for the clinic they required.

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Best practice recommendations state that the outpatient hysteroscopy area can be a dedicated suite or a multi-purpose facility, staff working within the clinic said they were working towards a stand-alone suite due to the increase in demand. A one-stop clinic had been operating for a year whereby patients were scanned and had a hysteroscopy performed when necessary.

We observed that many outpatient clinics provided a suitable waiting area with sufficient seating, toilets and magazines. There were separate waiting areas for children in some specialities. These areas had suitable toys, books and seating for children. On the previous inspection in December 2017, we found that the fracture clinic did not have a suitable separate children’s area and the waiting area was combined with the emergency department. On this inspection, we found that children waiting to be seen in the temporary fracture clinic waited in a different area to adults but this was not a dedicated area for children. Efforts had been made to ensure children’s toys and books were available. The new fracture clinic had a dedicated children’s waiting area and was due to be opened by the end of February 2019. There was also a temporary waiting area for children who were waiting to be seen in the maxillo-facial clinic. However, during our inspection, children were waiting in the main waiting area. We were told this was a choice made by the patient’s parent. The clinic was due to move in March 2019 and plans for a dedicated children’s area were incorporated in the plans.

A pager system was available to patients attending the fracture clinic. Where an appointment was delayed and a patient wanted to leave the department either to go to a coffee shop or walk, they could ask a member of staff for a pager which would be made available to them. There was a café and shop at the main outpatient reception and waiting areas had water dispensers and vending machines.

Meeting people’s individual needs The service took account of patients’ individual needs. The outpatient department had access to a range of support to meet patients’ individual needs including: physiotherapy, speech and language therapists for voice, ear nose and throat (ENT) and respiratory disorders.

We observed adjustments were made for people with a disability, impairment or sensory loss, to meet their communication needs. Information was available in accessible formats. For example, ophthalmology staff could request information was sent in large text for patients who were visually impaired. Hearing loops were available in waiting areas, which helped those who used hearing aids to access services on an equal basis to others. An interpreting service for patients who did not speak English and British sign language interpreters were available when required, and staff knew how to access them. There were volunteers who were located at the outpatient department front desk. They assisted patients in finding the correct department for their appointments.

The trust provided a wide range of paper based information for patients within each speciality of outpatients. Staff told us the trust provide printed information in a range of languages upon request and we observed some leaflets, for example, the PALS (patient advice and liaison

20171116 900885 Post-inspection Evidence appendix template v3 Page 208 service) leaflet was available in clinic areas in different languages, such as Polish. This was also advertised in waiting areas in different languages so that patients who did not speak English knew they could request information in the language they required and an interpreter, if needed. High-back chairs were available in most waiting areas to accommodate older patients or those with mobility issues. We also observed that bariatric chairs were also available in the main outpatients waiting area.

Appointment letters contained clear information about appointments and what to expect. Booking administrators sent information about how to get to the hospital and specialist information depending on which outpatient clinic they were attending.

During our last inspection in 2017, rooms were not always available and conversations with patients had to be held in clinic areas where they may be overheard. During this inspection, we saw no evidence of private conversations happening in waiting areas. Quiet rooms were always available throughout the duration of the inspection. The main outpatient department had a quiet room which was available for patients who required private conversations. These rooms were also available for use by other outpatient clinics that were not located in the main outpatient department and did not have a quiet room of their own. Information packs with details of organisations that could help following a life limiting diagnosis were available and staff gave out contact details of clinical nurse specialists (CNS) and Macmillan nurses that could provide support to these patients.

There was an electronic alert facility which flagged patients living with dementia on the electronic system. We observed patients living with dementia or a learning disability were prioritised to ensure least disturbance to them and enable them to spend minimal time in the department. A patient who regularly attended the ENT clinic and had a learning disability, was taking time- dependent medication and was therefore prioritised to ensure they did not take their medicines late. We also observed that children were prioritised when attending outpatient areas.

During our last inspection, not all staff could recall receiving dementia specific training to enable them to provide the best care to this patient group. During this inspection, most staff we spoke with had received dementia training. This included HCAs, administrative staff, nursing staff and medical staff.

Patients were allocated appointment lengths based on the need for the appointment. If a patient was going to be given bad news following a diagnostic test, they would be provided with a longer appointment to ensure there was time for staff to answer all questions they had. New patients were also given longer appointments.

The service was registered with ‘Disability Go’ website; this allowed patients to understand the physical layout of the department and hospital prior to attending. During our last two inspections in 2016 and December 2017, we found that patients in wheelchairs or on trolleys could not access all outpatient areas. During this inspection, we reviewed areas that had restricted access and saw that estate plans to move departments incorporated disabled access. During our inspection, we observed staff in the ENT clinic clear corridors and unlock double doors to allow access for a patient in a large wheelchair. We observed medical staff moving to accessible rooms to see patients on trolleys or in wheelchairs.

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Access and flow Patients with cancer, and patients with suspected cancer, were able to access the service when they needed it. Whilst waiting times had improved, not all patients could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were lower (worse) than the England average for some specialties.

The NHS Constitution states that patients should wait no longer than 18 weeks from GP referral to treatment (RTT). All NHS acute hospitals are required to submit performance data to NHS England, which then publicly report how hospitals perform against this standard. The maximum waiting time for non-urgent consultant-led treatments is 18 weeks from the day a patient’s appointment is booked through the NHS e-Referral Service, or when the hospital or service receives the referral letter.

Admitted pathways are the waiting times for patients whose treatment started during the period and involved admission to hospital. They include the complete time waited from referral until start of inpatient treatment. Although data on admitted pathways are still collected, there is no longer an operation waiting time standard. Non-admitted pathways are the waiting times for patients whose wait ended during the period for reasons other an inpatient or day case admission for treatment. These are also often referred to as outpatient waiting times.

There were 407 patients who waited over 46 weeks for treatment from January 2018 and December 2018. The service completed harm reviews for all patients who were waiting longer than 46 weeks for an appointment. One patient was found to have moderate harm, 37 were found to have low harm and 369 had no harm.

At the time of our inspection, there were no patients waiting over 48 weeks. This was an improvement in comparison to our previous inspection where data showed 413 patients were waiting over 52 weeks. There were four patients waiting 47 weeks, three patients waiting 46 weeks, and six patients waiting 45 weeks. The majority of patients waiting over 18 weeks were waiting for an ophthalmology appointment (462 adults and 160 children), followed by trauma and orthopaedics (191), and urology (159). In total, there were 1,179 patients waiting between 18 weeks and 47 weeks at the time of our inspection. Patients who were not seen within 18 weeks were sent a letter advising them of lengthy waits for that particular specialty.

Referral to treatment (percentage within 18 weeks) – non-admitted pathways

At our previous inspection in December 2017, we found that 83.8% of patients were treated within 18 weeks. This was below the England average. On this inspection, we found this had deteriorated from October 2017 to September 2018 where the trust’s referral to treatment time (RTT) for non-admitted pathways was consistently worse than the England overall performance. The data for September 2018, showed 78.8% of this group of patients were treated within 18 weeks against an England average of 86.7%. However, more up to date data we reviewed during our inspection showed an improvement. As of February 2019, the RTT for non-admitted pathways was 88%. This was slightly higher (better) than the England average. Board papers reviewed showed a continuous trend of improvement in RTT performance from September 2018 to February 2019.

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The 18-week referral to treatment waiting times continued to be an area that the service found challenging. The November 2018 board report details plans to improve this including additional capacity to reduce RTT waiting list volumes and times, with additional staffing and increasing the estate capacity.

Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways, Kettering General Hospital NHS Foundation Trust.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) non-admitted performance – by specialty

Three specialties were above the England average for non-admitted pathways RTT (percentage within 18 weeks).

Specialty grouping Result England average General medicine 11 100.0% 91.1% Rheumatology 11 94.6% 88.0% Neurology 11 88.5% 79.3%

Fourteen specialties were below the England average for non-admitted pathways RTT (percentage within 18 weeks).

Specialty grouping Result England average General surgery 10 88.4% 88.8% Ear, Nose & Throat (ENT) 83.8% 84.7% 11 Cardiology 11 83.2% 86.1% Plastic surgery 11 79.6% 90.5% Ophthalmology 00 78.5% 89.1% Dermatology 01 77.9% 89.1% Other 77.7% 90.9% Thoracic medicine 01 76.3% 86.7%

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Trauma and orthopaedics 75.1% 86.1% 01 Geriatric medicine 11 74.1% 95.4% Gastroenterology 11 69.9% 83.4% Urology 11 61.1% 86.9% Oral surgery 01 61.0% 83.0%

(Source: NHS England)

During our inspection, we asked for the updated RTT performance for non-admitted pathways. The percentage of patients seen within 18 weeks had increased in all specialties with the exception of ophthalmology.

Specialty grouping Data provided by the England average trust (February 2019 position) General medicine 100.00% 91.1% Rheumatology 97.41% 88.0% Neurology 88.50% 79.3% General surgery 93.67% 88.8% Ear, Nose & Throat (ENT) 91.58% 84.7% Cardiology 90.75% 86.1% Plastic surgery 85.71% 90.5% Ophthalmology 73.68% 89.1% Dermatology 87.18% 89.1% Thoracic medicine 96.20% 86.7% Trauma and orthopaedics 83.62% 86.1% Geriatric medicine 88.95% 95.4% Gastroenterology 100.00% 83.4% Urology 82.06% 86.9% Oral surgery 94.79% 83.0%

RTT positions were discussed at governance meetings. For example, the oral surgery team discussed their RTT position within the governance meeting in January 2019. Whilst their RTT performance had improved, they had 300 patients waiting more than 18 weeks at the time of the meeting, including those on an inpatient waiting list. This was due to a shortage of consultants and the advertised post not being filled. November 2018 ENT governance meeting minutes showed that the RTT performance was 87.9% which was a 1% drop from the previous month. They reported this was due to staff sickness and they had seven patients cancel their appointments. They had recovered their performance to 91.6% by February 2019.

Referral to treatment (percentage within 18 weeks) – incomplete pathways

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for incomplete pathways has been consistently worse than the England overall performance. The latest figures for September 2018, showed 79.2% of this group of patients were treated within 18 weeks versus the England average of 86.2%. Data showed that there were no patients waiting over 52 weeks and senior staff at the trust told us they did not anticipate any. There had been improvements in certain specialities. General Surgery, for example, had improved from 67.7% in the previous year to 83.2%. There are plans to outsource some activity to an external resource which is expected to improve performance.

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Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, Kettering General Hospital NHS Foundation Trust.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty

Five specialties were above the England average for incomplete pathways RTT (percentage within 18 weeks).

Specialty grouping Result England average General medicine 99.6% 92.6% Rheumatology 98.5% 92.5% Neurology 93.8% 87.2% Ear, Nose & Throat (ENT) 90.0% 84.5% Plastic surgery 89.5% 82.7%

Twelve specialties were below the England average for incomplete pathways RTT (percentage within 18 weeks).

Specialty grouping Result England average Dermatology 87.0% 90.5% Geriatric medicine 85.7% 96.0% Other 84.9% 89.9% ENT 84.3% 86.5% Cardiology 84.0% 89.6% Gastroenterology 83.8% 89.8% General surgery 81.2% 84.1% Thoracic medicine 77.5% 88.6% Oral surgery 73.7% 84.0% Trauma and orthopaedics 72.8% 81.8% Urology 68.4% 86.4% Ophthalmology 65.0% 88.0%

(Source: NHS England)

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Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers)

The trust was performing better than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below.

Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers), Kettering General Hospital NHS Foundation Trust

(Source: NHS England – Cancer Waits)

Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers)

Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers), Kettering General Hospital NHS Foundation Trust

The trust was performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below.

(Source: NHS England – Cancer Waits)

Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment

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The trust was generally performing better than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. The performance over time is shown in the graph below. The cancer wait time report, dated December 2018, showed that in August 2018 and September 2018 87.2% and 87.3% respectively of patients first seen at Kettering General Hospital received care within 62 days. 20 patients breached the 62-day standard. Of these 20 patients, nine of them received their first definitive treatment after 104 days. It was found that over half (55%) of these 62-day breaches were urology and upper gastrointestinal specialties. The theme for these breaches was delays in diagnostic testing, delays to first outpatient appointment and patient choice. There were no clinical harms identified. A number of actions had been developed which included: • Scans being ordered at multidisciplinary team meetings via the new order system. • Reviewing the number of consultants who can be on annual leave at the same time. • Additional surgical lists for diagnostics such as biopsies to be performed.

Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment, Kettering General Hospital NHS Foundation Trust

(Source: NHS England – Cancer Waits)

There was an electronic, room booking system within outpatient services. This system allowed nursing and operational managers to view which rooms were available at certain times. This system helped to provide a streamlined system which enabled managers to ensure the appropriate rooms were used for each clinic, and improved room utilisation following cancellations of clinics.

The management team and outpatient staff were working hard to improve patient waiting lists by identifying capacity for additional activity for services across the trust including those that sat outside of the specialities that fell within outpatients. For example, surgery and medicine specialities. The trust was in the process of recruiting three consultant ophthalmologists. The outpatient matron had implemented a ‘6-4-2’ process. This process involved a review of clinic templates and room utilisation, cleansing of nursing rosters, and then aligned both in a planned pre-emptive way. Managers told us this had given them assurance that that they were making the best use of their two most valued commodities; staff and clinic space, to enable them to provide more clinics to more patients. It involved a three-step process. Tasks were completed and meetings held with specialty matrons at six, four, and two weeks in advance. The table below

20171116 900885 Post-inspection Evidence appendix template v3 Page 215 shows that 4,787 extra patients had been seen over three-month time period due to identifying capacity within the clinics.

(Data Source: 181106 CQC Outpatient Presentation)

Facilities were in place to allow patients to manage their appointments. Along with text and voicemail appointment reminders, patients could use a designated email address to request an alternative appointment or to rebook an appointment. Patients felt these methods were all convenient and saved time.

There were 296 clinics cancelled from October 2017 to September 2018, 169 of these were cancelled from the main outpatients at Kettering General Hospital. The most common reason for cancellation across all sites was the clinician being on holiday; there were 98 cancelled. Other reasons included no consultant, staff shortage and study leave. Whilst managers understood the impact of clinic cancellations, the ‘6-4-2’ process meant that where clinics had to be cancelled, other clinics could be planned and held in their place.

During our previous inspection in December 2017, we found that the trust used a private patient transport service for patients with mobility issues; however, there were concerns with delayed pick up of patients after appointments. The trust and departmental managers had recognised this issue and were taking action to mitigate impact on clinics and were liaising with the private ambulance service. At this inspection, we found patients who arrived late due to transport issues were prioritised.

The service risk register highlighted that there was potential for delays to clinic wait times which could lead to an increase in complaints and poor patient experience. They had attempted to mitigate this by giving patients in the temporary fracture clinic, pagers. This meant that they could leave the waiting areas and return when their appointment was available. Waiting times and delays in clinics were not always displayed on the whiteboards. At times, staff were updating boards with inaccurate waiting times which was unhelpful for managing patients’ expectations and resulted in patients becoming frustrated. We raised this several times during our inspection with senior nurses and managers, who addressed this with the relevant staff members and ensured the whiteboards accurately reflected the waiting times.

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Did not attend (DNA) rate The number of patients who did not attend (DNA) their appointment had decreased (improved) from the previous year.

The DNA rate for June 2018 was 6.7%, national average (7.6%). This had improved from the previous year which was 7.6%.

From August 2017 to July 2018,

• The ‘did not attend’ rate for East Northants Outpatient Department was similar to the England average. • The ‘did not attend’ rate for Isebrook Hospital was higher than the England average. • The ‘did not attend’ rate for Kettering General Hospital was similar to the England average. • The ‘did not attend’ rate for Kettering General Hospital NHS Foundation Trust was higher than the England average. • The ‘did not attend’ rate for Nuffield Diagnostic Centre was higher than the England average.

The chart below shows the ‘did not attend’ rate over time.

Proportion of patients who did not attend appointment, Kettering General Hospital NHS Foundation Trust.

(Source: Hospital Episode Statistics)

Staff within outpatient clinics understood the process for managing patients who ‘did not attend’ (DNA). Patients would be provided with a second appointment, and if they did not attend this second appointment they would be removed from the waiting list and discharged back to the care of their GP. The exceptions to this were paediatric patients and cancer patients.

Information regarding DNA rates was displayed on some notice boards in waiting rooms. This provided information to patients and the public on the impact DNAs had on the service and the cost implications they had on the trust and the NHS.

Managers within outpatient service were aware that improvements needed to be made in relation to DNA rates. The rates were highest in paediatric clinics. During our inspection we observed that a pilot had been completed which involved leaving voicemail messages to remind patients of their appointment, this ran alongside the usual text message service the trust provided. Following an

20171116 900885 Post-inspection Evidence appendix template v3 Page 217 improvement in DNA rates the service planned to continue utilising the voicemail service. DNA rates were discussed at departmental meetings, with all managers having oversight of current performance. Some staff told us they had concerns about the link between DNAs and the text messaging service. They said patients were able to cancel their appointment by text message at late notice and that this sometimes was recorded as a DNA rather than a rebooking.

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff. However, complaints were not always responded to in a timely manner. Specialties within the outpatient department were informed of any complaints within their area. They worked with the matron to investigate complaints and respond to complainants. All necessary staff, including nurses, doctors and allied healthcare professionals were involved in complaint investigations. Learning was shared with divisional leads and cascaded to clinical teams to reinforce findings and best practice. Staff said they tried to resolve concerns as they arose. All staff we spoke with felt confident in being able to appropriately direct patients who had a complaint about their care or experience. If a complaint related to clinic delays or something that could be dealt with at the time staff tried to resolve this with the patient. If a complaint could not be resolved locally, staff told us they would refer the patient to a senior nurse and provide details of how to make a formal complaint. Patients knew how to raise concerns and make complaints. Staff directed patients and relatives to the Patient Advice and Liaison Service (PALS) if they were unable to deal with concerns directly. PALS information leaflets provided contact details for the service and were available throughout the outpatient departments. Some staff told us about change in practice following a complaint. For example, conversations and examinations being overheard resulted in a review of clinic rooms and how they were used. Clinicians were allocated to alternate rooms, when space allowed, to minimise overhearing of conversations. Radios were also playing in waiting areas to minimise level of noise heard from consulting rooms. Summary of complaints

From October 2017 to September 2018 there were 52 complaints about outpatients. The trust took an average of 67.2 days to investigate and close complaints. This is not in line with their complaints policy, which states complaints should be completed within 35 days. This was on the family health directorate risk register. Actions had been put into place to reduce the time taken to respond to complaints including: • Complaints were a standing agenda item at the governance meeting. • Weekly tracking of complaints by a divisional director and a governance manage. • Ensuring complaints were assigned to the most appropriate lead person.

The attitude and behaviour of medical staff was the most common subject of outpatient complaints. Outpatient managers told us that there were staffing issues within the complaints department and that this had impacted on response times.

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(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust

From October 2017 to September 2018 there were 22 compliments within outpatients.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led?

Leadership

The service had managers at all levels with the right skills and abilities to run a service working to provide high-quality sustainable care. Main outpatient services sat within the family health division and was managed day to day by an associate divisional manager, and the matron for main outpatients. All managers were responsible for a number of specialties within the hospital and at satellite outpatient facilities. These included trauma and orthopaedics, oncology, and paediatrics. Managers understood the pressures within outpatient services and could also explain improvements made since previous CQC inspections.

We observed that managers worked well together and with executive team in the trust in relation to the transformation programme that was ongoing. Managers in outpatients spoke highly about their divisional management team. Senior staff we spoke with said they generally had the capacity to lead their services effectively. Matrons reported they had positive relations with divisional managers and were included in discussions about business cases to effect change.

On the previous inspection in December 2017, most staff we spoke with had never seen anyone from the executive team within outpatient services. During this inspection, staff we spoke with felt that the new chief executive was very visible. Staff told us members of the executive team had visited the department. Members of the family health divisional team regularly visited outpatient areas.

We observed positive leadership from managers, matrons and senior nurses across outpatient areas. These staff showed enthusiasm for their role and in supporting staff to provide the best patient care for their outpatient area.

Each clinical area had a senior nurse or therapist who managed the clinical speciality and worked alongside staff daily. There was a management structure and lines of responsibility and accountability. There was strong local leadership and all staff we spoke with told us their divisional and immediate managers were visible and approachable. Staff told us they felt encouraged by their managers to provide individualised care to patients using the service.

Senior nurses managed the satellite services and were supported by the matron at the main site. They told us they spoke with their managers daily and met with them monthly.

Vision and strategy

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Whilst the service had a vision for what it wanted to achieve, some workable plans remained under development due to the limitations of the buildings. The vision for the outpatient’s department continued to be one that focused on the delivery of safe and high quality patient care. The trust had a vision for what it wanted to achieve. Its vision was to excel in providing high quality care to individuals, communities and the population they serve.

The vision had been developed in line with the trust values, “CARE”: • Compassionate • Accountable • Respectful • Engaging

CARE awards were carried out within the trust, this allowed staff to nominate individuals, teams or departments who they felt met the CARE values and went the extra mile. We saw these awards displayed in areas, such as maxillo-facial clinic, where staff had received them. They were also documented within the bi-monthly staff newsletter. Staff were aware of the CARE values and felt that they truly reflected the organisation and the care provided to patients. The staff within the outpatient service felt that they demonstrated the trust values. We observed nursing, medical, and managerial staff demonstrated the values throughout our inspection.

The four strategic aims described within the trust strategy were: • To provide high quality CARE to individuals, communities and the population it serves • To be a clinically and financially sustainable organisation • To maintain a fulfilling and developmental working environment for its staff • To be a strong and effective partner in the wider health and social care community.

Staff were asked daily to provide examples of how they had contributed to delivering the strategic aims in their own role. A daily email also highlighted examples of this to encourage staff to think about what the strategic aims meant to them and their area of work.

A five-year outpatient transformation programme was set up in September 2016. This plan was in place during our previous inspections with work focused on do not attend (DNA) rates, clinic template changes and reducing clinic cancellations. During our previous inspections, we found that there had been improvements in all of these key deliverables with positive outcomes on flow and patient care. The scope included choice for patients, better attendance rates and fewer cancelled clinics. The programme was designed to identify potential areas for improvement, oversee the design and implementation of solutions and monitor progress to achieve an outpatient service that was benchmarked as performing in the top quartile. The programme key deliverables included: • E-Referral implementation for GP • New Access Policy • Patient Reminder Service (2 Way-Text service implementation) • Clinic template optimisation achieved through the introduction of new tools. During this inspection, further work and improvements had been made. The two-way text service had been implemented. Clinic template optimisation had been incorporated into the new ‘6-4-2’ model which was being monitored and evidence of impact was recorded.

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Other improvements included changes to the estates. Environmental risks had been highlighted in the November 2018 board report. The scheduling of the estate works were discussed and agreed. A new fracture clinic was due to open the week following our inspection. Plans to relocate ophthalmology clinics and the maxillo-facial clinics had also been agreed. We reviewed transformation plans for the estate in main outpatients which had been designed with input from staff, managers and an architect.

Work was underway with a partnership, known as Sustainability and Transformation Partnership (STP), to jointly plan and develop proposals to improve health and care. Strategic plans continued to be developed regarding the reconfiguration of services within the department in corroboration with the STP and other trusts in Northamptonshire.

A matron explained plans in place for moving towards a digitally-enabled outpatient service. This work had already begun by increasing the number of virtual consultations available to patients and the use of electronic GP referrals instead of paper referrals. Further developments such as waiting area digital educational programmes and digital transcription were outlined in the outpatient improvement plan.

Staff working in outpatients were aware of planned changes, reconfiguration and estates plans that affected them and the speciality or area they worked within. Senior nurses and managers kept staff updated with timescales for changes to take place. Staff were aware of the outpatient improvement plan.

Culture Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. We observed a culture of commitment, teamwork, and support across all departments. Staff morale was good amongst staff in all specialties and staff told us they enjoyed working at the trust; they shared their views about the service openly and constructively. All staff we spoke with and observed, were caring and passionate about the service and the care they provided to people who used the service. The culture was centred on the needs and experience of people who used services.

Managers spoke very highly of the clinical and support staff that worked within the outpatient departments. They told us staff were flexible and highly motivated to provide a positive patient experience and best patient care. We observed cooperative, supportive and appreciative relationships between managers, consultants, nursing and support staff, regardless of seniority.

The culture within outpatient areas encouraged openness and honesty. Staff and managers understood the importance of being able to raise concerns without fear of retribution. Staff we spoke with were aware of the freedom to speak up guardian and told us that they could access contact details through the intranet if they wished.

Staff had opportunities for professional development. They told us they had annual appraisals and supervision sessions. Registered nurses and medical staff had access to the appropriate support to complete requirements for their revalidation.

There was a strong emphasis on the safety and well-being of staff members. Staff told us of occasions when they had been contacted by a colleague or manager to check on their well-being following a challenging situation. Teams were visited by a mindfulness expert on a regular basis. Mindfulness sessions were thought highly of, particularly by staff caring for patients with cancer. Debriefs were held and time away from clinical areas was provided when necessary.

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Governance The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care and it continued to aim to create an environment in which good clinical care would flourish. However, there was further work required to ensure all levels of the governance structure functioned effectively to ensure joint working and shared learning across specialties. Outpatients sat within the family health division. Governance structures were in place to support the functions of outpatient services. Monthly governance meetings were conducted to allow oversight of some specialties within the outpatient service. All senior outpatient managers and clinical managers attended these meetings. Governance meetings had a set agenda and we saw this was followed during each meeting. There was a clear reporting structure within main outpatients and the family health division. Not all levels of governance functioned effectively and interacted with each other appropriately. There was a lack of joint up working between surgical and medical specialities within outpatients and the specialties that sat within main outpatients. For example, managers and staff were not always aware of incidents that had happened within a specialty other than their own despite this occurring in an outpatient setting. Senior local managers agreed that there was further work to do to improve governance and joint up working. Following our inspection, we saw evidence that a cross-divisional shared learning meeting had been implemented which focussed on the learning and themes from serious incidents, incidents and complaints. We reviewed the outpatient governance meeting minutes for both October and November 2018 and found they were very brief. There was no set agenda and they did not cover the governance of the department. For example, they did not discuss complaints, incidents, department performance or audits, although they did discuss risk. However, following the inspection, the trust provided us with minutes and agendas of governance meetings that took place in January and February 2019. We found there was a marked improvement in the detail. We saw evidence that detailed exception reports were reviewed at the meetings and the reports included data about incidents, complaints, performance and risk. There still remained a risk that managers did not have oversight of issues arising in other specialties. The matron held a monthly quality forum meeting with the sisters from each department where these areas were all discussed. We also reviewed specialist department governance meetings between October and December 2018, including ear, nose and throat (ENT), dermatology and ophthalmology, where these crucial subjects were discussed. Most staff groups attended staff meetings which were structured and included standing agenda items that included an overview of serious incidents and lessons learned. Staff confirmed these meetings were valuable and informative. Staff occasionally attended the hospital’s daily safety huddle however some staff said the huddles were not always relevant to outpatient staff. Instead, the department held a daily safety huddle of their own and daily summary emails were sent by a senior manager. These emails communicated key messages and updates. Staff meetings were held as well as a monthly sisters meeting and the matrons monthly check and challenge meeting. Senior clinicians had access to governance systems that enabled them to monitor the quality of care provided. This included the provider’s electronic incident reporting system and electronic staff training record. There were effective structures and processes in place to monitor and improve referral to treatment times (RTT). RTT executive assurance groups were held every two weeks between RTT leads and executive trust leaders. We reviewed minutes of meetings and found these to detail necessary areas of risk and performance relating to RTT.

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Outpatient transformation and improvement steering group meetings were held every two weeks which were chaired by the chief operating officer. These meetings ensured oversight of improvement, quality and risk whilst changes occurred within the service. Managers felt these meetings were productive and had led to quality changes that improved efficiency and patient care. Service level agreements (SLA) were in place with other providers where necessary. The diabetic centre at Kettering General Hospital was run by another NHS Trust but the oversight of the facilities and equipment was the responsibility of Kettering General Hospital NHS Trust. Staff in this service were aware of their responsibilities and who to speak to at the trust if they had problems with the facilities or equipment. Since out previous inspection in 2017, dermatology services had moved to nearby GP practice. There was a SLA in place with the practice. Similarly, there was an SLA in place with a neighbouring trust for services to be provided from Corby.

Management of risk, issues and performance

The outpatients’ department had effective systems for identifying risks and timely plans to eliminate or reduce risks. There was a governance framework that ensured responsibilities were clear while quality and risks were understood and managed. We saw the integrated family health directorate risk register had six risks associated with outpatients. These included: • Risk of cancellation of patient clinical appointment due to ECG not being performed at an appropriate time & current ECG machine coming to the end of asset life • Risk to effective delivery of safe, high quality care due to flow machine and urodynamics machine coming to the end of asset life • Unknown quantities of backlogs of loose leaf filing across the trust which belong in patient medical records. Resulting in some remaining patient medical records being incomplete • Non- delivery of service and impact on RTT due to insufficient staffing in OPD • Risk of poor patient experience and ability to deliver high quality care as a result of main OPD environment not being suitable. Access to wheelchair users and stretcher patients restricted. • Risk of poor patient experience and increase in complaints as a result of clinic delays.

Managers and nursing and support staff had a good knowledge of the risks in their departments. They were familiar with the risk register and advised it was reviewed at the outpatient governance meeting monthly. Risks were regularly reviewed and mitigating actions were monitored. Any high- level risks were escalated to corporate level for review. For example, in November 2018 OPD governance meeting, they discussed whether they could combine the estates risks into one. This was then escalated to head of department meeting. There were clear structures and processes in place which ensured performance issues were escalated appropriately. A systematic internal audit programme was also in place to review the quality of services. Risks and the impact on quality and sustainability were considered when developments, improvements and changes were planned.

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Information management The service collected, analysed, managed and used information to support all its activities, using secure electronic systems and security safeguards. The service had clear performance measures, which were reported and monitored. These included key performance indicators, audit results and referral to treatment times. Some specialties within outpatients participated in national audits to ensure they continuously improved patient care in line with national guidance and clinical data outcomes. Data was submitted to external bodies, such as the lung cancer audit. This enabled the service to benchmark performance against other providers and national outcomes and were used as a driver for change. For example, there were initiatives in place to reduce the need for admissions for conditions such as chronic obstructive pulmonary disease (COPD) and provide timely access to treatment. For example, the service had introduced rapid access outpatient COPD clinics to assess and treat patients at risk of admission where access to a consultant could mitigate this. The paper patient record system was labour intensive however, staff generally had access to up- to-date, accurate and comprehensive information on patients’ care and treatment. Staff were aware of how to use and store confidential information. The service had developed an electronic referral system and plans to transition to a new electronic patient information system were under review. Requests for diagnostic tests were electronic at the time of our inspection. The data quality team and data validators were integral to ensuring outpatient referral to treatment performance data was accurate. Work was underway to validate and cleanse historical referral data. The trust had identified 126,000 referrals that were open on the system but did not have a future appointment booked. 86,000 of those referrals were identified for batch closure. The operations management group had developed, tested and approved five different set of criteria for closing the 86,000 referrals in line with NHS Improvement guidelines. The lead for this piece of work told us there was 40,000 remaining referrals that required manual validation at the time of our inspection. We were told this work would be completed by the end of March 2019. Engagement The service engaged well with staff and collaborated with partner organisations effectively. Patient feedback was sought by staff and comments shared amongst the team and was used to influence change within the service. Feedback was sought from patients through friends and family test (FFT) questionnaires and local patient feedback surveys. Patients were verbally encouraged to feedback about the service and written information was available in all clinic areas. During our last inspection, service managers were aware that there were some areas of consistently low or nil FFT returns. The patient experience team had secured funding for a new system to support with the collection of FFT and wider patient experience feedback. There was a bi-monthly newsletter for staff in main outpatients and medical records called. Staff were involved in decisions relating to the department and service improvement. For example, September 2018 newsletter showed a cross section of nursing staff reviewed the CQC self- assessment documentation and decided on a pre-inspection rating. The outpatient department had monthly ‘BOO awards’; this stood for ‘best of outpatients’. Each month, staff within the department voted for their colleagues to win a prize. We saw that in November 2018 a member of staff won as they went the extra mile to say goodbye to a colleague

20171116 900885 Post-inspection Evidence appendix template v3 Page 224 on their last day. They came in on their day off and cooked a full breakfast for the outpatient department staff as a celebration for the colleague. There was a section within the monthly newsletter for staff to write a message of thanks and appreciation to each other. We saw examples of this in both the September 2018 and November 2018 newsletters. Staff told us they felt fully engaged in the outpatients’ service and recommended the department as a place to work. Staff said they felt motivated to come to work and knew they provided an invaluable service to their patients. Staff collaborated with partner organisations. External confirm and challenge meetings about RTT performance and data we held bi-monthly. Patient representatives were present at steering groups and transformation group meetings. we were told that volunteers attended and representatives from hard to reach groups. Patient feedback had been used when planning the outpatient estate reconfiguration. Learning, continuous improvement and innovation Staff were committed to improving services for patients and learning from when things went wrong. There was an improvement plan which detailed aims and objectives. We found some service improvements had been made since our previous inspection in 2017. There had been a focus on addressing the concerns reported in the December 2017 CQC inspection report. During our inspection, we found many improvements had been made to provide a safe and effective service. This included • Building a new fracture clinic and dedicated treatment area. • Management of patient notes and increasing the availability of notes for outpatient clinics.

However, there were some issues that were yet to be resolved despite improvements being made: • Overcrowding in clinic waiting areas • Reducing the waiting times so that people did not have to wait over 18 weeks for an appointment. • Work towards soundproofing of the consulting rooms.

There was an outpatient improvement plan which clearly documented what the department hoped to achieve and what they had already achieved. There were five main aims:

• Avoid unnecessary hospital site appointments • Reduce variation in processes • Support engagement of clinical teams in managing their services • Encourage patients to take responsibility for their care • Deliver care in the most appropriate environments

Each aim had initiatives and associated actions that were ongoing. There were clear definitive timescales aligned to key milestones. In 2018/19, the outpatient team achieved a number of the objectives they had set. There had been a 20% increase in patients receiving a virtual consultation, the development of a one-stop urology clinic, improved clinical coding, a purpose- built fracture clinic, and a community setting for dermatology outpatient services. Whilst we saw improvements in managing hospital cancellations and reducing wait times, the management team acknowledged there was still further work to do.

An example of improvement through innovative working was the ‘6-4-2’ methodology that had been developed. The matron had seen a similar process used to improve theatre utilisation. This had been adapted for the use in outpatients. It involved a review of clinic templates and room

20171116 900885 Post-inspection Evidence appendix template v3 Page 225 utilisation, cleansing of nursing rosters, and then aligned both in a planned pre-emptive way. Managers told us this had given them assurance that that they were making the best use of their two most valued commodities; staff and clinic space, to enable them to provide more clinics to more patients. It involved a three-step process. Tasks were completed and meetings held with specialty matrons at six, four, and two weeks in advance. The impact was continuously monitored. For example, there was evidence of the number of patients seen in clinics through additional capacity.

Diagnostic imaging

Facts and data about this service

Kettering General Hospital NHS Foundation Trust provides a diagnostic and imaging service which forms part of the medicine division at the hospital. Diagnostic imaging services provided by the trust are located at four sites: Kettering General Hospital and satellite services at Corby Diagnostic Centre, Isebrook Hospital and Nene Park. The service is managed by one management team based at Kettering General Hospital.

The diagnostic imaging department provides a range of diagnostic imaging modalities, including general radiography, computerised tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, interventional radiology, fluoroscopy, mammography, and ultrasound. The department performed approximately 20,000 examinations each month.

Diagnostic investigations also take place in the cardiac investigations unit. These investigations included non-radiological investigations, such as electrocardiograms, heart monitoring, echocardiograms, and exercise tests. These were performed by specialist technicians managed by a lead physiologist.

In February 2018, diagnostic and imaging services was rated overall as inadequate. Safe and well led were rated as inadequate, caring was rated as good, and responsive was rated as required improvement. We carried out our inspection from 5 February to 7 February 2019, with a further announced visit on 12 February 2019 at the satellite sites. During our inspection, we visited all the modalities, including the cardiac investigation unit and mammography (excluding breast screening services). Interventional radiology sits under the surgery framework and therefore we did not inspect this modality.

We spoke with 15 patients and relatives, and 29 members of staff, including radiologists, radiographers, ultra sonographers, physiologists, nurses, unit managers, and health care support workers. We reviewed eight patient records and observed care being delivered.

The inspection team consisted of a lead inspector and a specialist advisor (senior radiographer/lecturer).

Is the service safe?

Mandatory training The service provided mandatory training in key skills to all staff and made sure most staff completed it. The trust target of 85% completion was met for the majority of mandatory training courses.

Staff received effective mandatory training in the safety systems, processes and practices.

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Mandatory training covered key areas such as mental capacity awareness (MCA), safeguarding (both adult and children), infection control, manual handling, health and safety and risk management, fire safety, information governance, conflict resolution, and equality, diversity and respect. Training was provided via e-learning modules and face-to-face sessions. Staff understood their responsibility to complete mandatory training.

Mandatory training completion rates

The trust set a target of 85% for completion of mandatory training.

Trust level

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for qualified nursing staff in diagnostic imaging is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Conflict Resolution 13 13 100% 85% Yes Equality, Dignity & Respect 13 13 100% 85% Yes Prevent Health Wrap 13 13 100% 85% Yes Manual Handling Non-Patient 1 1 100% 85% Yes Information Governance 13 13 100% 85% Yes Manual Handling Patient 12 12 100% 85% Yes Infection Control 12 13 92% 85% Yes Health and Safety & Risk Management 12 13 92% 85% Yes Fire Safety 12 13 92% 85% Yes MCA Awareness 11 13 85% 85% No Basic Life Support (Adult) 10 13 77% 85% No Sepsis 7 12 58% 85% No Medicines Management 1 3 33% 85% No

In diagnostic imaging the 85% target was met for nine of the 13 mandatory training modules for which qualified nursing staff were eligible.

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for medical staff in diagnostic imaging is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Prevent Health Wrap 28 28 100% 85% Yes Manual Handling Non-Patient 10 10 100% 85% Yes Conflict Resolution 34 35 97% 85% Yes Information Governance 34 35 97% 85% Yes Equality, Dignity & Respect 34 35 97% 85% Yes Manual Handling Patient 24 25 96% 85% Yes Fire Safety 33 35 94% 85% Yes Infection Control 33 35 94% 85% Yes Health and Safety & Risk Management 32 35 91% 85% Yes Basic Life Support (Adult) 21 26 81% 85% No MCA Awareness 22 28 79% 85% No Sepsis 11 16 69% 85% No

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Medicines Management 14 24 58% 85% No

In diagnostic imaging the 85% target was met for nine of the 13 mandatory training modules for which medical staff were eligible.

A breakdown of compliance for mandatory training courses from October 2017 to September 2018 at trust level for qualified allied health professionals in diagnostic imaging is shown below:

staff eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Conflict Resolution 86 87 99% 85% Yes Information Governance 85 87 98% 85% Yes Health and Safety & Risk Management 84 87 97% 85% Yes Equality, Dignity & Respect 84 87 97% 85% Yes Infection Control 84 87 97% 85% Yes Fire Safety 83 87 95% 85% Yes Manual Handling Patient 83 87 95% 85% Yes Prevent Health Wrap 80 87 92% 85% Yes Basic Life Support (Adult) 71 87 82% 85% No MCA Awareness 66 87 76% 85% No Sepsis 44 87 51% 85% No Medicines Management 3 6 50% 85% No

In diagnostic imaging the 85% target was met for eight of the 12 mandatory training modules for which qualified allied health professionals were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

During our inspection, staff of all disciplines in diagnostic services told us they were up to date with their mandatory training requirements. We requested the training compliance figures as at 1 February 2019. Completion of mandatory training within the service was compliant with the trust’s target of 85%. Data provided by the service as at 1 February 2019 showed staff in radiology had an overall mandatory training completion rate of 90.7% for all courses, except for basic life support (adults) where compliance was 80.3%, MCA awareness (83.6%), medicines management (50%), and sepsis (80.4%). Managers were aware of compliance with these training modules, and plans were in place to improve compliance by ensuring all staff were booked on to these modules.

Data provided by the service showed 94 out of 117 (80.3%) eligible staff across all staff groups had received basic life support (BLS) training. All medical and nursing staff (100%) had received BLS training, and 73.2% of allied health professional had received this training. In addition, 85.7% of additional clinical support staff had received basic life support training.

We saw evidence that staff working with radiation had received appropriate training in the regulations, radiation risks, and use of radiation. All staff working as operators under IR(ME)R (Ionising Radiation (Medical Exposure) Regulations 2000) had undertaken a recognised academic course of training, and were either registered with the HCPC (Health & Care Professions Council) or worked as Assistant Practitioners under the supervision of an HCPC registered radiographer.

As part of compliance with IR(ME)R, all staff maintained a competency portfolio with annual refreshment of competencies for all items of equipment that produced ionising radiation that they used. Safeguarding

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Staff understood how to protect patients from abuse and knew how to recognise and report abuse, including how to escalate concerns. Safeguarding training compliance was above the trust target for all staff.

There were clear systems, processes and practices in place to safeguard adults and children from avoidable harm, abuse and neglect that reflected relevant legislation and local requirements.

Staff were trained to recognise patients at risk and were supported with effective safeguarding policies that reflected relevant legislation and local requirements. Staff demonstrated they understood their responsibilities and adhered to safeguarding policies and procedures.

Safeguarding training completion rates

The trust set a target of 85% for completion of safeguarding training.

Trust level

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for qualified nursing staff in diagnostic imaging is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Adults - Level 2 13 13 100% 85% Yes Safeguarding Children Level 1 1 1 100% 85% Yes Safeguarding Children Level 2 12 12 100% 85% Yes

In diagnostic imaging, the 85% target was met for all of the three safeguarding training modules for which qualified nursing staff were eligible.

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for medical staff in diagnostic imaging is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Children Level 1 6 6 100% 85% Yes Safeguarding Adults - Level 1 6 6 100% 85% Yes Safeguarding Children Level 2 28 29 97% 85% Yes Safeguarding Adults - Level 2 27 29 93% 85% Yes

In diagnostic imaging the 85% target was met for all of the four safeguarding training modules for which medical staff were eligible.

A breakdown of compliance for safeguarding training courses from October 2017 to September 2018 at trust level for qualified allied health professionals in diagnostic imaging is shown below:

eligible Completion Trust Met Name of course staff trained staff rate Target (Yes/No) Safeguarding Adults - Level 2 86 87 99% 85% Yes Safeguarding Children Level 2 86 87 99% 85% Yes

In diagnostic imaging the 85% target was met for both of the safeguarding training modules for which qualified allied health professionals were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

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Data provided by the service showed seven members of staff across all staff groups were eligible for safeguarding level 3 training. Data showed that thirty-two members of staff had completed safeguarding level 3 training, which meant more staff were trained than required.

There were named safeguarding nurses for adults and children in the trust who were available to provide support, supervision, training and updates for staff. Staff knew who the safeguarding leads were and had a good understanding of how to recognise safeguarding concerns. Staff were aware of safeguarding policies and procedures and could explain the escalation processes. Staff were also aware of their responsibilities surrounding female genital mutilation (FGM) and how to escalate concerns.

There were processes in place to ensure the right person received the right radiological scan at the right time. Patients were called into the department and asked to confirm identity, by giving their full name, date of birth and address. The Society of Radiographers “pause and check” system was used across all areas with posters displayed. Pause and check refers to the Society of Radiographers operator checklist which prompts radiographers to confirm the patient and the investigation using set prompts. Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Staff had received training on infection control. However, flooring in the x-ray rooms within the breast unit did not comply with relevant Health Building Note (HBN) requirements.

At the time of our inspection, all areas in the diagnostic and imaging departments were seen to be visibly clean and tidy.

There were specific environmental cleaning schedules in place throughout all clinical areas. Domestic staff cleaned all areas daily, and allied health professionals/nursing/support staff cleaned between patients. We noted that cleaning schedules were signed and dated to evidence regular cleaning took place.

The service had access to infection prevention and control nurses. Clean equipment was labelled with dated ‘I am clean’ stickers so staff knew the items were clean and ready for use. The examination couches seen within examination rooms were clean, intact and made of wipeable materials. This meant couches could easily be cleaned between patients. Disinfectant wipes were available in all clinical areas to wipe down treatment couches and equipment between patients. We also noted white paper rolls were used on examination couches in consultation rooms which were changed between patients.

Disposable curtains were in use around waiting areas and examination couches. These were dated with the date on which they were last changed. All curtains we checked had been changed in line with the trust policy.

Staff complied with the trust’s policies for infection prevention and control. This included wearing the correct personal protective equipment (PPE), such as gloves and aprons, and lead gowns, which were readily available in sufficient quantities. Clinical staff adhered to the trust’s ‘arms bare below the elbow’ policy to enable effective handwashing and reduce the risk of spreading infections. All staff were required to complete infection prevention and control (IPC) training. Data provided by the trust showed 93.3% of staff in radiology had received IPC training, meeting the trust target of 85%. This meant we were assured most staff had up to date infection prevention and control knowledge.

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The service participated in regular audits of infection prevention and control. Hand hygiene audit compliance was consistently 100% in November 2018, December 2018 and January 2019.

There were adequate hand washing facilities and hand gel for use at the entrance to each of the modalities and clinical areas. Paper towels were readily available in areas where people washed their hands. We observed staff adhering to good hand hygiene practices. Patients we spoke with corroborated this. Information charts about hand hygiene were displayed throughout the clinical rooms we visited.

Staff were aware of the procedures to follow if a patient had a communicable disease, such as tuberculosis or flu. Posters were displayed advising staff on procedures to follow. Where possible, patients with infectious diseases were treated as an ‘alert’ and would be seen towards the end of the day. Appropriate PPE, such as gloves and aprons, were readily available for staff to use. Staff could describe what they would do if a patient required isolation due to infection.

Probes used for intimate examinations in the ultrasound department were cleaned appropriately between use. Probe covers were used to reduce the risk of cross contamination, and a three-wipe cleaning method was used following each procedure. Probes used for intimate examinations were appropriately tracked and traced, in line with best practice. Once a probe was used on a patient, the unique identifying number was recorded in a logbook and in the patient’s record. This allowed identification of patients who may be affected if cross-infection occurred.

Patients who required a vascular access device had their risk of infection minimised by the completion of specified procedures necessary for the safe insertion, maintenance and removal of the device.

Staff and patients, we spoke with, told us they were satisfied with the level of cleanliness in the department and if they identified a concern, they contacted housekeeping who responded in a timely manner.

Not all the environment was maintained in accordance with Department of Health guidance. Flooring in the x-ray rooms within the breast unit did not comply with relevant Health Building Note (HBN) requirements. HBN 00-10 regulations considers floors should be washable, and have curved edges to prevent bacterial growth. Flooring in the x-ray rooms in the breast unit did not have curved edges. This was fed back to senior leaders. Environment and equipment The service had suitable premises and equipment and looked after them well. Although the cardiac investigation unit remained cramped since the last inspection, plans were in place to expand and improve the environment. Equipment was checked at regular intervals to ensure it was safe for use.

Diagnostic and imaging services were located on the ground floor in the main hospital and mammography services at the treatment centre a short distance away. General radiography, CT fluoroscopy, and nuclear medicine were located together, with MRI and ultrasound adjacent. Urgent and emergency care included two x-ray facilities, linked to the main radiology department, for patients attending the emergency department. The location and close proximity of all modalities enabled timely access to scanning and staff were able to move between departments easily. Cardiac investigations were completed in the cardiac investigations unit which was located next to the radiology department. All departments were clearly signposted from the hospital main entrance.

The main reception desk was at the entrance to the main x-ray department. This was where all patients and visitors were greeted and their identity verified. From here, patients were redirected to the various modality areas. All modalities included a separate designated inpatient and outpatient

20171116 900885 Post-inspection Evidence appendix template v3 Page 231 waiting area to maintain patients’ privacy and dignity. Waiting and clinical areas were clean and tidy.

The design of the environment within diagnostic imaging kept people safe from avoidable harm. Rooms where ionising radiation exposures occurred were clearly signposted with warning lights. These were in place in all relevant modalities to warn people about potential radiation exposure. There were radiation warning signs outside any areas that were used for diagnostic imaging. Illuminated no entry signs were clearly visible and in use throughout the departments at the time of our inspection to ensure that staff or patients did not enter rooms whilst imaging was taking place. The service ensured that ionising radiation in plain film and fluoroscopy rooms had arrangements in place to control the area and restricted access. There were strict security controls within the unit. Access to the MRI unit and nuclear medicine was by means of swipe card or an intercom system to gain entry.

The MRI scanners were kept secure behind locked doors. Radiographers performed adequate screening by means of safety questionnaires to ensure anybody entering these areas were kept safe from the high magnetic field. For example, the safety questionnaire asked female patients if they were pregnant prior to any scan.

A control/observation area allowed visibility of all patients during CT and MRI scans. There was sufficient space around the scanners for staff to move and for scans to be carried out safely. Patients had access to an emergency call buzzer, ear plugs and defenders during scanning. A microphone allowed contact between the radiographer and the patient at all times.

Risk assessments had been carried out on all new or modified imaging equipment. Risk assessments addressed occupational safety, as well as considering risks to people who use services. Staff wore radiation badges to monitor any occupational doses and to ensure that staff were not over exposed. Lead aprons were used, and checked annually to ensure they were not damaged. There were regular annual audits and testing of lead aprons, with the last lead apron audit completed in November 2018.

The service had a well established IR(ME)R group, supported by a radiation protection advisor and the medical physics expert. They met monthly to discuss all aspects of radiation safety within the department. Risk assessments and local rules were in place for all controlled areas and these were reviewed regularly. All operators had access to these with local rules also being displayed in each controlled area.

All diagnostic and imaging equipment was tested at regular intervals in line with the manufacturers’ specifications. Regular quality assurance and servicing was in place to ensure that the equipment was functioning safely. Equipment that needed to be repaired was dealt with in a timely manner. All other equipment we saw had evidence of electrical safety testing where appropriate to ensure it was safe for patient use. We reviewed 36 items of equipment from the radiology and cardiac investigations unit and found all equipment had been serviced within the date indicated.

The scanners, such as the MRI and CT equipment, were wide bore to accommodate larger patients.

We saw records that showed that staff had been trained on imaging equipment they used. These were updated when skills or equipment changed. Data provided by the service showed 100% of staff working as operators under IR(ME)R had undertaken a recognised academic course of training and were either registered with the Health & Care Professions Council (HCPC) or worked as assistant practitioners under the supervision of an HCPC registered radiographer. As part of compliance with IR(ME)R, all staff maintained a competency portfolio with annual refreshment of competencies for all items of equipment that produced ionising radiation that they used.

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The environment in each area visited was clean and uncluttered. During our last inspection, we found in the corridor leading to the nuclear medicine area, there were unused clinical waste trolleys and several items of decommissioned equipment. At this inspection, we found this had improved and the area was tidy and uncluttered.

At our last inspection, we found the cardiac investigation unit was cluttered and the environment cramped. Staff had expressed their concerns that the environment was a hazard to safety for staff and patients. In an emergency, there would be very limited space for a resuscitation trolley as well as for the emergency resuscitation team, doctors and nurses to manoeuvre efficiently and immediately during an arrest. During this inspection, we found this had improved. Although the environment remained cramped, staff had re-arranged some of the equipment to ensure the space was not a hazard to patients and staff. Plans were in place to expand the department into a two- storey unit, with the project expected to be completed by July 2019. The new department will include:

• Three new scanning rooms for cardiac ultrasound, increasing capacity by 50% • A new procedure room • Additional waiting area giving 50% more seating and dedicated children’s waiting room • Larger exercise tolerance testing room • Additional ECG room

The nuclear medicine department had designated ‘hot’ and ‘cold’ facilities, with separate cleaning materials to prevent contamination. Hot and cold facilities refer to patients who are awaiting administration of the radiopharmaceuticals (cold), and those who have been given the radiopharmaceutical (hot).

Resuscitation equipment was readily available. The radiology department had adult resuscitation trolleys in the main x-ray, fluoroscopy, and CT units. There was also a paediatric resuscitation trolley in the CT unit. The trolleys were all tagged with tamperproof seals when not in use. The MRI unit had a resuscitation grab bag, a drug bag and a defibrillator kept on a shelf in an accessible area. The bags were all sealed and tagged. The cardiac investigation unit had paediatric and adult resuscitation trolleys. They were tagged when not in use. All resuscitation equipment was checked daily to ensure the electrical equipment was in working order and tamper seals were in place. A weekly check of all equipment and medicines stored in the resuscitation trolley was also undertaken, to ensure all items required were present and in-date. We reviewed the checklists for all resuscitation trolleys located in radiology and the cardiac investigation unit from November 2018 to January 2019, and all were complete.

The arrangements for managing waste kept people safe from avoidable harm. Cleaning materials were stored appropriately in locked cupboards, in line with the Control of Substances Hazardous to Health Regulations 2002 (COSHH). COSHH is the legislation that requires employers to control substances, which are hazardous to health. This meant unauthorised persons could not access hazardous cleaning materials. Waste was separated and in different coloured bags to signify the different categories of waste. This was in accordance with the Health Technical Memorandum (HTM) 07-01, control of substance hazardous to health (COSHH), health, and safety at work regulations. All sharp boxes were correctly assembled, labelled, and dated. None of the bins were more than half-full, which reduced the risk of needle-stick injury. This is in accordance with HTM 07-01: Safe management of healthcare waste. All sharp bins had temporary closures in place. Temporary closures are recommended to prevent accidental spillage of sharps if the bin was knocked over and to minimise the risk of needle-stick injuries.

The service had 24-hour Picture Archiving and Communication System (PACS) support. There was a 24-hour helpline which was used to provide assistance with any IT problems. Staff could access the number from the intranet or from the hospital switchboard.

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Assessing and responding to patient risk Safe systems and procedures were in place to assess, monitor and manage risks to patients. The service had a safety monitoring system in place to monitor their performance against targets. Staff completed and kept clear records of risk assessments and safety checklists for patients.

There were comprehensive risk assessments carried out for people who used the service. Risk management plans had been developed, in line with national guidance. For example, in the MRI and CT unit, we saw evidence of safety questionnaires used to risk assess a patient before they received a scan.

There were processes in place, to ensure that women who were or may be pregnant always informed a member of staff before they were exposed to any radiation, in accordance with IR(ME)R. Processes were in place to identify any pre-existing clinical conditions that a patient may have which could impact on the ability to perform the investigation. For example, patients with an impaired kidney function received a different dose of contrast media. Contrast media are substances which increase the contrast of structures or fluids within the body used in certain types of radiological investigations. Staff checked that patients, who required a contrast media, were not allergic to any substances prior to administering the medicine. An anaphylaxis box was available in scanning rooms if patients were to react to any substance. Anaphylaxis is a serious, life threatening allergic reaction which can be triggered by medicines.

Staff were trained in cannulation and explained to us the need to monitor cannula sites for extravasation. Extravasation is the accidental leakage of certain medicines into the body from an intravenous drip in the vein. Staff could describe the process if a patient was to experience extravasation. Cannulas were left in situ for 10 minutes after injection of contrast in case the patient should experience a delayed contrast reaction.

The service had a policy for prioritisation of reports for all staff to follow which contained the timescales that the different types of images should be reported within.

At our last inspection, there were delays in image reporting which meant there was a risk that patients’ consultants or their own GPs did not always have timely information about their patients’ conditions. There was a backlog of 10,723 unreported images (as at 27 October 2017). Routine outpatient tests, GP plain films, and A&E plain films were part of the backlog. During this inspection, we found significant improvements had been achieved within the service. The reporting backlog was almost cleared and reporting turnaround times dramatically reduced. This had been achieved as a result of increasing the reporting capacity through use of locum consultants and increased outsourcing to the trust's two teleradiology providers.

Radiological Reviewing by Non-Radiology Clinicians During our last inspection, we also found the trust had relied on non-radiology clinicians to review inpatient plain films. There had been no quality monitoring of the clinicians to test their competence before they were allowed to review the images. There was no monitoring of the accuracy of the reviews. There was no monitoring of the impact of this decision and how patients’ health was affected. There were no audits or records kept of the number of these images that had been reviewed. This was raised as a concern and the trust have since changed its processes for reporting on inpatient plain films. In December 2017, the service resumed formal reporting of in- patient x-ray examinations, removing the risk of inexperienced doctors reviewing the images at ward level. A robust harm review process had been undertaken to review any study with a delayed report that demonstrated a pathology. A total of 14 studies had been subject to a detailed review either by the referring clinician or by the medical director. Of these, 11 have been confirmed as either no harm or low harm and reviews were underway for the remaining three cases. During our inspection, we found all inpatient plain film x-rays have continued to be formally reported by radiologists. 20171116 900885 Post-inspection Evidence appendix template v3 Page 234

The service had named staff fulfilling the essential roles of radiation protection advisor, medical physics expert, radiation protection supervisors, senior radiologist and infection control lead. Staff were able to easily contact a radiation protection advisor and medical physics expert (MPE) based at a neighbouring trust for advice. Contact details for the radiation protection advisor were available in the local rules and the MPE was accessible by phone or email.

The service had local rules (IRR) and employers’ procedures (IR(ME)R) in place to protect staff and patients from ionising radiation. Local rules were displayed across all clinical areas. These identified the risks associated with each modality and steps taken by staff to ensure that procedures were completed safely.

There were processes in place to ensure that the right person received the right investigation. Staff used The Society of Radiographers (SoR) “Paused and Checked” system, to reduce the risk of referrer error. Pause and Check consisted of the three-point demographic checks to correctly identify the patient, as well as checking with the patient the site/side to be imaged, the existence of previous imaging and for the operator to ensure that the correct imaging modality is used.

Staff told us what action they would take if a patient became unwell or distressed while waiting for, or having a scan. They said this depended on the specific situation and gave us examples which indicated they would take appropriate action.

Nurse Staffing The service had enough nursing staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.

The trust has reported their qualified nurse staffing numbers for diagnostic imaging below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

WTE Number in Post (September 2017 to October Ward / Team Staff 2018) Blood Transfusion (3495) 1.0 1.0 Bowel Cancer Screening Centre (1215) 7.2 8.0 Radiography - Kettering (4130) 3.4 4.0 Grand Total 11.6 13.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 2.1% for qualified nursing staff in diagnostic imaging. This is lower than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 0% for qualified nursing staff in diagnostic imaging. This is lower than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

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Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 1.4% for qualified nursing staff in diagnostic imaging. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

From October 2017 to September 2018, the trust reported that bank staff were used to supply 99% of required nursing cover in diagnostic imaging.

(Source: Routine Provider Information Request (RPIR) - Nursing – Bank and Agency tab)

Internal bank staff were offered unfilled shifts to ensure establishment was met. Staff told us that the bank staff used were generally the same staff and were known to the service. All bank and agency staff received an induction and orientation before they commenced duties.

At our last inspection, the established number of nursing staff in the main radiology department was not adequate. There was only one trained nurse in the whole department on Tuesdays, Wednesdays, and Thursdays. During this inspection, we found this had improved. Nurse staffing levels across the service were appropriate to deliver safe care and treatment to patients in diagnostics and imaging services. None of the staff we spoke with raised concerns about nursing staff levels, and the departments we visited were visibly calm and well managed during our inspection.

Medical staffing The service had enough medical staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The service outsourced activity to ensure timely treatment was provided.

The trust has reported their staffing numbers for diagnostic imaging below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

WTE Number in Post (September 2017 to October Ward / Team Staff 2018) Haematology (3490) 1.0 1.0 Pathology Medical Staffing (3410) 17.9 18.0 Radiology Medical Staffing (4110) 14.6 16.0 Grand Total 33.5 35.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 8.7% for medical staff in diagnostic imaging. This is higher than the trust target of 7%.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

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Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 13.9% for medical staff in diagnostic imaging. This is higher than the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 2.1% for medical staff in diagnostic imaging. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage

From October 2017 to September 2018, the trust reported that bank staff were used to supply 17% of required cover and locum staff an additional 80%.

(Source: Routine Provider Information Request (RPIR) – Bank Agency Locum)

During our last inspection, we found the service did not have enough medical staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. At this inspection, we found recruitment into the radiologist workforce remained an ongoing challenge and locum doctors were used as an interim measure to keep people safe from harm. Despite numerous attempts to advertise and interview radiologists, the hospital continued to struggle in recruiting and filling vacancies, particularly for certain modalities such as breast. Managers we spoke with were aware of these challenges and locum doctors were used as an interim measure.

The imaging service had a budgeted establishment of 13 whole time equivalent (wte) consultant posts, with 10.45 in post, which meant there were 2.55 wte vacancies. In addition, following a resignation and the retirement of two consultants, there would be a further two wte vacancies from February 2019. Consultant capacity shortfall was made up by outsourcing to teleradiology.

Additional in year funding had been agreed to increase the establishment by a further 2.45 wte enabling the department to advertise five wte consultant posts. At the time of our inspection, 1.6 wte had been recruited (post holders commencing in February and April 2019).

The breast imaging service had a budgeted establishment of three wte, comprising two consultant posts and one consultant mammographer post. The consultant mammographer post was vacant at the time of the inspection, but had been recruited to with the post holder commencing at the trust in March 2019. The two consultant posts would both become vacant in February 2019 and April 2019. A recruitment process was ongoing for these posts and locum staff had been identified to provide cover from February 2019.

Radiologists provided onsite cover from 8am until 8pm weekdays and 10am until 4pm at a weekend, with an additional out of hours cover. Radiologists were available 24 hours per day to discuss any concerns. Staff told us that there were never any issues contacting a consultant.

The department had access to a paediatric radiologist one day a week. Arrangements had been made with another local NHS acute trust for a paediatric radiologist to be on site one day a week (from 10am to 4.30pm). The department also had a service level agreement with a neighbouring trust to support with remote reporting and telephone advice, if necessary.

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In order to clear the backlog of unreported images, the service had outsourced some of the image reporting, and was also engaged in training reporting radiographers to improve the backlog.

Qualified allied health professional staffing

The trust has reported their staffing numbers for diagnostic imaging below for the period from September 2017 and October 2018. The trust did not report a planned staffing figure in order to provide a fill rate.

WTE Number in Post (September 2017 to October Ward / Team Staff 2018) Cardiac Investigations (1835) 2.3 3.0 Mammography (4160) 12.4 16.0 MRI / CT (4010) 17.3 20.0 Radiography - Kettering (4130) 33.2 36.0 Ultrasound (4180) 9.2 13.0 Grand Total 74.4 88.0

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From October 2017 to September 2018, the trust reported a vacancy rate of 17.0% for qualified allied health professionals in diagnostic imaging. This is higher than the trust target of 7%. At the time of our inspection, the service was in progress of recruiting more staff.

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From October 2017 to September 2018, the trust reported a turnover rate of 11.2% for qualified allied health professionals in diagnostic imaging. This is lower about the same as the trust target of 11%.

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From October 2017 to September 2018, the trust reported a sickness rate of 2.6% for qualified allied health professionals in diagnostic imaging. This was lower than the trust target of 4%.

(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

Data provided by the service showed between October 2018 and December 2018, no agency staff were used. For sonographers and radiographers, any unfilled shifts against establishment was covered from the bank team, wherever possible. Records Staff kept appropriate records of patients’ care and treatment. There were systems in place to flag records when patients had particular needs. Records were clear, up-to-date and available to all staff providing care.

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The service used two electronic record systems. The Computerised Radiology Information System (CRIS) and the Picture Archiving and Communication System (PACS). CRIS was a password protected record of patient’s demographics and could be used to book patients into vacant investigation slots. PACS was the system for storing completed images and the associated reports, which was password protected and accessible to radiology staff for reporting and clinicians who had requested the image. We saw that services did not maintain written patient records; details of all investigations and their findings were recorded electronically.

Patients’ individual records were written and managed in a way that protected patients from avoidable harm. We reviewed eight patient records. All records reviewed contained relevant information, such as patient details, medical history, referral details and allergies. All records seen had been completed appropriately. There were systems in place to identify patients with particular needs, such as a learning disability, allergies and safeguarding or mental health concerns. This was flagged in their record.

The service had moved from being paper based to predominantly electronic. Where there were paper records, such as paper referrals, these were shredded as per policy once the information was uploaded.

Throughout all departments, care was taken to ensure that computer screens were not accessible or in view of unauthorised persons. Computers were locked when not in use. Medicines The service administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.

There were suitable arrangements in place for the management of medicines, including contrast media, that protected patients from avoidable harm. This included the safe ordering, administering, recording, handling, storage and security of medicines.

The Society of Radiographers (SoR) recommended “Paused and Checked” system was used to check medications prior to administration. Care was taken to ensure the right patient received the right medicine. Patient’s identity was checked, confirmed and then checked against their prescriptions. Patients did not wear identity (ID) bracelets when visiting the department as an outpatient, however, inpatients were expected to wear ID bracelets throughout their admission.

Arrangements were in place for managing radiopharmaceuticals that protected patients from avoidable harm. There were processes in place to ensure the right radiopharmaceutical was injected, and appropriate checks were in place when the radiopharmaceutical was dispensed, drawn up and level of radioactivity measured. A second member of staff checked the dosage prior to administration.

Staff maintained a record of medicines being stored and used. Medicines, including intravenous fluids, were stored securely. Medicines requiring storage within a designated room were stored at the correct temperatures, in line with the manufacturers’ recommendations, to ensure they would be fit for use. Contrast media was stored appropriately and was accessible to key members of staff.

Staff were trained on the safe administration of contrast media including intravenous contrast. We reviewed staff competency files and saw all staff had received this training.

Room temperatures were recorded as part of the daily checks by staff. The temperature records showed temperatures had been checked daily and were within the required range. Staff knew what to do if the temperatures were not within the required range.

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Patient Group Directions (PGDs) were used in the service. This enabled radiographers to inject contrast within CT and MRI without the requirements for medical staff to complete a prescription for each patient. We saw evidence these were signed and dated, in line with best practice. Patient Group Directions provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber).

The service ensured the Medicines (Administration of Radioactive Substances) Regulations 1978 (MARS), were taken account of.

Staff were aware of procedures to follow if a patient was to have an allergic reaction. Emergency medicines were readily available in the event of an anaphylactic reaction. These were stored appropriately and were in date.

The pharmacy team were available for assistance and advice if required.

Radiation Dose Dose reference levels were set by an external radiation protection service. Staff reported that there was an effective relationship with the external provider and told us that they were responsive to their needs. Radiographers displayed a good understanding of dose reference levels.

Local rules were displayed on the doors of each imaging room. The team maintained a signature sheet to show that staff had read the local rules and this was updated annually, in line with good practice and IR(ME)R regulations. Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

From November 2017 to October 2018, the trust reported no never events for diagnostic imaging.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

Serious incidents are events in health care where there is potential for learning or the consequences are so significant that they warrant using additional resources to mount a comprehensive response.

(Source: Strategic Executive Information System (STEIS))

Serious Incidents (SIRI) – Trust data

In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents (SIs) in diagnostic imaging via the RPIR which met the reporting criteria set by NHS England from November 2017 to October 2018. These related to:

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• Treatment delay meeting SI criteria: One • Diagnostic incident including delay meeting SI criteria (including failure to act on test results): One • Radiation incident (including exposure when scanning) meeting SI criteria: One

Serious incidents reported to IR(ME)R NHS hospitals are required to report any unnecessary exposure of patients to radiation under the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R). Between January 2018 and December 2018, there had been four incidents in the diagnostics department. These incidents involved IR(ME)R investigations and were reported to CQC at the time. The CQC IR(ME)R inspection team who oversee these notifications had undertaken extensive investigation into the incidents and were assured the trust had carried out necessary actions. The four notifications all related to computed tomography (CT) and included:

• Patient had a CT scan of brain, but it should have been a CT scan of sinuses. • Out of hours vetting by teleradiology company where the call handler misheard the instruction from their own radiologist, and communicated it incorrectly to the radiographer. • A failure to check protocol meant whole spine CT instead on C-spine only scan • Wrong patient with a similar name was brought to CT. Patient was unable to speak and radiographer failed to undertake any ID checks or confirmation that the patient was expecting a scan.

The service held a number of IR(ME)R workshops following these incidents to share learning and to prevent them from occurring again.

There was an electronic reporting system in place to allow staff to report incidents. Any radiation incidents would be reported using the correct procedures. Staff would report to the team lead who would inform the Radiation Protection Supervisor (RPS), who would inform the Radiation Protection Service in Northamptonshire and the Radiation Protection Adviser (RPA). They would decide whether to refer the matter to CQC.

Arrangements were in place if a radiation or radioactive incident occurred, such as radioactive spillage, whilst carrying out nuclear medicine imaging. The radiation protection advisor and/or the medical physics expert would be contacted to seek advice. Staff told us a spillage had not occurred in the last 30 years, however, staff were aware of the procedures to follow if this were to occur.

Staff understood their responsibilities to raise concerns, to record safety incidents and near misses. The service had an incident reporting policy and procedure in place to guide staff in the process of reporting incidents. The service had recorded 192 incidents from 1 January 2018 to 31 January 2019. Incidents were categorised into subjects and levels of harm. There had been one death (not related to patient safety incident), four cases of moderate harm, 62 cases of low harm, 85 cases where there was no harm, and 40 near misses. The incident log included a description, immediate action taken, action taken as a result of an investigation, and lessons learned.

There was a positive incident reporting culture in the department; all staff we spoke with had received training and were encouraged to report incidents. Staff knew how to access the system and their responsibilities to report incidents, and felt confident to do so. All staff could give examples of when they had or would need to report an incident.

Staff told us they were provided with feedback after reporting an incident and that learning from incidents was shared across areas through staff meetings. Lessons learned from serious incidents also formed part of the services’ bulletin. They produced a ‘Learning Leaflet’ (also referred to as

20171116 900885 Post-inspection Evidence appendix template v3 Page 241 learning bulletins), which was circulated to all the staff. We saw evidence of the last two ‘Learning Leaflets’ for diagnostics and radiology.

The radiologists held a monthly learning from discrepancy meeting. Cases discussed at this meeting were not limited to discrepancies. Contributions of difficult cases and interesting cases for discussion were positively welcomed. The minutes of these meetings were widely circulated to all staff. The Royal College of Radiologists recommends that there should be such a meeting to discuss errors that have been reported for learning and reflective purposes.

Staff used The Society of Radiographers (SoR) “Paused and Checked” system. Referrer error was identified as one of the main causes of incidents in diagnostic radiology. The six-point check had been recommended to help combat these errors. Pause and Check consisted of the three-point demographic checks to correctly identify the patient, as well as checking with the patient the site/side to be imaged, the existence of previous imaging and for the operator to ensure that the correct imaging modality is used.

When things went wrong, staff apologised and gave patients honest information and suitable support. Staff knew their responsibilities regarding the duty of candour and knew what the trigger for application of duty of candour was. There were local arrangements in place for ensuring that patients were kept informed of incidents and any investigations and their outcomes. Staff told us information regarding duty of candour was available on the trust intranet.

We saw an example of a written apology which evidenced duty of candour principles had been applied. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person, under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Major incident awareness The service planned for emergencies and staff understood their roles if one should happen. The trust had a policy and plans in place for emergencies and other unexpected or expected events, such as adverse weather, flu outbreak or a disruption to business continuity.

There was regular testing of generators in case there was a failure of the electricity supply to the hospital. Staff were aware of the procedures for managing major incidents, winter pressures and fire safety incidents. Fire safety awareness training was a mandatory training and staff attended the training annually. As of 1 February 2019, 94% of staff across all staff groups were up to date on fire safety training.

In the event of a radiation or radioactive incident, there were effective arrangements in place. For example, training had been provided to staff and all staff we spoke with were aware of the procedures to follow in the event of a radioactive incident.

There was an effective understanding amongst staff about their roles and responsibilities during a major incident.

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Care and treatment was delivered in line with legislation, standards and evidence based guidance.

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The diagnostic and imaging service delivered care and treatment in line with the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R), guidelines from the National Institute for Health and Care Excellence (NICE), the Royal College of Radiologists (RCR), the Society of Radiographers and other national bodies.

At our previous inspection, the service had not followed the guidelines issued by the RCR on non- radiology clinicians reviewing images. This was raised as a concern and the trust took urgent actions to develop a detailed action plan to address this concern. During this inspection, we were told that from December 2017 the service resumed formal reporting of all in-patient x-ray examinations, removing the risk of inexperienced doctors reviewing the images at ward level.

All radiation protection policies and procedures were stored on the trusts intranet, and reflected current guidance. Staff said they had access to policies, procedures, national and specialist guidance through the hospital’s intranet.

Policies, procedures and staff competence ensured, in relation to diagnostic procedures, the practitioner noted the diagnostic reference level for each investigation. Activity for each exposure was the optimised so it was the lowest practicable dose to the patient.

Radiation protection services were provided by an external provider. The trust had a service agreement with a neighbouring NHS trust to provide medical physics support, a radiation protection advisor, and medical physics experts, as required by law. The medical physics teams provided scientific support, advice and guidance on IR(ME)R regulations concerning the use of imaging equipment, and monitored the radiology equipment and staff radiation dosages. The main legal requirements enforced by the Health and Safety Executive are the Ionising Radiations Regulations 1999 (IRR99). In line with IRR99, the diagnostics department appointed radiation protection supervisors whose role was to ensure staff followed the trust standard operating procedures and adhered to the radiation protection procedures. IRR99 requires employers to keep exposure to ionising radiations as low as reasonably practicable. Exposure must not exceed specified dose limits.

‘Pause and Check’ posters were displayed in all imaging areas visited. The Society and College of Radiographers produced this resource to reduce the number of radiation incidents occurring within radiology departments.

Policies were in place to ensure patients were not discriminated against. We saw no evidence of any discrimination, including on grounds of age, disability, gender, gender reassignment, pregnancy and maternity status, race, religion or belief and sexual orientation when making care and treatment decisions. Staff were aware of these policies and gave us examples of how they followed this guidance when delivering care and treatment for patients. Staff were aware of how to access policies and procedures. Staff told us that they would escalate any concerns, and seek further guidance if necessary.

Since our last inspection, the service had developed an improved audit programme covering clinical, technical, and quality aspects of the service. The service was involved in national and local audits, and an audit programme for the current financial year was in place. The service collated evidence to monitor and improve care and treatment for patients. We were provided with evidence of audits the service had been involved in. This included national audits such as:

• RCR National Audit of Seven Day Care in Radiology • RCR National Audit of Radiology Involvement in Cancer Multi-Disciplinary Team Meetings • RCR National Audit of the Provision of Imaging of the Major Trauma Patient • UK National Audit of Safety Checks for Radiology Interventions

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• Image Quality Audits • Audit of Staff Knowledge of Royal College of Radiologist Current Recommendation on the Management of Mild and Severe Contrast Medium Reaction • CT Guided Biopsies, Tunnelled Central Venous Lines • Radiation Risk Amongst Personnel Performing IR(ME)R practitioners’ functions

The service also undertook monthly audits of reporting accuracy with each of their teleradiology providers. Any reporting discrepancies were fed back to the providers on a regular basis. Actions were taken to improve care and treatment where compliance was poor.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. Patients attending the department were not routinely provided with food or drinks. The majority of patients attending the department as outpatients were in the department for a short period. There was a water dispenser available in all the waiting areas for patients and visitors to help themselves. This meant that patients were able to keep themselves hydrated while waiting to be seen.

Processes were in place for vulnerable patients, for example, frail patients or diabetic patients who required pre-examination fasting. The service ensured these patients were examined earlier in the day. Pain relief Pain relief was not routinely used in diagnostic imaging. However, patients were asked by staff if they were comfortable during their appointment.

Pain relief was not routinely used in diagnostic imaging, with the exception of when patients were attending for invasive procedures. Patients were asked by staff if they were comfortable during their appointment, however no formal pain level monitoring was undertaken as these procedures were pain free.

Patients we spoke with had not required pain relief during their attendance. Patient outcomes The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. During our inspection, senior managers told us that the service was planning to participate in the Imaging Services Accreditation Scheme (ISAS), and were hoping to be accredited within the next two years. The Royal College of Radiologists and College of Radiographers had developed (ISAS) to support diagnostic imaging services to manage the quality of their services and make continuous improvements; ensuring that their patients consistently receive high quality services delivered by competent staff working in safe environments.

Information about the outcomes of patient’s care and treatment was routinely collected and monitored. The service regularly reviewed the effectiveness of care and treatment through local audit and national audit. They took appropriate action to monitor and review the quality of the service and to effectively plan for the implementation of changes and improvements required. Staff ensured they had ownership of things that had gone well and that needed to be improved.

The service recorded the time between when a referral to the service for a scan was received and that scan being booked. They also reported on the time between the scan to when the scan was reported on. These were monitored daily through key performance indicators.

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At our previous inspection, we found no image quality audits had taken place from November 2016 to October 2017 because of shortage of staff. This meant that patients may have received inappropriate treatment because the images may not have provided the diagnostic information required. During this inspection, we found improvements had been made and audits of quality of images were carried out. For example, a chest x-ray quality audit was undertaken in November 2018 which found compliance ranged between 90-100% with all standards measured. Additionally, an abdomen x-ray quality audit was undertaken in January 2019 which found compliance ranged between 75-100% with standards measured. Any issues found were fed back to staff for learning and improvement.

Also, at our last inspection, radiographers were not conducting reject analysis (where a radiographer finds that an image they have taken is unusable and has to be taken again). Reject analysis looks at the percentage of reject images for each body part and type of image. This is used to learn lessons and improve technique, to reduce the reject rates in future). We found evidence during this inspection that audits of reject analysis (also referred to as technique audits) were undertaken. Data requested from the service showed the last chest technique audit conducted in November 2018, showed high compliance (more than 90%) with standards measured.

Findings from audits were shared with staff and discussed at the radiology quality governance meetings and staff meetings.

Although a formal peer review process was not in place, the quality of images and any deficiencies were regularly discussed at staff meetings for learning. The radiologists held a monthly learning from discrepancy meeting. Cases discussed at this meeting were not limited to discrepancies. Contributions of difficult cases and interesting cases for discussion were positively welcomed. The minutes of these meetings were widely circulated. The Royal College of Radiologists recommends that there should be such a meeting to discuss errors that have been reported for learning and reflective purposes.

Ultra sonographers told us they regularly undertook peer reviews of images.

Quality checks were carried out regularly on all diagnostic and x-ray equipment. Lead aprons were checked annually in line with good practice to ensure they were fit for purpose and not damaged. Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Appraisal compliance was 90.6%, which met the trust target of 85%.

Appraisal rates

As of September 2018, 70% of staff within diagnostic imaging department at the trust received an appraisal compared to a trust target of 85%.

Appraisals Individuals complete Completion Staff group required (YTD) (YTD) rate Nursing and Midwifery Registered 9 9 100% Add Prof Scientific and Technic 50 36 72% Healthcare Scientists 17 12 71%

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Administrative and Clerical 12 8 67% Additional Clinical Services 15 8 53% Allied Health Professionals 3 1 33% Grand Total 106 74 70%

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)

However, during our inspection we found compliance with staff receiving an appraisal had improved. Data requested from the service showed overall 90.6% of staff within the diagnostic imaging department received an appraisal. This was above the trust target of 85%.

The service had processes in place to identify training needs and compliance, which ensured staff were confident and competent to undertake their roles.

All eligible staff had had their professional registration in the last 12 months. All radiographers were HCPC (Health & Care Professions Council) registered and met the standards to ensure delivery of safe and effective services to patients. All medical and nursing staff had revalidated their professional registrations in a timely manner.

The service provided development opportunities for staff. For example, the service had a small team of reporting radiographers to report on plain film x-rays. Staff were encouraged and supported to develop their knowledge, skills and practice. Staff undertook competency assessments to ensure they had the appropriate clinical skills and knowledge to manage patients safely and effectively.

All staff administering radiation were appropriately trained to do so. Those staff that were not formally trained in radiation administration were adequately supervised in accordance with legislation set out under IR(ME)R. Each area within the imaging department had lead radiographers. This was a senior practitioner who worked with the senior manager of the department to ensure delivery of recommended standards as recognised by the Society of Radiographers.

We saw records that showed that staff had been trained on equipment they used. These were updated when skills or equipment changed. Data provided by the service showed 100% of staff working as operators under IR(ME)R had undertaken a recognised academic course of training and were either registered with the HCPC or worked as assistant practitioners under the supervision of an HCPC registered radiographer.

The service had an established IR(ME)R group supported by the Radiation Protection Advisor and the Medical Physics Expert that met monthly to discuss all aspects of radiation safety within the department.

There were clear records showing who was entitled to administer radioactive medicinal products (RMP) together with who had the necessary certificate from ‘The Administration of Radioactive Substances Advisory Committee’ (ARSAC).

During our last inspection we found the trust had relied on non-radiology clinicians to review inpatient plain films. There had been no quality monitoring of the clinicians to test their competence before they were allowed to review the images. There was no monitoring of the accuracy of the reviews. There was no monitoring of the impact of this decision and how patients’ health was affected. This was raised as a concern and the trust have since changed its processes for reporting on inpatient plain films. In December 2017, the service resumed formal reporting of in-patient x-ray examinations, removing the risk of inexperienced doctors reviewing the images at

20171116 900885 Post-inspection Evidence appendix template v3 Page 246 ward level. Inpatient x-ray studies were now formally reported by either a consultant radiologist or an experienced qualified reporting radiographer.

Arrangements were in place for supporting and manging staff. Staff completed an annual appraisal as part of their personal development review. Staff said they had completed an appraisal within the previous year and found it useful. Staff were encouraged to identify learning needs they had, and any training they wanted to undertake. Staff were supported to reflect, improve and develop their practice.

Multidisciplinary working Staff of all disciplines worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

Staff in all areas of the diagnostic and imaging service at Kettering General Hospital told us they worked closely to make sure patients received safe and effective care. This included working closely with other departments within the trust, external organisations and healthcare professionals.

We saw evidence of multidisciplinary working, for example, nurses, porters, administration staff, radiographers, radiologists, and sonographers working collaboratively to improve the patient experience.

The service completed joint multidisciplinary team meetings with other specialities within the trust, for example, with cancer specialities. The service was part of the medicine division and managers attended joint meetings to discuss performance.

The service had regular team meetings which were used to share information across all modalities, specific to the service or trust. These were well attended, with minutes available to all staff.

Throughout our inspection, we observed good interactions between medical, nursing and support staff in the radiology department and cardiac investigation unit. Staff confirmed there was good multidisciplinary team working within the service and with external organisations. Seven-day services The service made sure patients had access to the main diagnostic services seven days a week.

Patients were able to access the main diagnostic services 24 hours a day, seven days a week.

There were two radiographers on night duty and they were assisted by a health care assistant. The radiographers offered a 24-hour, seven-day week service for plain film and CT x-rays for both inpatients and A&E patients. Plain film x-rays for GP patients and outpatient clinics were available from 8am until 8pm during the week, on a walk in basis at Kettering general hospital. Other x-ray departments were available at other locations and offered an appointment service for GP patients.

Radiologists provided onsite cover from 8am to 8pm weekdays and 10am to 4pm during the weekend. Outside of these hours, the department had a service level agreement with two tele- radiology companies who provided reporting services for CT and MRI scans performed overnight. The cardiac investigations unit was open 8am to 6pm Monday to Friday for opening and preparing equipment, with electrocardiogram appointments available from 8.30am to 5.30pm and all other investigations available from 9am to 5pm.

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A paediatric radiologist was on site one day a week (from 10am to 4.30pm). The department also had a service level agreement with a neighbouring trust to support with remote reporting and telephone advice, if necessary. Health promotion Patients were supported to live healthier lives and manage their own health, care and wellbeing.

Health promotion information leaflets and posters on subjects such as living with cancer were on display in the waiting rooms. Various information leaflets were available in all clinical areas and waiting rooms. This included, but was not limited to, ‘Vacuum Assisted Biopsy’, ‘Breast Service Prosthetic Fitting’, ‘Fat Necrosis’, ‘Duct Ectasia’, ‘Breast Pain’, and ‘Breast Reconstruction’.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked capacity to make decisions about their care.

The trust had policies in place regarding consent and the Mental Capacity Act 2005 (MCA). Staff could access these through the intranet. Staff understood the relevant consent and decision- making requirements of legislation and guidance and had received training on mental capacity and deprivation of liberty safeguards.

Staff had an effective understanding of gaining consent. They were aware of what to do if they had concerns about a patient and their ability to consent and were familiar with processes such as best interest decisions.

There were no patients attending at the time of inspection, who lacked capacity to make decisions in relation to consenting to treatment. Staff told us if, for example, a patient with a learning disability or a person living with dementia was due to attend, they would be advised to attend with a relative or carer to provide the necessary support.

We observed staff obtaining verbal consent from the patients during their interventions. Patients we spoke confirmed their consent had been obtained throughout the scanning process.

Scan safety checklists were completed by patients prior to certain scans, such as MRI and CT. These were signed by both the patient and staff.

Mental Capacity Act and Deprivation of Liberty Training Completion

The trust reported that from October 2017 to September 2018, Mental Capacity Act (MCA) training was completed by 75% of staff in diagnostic imaging compared to the trust target of 85%.

(Source: Routine Provider Information Request (RPIR) – Training tab)

During our inspection, data provided by the service confirmed compliance with training for MCA had improved. As at 1 February 2019, 83.6% of radiology staff had completed MCA training.

Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

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We observed patients being treated with respect and compassion throughout our inspection. We spoke with 15 patients and relatives. All patients we spoke with were highly complementary of the care they had received. Patients and their relatives told us staff were extremely friendly and helpful despite working under pressure and being very busy. Comments we received from patients included: “the staff are very professional at all times”, and “all staff are extremely friendly and helpful”.

Staff took the time, where possible, to interact with patients and those close to them in a respectful and considerate manner. Staff were encouraging, sensitive and supportive to patients and those close to them.

Care observed met National Institute for Health and Care Excellence (NICE) QS15 Statement 1: ‘Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty’, NICE QS15 Statement 2: ‘Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills’, NICE QS15 Statement 3: ‘Patients are introduced to all healthcare professionals involved in their care and are made aware of the roles and responsibilities of the members of the healthcare team’ and NICE QS15 Statement 13: ‘Patients’ preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care’.

Staff respected patients’ social, cultural, and religious needs. We observed positive interactions between staff, patients and their relatives. We saw staff respecting patients’ privacy and dignity, for example by knocking on doors to rooms, ensuring curtains were drawn, and closing doors to protect patients’ privacy. All patients we spoke with, were satisfied with the standard of care provided by staff and told us their privacy and dignity was respected always.

Chaperones were available in all departments if patients required them. We saw signs displaying this information to make patients aware. A permanent chaperone was available in the ultrasound department, particularly for intimate procedures.

Every patient had the opportunity to complete the NHS Friends and Family Test (FFT) and indicate their likelihood to recommend the service. The Friends and Family Test (FFT) is an important feedback tool that supported the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. Between May 2018 and January 2019, nine patients completed the FFT. Of these, 89% of patients said they would be ‘extremely likely’ to recommend the radiology service, with the remaining 11% ‘neither likely or unlikely’ to recommend the service. Staff were aware of the low response rate, and tried to encourage patients to complete a survey following their appointment. Emotional support Staff provided emotional support to patients to minimise their distress. Staff throughout the diagnostic and imaging service understood the need for emotional support. We spoke with patients who all felt that their emotional wellbeing was cared for. Patients we spoke with said they had received good emotional support and felt they had been given enough time to ask questions.

Staff understood the impact that a patient’s care, treatment or condition had on their wellbeing and on their relatives, both emotionally and socially. Staff were aware patients attending the service were often feeling nervous and anxious and provided reassurance and support.

Staff told us, if a patient became distressed, staff could take them in to a private room to talk to them to assist them to maintain their privacy and dignity. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment.

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Staff communicated and involved patients so that they understood their care, treatment and condition. Staff took the time to explain the procedure and what would happen during their appointment. Patients felt well informed and could explain what would happen next. Patients and those close to them told us they felt listened to, respected and had their views considered. They felt comfortable asking questions about their care and said they had been given time with staff to ask questions.

Staff recognised when patients required additional support to help them understand and ask relevant questions about their care and treatment. Staff had telephone access to language interpreters if they required, and interpreters could attend when booked in advance.

Staff made sure that patients and their relatives, were able to find further information or ask questions about their care and treatment. There was a range of leaflets available, for example, information about the scan and information about common health conditions.

Patients were able to be escorted by their relatives or friends if they wished.

Is the service responsive?

Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. The hospital provided a range of diagnostic and imaging services, which included general radiography, computerised tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, interventional radiology, fluoroscopy, mammography, and ultrasound. Diagnostic investigations also occurred in the cardiac investigations unit. These investigations included non- radiological investigations, such as electrocardiograms, heart monitoring, echocardiograms, and exercise tests.

The trust was one of six belonging to the East Midlands Radiology Consortium (EMRAD) to serve the local population of the East Midlands. EMRAD is a vanguard consortium designed for sharing radiology workloads between the trusts in the consortium in order to work efficiently and safely. It was based around a system that stores and transmits images and reports seamlessly throughout the region, supporting services 24 hours a day, seven days a week. The consortium aims to be part of a sustainable long-term model for radiology services in the region. This initiative required the work processes and data formats to conform to international standards, as advised by the consultancy integrating the Healthcare Enterprise (IHE). A private company had provided a picture archiving and communication system (PACS), and had provided the data communication facilities. Clinicians at all locations could view all patient data. They shared information with other NHS organisations and private contractors. NHS England had chosen EMRAD as an NHS vanguard project. This meant that the project was intended to serve as a centre of excellence in a leading- edge field to provide a model, which can be rolled out nationally. The EMRAD vanguard was devising techniques for pooling diagnostic imaging services among trusts in order to provide higher quality services with increased throughput and lower response time and at lower cost. This was expected to improve clinical care for urgent requirements such as major trauma and stroke conditions, and to support regional acute surgical centres. In some cases, care could be provided to patients closer to home, because the imaging data is now available at more local sites.

Radiographers worked a shift system and generally worked between the hours of 8am till 8pm. There were two radiographers on night shift with one for the CT unit and one for general x-ray. There was a healthcare assistant to assist them. There was a radiographer on call each night from home.

Paediatric radiology provision was limited. The department had access to a consultant radiologist specialising in paediatric radiology one day a week. The service also had a service level 20171116 900885 Post-inspection Evidence appendix template v3 Page 250 agreement with a neighbouring trust to support with remote reporting and telephone advice, if necessary.

The trust provided one stop clinics, where possible, to reduce the number of patients’ hospital appointments. For example, patients attending for an endoscopic procedure who then required imaging had their appointment at the same time, preventing patients from attending the hospital on two separate occasions.

The facilities and premises were appropriate for the services that were planned and delivered. The diagnostic and imaging services were clearly signposted from the entrance of the hospital and was a short walk from the main reception on the ground floor. Volunteers were also available at the main reception to help direct patients. This meant that the department was easily accessible for all patients. All departments had appropriate facilities to meet the needs of patients awaiting appointments. This included comfortable seating, access to bathrooms, water dispensers and reading material. Additional drinks and snack were available in the main hospital building. Each examination room was assessed for suitability prior to its use and provided privacy and dignity. All modalities included a separate designated inpatient and outpatient waiting area to maintain patients’ privacy and dignity.

Information was provided to patients in accessible formats before appointments. Appointment letters containing information required by the patient such as contact details, a map and directions and information about the procedure including any preparation such as fasting was required. Patients who required additional support, for example patients living with dementia or a learning disability, were able to bring a carer/relative.

Staff felt they had worked well with local GPs, other healthcare providers and local authorities to meet the needs of the local population. Meeting people’s individual needs The service took account of patients’ individual needs. Patients’ individual needs were accounted for. Staff delivered care in a way that took account of the needs of different patients on the grounds of age, disability, gender, race, religion or belief and sexual orientation. Staff had received training in equality and diversity and had a good understanding of cultural, social and religious needs of the patient and demonstrated these values in their work.

Reasonable adjustments were made so patients living with a disability could access and use services on an equal basis to others. Patients with mobility difficulties had easy access to the waiting areas and examination rooms as all departments were located on the ground floor. The corridors were wide which meant there was easy access for wheelchair users. There were patient toilets located in all clinical areas, and all were suitable for the use of patients who had reduced mobility and required mobility aids or wheelchairs. Bariatric equipment could be accessed if required. We saw bariatric seating, examination couches, and wide-bore scanners that were compatible with heavy weights. Wide-bore MRI scanners were also used for claustrophobic patients.

During an MRI scan, staff made patients comfortable with padding aids, ear plugs and ear defenders to reduce noise. Patients were given an emergency call buzzer to allow them to communicate with staff should they wish. Microphones were built into the scanner to enable two- way conversation between the operator and the patient.

Staff had a good awareness of patients with complex needs and those patients who may require additional support should they display difficult behaviours during their time in hospital. Patients knew whom to contact if they had any concerns about the care. There was a system to notify staff if patients required additional support, such as patients living with a learning disability, dementia,

20171116 900885 Post-inspection Evidence appendix template v3 Page 251 or mental health problems. This information was added to patients’ electronic record so that the department could make necessary adjustments prior to their appointment, for example fast- tracking patients to avoid unnecessary distress.

An interpreting service was available to patients and their families where English was not their first language. Staff told us that they were able to book translators to accompany patients to the department in advance of their appointments. This was dependent on the knowledge that the patient required assistance. Staff also had access to language line, a phone translation service where appropriate.

Hearing loops were installed at the reception desks for patients with hearing difficulties.

Information leaflets were sent to patients with their appointment letters and were available in the waiting rooms. These leaflets included information about what the scan would entail and what was expected of the patient before and after the appointment.

General information leaflets relating to most services provided, including complaints, were also available in the waiting areas. Written information on medical conditions and procedures was available and accessible throughout the department.

The service provided spiritual and religious support for patients and their families. A multi-faith chaplaincy service was available for support. Access and flow Patients could access the service when they needed it. Waiting times to treat patients were generally in line with good practice. Most patients received diagnostic imaging within the six week target. The backlog of unreported images and delays in reporting had significantly improved.

Diagnostic waiting times (percent waiting 6+ weeks)

Between October 2017 and September 2018, the percentage of patients waiting more than six weeks to see a clinician was lower than the England average. The England average is the mean value from NHS Trusts, NHS Foundation Trusts and Independent Sector Providers in England. The chart below shows 6+ weeks percentages over time

(Source: NHS England – Diagnostic Waits)

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The department aimed to ensure all appointments met the six week suggested target. Any patient with a suspected cancer diagnosis would be seen within one week and the images would be reported within another week, which was better than the two-week cancer pathway target.

We spoke with patients in the waiting areas. The patients were seen on time and had not waited long for their appointment.

Waiting Times for Imaging During our inspection, we made a further data request for waiting times for appointments to take the image, excluding reporting, for all modalities for the period December 2018. The target was six weeks / 42 days from the date of referral to image acquisition. The trust ran a weekly report and all referrals validated against the target of six weeks. There were no reportable six week breaches of the Referral to Treatment (RTT) target. As at December 2018, 94.6% of patients were seen within six weeks. Waits of over six weeks were due to clinical requirements for future planned imaging or were as a result of patient choice.

Summary 6weeks 0-41 Breast Care 82.73% CT 95.43% Fluoroscopy 98.87% MRI 95.34% Nuclear Medicine 95.00% Obstetric 72.12% Plain Film 99.68% Ultrasound 88.04% Grand Total 94.65%

DNA Rates During our last inspection, we found the department had no monitoring system in place for patients who did not attend (DNA) an arranged appointment. The service had no record of the ‘did not attend’ performance rate. At this inspection, we found this had improved. Data requested from the trust showed during January 2019, the service had a 2.11% DNA rate across all modalities. This information was used to plan treatment. For example, the service had implemented the mobile phone text reminder service which would prompt patients of their appointment date. Patients who did not attend were referred back to the requesting doctor to enable a follow up appointment.

We saw evidence of DNA audits. The most recent DNA audit completed looked at the number of in-patient ultrasound slots which were wasted due to non-attendance. The audit took place over a one month period with the outcomes demonstrated on a poster. As an action, the poster had been sent to all lead nurses across the trust for them to forward to ward managers to share learning. The information was also being developed on to a trust PC screensaver in order to raise awareness.

Backlog of Unreported Images The diagnostics department had a number of methods of taking an image, termed modalities, which included x-rays, CT, MRI, and ultrasound. There were two waiting periods involved. First, a wait for the patient to be scheduled to see the radiographer for the image to be taken, which is termed ‘imaging’. The image may then need to be interpreted by a radiologist, a step termed ‘reporting’.

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At our last inspection, we saw delays in image reporting which meant there was a risk that patients’ consultants or their own GPs did not always have timely information about their patients’ conditions. There was a potential risk that patients may have experienced some identifiable level of harm due to their condition worsening. There was a backlog of 10,723 unreported images (as at 27 October 2017). Routine outpatient tests, GP plain films, and A&E plain films were part of the backlog. We found there were no formal processes for prioritisation of images on the backlog. There was not a formal individual assessment of risk that this delayed reporting may have for a patient. We raised this as a significant concern and senior managers took urgent actions to develop and implement an ongoing action plan with clear work streams and timescales to continue to reduce this backlog. Actions included setting up a new data collection process and bi-weekly reports with the commencement of a weekly radiology executive assurance group, led by the chief operating officer and a non-executive director, and chaired by the chief executive officer of the trust. A radiology reporting recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery.

During this inspection, we found significant improvements had been achieved within the service. The reporting backlog had been almost cleared and reporting turnaround times had been dramatically reduced. This had been achieved as a result of increasing the reporting capacity through use of locum consultants and increased outsourcing to the trust's two teleradiology providers. More recently, in the last few years the trust had been using the East Midlands Radiology Consortium (EMRAD) insourcing capacity from both within Kettering General Hospital and from other EMRAD trusts. EMRAD is a vanguard consortium designed for sharing radiology workloads between the trusts in the consortium in order to work efficiently and safely. The PACS system recently implemented was now monitored daily to ensure a steady and consistent service. New key performance indicators (KPI’s) and reporting processes were introduced to measure improvements, and to facilitate the ongoing management of the reporting workload. The service was now working to, or very close to, its agreed KPIs for most modalities. Typically, in December 2017, the trust reported the wait time for a routine CT or MRI report was up to seven to eight weeks. As of October 2018, the average wait for similar studies was just over two weeks. The trust also reported improvements in the turnaround of A&E extremity reporting, which was now usually within four days or less (over four weeks in December 2017). The service had an operational plan to create a sustainable and cost effective reporting team and to move away from reliance on third party support.

Delays in Image Reporting The service had ensured patients with suspected cancer had images taken within one week and the images were reported in a further week. This was better than the two weeks target for the cancer pathway.

The average reporting wait time as of 7 February 2019 for plain film x-ray was nine days, 15 days for CT, and 13 days for MRI.

For the last 12 months, from January 2018 to January 2019, the service had been working to reduce its backlog of reporting. In November 2017 the number of unreported studies was over 225,000. The total as of 31 January 2019 (provided as a data request) was 1,519. During our inspection, we were shown data on the total number of unreported images in the system, as it varied in time, supplementary to the data in the additional data requests. As of 7 February 2019, the number of unreported images was approximately 1,200.

In the absence of any national target for reporting turnaround times, the service (as part of the improvement plan) had developed a set of key performance indicators which have been in a trial phase since October 2018 with a review planned for February 2019.

As of 31 January 2019, the service had 139 studies outside the maximum 10 working days for report, giving 91% compliance against the trust agreed target.

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Awaiting Report 31/01/2019 Plain Film 892 MRI 203 CT 268 Ultrasound 58 Fluoroscopy 45 Nuclear Medicine 47 Breast Care 6 Total 1519

Delays in Image Reporting by Modality from January 2018 to December 2018

Grand month: 1 2 3 4 5 6 7 8 9 10 11 12 Total Breast Care 33 1 29 5 7 3 2 13 25 105 74 30 327 13 35 CT 185 120 137 46 73 71 277 205 432 333 3 2 2364 Endoscopy 4 5 5 11 9 8 3 1 4 4 54 Fluoroscopy 57 30 39 49 26 52 41 27 16 30 23 39 429 14 16 MRI 418 99 276 212 133 236 506 569 612 186 2 5 3554 Nuclear Medicine 4 1 4 1 3 21 4 1 6 45 Obstetric Ultrasound 287 186 210 190 127 26 120 181 128 8 6 1469 226 152 270 176 121 157 132 285 219 47 15 Plain Film 1 4 2 9 5 2 2 1 3 769 7 1 18806 Ultrasound 32 35 28 27 33 28 41 35 12 5 22 21 319 328 200 342 230 162 200 231 388 344 144 88 76 Grand Total 1 1 1 3 5 1 8 7 0 4 2 4 27367

Information received from the trust showed that between January 2018 and December 2018, of the 27,367 patients who waited more than 10 working days to receive their report, 25,783 were delayed by between two and 14 days, 1,285 were delayed by 15 to 30 days, and 299 were delayed by 31 to 54 days. The maximum delay was 54 days. This was an improvement since our last inspection, where we saw some images were taking up to 46 weeks to report.

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. However, the service took longer than the trust target to investigate and close complaints.

Summary of complaints

From October 2017 to September 2018 there were 26 complaints about diagnostic imaging. The trust took an average of 59.6 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be closed within 35 days. There were no specific themes emerging for the subject of the complaints that were received.

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

The hospital had a clear process in place to ensure complaints were dealt with effectively. Staff were aware of the complaints procedure and informed us that they tried to resolve any patient concerns immediately to prevent the concerns escalating to a complaint. Staff understood the

20171116 900885 Post-inspection Evidence appendix template v3 Page 255 principles of duty of candour and could describe them. Complaint leaflets, on how to make a complaint or raise a concern, were available to patients in all the waiting areas.

Patients knew how to make a complaint, although none of the patients we spoke with during our inspection felt the need to complain.

As part of the complaints process, the outcome and learning was shared with individuals involved and any action to support development put in place. Staff told us learning from complaints and feedback was shared with staff through a variety of means such team meetings, clinical governance meetings, ‘learning from discrepancies’ meetings, and the patient experience report. Most complaints related to delays in receiving radiology results, delays in investigations or GP concerns relating to delays in image reporting. As a result of the delays in reporting of radiology images, a teleradiology provider was used to provide additional reporting capacity. Staff had also been reminded to provide patients with realistic timescale of reporting scans, and the scan pathways have been reviewed to ensure the correct scan appointments are booked for patients.

A new information technology (IT) system had been installed which enable alerts to be notified to referring clinicians that results on diagnostic radiology testing were available. This was piloted in the emergency department during March 2018, and the system was in the process of being rolled out trust wide.

One complaint relating to the radiology service had been referred to the Parliamentary and Health Service Ombudsman (PHSO). The complaint was upheld, and the recommendation concluded that there was a delay in the reporting of the MRI scan and a delay in the complaints investigation. An apology was provided to the patient concerned, and in accordance with the PHSO recommendation, a payment of £150 for any distress caused. The PHSO were assured an action plan was in place overseen by the medicine division.

Number of compliments made to the trust

From October 2017 to September 2018, there were nine compliments within diagnostic imaging.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led?

Leadership The service generally had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

During our last inspection, we found the service lacked leadership capacity to run a service providing high-quality sustainable care. The radiology manager was formerly accountable for all the services which fell within the clinical support business unit. They had a large work portfolio to oversee the day-to-day management of the diagnostic imaging service, handling the backlog of unreported images, as well as performing the role of a general manager for a number of other services in the trust. We did not see clear evidence that the leadership team had driven sustainable improvements. Service managers did not have the capacity to lead effective service change. There was an acceptance of the delayed reporting of images as this was ascribing to be a part of the national problem with radiology and radiographer staffing.

Since our last inspection, the trust had restructured the organisation with diagnostic and imaging services falling under the medical division. The radiology manager’s portfolio was seen to be manageable, however, a clinical director/lead was not in place to provide additional support and

20171116 900885 Post-inspection Evidence appendix template v3 Page 256 oversight of the service. We saw significant improvements had been made since our previous inspection. The backlog of unreported images and delays in reporting had significantly improved.

We met with the diagnostic and imaging services senior management team who demonstrated knowledge of the service’s performance. They understood the challenges to quality and sustainability the service faced and had pro-active ongoing action plans in place to address them.

The trust provided development programmes for staff, which supported them to develop leadership and management skills. Senior management staff told us the trust was supporting external leadership courses.

All staff reported leadership within the diagnostic and imaging departments was very strong, with visible, supportive, and approachable managers and superintendents. Staff commented that the head of radiology was visible within the department and was always available for advice.

Staff were aware of the senior trust team, and could recall the name of the chief operating officer and chief executive.

Vision and strategy The service had a vision and strategy for what it wanted to achieve, which was linked to and supported delivery of the core elements within the trust strategy.

During our previous inspection, we found the service did not have a meaningful plan or strategy to address the issues concerning the high number of unreported images. There was no robust monitoring system to indicate the true extent of the backlog of unreported images or full consideration of potential risks to patient safety.

At this inspection, we found this had improved. The vision for the diagnostic and imaging service had been developed to create a vision for the department, to help work closely to deliver the trust values. The service’s vision was to “provide a safe and responsive imaging service to all patients coming to Kettering General Hospital”. Their strategy to achieve this is was as follows:

• To ensure a fulfilling and developmental working environment for our staff • To be a clinically and financially stable service where innovation and making best use of resources are embedded into the culture of the service • To work collaboratively and effectively with partners both within the Trust, the county and the wider region • To provide the best possible experience to all our patients, service users and colleagues

These objectives were linked to the refreshed trust strategy, and supported delivery of the core elements of that. Culture Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were committed to improving the quality of care and patient experience. Throughout our inspection, we observed a strong patient-centred culture across diagnostic and imaging services.

All staff we met were welcoming, friendly and helpful. It was evident that staff were passionate about the services they provided. Staff were committed to providing the best possible care for patients.

During our last inspection, staff felt the volume of work was overwhelming at times and were concerned about patient safety due to the high number of unreported images. We found this had

20171116 900885 Post-inspection Evidence appendix template v3 Page 257 improved at this inspection. Staff were happy with the improvements made and said morale in the service was much better.

We observed good working relationships across the service and it was evident that staff morale was good in all areas we visited. Staff spoke with pride about their role in diagnostic and imaging services, and told us they felt respected and valued by their managers and senior management team.

Staff at all levels told us there was good team working throughout the service. Staff worked together to provide the best possible care for patients. During our inspection, we observed positive and respectful interactions, which were focused on meeting patients’ needs and providing safe care and treatment.

The service had mechanisms in place for providing all staff at every level with the development they required, including high-quality appraisal and career development conversations. We saw 90.6% of staff within the diagnostic imaging department received an appraisal. This was above the trust target of 85%. Staff told us they found appraisals useful.

Staff were encouraged to report incidents and felt confident in doing so. The culture regarding duty of candour was positive and staff described a working environment where any errors in patient’s care or treatment were investigated and discussed with the patient. Governance The service used a systematic approach to continually improve the quality of services and safeguarding high standards of care.

At our last inspection, we found the clinical governance of diagnostic imaging was not adequate. There was no effective auditing and monitoring of the numbers of images delayed for extended periods. We found there were no formal processes for prioritisation of images on the backlog. There was not a formal individual assessment of risk that this delayed reporting may have for a patient. We raised this as a significant concern and senior managers took urgent actions to develop and implement an ongoing action plan with clear work streams and timescales to continue to reduce this backlog. Actions included setting up a new data collection process and bi-weekly reports with the commencement of a weekly radiology executive assurance group, led by the chief operating officer and a non-executive director, and chaired by the chief executive officer of the trust. A radiology reporting recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery.

During this inspection, we found significant improvements had been achieved within the service, with the reporting backlog almost cleared and reporting turnaround times dramatically reduced. Effective monitoring systems and governance processes were introduced to ensure backlogs do not develop again in the future. The picture archive and communication system (PACS) system recently implemented was now monitored daily to ensure a steady and consistent service. New key performance indicators (KPI’s) and reporting processes were introduced to measure improvements. The service had an operational plan to create a sustainable and cost-effective radiographer reporting team and to move away from reliance on third party support.

There were governance frameworks to support the delivery of good quality care. The service undertook several quality audits. Information from these assisted in driving improvement, giving all staff ownership of things that had gone well and action plans identified on how to address things needed to be improved.

Also, during our last inspection, we found the trust had introduced reviewing of images by non- radiology clinicians in 2012, but had not followed the guidelines issued by the Royal College of Radiologists (RCR). They had not arranged the stipulated training programme and had not assessed the competence of individual clinicians to review particular kinds of images. The issues 20171116 900885 Post-inspection Evidence appendix template v3 Page 258 surrounding the safety of this change had not been audited. This process had been risk assessed in 2012, but not reviewed regularly since. During this inspection, we were told that from December 2017 the service resumed formal reporting of all in-patient x-ray examinations, removing the risk of inexperienced doctors reviewing the images at ward level.

Monthly clinical governance meetings were held, with performance and action plans discussed. These meetings were used to discuss wider governance issues and shared learning from incidents and complaints. Diagnostic imaging risks fed into the divisional risk register. This was regularly reviewed at the governance meetings. There was also a radiation protection committee annual meeting, as well as monthly meetings between modality leads and medical physics. The radiation protection committee met to discuss any issues relating to radiation protection. They reported any concerns to the health and safety steering group, which subsequently reported to the integrated governance committee. Any concerns raised were escalated to the chief operating officer and the board.

Staff were clear about their roles and understood what they were accountable for. All clinical staff were professionally accountable for the service and care that was delivered within the department. Staff working with radiation were provided with appropriate training in the regulations, radiation risks, and use of radiation.

Management of risk, issues and performance The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. A local risk register was in place which was regularly reviewed at local and divisional level.

The service had arrangements in place for identifying, recording and manging risks. The radiology service had a local risk register which identified key risks and was reviewed at monthly governance meetings. Risks were also reviewed regularly at divisional meetings. An action log was also included identifying timescales and accountability.

Staff were aware of the main risks within the service, which included shortage of medical staff in breast radiology, and lack of compliance with regulations. Information regarding the service’s risks, incidents and complaints was shared with staff through regular team meetings.

During our last inspection, we found risks in this service were not given an appropriate level of visibility in relation to their impact on patients, such as the delays in radiology reporting and the number of unreported images. At this inspection, we found this had improved and risks within the service were given the appropriate level of visibility.

The local risk register included 19 radiology specific risks which included, eight risks rated as low risk, nine risks rated as moderate, and two risks rated as high. The high risks included:

• Reduced medical staffing in breast radiology • Lack of compliance with IR(ME)R schedule 1 procedures (Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) resulting in loss of reputation and loss of income and risk to patient safety and potential for harm. Recognition that human factors led to four reportable incidents

Staff were aware of the duty of candour requirements which identified the importance of sharing information with patients when an incident had occurred which involved them. We saw an example of a written apology which evidenced duty of candour principles had been applied to a particular incident.

During our last inspection, we found the department had no monitoring system in place for patients who did not attend (DNA) an arranged appointment. The service had no record of the ‘did not 20171116 900885 Post-inspection Evidence appendix template v3 Page 259 attend’ performance rate. At this inspection, we found this had improved. Data requested from the trust showed during January 2019, the service had a 2.11% DNA rate across all modalities. This information was used to plan treatment. For example, the service had implemented the mobile phone text reminder service which would prompt patients of their appointment date.

Information management The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

The service had clear performance measures, which were reported and monitored. These included, key performance indicators, referral to treatment times, treatment to reporting times, and friends and family test results. The data from these was used to drive forward changes in practice.

The service participated in national audits to ensure they continuously improved patient care in line with national guidance and clinical data outcomes. Data was submitted to external bodies, such as the Royal College of Radiologists (RCR). This enabled the service to benchmark performance against other providers and national outcomes.

Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Staff were aware of how to use and store confidential information. We requested the information governance training compliance figures as of the end of January 2019. This showed that 92% of all staff in radiology had completed the training, which was above the trust target of 85%.

The hospital joined the East Midlands Radiology Consortium (EMRAD) radiology consortium, which includes five other NHS hospitals in the East Midlands, on the 5 June 2016. This consortium, which has vanguard status and national funding, was designed to replace existing PACS and RIS (Radiology Information System) to enable images and reports to be shared across the consortium hospitals. This will eventually allow outsourcing of reporting amongst the hospitals that will support the capacity and cost reduction required to sustain timely radiology reporting. They will also have access to more specialised reporting across the region.

Staff were able to access patient electronic records appropriate to the needs of the investigation being completed. Electronic patient records were kept secure to prevent unauthorised access to data, however, authorised staff demonstrated they could be easily accessed when required.

There were sufficient computers available to enable staff to access the system when they needed to. Computers were available in all the areas we visited. All staff had secure, personal login details and had access to email and all hospital information technology systems.

The service was aware of the requirements of managing a patient’s personal information in accordance with relevant legislation and regulations. General Data Protection Regulations (GDPR) had been reviewed to ensure the service was operating within the regulations. Staff viewed breaches of patient personal information as a serious incident and would therefore manage this as a serious incident and escalate to the appropriate bodies.

Engagement The service engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

During our last inspection, we found there was limited evidence of meaningful engagement with patients and the local community. We saw an improvement at this inspection.

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People who used the services were actively engaged and involved when planning services. Patients’ views and experiences were gathered and used to shape and improve the services and culture. Patients were regularly asked to complete satisfaction surveys on the quality of care and service provided. The hospital also gathered patient opinion from the friends and family test (FFT). However, the response rate was low: Between May 2018 and January 2019, only nine patients completed the FFT. Departments used the results of the survey to improve the service. It was clear that the department recognised the value of public engagement.

Staff told us that managers at all levels were approachable and that they felt comfortable to raise any concerns with them. Staff told us they had regular team meetings. Information was shared with staff in a variety of ways, such as face-to-face, email, staff newsletters, monthly trust communications, and noticeboards. The trust’s intranet, had been updated to increase accessibility. Recent feedback from ‘Patient Choices’ was also shown prominently on the home page, increasing the link between comments and action.

Employee engagement was also measured through an annual staff survey, which was conducted by an independent organisation to ensure confidentiality. In response to the survey, action plans were developed and progress against the plans was measured on a regular basis. Some of the actions from radiology included:

• Radiology improvement plan – supporting the team to remove the reporting backlog has improved working conditions for all staff, reducing the number of complaints and removing the pressure of crisis management enabling staff to focus on doing their core duties well. • All staff supported to complete timely mandatory training and appraisals. • Introduction of a staff newsletter • Development of a ‘shared access area’ for information, policies procedures etc • Introduction of a more methodical approach to recording training and competencies which the staff have direct access to which is linked to their annual appraisal • Increased involvement of team members in the management of safety within the service through the Patient Safety Group and the IR(ME)R group • All staff now have access to the incident reporting system through a generic log on to see the risk register, complaints / patient advice and liaison service information and incident reports.

The service had a good relationship with the neighbouring NHS trust, with regular communication and a good culture of collaborative working with the medical physics team.

Learning, continuous improvement and innovation The service was committed to improving services by learning from when things went well and when they went wrong, they promoted training and innovation.

During our previous inspection, we found there was limited evidence of innovation or improvement. We found high numbers of images with delayed reporting which had not improved over time.

At this inspection, we found the service had focussed on addressing the concerns we reported in the February 2018 inspection, and we found significant improvements had been made to provide a safe and effective service. The head of radiology confirmed they were continuously striving to implement changes and improvements for the benefit of the service.

Patients attending for an endoscopic procedure found with a positive cancer diagnosis were offered a CT scan on the same day rather than being referred. This had taken six to eight days off the cancer pathway leading to quicker diagnosis and staging.

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Staff of all disciplines were committed to improving service provision and the patient experience. Staff could provide examples of improvements and changes made to processes based on patient feedback, incidents and staff suggestion. Staff were alert to new initiatives and ways of working. For example, the service was in the process of creating a sustainable and cost-effective reporting radiographer service to manage the workload in-house and to move away from reliance on third party support.

The imaging service had developed key staff led groups which focused on patient safety and had improved meeting and communication processes for staff.

The department aimed to avoid junior radiographer anticipated vacancies through offering student jobs early on in their third year of training (on the condition of qualification) for when they had completed their degree. These radiographers were initially employed as assistant practitioners while their professional registration was processed and once registration had been achieved, they were appointed as radiographers.

During our last inspection, we found nurse staffing levels were not sufficient. However, at this inspection, we found staffing arrangements had improved and nursing staff told us they felt well supported.

The service was working closely with the other trusts in the EMRAD consortium. The consortium allowed the service to share radiology images with neighbouring trusts to combine expert opinion, reduce delays when moving between hospitals, and quicken response times for the results.

The service was committed to training and staff development. All staff told us they were encouraged and supported to complete additional training. During our inspection, we spoke to staff who were able to complete the Kings Fund Management Course.

The radiology department were working towards accreditation with the Imaging Services Accreditation Scheme (ISAS) and were hoping to be accredited within the next two years. The Royal College of Radiologists and College of Radiographers had developed (ISAS) to support diagnostic imaging services to manage the quality of their services and make continuous improvements; ensuring that their patients consistently receive high quality services delivered by competent staff working in safe environments.

Plans were in place to expand the cardiac investigation department into a two-storey unit, with the project expected to be completed by July 2019. The new department will have:

• Three new scanning rooms for cardiac ultrasound, increasing capacity by 50% • A new procedure room • Additional waiting area giving 50% more seating and dedicated children’s waiting room • Larger exercise tolerance testing room • Additional ECG room

The trust set up a forum called ‘The Shared Learning Group’ where services provide updates on the trust’s journey to becoming ‘outstanding’.

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