Kettering General Hospital NHS Foundation Trust
Evidence appendix Rothwell Road Date of inspection visit: Kettering 7 November to 10 November 2017 Northamptonshire 24 November 2017 NN16 8UZ 29 November to 1 December 2017
Tel: 01536 492000 Date of publication: www.kgh.nhs.uk February 2018
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 Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 275,000 in north Northamptonshire, South Leicestershire and Rutland.
There are approximately 640 inpatient beds and over 3,400 whole time equivalent staff are employed. 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 three sites that we did not inspect: Nene Park, Corby diagnostic centre and Isebrook outpatients.
In 2017/18, the trust has a budget of £218,465,000, with a projected deficit for the year of £19,539,000.
In 2016/17 the hospital had: 87,509 A&E attendances (October 2016 to September 2017). 81,030 inpatient admissions (October 2016 to September 2017). o 5,062 of these were children and young people inpatient admissions (6.3%). 341,567 outpatient appointments (October 2016 to September 2017). 3,361 births June 2016 to June 2017). 1,210 in hospital deaths (October 2016 to September 2017).
Number of beds: Acute - 590 (July 2017 to September 2017).
20180222 KGHNHSFT Evidence Appendix Page 1
Maternity – 49 (July 2017 to September 2017). Critical care – 16 (November 2017). Number of bed days - 250,363 (October 2016 to September 2017).
Number of staff (in whole time equivalent posts): Medical - 424. Nursing – 884. Other - 2,098. Total - 3,406.
Ethnicity of admissions (%) from October 2016 to September 2017: White - 93.4% Asian - 2.3% Not stated - 1.7% Black - 1.3% Mixed - 1.0% Other - 0.4%. (Source(s): Hospital Episode Statistics)
Population served The trust provides hospital care for a population of 275,000. The local population from April 2016 to March 2017 was predominantly white (86%), with 3% Asian, 2.5% black and 1.2% mixed. Northamptonshire is a centrally situated county incorporating a mix of urban and rural areas. The population density is in the lowest 25% of upper tier authority areas within England. In spite of this, the county has seen one of the most significant levels of growth during the past 30 years, well in excess of national and regional growth trends. Whilst the population has grown across all broad age groups, this has been particularly high in those aged 65 and above. This is expected to continue in projections to 2021, with particular emphasis on the group aged 70 years and above. In spite of this growth at the top end of the age profile, the proportion of those aged 65 and above within Northamptonshire remains comparatively low against the national profile, with the child population (0 to 15 years) comparatively high. Deprivation Socio-economic deprivation is considered to represent an important health determinant. This is supported by the notable difference, which has been recorded between life expectancy in the most deprived and the most affluent areas of England. The extent of socio-economic deprivation in Northamptonshire is not as considerable as other parts of England, but specific pockets can be identified, particularly in the Corby and Northampton areas. Deprivation has a tendency to be concentrated in urban areas of the county. Health deprivation however has a higher occurrence at the most significant level in the county than overall deprivation. This is found within areas of Corby, Northampton, and to a lesser extent Kettering. The link between health deprivation and other forms of deprivation considered determinants is by no means explicit. Whilst 57% of those areas experiencing health deprivation amongst the top 30% in England also recorded similarly high levels of income deprivation, for environment deprivation, this was 22% and for barriers to services was just 8%.
20180222 KGHNHSFT Evidence Appendix Page 2
Is this organisation well-led? To write this well-led report, and rate the organisation, we interviewed the members of the board, both the executive and non-executive directors, and 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. We looked at a range of performance and quality reports, audits and action plans; board meeting minutes and papers to the board, investigations, and feedback from patients, local people and stakeholders.
Leadership The leaders had most of the skills, knowledge, experience and integrity to lead the trust with some changes to personnel and roles taking place over the last year. Sustainability of improvements was to be an ongoing focus for the leadership team. The trust board now had the appropriate range of skills, knowledge and experience to perform its role. The trust now had a senior leadership team in place with the appropriate range of skills, knowledge and experience. The leadership team had the capacity to continue to drive improvements. Understanding and management of risks had improved.
The trust board comprised of an interim chief executive officer (CEO) and five other executive directors and a chair of the board and six other non-executive directors (NEDs). Since our last inspection, there had been significant changes to the trust board. The acting CEO, who was in post in October 2016, had resigned to move to another trust and left in February 2017. The substantive CEO, who had been on sickness leave at the time of the October 2016 inspection, resigned in July 2017. An interim CEO was appointed and started at the end of February 2017 and was expected to stay until February 2018. In July 2017, the chair of the board resigned. A new substantive chair commenced in August 2018. A new substantive CEO had been appointed and was due to commence in post in March 2018.
The finance director left in February 2017. A new director of finance and contracting was appointed in June 2017. The medical director had been in post seven years, the director of nursing three years, the chief operating officer since early 2016 (having taken on the role of deputy chief executive in late 2016) and the director of human resources for three years who was overseeing strategy supported by a director of strategy. Other than the medical director, the remaining executive directors had been in post three years or less, with the chief operating officer starting in early 2016. The board was therefore still relatively new.
When senior leadership vacancies arose the recruitment team reviewed capacity and capability needs. The trust reviewed leadership capacity and capability on an ongoing basis. This was an improvement on the October 2016 inspection. There were three other director posts supporting the board: a director of digital services, director of estates and facilities and a director of integrated governance. This last post was a new post appointed to on an interim basis in August 2017. This new role of director integrated governance was responsible for embedding an effective strategy for governance and assurance across the trust, incorporating all aspects of corporate and clinical/quality governance. The trust leaders had recognised the lack of capacity within the executive team following the last inspection and this new role enabled more capacity to be available for each role. An improvement director from NHS Improvement had started in August 2017 to support the trust to drive the quality improvements required. There was better capacity in the executive team to recognise and respond proactively to new and emerging risks.
The NEDs had a range of experience including business, public and private sector. The NEDs that we interviewed had a clear understanding of their roles and the remit and accountability, including addressing the challenges for the trust, of the governance or performance committees they chaired. Driving improvements throughout the trust was a clear focus. We attended a board meeting in October 2017 and found there was greater discussion and challenge from the NEDs compared to the previous inspection in 2016. This was confirmed by minutes of the board
20180222 KGHNHSFT Evidence Appendix Page 3 meetings that we reviewed as there were clear records of discussions and challenges about performance, accountability and confirmation of the actions agreed
Executive directors spoke positively about the support they were receiving from the new chair and interim CEO. All were receiving regular one to one meetings with both the CEO and chair and had a mentor to support their development.
In response to the findings of the previous inspection, the trust had, through NHS Improvement, commissioned a review of trust leadership and governance by an independent provider. A redacted summary of the report was made available on the trust’s website on 2 September 2017. The report looked in detail at the strengths and values of the executive team and made 37 recommendations in terms of governance, ownership, equal distribution of portfolio responsibility. Changes such as that made to separate quality from the director of nursing role and strategy from the director of human resources role aimed to provide extra capacity in the executive team.
The trust shared their plans to reconfigure the clinical business unit structure and to consult and implement a new divisional governance structure. They had recognised that there needed to be stronger clinical leadership and accountability at this level. The consultation was completed just prior to the inspection, with 78 comments received. The trust planned to have the new divisional structure in place at the start of 2018. The new leadership teams in these divisions would be accountable for the quality, performance and effective use of resources within their division. Not all posts had been recruited to at the time of the inspection.
Board members1 There was no representation on the board from black and minority ethnic groups: there was however equality in the gender spilt. Of the executive board members at the trust, none were BME and 57.1% were female. Of the non-executive board members, none were BME and 33.3% were female. BME % Female % Executive 0.0% 57.1% Non-executive 0.0% 33.3% Total 0.0% 46.2%
Fit and proper persons
Effective Fit and Proper Person checks were in place. The fit and persons requirement (FPPR) for directors was introduced in November 2014. It is a regulation that intends to make sure senior directors are of good character and have the right qualifications and experience to work in this role. This regulation ensures that directors of NHS providers are fit and proper to carry out this important role. At our October 2016, there were not effective systems in place to ensure evidence of all required pre-employment checks had been carried out. The trust did not have a policy in place governing this requirement. At this inspection, comprehensive mechanisms were in place for the fit and proper person test for newly appointed executives and board members. A clearly defined policy was in place to govern this process. The new FFPR policy had been ratified and implemented that reflected all the requirements of the requirement. The trust had carried out an audit of all relevant files and processes and we saw that all recommendations from this audit had been carried out. The process included comprehensive pre-employment checks that included enhanced Disclosure and Barring Service (DBS) checks, insolvency and bankruptcy checks, disqualified director register checks and occupational health checks. There were further checks on appointment through self-declaration and previous employment checks and on-going assurance through an annual declaration process. We reviewed a sample of five director’s (including non- executive directors) files to assess compliance against fit and proper person legislation and found
1 RPIR – Universal: Board tab 20180222 KGHNHSFT Evidence Appendix Page 4 that all the required checks had been carried out. Each file was well maintained and organised with a clear referencing system. The trust planned to carry our regular audits of staff files on a cyclical basis to ensure appropriate documentation was in place. This represented a significant improvement from the October 2016 inspection.
The trust leadership team had an effective knowledge of current priorities and challenges and was taking actions to address them. Although the leadership team had oversight of the most of the challenges that the organisation faced, we raised issues that had been found on the core service inspection they were unaware of or their oversight was insufficient. For example, the security concerns found on Skylark ward and the potential risks to patients’ safe care and treatment due to delayed reporting of diagnostic images. They responded urgently with clear and detailed action plans to address these concerns. This was an significant improvement on the October 2016 inspection, when we found a lack of urgency and ownership to address some key risks that we had raised.
Departments had a documented accountability structure. Ward matrons reported to the lead nurse, medical staff reported to the clinical director; there was a general manager for the clinical business unit (CBU). The lead nurse, clinical director, and general manger reported to the CBU director, who in turn reported to the medical director and director of nursing.
There was a programme of board visits to services and the majority of staff fed back that leaders were generally approachable and accessible. The visibility of leaders at the senior level was variable in each area we visited. During discussions with staff in focus groups and during the core service inspection, we heard from a minority of staff that some senior leaders were not always visible and approachable. This was despite a number of initiatives the executives and NEDs had implemented to improve this. Some staff told us members of the board did not routinely visit different areas of the trust throughout the year to increase visibility and to enable engagement with staff at all levels. However on speaking to members of the executive team, we heard of a number of initiatives to increase the visibility and approachability of senior leaders, for example, the CEO’s Friday message an email to all staff, coffee mornings with the CEO, the ‘Link Listeners’ initiative (monthly meetings held with junior staff, for example, catering and ancillary staff). There were also regular walk arounds by the executive and NEDs. The NEDs visited wards and departments had been being strengthened to be more structured and build on the ad-hoc visits that had previously taken place.
Leadership development opportunities were available, including opportunities for staff below team manager level. Succession planning was a focus for the trust. The trust was developing an experienced leadership team with the skills, abilities, and commitment to provide high-quality services in all areas. They were recognising the training needs of managers at most levels, including themselves, and were working to provide development opportunities for the future of the organisation. There were clear priorities for ensuring sustainable, compassion, inclusive and effective leadership, underpinned by the trust’s values. Succession planning was a strategic priority for the trust board. There was a succession plan in place which identified the current position relating to board and executive team members but did not identify any timelines. There was a preceptorship programme in place for new nurses to the trust and the healthcare support staff undertook the care certificate national programme.
The council of governors consisted of 25 members, 13 of which were publically elected members; eight were nominated stakeholder representatives and four staff elected members. Public and staff governors were elected for a three year term with no governor being allowed to stand for more than two terms. Governors reported that they were now more activity involved in the way the trust was being managed and this had been actively driven by the new chair.
Key stakeholders expressed the view that, for a long time, the trust had been inward looking and had only over the past year recently began to fully engage with relevant partners and peers outside the trust to develop appropriate initiatives to drive improvements. The chief operating
20180222 KGHNHSFT Evidence Appendix Page 5 officer had led a more effective approach to understanding and addressing the urgent care and referral to treatment time performance issues for the trust. The director of estates had been in post two years and had taken action as a priority to review the infrastructure of buildings and premises and to develop and deliver plans to address longstanding issues of concern, such as the limited car parking on site and the theatre estate.
Vision and strategy There was a clear short term vision and strategy for the next six to 12 months but a longer term vision was yet to be developed. The trust had a vision for what it wanted to achieve but workable plans to turn it into action were not yet fully in place. In 2014, the trust developed a five year strategy for 2015 to 2020, a key element of which was the development of the site as a health and well-being campus. The strategic objectives were: To provide high quality care to individuals, communities and the population served. To be a clinically and financially stable organisation. To maintain a fulfilling and developmental environment for our staff. To be a strong and effective partner in the wider health and social care community. Members of the trust board and senior management team were able to explain the strategy of the trust, which involved closer working with the other health economy members including the local clinical commissioning group and local authority to develop an integrated health and social care system. However, with the board’s focus on the significant operational, financial and quality issues over the last 12 months, momentum on this strategy and also the trust’s contribution to the Sustainability and Transformation Plan (STP) for Northamptonshire had also not progressed across the local area with limited opportunities for engagement with partners across Northamptonshire. The senior team recognised this as an issue and had developed key strategic objectives, based on the trust’s financial management plan, for the next year with plans to develop a longer term strategy. These key objectives were: Improving staffing – numbers and competencies. Improving the provision of training including safeguarding. Strengthening culture with regards to identifying and managing risks. Strengthening culture in complying with procedures (including medications) and learning from incidents. Improve emergency department processes. Improving care plans and documentation.
The main areas of focus for the trust at the time of the inspection were: The implementation of Clinical Business Unit (CBU) restructure. Governance systems and processes restructure to fully develop a risk management and reporting culture. Streamline data for ease of use and analysis for action. Further develop clinical harm review processes and drive down waiting times. Provide further risk and governance training for all staff. Revise the board assurance framework.
The trust’s Operational Plan was built on the five year strategy by identifying 16 annual operational objectives that supported delivery of the long term strategic objectives. These were in line with the work streams and aims of the newly formed STP as well as addressing performance issues on quality, finance and operational metrics. These objectives were set and agreed by the trust management committee (TMC) which includes all executives, business unit medial directors, all heads of nursing and heads of service (for example, chief pharmacist) and operational senior managers. Progress against delivering the 16 operational objectives (which fed into delivery of the trust’s strategic aims) was monitored by the trust management committee and trust board on a
20180222 KGHNHSFT Evidence Appendix Page 6 quarterly basis. Performance was rag rated and as at quarter one for 2017/18 the trust performance was: 50% green – achieving the target or planned trajectory. 21% amber – within 5% of the target/trajectory. 21% red – 5% adrift of the target or trajectory. 8% measurement of performance was still being refined.
Specific areas of performance were monitored and managed through the relevant sub board committee (for example, the workforce development committee, and performance and finance committees). Exception reporting was escalated to trust management committee and board as appropriate and risks to delivery were included on the trust risk register as appropriate.
The Northamptonshire Sustainability and Transformation Plan (STP) set out how health and social care in the county will change over the next five years. The STP is a collaborative venture and in December 2016, Northamptonshire’s health and social care organisations published the five year plan to reshape and improve the way that care is delivered within the county. ‘Northamptonshire’s Sustainability and Transformation Plan 2016-2021: How we will Support Local People to Flourish’ summary document was produced by Northamptonshire’s NHS trusts and Northamptonshire County Council). Healthwatch Northamptonshire, Voluntary Impact Northamptonshire, the local GP Federations, and other local organisations involved in providing care in the region had all inputted into the development of the proposed plan. Leaders spoke of how the priorities for the region were out of hospital support, delayed transfers of care and the urgent care pathways in the county. Work was ongoing to revise the STP in light of the current system wide pressures being faced.
In the trust’s Quality Account for 2016 to 2017, the quality priorities for the trust covered patient safety, experience and clinical effectiveness and were:
Patient Safety Reducing pressure tissue damage. Reducing the risk of falling in hospital. Preventing avoidable deterioration (sepsis management).
Patient Experience Improving engagement with our Friends and Family Test. Discharge experience. Reducing noise at night on our wards.
Clinical Effectiveness Prevention of Venous Thromboembolism (VTE). Meeting the needs of mental health A&E patients. Paediatric inpatient standards for those identified at risk of self-harm.
The trust also had a Patient Safety Improvement Plan as part of the NHS Sign up to Safety Campaign: the national ‘Sign up to safety’ campaign was launched in 2014 with the overall aim of reducing avoidable harm in the NHS by 50% and saving 6,000 lives (nationally). The trust signed up to the campaign in August 2014 and continued to support this ambition and has continued to develop its Patient Safety Quality Improvement Plan (April 2016). It set out how the trust would continue to develop the Patient Safety Campaign, quality improvement projects and methodologies. The trust’s Quality and Safety Strategy had formed the basis of this Safety and Quality Improvement Plan. The Integrated Governance Committee sought assurance that learning from incident outcomes and clinical negligence was informing the work of our plan and this work commenced towards the end of 2016/17. The trust’s Patient Safety Advisory Group (PSAG) monitored progress of the plan and agreed the projects together with identifying leads for each.
20180222 KGHNHSFT Evidence Appendix Page 7
Leaders spoke of plans to publish a revised Quality Strategy to ensure all staff know what our quality improvement journey looks like and their role in its delivery.
The trust’s workforce strategy detailed the trust’s high performance on the staff survey with regard to equality and diversity and equal opportunities for career progression and promotion.
As part of the trust’s estates strategy, the significant theatre refurbishment programme was nearing completion and the development of the trust’s pharmacy, complete with a ‘robot’ had now been achieved. The new pharmacy facilities were a significant achievement for the trust.
There was no specific nursing strategy in place, this had been considered but a decision made that it needed to be a part of the wider trust quality strategy. Planning on its development was just starting with recognition that it would need to go through staff engagement and consultation processes.
Most staff that we spoke with knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. Our review of corporate information received confirmed that the trust was embedding the vision, values and strategy in policies and communications. Development plans for services had taken into account the needs of the local population. During discussions with the trust board, it was clear that there was an emerging plan for future services. This was to include: A clear vision and set of values with quality and sustainability as the top priorities. A realistic strategy for achieving the priorities and developing good quality, sustainable care. Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy, especially where there were plans to change services. Local providers and people who use services to be involved in developing the strategy. Staff to know and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. To embed its vision, values and strategy in corporate information received by teams. The trust to align 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. The trust to plan services to take into account the needs of the local population.
In 2016, following engagement sessions with staff, the trust had introduced a set of values, with the acronym of CARE which stood for: Compassionate. Accountable. Respectful. Engaging.
In the October 2016 inspection, we found most staff could list what the values were but had little understanding beyond the words. At this inspection, the CARE values were more embedded into ways of working and the trust induction had been revamped to include the values. However, senior staff acknowledged that they were not yet confident that the values were demonstrated at all levels throughout the whole organisation. 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. Staff were aware of the CARE values and felt that they reflected the organisation and the care provided to patients. Generally, staff were familiar with the trust wide vision and values and felt part of the trust as a whole. CARE values were being used to underpin the transformation change process throughout services.
20180222 KGHNHSFT Evidence Appendix Page 8
Staff were familiar with the trust’s ‘I will’ campaign. This was introduced in response to a death and a campaign known as ‘Victoria’s Legacy’: it meant that staff made a pledge to patients of ‘I will’: Keep you safe. Keep you comfortable. Keep your environment tidy. Treat you with compassion. Abide by the core values and behaviours of the organisation.
The “I Will” campaign was an amalgamation of these five practice development campaigns and sets an expectation was that individual staff would sign a pledge promising patients that they would, keep them safe, keep them comfortable, keep their environment tidy, treat them with compassion and abide by the core values and behaviours of the organisation. We saw posters on display outlining the campaign and staff stated they used this to ensure the provided patients with the best care available.
There was a clear set of values, with quality and sustainability as the top priorities in the areas we inspected. Almost all staff were aware of the values of the trust and these were visually displayed on posters throughout the department. The trustwide strategy included the performance of the emergency department (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 strategy for surgery and anaesthesia services. Service leaders understood their role in achieving the aims of the strategy. The strategy was reviewed and updated annually and it was clearly aligned with the trust’s five year strategy. Service leaders were able to explain the main priorities for the service which were also included within the strategy. Service leaders also felt the strategy was achievable despite the need for increased staffing. The strategy was aligned to local plans in the wider health and social care economy, for example, partnership working with stakeholders and integrated care pathways across the county.
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 launched a ‘Maternity Safety Improvement Plan, 2016 to 2020’ in January 2017 to respond to the recommendations laid out ‘Better Births’ (NHS England, 2016) and ‘Safer Maternity Care’ (Department of Health, 2016). The plan also linked with the Northamptonshire’s sustainability and transformation plan 2016 to 2021. Progress against delivering the Maternity Safety Improvement Plan was regularly monitored and reviewed. A traffic light system was used to flag performance against the estimated delivery date.
The outpatients’ service had set up a five-year outpatient transformation programme in September 2016 aligned with the trust’s strategy. This plan was in place during our previous inspection with work focused on do not attend rates, clinic template changes and cancellation of clinics. 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 (two way-text service implementation). Clinic template optimisation achieved through the introduction of new tools.
Culture Leaders across the trust were promoting a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There were mixed views from staff on how they felt supported, respected and valued.
20180222 KGHNHSFT Evidence Appendix Page 9
Leaders believed they had significantly improved trust performance around safety within the last 12 months. They had implemented a number of measures which had improved the incident reporting culture. They believed they were operating a much safer service but recognised they still had improvements to be made in the coming year. Junior medical, nursing and midwifery staff generally 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 nurses and other grades of staff. Almost all staff we met were welcoming, friendly, and helpful. It was evident that staff cared about the services they provided and were proud to work at the trust. Almost all staff said colleagues were committed to providing the best possible care for patients. Most staff felt there was a positive working culture and all teams and wards reported positive team working.
Most staff told us that they had good working relationships with their managers and felt able to raise concerns if they needed to and that on the wards they regularly saw their local managers. There were clear lines of responsibility and accountability. Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
Staff we spoke with said that morale was continuing to improve after the comprehensive inspection report was published in April 2017. They were proud that their hard work in making improvements had been recognised in our June 2017 inspection (report published in August 2017). Staff at all levels were committed to ensuring the hospital delivered the best possible care for all patients.
Most staff said the executive team had an open culture. Suggestions from clinical teams were implemented where practicable. However, some clinical staff we spoke with told us that they felt there was a disconnection between tiers of management and did not always get feedback on issues raised. One example of a lack of feedback related to business cases: some staff said they only got feedback on whether it had been successful or not rather than wider learning for future submissions. Other staff spoke of being ‘stuck in a rut’ with feeling that there would be ‘no difference so why bother’. A minority of staff were not positive about the way managers’ listened to their concerns and did not always feel supported by leaders. Some staff were critical about the way messages about CQC inspections had been communicated to staff teams.
Staff were generally positive about the trust’s appraisal process and how it met their ongoing developmental needs. Senior staff told us of plans to enhance the trust’s appraisal process to provide clarity for staff on how the organisational objectives link to theirs, reinforce the trust’s CARE values and link back to the overall assessment of the individual staff member. This was designed so individual and organisational performance was considered together to better determining pay progression and future talent. This would provide a more structured and organisational approach which would be transparent and give staff career pathways over the longer term. The trust had an annual staff awards programme to recognise and reward staff.
The trust had implemented a range of health and wellbeing initiatives for staff including yoga, weight management and the hospital had now become a smoke free site. Staff feedback on these initiatives was positive.
The trust had implemented a leadership development programme to support effective workforce development strategy with 81 staff completing the programme from 2015 to 2016 and another 96 attended from 2016 to 17. Staff spoke positively about this programme.
Not all staff we spoke with felt supported, respected and valued. Some staff within theatres reported a culture of bullying and harassment and told us they were unhappy in their roles. We were not assured that all leaders and staff in theatres understood the importance of being able to
20180222 KGHNHSFT Evidence Appendix Page 10 raise concerns without fear of retribution. Staff told us they did not raise such issues with their managers out of fear it would make matters worse. We raised this with the trust immediately who were aware of some but not all of the cultural issues in theatres. During our unannounced inspection on 24 November 2017, we saw actions the trust had taken to improve cultural issues in theatres. For example, the general manager for surgery and anaesthesia and the chief operating officer had attended a monthly meeting and there were plans for this to continue to ensure they were aware of any issues amongst staff. Staff had been encouraged to raise issues as they arose and were provided with employee support contact details. Staff were also reminded about the purpose of the trust’s freedom to speak up guardian. This had a positive impact and staff we spoke with said they had approached senior leaders following their attendance at the meeting. Staff also reported they were more confident that action would be taken if they raised concerns. Despite the cultural issues identified within theatres, we found staff were dedicated to their roles. Service leaders spoke highly of staff in theatres and how hard they had worked throughout a surge in the number of patients as well as the theatre refurbishment programme. Staff had adapted well to the continuous changes throughout a period of transition.
The leaders in ED were passionate about improving their service and had come a long way in making a difference but were faced with the challenges of the culture. They acknowledged that a change in culture would take time. The local leaders required enhanced support from the executive and senior leaders to provide clear messages to staff on what culture, behaviours and practices will not be accepted. At this inspection, we found the culture of the nursing and medical staff to be one of not accepting the previous ratings and outcomes of the previous inspection.
Staff were encouraged to be open and honest when things went wrong. Leaders understood the importance of staff being able to raise concerns without fear of retribution. However, a minority of staff did not feel comfortable of raising issues for fear it would make the situation worse.
Duty of Candour 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. 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 reasonable support to the person. The majority of staff were aware of their responsibility to be open, transparent, and honest and gave examples of when they had offered patients and relatives an apology. Staff were aware of the trust’s policy and their requirement to apply Duty of Candour for any incident that was investigated and categorised as moderate or above and knew the thresholds for when Duty of Candour processes were triggered.
Our observation of records showed that when things went wrong patients, and their relatives, were offered a verbal and written apology and complied with Duty of Candour processes. This also included arranging local meetings and support for patients and relatives. Trust policies referred to Duty of Candour and detailed clearly how staff should manage incidents or complaints taking duty of Candour into consideration. We reviewed ten serious incidents and medium incident reports, which showed clear evidence of Duty of Candour maintained by the trust. The reports showed that there were clear apologies and explanation to patients and their loved ones. The trust offered individuals to assist patients and their families to participate with investigation processes and offer explanations. We saw that copies of final investigation reports were shared with patients and their families. Duty of Candour was reported on quarterly to the trust’s governance committee. The staff 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. However, in some areas, such as the ED and maternity, we were concerned that not all incidents were being recognised in terms of severity and therefore opportunities to meet the Duty of Candour requirement may not be fully met.
20180222 KGHNHSFT Evidence Appendix Page 11
Freedom to Speak Up Guardian The Freedom to Speak Up review by Sir Robert Francis into whistleblowing in the NHS in 2015 concluded that there was a serious issue in the NHS that required urgent attention if staff are to play their full part in maintaining safe and effective services for patients. A number of recommendations were made to deliver a more consistent approach to whistleblowing across the NHS, including the requirement for all organisations to appoint a Freedom to Speak Up Guardian and the development of a single national integrated whistleblowing policy to help normalise the raising of concerns.
The trust had followed all these recommendations and staff could access the Freedom to Speak Up Guardian (FTSUG) in confidence. We saw that regular reports were prepared highlighting the main themes arising from contact with the FTSUG. The deputy director of quality governance had taken on the role alongside their current responsibilities in June 2016. The role had not been advertised. There had been nine contacts with the FTSUG from staff between June 2016 and November 2017. The FSUG provided a six monthly report to the board, which identified themes and trends. We saw at the board meeting in January 2017 that trends had been identified which included, quality and safety, management capability and bullying, fraudulent work practice, staff shortages, provision of training and issues with equipment and maintenance. Fraudulent working practice covered allegations relating to some staff working shorter hours than they should, doing private work in NHS contracted hours and misreporting of referral to treatment information. We saw actions had been taken to address concerns.
The FTSUG and freedom to speak up non-executive director (NED) identified that some investigations were unnecessarily protracted and not given sufficient priority by investigators (trust staff). Identified causes related to a lack of experience in whistle-blowing investigations and competing pressures of work, where no protected time and support was provided. This had impacted on those who were speaking up and delayed potential learning opportunities. The trust requirement to ensure investigation timescales were in place and complied with was highlighted to the board in January 2017. At the time of the inspection, there was no set timescale for investigations to be completed.
Not all staff were aware of the role of the FTSUG and a minorty of staff did not feel confident in approaching them. Some staff stated they did not feel comfortable of raising issues with the trust’s FSUG for fear it would make the situation worse. Some felt there was a blame culture in the trust and held the view ‘come to work, keep your head down, and go home’. At the time of the inspection, the trust had not carried out a review of the trust’s process. Therefore, we were not assured the trust had a systematic approach to measure the effectiveness of its speaking up policies, procedures and culture. There was evidence the trust’s interim chief executive officer (CEO) was taking steps to improve the speaking up culture and many workers told us they could see that the interim chief executive’s leadership and the chair’s leadership was beginning to make a difference. The FSUG met with the CEO monthly to discuss themes. The trust had a whistle blowing policy in place for staff who felt there was a need to raise concerns about standards of care. The trust was in the process of revising the policy to incorporate the FTSUG role. There was no completion date for this revision at the time of the inspection.
In the staff survey of 2016, staff confidence and security in reporting unsafe clinical practice had improved from the previous year and was slightly better than the national average at 3.68 compared to 3.65.
The trust reported 17 whistleblowing incidents in the period 1 July 2016 to 31 July 2017. Improvements made as a result of the investigations into these concerns were:
Mentors in place for ward matrons with support from Practice Development Nurses. Clarification of roles and responsibilities for medical device management and maintenance. Provision of management training. Listening events established for staff with the head of nursing. 20180222 KGHNHSFT Evidence Appendix Page 12
Review of referral pathway for image scans. Outpatient notes kept up to date to assist with booking further appointments and identification of priorities. Improved compliance with trust annual leave policy relating to potential impact on clinics.
NHS Staff Survey 20162 The trust has three key findings where they are in the top 20% similar trusts in the 2016 NHS Staff Survey and two where they are in the bottom 20% of similar trusts.
Trust National Key Findings where trust is in top 20% Score Average Percentage of staff believing that the organisation provides equal 89.7 86.0 opportunities for career progression Percentage of staff experiencing physical violence from patients, relatives 11.6 15.0 or the public in last 12 months Percentage of staff reporting errors, near misses or incidents witnessed in 92.8 90.3 the last month
Trust National Key Findings where trust is in bottom 20% Score Average Percentage of staff experiencing harassment, bullying or abuse from staff 28.0 25.2 in last 12 months Percentage of staff/colleagues reporting most recent experience of 40.4 45.4 harassment, bullying or abuse
NHS Staff Survey 2016 – Performance on questions relating to harassment, bullying and equal opportunities3 The scores presented below are the un-weighted question level score for question Q17b and un- weighted scores for Key Findings 25, 26, and 21, split between White and Black and Minority Ethnic (BME) staff, as required for the Workforce Race Equality Standard. Note that for question 17b, the percentage featured is that of “Yes” responses to the question. Key Finding and question numbers have changed since 2015.
2 NHS Staff Survey 2016 3 NHS Staff Survey 2016 20180222 KGHNHSFT Evidence Appendix Page 13
The response from BME and White staff at the trust was significantly different for Q17b. In the 2016 staff survey, the trust was in the bottom 20% for the percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months and for the percentage of staff reporting most recent experience of harassment, bullying or abuse. In addition, staff from black minority and ethnic groups reported a more negative experience than their colleagues from a white background. The trust had looked in detail at the information on bullying and harassment identifying that ancillary staff felt more bullied, felt communication was less effective and tended to have higher sickness levels. Further embedding the CARE Values was seen as essential to improving this.
The NHS staff survey 2016 demonstrated improvement over the last two years although further work was required to continue this improvement. The trust had an action plan in place, a key element of which was embedding the CARE values. The trust induction for new staff had been revamped to include the values. In order to improve the culture and recognise staff contribution a number of initiatives had been introduced. For example, historically the trust had only recognised long service at 25 years, this had been lowered and service was now recognised at five, 10, 15 and 20 years as well. Random acts of kindness had also been introduced whereby staff would be given cards of thanks, chocolates or free tea and coffee made available. In December 2017, ‘Care Congratulations’ was to commence whereby at the leadership briefing meeting credit notes would be handed out for leaders to give to staff who have displayed the CARE values. These credit notes can be used at the onsite vendors, for example, for fruit coffee. The trust would then collect the notes back from the vendors and will be able to see which values are most frequently recognised as well as least recognised and will be able to look in more depth at these areas.
The trust generally worked appropriately with trade unions and feedback from trade union representatives was generally positive about the way leaders worked with staff groups to address challenges and concerns across the trust. Most feedback we received was positive about the way human resources issues were handled, but a minority of staff did not consider they had been effectively supported.
Sickness rates4 The trust’s sickness levels from July 2016 to May 2017 were similar to the England average, with rates increasing in line with the England average over the winter period and falling again in 2017.
The trust had a single equality strategy in place for 2017 to 2020 to ensure it met the legislative requirements outlined in the equality act (2010) and the Human Rights Act (1998). The strategy set out the organisation’s approach to equality and diversity; both as an employer and as a
4 Source: NHS Digital 20180222 KGHNHSFT Evidence Appendix Page 14 healthcare organisation providing secondary care services. It referred to the ‘Single’ Equality Strategy to reflect the trust’s statutory duties to promote equality amongst groups of people who have specific protected characteristics, as defined by the Equality Act 2010. The Equality Act (2010) ensures that there is no discrimination against groups of people with protected characteristics. These groups are age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief (including lack of belief), sex (i.e. gender) and sexual orientation.
The Equality Act 2010 created a new general duty on the NHS, when carrying out their functions to have due regard to: The need to eliminate discrimination, harassment and victimisation. The need to advance equality of opportunity between persons who share a relevant protected characteristic and those who do not. The need to foster good relations between people who share a relevant protected characteristic and people who do not (which will therefore cover good relations between people of different faiths and between people who have a religious faith and those who do not).
Staff diversity5 The largest proportion of staff at the trust is from a white background (77.4%). A breakdown of all ethnic background can be seen below; A – White – British 51.4% B – White – Irish 0.9% C – Any other white background 25.2% D – Mixed White and Black Caribbean 0.2% E – Mixed White and Black African 0.3% F – Mixed White and Asian 0.2% G – Any other mixed background 0.7% H – Asian or Asian British – Indian 8.6% J – Asian or Asian British – Pakistani 1.1% K – Asian or Asian British – Bangladeshi 0.3% L – Any other Asian background 2.9% M – Black or Black British – Caribbean 0.5% N – Black or Black British – African 3.4% P – Any other Black background 0.6% R – Chinese 0.3% S – Any other ethnic group 1.9% Z – not stated 1.6%
In July 2014, the Equality and Diversity Council agreed new work to ensure employees from black, minority and ethnic (BME) backgrounds had equal access to career opportunities and received fair treatment in the workforce. There were two measures in place the equality and diversity system 2 (EDS2) and the workforce race equality standard (WRES) to help local NHS organisations, in discussion with local partners including local populations, review and improve their performance for people with characteristics protected by the Equality Act 2010.
NHS Employers had selected the trust as one of its 2016 to 2017 Diversity and Inclusion Partners. In fact, it was the trust with the highest score. This indicated that the trust had placed equality,
5 RPIR – Universal, submission P104 Care Organisation Stock Take 20180222 KGHNHSFT Evidence Appendix Page 15 diversity and inclusion at the centre of everything that they did. The trust had provided a ‘meet and greet’ service at the main reception to help all patients and visitors.
A practice and professional development forum had been organised to ensure staff from all backgrounds received an assessment of training and development needs and were given opportunities to meet those needs. Job applications had been produced in an easy read format to support people with learning difficulties in applying for posts. The percentage of staff receiving equality and diversity training was one of the highest in the country.
There was good support for a diverse community by providing extensive interpreter and translation service, including for sign language. Information had been provided in easy read and picture- based formats for patients with learning disabilities. Patient satisfaction levels had been monitored by equality groups, such as cancer services. The trust had been proactive in celebrating and raising awareness of social and religious occasions.
The trust’s most recent report against the Workforce Race Equality Standard was dated July 2017. The trust reported:
Percentage of staff in each of the AfC Bands 1-9 and VSM (including executive Board members) compared with the percentage of staff in the overall workforce. Non-Clinical: Clinical BME higher 5-9 bands BME higher at all grades except 1-4 (1.7% BME 10% lower 1-4 bands lower but increased by 4.75 since last year) and BME 0% VSM level 8A-9 (1.9% lower and decreased by 0.7% since last year)
Relative likelihood of staff being appointed from shortlisting across all posts.
1st March 2017 31st March 2016 WHITE:BME WHITE:BME 0.72:1.0 0.91:1.00 White staff are 28% less likely to be appointed from shortlisting compared to BME staff. The disadvantaged ratio for White staff has increased from 9% in 2016 to 28% in 2017.
Relative likelihood of staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation 31st March 2017 31st March 2016 BME:WHITE BME:WHITE 0.66:1.00 1.70:1.0
For 2017 BME staff were 34% less likely to enter the formal disciplinary process. This is a dramatic improvement given that in 2016 BME staff were 70% more likely. The issue raised is whether higher level of White staff entering the formal disciplinary process is justifiable.
Relative likelihood of staff accessing non-mandatory training and CPD.
31st March 2017 31st March 2016
20180222 KGHNHSFT Evidence Appendix Page 16
WHITE:BME WHITE:BME 1.05:1.00 0 82:1.00
Access to non-mandatory training and CPD is fairly similar for both groups. This is as a result of an increase of 23% for White staff from 2016 to 2017
Percentage difference between the organisations’ Board voting membership and its overall workforce.
31st March 2017 31st March 2016 WHITE: 22.2% WHITE: 20.3% BME: -20.4% *BME: -18.3%
*At least 1 BME VSM was employed at Board level. However, he left the Trust in February 2017. There is no BME voting Board member currently.
Calculation for 2017 White: % White Board / % Overall White workforce [100% - 77.8% = 22.2%] BME: % BME Board / % Overall BME workforce [0% - 20.4% = -20.4%]
Staff survey 2016 Percentage of staff believing that trust provides equal opportunities for career progression or promotion: White 87% BME 71%
In the last 12 months have you personally experienced discrimination at work from any of the following? b) manager, team leader or other colleague
White 8% BME 18%
An action plan was in place to address these findings and both the report and action plan were available on the trust website.
Governance The trust was embedding a systematic approach to improving the quality of its services and safeguarding high standards of care by aiming to create an environment in which excellence in clinical care would flourish. Governance structures were in place to support the functions of the services. Monthly governance meetings were conducted to allow oversight of the service. Senior 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 the service and with the rest of the trust. The governance systems in place had improved to allow better oversight at board level of the potential risk to patients.
20180222 KGHNHSFT Evidence Appendix Page 17
Governance systems in place had improved so that most staff, at all levels, from ward to board, understood the areas of risk within the service, and we saw that a series of actions had been implemented but not always embedded in the service to minimise risk to patients. There was an improved focus on patient safety, effective risk assessment and management throughout the service, but this was not yet fully embedded in the service by all staff. Procedures and guidance available to staff was comprehensive and up-to-date, which was an improvement on the October 2016 inspection. For example, staff were better able to respond appropriately with internal security arrangements that kept children and young people safe.
The trust generally had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees and team meetings. Leaders had reviewed these structures. This included sub-board committees, divisional committees and team meetings. On reviewing papers board papers and the quality committee papers, they were generally of a good standard and contained appropriate information. Papers for board meetings and other committees were of a reasonable standard and contained appropriate information. Non-executive and executive directors were clear about their areas of responsibility. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance. A clear framework set out the structure of ward, team, CBU and senior trust meetings. Managers in most areas used meetings to share essential information such as learning from incidents and complaints and to take action as needed. Staff at all levels of the organisation generally understood their roles and responsibilities and what to escalate to a more senior person. The trust was working with third party providers effectively to promote good patient care. A partnership arrangement was in place for the provision of psychiatric liaison services with appropriate governance arrangements. The governance framework addressed the need to meet people’s mental health needs. Another trust provided a mental health liaison service. The trust’s contract management team monitored compliance with Psychiatric Liaison Accreditation Network (PLAN) quality standards. Senior staff told us that the trust was redesigning its assurance, risk, and governance processes to build on its existing methods. At the time of the inspection, the trust was carrying out a restructure of the CBUs, moving to a three divisional structure in the New Year. Governance systems and processes would then be restructured to develop a holistic risk management and reporting culture with streamlining data for ease of use and analysis for action. The structures, processes and systems of accountability were being developed to support the delivery of good quality care. Since the last inspection, a governance review had been undertaken by NHS Improvement and a further well led review of leadership and governance by an independent organisation. The trust was working through the recommendations from these reviews. This included review of the committee structures and terms of reference. The new divisional structure also aimed to take more local accountability for governance. At the time of this inspection, the sub board committees were working to the existing schedule with meeting dates all in the same week as the board meeting, going forward a more structured approach was planned with revised meeting dates scheduled from January 2018. Trust governors now had a seat on the committees but in line with their role did not have voting rights.
Following the recent well led review, the trust was redesigning its assurance, risk and governance processes to build on its existing methods. Leaders said this was working towards a ‘single version of the truth’ integrated performance report to be used in CBUs, building upon the existing reporting processes. The different elements of these would then be scrutinised for assurance purposes at the three trust board sub-committees, (Performance, Finance and Resources, Quality and Safety, and Workforce Development committees). These elements would then be brought back together for a single reporting process to trust board. In terms of assurance against the trust performance on quality, risk, performance and finance, leaders said this was achieved in a number of ways; management action and accountabilities through the executive team; assurance walk rounds such as the clinical quality visits which included NEDs, executive directors and governors and by the scrutiny of assurance through the board and its sub-committees. Alongside this there were additional safeguards and mechanisms in place where there was improved transparency
20180222 KGHNHSFT Evidence Appendix Page 18 around quality, safety and risk. These included daily patient safety huddles, regular patient safety meetings and mortality reviews. Both NEDs and executive directors ‘dropped in’ to these meetings and visited front line services.
The trust had appointed to the newly created director of integrated governance role in August 2017. The interim director, employed on a one-year contract, was responsible for embedding an effective strategy for governance and assurance across the trust, incorporating corporate and clinical/quality governance. They assisted the board in embedding the new proposed integrated management structure and implement actions arising from the recent NHS Improvement governance review and trust well-led review. Leaders had improved our performance in safety in the last 12 months by revisiting our profile around risk management, reporting and learning from lessons. They acknowledged they had a way to go to seeing this fully embedded across the trust and at all levels of staffing. Areas to be strengthened in the coming year were: Improving the use of the trust’s electronic incident reporting system and learning from incidents. Making risk awareness and management part of everyday language so that all issues were directly linked, recorded, reported and mitigated. Transferring of risk registers to the electronic system from paper based systems and strengthened reporting into a risk management steering group for escalation to trust board. In diagnostic imaging: to improve performance around safety with improved reporting times.
The trust had introduced learning bulletins following incidents and introduced topics for the week that were shared through the clinical safety huddles. Also, the maternity dashboard was now in line with Royal College of Obstetricians and Gynaecology guidance and formally reported to the trust’s Integrated Governance Committee.
The trust had a process in place to ensure policies were identified prior to expiry and review considered relevant stakeholders and was signed off by the relevant group or committee. Trust policies were reviewed and ratified at the individual services monthly scrutiny groups (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 in some areas. The trust had systems in place to manage concerns and complaints raised by patients and their carer’s. The trust had received 395 formal complaints (those requiring a written response) in 2016/17 compared to 385 in 2015/16. Of the 395 formal complaints received, 91 were not upheld, 194 were partially upheld and 73 were upheld. 37 complaint responses were currently on going at the date of the report submitted to trust board (May 2017).
We reviewed recent complaint files and found that they were responded to within the timeframes outlined in the policy. They acknowledged 89% of complaints within three working days between March 2016 and March 2017. The trust completed dealing with a complaint within 25 working days for 90% of cases and for complex complaints, the trust responded to 100% within 30 working days or the timescale as agreed with complainant between March 2016 and March 2017. Timeliness of responding to formal complaints had improved compared to 2015/16 and previous years. The average response time met policy requirements and were generally between 26 to 47 days (47 days was the exception and related to one CBU).
We found generally the complaints investigator was independent to the incident, however; we were not assured that all had received formal training in carrying out complaints investigations. Most reports identified the lessons that should be learnt from the complaint, recommendations and an action plan. There was some variation on the quality of the lessons learnt. The complaints team were aware of the variable quality of the investigations and work was being carried out to improve the support and training provided to team members responsible for carrying out the complaints
20180222 KGHNHSFT Evidence Appendix Page 19 investigations. The complaints team presented a review of the complaints process to the integrated governance committee and the quality governance steering group on a monthly basis.
Board Assurance Framework6 The trust provided their Board Assurance Framework which, for 2017/18, contained 10 strategic risks. The 10 strategic ambitions outlined by the trust were as follows:
Current Risk Score Ref Strategic Risk Board Committee (Q3) (2017-18)
Performance, Finance & Resource SR1 The Trust fails to recover the Referral to Treatment position 16 Committee
The Trust partners are unable to manage demand effectively Performance, Finance & Resource SR2 25 and reduce delayed transfers of care. Committee Performance, Finance & Resource SR3 The Trust fails to deliver its financial plan for 2017/18 20 Committee Failure to maintain estates and its infrastructure at the Performance, Finance & Resource SR4 standard required resulting in an inability to deliver service and 20 Committee objectives of organisation
The Trust does not have information systems in place to rely SR5 Trust Management Committee 16 on the quality of data to manage effective decision making
Impact of system wide health and social care changes on the SR6 Trust Management Committee 20 Trust
Workforce challenges relating to recruitment and retention and SR7 Workforce Development Committee 16 staff experience
The Trust fails to implement the Quality Strategy and fails to SR8 Integrated Governance Committee 20 achieve improvement in harm free care
SR9 The level of intervention and requirements from the Regulators Integrated Governance Committee 20
The borrowing and repayment required of the Trust affects the SR10 Trust Management Committee 20 long term sustainability of the organisation (New risk 2017/18)
The board assurance framework had not significantly changed since the October 2016 inspection. It remained a complex document lacking clear links with the corporate risk register. The trust recognised that trust-wide governance was not as effective as it needed to be and that key information was not getting from ward to board. In May 2017, NHS Improvement had undertaken a governance review of the trust. The findings were similar to the CQC inspection in October 2016. There was recognition from the executive team, supported by the non-executives, that further integration of risk management was required. In order to take governance further forward the trust had appointed a director of integrated governance.
There was no operational or general management function within the structure of the CBU to support the emergency department (ED). This meant there was limited operational management oversight of the department, and operational work required. The matron and clinical lead recognised this as a challenge for the service. The lack of an operational support management function in the service was challenging the speed of change implementation. The staff reported that they regularly saw members of the senior and executive team within the department; they knew who they were and could speak with them if they were in the department.
Mortality and morbidity review processes were well established in the trust and different services and were mostly effective. Meetings were scheduled to be held monthly; however, only four took place in the last six months due to the level of activity within the ED service. We reviewed the cases provided to us as evidence for these meetings. These cases were individual deaths
6 RPIR – Universal – submission P112 PAT BAF July 20180222 KGHNHSFT Evidence Appendix Page 20 reviewed for the meetings. In the majority of the five reviewed, they identified key points to consider, as well as areas of good practice. However, there were no minutes of the meetings, or action points for learning on any learning log to be taken forward for discussion at governance meetings or for inclusion on the risk register if appropriate.
The surgical service was made up of two CBUs; surgery and anaesthesia services. The surgery and anaesthesia governance meeting was held monthly and discussions were held around performance, patient safety and any issues. This included incidents, risks, complaints, finance and activity. Meetings were well attended by a range of senior medical and nursing staff as well as service leaders, human resources advisors and finance service leads. Governance and managerial staff interacted often and functioned effectively. The governance meeting discussions supported the strategy. There was a clinical governance group who were responsible for reviewing surgical procedures. There was a clear governance structure in place for reviewing sepsis associated deaths. The management and reporting of sepsis was the responsibility of the clinical business unit director for anaesthesia.
Monthly clinical governance meetings were held by the maternity service, which discussed service performance, incidents, complaints, clinical audit outcomes and guidelines. We reviewed the minutes of these meetings from August 2017 to October 2017, and found they were detailed and contained copies of relevant reports, action plans and lessons learned. The governance meetings were frequently attended by all grades of midwifery staff. However, there was limited representation from medical staff within the service. We attended the November 2017 clinical governance meeting and noted there was no medical staff from the maternity service present. There was also no medical staff in attendance at the October 2017 clinical governance. We corroborated this with medical staff who told us that they did not have the time to attend governance or risk meetings. We saw there had been improvements with trust board oversight of the maternity service since our last inspection in October 2016. For example, the head of midwifery presented the maternity risk register to senior staff at the risk management steering group in November 2017, and presented the Maternity Safety Improvement Plan to the trust board in March 2017. The head of midwifery was also due to attend the trust board meeting in December 2017. The service did not have a non-executive director representative at board level. The director of nursing and quality was the service’s direct link to the trust board.
We reviewed fire safety risk processes in a number of clinical areas and found that all fire safety equipment and processes were effective and in date. Risk assessments were thorough and were reviewed frequently. In accordance with trust procedures, regular checks of fire safety equipment and environmental checks were carried and documented. The trust had also carried out of review of all high rise buildings on site to ensure no risks due to building ‘cladding’ were present. Governance processes surrounding fire safety were well established and effective. We saw that the trust had taken appropriate actions following a fire alarm alert in the month prior to the inspection and had a rolling programme of replacement of fire activation points in place. The trust’s interim fire officer had reviewed the trust’s fire safety risk assessment and we saw effective systems were in place to ensure regular fire safety risk assessments were carried out in all areas. The trust had also revised its fire safety training programme and had trained sufficient staff to ensure a fire warden was on shift in each clinical are visited. On one day of the inspection, a fire call point had been activated in error and we saw that staff responded appropriately and that a horizontal evacuation of the affected area was carried out in accordance with the trust’s fire safety procedures. Arrangements for monitoring staff and patient health and safety were generally effective.
Management of risk, issues and performance The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected, but these were not always effective. We were not assured levels of harm were always being correctly identified in all services.
20180222 KGHNHSFT Evidence Appendix Page 21
Fully effective arrangements for identifying, recording, and managing risks, issues, and taking mitigating actions were not yet in place. We found that risk management processes had improved and were sufficient to recognise, assess, monitor, review, and therefore reduce most risks.
Since the October 2016 inspection, the trust had appointed a risk manager and had revised its local and corporate risk register function, by using an electronic system to capture all local, clinical business unit risks. All significant risks were then transferred into the corporate risk register. Senior managers said that this was work in progress, and a detailed review of all risks, actions and mitigations was being carried out so that the corporate risk register would present a more structured and current assessment of risks in the trust. At the inspection in October 2016, we found a lack of clear links between the board assurance framework and the corporate risk register, limited consistency in the rating of risk and that not all risks were identified. There lacked clear links between the further control and mitigating action and the wording of the risk description. Each clinical business unit reviewed their risk profile monthly and these were reviewed by the risk management steering group. Training on the risk register was provided for board members and senior managers in August 2017. Some managers including directors had received one to one training with the risk manager.
A quality improvement plan had been developed to address the issues from the last inspection, this was aligned to the trusts’ values. The plan clearly detailed the ‘must do’s’, actions required, timescales, if external support was required, progress against the original timescale, monitoring arrangements and executive lead. Ratings of the delivery of the action against a red, amber or green scale this had been completed and the trust saw sustainability as a key to success. The place of this plan within the governance structure was clearly articulated, as was the communication plan for both internal and external stakeholders.
The trust had an integrated governance committee, which was a subcommittee of the trust board; its purpose was to monitor the strategic direction for governance and the management of risk within the trust. It had been due for review in January 2016. We did not find evidence that the function and purpose of committee had been reviewed as had been planned.
There was a corporate risk register which did not always link clearly with the board assurance framework (BAF) All risks were assigned a current risk rating and a target risk rating. Controls in place and actions identified to address the gaps in controls to mitigate the risks. Risks had been reviewed at CBU level, but this had not always translated through to the corporate risk register. Senior leaders could describe how risks and concerns were escalated and were aware of the risks in the trust.
We reviewed the board assurance framework and the corporate risk register. There was a lack of clear links between the two documents. In addition, the flow of information on risk from ward to board was limited with a lack of consistency in the rating of risks. There was a lack of updating or closing of risks on the current management system. Risks in the clinical business units went through their governance meetings and were added to the corporate risk register on the basis of their risk rating. The trust had undertaken a review of the corporate risk register and Board Assurance Framework at the end of 2015/16 with a paper to the board. The trust told us that both documents had therefore been refreshed as a result of the review process.
Leaders had made significant improvements in the way that risks were assessed and managed following our October 2016 inspection. However, at this inspection, we found that some ward processes and safety systems had not been consistently followed by all staff. When we raised these concerns during the inspection, leaders took urgent actions to address them. Sustainability of improvements was to be an ongoing focus for the leadership team. The trust had recognised a review of all risk registers was required and had engaged some specialist advice to support them with this just prior to the inspection. We found that the clinical business unit risk registers that were in place at the time of the inspection had improved but did not always accurately reflect all the risks in services.
20180222 KGHNHSFT Evidence Appendix Page 22
The trust policy for serious incident reporting included a two tier reporting system where serious incidents were declared internally and externally. The maternity service declared three serious incidents externally and reported another two serious incidents internally. Of these internal serious incidents, one should have been declared externally as a serious incident. This incident related to an intrauterine death. The trust’s internal investigation identified improvements of care, which may have led to a different outcome. This would normally meet the criteria for an externally reportable serious incident. However, this was not reported and the service classified the severity of the incident as ‘no harm’. We reviewed 593 incidents reported from August 2016 to September 2017 and identified 71 (12%) incidents which had been graded as ‘no harm’. Of these, examples were where a woman who suffered a major postpartum haemorrhage (the loss of more than 1000ml of blood from a woman’s genital tract within 24 hours of a birth of a baby) on transfer to recovery, which resulted in a hysterectomy, and an admission to the intensive care unit (ICU). Another incident, which involved a woman being transferred to ICU after suffering a major postpartum haemorrhage following an emergency caesarean section, was also graded as ‘no harm’. Another incident where an emergency caesarean section was completed for suspected fetal compromise and the baby was found to be stillborn was graded as ‘no harm’. On our inspection, staff said they categorised the level of harm when they initially reported an incident. The managers for each clinical area reviewed the incidents, followed by a final sign-off review by either the head of midwifery or clinical director. At both these reviews, the categorisation of harm could be changed in line with national guidance. Following our inspection, we sought clarification that incidents were being reported and investigated appropriately. Therefore, we spoke with senior staff at the trust who supplied us with further information. This information explained that the level of harm was determined by staff’s influence into the incident. For example, postpartum haemorrhages were reviewed and if no clinical attributing factors that caused the bleeding was identified, the level of harm was graded as ‘no harm’. This was in line with national guidance for reporting of incidents under the National Patient Safety Agency (NPSA) (2009) guidance for the identification and reporting of patient safety incidents (PSI). This guidance provides a definition of a PSI: ‘Local organisations should investigate these to determine if a PSI contributed to the unexpected outcome or unexpected death. Organisations should not enter a harm grading of severe or death on a PSI report unless they believe that permanent harm or death actually resulted and was directly attributable to a PSI.’ Senior staff completed internal investigation reports for all incidents initially graded as ‘moderate harm’. We found thorough investigations were completed, including evidence of duty of candour application. Some incidents were downgraded to ‘no harm’ following an investigation where no patient safety incident had been determined. We saw that the management of both internally and externally reported serious incidents followed the same process. A senior member of staff was appointed as the lead for the serious incident investigation and conducted the root cause analysis (RCA). We reviewed the RCAs of the external and internal serious incident investigations. We saw detailed RCAs had been completed, which included recognition of care management and service delivery problems, contributory factors, lessons learned and actions to be completed to reduce the risk of further incidents. All serious incident investigation reports were presented at the serious incident review meetings and needed to be signed off by the serious incident panel (comprised of senior staff) prior to the report being shared.
The emergency department had a risk register, which contained 35 risks added over the last 18 months. The leads for the service acknowledged there were too many risks on the register. The leads were able to clearly articulate the risks in the service and what was to be done about them; however, there were many risks making it difficult to manage. The lack of an operational lead to support the management of the service had not been identified as a risk for the service, but the lack of support in this function was a risk to the delivery of the service. At the last inspection, the identification of risk was a concern and departmental risks were not reflected on the register. At
20180222 KGHNHSFT Evidence Appendix Page 23 this inspection, the majority of risks we identified were on the risk register, the service was aware of them and trying to manage the risk to safe patient care and staff were working to reduce and make improvements. Risks were routinely discussed at the ED governance meeting.
We saw an improvement in the identification and recording of risk on the risk register for maternity since our last inspection in October 2016 and the senior leads were able to clearly articulate the risks in the service and was to be done about them. However, we identified risks that were not documented on the risk register. These were women experiencing a miscarriage, not always being provided care in a single room, and poor medical staff engagement with both clinical governance and risk.
Image reporting delays had been included on the service risk register since November 2012. The department had attempted to mitigate this risk by outsourcing imaging to external companies and offering overtime to staff in the department. In 2012, we saw evidence that the department had risk assessed an agreement to not make formal reports on some examinations which would be viewed and reported by other clinicians in the hospital. Even with these actions in place, we saw evidence of two further peaks in imaging backlog (in October 2015 and summer 2016). The second peak in 2016 was largely beyond the trust’s control due to problems in the transition to the new RIS and PACS systems. However, 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. The image backlog was formerly on the corporate risk register but was downgraded to the departmental risk register alone. This would have meant that the backlog had only been dealt with at local level. Staff we spoke with were very aware that the high number of unreported images might be compromising patient safety. 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 recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery. The radiology recovery plan set out the key areas of work which the trust would undertake to address the removal of the radiology reporting backlog. This included ensuring the service had adequate reporting capacity to remove the current backlog and to meet service needs in the future, to ensure there was a robust governance structure and processes were in place to manage the risks associated with any reporting delays and that a clear harm review process was developed. In addition a further work stream was to identify training needs within the trust regarding interpretation of images by non-radiological staff and processes for audit to monitor this.
The trust reported incidents through an electronic database, which was easily accessible for staff and located on the trust intranet. The governance team managed incident reporting though the Strategic Executive Information System (STEIS). Departments had a monthly dashboard that was used to set the targets for safety performance and also used nurse sensitive indicators such as compliance with infection control protocols and care associated risk assessments. The dashboards also included the numbers of incidents and complaints, which were discussed at governance meetings and as ‘hot topics’ at daily nursing and medical safety huddles. Our observations and discussions with most staff at all levels confirmed that they were aware of the ‘hot topics’ within their department. There was generally a positive culture towards reporting incidents and learning from these to improve patient safety. Staff at all levels understood their responsibility to report incidents both internally and externally. All staff had access to the hospital’s electronic system for reporting incidents and staff that we spoke with described the process they followed.
Mortality and morbidity meetings were conducted monthly and there was an effective process in place to disseminate information to staff at all levels. Mortality and morbidity meetings were peer reviews of the care and treatment patients received with the objective to learn from them.
20180222 KGHNHSFT Evidence Appendix Page 24
Consultants identified those patients from the previous month to review and identify areas of learning. Minutes were circulated to ensure all staff had access to the cases discussed and junior doctors told us the learning was positive. Staff at all levels were invited to attend and relevant information was available on the trust’s intranet, and hard copies were available in clinical areas for staff. The trust played an active role in the countywide mortality forum where learning was shared between different organisations.
Finances overview7 HISTORICAL DATA PROJECTIONS Previous Last Financial This Financial Next Financial Financial Metrics Financial Year Year Year Year (2 years ago) (2016/17) (2017/18) (2018/19) Income (deficit) £218.5m £234.5m £238.1m £241.3m Surplus (deficit) (£11.2m) (£24.6m) (£19.9m) (£14.0m) Full costs (deficit) (£229.7m) (£209.9m) (£218.2m) (£227.3m) Budget (deficit) (£12.3m) (£6.4m) (£19.9m) (£14.0m)
At the time of the inspection, the trust had not signed up to its control total in 2017/18. The control total was set at £6.6m and the financial plan required the trust to commit to an underlying deficit of £13.7m. Given the trust had a 2016/17 deficit of £24.6m and an underlying deficit going into 2017/18 of £25.8m, the trust committed to £19.9m deficit requiring £22m of recovery actions. The trust had an NHSI assigned Financial Improvement Director who was monitoring progress against the 2017/18 financial plan and recovery actions and was subject to further oversight at quarterly review meetings with the regional NHSI leads. The Trust had a capital plan of £16.1m and authorisation to progress to full business case for a fit for purpose emergency department. The trust also had a significant (£100m plus) backlog maintenance that required capital investment The trust board had sight of the most significant risks and mitigating actions were clear. There were plans in place for emergencies, for example, adverse weather, a flu outbreak or a disruption to business continuity. Where cost improvements were taking place, there were arrangements to consider the impact on patient care. Managers monitored changes for potential impact on quality and sustainability. Where cost improvements were taking place, they did not compromise patient care.
Referral to treatment (RTT) executive assurance group meetings were held every two weeks between RTT leads and executive trust leaders. We reviewed minutes of the last three meetings and found these to detail necessary areas of risk and performance relating to RTT. Governance and risk oversight had continued to improve so that the trust’s Board of Directors and all external stakeholders could be assured as to the trust’s ongoing RTT performance and potential risks to patient safety. Following the introduction of a transformation lead into the service, steering groups were held every two weeks. 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.
The trust generally had effective systems in place to identify learning from incidents, complaints and make improvements. The governance team regularly reviewed the systems. Senior management committees and the board reviewed performance reports. Leaders regularly reviewed and improved the processes to manage current and future performance. Leaders were satisfied that clinical and internal audits were sufficient to provide assurance. Teams generally acted on results where needed. Staff had access to the risk register either at a team or
7 RPIR – Universal – Finances tab 20180222 KGHNHSFT Evidence Appendix Page 25 division level and were able to effectively escalate concerns as needed. Staff concerns generally matched those on the risk register.
There was a more holistic approach to the monitoring of safety and performance data, supported and informed effective, ongoing clinical audits in all services. Actions plans had usually been developed to address areas of risk or poor performance and those that were in place were usually effectively monitored. The trust historically was reliant on those areas of quality and safety that required improvement as identified by the nurse sensitive indicators. The trust told us that the nurse sensitive indicators system was planned to be developed into a system for ward accreditation. The quality and performance governance systems in place had now recognised risks in most services.
There was an active audit plan in place. Audits were identified from national, local and specialist sources as well as clinician based interest. All were logged centrally. A small percentage was behind their completion target date, the longest of which was over 500 days, however most were completed on time. Responsibility for implementing audit outcomes sat with the senior clinical lead for the area. The clinical governance indicators, including the nurse sensitive indicators, were compiled each month into a comprehensive Integrated Governance Report, which was presented to the monthly Integrated Governance Committee. Ward dashboards were in place so that areas for improvements could be identified, including compliance with training, infection control, pressure area are care and risk of falls. The trust had a quality improvement team, who maintained an overarching quality improvement plan: we found this plan did now directly link to the Health and Social Care Act (2008) regulatory breaches that we identified at the last inspection, and to the main risks on local risk registers.
Safeguarding There was an executive and a non-executive lead for safeguarding who attended a monthly safeguarding steering committee. This meeting was also attended by representatives of the local clinical commissioning group. We noted the trust’s adults safeguarding policy was out of date as it did not reference the Care Act 2014, which is the legislation governing adult safeguarding. Senior staff gave us an updated version of the safeguarding adults’ policy that was awaiting ratification. However, it did not include reference to a domestic abuse policy or a restraint policy. The updated policy did contain a referenced link to the statutory guidance to the Care Act 2014 and reference to making safeguarding personal. Making Safeguarding Personal (MSP) is a sector led initiative, which aims to develop an outcomes focus to safeguarding work, and a range of responses to support people to improve or resolve their circumstances. The policy did not have a link to the updated Prevent guidance (2015). The Counter-Terrorism and Security Act 2015 contains a duty on specified authorities to have due regard to the need to prevent people from being drawn into terrorism. This is also known as the Prevent duty. The trust’s safeguarding adults’ training strategy was out of date: staff we spoke with were aware of this and we were informed the trust were waiting for the local authority safeguarding team’s training strategy to be updated before the trust took action. We did not have a timescale for these changes at the time on the inspection. We reviewed the safeguarding children’s policy. The review date was December 2019; however, it would need to be reviewed before that date in light of an update to working together (2015) and the intercollegiate document (2014). As with the safeguarding adult policy, the policy did not have a link to the updated Prevent guidance (2015) or a reference to a restraint policy, or a policy to cover restraining children who self-harm. The trust’s safeguarding children’s training strategy had been updated in April 2017: it reflected the intercollegiate guidance (2014). As a result safeguarding children, training was a priority for the trust for the coming year.
Information management
20180222 KGHNHSFT Evidence Appendix Page 26
The trust had improved the way it collected, analysed, managed and used information well to support all its activities. A refreshed IT Strategy (Digital Strategy) was approved by the Trust Board on 27th May 2016. The strategy’s vision was to delivering digital services that enabled person-centred health and transformational change to frontline care. The strategy’s key objectives were: To develop infrastructure to ensure it was secure, reliable, responsive and resilient to the business needs. To provide fit for purpose information systems which enable staff to fully understand the business and support the provision of the highest possible quality of care to patients. To work in collaboration with all staff, other technology professionals, partner organisations and our suppliers in order to design, procure and implement digital solutions that enable the overall strategy.
The Digital Hospital Steering Group was established in April 2017. All technology-related projects and programmes of work come under the remit of this group including: Agreeing and optimising, in line with the needs of the business, the full clinical, contracting and business information requirements of the Trust; To provide strategic direction for the development and deployment of digital care records capabilities across the Trust; The implementation and deployment of all information systems across the Trust; To maximize the benefits of technological innovation in improving the efficiency of healthcare delivery and ensuring the delivery of the Trust’s corporate objectives and vision.
The trust had also developed a job description/personal specification for a Chief Clinical Information Officer (CCIO) to provide strategic level clinical guidance, working collaboratively with key stakeholders to ensure the successful use of integrated knowledge and information systems and was in the process of recruiting to this post. Leaders said the trust had some considerable concerns about the quality of its data that it had been collecting and reporting in the past, and had been working with subject specialists and external companies to ensure that this position was improved. However, the leaders were not complacent about this and continued to work to improve the quality of the data collection systems and data. Referral to treatment (RTT) data was now reliable and accurate and it gave leaders and staff the assurance of knowing the day to day position for those patients awaiting an appointment. Nurse sensitive indicator information was reviewed and used to highlight areas to develop.
Managers generally had an effective oversight of the hospital’s RTT performance and could clearly show how the recording system worked and the number of patients waiting to be seen. This continued improvement in understanding the hospital’s RTT position and performance was continually checked performance at the service’s two weekly ‘RTT Confirm and Challenge’ meetings. Clear, ongoing communication with NHS improvement (NHSI) and the local clinical commissioning groups was evident.
There were effective arrangements to ensure the information used to monitor, manage and report on quality and performance was accurate, valid, reliable, timely and relevant. The data quality team and data validators were integral to ensuring outpatient referral to treatment performance data was accurate. The trust had recruited its own team of data validators. They removed duplicate patients added in error, and provided weekly reports to managers to help drive improvements in meeting targets and patient flow. Senior managers felt confident that the quality of RTT data had significantly improved and accurately reflected the trust’s position. The hospital had recruited a clinical harm coordinator in January 2017 and their role was to lead the harm review process. Patient pathway managers and service support managers were newly recruited to support service delivery and to sustain improvements. Service support managers were now trained to validate patient records and RTT data.
20180222 KGHNHSFT Evidence Appendix Page 27
The arrangements to ensure that the information used to monitor, manage and report on quality and performance was mostly effective; however, with the volume of information being considered by the service it was challenging to manage. The ED staff were not enabled to manage their outcomes to the best of their ability. The TARN outcomes for the ED were managed and overseen by the orthopaedic service. The data was compiled and reported on by this service and not the emergency department. This means that the emergency department did not own the outcomes for which it is measured against. The information technology systems used by the trust presented them with challenges. This did have a direct impact on the ED. The patient record system was predominantly paper based making management of records very challenging. Staff had access to the trust’s electronic records system. Information to deliver effective care and treatment to patients was consistently documented or available. Patient records were requested as needed on admission or in advance for outpatient appointments. The trust reported low incidence of notes not been available in outpatients’ clinics and staff followed the trust’s temporary notes procedure in these cases. This had been identified as a risk on the service risk register and was being monitored by senior staff.
A copy of the patient’s discharge summary was given to the patient as well as sent to the patient’s GP. Staff reported there had been delays and a backlog of GP letters being sent following a patient’s discharge and that some delays were a number of weeks. Additional resources had been dedicated to address the backlog and there had been significant improvements and that this was now being monitored closely; it remained a risk on the risk register. GPs were able to contact the service for telephone advice if they needed to. Test results were obtained promptly from the relevant departments to ensure clinical decisions could be made based on supporting pathology results. The board received holistic information on quality and sustainability. Leaders used generally 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 key performance indicators and other metrics in most areas. 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. The board and senior staff expressed limited confidence in the quality of the data in some areas and told us of plans to ensure information collection and management systems were being developed.
Information was generally in an accessible format, timely, accurate and identified areas for improvement. Systems were in place to collect data from wards and teams and this was not over burdensome for front line staff. IT systems and telephones were working well and they helped to improve the quality of care. Staff generally had access to the IT equipment and systems needed to do their work. Leaders submitted notifications to external bodies as required. The trust had completed the Information Governance Toolkit assessment. An independent team had audited it and the trust took action where needed. Information governance systems were in place including confidentiality of patient records. The trust learned from data security breaches.
Engagement The trust engaged with patients, staff, the public and local organisations to plan and manage appropriate services, but this had been limited. There were plans now in place to improve this. There was some evidence that the views and experiences of patients and those close to them were gathered and acted on to shape and improve the service. Leaders knew this was an area to develop. Leaders recognised that there were weaknesses in capturing public feedback from the engagement activities undertaken to help shape services at the hospital. However, steps were
20180222 KGHNHSFT Evidence Appendix Page 28 being put into place with the trust’s patient experience team to incorporate a more structured approach to ensure that patient feedback was captured and acted upon. The trust had arranged a community engagement event prior to the inspection, which had been well attended by the public and also by key stakeholders and system partners. The trust was also planning a series of further events in the New Year.
The service used comment cards, which we saw were available to patients and relatives. Patients could also provide feedback using NHS Choices. Child friendly comment cards were also handed out to children to gauge their perception of the care and treatment they had received. The service had also engaged with Young people’s Healthwatch had undertaken a review of the paediatric ward. Healthwatch is an external consumer champion for health and social care. A report was produced in 2016, which included some suggestions for actions, for example more comfy chairs for parents and carers as well as magazines for adults. Another review was being planned to help capture the voice of young people using the service.
The service gathered feedback from staff through staff meetings and discussions. Staff told us they would not hesitate to give feedback and discuss any concerns or issues with colleagues and management. The head of service held staff ‘huddles’ twice a week to share information and highlight risks with ward staff. These were held at different times of day so that as many staff as possible attended. Three whole team days were organised over the summer, but only one took place because the service was so busy. These were intended to strengthen staff engagement for greater resilience and more opportunity to share experiences internally. CARE ‘Smile’ awards were held monthly as a celebration and recognition of staff from all levels; staff that have ‘gone the extra mile’ and shared via the trust’s intranet screen saver. Leaders also were embedding CARE values through activities such as ‘Random Acts of Kindness Campaign’ and encouraging staff to be kind to themselves and others.
The trust worked with other stakeholders and commissioners to improve engagement with the public. This included working jointly within the commissioning area to promoted alternative options to patients to help avoid unnecessary attendances to the emergency department. The service also supported national flu campaigns, and displayed these signs. Regular newsletters, emails, notices in staff areas and ‘hot topics’ ensured ongoing staff engagement took place, this included a “you said, we did” notice board in the handover room on delivery suite. Most teams held monthly team meetings. Staff told us they had the opportunity to provide feedback to their managers during team meetings or appraisals and felt listened to when they raised concerns. However, not all teams documented these meetings, which meant opportunities to share and embed learning did not always take place. Some staff felt actively engaged and involved in the planning and delivering of services. An example of this was the way the community midwives were instrumental in setting up the ‘Great Expectations Group’, which provided support and guidance for women who had been identified as being at risk of suffering with mental health concerns during their pregnancy and the postnatal period. There was a staff recognition scheme called the ‘Smile’ awards. Patients, relatives, staff and visitors were invited to recognise staff that went the extra mile by nominating them for a smile award. In the NHS Staff Survey 2016, the trust scored 3.78 for staff engagement which although an improvement on the previous year remained lower (worse than) average when compared with trusts of a similar type. Possible scores range from one to five, with one indicating that staff are poorly engaged (with their work, their team and their trust) and five indicating that staff are highly engaged. Communication systems such as the intranet, social media, newsletters and bulletins were in place to ensure staff, had access to up to date information about the work of the trust. The trust had Governors in place and they told us that they all had received training on appointment and were actively involved in the operation of the trust.
The trust held public engagement sessions when new services were proposed, for example the development of the trust’s new patient engagement tool. The trust had around 100 volunteers who 20180222 KGHNHSFT Evidence Appendix Page 29 worked across all service areas. They all had the appropriate checks and had undertaken safeguarding level two training. The trust was engaged in collaborative work with external partners such as involvement with the local sustainability and transformation plans. They also worked with Healthwatch and commissioners.
Patients were encouraged to be involved and had attended trust board meetings. Patients had attended board meetings to present their patient stories.
The Patient Experience Steering Group (PESG) met regularly, was well attended and reviewed themes arising from complaints to consider changes in services to improve the patient experience. The PESG had wide ranging membership including volunteers, members of the public, governors, commissioners and Healthwatch. The PESG had developed a Patient Experience and Improvement Strategy with an associated work programme. Priority areas for action had been identified as the trust’s telephone response service, clinic letters and availability of car parking, The trust had also implemented mobile listening booths where patients and visitors could provide feedback, which was then reviewed by the PESG. Medical wards had also set up informal fortnightly ‘surgery’ meetings where patients and carers could meet with staff and provide feedback.
There was a quarterly learning disability forum, which was chaired by the deputy director of nursing and the learning disability lead. Membership included people living with a learning disability and representatives from the community learning disability team. There was also a disability and sensory impairment working group which was chaired by the diversity and inclusion manager and held quarterly. The group was made up of community and voluntary sector organisations who represented patients, carers and families of patients living with a disability. Patient service managers gave presentations about different services provided by the trust. The group there are presentations by different patient service managers and these are scrutinised by the group members as to the extent to which the services meet the needs of patients, carers and family with disabilities / complex needs. The trust held a multi-faith group meeting twice a year. There were representatives from many faiths in attendance. Members of the group made themselves available to visit patients in hospital when requested.
Learning, continuous improvement and innovation The service had improved its commitment to developing services by learning from when things go well and when they go wrong, promoting training, research and innovation, since the last inspection but further work was required. There was limited innovation in the service development. The trust, and staff, had been focused on addressing the significant safety and risk management concerns that we had found, and escalated, at the October 2016 inspection. Many improvements had been made to provide an effective, safe, high quality service, but ongoing work was required to fully embed all the improvements in all areas. The ED had recently established an ambulatory care unit with the acute medicine division. This service, when open, would enable direct referrals to the medical team to support conditions such as deep vein thrombosis, diabetes, leg ulcers, and anticoagulation as well as undertaking minor procedures without the patient having to wait in the emergency department. The RTT recovery scheme was well embedded and progress had been made. It was recognised that the number of patients waiting over 52 weeks for a procedure had continuously decreased since our last inspection. Staff within specialities understood the importance of ensuring all patients waiting had their risk of harm reviewed. The clinical harm review process had been positively recognised and was presented to the national elective care conference in 2017. Staff had worked well throughout the theatre refurbishment programme. Lessons learnt from the programme had been recorded and staff told us the lessons learnt would be shared with teams who planned to relocate, for example, the maxillofacial service. There were also plans to make
20180222 KGHNHSFT Evidence Appendix Page 30 better use of space within the day case unit. A business case had been approved to convert a room into a bay of four chaired cubicles for pre-operative minor procedure admissions.
Complaints process overview8 The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months. Current In Days Performance 89% (March What is your internal target for responding to* complaints? 3 working days 17) What is your target for completing* a complaint? 25 90% 30 or If you have a slightly longer target for complex complaints timescale as 100% please indicate what that is here. agreed with complainant * The trust qualified completing the complaint is defined as closing the complaint, having been resolved or decided no further action can be taken Complaints9 The trust received 173 complaints between August 2016 and July 2017. Surgery received the most complaints with 63 (36% of all complaints). 134 of the 173 complaints (77%) were either closed within the 25 working day agreement or closed within an agreed extension deadline. 26 complaints remained open.
The timescale for response was three working days. The timescale for responding to a complaint was 25 working days: more complicated complaints had a timescale of 30 days, or longer, if agreed with the complainant. There was a process in place for responding to complaints and information was available to make patients aware of how to complain. Leaflets informing patients how to make a complaint or contact the Patient Advice and Liaison service (PALS) service were available on the ward and NICU. Most complaints were resolved and responded to immediately and that these were mostly due to communication issues from nursing and medical staff. Formal complaints were rarely received. Staff were aware of the process for supporting patients in making complaints.
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. Staff spoke very positively about the practice development team and said they were encouraged and supported to complete additional training. This included a midwifery sonography course, high-dependency
8 RPIR – Universal – Complaints overview tab 9 RPIR – Universal – Complaints tab 20180222 KGHNHSFT Evidence Appendix Page 31 training and the newborn infant physical examination training. A staff member also told us that the service funded them to complete their assistant practitioner training. A successful bid with Health Education England enabled the maternity service to invest and provide integrated multidisciplinary training, which also included paramedics and theatre teams. Both community midwives and paramedics attended the ‘childbirth emergencies in community’ training. The service developed new assistant practitioner roles to bridge the gap between healthcare assistants and registered midwives. The hospital achieved the United Nations Children’s Fund (UNICEF) Baby Friendly full accreditation in 2016.
Accreditations10 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. The trust participated in several schemes however the table below shows which services within the trust have been awarded an accreditation together with the relevant dates of accreditation. Details of accreditation and date (if Accreditation scheme Related core service available Joint Advisory Group Endoscopy Unit. Accredited March Medicine (including older on Endoscopy (JAG) 2013. Revisit in 2018 people's care) Biochemistry granted ISO15189 14/04/16 Immunology granted ISO15189 27/10/16 Cellular Clinical Pathology Pathology granted ISO15189 Accreditation and its 26/04/17 Haematology/Blood Diagnostic Imaging successor Medical Transfusion grated ISO15189 (additional service) Laboratories ISO 15189 26/04/17 Microbiology awaiting grant of accreditation subject to assessment of findings, currently accredited by CPA - since May 2014. Full Decontamination compliance for the reprocessing and sterilisation of surgical instruments and associated ISO 13485:2012 No medical devices Issued 22nd June 2016. Valid until 31st March 2019 Full Decontamination compliance for the reprocessing and sterilisation of Medical Devices surgical instruments and associated No Directive 93/42 EEC medical devices Issued 22nd June 2016. Valid until 31st March 2019
The trust had implemented a learning from deaths policy, which had been ratified by the trust’s board in September 2017 and was reviewing patients’ deaths in accordance with the NHS National Quality board ‘National Guidance on Learning from Deaths’ guidance (March 2017). The
10 RPIR – Universal – Accreditation tab 20180222 KGHNHSFT Evidence Appendix Page 32 trust had a system for reviewing deaths in accordance with this guidance, using the recommended structured judgement review tool, and had collated information for reporting data gathered in the first quarter to the trust board. Mortality reviews were undertaken to look at any learning that could be implemented to help minimise the risks of any future unavoidable deaths. Senior staff told us that each department had its own mortality and morbidity review meetings but some were less frequent than others. Learning from these meetings went to the trust’s mortality meeting.
The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at trust level across the NHS in England using a standard and transparent methodology. Between April 2016 and March 2017 the trust SHMI was 105.9 which is within the ‘as expected range’ for the trust. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. Risk is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to the England average. A score of more than 100 means more adverse (worse) outcomes than expected. The trust held grand rounds on a regular basis. These facilitated learning across all disciplines in the organisation. Grand rounds help doctors and other healthcare professionals keep up to date in important evolving areas which may be outside of their core practice. There was a weekly serious incidents review group meeting. The purpose was to improve patient safety and to learn from incidents to prevent more serious harm happening to patients. All potential serious incidents were also discussed at the meeting. Once discussed and investigation was requested to be undertaken by the area, this was fed back at a future meeting with the proposed changes in practice if applicable. We attended this meeting and found decisions were made in accordance with the trust’s serious incident policy. We reviewed 10 investigation reports on serious incidents and found these were all detailed and followed trust policy.
20180222 KGHNHSFT Evidence Appendix Page 33
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 13 bays for patients within majors, six 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 majors areas. We inspected the following areas on the Kettering General Hospital site: Accident and Emergency. Emergency Decision Unit. Following the comprehensive inspection of the trust in October 2016, we rated Kettering General Hospital NHS Foundation Trust as inadequate. We rated two key questions, safe and well led, as inadequate. We rated caring as good and effective and responsive as requires improvement. We undertook a focused inspection of this core service in June 2017. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. 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 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. spoke with the managers, matrons, and clinical leads for the department. spoke with 14 other staff members; including doctors, nurses and support staff. observed handover and bed meetings as well a clinical ward round. 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.
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.
20180222 KGHNHSFT Evidence Appendix Page 34
There were 87,505 attendances between April 2016 and March 2017 at Kettering General Hospital NHS Foundation Trust as indicated in the chart above. (Source: NHS England)
Urgent and Emergency Care attendances resulting in an admission
The percentage of A&E attendances at this trust that resulted in an admission increased noticeably between 2015/16 and 2016/17. In both years, rates were higher than the England average. (Source: NHS England)
20180222 KGHNHSFT Evidence Appendix Page 35
Urgent and Emergency Care attendances by disposal method
^ Includes: to A&E clinic, fracture clinic, other OP, other professional (Source: Hospital Episode Statistics) Is the service safe?
Mandatory Training Mandatory training was provided, and in the majority of subjects, the service met the trust set target of 85% for completion of mandatory training. However, life support training rates were low. Only three of the nine mandatory training modules met the trust target for completion rates in the medical and dental staff group. Life support modules had the lowest completion rates with adult basic life support achieving 66% and paediatric basic life support achieving 44% (12 of 27 required staff having completed the training). Nursing and midwifery staff in the ED met, or were near to, the trust target completion rate of 85% across all modules. However, paediatric basic life support achieved 74% and adult basic life support achieved 85%. Advanced life support training had been attended by 81% of medical staff, 90% of junior medical staff. However, only 50% of nursing staff attended this training. Paediatric Intensive Life Support (PILS) training had been attended by 88% of nursing staff. Emergency paediatric life support (EPLS) training had been attended by 61% of medical staff and 4% of nursing staff. No junior doctors had attended this training. Training on mental health awareness, dementia awareness and safe breakaway was well below the trust target for nursing staff, and no doctors had received this training. Training records provided showed that 54% of nursing staff and 0% of medical staff had been trained in mental health awareness. For dementia awareness, 54% of nursing staff and 0% of medical staff had been trained. For safe breakaway training, 62% of nurses and 0% of doctors have received this training. The trust shared that it was not mandatory for the doctors to have training for dementia, mental health, or safe breakaway. A breakdown of compliance for mandatory courses as of July 2017 for medical/dental and nursing staff in Urgent and Emergency care is shown below:
20180222 KGHNHSFT Evidence Appendix Page 36
(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Safeguarding
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 midwifery staff group. The percentage of medical staff trained in safeguarding adults level 2 was 87%, safeguarding children level 2 was 100% and safeguarding children level 3 was 76% with 22 of 29 required staff having completed the training. This meant that whilst safeguarding children training rates had improved
20180222 KGHNHSFT Evidence Appendix Page 37 they were still lower than expected to ensure safeguarding children knowledge was sufficient in the department, and not in line with national guidance. We observed two incidents where staff considered the safeguarding requirements for adults in the department. They spoke with the safeguarding lead nurse for support and they attended the department to support the completion of the safeguarding adult referral. Both cases demonstrated safeguarding adult requirements for neglect and harm had been recognised by staff, and appropriate protocols and trust policy followed. We reviewed the policy for safeguarding children in the children’s emergency department. The policy was clear on when patients would be flagged or assessed as a safeguarding concern. However, two nurses we spoke with out of four did not have a clear understanding of when they should raise a safeguarding concern. We were informed by these nurses it would be a calculation of their age and number of attendances, which meant children with multiple attendances might not be flagged. This was not the view of the other two who understood the policy requirements. We asked the doctor in the department the policy for identifying and flagging safeguarding for multiple attendances and at what point this would occur. They were not aware of the policy and would need to refer to it before making a decision. We identified one children’s attendance where the knowledge of staff around processes placed patients at risk of harm from abuse. The child who attended was flagged by the staff for support with their learning disability. However, they did not flag the child as a safeguarding concern despite five previous attendances in 12 months. Our analysis of this incident was that this was due to staff lack of knowledge of the children’s safeguarding policy and systems in place. The service did not have a local bruising protocol for immobile babies and children as staff at the trust followed the local safeguarding children’s board‘s (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’. Any bruising, or what is believed to be bruising, in a child of any age that is observed by, or brought to the attention of any professional should be taken as a matter for inquiry and concern. We reviewed the records of seven children under the age of 18 months with injuries. We found no reference to the recommendations of NICE CG 89 in the notes. Though the standard safeguarding boxes were ticked, this was not directly in respect of bruising in children or babies who were not mobile. A breakdown of compliance for safeguarding courses as of July 2017 for medical/dental and nursing staff in Urgent and Emergency Care is shown below:
20180222 KGHNHSFT Evidence Appendix Page 38
(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control, and hygiene
The systems in place to ensure that standards of cleanliness and hygiene were maintained were not always effective. There were some minor concerns about practices for disposal of sharps in the main emergency department. We also observed some staff not adhere to good hand hygiene techniques. Equipment was visibly clean and we observed staff thoroughly clean equipment between uses.
20180222 KGHNHSFT Evidence Appendix Page 39
We observed many staff use hand gels between patients and there were gel dispensers and basins throughout the department to allow the staff to sanitise their hands at the point of care. However, we noted that medical staff from medicine and surgery did not always wash their hands between patients during rounds and referral reviews. We also observed two ED medical staff not adhere to good hand hygiene and PPE techniques. For example, one put their gloves on for a procedure then opened a public door, and then went into an office and came back to the patient to treat them wearing the same gloves. The nursing and support staff, as well as many doctors, were observed in the majority to adopt good hand hygiene techniques and use appropriate PPE. Waste was segregated appropriately but was not always disposed of correctly. Clinical items were disposed of using clinical waste bags. Cytotoxic items were disposed of using an appropriate identifiable secure container. On four occasions during the inspection, we observed sharps placed on top of the sharps bin the majors area of the department, which meant they were not disposed of correctly and risk being knocked causing an injury or blood borne exposure to a staff member, patient or the public walking past. The service undertook hand hygiene audits on a monthly basis. The results of these audits showed a compliance rate of 77% and 98%, with the trust target being between 95% and 100%. The audit included observation of hand hygiene, and the cleanliness of commodes and equipment in the department. Due to the environment challenges, it would not be possible for the service to fully isolate patients if they were identified as having a potential infection. For example, the side room in the majors pod was at the furthest end of the majors department from the majors entrance. This would expose other patients during transport in and out of this area. Personal protective equipment was available for staff to use. This included gloves, aprons, and masks for use when required. Staff were observed to use these frequently and appropriately throughout the inspection.
Environment and equipment
The design, maintenance, and use of facilities and premises generally met all patients’ needs with risk assessments in place where the environment was challenging to deliver care. However, the children’s emergency department was not fit for purpose. The children’s department has two cubicles and a treatment area within the waiting room. The waiting area was very small and was not able to accommodate the volume of children and parents attending. The main environment was largely unchanged since our last inspection. The waiting area could not be observed due to being in a room opposite reception. CCTV was in use in the waiting room and was monitored at reception for emergencies. The resuscitation equipment was not always checked daily. We checked four resuscitation trolleys during the inspection and found all had gaps in the checks to be undertaken, including checks on the defibrillator. The four trolleys were in the majors ‘pod’, resuscitation area, escalation area and paediatric emergency department. The paediatric emergency department only had one recording gap in three months, and was better than the other three trolley checks. 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.
20180222 KGHNHSFT Evidence Appendix Page 40
The children’s emergency department (CED) was not fit for purpose. The CED 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. The children’s department was located within the main emergency department. 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 trust was unable to meet this in the current environment with almost 20,000 attendances per year being for children. The waiting area was very small and was not able to accommodate the volume of children and parents attending. This meant that there were occasionally queues forming in the corridor to get into the waiting room, and children would often have to wait outside in the adult waiting room. The CED had three cubicles and a waiting room. The design meant that protecting the privacy of the child or parents was not possible as the neighbouring bay and the waiting room could hear the consultation. The CED did not have a cubicle with a door for consultations where privacy and confidentiality is paramount. The department also did not have appropriate areas suitable for breastfeeding and nappy changing. The doors to the children’s department opened to the bays exposing children to those who entered the department. There was no camera entry system, people would press a buzzer and gain entry automatically without staff knowing who it was. This could present a risk for safeguarding and security if a child or parent was at risk. This had not been identified as a risk by the service and was not on their risk register. There was no high dependency area within the children’s department. The staff informed us of the procedure to take the child down the corridor immediately to the resuscitation department should support be required. There was a resuscitation trolley in the department to support a deteriorating child. However due to crowding at peak times, the team would be challenged in getting a child into the resuscitation department, and whilst we were assured that staff were vigilant the staff recognised the environment was not suitable for the growing needs of the population. Some of the risks associated with the environment of the children’s emergency department were recognised by the service and by the trust as it was on their risk register. The staff and department leads informed us that the children’s department would be redesigned as part of the larger rebuild project, which they hoped would commence in 2022. We reviewed a selection of equipment in the adult and CED as well as emergency decisions unit (EDU). All equipment was in good condition. However there was a lack of clarity around the servicing and maintenance of equipment including when it had last been safety tested. Three of the four ECG machines we examined in the main adult ED had not had their clocks adjusted following the clock change from British summer time (BST). This meant that the ECG printouts were displaying the incorrect time. This could ultimately give an incorrect timeframe for treatment and place a patient at risk of harm. Staff ensured this was corrected during our inspection.
Assessing and responding to patient risk
Patients did not always receive assessment, treatment and observation in a timely way.
20180222 KGHNHSFT Evidence Appendix Page 41
We examined 13 observation charts, where patients’ temperature, blood pressure, pulse and respirations were recorded. The trust used the national early warning score (NEWS) system. Of the 13 charts we reviewed, all were calculated correctly, four were well completed and one patient was appropriately escalated. However, frequency of observations did not follow trust policy in four cases, no neurological observations were completed for a patient with a head injury, and three patients did not receive appropriate escalation for deterioration in line with trust policy. This could have placed the patient at risk of deterioration if observations are not undertaken, and concerns not escalated in a timely manner. We examined five ECG test results and saw that these had not been reviewed, dated and timed by medical staff in four cases. In the fifth case, the ECG had been signed and a time added, though this was before the time listed on the printout. This was due to the clocks not being altered on the ECG machine following the clock change 11 days earlier. There were no entries on the patient records of the review of the ECG results in two of five cases. Two ECGs showed new onset atrial fibrillation (a heart condition), which from the records showed they had not been reviewed for more than one hour after it had been taken. We raised this with staff who assured us this was a records issue as the patients had been treated. They promptly updated the patient records. Patient risk assessments were mostly completed. Once a patient was admitted to the hospital, nursing staff would complete a nursing assessment booklet. We reviewed six nursing assessment booklets and found four had been completed. Of the two booklets that had not been completed, moving and handling, skin integrity and falls assessment had not been completed. This was significant for one patient who was admitted following a fall that resulted in an injury, who had not had a falls assessment completed despite being in the department for several hours. A key concern identified at the last CQC inspection was that the service was not performing observations on self-presenting patients within 15 minutes; which was recognised as a patient safety risk. We were still not assured the trust were performing initial observations on self- presenting patients (minors) within 15 minutes of arrival. The trust undertook an initial assessment at the front door of the main department. This area was for self-presenting patients who checked in with the receptionist. Once checked in the patient would have an initial assessment with a senior nurse. The patient would then be streamed to the appropriate area for treatment. Whilst 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 this system. However we could not be assured how accurate the categorisation of each patient was if observations had not been undertaken. There was some confusion over the recording of time to triage process. We observed staff recording time to streaming rather than to triage. Patients who attended through the self-presentation (minors) route could have been unwell and could have benefited from having a set of observations undertaken at initial assessment. We observed 10 patient pathways through the minors route to assess the time to initial assessment and the time to treatment. This included patients with head injury, chest pain, and shortness of breath.
20180222 KGHNHSFT Evidence Appendix Page 42
Eight of the 10 patients we observed had seen the nurse within 15 minutes, however only one had a first set of observations completed within 15 minutes. The times to observations for the other nine patients ranged from 24 minutes to 92 minutes. The time to take observations were recorded manually on patient records. Regular audits were being carried out. The trust provided us with their audits on the time to initial assessment for self-presenting patients. The audits provided asks the question: ‘Do all patients who are seen, receive an initial clinical assessment by a registered healthcare practitioner within 15 minutes of the time of arrival?’ The detail of the audit includes ‘audit of our Time to Obs in Minors’, demonstrating the service monitored this measure. The results of the audits for June (range 20.4%- 41.1%) July (37.5%), August (31%), October (38.2%) and November (36.4%) showed that patients who arrived through a self-presentation route (minors) did not always receive a set of observations within 15 minutes. Between June and November 2017 between 1.8% and 22.5% of patients waited more than 60 minutes to have their first set of observations undertaken through the self-presentation (minors) route. Senior managers told us that the ED’s computer system was being upgraded so that there would be an electronic record of patients’ observations. It was anticipated this system upgrade would be completed by the end of December 2017. The EDU was part of the emergency department but in an area separate to the main area. It was staffed by two senior nurses and had a doctor allocated to it. There were criteria for admission on the EDU, which staff were aware of. All the patients we observed in the EDU all met the safe criteria for admission. When escalation protocols are implemented due to crowding within the department the service will place patients in the corridor area of the department. The safe clinical management of patients in this area has been a long-standing concern for the service, and was recognised on the risk register as a risk. During the inspection, we saw the corridor in use due to the department being busy. We reviewed the protocols for the management of patients in these areas, and were assured that staff would clear this area as soon as possible. We were informed the area would be staffed with one nurse to four patients. However, on two occasions we did not see a nurse allocated to this area when more than four patients were present, the nurse overseeing the patients was the senior nurse taking clinical handover. When the department was busy the patients who arrived by ambulance had to queue. We observed that patients in this queue were not being clinically prioritised to determine who needed to be treated first as the assessment was undertaken after handover which was done in order or arrival by ambulance. In one example, we observed a patient with suspected sepsis wait in the corridor. They were registered as arriving in the department 11 minutes after arrival, and they received an initial assessment 33 minutes after arrival. Despite the potential seriousness of their condition (as indicated by a NEWS score of six), the patient was not prioritised to the front of the queue of patients. The trust reported to us that for those patients who arrive by ambulance, there is an expectation that they will have had observations completed by the ambulance crews prior to clinical handover: after which point they would fall under the care of staff within their ambulance bays. However, this is not agreed in any service level agreement (SLA) or protocol with the ambulance service.
20180222 KGHNHSFT Evidence Appendix Page 43
It is nationally recognised that once a patient arrives at the hospital they become the hospital’s responsibility to ensure safe care is provided. This has also been confirmed by coroners during inquests nationally. On 30 September 2017, the Chief Inspector of Hospitals wrote to all acute trusts in England regarding the safety and quality of emergency care. In this letter, it clearly stated ‘Any patient physically on the hospital site should be regarded as under the care of the emergency department’. The trust were not fully taking on this responsibility for their patients. The emergency department had an escalation policy in place. The assessment of the position of the department from green to amber, red or black was undertaken by the nurse in charge every two hours. However, there was no real time or visual trigger or aid to monitor the levels within the department, which meant the service risked hitting a new level without senior managers realising it. Items of concern for the department were escalated at bed meetings, and we observed support was provided where required. Sepsis screening and treatment required improvement. The department had quality initiative indicator in place (CQUIN) for the improvement of sepsis management. The audits for this show that the service was screening and treating a majority of patients but improvements are still required. From January to March 2017, the service screened 32% of patients, and 81% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. This was identified as an issue with completing records. From April to June 2017, the service screened 63% of patients, and 86% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. From June to October 2017, the service screened 63% of patients, and 60% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. Several cases of sepsis were observed during the inspection. Of the five sepsis cases reviewed, three were appropriately treated. Of the two where concerns were identified, for one we were concerned the origin of sepsis and course of treatment had not been correctly determined. In the second case, the sepsis treatment had commenced yet the sepsis tool and notes of treatment were not documented.
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 trusts later. 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 trusts by other patients or visitors? 20180222 KGHNHSFT Evidence Appendix Page 44
(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
Median time from arrival to treatment (all patients) The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust did not meet the standard for between December 2016 and June 2017, peaking in March at 71 minutes compared to an England average of 58 minutes. We observed 10 patient pathways through the minors route to assess the time to initial assessment and the time to treatment. Of the 10 patient pathways observed, only one patient was seen for treatment within 60 minutes. Ambulance – Time to treatment between September 2016 and August 2017 at Kettering General Hospital NHS Foundation Trust
(Source: NHS Digital: A&E Quality Indicators)
Median time from arrival to initial assessment (emergency ambulance cases only) The median time from arrival to initial assessment was consistently worse than the overall England median between September 2016 and August 2017. The trust showed a slight improvement in July and August 2017, but has generally been around six to seven minutes longer than the England median of seven minutes. The ambulance handover data provided shows that of 15,530 journeys recorded to the department that 8,396 (54%) patients had a clinical handover within 15 minutes. Of those who waited the longest 628 (4%) patients waited over 45 minutes for a clinical handover. A clinical handover is where the ambulance crew provides the full history, reason for bringing the patient to hospital and any observations. The patient is then reviewed by the hospital team where an initial assessment (including a first set of observations in hospital) is undertaken. To investigate the length of time from arrival until a set of observations are completed on the ambulance arrival patients, the trust undertook an audit. The audit of 22 records in November 2017 revealed that 68.18% of patients had a set of observations documented within 15 minutes, 95.45% received observations within 30 minutes. This demonstrates that for both self-presenting and ambulance arrival patients that 15-minute assessments, including observations, are not being consistently undertaken. We observed the time to initial assessment and observation for 15 patients who arrived by ambulance. Of the 15 patients observed, 10 had received an initial assessment and observation within 15 minutes. Ambulance – Time to initial assessment between September 2016 and August 2017 at Kettering General Hospital NHS Foundation Trust
20180222 KGHNHSFT Evidence Appendix Page 45
(Source: NHS Digital: A&E Quality Indicators)
Percentage of ambulance journeys with turnaround times over 30 minutes for this trust
Between October 2016 and September 2017 there was a slight improvement in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Kettering General Hospital. Performance improved from a peak in January 2017 of 53% to 42% in September 2017.
Ambulance: Percentage of journeys with turnaround times over 30 minutes - Kettering General
Hospital (Source: NHS Ambulance Trust Data – Ambulance Turnaround Times)
Number of black breaches for this trust Staff were trying to manage black breaches as best as they could within the restricted space of the department. 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. Between August 2016 and September 2017, the trust reported 1,107 “black breaches”, with a fluctuating trend over the period. There was a sharp peak in January 2017, although this would correspond to the winter pressures period. On average between April 2017 and September 2017, performance showed that whilst 54% of ambulances waited for over 15 minutes to be off loaded that 86% of ambulances were offloaded within 30 minutes or arrival. 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. However, when several ambulances arrived within a short space of time the service did not have the physical space to safely offload the patients.
20180222 KGHNHSFT Evidence Appendix Page 46
(Source: Routine Provider Information Request (RPIR) AC11 – Black Breaches)
Nurse staffing
Nursing staffing levels were sufficient to provide safe care. However, the deployment of those nurses and support staff meant that sometimes there were delays to care and treatment. The addition of the ‘POD’ in the majors area of the department added additional cubicles to the department. We were informed that the nurses were to work in their respective zones once allocated. We observed this was the case for minors, resuscitation, EDU and the children’s area. However, due to the layout of the majors area the staff were going between the two main areas. This provided a lack of consistency in care and overview of treatment and observations required. For example, we identified five patients who observations were not completed in a timely way. We identified through observation that this was due to the layout and overview of the majors area of the department being separated into two areas. With patients moving between these areas and other parts of the service, such as radiology, the staff were not able to maintain oversight of the patients because their deployment was not fixed to one specific part of the majors area. Nursing staff fill rates were reported at 80.4% for all shifts in the ED. Where there was any shortage of nursing staff this was filled through bank and agency workers. We observed agency staff working in the department during the inspection who were familiar with the service. When reviewed the majority of agency staff work in the service on a long term basis to cover vacancies and provide continuity. The trust reported their staffing numbers below as of July 2017.
Directorate WTE planned staff WTE in post Urgent Care 146.72 117.89
(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
20180222 KGHNHSFT Evidence Appendix Page 47
At October 2017, there were 12.9 nursing vacancies in the emergency department, including the children’s emergency department. All of the vacancies had been recruited to and staff were scheduled to start imminently. The emergency department had a turnover rate of 11%. All vacant positions had been recruited to, and reviews were undertaken on reasons for leaving, which did not identify any significant trends. From August 2016 to July 2017, the trust reported a sickness rate of 3.32% in Urgent and Emergency Care. This is better than the trust threshold of 4%. Where there were vacant shifts the service utilised bank and agency staff to backfill any gaps in the rota. From August 2016 to July 2017, the trust reported they utilised 2140 shifts for health care assistant staff (average 148-216 per month). There were 3668 nursing shifts covered for nurses (average 255-374 per month). These staff members were mostly long term booked agency staff to provide consistent care in the department. 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, such as the administration of medicines.
Medical staffing
Medical staffing levels were sufficient to provide safe care. Within the department there were six full time equivalent consultants employed. The service also employed associate specialists who work at consultant level bringing the number covering the on call rota to 10. Four consultant vacancies had now been recruited to and were awaiting pre-employment checks to be carried out. 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 are two consultants within the emergency department who have subspecialist interests in paediatrics. Paediatric support is also provided by the children’s ward where 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 listed vacancies below, however there were clear plans in place for recruitment of staff with all posts being filled but the staff had not yet started due to visa requirements.
Directorate WTE planned staff WTE in post Urgent Care 36.44 28.10
(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
Medical staff recruitment and retention was one of the top risks identified on the risk register. The risk level was graded as 15, one of the highest possible outcomes. This had not changed since the last inspection.
20180222 KGHNHSFT Evidence Appendix Page 48
At October 2017, there were four consultant vacancies in the emergency department. All had been recruited to and these doctors were due to start working once visa clearance was approved. For permanent staff the turnover of the department was 0%. From August 2016 to July 2017, the trust reported a sickness rate of 1.46% in Urgent and Emergency Care. This is better than the trust threshold of 4%. The fill rate for medical staff on shift was 77.1%, and any gaps reported were filled by locum doctors. 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. From August 2016 to July 2017, the trust reported they utilised 458 agency locum shifts for associate specialists (average 30-60 shifts per month), 125 consultant shifts covered (average 2- 17 shifts per month), 111 middle grade doctor shifts covered (average 0-26 shifts per month), and 923 trainee doctor shifts covered (average 29-107 shifts per month). 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. As of June 2017, 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 also lower. The medical staffing skill mix for the 28 whole time equivalent staff working in Urgent and Emergency Care at Kettering General Hospital NHS Foundation Trust was as follows:
This Trust England average Consultant 22% 29% Middle career 51% 15% Registrar Group 24% 31% Junior 4% 25%
(Source: NHS Digital Workforce Statistics)
Records
Patients’ individual care records were not well managed or stored appropriately. Records seen were not accurate, complete, legible or up to date in all cases. Notes were stored either in the patient cubicle, or in a file tray in the main areas of the minors, majors, or children’s areas, which was not lockable or secure. The EDU had a notes trolley but this was not lockable or secure. We examined the records of 25 patients during our inspection. We found the quality of record completion was poor. Of the 25 sets examined, we identified records specific concerns with seven. 20180222 KGHNHSFT Evidence Appendix Page 49
These included four records without signature, four with only partially completed risk assessments, two sets of records were lost, and four sets did not have entries of care received recorded. Where entries of care had not been recorded, we observed that care had been provided, and we raised this with staff who completed the records. For example, a patient who was on a sepsis pathway was not recorded as commencing the pathway in the clinical notes, yet the medicines had been prescribed on the chart and the patient was receiving oxygen. The clinical decisions for these and actions were also not recorded. Availability of records was a concern. When teams were undertaking audits and retrospective reviews, some records could not be located. This was discussed during a risk meeting at the time of our inspection. This was further corroborated by a review of an audit undertaken on the Mental Capacity Act in the department. Of the 60 cases selected for the audit, 10 had to be excluded as the records could not be located.
Medicines
There were effective systems in place regarding the storage and handling of medicines. However, medicines reconciliation was a minor concern. We checked a sample of medicines, including emergency medicines, these were in date and stored at the correct temperature. Fridge temperatures for medicines requiring refrigeration were checked daily to ensure those medicines were stored correctly. Fridge temperatures observed were within the expected range. Although the department did not have a commissioned full time pharmacist the pharmacy team ensured that a pharmacist visited the department daily to liaise with and support staff with medicines. Medicines were available out of hours and staff knew how to obtain them if needed. Additional medicines were available to staff and staff knew where to locate them. We observed an excellent example of the nursing staff in the resuscitation area obtaining additional anaesthetic medicines to support the anaesthetist during a medical emergency. 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. Controlled drugs (CDs) (medicines that require extra checks and special storage arrangements because of their potential for misuse) were not always reconciled correctly in the register, and a practice observed was not in line with trust policy. We observed that waste from partially used ampoules was not recorded in the CD register. The amount used was recorded and the service had the correct denaturing kits available, which meant there was a low impact but this form of not recording waste was not best practice. We spoke to a member of the pharmacy team who confirmed this was not trust policy. Many patients were in the department for more than eight to 12 hours awaiting an inpatient bed during the inspection. Some of these patients required medicines for their pre-existing conditions however there were delays in reconciliation, prescribing and administration of the medicines in a few cases.
20180222 KGHNHSFT Evidence Appendix Page 50
For example, we observed one patient who had been in the department for 14 hours who had not been given their insulin despite records showing they were experiencing high blood sugars. Another patient who had been prescribed antibiotics for sepsis waited more than 45 minutes for the medicines to be administered. Both of these examples were raised with staff to ensure that both patients received safe care and treatment. Staff reported incidents related to medicines on the trust’s reporting system with 92 incidents being reported over the 12 months from October 2016 to November 2017. However, we observed some near miss incidents that were being picked up by staff but not being reported. We spoke with staff about both events detailed above, and when we checked later these had not been reported as incidents, we discussed this with staff who informed us they would report these incidents. The previous inspection findings and the current nursing dashboard identified that patients allergy status not being recorded on the medicines chart was a concern. Of the four medicines charts we specifically looked at for allergy status all had the status clearly recorded.
Incidents
Staff were aware of their responsibility to report incidents both internally and externally and used the hospital’s electronic reporting system. The emergency department reported 692 incidents from 31 October 2016 to 1 November 2017. This was lower than expected for a hospital with more than 87,000 patients attending each year. The top reported incidents related to access to care, delays and transfers (143), Delay to care, monitoring or treatment (138), medication (92), and documentation (66). Evidence of learning from incidents was disseminated through the local governance meetings, team meetings and through a private social media page. We were not assured that the service was reporting all incidents when they occurred. During our inspection, we observed 11 incidents, four related to medication, one related to staffing and six related to documentation and care. We raised these with staff who had not reported incidents but said they would following our discussions. 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. 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 was evidenced by the service. The service was able to demonstrate where the duty of candour was 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 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. Between September 2016 and August 2017, the trust reported no incidents classified as never events for Urgent and Emergency Care. The service did not manage serious patient safety incidents well. In accordance with the Serious Incident Framework 2015, the trust reported seven serious incidents (SIs) in Urgent and
20180222 KGHNHSFT Evidence Appendix Page 51
Emergency Care, which met the reporting criteria, set by NHS England between September 2016 and August 2017. The trust policy for serious incident reporting included a two tier reporting system for serious incidents where serious incidents were declared internally and externally. We did see that one internally investigated incident was escalated and reported externally: Delayed diagnosis of a ruptured patella tendon that resulted in moderate harm was declared as an external serious incident and reported via STEIS. Of the external reported serious incidents, the most common type of incident reported was diagnostic incident including delay meeting SI criteria (including failure to act on test results) with four (57% of total incidents). The remaining types of incident each occurred once during the period: Treatment delay meeting SI criteria. Surgical/invasive procedure incident meeting SI criteria. Confidential information leak/information governance breach meeting SI criteria.
(Source: NHS Improvement - STEIS (01/09/2016 - 31/08/2017))
Mental Health
The mental health room was located in the emergency decisions unit. At the last inspection, concerns were identified in regards to the safety of patients who stayed in this room, as well as in the main emergency department and children’s emergency department. Concerns were also identified with safety and training of staff. At this inspection, we found that improvements had been made to the room, and that an anti- ligature risk assessment form had been completed for the department. There were identifiable ligature points in the assessment room. The service had removed as many as possible but some remained. Staff were now required to assess patients for their suitability to be placed in this room. The mental health risk assessment tool was being used during the course of the inspection and we observed its use on four patient cases. The tool would identify the risks to the patient, and others and inform staff of what measures to put in place to keep the patient and others safe. The assessment tool identified that when at significant risk that one to one nursing should be considered and provided. In two cases where this was required, this was not included on the risk assessment. One patient with a mental health condition became increasingly agitated and required support from several staff and it was only at this point the request for one to one support was made. The toilets for the patient use was in the main department. These rooms had doors that opened outwards, and had locks on the inside of the door. Inside the toilets were a number of ligature
20180222 KGHNHSFT Evidence Appendix Page 52 points that could be used by a patient. Where a patient was identified as high risk, we were informed they would be escorted and observed to use this area. However, in one case of a patient, who was high risk of self-harm or suicide, we observed they were freely allowed to go to this area and lock the door without supervision. The bays in the main majors area, where patients in crisis could be observed, were not adapted to minimise risk of ligatures prior to placing a patient in the bay. This included removing wires, suction tubing, and other items that could be used to cause self-harm. There was no formal procedure for asking patients or checking their property when they presented after self-harming or taking an overdose. This meant that patients who could have items with them, which could place the patient, staff, and others at risk of harm. Staff had systems to request a specialist mental health assessment such as from the local mental health trust and crisis support teams. We observed staff refer patients into this service during the inspection; however, two cases observed were delayed. When asked staff said they were not medically fit to be referred, at the time of asking both patients had received and completed all their acute treatment yet staff had not referred them delaying their treatment. The department could access a Section 12 registered doctor through the local mental health trust. A Section 12 approved doctor is a medically qualified doctor who has been recognised under section 12(2) of the Mental Health Act (the Act). They have specific expertise in mental disorder and have additionally received training in the application of the Act. Whilst all medical members of RCEM in the department should be able to undertake an initial psychiatric assessment, this was not observed in the notes. The clinical lead for the service said this was an area of staff competencies that required improvement, and medical staff skills for psychiatric assessment needed to be reviewed and improved. Staff knowledge was not sufficient to support patients with mental health needs and keep them safe. Only 54% of nursing staff had received training in mental health awareness, and 0% of doctors. This meant that staff knowledge was not sufficient to support the safe care of those with mental health needs.
Major incident awareness and training
Potential risks to the service were mostly anticipated and planned for in advance. However, staff training rates were low for medical staff and planned exercises had not been undertaken recently. The trust had a major incident plan that had been updated in 2016. The plan had not been updated in 2017 due to a vacancy in the position of the role that would complete this update. The emergency department had not taken part in any major incident exercise since our last inspection. This was due to the vacancy in the trust wide resilience position. The service was involved in an internal major incident, which was declared in November 2017. Another hospital required a full divert of ambulances which meant the department came under significant pressure with additional patients arriving. This was coordinated and recorded in line with trust procedure. Learning points for sharing were to be discussed at the next emergency resilience meeting, which had not yet taken place at the time of the inspection. The service had trained 89% of nursing staff in chemical, radiological, biological and nuclear (CBRN) core training. However, 0% of medical staff had received this training. CBRN defence or
20180222 KGHNHSFT Evidence Appendix Page 53
CBRNE defence is protective measures taken in situations in which hazards related to chemical, biological, radiological or nuclear warfare (including terrorism) may be present. The department was able to implement lock down by securing the main doors at either side of the department and at the ambulance bay. There was no lockdown specific policy for the department, and the lock down capabilities had not been tested. Staff showed appropriate awareness of fire safety protocols throughout the department. Is the service effective?
Evidence-based care and treatment
The service provided care and treatment based on national guidance and evidence of its effectiveness. There was a clear protocol for staff to follow with regards to 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. These pathways were clear and detailed, and would work well however records completion was a concern. The service had reported good outcome for patients in a recent national audit. We reviewed the notes of five adult patients who were admitted with a potential diagnosis of sepsis. Of those patients, three had appropriate sepsis pathways followed, and treatment was commenced within one hour as per national recommendations. We reviewed the policies and pathways for the admission of patients with stroke, 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 observed the care of two potential stroke patients who had attended the department. They were immediately referred to the stroke team who attended the department to provide care. The care provided to this patient, followed the pathway for stroke in emergency care. The children’s emergency department had a range of well-used pathways to support the care provided to children in the service. This included pathways for head injury, jaundice, sepsis, and asthma. The department took part in all required national audits. There was limited local audit activity in the department. The audits undertaken were based on the RCEM standards; however, the local audit programme had only recently been revised and was still being embedded. Within the children’s emergency department, we were informed that local audits were undertaken to improve the quality of care. However, we were not provided with evidence of these audits.
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health. 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. 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 patient being in the department whilst waiting for a bed on a ward.
20180222 KGHNHSFT Evidence Appendix Page 54
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 for risks associated with weight loss during their initial assessment. 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 than other trusts.
Pain relief
Patients’ pain relief provision was delayed, and the recording of pain relief was sometimes not sufficient. Audits undertaken showed management of pain had not improved. Action plans that had been put in place were not always driving improvements. When a patient entered the department, via the self-presenting route (minors) the streaming nurse enquired about the patient’s level of pain. If pain was recorded, the nurse would request for pain relief at the next stage initial assessment. However, this could result in a delay in the provision of pain relief when the department was busy. Patients who arrived by ambulance were asked about pain following clinical handover, and were provided with pain relief following initial assessment. However, this could be delayed due to the time taken to assessment when the department is busy. We selected the records of five patients, and spoke with three of these patients to assess pain scores. Of the patients we spoke with all stated that pain relief was provided and their pain was well managed. On review of the records only two patients had a pain score recorded. The quality of record keeping and recording was poor, however pain levels were assessed and relief was provided to these patients. We reviewed a pain audit completed by the department, which showed that pain management required improvement. The audit undertaken on 181 cases showed that 70% of presentations to the ED were of pain or associated with pain. Of those 40% received some form of analgesia, and the average wait time for analgesia in the department was two hours, with no difference between those in mild or moderate pain. The audit also identified there were no PGDs are available for early analgesia administration at triage, and that there was limited documentation of efficacy of analgesia after administration. An action plan from this audit identified an action to consider early analgesia before clinical assessment, and completing a formal pain score. However, an implementation date for these actions was set for mid-July 2018. This is a significant delay in improving an outcome for patients. 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. Question – Effective Score RAG Q31. How many minutes after you requested pain 6.3 About the same as relief medication did it take before you got it? other trusts Q32. Do you think the hospital staff did everything 7.7 About the same as they could to help control your pain? other trusts Q35. Were you able to get suitable food or drinks 7.6 About the same as when you were in the emergency department? other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
20180222 KGHNHSFT Evidence Appendix Page 55
Patient outcomes
The service monitored the effectiveness of care and treatment. Some outcomes of care were below the expected levels but the service was working to improve these. The service contributed to the local trauma network, though was not a receiving service for major trauma. The Trauma Audit and Research Network (TARN) is a national organisation that collects and processes data on moderately and severely injured patients. The TARN report from September 2017 showed the median time to a computerised tomography (CT) scan at Kettering General Hospital was 0.98 hours, which is much worse than the England average of 0.53 hours. At the time of the inspection, the time to CT was reaching an average of 100 minutes. An action plan was provided regarding this outlier. This showed that an audit was planned to review CT head cases and would be completed by February 2018. However, there were no immediate actions identified in terms of discussing any emerging concerns with radiology for escalation. TARN, despite being a measure of outcomes for emergency patients, was monitored and managed by the orthopaedic service. We discussed the outcomes regarding CT with the leads, who shared that they were not aware as these outcomes were overseen by a different business unit. The leads would attend meetings but not be able to effect change on the outcomes. The service took part in all national audits in 2016/17. 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 local audits provided as evidence included cocaine associated chest pain, head injury, and pain audits. These were completed by medical staff within the department and presented at the department audit meeting and shared with staff for learning and development. In the 2016/17 RCEM audit for severe sepsis and septic shock, Kettering General Hospital was in the top 25% compared to other hospitals for two of the eight agreed measures and was in the in the middle 50% of trusts for the remaining six measures. The measures for which the trust performed in the upper quartile were: 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 (69.1%). Standard 2: Review by a senior (ST4+ or equivalent) ED medic or involvement of Critical Care medic (including the outreach team or equivalent) before leaving the ED (78.6%). The 2016/17 Consultant Sign off Audit monitors the proportion of patients of various groups who were reviewed by a consultant in emergency medicine prior to discharge from the ED. For each group, the RCEM standard is that 100% of all patients receive a review from a senior member of the medical team before they are discharged. Of all patients aged over 30 admitted for chronic chest pain the audit showed that 18.8% were seen by a consultant, and 48.5% were seen by an ST4 or above. This was similar to the national average. Of all children under 1 year of age admitted with a fever the audit showed that 17.8% were seen by a consultant, and 48.9% were seen by an ST4 or above. This was similar to the national average.
20180222 KGHNHSFT Evidence Appendix Page 56
Of all patients making an unscheduled return to the ED in 2016/17 with the same condition within 72 hours of discharge, 25.7% were seen by a consultant and 45.5% were seen by an ST4 or above. This was better than the national average. Of all audited patients over 70 years of age who were admitted with abdominal pain, 21.7% were seen by a consultant, and 50.0% were seen by an ST4 or above. This was better than the national median. In the 2016/17 RCEM audit for moderate and acute severe asthma, Kettering General Hospital was better than the national average for two of the seven agreed measures, was worse for one and was similar to the national median for the remaining four measures. The measures for which the trust performed better than the national median were: Standard 1a: O2 should be given on arrival to maintain ‘sats’ 94-98% (32.1%). Standard 3: High dose nebulised β2 agonist bronchodilator should be given within 10 minutes of arrival at the ED (40.7%). The measure in which the trust performed worse than the national median was: Standard 4: Add nebulised Ipratropium to nebulised β2 agonist bronchodilator therapy (67.7%). Between September 2016 and August 2017, the trust’s unplanned re-attendance rate to A&E within seven days was consistently worse than the national standard of 5% and generally similar to the England average. The trust’s performance has worsened slightly over the period, although still remains within a percentage point of the national average with performance in August 2017 at 8.0% compared to an England average of 7.8%. Unplanned re-attendance rate within 7 days - Kettering General Hospital NHS Foundation Trust
(Source: NHS Digital - A&E Quality Indicators)
Competent staff
The service made sure staff in the adult emergency department were mostly competent for their roles. Within the children’s department work was needed to improve the competencies of nurses, who were not registered children’s nurses. Within the children’s emergency department adult nurses
20180222 KGHNHSFT Evidence Appendix Page 57 supported children’s nurses to provide care. To demonstrate competencies the team had developed a booklet containing all the competencies a nurse requires to work in the department. We checked three of these booklets and found them to be comprehensive in scope and range of competencies to meet the role. However, of the three we checked only one had completed their competencies. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. As of July 2017, 87% of staff within Urgent and Emergency Care at the trust had received an appraisal compared to a trust target of 85%. A split by staff group can be seen in the graph below:
(Source: Routine Provider Information Request (RPIR) P43 Appraisals)
Multidisciplinary working
Staff 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 spoke with three members of the ambulance service who reported that there continued to be long waits for them to hand over patients to the department’s staff. They reported that the service was trying to improve the situation but would not take handover or responsibility for the patient until they could assess them, which delayed their releases. We observed excellent multidisciplinary working during two cardiac arrest calls. Staff communicated well, understood their roles, and worked together to provide the best outcome for the patient possible. 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. 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.
Seven-day services
20180222 KGHNHSFT Evidence Appendix Page 58
The ED was open seven days per week, 24 hours per day. The children’s ED was not open 24 hours per day. It was open from 8am to 11pm with the main department seeing children outside of these ours. Medical staff were available from 8am to 10pm daily and cover from the adult emergency department and paediatric service was provided out of those hours. Radiology services currently did not operate seven days per week but on call services were provided for emergency cases when needed to support the service. There is an on-call radiologist available for advice when there is not a radiologist in the department. 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 and support. The ED had access to an emergency and trauma theatre as per national guidance 24 hours a day, seven days a week.
Health Promotion
The service promoted alternative options to attending the emergency department. The service recognised that a number of attendances who self-presented in the department could attend an alternative service for their treatment. Through the trust website, leaflets and posters displayed explaining alternative options available instead of attending the ED for minor ailments. This included what conditions a patient should visit a pharmacy or GP for.
Consent, Mental Capacity Act and Deprivation of Liberty safeguards
Not all staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA). They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff knowledge of MCA was limited and not all medical staff had received MCA training. The trust reported that as of July 2017 MCA training had been completed by 88.8% of staff in within Urgent and Emergency Care against a trust target of 85%. Nursing and midwifery staff had a training completion rate of 91% while medical and dental staff had a completion rate of 76%. We spoke with four members of staff (two nursing and two medical) specifically about the completion of mental capacity assessments. Two of the four staff members were unclear of how to complete the MCA or when it would be required. The knowledge of medical staff with MCA was a recognised risk on the risk register. An action for completion was to undertake an audit to assess if compliance and understanding had improved following increased training. The audit was completed in September 2017 and was to include 60 cases of patients with a diagnosed severe learning disability attending the department. However, 10 patient cases were excluded as the attendance cards could not be located. Of the 50 cases considered, 26% had mental capacity and best interest assessment completed. This demonstrated that the knowledge amongst staff and quality of records required improvement. We observed in two cases the care had been provided to a patient and mental capacity assessments completed retrospectively by the advanced clinical practitioners who ensured the paperwork was complete. However, the records of care from the clinicians providing treatment did not reference any requirement to MCA. For example, in one case a patient was admitted for an injury. The records of care were minimal yet a Do Not Attempt Cardio Pulmonary Resuscitation Order (DNACPR) was completed for 'old
20180222 KGHNHSFT Evidence Appendix Page 59 age/frailty'. The form states not discussed with patient discussed with family. The form was signed by one consultant. On review of this case, the patient’s capacity had not been assessed prior to completing the form and the family did not have lasting power of attorney for decisions on health meaning they could not make this decision for their relative. Therefore, the process for MCA, best interest and DNACPR had not been adequately followed. We escalated this case to the matron who resolved matter with doctors through MCA processes. The ED used a triplicate book for DNACPR forms to maintain a record of all forms issued within the department, this was good practice. However, the DNACPR book reviewed for the ED identified a number of cases where decision and reasons for treatment were not appropriate. For example, ‘old age’, ‘frailty’, and ‘surgical abdomen’. Parts of the forms were also not well completed. For example, where it says discussed with patient it says ‘no’ but the mental capacity box has not been completed. This meant that we could not be assured DNACPRs were being issued in accordance with legal requirements. Is the service caring?
Compassionate care
Staff mostly cared for patients with compassion. The majority of patients were provided with compassionate care, with one exception where a patient with a mental health concern was provided with care that was not compassionate. The trust’s urgent and emergency care Friends and Family Test performance (% recommended) has fluctuated considerably between September 2016 and August 2017 (64%-97%). It should be noted that low response rates are common for emergency departments and may cause recommendation rates to be variable. The results of the CQC Emergency Department Survey 2016 showed that the trust scored about the same as other trusts in all of the 24 questions relevant to caring. 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 treatment. In the children’s department, two of the parents mentioned to us that they felt the care was good this time; however, it is not always good in the children’s department. This was partly linked to the environment and privacy during consultation. We shared this feedback with staff for their information. Throughout the inspection, we observed examples of care where doctors and nurses were kind and compassionate towards acutely unwell patients and treated them with dignity. We observed several examples of staff asking for the patient’s consent prior to entering their cubicle area, respecting their dignity. The department staff adopted the use of the “Hello, my name is” approach when introducing themselves to patients. We observed nursing and support staff attending to a patient with challenging behaviour. The patient swore at the staff members and was unpleasant in their tone. This did not affect the way staff cared for the patient, staff provided additional support to the patient and maintained a kind, compassionate and caring approach to the patient. This demonstrated a true caring nature of those staff.
20180222 KGHNHSFT Evidence Appendix Page 60
We observed a patient who unfortunately died during the inspection. The care they were provided by the nurses and support staff who stayed with them was very compassionate and reassuring. They held the patient’s hand and kept them calm during their short time in the department reassuring them to the time they died. We observed one incident where a patient’s privacy and dignity was not maintained and treatment provided degraded the patient. We discussed the need to raise a safeguarding referral for this treatment but the patient did not fit criteria of a vulnerable adult. We discussed this with leads in the department who recognised this care and treatment did not respect the dignity of the patient. They informed us they would undertake a round table discussion for learning on this case with all staff. A&E Friends and Family Test Performance - Kettering General Hospital NHS Foundation Trust
(Source: NHS England Friends and Family Test)
Emotional support
Staff mostly provided emotional support to patients to minimise their distress. However, the emotional needs of patients with mental health conditions required improvement. Staff were challenged when faced with caring for patients with a mental health concern, in crisis or with a complex condition that was not medical. We observed four patients with mental health conditions who were receiving care in the department. The care was medicalised and was not focused on the psychological and emotional needs of the patient. We spoke with three doctors and two nurses about support for those with mental health conditions. They told us that they do struggle more to support those with psychological needs. For example, the doctors felt they had become deskilled in how to undertake a psychiatric assessment. This was further demonstrated in one case where a patient arrived in clear need of mental health support but was assessed for an acute complaint and discharged without any consideration of the need to assess their psychological state. This patient was readmitted 40 minutes after discharge and was subsequently assessed by the mental health trust and admitted for assessment and treatment to a mental health unit. Due to the busyness of the department when there was a death, staff were upset or a serious incident occurred staff did not always have an opportunity to have an immediate break or debrief. This meant that staff did not always get immediate emotional support. Though we were assured by the matron that debriefs did always happen but often at a later point when the situation in the department was calmer. They try to undertake debriefs within one week of the event. 20180222 KGHNHSFT Evidence Appendix Page 61
Clinical nurse specialists were available to provide support to patients in the department and we observed the nurse specialists for with pressure ulcers or safeguarding concerns attend the department at the request of staff. These staff supported the care of the patients who required specialist support. However, on one day of the inspection, there was no support for patients with learning disabilities available, and there was an adult and child who required specialised support but could not access this. 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. All patients, relatives and parents we spoke with felt that they were being kept informed and updated by staff on what was happening, and what they should expect regarding their or their relatives care. The results of the CQC Emergency Department Survey 2016 showed that the trust scored about the same as other trusts in all of the 24 questions relevant to caring. Trust Question 2016 RAG 2016 Q10. Were you told how long you would have to wait 4.1 About the same as to be examined? other trusts Q12. Did you have enough time to discuss your 8.5 About the same as health or medical problem with the doctor or other trusts nurse? Q13. While you were in the emergency department, 8.1 About the same as did a doctor or nurse explain your condition and other trusts treatment in a way you could understand? Q14. Did the doctors and nurses listen to what you 8.6 About the same as had to say? other trusts Q16. Did you have confidence and trust in the 8.8 About the same as doctors and nurses examining and treating you? other trusts Q17. Did doctors or nurses talk to each other about 8.9 About the same as you as if you weren't there? other trusts Q18. If your family or someone else close to you 8.0 About the same as wanted to talk to a doctor, did they have enough other trusts opportunity to do so? Q19. While you were in the emergency department, 8.5 About the same as how much information about your condition or other trusts treatment was given to you? Q21. If you needed attention, were you able to get a 8.2 About the 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 say one thing and another will say something About the same as quite different. Did this happen to you in the other trusts emergency department? Q23. Were you involved as much as you wanted to 8.0 About the same as be in decisions about your care and treatment? other trusts Q44. Overall, did you feel you were treated with 9.1 About the same as respect and dignity while you were in the other trusts emergency department? Q15. If you had any anxieties or fears about your 7.3 About the same as
20180222 KGHNHSFT Evidence Appendix Page 62
Trust Question 2016 RAG 2016 condition or treatment, did a doctor or nurse other trusts discuss them with you? Q24. If you were feeling distressed while you were in 7.3 About the same as the emergency department, did a member of staff other trusts help to reassure you? Q26. Did a member of staff explain why you needed 8.2 About the same as these test(s) in a way you could understand? other trusts Q27. Before you left the emergency department, did 8.2 About the same as you get the results of your tests? other trusts Q28. Did a member of staff explain the results of the 8.8 About the same as tests in a way you could understand? other trusts Q38. Did a member of staff explain the purpose of 9.1 About the same as the medications you were to take at home in a other trusts way you could understand? Q39. Did a member of staff tell you about medication 4.6 About the same as side effects to watch out for? other trusts Q40. Did a member of staff tell you when you could 5.6 About the same as resume your usual activities, such as when to go other trusts back to work or drive a car? Q41. Did hospital staff take your family or home 5.2 About the same as situation into account when you were leaving the other trusts emergency department? Q42. Did a member of staff tell you about what 6.4 About the same as danger signals regarding your illness or treatment other trusts to watch for after you went home? Q43. Did hospital staff tell you who to contact if you 7.7 About the same as were worried about your condition or treatment other trusts after you left the emergency department? 8.2 About the same as Q45. Overall... (please circle a number) other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016) Is the service responsive?
Service delivery to meet the needs of local people
The trust was not able to plan and deliver services in a way that met the needs of local people. The emergency department (ED) was originally built to deal with 30,000 patients per year and now sees in excess of 80,000 per year. The service had increased the footprint of the department by adding an additional area known as the ‘POD’. This had helped to improve the flow and experience for patients. The service was looking to add a further expansion area to support flow in the department. The waiting area for the ED was shared with fracture clinic, which was very confusing for patients. The signage for this area was confusing and caused challenges for the receptionists in fracture clinic. When the department was busy patient queued outside of the department and round the corner of the building, which did not meet their needs, especially in inclement weather. The reception area of the ED was not supportive of patient’s privacy and dignity needs and had not changed since the last inspection. Patients would have to share confidential information in front of others on arrival. However, there was a clinic room next door to reception not in use during 20180222 KGHNHSFT Evidence Appendix Page 63 the inspection, which could have been utilised for the nursing staff to take the history of the patient and assess their needs. This would have met the public needs more but this option was not being utilised. Leaders informed us of plans to redesign the front of the reception desk to provide more private booth spaces and plans were in progress to establish this. The trust spoke of some plans that were in the early stages of development to create a new department, which they hoped would be built by 2022, though no plans had been formalised or agreed. The emergency decision unit was an area within the ED and was made of older clinic rooms. 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 struggled 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 most 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 patients drinks. 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 with dementia, however we observed that knowledge and understanding of how to meet the needs of patients with learning disabilities, mental health or complex needs was lacking in some areas. Training on mental health awareness and dementia was well below the trust target for nursing staff, and no doctors had received this training. This was evident when we observed staff in department supporting patient’s with mental health needs. Staff were unsure of how to support or interact with these patients. The ED had a clear process for the support of those with learning disabilities coming through the service. In the event a patient with known learning disabilities attended the department, the service would contact the learning disabilities specialist nurse. However we observed poor support for a patient with a learning disability. Staff did not know how to support this patient despite them being in the department for several hours. We asked if they had contacted the lead nurse for learning disabilities, which they had not done. 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.
Emergency Department Survey 2016 The trust scored “about the same as other trusts” for all of the three Emergency Department Survey questions relevant to the responsive key question. Question – Responsive Score RAG Q7. Were you given enough privacy when discussing 6.7 About the same
20180222 KGHNHSFT Evidence Appendix Page 64
your condition with the receptionist? as other trusts Q11. Overall, how long did your visit to the emergency 7.4 About the same department last? as other trusts Q20. Were you given enough privacy when being 9.4 About the same examined or treated? as other trusts
(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
Access and flow
Patients could always access the service when they needed it. However, waiting times for treatment and times to admission were often delayed. 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 April 2017 to September 2017, there remained a concern with how responsive the emergency department was to moving patients through in a timely way. Through an analysis of the data, it was determined that 46.7% of all breaches of the national four hour standard recorded were linked to bed capacity, and 35.8%% 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 four-hour standard. From the data, it was determined that the hospital struggled mostly with capacity for medical beds with 40.4% of all breaches of the four hour standard being linked to a lack of available medical beds. The service planning for the trust had not yet reconfigured the medical bed base sufficiently in the short, medium or long term to ensure that the flow through the ED improved. The trust failed to meet the four hour recommendation between October 2016 and September 2017 and was generally worse than the England average throughout the period. Following a low in January 2017, the trust performance had improved and was closer to the England average.
Four-hour target performance
(Source: NHS England - A&E Waiting Times) Between October 2016 and September 2017, the trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted to an inpatient bed for this trust was consistently worse than the England average.
20180222 KGHNHSFT Evidence Appendix Page 65
Performance against this metric showed a sharp increase during the winter pressures period, peaking in January 2017, but this had since dropped and had been closer to the England average between June and July 2017. We observed some staff who were very focused and dedicated to improving flow through the department, and we observed some staff who did not try and drive improved flow. This meant that performance varied in managing flow and breaches occurred at times. For example, for those patients who attended the department with mental health concerns in two cases of the four we observed, the referral to the support mental health team was not undertaken in a timely way. There were also no plans of ongoing care for two of those patients which could have been determined earlier. This would have improved the flow of these patients through the department to access the services they needed. Percentage of patients waiting between four and 12 hours from the decision to admit until being admitted
(Source: NHS England - A&E Waiting Times)
Number of patients between Number of patients over 12 4 and 12 hours hours Oct-16 350 0 Nov-16 771 0 Dec-16 631 0 Jan-17 1143 0 Feb-17 839 0 Mar-17 770 0 Apr-17 575 0 May-17 497 0 Jun-17 347 0 Jul-17 346 0 Aug-17 639 0 Sep-17 527 0 (Source: NHS England - A&E Waiting Times)
Over the 12 months from October 2016 and September 2017, no patients waited more than 12 hours from the decision to admit until being admitted. The trust informed us that they had not had
20180222 KGHNHSFT Evidence Appendix Page 66 any 12-hour breaches. They defined this as patients who had been waiting for treatment or admission for more than 12 hours from the time a decision to admit was made. This meant that the time for 12 hours does not start from the time the patient arrived in the department. During the inspection, we observed six of 12 patients who had been in the department for more than 12 hours were on trolleys. However, they had a pressure relieving support mattress to meet their skin care needs. The time observed for these patients in the department ranged between seven hours and 15 minutes and 14 hours and 26 minutes. Each day we arrived on the inspection, there were patients in the department who were awaiting beds, and these patients had been in the department for more than 12 hours. During the inspection, the number of patients observed to be in the department for more than 12 hours, who were admitted by waiting on an inpatient bed was higher than we would have expected it to be. For example, on the three days we were on site, there were 16 patients in the ED for more than 12 hours. We observed four operational bed meetings 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. The team responded with providing additional support to the department, which was by senior nurses and head nurses during the inspection. Between October 2016 and September 2017, the monthly median percentage of patients leaving the trust’s urgent and emergency care services before being seen for treatment was consistently better than the England average. The trust had generally been around 1.3 percentage points lower than the England average and as of August 2017 the percentage of patients leaving the trust’s urgent and emergency care services before being seen for treatment was 2.0%, compared to the England average which was 3.0%. Percentage of patient that left the trust without being seen
(Source: NHS Digital - A&E Quality Indicators)
Between October 2016 and September 2017, the trust’s monthly median total time in ED for all patients was generally longer the England average. Performance against this metric showed a trend of improvement following a peak in December 2016 of 178 minutes compared to the England average of 158 minutes. Median total time in A&E per patient
20180222 KGHNHSFT Evidence Appendix Page 67
(Source: NHS Digital - A&E Quality Indicators)
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 through governance meetings. However, the trust routinely took longer than 31 days to respond to patient complaints. Between August 2016 and July 2017, there were 17 complaints about the ED and two about the ambulatory emergency care unit. Of the 16 closed complaints, the trust took an average of 35 working days to investigate and close complaints and three breached the agreed deadlines for closing. The most common complaint subject was delay (diagnosis) with five complaints. Self- presenting patients (Minors) reported the most complaints with eight of the 17 attributed to the emergency department. The style and tone of the responses to complaints was empathetic and understanding. Complaints offered an apology to the concerns raised and also addressed the key points of the complaint reported. We reviewed three complaint responses and noted they were well written, apologetic, accepting of the complaint and addressed the points raised by the complainants. The action plans from reported complaints required improvement. Each complaint had identified action to be completed to improve quality of care. However, these actions were not always measurable and would not immediately show improvements in care provided. For example, a complaint relating to an undiagnosed fracture the action agreed was ‘partially achieved by recognising the risk’ and also by ‘training and reflection’. The radiology team in the trust was trying to recruit more consultants to ‘reduce reporting time to minimum’ but this did not demonstrate that the ED was trying to improve quality of care regarding undiagnosed fractures. Is the service well-led?
Leadership The emergency department (ED) had local leaders with the right skills and abilities to run a service with a vision of providing high-quality sustainable care.
20180222 KGHNHSFT Evidence Appendix Page 68
The ED was part of the medicine clinical business unit (CBU). The division was led by a CBU director, a head nurse and manager. Locally, the ED was led by a clinical lead and a matron. The matron and clinical lead were recognised as good leaders within the department; staff spoke highly of the matron and felt supported by them. All medical staff spoken with spoke highly of the clinical lead. We found the matron and clinical lead to be exceptionally knowledgeable about their department, their roles, the challenges within the service and the challenges they still needed to improve. Both had excellent insight into where the challenges were and had worked very hard, and with tenacity to make a difference. The difference was noted with local leadership showing an improvement since the last inspection. The challenge was with the culture within the whole staff team, which takes time to change. The clinical lead had appointed leads for various subjects, including sepsis, audit and risk. The matron had developed lead matron roles for nursing staff within the department to support the nursing function. This work had increased additional leadership presence and ownership of the service within the department. There was no operational or general management function within the structure of the CBU to support the ED. This meant there was limited operational management oversight of the department, and operational work required. The matron and clinical lead recognised this as a challenge for the service. The lack of an operational support management function in the service was challenging the speed of change implementation. The staff reported that they regularly saw members of the senior and executive team within the department; they knew who they were and could speak with them if they were in the department. The local leaders required practical additional support to help them to continue to drive improvements with the culture in the department. The work undertaken to improve the leadership of the department was only visible at a local level rather than senior level. The band six and seven tier of nurses had not received any leadership development and management training, nor had the associate specialist and middle grade doctors. This was an area for development, and was something the service had planned to do now they had established a stronger leadership structure within the service.
Vision and strategy Whilst the trust 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 ED did not. We asked several staff, the clinical leads and nursing leads about the defined strategy for the ED and were informed the focus was to build a new department for 2022, and to ‘get the service out of special measures’. There were no medium or long-term plans for what was to happen should this occur or not occur. There was no solid focus for the department long term. The CBUs were all subject to change and about to go through a formal consultation to reduce the total number from seven to three. This was noted by the local team, and they were unaware of what this would mean for them and where they would sit in future. There was 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. 20180222 KGHNHSFT Evidence Appendix Page 69
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.
Culture The culture of the department was a concern with medical staff not all accepting the risks identified during previous inspections, and subsequently not willing to accept and embrace changes to improve the overall quality of care. The focus on patient safety had improved but not at the pace required. At this inspection, we found the culture of the nursing and medical staff to be one of not accepting the previous ratings and outcomes of the inspection. Some staff were reluctant in their acceptance of the risks. For example, two nurses shared with us they did not agree with our last report findings, and two doctors were challenging in their approach to us and the inspection process. They informed us they felt we were there ‘to cause them difficulty and stress’, and they felt our focus was ‘on finding fault not success’. We recognised during the inspection that many aspects of safety were linked to the culture of the service. For example, we observed sharps placed on top of sharps bins rather than inside sharps bins, we observed staff not adopting good hand hygiene practices at all times, and records were not well completed despite repeated reminders from leaders. This was linked to the culture of the service, and some staff not accepting that there were concerns with some of the practices being carried out. The leads for the service were passionate about improving this service and had come a long way in making a difference but were faced with the challenges of the culture. We acknowledge that a change in culture will take time. The local leaders required enhanced support from the executive and senior leaders to provide clear messages to staff on what culture, behaviours and practices will not be accepted. The culture regarding Duty of Candour was positive, and where incidents were recognised to have caused harm being open meetings were taking 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 also understood its meaning. However, we were concerned that not all incidents were being recognised in terms of severity and therefore opportunities to meet the Duty of Candour requirement may not have been fully met. Overall, the 2017 General Medical Council trainee survey showed that of the 17 overall questions, seven questions had improved, seven had worsened and three results were not counted as they were new to this year’s survey. The questions were outcomes had been lower than expected were the overall satisfaction rate (61.38%), clinical supervision (75.71%), clinical supervision out of hours (73.54%), local teaching (46%), supportive environment (60.63%), handover (44.79%), and study leave (31.25%). We spoke with the clinical lead and other consultants about the outcome of this survey. The service had only taken on trainee doctors again within the last two years and were establishing the programme for them. There was a clear action plan in place with measurable actions to support the improvement of the training programme and feedback from trainee staff.
Governance
20180222 KGHNHSFT Evidence Appendix Page 70
With the changes to the staffing structures within the ED and appointing leads to various roles, this had ensured that all staff were clear on who was the lead for each item. There was a board in the main ED with the names, pictures and roles of each staff member for all to see. This demonstrated clear lines of accountability on each subject to the clinical lead and matron for the service. We reviewed the governance meeting minutes for six months between April and October 2017. Governance meetings were mostly well attended by nursing, divisional and support staff. However, there were two meetings where there was no medical representation at the meetings. These minutes were detailed and comprehensive on the discussions held during the meetings. All action points were recorded and discussed at the next meeting. Highlighted in these minutes were the challenges for nursing staff attending the mortality and morbidity meetings. This was actioned with changes to the times and dates of meetings to ensure increased nursing attendance. Mortality and morbidity review processes were well established in the service and were mostly effective. Meetings were scheduled to be held monthly; however, only four took place in the last six months due to the level of activity within the service. We reviewed the cases provided to us as evidence for these meetings. These cases were individual deaths reviewed for the meetings. In the majority of the five reviewed, they identified key points to consider, as well as areas of good practice. However, there were no minutes of the meetings, or action points for learning on any learning log to be taken forward for discussion at governance meetings or for inclusion on the risk register if appropriate. Deteriorating patients was a recognised risk on the risk register; however, there was no link on these risks to the work undertaken by clinicians on the mortality and morbidity reviews. There was also no link on the mortality and morbidity reviews to the incident and complaints systems to assess and identify any potentially corroborating trends to risk identification. We were informed by the clinical staff that all deaths were reviewed each month. We reviewed one serious incident was declared because of review at the mortality and morbidity meeting, which demonstrated the effectiveness of the review process.
Management of risk, issues and performance The trust had improved their systems for identifying risks; however, the planning to eliminate or reduce them was not always effective. The emergency department had a risk register, which contained 35 risks added over the last 18 months. The leads for the service acknowledged there were too many risks on the register. The leads were able to clearly articulate the risks in the service and what was to be done about them; however, there were many risks making it difficult to manage. The lack of an operational lead to support the management of the service had not been identified as a risk for the service, but the lack of support in this function was a risk to the delivery of the service. At the last inspection, the identification of risk was a concern and departmental risks were not reflected on the register. At this inspection, the majority of risks we identified were on the risk register, the service was aware of them and trying to manage the risk to safe patient care and staff were working to reduce and make improvements. Risks were routinely discussed at the ED governance meeting. The risks on the register were generally appropriately graded and monitored through discussion at each governance meeting. Not all risks added were sufficiently detailed. The two main owners of the risk register entered detailed risks; however, others who entered items did not provide a 20180222 KGHNHSFT Evidence Appendix Page 71 sufficient level of detail to describe the risk. For example, a risk said ‘The outcome from the CQC inspection in October 2016 has identified that the CBU has MUST DO and SHOULD DO actions as a result of their findings’. The actual requirements were not listed, making it unclear how this would be monitored or managed. Some controls listed for risks did not provide assurances that the risk had been managed or reduced. For example, there was a risk on the register associated with poor understanding of the Mental Capacity Act amongst medical staff. The assurances included to implement a training programme for medical staff and re-audit compliance with the act by 30 September 2017. We noted that training rates had improved to 71%; however, records of care did not support that improvements had been made regarding compliance with the Act. There was a risk regarding the safeguarding of children in the ED due to staff not all being trained to level three safeguarding children. The service had reported seven serious incidents for deteriorating patients; however, learning from these could not be clearly demonstrated and further examples of deterioration were noted for patients during this inspection. Lack of ownership of Trauma Audit and Research Network (TARN) performance data meant that the ownership of risk was unclear. As this process was managed and overseen by the orthopaedic service, any outliers or concerns should have been included on the surgical risk register, despite the risk being an ED risk. However, the risks associated with the outliers on TARN were not identified on either the surgical or ED risk register. We were not assured that the service was reporting all incidents when they occurred. During our inspection, we observed near miss incidents that were occurring in the department and being resolved prior to any harm occurring. Whilst this was proactive, the service was not recording these events to monitor and track trends, and improve safety and quality of care. 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 There were clear service performance measures in place for the service. These were reported on and monitored at local governance meetings, and at executive board meetings. The indicators include time to treatment, four-hour performance and 12 hours performance. The arrangements to ensure that the information used to monitor, manage and report on quality and performance was mostly effective; however, with the volume of information being considered by the service it was challenging to manage. For example, manging and overseeing 35 risks on a risk register would make it difficult to assess the overall picture of quality and safety when so many concerns have been identified and remain open. The ED staff were not enabled to manage their outcomes to the best of their ability. The TARN outcomes for the ED were managed and overseen by the orthopaedic service. The data was compiled and reported on by this service and not the emergency department. This means that the emergency department did not own the outcomes for which it is measured against. The information technology systems used by the trust presented them with challenges. This did have a direct impact on the ED. The patient record system was predominantly paper based making management of records very challenging.
20180222 KGHNHSFT Evidence Appendix Page 72
Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations where possible. The ED sought comments from the patients. They were engaged through feedback forms, comment cards, the friends and family test. Posters were displayed throughout the ED asking for their comments in an effort to improve the service. However, there were no other innovative methods considered for measuring feedback in the service. The leads for the ED communicated key messages to the department using alternative communication methods on social media. They had recognised that sending emails to staff was not getting key messages across. Key urgent issues were shared through a messaging service, and there was a private page on a social media site for all staff to join. Where messages requiring feedback were shared staff provided comments and noted they had read the item. The clinical lead and matron informed us that this method of engagement had generated some healthy, open and honest discussions on topics such as support for patients who want to go outside and smoke, which resulted in a recommended change to policy. The trust worked with other stakeholders and commissioners to improve engagement with the public. This included working jointly within the commissioning area to promoted alternative options to patients to help avoid unnecessary attendances to the emergency department. The service also supported national flu campaigns, and displayed these signs. The service was demonstrating that despite a challenging financial position that they were able to obtain investment to improve 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 about the chances of future investment in the service if funding was required. Learning, continuous improvement and innovation The department had recently established an ambulatory care unit with the acute medicine division. This service, when open, would enable direct referrals to the medical team to support conditions such as deep vein thrombosis, diabetes, leg ulcers, and anticoagulation as well as undertaking minor procedures without the patient having to wait in the emergency department. The structure of nursing 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.
Surgery
Facts and data about this service The Kettering General Hospital NHS Foundation Trust has 13 main operating theatres covering general surgery, medical oncology, urology and trauma and orthopaedics, and two gynaecology theatres, across the one hospital site. The hospital also had five surgical wards, a surgical day case unit and treatment centre.
20180222 KGHNHSFT Evidence Appendix Page 73
The trust has 152 surgery inpatient beds. The trust had 25,567 surgical admissions between June 2016 and June 2017. Emergency admissions accounted for 6,300 (24.6%%), 15,869 (62 %) were day case, and the remaining 3,398 (13%) were elective. All patients admitted were treated under the direct care of a consultant. A senior house officer supports surgical care 24 hours a day, seven days a week. Patients are cared for and supported by registered nurses, care assistants and allied health professionals such as physiotherapists employed by the hospital. We inspected the hospital from 7 to 10 November, and on 24 November 2017. As part of the inspection, we visited the pre-assessment clinics and emergency acute assessment unit, the operating theatres, the theatre recovery area and the surgical wards. During the inspection, we spoke with 34 staff at different grades, including ward and theatre managers, nurses, therapists, consultants, healthcare assistants, pharmacist technicians and housekeepers. We spoke with nine patients and their families, observed care and treatment and looked at 36 patient’s medical records. We received comments from people who contacted us to tell us about their experiences, and reviewed performance information about the hospital. Is the service safe?
Mandatory training The service provided mandatory training in key skills but did not ensure all medical staff completed it. Basic life support training compliance was poor for medical and nursing staff. There was an action plan in place to address this.
Basic life support (BLS) training compliance was poor for medical and nursing staff. Mandatory training classroom based courses were offered monthly and covered topics such as basic life support. Some modules were completed through e-learning such as information governance.
Most staff told us training was accessible and effective. However, nursing staff in theatres told us they found it difficult to attend mandatory training due to demand and pressures in theatres. Two members of staff had not attended their annual BLS update for this reason. The trust had developed an action plan to address this. Actions to address low levels of compliance included an increased number of drop-in sessions for medical staff and weekend and evening sessions for nursing staff and healthcare assistants. All actions were due to be completed by the end of 2017.
Medical and nursing staff received annual training on sepsis management. The training was mandatory and was provided by the trust’s sepsis nurse practitioner. The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory courses between July 2016 and July 2017 for medical/dental and nursing/midwifery staff in surgical care is shown below:
20180222 KGHNHSFT Evidence Appendix Page 74
Training standards for medical and dental staff fall below the trust goal of 85% compliance, in over 50% of courses there is a gap of over 20% between the goal and the actual level of trained personnel.
Conversely, nursing and midwifery training compliance was at a much higher level, with 80% of the training courses achieving over the 85% trust target for compliance. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
We requested the updated training compliance figures as of the end of November 2017 for basic life support for adults (BLS), which showed that:
For anaesthesia staff: 44 out of 54 medical staff had completed this (81%). 130 out of 177 nursing staff had completed this (73%). For surgery staff: 54 out of 107 medical staff had completed this (50%). 134 out of 194 nursing staff had completed this (69%).
We requested the updated training compliance figures as of the end of November 2017 for paediatric basic life support (BLS), which showed that:
For anaesthesia staff:
20180222 KGHNHSFT Evidence Appendix Page 75
21 out of 39 medical staff had completed Newborn Basic Life Support (54%). 45 out of 54 medical staff had completed Paediatric Basic Life Support (83%). 6 out of 7 nursing staff had completed Newborn Basic Life Support (86%). 53 out of 128 nursing staff had completed Paediatric Basic Life Support (41%).
For surgery staff: 20 out of 53 medical staff had Paediatric Basic Life Support (38%). 18 out of 25 nursing staff had completed this (72%). The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register. The timescale to achieve compliance was March 2018. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Most staff had received training on how to recognise and report abuse and they knew how to apply it. Most staff had received safeguarding training in level two for adults and children. Staff told us the training was effective and taught them how to recognise and report abuse. However, training compliance in level three safeguarding for children was poor amongst nursing staff. Medical staff training compliance for safeguarding both adults and children was also below the trust target. Staff understood how to protect adults from abuse and the service worked well with other agencies to do so. Staff we spoke with knew how to recognise safeguarding concerns and how to report them. Staff had a good understanding of their responsibilities in relation to safeguarding of vulnerable adults and children. The 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. All staff knew who the trust’s safeguarding lead for adults and children was and knew how to access the safeguarding team. We observed the safeguarding lead for adults was responsive and helpful when a senior nurse contacted them for advice.
The hospital had safeguarding policies and procedures available to staff on the intranet. The policy included out of hours contact details for hospital staff. Staff were able to locate the policy. The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding courses between July 2016 and July 2017 for medical/dental and nursing/midwifery staff in surgery is shown below:
20180222 KGHNHSFT Evidence Appendix Page 76
Safeguarding levels for medical staff are just below the trust target, both sitting at 83%. Performance for nursing staff was better with two of the three courses exceeding the trust target. This improved performance may indicate the trust puts greater impetus behind providing training in this area. (Source: Trust Provider Information Request P18) We requested the updated training compliance figures as of the end of November 2017 for safeguarding children level 3 training, which showed that:
For anaesthesia staff: 1 out of 1 medical staff had completed this (100%). 43 out of 107 nursing staff had completed this (40%). For surgery staff: 1 out of 2 medical staff had completed this (50%). 2 out of 2 nursing staff had completed this (100%). The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register.
Cleanliness, infection control and hygiene The service did not control infection risk well in all areas. Staff did not always keep themselves and equipment clean. Some control measures were in place to prevent the spread of infection.
The environment and equipment in most of the wards and theatres were visibly clean and tidy. Each ward and theatre had a cleaning schedule and we observed these to be completed on a daily and weekly basis. However, we found the adjustable light in the treatment room on the day case unit to be visibly dusty which meant that it had not been cleaned for some time. Staff told us they were unsure who was responsible for cleaning the room as it was a shared facility amongst different surgical specialities therefore we were not assured that the room was cleaned regularly. We also found inconsistent use of ‘I am clean’ stickers across the wards and theatres which meant staff could not always be assured that equipment was clean and ready for use. Environmental improvements were seen in the maxillofacial service which had reduced infection prevention and control risks identified during our last inspection. For example, carpets had been
20180222 KGHNHSFT Evidence Appendix Page 77 removed which had been damaged due to clinical waste bags being carried through the department. The carpet had been replaced with flooring which could be decontaminated should clinical waste be leaked in transit. Improvements had been made in the breast pre-assessment clinic. During our last inspection in October 2016, the clinic used fabric chairs and privacy curtains. The chairs had been replaced with plastic, wipe-clean chairs and disposable curtains with dates of when they were changed.
Staff did not always adhere to hand hygiene processes. Hand hygiene audits carried out across each department showed that from August 2017 to October 2017, the service was 98% compliant. Hand hygiene audits were not completed in the pre-operative assessment unit; however this had been identified by the senior nurse who had plans in place to carry out hand hygiene audits by December 2017. We observed staff on surgical wards washed their hands before and after each episode of direct contact of care. However, we observed that whilst most staff followed the trust’s policy regarding being ‘arms bare below the elbow’, not all staff were compliant with hand washing. We observed some nursing and medical staff moving from one clinical area to another without washing their hands or using the alcohol gel on departure and arrival despite hand hygiene gels being available throughout the wards and theatres. Personal protective equipment, such as gloves and aprons were available in sufficient quantities and were used appropriately. Waste management was handled appropriately most of the time with separate colour coded arrangements for general waste, clinical waste, sharps bins and the bins were not overfilled. Sharps within theatres were not managed safely. We found a tray of more than ten ampoules, needles and syringes located next to a sharps bin. Staff said this happened routinely so they could identify which medicines a patient had been given on induction in the event that the patient had an allergic reaction. The sharps were not emptied in to the sharps bin after each procedure and the tray of ampoules and sharps were from several previous surgical cases that day. We raised this with the trust during our inspection. Staff said during our second inspection told us they had been reminded of the correct process in which sharps should be disposed of. We observed this had been adhered to and plans were in place for this to be monitored by the theatre manager. Theatre attire was not always used appropriately by staff. During our last inspection in October 2016, we observed a lack of compliance by theatre staff with regard to the correct use of theatre attire. On this inspection, cover gowns were worn by staff but were not used correctly. We saw staff wearing cover gowns in theatres and leaving the theatres in the same cover gowns. Cover gowns were not fully fastened. One staff member told us cover gowns were often used by staff in theatres because they felt cold. This was not in line with the Standards and Recommendations for Safe Perioperative Practice 2011 by the Association for Perioperative Practice (AFPP). Theatre attire audits were undertaken monthly since April 2017. Audit results for the appropriate use of cover gowns showed an average score of 62% from April 2017 to September 2017 which did not meet the trust target of 100%. There were no documented plans to address poor compliance with theatre attire audits. We raised this with the trust who took action to mitigate risks. The AFPP recommends that footwear worn in theatres should be for that use only and should be cleaned regularly. However, we observed footwear worn in the main theatres was visibly dirty (but not contaminated). Staff did not have access to washer-disinfectants or autoclaves and were responsible for ensuring they cleaned their own footwear. Risk assessments had not been carried out to ensure footwear not supplied by the trust met all necessary standards. We observed theatre staff wearing wooden shoes which meant there was a risk that shoes could not be decontaminated thoroughly after use. Porters wore their outdoor shoes in theatres and anaesthetic rooms when required to help manoeuvre patients. This had not been risk assessed. From the theatre attire audits undertaken monthly since April 2017, results for staff who left theatres wearing their outdoor shoes showed an average score of 68% from April to September
20180222 KGHNHSFT Evidence Appendix Page 78
2017. Medical, nursing and support staff we spoke with were not aware of any trust policies regarding theatre attire. We raised this with the trust and they took action to develop a draft theatre attire standard operating procedure (SOP) however, the SOP did not contain information or guidance in relation to the cleaning of footwear. There were infection control policies available on the intranet, including management of patients with MRSA and an infection outbreak. During our inspection, there was an outbreak of norovirus in the hospital. We observed the outbreak on Deene B ward was managed in line with trust policy. Surgical site infections (SSI) rates were monitored, audited and reported appropriately. Rates that were worse than the national average, such as hip replacements, were reviewed at the orthopaedic multidisciplinary team meeting. SSI rates from January 2017 to March 2017 were: Fractured neck of femur: The hospital had a SSI rate of 0%, which was better than the national average of 1.4%. Hip replacement: The hospital had an SSI rate of 3.6%, which was worse than the national average of 1.1%. Knee replacement: The hospital had an SSI rate of 0%, which was better than the England average of 1.5%. Patient-led assessments of the care environment (PLACE) undertaken in April 2017 for Barnwell B, Barnwell C and DASU showed scores of 100%, 99% and 95% respectively.
Environment and equipment The service did not always have suitable premises in all areas and systems to ensure equipment was well looked after required improvements. During our last inspection, we raised concerns about the environment within the maxillofacial service. Emergency treatment was provided for all patient groups, which included prisoners, children and patients with severe facial disfiguration at various stages of their cancer treatment. There was no dedicated waiting room for patients who wanted privacy or a separate waiting room for children. The office and computer used by the nursing staff was located in the dirty utility room. These issues were on the risk register and staff were knowledgeable about the risks to the environment. Staff worked together to temporarily mitigate risks as best they could whilst waiting for a business case approval to relocate the service. At the time of this inspection, a business case had been approved for the maxillofacial service to relocate to a different area of the hospital and we saw plans which addressed the environmental risks. The environment on the Barnwell wards was in a poor condition. Some washing facilities were not appropriate and therefore could not be used. There was a very large step up to some shower facilities and therefore were unsuitable for the surgical patients on the ward. Other showers were out of use due to broken tiles. Patients were offered bedside and sink washes. All environmental risks had been assessed and were on the risk register. At the time of our inspection, building work was underway to refurbish areas of the wards. This included the washing facilities. Staff had not been informed of when the building work was due to be completed.
Some corridors were not free from obstruction. For example, on the day case unit we found the corridor leading to theatres was obstructed with four large broken items of equipment such as beds and theatre equipment. Two pieces of equipment had been there for one day and the other two longer than one week. Some junior nursing staff were unclear as to what the processes were for faulty equipment to be removed. The main theatre area was undergoing a refurbishment at the time of our inspection, which was almost completed. Five of the six theatres and anaesthetic rooms were fully operational. The theatre recovery and holding areas had also been refurbished and were fully functional at the time of our inspection.
20180222 KGHNHSFT Evidence Appendix Page 79
Condensation from the air conditioning unit had leaked through a light outside theatre one. Temporary guttering and a bucket was still fixed in place to prevent the spread of water, however this had not been risk assessed despite the exposed electrical wiring being at risk of getting wet. The trust took immediate action to address this issue once we had raised it as a concern. It was immediately risk assessed. We inspected the trust again on 24 November 2017 and found the guttering and bucket had been removed, the ceiling had been repaired and a new light had been fitted.
Resuscitation equipment, for use in an emergency was checked daily and weekly. We observed checks across surgical wards and theatres were completed and equipment was ready for use at the time of our inspection.
There was sufficient equipment to maintain safe and effective care such as anaesthetic equipment, theatre instruments, blood pressure and temperature monitors, commodes and bedpans. Single use sterile instruments were stored appropriately and kept within their expiry dates. Surgical procedure packs, implants and consumable items were stored in a tidy and organised manner.
A senior manager told us daily checks of anaesthetic equipment had not always been carried out in theatres; therefore a new checklist book and system of checking had been introduced the month prior to our inspection. The daily checks were in accordance with recognised guidance by the Association of Anaesthetists of Great Britain and Ireland (AGGBI), ‘Checking Anaesthetic Equipment’ 2012 guidance. Anaesthetists we spoke with were knowledgeable about the new process. Checks were completed and recorded daily.
We were not assured there were reliable systems and arrangements in place to review and check all equipment in theatres. We found refrigerators and a diathermy machine in main theatres that had not been tested in the last 12 months. We were told by a senior manager that the medical devices audit for equipment in main theatres was inaccurate and did not reflect all equipment in the main theatres. The trust provided a service report for equipment in main theatres which showed 61 out of 287 pieces of equipment did not have a service due date recorded. The equipment which did have due dates recorded only had the year of a due service recorded but not the month. Equipment and appliances viewed on wards and in the pre-operative assessment clinics had been appropriately electrically tested. We raised this with the trust who said that the medical device technicians had undertaken an audit of all theatre equipment. The audit ensured that the appropriate service sticker was on the equipment (i.e. whether it was an in-house service or undertaken by the manufacturer on a service contract). The audit identified all theatre equipment and noted the date that the service was required. In order for any services to be undertaken the following actions had been implemented: Equipment kept in the medical device library was swapped with that in theatres to enable them to service in the workshop. In addition where swapping was not appropriate for theatre only equipment, the technicians were liaising with theatre managers to gain access when theatres not in use which may mean weekends or evening working. High risk equipment was prioritised and service contracts for these were in place. They aimed to have all servicing complete in theatres by the end of January 2018.
Four theatres had laminar flow. Laminar flow in theatres works by frequent air changes via a filter to prevent airborne bacteria from getting into open wounds, as well as removing and reducing levels of bacteria on exposed surgical instruments, surgeons and the patient's own skin. Airflow systems were revalidated and checked against standards set out in national guidance Health Technical Memorandum (HTM) 03-01: ‘Specialised Ventilation for Healthcare Premises’, 2007.
20180222 KGHNHSFT Evidence Appendix Page 80
Staff on wards and theatres had access to bariatric equipment. We observed bariatric equipment in the breast pre-assessment clinic was suitable and ready for use.
We reviewed copies of the Control of Substances Hazardous to Health risk assessments on Barnwell B and Deene Acute Surgical Unit (DASU). The assessments were appropriate and included guidance on the handling of items such as cleaning products and precautionary measures for safe handling.
Assessing and responding to patient risk Generally, there were effective systems in place to recognise and respond to deteriorating patients’ needs. Risk based pre-operative assessments were carried out in line with national guidance from the Modernisation Agency. Patients for elective surgery attended a pre-operative assessment clinic prior to the day of their operation. During the assessment any required tests were undertaken, for example, MRSA screening and any blood tests. The hospital offered a consultant-led pre- operative assessment clinic weekly for patients with complex health needs and comorbidities. Risk assessments were undertaken in areas such as venous thromboembolism, falls, malnutrition and pressure ulcers. These were documented in the patient’s records and included actions to mitigate any identified risks. The hospital used nationally recognised risk assessments such as the Malnutrition Universal Screening Tool (MUST) and Waterlow score. MUST is a five-step screening tool to identify patients, who are malnourished, at risk of malnutrition (under nutrition) or obese. The Waterlow score gives an estimated risk for the development of a pressure sore in a patient. We observed that patients identified at risk were placed on care plans and were monitored more frequently by staff to reduce the risk of harm. Staff carried out venous thromboembolism (VTE) screening on admission and patients received a reassessment within 24 hours for risk of VTE and bleeding. This was in line with National Institute for Health and Care Excellence (NICE) Quality Standard (QS) 29: ‘Venous thromboembolism in adults’ (2013). The national early warning score (NEWS) was used to identify deteriorating patients in accordance with NICE Clinical Guidance (CG) 50: ‘Acutely ill adults in hospital: recognising and responding to deterioration’ (2007). Staff used the NEWS to record routine physiological observations, such as blood pressure, temperature, heart rate and the monitoring of a patient’s clinical condition. There were clear directions for actions to take when patients’ scores increased, indicating a deterioration and members of staff were aware of these. We reviewed 22 patients’ notes and found NEWS charts were being used to record patients vital signs. Staff knew when and how to escalate a high score. We reviewed the nurse sensitive indicators (a trust tool which measures nursing performance and outcomes from nursing care) from May 2017 to October 2017. The results showed patients were having their NEWS scores calculated appropriately and escalated as per the trigger algorithm. There was 24 hour access to emergency surgery teams, including theatres, and doctors. During the night, there was a senior house officer present, who covered the surgical wards and was supported by the on call consultant for surgery. However, trust policy was that patients assessed as stable and ‘fit for discharge’ were not reviewed by a doctor daily during weekends. We looked at 11 trauma and orthopaedic patients’ medical records and nine of those patients had not been medically reviewed over the weekend. One patient’s notes showed no evidence of a medical review for eight days. This was escalated to the trust, who took immediate action to address this. We reviewed a further three records during our follow up inspection and found patients three patients were medically fit and awaiting discharge therefore did not require a daily medical review despite one of the patients having a recorded NEWS of three. Not all staff had received the training to care for and resuscitate patients in a medical emergency. The trust’s resuscitation policy dated May 2015 clearly outlined the requirement that all staff must have received basic life support (BLS) training yearly. We spoke with a senior member of staff who informed us of two nurses in theatres whose BLS training had expired but due to demands in
20180222 KGHNHSFT Evidence Appendix Page 81 theatres, they were unable to attend refresher courses. The trust’s training system did not capture compliance levels for each job role and was reliant on staff informing the trust if they had undertaken courses outside of the trust. This information then had to be manually added to the system. The trust had identified poor compliance levels and had developed an action plan to improve BLS compliance levels amongst all levels of clinical staff. The trust responded to say at every induction of all junior doctors, the resuscitation team provide an overview of trust policy, equipment, bleep numbers and made explicit the trust’s expectation regarding individual responsibilities. The trust had an action plan with the achievement date of 28 February 2018 provided. The trust used the five steps to safer surgery, World Health Organisation (WHO) surgical checklist, in line with national guidelines and we observed this on inspection. The safer surgery checklist was audited daily and compliance rates ranged from 70% to 100% from August 2016 to July 2017. Compliance rates were improving. WHO audit results were shared with senior managers and discussed at the anaesthetic clinical business unit meeting. Observational reviews had been carried out which highlighted improvements had been made to the involvement of team members when completing the surgical checklist. Staff told us they completed the WHO checklist for radiological interventions. A modified version of the checklist was used for cataract surgery. Patients with known allergies wore a coloured wristband, which acted as an alert to staff who were providing care and treatment. Clinical harm reviews had been completed for 79% of patients who were waiting over 18 weeks from referral to treatment (RTT) for surgery. Harm reviews were implemented as part of the trust’s RTT recovery programme to determine whether there was a risk of harm to patients due to the length of wait for a procedure. All patients received a letter which informed them of the long waits for treatment and details of who to contact if their condition deteriorated. 72% of all patients who had received a clinical harm review were confirmed as coming to ‘no harm’. 7% of patients were recorded as low harm and 2% of patients were recorded as moderate harm. Patients who had come to harm whilst waiting were prioritised on the patient tracking list. The trust had an access to care policy that laid out the risk based process for staff to follow to prioritise care and treatment. Staff told us they were aware of the trust sepsis policy and some had training in sepsis awareness and ‘sepsis six’. Sepsis is serious complication of an infection. ‘Sepsis six’ is six steps to managing patients suspected of having severe sepsis, neutropenic sepsis or 'sepsis shock. Patients who had been identified as potentially having sepsis had been assessed and managed appropriately. Two patients with confirmed sepsis received a prompt assessment when escalated to the critical care team. Completion of the sepsis bundle was consistent in the patient records seen. Staff had a good understanding of actions required and a sepsis ‘grab bag’ was fully stocked and readily available on all surgical wards. We observed staff caring for two patients with confirmed sepsis those patients had received antibiotics within the one hour required timeframe. Fluid balances and intravenous fluid administration were also completed in line with the trust sepsis management policy. From July 2017 to September 2017, audit results showed 77% of inpatients that met the criteria for screening were screened. However, the audit results were not separated by clinical business units so this was not specific data for surgery patients. We saw intentional care rounding was completed by healthcare assistants (HCAs) on the surgical wards. Intentional care rounding is a structured process where staff carry out regular checks with individual patients at set intervals. For example, we observed HCAs visited patients hourly to check that call bells and drinks were in reach and asked if the patient was comfortable or in any pain. This was documented in the patients’ notes. The trust had implemented discharge checklists to improve the quality of discharges. We reviewed one discharge checklist and saw that it had been completed appropriately. The checklist included ensuring the patient had documentation related to their stay and medicines prescribed. The service did have a plan for emergencies but staff did not understand their roles if one should happen. Staff of all levels we spoke with, on wards and in theatres were unclear on what the major incident plan was and what steps to take in the event of a major incident. This was fedback
20180222 KGHNHSFT Evidence Appendix Page 82 to the trust senior managers at the end of the inspection. In the interventional radiology unit, nursing staff assessed the patient and completed the observation charts prior to the procedure being undertaken. After the procedure, nursing staff observed the patient and completed the NEWS chart as specified until the patient’s condition was stable before discharging them.
Nurse staffing The service had enough 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 reported their nurse staffing numbers below as of 30 September 2017. Ward/Site Headcount WTE Ashton Ward (4375) 19 17.93 Barnwell B Ward (2800) 36 31.35 Breast Service (4380) 13 9.11 CMT Management (2720) 4 3.60 Day Case Unit Ward (1535) 12 9.71 Deene Acute Surgical Unit (4360) 18 16.05 Deene B (4365) 16 13.76 ENT OPD (2130) 2 2.00 Geddington Ward (1545) 17 15.69 General Surgery Specialist Nursing (4330) 14 11.56 OMFS Outpatients (2220) 5 4.48 Spencer Ward (2180) 20 16.64 T&O Nurse Practitioners (2725) 6 5.56 Urology Specialist Nursing (4340) 6 5.53 Total 188 162.98 (Source: Additional request DR94) There were systems and processes in place to assess, plan and review staffing levels, including skill mix. A staffing tool was used to calculate the number of nurses and HCAs required for each shift based on the acuity (level of care patient requires) and needs of the patients. The staffing tool was in line with NICE staffing guidance. Required and actual staffing levels were displayed in each surgical ward or just outside. During our inspection, staffing levels met the needs of the patients in areas we visited.
The day case unit remained open overnight as an escalation area and was staffed by bank and agency nurses. This had been risk assessed and arrangements had been put in place to mitigate the risk. For example, a substantive nurse from another surgical ward was swapped for a temporary nurse to ensure the unit was not staffed solely by temporary staff overnight. New agency staff had an induction checklist completed to ensure they were familiar with the ward layout and processes.
Some staff we spoke with were unhappy about theatre rotas and the way they were managed. We discussed this with managers within theatres. During our follow up inspection, new processes were in place for managers to review and approve all rotas.
The trust provided information that, as of the 30 September 2017, there was a 16.18% vacancy rate for nursing staff in surgery. This was worse than the trust target of 7%.
20180222 KGHNHSFT Evidence Appendix Page 83
We discussed nursing staffing levels with a senior nurse who told us they continued to hold events to recruit HCAs and nurses such as “talent Tuesdays” however they had found it particularly hard to recruit junior nurses. There had been an increase in the number of student nurses who had accepted permanent positions at the trust once they had qualified. In September 2017, the decision had been made by the trust board for clinical business unit managers to recruit HCAs.
The trust provided information that, as of the 30 September 2017, there was a 14.35% annual turnover rate for nursing staff in surgery. This was worse than the trust target of 11%. The trust provided information that, as of the 30 September 2017, there was an annual sickness rate of 4.33% for nursing staff in surgery. This was similar to the trust target of 4%. Work had begun to understand the drivers for non-work-related absence as well as a review to into whether there was a county-wide issue.
The trust provided the total number of shifts covered by bank and agency staff over the last twelve months; however, they have not provided the total number of shifts so we are unable to provide a percentage usage. The units with the highest number of shifts covered by bank and agency staff are Barnwell Trauma Unit, DASU, and the Deene B Ward.
Medical staffing The service had enough 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 most of the time.
Consultants from each speciality were usually on-call for four days in one week, and three days the following week. They were then not on-call for one month until the cycle started again. In addition, the trust had an ‘on-call consultant for the day’. This started from 8am on a Monday to 8pm on a Friday. The ‘on-call for the day’ was freed from all other activity during this period. Medical handovers happened daily. Medical staff we spoke with felt handovers were appropriate and informative.
The trust has reported their medical staffing numbers as of 30 September 2017. They are at the expected medical WTE, or above, in all areas. Number in post Ward/Site WTE Staff September 2017 Breast Service 3 3 ENT 12 12 General Surgery 32 32 Ophthalmology 11.28 12 Oral Surgery 6.7 8 Plastic Surgery 1.8 2 Trauma & Orthopaedics 26 26 Urology 13 13 Total 105.78 108 (Source: Additional request DR94) The trust provided information that showed, as of the 30 September 2017, there was a vacancy rate of 16.67% for medical staff in surgery. This was worse than the trust target of 7%.
20180222 KGHNHSFT Evidence Appendix Page 84
The trust provided information that, between October 2016 and September 2017, there was a 21.77% turnover rate for medical staff in surgery. This was worse than the trust target of 11%.
The trust provided information that, between October 2016 and September 2017, there was a 1.23% sickness rate for medical staff in surgery. This was better than the trust target of 4%.
The trust has provided the total number of shifts covered by bank and locum staff however has not provided the total number of shifts available so we are unable to provide a percentage usage. The wards with the highest number of shifts covered by bank and locum staff were general surgery, trauma and orthopaedics, and ophthalmology.
Between July 2017 and July 2017, the proportion of consultant staff reported to be working at the trust was the same as the England average and the proportion of junior (foundation year 1-2) staff was slightly lower than the England average. We discussed this with the trust who told us work was underway to make posts for junior doctors look more attractive. This England Trust average Consultant 47% 47% Middle career 15% 11% Registrar Group 28% 29% Junior 11% 13%
(Source: NHS Digital Workforce Statistics)
Records Staff generally kept appropriate records of patients’ care and treatment. Records were generally clear, up-to-date and available to all staff providing care.
We reviewed 22 sets of nursing and medical records and found most notes to be in good order. However, we reviewed four sets of notes on Geddington ward and found the information was difficult to access and records were not in any particular order.
Records included details of a patient’s admission, risk assessments, pre-assessment forms, treatment plans, and records of therapies provided. Records were legible, accurate, and up to date. Daily care records such as fluid balance records and care plans were stored in folders at the bottom of patient’s beds. We looked at samples of daily care records, which were fully completed, legible with entries timed, dated and signed. Records contained clear details of patients’ mental health, learning disability and dementia needs.
Nursing and medical records for inpatients were stored securely in locked trolleys in most areas visited. However, we found 41 medical records stored behind the nursing station on the day case
20180222 KGHNHSFT Evidence Appendix Page 85 unit in unlocked cupboards for patients who had been discharged without a discharge letter. We raised with the staff on duty.
Discharge letters were supposed to be typed up immediately after a surgical procedure and sent electronically to the patients’ GP; however, this did not always happen. Some patients had not received a discharge letter within two months of being discharged and their records were stored awaiting a letter to be typed and filed. A doctor attended the unit two evenings a week and was responsible for ensuring the backlog of discharge letters was reduced by typing the discharge letters and sending them to patients and their GPs on behalf of the consultants that carried out the procedure. The risks associated with the delays in patients and their GPs receiving discharge letters had been assessed and acted upon.
Discharge summaries were sent to patients’ GPs to ensure continuity of care in the community. We also saw evidence that details of surgery including any implant used was included in the discharge letter to patients and their GPs.
Medicines The service prescribed, gave, and recorded medicines well. Patients generally received the right medication at the right dose at the right time. Pharmacy services were available on weekdays from 08:30 to 18:30 and Saturdays from 09:30 to 12:30. There was an on-call pharmacist available on Sundays and out of hours. Some wards had a dedicated pharmacy technician. There was a pharmacy communication book on the wards which was reviewed daily. Medicines were stored in secure temperature controlled rooms that had suitable storage and preparation facilities for all types of medicines such as controlled drugs and antibiotics. We saw records of the daily checks of ambient temperatures in the medicines’ storage room had been routinely completed. During our last inspection, we identified issues with the unsafe and unsecure storage of medicines within the maxillofacial service. During this inspection, we saw action had been taken to address this. Medicines were stored within a secure locked cupboard. Medicines that required refrigeration were kept at the correct temperature. We reviewed records of the daily checklists of ambient fridge temperatures. The checklists indicated what the acceptable temperature range should be, to remind staff at what level a possible problem should be reported. Staff were aware of what action to take if the fridge temperature was outside safe parameters. However, on a few occasions, when the fridge temperature had exceeded the temperature range this had not always been escalated. Drug cupboards which contained anaesthetic induction and reversal medications were left unlocked in the anaesthetic rooms, whilst theatres were in use to allow easy access. A risk assessment for this had not been undertaken. We observed the cupboards were kept locked when theatres were not in use. Controlled drugs were stored in a locked unit and the keys held separately from the main drug keys. Controlled drugs are medicines such as morphine and methadone which are controlled under the misuse of drugs legislation. We reviewed the controlled drug cupboards which were tidy and did not hold any other equipment or medicines in these cupboards. Entries in the controlled drug register were made correctly regarding the administration of drugs
20180222 KGHNHSFT Evidence Appendix Page 86 to the patient and were signed appropriately. New stocks were checked and signed for. All intravenous fluids were stored safely behind locked doors and only accessible to appropriate staff. We reviewed a total of seven drug charts and found them to be complete with relevant information and up to date.
Incidents The service generally managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and however there was a lack of formal systems to share 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 reported most patient safety incidents. Staff generally recognised incidents and incidents were reported. The trust used an electronic incident reporting system and all staff knew how to report incidents. Most staff understood their responsibilities to raise concerns and report incidents however we saw an example of when an incident had not been reported. For example, nursing staff had failed to report an incident whereby a patient was not accepted for review by medical staff following transfer to the hospital. The patient was readmitted through the emergency department as a result of the incident. There were 1,710 incidents reported from November 2016 to October 2017. The level of harm was graded appropriately for the four incidents we reviewed. Records showed: 373 incidents were classified as a near miss. 796 incidents were classified as no harm. 412 incidents were classified as low harm. 97 incidents were classified as moderate harm. 4 incidents resulted in death (but not as a result of patient safety). 28 incidents were classified as severe harm.
The most commonly reported incidents were around medical records, documentation and patient information. 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. Between September 2016 and August 2017, the trust reported two incidents classified as never events for Surgery.
20180222 KGHNHSFT Evidence Appendix Page 87
(Source: Strategic Executive Information System (STEIS))
The two never events were: Wrong site surgery during a dentistry procedure in October 2016. Retained foreign object following orthopaedic surgery April 2017. Staff of all levels we spoke with were aware of the never events that had happened in the trust. Most staff were able to describe the learning from the most recent never events. Staff we spoke with said they had been made aware of never events at handovers and safety huddles. Action plans were in place to prevent the likelihood of the incident happening again. In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents (SIs) in surgery which met the reporting criteria set by NHS England between September 2016 and August 2017. Of these, the most common type of incident reported was Surgical/invasive procedure incident meeting SI criteria with two (67% of total incidents). HCAI/Infection control incident meeting SI criteria with one (33% of total incidents).
(Source: Strategic Executive Information System (STEIS)) We reviewed the three SI investigations and saw they were completed appropriately. Reports included action plans. A duty of candour checklist was also included and all duty of candour tasks had been completed. Actions had been implemented and most completed following the healthcare associated infection incident on the Barnwell wards. This included ward-based teaching sessions focused on infection control processes and information about hand hygiene and infection prevention for both staff and visitors was clearly displayed on the ward. Lessons learned from incidents were not consistently shared with the whole team and wider service. Staff received individual feedback from incidents they had reported. Staff told us the sharing of learning from incidents was usually communicated on private social media forums and at staff meetings however we did not see any evidence of this. Ward staff were unable to provide examples of learning from incidents. There were no formal processes in place for staff to share learning from incidents with other surgical wards. 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. 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 reasonable support to the person. Staff understood their responsibilities with regard to the duty of candour legislation. Nursing and medical staff were
20180222 KGHNHSFT Evidence Appendix Page 88 aware of the duty of candour. Duty of candour had been applied appropriately following the never events.
Safety thermometer The service used safety monitoring results. Staff collected safety information and shared it with staff, patients and visitors. 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 suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 20 new pressure ulcers, two falls with harm and 22 new catheter urinary tract infections between September 2016 and September 2017 for surgery.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Kettering General Hospital NHS Foundation Trust
Total Pressure ulcers (20)
Total Falls (2)
Total CUTIs (22)
(Source: NHS Digital) The safety thermometer data was clearly displayed in surgical wards.
Major incidents
20180222 KGHNHSFT Evidence Appendix Page 89
The service planned for emergencies and but not all staff understood their roles if one should happen. Not all staff we spoke with in theatres and on surgical wards knew what to do or which action to take in the event of a major incident. Staff knew where to find major incident plans on the trusts intranet. We reviewed the major incident plan guidance displayed on Barnwell B and on the orthopaedic wards. The plan was out of date and had not been reviewed since July 2014. Staff completed fire safety training as part of their mandatory training. Nursing and medical staff we spoke with knew what the evacuation procedure was and their individual meeting points. 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. Policies were up to date and followed guidance from the National Institute for Health and Care Excellence (NICE) and other professional associations for example, Association for Perioperative Practice (AfPP). Local policies, such as the infection control policies were written in line with national guidelines. Staff we spoke with knew how to access them on the trust’s intranet. The pre-operative assessment clinic assessed patients in accordance with NICE NG45 ‘Routine pre-operative tests for elective surgery’ (2016). For example, MRSA screening and blood tests. There was participation in relevant local and national audits, including clinical audits such as surgical site infections in line with NICE guidelines QS49 ‘Surgical site infections’ (2013). Patients were assessed for venous thromboembolism (VTE) prior to surgery and were offered VTE prophylaxis in accordance with NICE guidelines QS3 statement 5: ‘Venous thromboembolism: reducing the risk for patients in hospital’ (2010). For example, the choice of mechanical VTE prophylaxis was based on the patients clinical condition, they type of procedure they were having and the patients preference. Patients who required anti-embolism stockings had their legs measured and patients were encouraged to wear the stockings until their mobility was no longer reduced. Consultants explained ways in which the service met the Royal College of Surgeons (RCS) ‘Standards for unscheduled surgical care’ (2011). For example, critically ill patients had priority over elective patients and all services were consultant-led. All patients who were considered as high risk had their procedure performed under the direct supervision of a consultant surgeon and a consultant anaesthetist. Medical staff followed professional guidance in relation to the recording and the management of medical device implants by using the National Joint Registry (NJR). The NJR collects information on joint replacement surgery and monitors the performance of joint replacement implants. Staff inputted each device used onto the NJR and a summary of this information was reviewed and discussed at appraisals. This ensured all medical device implants could be traced if concerns were raised about the quality or possible adverse effects at national level. Staff assessed patients’ physical, mental health and social needs in a holistic manner. Medical staff obtained this information when patients were admitted. In addition, nursing staff also recorded information about patients’ living accommodation to help discharge planning.
Nutrition and hydration
20180222 KGHNHSFT Evidence Appendix Page 90
Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences. Patients nutrition and hydration needs were assessed, monitored and recorded by 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 observed MUST assessments were up to date and consistently completed across all surgical wards. Staff used fluid balance charts to monitor patients’ fluid intake. Patients were given clear instructions about fasting prior to admission. Information was given verbally at the pre-operative assessment and in writing. For example, patients were told not to eat for six to eight hours before a general anaesthetic and were encouraged to drink water up to two hours prior to a surgical procedure. Patients were provided with effective management of nausea and vomiting, such as by using an antiemetic (a drug effective against vomiting and nausea). Patients had access to dietitian services, particularly patients who had undergone bowel surgery or were receiving bariatric surgery. Patients who were at risk of malnutrition were referred to a dietitian. Patients had jugs of water on their bedside tables within reach. We observed these to be regularly replenished. Intravenous fluids were also prescribed and recorded appropriately.
Pain relief Patients’ pain was assessed and managed effectively. Pain was risk assessed and recorded using the National Early Warning Score (NEWS) scale and we saw these were completed. Staff regularly asked patients if they were in any pain. Staff had access to an appropriate tool to help assess the level of pain in patients who were non-verbal, such as happy and sad faces. Staff also said they would observe patients facial expressions, body language and a change in behaviour. Patients were provided with pain relief in a timely manner. Patients we spoke with said they were regularly asked if they were in any pain by nurses and health care assistants. Pain relief was discussed during handovers and concerns were referred to the consultant and a member of the pain team. Patients were also provided with a leaflet titled ‘Pain relief after your operation’. The leaflet provided day surgery patients with information about recommended pain relief and doses upon discharge if they experienced pain. Stronger painkillers were prescribed if they were required.
Patient outcomes The service monitored the effectiveness of care and treatment but inconsistently used the findings to improve them. The service took part in national audits, such as the elective surgery Patient Reported Outcome Measures (PROMs) programme and the National Emergency Laparotomy Audit. PROMs were reviewed by the clinical lead for the relevant speciality and were presented to the patient safety advisory committee. The hospital benchmarked patient outcomes with other trusts and presented
20180222 KGHNHSFT Evidence Appendix Page 91 findings to speciality teams, for example, the hip fracture audit results and benchmarked outcomes were delivered in a presentation to orthopaedic surgeons and junior doctors. National audits the trust took part in included: Hip fracture audit In the 2017 Hip Fracture Audit, the risk-adjusted 30-day mortality rate was 7.8% which was within the expected range. The 2016 figure was 6.1%. The proportion of patients having surgery on the day of or day after admission was 79.9%, which was worse than the national standard of 85%. The 2016 figure was 77.8%. The perioperative medical assessment rate was 85.3%, which failed to meet the national standard of 100%. The 2016 figure was 81.5%. The proportion of patients not developing pressure ulcers was 99.2%, which falls in the top 25% of trusts. The 2016 figure was 98.2%. The length of stay was 25.1 days, which falls within the middle 50% of trusts. The 2016 figure was 21.8 days. (Source: National Hip Fracture Database 2016) A list of recommendations had been developed following the audit. This included plans to seek support from orthogeriatricians for perioperative assessments. The trust had also devised a list of best practice actions. Actions included all patients being assessed by a physiotherapist on the day or following day after surgery. The service was working towards a time to surgery target of 36 hours from admission. There were plans in place to improve the length of stay for patients being treated for a hip fracture including the mobilisation of patients the day after surgery and the development of a facilitated discharge process.
Bowel cancer audit
In the 2016 Bowel Cancer Audit, 57.6% of patients undergoing a major resection had a post- operative length of stay greater than five days. This was lower than the national aggregate. The 2015 figure was 63.9%. The risk-adjusted 90-day post-operative mortality rate was 2% which was lower than the national aggregate and within the expected range. The 2015 figure was 3.8% The risk-adjusted 2-year post-operative mortality rate was 22.9% which is slightly higher than the national aggregate but within the expected range. The 2015 figure was 40.5% The risk-adjusted 30-day unplanned readmission rate was 6.7% which is within the expected range. The 2015 figure was not reported. The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection was 51% which was slightly higher than the national aggregate but within the expected range. The 2015 figure was 44.2%. (Source: National Bowel Cancer Audit) The audit results had been analysed and shared with the patient safety group and clinical governance group. Recommendations had been documented and included actions such as reducing the need to slot elective patients on to emergency lists and the need to increase theatre capacity for colorectal surgery. Actions were ongoing at the time of our inspection.
Oesophago-Gastric Cancer National Audit In the 2016 Oesophago-Gastric Cancer National Audit (OGCNCA), the age and sex adjusted proportion of patients diagnosed after an emergency admission was 16.2%. This placed the trust within middle 50% of all trusts for this measure. The 90-day post-operative mortality rate was recorded as not eligible. The 2014 rate was also recorded as not eligible. The proportion of
20180222 KGHNHSFT Evidence Appendix Page 92 patients treated with curative intent in the Strategic Clinical Network was 42.5%, notably higher than the national aggregate. This metric is defined at strategic clinical network level; the network can represent several cancer units and specialist centres); the result can therefore be used a marker for the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results. (Source: National Oesophago-Gastric Cancer Audit 2016)
There was no action plan in place at the time of our inspection. We were told this was due to ongoing work to retrospectively update the monitoring system for clinical audit action plans.
National Emergency Laparotomy Audit In the 2016 National Emergency Laparotomy Audit (NELA), Kettering General Hospital achieved an amber rating for the crude proportion of cases with pre-operative documentation of risk of death. This was based on 146 cases. The Kettering General Hospital achieved a green rating for the crude proportion of cases with access to theatres within clinically appropriate time frames. This was based on 99 cases. The Kettering General Hospital achieved an amber rating for the crude proportion of high-risk cases with a consultant surgeon and anaesthetist present in the theatre. This was based on 78 cases. The service achieved a green rating for the crude proportion of highest-risk cases admitted to critical care post-operatively. This was based on 52 cases. The risk-adjusted 30-day mortality for the Kettering General Hospital was within the expected range, based on 286 cases. (Source: National Emergency Laparotomy Audit)
We requested to see the action plan however this was not provided. The trust told us that they did not have capacity to offer post-operative geriatric reviews and therefore surgeons sought advice from geriatricians on a case by case basis as and when they required support.
Relative risk of readmission Between June 2016 and May 2017, the trust’s performance around relative risk of readmission for six out of the eight metrics performed in line with or just below the England average. In elective, ophthalmology stands out as underperforming. In non-elective, trauma and orthopaedics was the underperforming metric. When coupled with its poor performance in average length of stay, this indicates issues within this metric.
Elective Admissions – Trust Level
Non-Elective Admissions – Trust Level
20180222 KGHNHSFT Evidence Appendix Page 93
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 is represents the opposite. Top three specialties for specific trust based on count of activity (Source: HES - Readmissions (01/06/2016 - 31/05/2017))
Between June 2016 and May 2017: All patients had a lower expected risk of readmission for elective admissions when compared to the England average. Ophthalmology patients had a higher expected risk of readmission for elective admissions when compared to the England average. Urology patients had a lower expected risk of readmission for elective admissions when compared to the England average. General Surgery patients had a lower expected risk of readmission for elective admissions when compared to the England average. All patients had a lower expected risk of readmission for non-elective admissions when compared to the England average. General surgery patients had a lower expected risk of readmission for non-elective admissions when compared to the England average. Trauma and orthopaedics patients had a higher expected risk of readmission for non-elective admissions when compared to the England average. Urology patients had a lower expected risk of readmission for non-elective admissions when compared to the England average.
Elective Admissions
20180222 KGHNHSFT Evidence Appendix Page 94
Non-Elective Admissions
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 is represents the opposite. Top three specialties for specific trust based on count of activity.
Patient Reported Outcome Measures In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations: • Groin Hernias. • Varicose Veins. • Hip Replacements. • Knee replacements. Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left.
In 2015/16 performance on groin hernias was better than the England average: For Varicose Veins, performance was not recorded. For hip replacements, performance was about the same as the England average. For Knee replacements was slightly better than the England average.
The number of completed questionnaires for hip and knee replacements had increased. Staff told us they felt this was because of the introduction of joint school. Joint school was a service offered to patients who were about to undergo a hip or knee replacement. It provided education sessions and set clear expectations for patients. It covered various steps from preparing for admission to recovery at home. The trust told us performance on varicose veins was not recorded due to the inconsistent completion of questionnaires. 20180222 KGHNHSFT Evidence Appendix Page 95
(Source: NHS Digital) No data was available for the national vascular registry at the time of production of this report. There was a local audit plan which included audits such as assessing catheterisation for elective and trauma patients in theatre and on surgical wards. We reviewed the perioperative anticoagulation local audit. Lessons learned had been documented and included good practice and areas where practice could be improved. All actions had been completed in a timely manner and a re-audit was planned to ensure learning was embedded. Evidence-based care bundles were used to improve patient outcomes. For example, sepsis and skin care bundles. A care bundle is a set of interventions that, when used together, significantly improve patient outcomes. Multidisciplinary teams worked together to deliver the best possible care supported by evidence-based research and practices, with the ultimate outcome of improving patient care. The department had not carried out an audit of the WHO surgical safety checklist which was used for all interventional radiology cases.
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, when required, to provide support and monitor the effectiveness of the service. Nursing and medical staff we observed and spoke with had the skills, knowledge and experience to deliver effective care and treatment to patients. Nursing staff and healthcare assistants (HCAs) were able to describe ways in which they managed and cared for patients living with dementia or a learning disability. There was an induction programme for all staff which included mandatory training. Staff we spoke with on Spencer, Geddington and Ashton wards told us they had attended an induction. Newly qualified staff were supported through a preceptorship programme. A newly qualified nurse we spoke with said the programme provided training and support in mandatory areas as well as support in additional areas that they had requested. Learning and development needs of staff were identified and we saw this documented in three staff members’ appraisals records. Clinical supervision was provided to staff by practice development nurse specialists; however, a documented process of clinical supervision for nurses and matrons was not yet fully embedded. The trust told us the clinical supervision policy and a project to embed the policy was presented to the nursing and midwifery strategy steering group in September 2017. Whilst most staff we spoke with reported they had received an appraisal, regular one-to-one meetings were not offered to staff. One-to-ones were available on request. Almost all staff reported effective informal or ‘ad hoc’ support from managers. Nursing staff on the wards told us they felt supported and their training needs were prioritised by their managers. Some nursing staff in theatres told us they were discouraged from attending training sessions due to high demand in theatres. Some staff in theatres felt unsupported in their roles by their managers. We raised this with senior leaders of the trust. Junior doctors were provided with a supervisory training list in theatres on a Friday afternoon whereby they would be supervised to learn new skills. Junior doctors attended scheduled training sessions and monthly audit days. We saw the presentation provided to junior doctors on the national hip fracture audit. All trainee doctors had an allocated educational and clinical supervisor
20180222 KGHNHSFT Evidence Appendix Page 96 who they met with periodically throughout their placement. Non-training grade doctors were also allocated a clinical supervisor for support. Trauma and orthopaedic doctors told us the data they inputted into the national joint register was reviewed and discussed at their annual appraisal. Between July 2016 and July 2017, 81% of staff within surgery at the trust had received an appraisal compared to a trust target of 85%. A split by staff group can be seen in the graph below:
(Source: Routine Provider Information Request (RPIR) P43 Appraisals) Appraisal rates had decreased since our last inspection in 2016. Appraisal rates for June 2016 showed 86% compared to data we saw during this inspection for July 2017 which showed appraisal rates were 81%. This was slightly lower than the trust target of 85%. Plans were in place to improve this.
Multidisciplinary working Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Effective multidisciplinary team (MDT) working practices were in place. All relevant staff, teams and services were involved in assessing, planning and delivering patient’s care and treatment and worked collaboratively to understand and meet the range and complexity of people’s needs. We observed patient care on surgical wards was supported by a variety of teams. This included pharmacists, physiotherapists and speech and language therapists. Most staff reported good working relationships between doctors and nurses. We observed effective working relationships between physiotherapists and nurses on Geddington ward. Patient records clearly showed there was regular input from allied health professionals. There was dedicated pharmacy support on surgical wards. A senior nurse on Deene B ward told us pharmacy technicians were an asset to their team and they helped to speed up discharges by preparing medications ‘to take out’. Staff were able to access practice development nurses, safeguarding teams and the critical care outreach team who were able to provide support and advice to the surgical team when required. Theatre and ward staff reported effective working processes were in place. We observed theatre staff informing nurses on the Deene Acute Surgical Unit (DASU) of any theatre delays. Wards were contacted when patients were ready to be taken back to the ward following surgery and if a porter wasn’t available, a nursing assistant with intermediate life support training was able to collect patients. 20180222 KGHNHSFT Evidence Appendix Page 97
Seven-day services The service was working towards seven days services. However, interventional radiology was only provided on weekdays, and only two days a week when sedation was needed. There was a consultant on-call 24 hours a day, seven days a week. However, we were not assured daily ward rounds were completed for all patients at weekends due to lack of medical staff and their capacity. There were different arrangements in place for different specialities at weekends. For example, general surgery patients were reviewed by a consultant or a registrar. Trauma and orthopaedic patients were generally reviewed by a consultant. Theatres, anaesthetics, and recovery had staff on duty out of hours and at weekends to cover emergencies. Pharmacy services were available on weekdays from 08:30 to 18:30 and Saturdays from 09:30 to 12:30. There was an on-call pharmacist available on Sundays and out of hours. Diagnostic services were available 24 hours a day, seven days a week. Staff we spoke to said they were easily accessible at any time. There was not 24 hour access to radiology intervention services within the hospital. However, there were arrangements in place for patients to go to a different hospital if they required radiological intervention out of hours. Speech and language and dietetics was available Monday to Friday and was not available out of hours or at weekends. These services were provided by a local trust. A member of the chaplaincy team was on-call 24 hours a day, seven days a week. The trust told us the on-call chaplaincy usually responded within 30 minutes. The interventional radiology service was only staffed from Monday to Friday, and sedation was only available on Mondays and Fridays.
Health promotion Staff supported patients to manage their own health, care and wellbeing and to maximise their independence following surgery and as appropriate for individuals. The enhanced recovery programme provided patients with information on how they could ensure they are as fit for their procedure as possible. It reminded patients of the importance of eating a balanced diet and quitting smoking. Staff identified patients and relatives who may need extra support. Patients were signposted to healthcare professionals if they required advice and support. Pre-operative assessment nurses had the ability to refer patients to smoking cessation clinics. Staff signposted patients to access services to give up smoking at their GP service.
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. The service reported that between July 2016 and July 2017, Mental Capacity Act (MCA) training has been completed by 83% of staff in within surgery, which was just below the trust target of 85%. Staff understood their responsibilities in relation to consent. The trust had a consent policy giving clear guidance for staff. The policy included competence assessment for relevant staff with authority to take informed consent.
20180222 KGHNHSFT Evidence Appendix Page 98
Consent to care and treatment was obtained in line with legislation and guidance, including the MCA 2005. The trust had a consent policy giving clear guidance for staff. The policy included competence assessment for relevant staff with authority to take informed consent. All consent forms we reviewed were for patients who were able to consent to their operation or procedure and they were completed in full. They contained details of the operation or procedure and any risks associated with this. Consent for surgery was generally obtained from patients in the outpatients department. The rights of people detained under the mental health act were acknowledged and protected by staff. We observed that staff were mindful of the code of practice and made timely referrals to the psychiatric liaison service for advice and specialist support for patients. Medical staff supported patients to make decisions in line with relevant legislation and guidance. Nursing staff were aware of processes of how to support medical staff to assess and record particular decisions about care and treatment if patients lacked mental capacity and how to make ‘best interest’ decisions. We spoke to staff on the wards who told us they knew the process for making an application for requesting a DoLS authorisation for patients and when these needed to be reviewed. We reviewed three DoLS authorisations that were in place for patients during our inspection. They were completed correctly and the patient’s family had been informed and were involved in the patient’s care. A joint best interests meeting was held for patients who had DoLs in place. The family of the patients had been involved and their wishes for the patients were documented. Staff had access to a link nurse for patients with learning disabilities who provided support with mental capacity assessment for patients with a learning disability. Is the service caring?
Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
We observed staff to be caring and compassionate with patients and their relatives without exception during the inspection, at all times. Staff promoted privacy, and patients were treated with dignity and respect. Staff members spent time with the patients, and interacted with them during any tasks or clinical interventions. We saw staff talking to 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. Nurses who cared for patients in the recovery area following surgical procedures were empathetic towards patients and did everything they could to ensure patients felt comfortable.
Feedback from patients confirmed that staff treated them well and with kindness. Staff respected patients’ privacy and dignity during personal care, for example, staff pulled curtains around the bed space. Nursing staff we spoke with on Deene B ward told us they did not do bedside handovers because there was a risk that they could be overheard by other patients. Instead, nursing and healthcare assistants conducted handovers outside of the bays, in the corridor.
Almost all patients we spoke with told us staff treated them well. However, one of the nine patients we spoke with raised concerns about the attitude of one temporary staff member during the night. We raised this with the senior nurse immediately who discussed this with the patient in more detail.
20180222 KGHNHSFT Evidence Appendix Page 99
The Friends and Family Test response rate for Surgery at Kettering General Hospital NHS Foundation Trust was 21% which was worse than the England average of 29% between September 2016 and August 2017. A breakdown of response rate by site can be viewed below.
A breakdown by surgery ward within Kettering General Hospital is below:
Avg. Total Ann. Ward name Resp. Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Resp Perf. Rate
Ashton 281 25% 97% 100% 100% 100% 100% 100% 98% 79% 88% 100% 94% 100% 95%
Barnwell B 282 63% 95% 100% 90% 100% 100% 100% 94% 95% 89% 100% 92% 100% 96% Barnwell C 352 69% 100% 100% 94% 96% 88% 91% 94% 100% 100% 95% 100% 96%
Deene Acute Surgical Unit 325 14% 83% 100% 85% 100% 93% 89% 93% 100% 95% 92% 100% 100% 94%
Deene Ward 258 34% 92% 88% 100% 93% 100% 100% 100% 92% 85% 91% 100% 95% 94% Geddington 1250 34% 96% 94% 100% 98% 99% 98% 99% 99% 97% 97% 97% 98% 98% Spencer 754 17% 100% 99% 97% 95% 98% 97% 100% 97% 100% 100% 98% Treatment Centre 762 11% 100% 100% 100% 96% 93% 97% 97% 98% 100% 94% 95% 97% Highest score to Lowest score Key 100% 50% 0%
Note - 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.
Note: sorted by total response (Source: NHS England Friends and Family Test) Friends and family test data showed that from September 2016 to August 2017, 96% of patients recommended the services they had used to their family and friends. Any poor response rates were being addressed by the trust. There were plans in place to implement an electronic feedback system which they hoped would increase response rates.
Emotional support Staff provided emotional support to patients to minimise their distress. Patients and those close to them were able to receive support to help them cope emotionally with their care and treatment. Staff provided emotional support to patients and staff directed patients to access the hospital multi-faith chaplaincy service and external support services, when required. Relatives we spoke with said they had felt very well supported, and that communication from both medical and nursing staff had been very open, with clear explanations about treatment. Staff showed an awareness of the emotional and mental health needs of patients and were able to refer patients for specialist support if required. Staff had access to an on-call chaplain and other spiritual advisors could be arranged to meet patients’ needs when requested.
Understanding and involvement of patients and those close to them
20180222 KGHNHSFT Evidence Appendix Page 100
Staff involved patients and those close to them in decisions about their care and treatment. Patients said they felt involved in their care. The views and preferences of patients were taken into account. Patients and relatives had been given the opportunity to speak with the consultant looking after them. Patients said the doctors had explained their diagnosis and that they were fully aware of what was happening. Most patients were very complimentary about the way they had been treated by staff. We observed most staff introduced themselves to patients at all times, and explaining to patients and their relatives about the care and treatment options.
Relatives told us they were involved in care planning and had regular contact with consultants caring for their relatives. We saw nursing staff encouraged those close to patients to be involved in their care. Patients and relatives knew which doctor was looking after them.
Staff sought accessible ways to communicate with people to meet their needs. Staff assessed patients’ communication needs to ensure effective communication. This meant the service was compliant with the Accessible Information Standards (2015). These standards direct and define a specific and consistent approach to identifying, recording, flagging, sharing and meeting information and communication needs of patients, where those are related to a disability, impairment or sensory loss. Is the service responsive?
Service delivery to meet the needs of local people The service generally planned and provided most services in a way that met the needs of local people. The interventional radiology (IR) service was not continuously available. There was no rota or fixed cover out of hours and therefore no IR service out of hours. The service understood the different needs of the local people it served. Staff generally acted on the needs of local people to plan, design and deliver services. The hospital had developed strong links with local independent and NHS hospitals to help meet the needs of local people. Services were planned in way, which ensured flexibility and choice. For example, pre-assessment clinics offered weekend appointments for patients who were unable to attend on a weekday. The hospital also had an agreement with an external provider, which allowed surgery to commence on weekends. This had an impact on reducing the time from referral to treatment and patients waiting over 52 weeks for a treatment. At the time of our inspection, the agreement was no longer in place. Discussions were being held internally with staff to look at the possibility of performing elective procedures on weekends. An enhanced recovery programme was in place to meet people’s needs. The aim of the programme was to: Ensure patients were as healthy as possible for their treatment. Ensure patients received the best care during their surgical procedure. Ensure patients received the best care whilst recovering post-operatively. Encourage early mobilisation to avoid complications such as venous thromboembolism (VTE), chest infections and pressure tissue damage.
We reviewed the colorectal surgery enhanced delivery programme information for patients. It was informative, relative and provided patients with contact details if they had questions pre and post- operatively. Length of stay - Elective patients
20180222 KGHNHSFT Evidence Appendix Page 101
The trust showed a mixed performance for elective patients across the July 2016 to July 2017 reporting period. Both ‘urology’ and ‘all’ electives outperformed the England average, with ‘All’ being almost a full day less than the England average. Despite this, trauma and orthopaedics and general surgery both underperformed, exceeding the England average. This follows the trend of non-electives in these disciplines, although the performance gap was not as severe as seen in non-elective. Between July 2016 and June 2017, the average length of stay: for all elective patients at the trust was 2.5 days, which was better compared to the England average of 3.3 days. for urology elective patients at the trust was 1.5 days, which was better compared to the England average of 2.0 days. for trauma and orthopaedics elective patients at the trust was 4.1 days, which was higher compared to the England average of 3.4 days. for general surgery elective patients at the trust was 3.7 days, which was about the same compared to the England average of 3.3 days.
(Source: Hospital Episode Statistics) Length of stay - Non elective patients The average length of stay for all non-elective patients at the trust was 5.8 days, which was slightly higher compared to the England average of 5.1 days. The average length of stay for general surgery non-elective patients at the trust was 3.7 days, which was slightly better compared to the England average of 4.0 days. The average length of stay for trauma and orthopaedics non-elective patients at the trust was 12.1 days, which was notably worse compared to the England average of 8.9 days. The average length of stay for urology non-elective patients at the trust was 4.1 days, which was higher compared to the England average of 3.0 days.
(Source: Hospital Episode Statistics)
The interventional radiology (IR) service was not continuously available. There was no rota or fixed cover out of hours and therefore no IR service out of hours. In order to obtain an out of hours interventional radiologist for a procedure, clinical teams had to call the IR consultants (who were not necessarily on call) to see if they would be happy to come in and do a case in their own time.
20180222 KGHNHSFT Evidence Appendix Page 102
When no one was available or agreeable patients had to be transferred to another trust. The IR service was available from Monday to Friday, but the IR capability was limited by the availability of nursing staff. Only Mondays and Fridays were possible for cases requiring sedation as there needed to be two nurses on shift.
Meeting people’s individual needs Services were planned to take into account the individual needs of patients. There were arrangements in place for patients with complex social health and social care needs. For example, patients were offered longer pre-operative assessments and could attend a consultant and anaesthetist-led pre-operative assessment clinic. Information from pre-operative assessments was clearly recorded, which included patients individual care needs and their medical conditions. There were specific admission checklists and discharge planning tools for patients living with a learning disability. Appropriate arrangements were put in place for older patients with complex needs. During our inspection, we observed nurses discussing discharge plans with patients. We reviewed four discharge plans and they each documented details of the patient’s needs, social and living circumstances and their ongoing care arrangements. Staff told us pharmacy technicians on the wards helped facilitate discharges at appropriate times. The ‘butterfly’ scheme was used to identify patients living with dementia. The symbol was recognised by all staff we spoke to on the wards and staff ensured additional care and support was available to patients living with dementia. For example, staff could access specialist dementia nurses who were able to give expert practical, clinical and emotional support to families of patients living with dementia. Patient passports and ‘This is me’ documents were used which enabled staff to provide individualised care to patients. Patients living with a learning disability or dementia were encouraged to discuss their personal preferences with staff. Patient passports included information about patients’ likes and dislikes, eating and drinking preferences, special requirements and personal information such as what patients enjoyed doing in their spare time and information about their family and pets. Communication requirements and preferences were also documented. The hospital complied with the accessible information standard. Patient passports and nursing records were used to identify, record, and flag communication requirements. Staff had access to translation services such as language and sign language interpreters. Staff we spoke with could explain how they would book an interpreter. Surgical information sheets were available in different languages. Information was also available in braille. The trust told us large print and audio information was provided on request. The learning disability lead nurse had developed picture based materials for surgical patients. The trust also had good links with a national language programme charity and had adopted some of their resources to aid communication with patients with complex needs. Adjustments were made for patients living with a physical disability. The treatment centre and the main hospital had disabled access in most areas. During our last inspection, we highlighted concerns with wheelchair access in the maxillofacial service. These concerns had been taken into consideration when planning for the relocation and refurbishment of the service. There were arrangements that supported the emotional and spiritual needs of patients. Patients and their relatives had access to the trust chaplaincy. There was an acute liaison mental health team based within the hospital that was able to provide psychiatric support to patients.
20180222 KGHNHSFT Evidence Appendix Page 103
We observed a breakfast time on Deene B ward and lunch time on Barnwell ward. There was good interaction between staff and patients. We observed a healthcare care assistant (HCA) encouraging a patient to eat their meal and ensuring meal trays were within good reach.
Access and flow Patients could not always access the service when they needed it but performance was improving. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were improving. Patients could be referred by their GP directly to the Deene Acute Surgical Unit (DASU). Patients would be assessed, treated and either admitted or discharged direct from DASU. If a patient was critically unstable or required immediate emergency management, they would be transferred to the emergency department. An on-call theatre team facilitated emergency surgery. Consultants in each speciality were on call at night and weekends and therefore could facilitate emergency procedures if necessary. The NHS Constitution sets out that patients wait no longer than 18 weeks from GP referral to treatment (RTT). Between September 2016 and August 2017, the trust’s RTT for admitted pathways for surgery was below the England average. Despite this, there was a marked improvement in performance in January 2017. This improvement brought the trust to within 15% of the England average. From April 2017 onwards, there was a trend of gentle decline.
(Source: NHS England) A breakdown of referral to treatment rates for surgery broken down by specialty is below. All five of these specialities fall below the England average. Specialty grouping Result England average General Surgery 29% 73% Neurosurgery 0% 70% Trauma & Orthopaedics 46% 62% Urology 40% 77% Plastic Surgery 78% 83%
Patients did not always have timely access to treatment. The trust had an RTT recovery programme in place. Elective waiting times were being monitored closely by the trust and was on the risk register. Weekly meetings were held to review patient tracking lists and supported the tracking of pathways. The trust had a contract in place with a private provider which had assisted with some cases. Additional support was also insourced for six months from May 2017 to October 2017. RTT performance was discussed at monthly governance meetings.
20180222 KGHNHSFT Evidence Appendix Page 104
At the time of our inspection, RTT performance had improved across all surgical specialities. Current RTT waiting lists showed: 72% of general surgery patients had been waiting 18 weeks or less. 78% of trauma and orthopaedic patients had been waiting 18 weeks or less. 70% of urology patients had been waiting 18 weeks or less. 88% of plastic surgery patient has been waiting 18 weeks or less.
The number of patients who were waiting over 52 weeks for surgery had decreased to a total of 37 patients across all surgical specialities at the time of our inspection. We reviewed up to date waiting times and the data showed: 339 patients were waiting over 40 weeks. 869 patients were waiting between 30 and 39 weeks. 2,972 patients were waiting between 18 and 29 weeks. A total of 4,180 patients were waiting over 18 weeks.
Harm reviews had been completed for 79% of patients who were waiting over 18 weeks. There were 451 harm reviews outstanding at the time of our inspection. Consultants and the general manager were fully sighted on each speciality’s elective waiting lists. They reviewed the number of patients waiting, and the minimum and maximum waiting times fortnightly. Consultants told us they could be released from outpatient clinics to work in theatres when necessary. The theatre refurbishment had also impacted on RTT performance. For example, the hospital had planned to refurbish one theatre at a time, which allowed maximum utilisation of all other theatres. However, this was not possible due to the building work therefore theatres with lamina flow had to be refurbished at the same time. This meant there were only two lamina flow theatres in use across the trust instead of four which had further impacted on trauma and orthopaedic elective waiting times. The theatre refurbishment plan was carried out in four phases. Phases one to three had been completed. Phase four was due to commence in January 2018 and the completion date for the theatre refurbishment was March 2018. The cancer 62 day standard was being met. The Department of Health (DoH) has set a standard whereby 85% of patients should start their first definitive treatment for cancer within 62 days. From July 2017 to September 2017, 90% of patients (134 patients out of a total of 149) with suspected cancer were seen and treated at the hospital within 62 days. This was better than the national cancer target of 85%. The service had achieved this by ensuring pathways were kept to a minimum by booking activity directly after multidisciplinary team meetings. This meant the capacity of doctors was placed on hold prior to breach dates. Surgical pathways were regularly reviewed and monitored. The number of ‘one stop’ clinics had also been increased which had further improved delays. A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital, or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice. The trust outperformed the England average across the entire reporting period. There was a notable decline in quarter three 2015/16, with a sharp return to previous standards by quarter four 2015/16. A further, less severe decline occurred in quarter four 2016/17, again returning to form by the following quarter. 20180222 KGHNHSFT Evidence Appendix Page 105
Percentage of patients whose operation was cancelled and were not treated within 28 days
Cancelled Operations as a percentage of elective admissions
Over the two years, the percentage of cancelled operations at the trust showed a trend of decline, but was generally lower than the England average. There is a sharp improvement at the end of the reporting period, indicating a significant change in quarter four 2016/17. Cancelled operations as a percentage of elective admissions only includes short notice cancellations. (Source: NHS England) Staff in theatres told us they were under clear instructions from managers not to cancel any surgical procedures at short notice unless it posed a safety risk. This was to help reduce waiting times and the number of cancelled operations. All cancellations were escalated to the divisional manager and a rationale review was completed. Staff told us that on rare occasions patients were cared for in the recovery area in main theatres. These patients were prioritised to be moved on to a ward. During our inspection, we did not observe patients being cared for, for longer than clinically required in recovery. Surgical outliers on medical wards were identified by bed pathway managers and escalated at daily site meetings. However, we were told by three members of staff that surgical patients were rarely placed on medical wards. During our inspection, there were some medical outliers on
20180222 KGHNHSFT Evidence Appendix Page 106
surgical wards due to capacity issues within the trust and the temporary closure of wards due to norovirus. We saw no evidence that medical outliers in surgical beds impacted on elective work. Bed pathway managers were visible on the surgical wards throughout our inspection and they told us outliers were assessed by a doctor of the appropriate speciality to ensure they were suitable to be moved. Discharge planning arrangements commenced during pre-assessment. This included discussions around the estimated length of stay and staff assessed if patients required additional support at home following their procedure. Whiteboards on wards had columns which displayed the estimated discharge date (EDD) for each patient. However, these were not always completed despite the EDD being documented in the patient’s notes. For example, the EDD was not completed on the whiteboard for any patient on Deene B ward. We discussed this with nursing staff who were unsure as to why the dates had not been recorded on the whiteboards. We saw the EDD column on the whiteboard was completed for patients on Ashton ward. We reviewed records of patients with mental health needs and saw that patients were seen by a mental health clinician in a timely manner. During our last inspection, the hospital did not record their theatre utilisation rates. Theatre utilisation rates were now being recorded. From November 2016 to October 2017, the average theatre utilisation rate for elective procedures was 86%. This was slightly better than the trust target of 85%.
Learning from complaints and concerns The service generally treated concerns and complaints seriously and investigated them. However, lessons learned were not always shared with all staff members effectively. Between August 2016 and July 2017, there were 63 complaints about surgical care. The trust took an average of 40.6 days to investigate and close complaints; this is not in line with their complaints policy, which states complaints should be resolved within 25 days and more complex complaints should be resolved within 35 days.
The number of complaints had reduced from 125 to 63 since our last inspection. We reviewed the 63 complaints related to surgery which showed: 20 complaints related to delays in receiving treatment/diagnosis/results. 12 complaints related to the attitude of medical and nursing staff. Ten complaints related to poor/lack of communication. Eight complaints related to treatment. Six complaints related to cancelled operations or procedures Four complaints related to discharge planning and inappropriate discharges. Three complaints related to care.
We discussed complaints with the surgical management team. Whilst the management team were familiar with the trust complaints policy, they were unable to provide us with a rationale for the length of time it took the team to respond to surgical complaints. A complaints report and the timeliness of investigating and responding to complaints was discussed amongst senior staff at the clinical business unit meetings. However, there were no plans in place to address this. Whilst the length of time to respond to complaints had decreased from 69 days to 41 days since our last inspection, this still did not meet the trust target of 25 days.
20180222 KGHNHSFT Evidence Appendix Page 107
We reviewed two complaints and all the necessary people involved had been asked to provide an account. The complaint responses we saw were detailed and investigations included appropriate actions to prevent the same issue arising. Patients knew how to raise concerns and make formal complaints. Posters detailing how to make a complaint were displayed on the wards and information was provided in leaflets for inpatients. Patients told us the nursing staff were approachable and if they wished to raise a concern they would do this by speaking with the nurses who were caring for them at that time. Medical, nursing and healthcare support staff understood the process for receiving, handling and responding to concerns and complaints. There was a form to document verbal complaints; however, this was inconsistently used across wards. Staff who were not aware of the form told us they reported all verbal complaints as an incident on the electronic incident reporting system. Not all charge nurses were aware of the verbal complaint form. Staff directed patients to the patient advice and liaison service if they were unable to directly address and resolve concerns. We could not be assured that the trust had an oversight of all verbal complaints due to the inconsistencies in reporting. Staff told us complaints and learning from complaints was shared and discussed at handovers and staff meetings. We requested to see evidence of this in staff meeting minutes for Deene B, Barnwell and the day case unit but they were not provided. We saw no evidence of complaints in staff communications on the wards or on private social media forums. We reviewed meeting minutes for the treatment centre theatres and saw no evidence of learning from complaints being shared. The number of complaints for each surgical ward was displayed on the ward notice board. Senior nurses told us improvements following complaints included recruiting ward coordinators on Deene B to improve the discharge process and plans were in place for all clinical staff to attend a mandatory medicines management refresher training session. Is the service well-led?
Leadership The service had managers at most levels with the right skills and abilities to run a service providing high-quality sustainable care. The surgery and anaesthesia service was led by a general manager, clinical business unit (CBU) director for anaesthesia and head of nursing for surgery. The CBU director for surgery post had been vacant for 18 months and the clinical leads for each surgical speciality temporarily filled this post to support the general manager. Senior medical staff spoke highly of the general manager and told us they were dedicated to making service improvements.
Service leaders had the skills and knowledge required to lead the service effectively. They understood the challenges to quality and sustainability and were able to explain actions taken to address them. However, we were not assured that operational managers had the skills and experience to lead their individual areas and manage staff efficiently. We requested performance, operational and training data on inspection from operational and departmental managers however they were unable to locate the information. The task was passed to a different manager who was also unable to locate the information relative to their department.
Staff told us leaders were generally visible and approachable. Ward staff spoke highly of lead nurses and matrons in their individual areas and described them as knowledgeable and supportive. We saw strong nursing leadership and commitment across the wards. Junior surgical doctors we spoke with said the clinical leads were supportive and reported feeling well supervised. Not all theatre staff felt they could approach their management team.
20180222 KGHNHSFT Evidence Appendix Page 108
Most staff were aware of the trust’s senior leadership team. For example, the chief executive officer (CEO) and the director of nursing (DoN); however most junior staff said they had not seen them visit their ward or department.
Each ward had a matron who provided day to day leadership to staff. The matrons reported directly to the lead nurses. There was a theatre manager who was primarily based in main theatres.
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 trust values were compassion, accountable, respectful, and engaging (CARE); all staff we spoke with were familiar with the trust values. At our last inspection, not all staff were not aware of the values as they had only just been introduced. During this inspection we found staff understood the values and were able to explain what they meant for patients in their individual roles. Plans were in place to purchase new patient notice boards which outlined each of the values and the relevant information for individual wards. For example, Friends and Family Test performance and the number of days since the last complaint would be displayed under the ‘engaging’ section of the new notice board.
There was a strategy for surgery and anaesthesia services. Service leaders understood their role in achieving the aims of the strategy. The strategy was reviewed and updated annually and it was clearly aligned with the trust’s five year strategy. Service leaders were able to explain the main priorities for the service which were also included within the strategy. Service leaders also felt the strategy was achievable despite the need for increased staffing. The strategy was aligned to local plans in the wider health and social care economy, for example, partnership working with stakeholders and integrated care pathways across the county.
Strategic and business plans were discussed with senior nurses and medical staff at their annual appraisal.
Culture Most managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Despite the cultural issues identified within theatres, we found staff were dedicated to their roles. Service leaders spoke highly of staff in theatres and how hard they had worked throughout a surge in the number of patients as well as the theatre refurbishment programme. Staff had adapted well to the continuous changes throughout a period of transition.
Not all staff we spoke with felt supported, respected and valued. Four members of staff within theatres reported a culture of bullying and harassment and told us they were unhappy in their roles. We were not assured that leaders and staff in theatres understood the importance of being able to raise concerns without fear of retribution. Staff told us they did not raise such issues with their managers out of fear it would make matters worse. We raised this with the trust immediately who were aware of some but not all of the cultural issues in theatres. During our second visit, we saw actions the trust had taken to improve cultural issues in theatres. For example, the general manager for surgery and anaesthesia and the chief operating officer had attended a monthly meeting and there were plans for this to continue to ensure they were aware of any issues amongst staff. Staff had been encouraged to raise issues as they arose and were provided with employee support contact details. Staff were also reminded about the purpose of the trust’s
20180222 KGHNHSFT Evidence Appendix Page 109 freedom to speak up guardian. This had a positive impact and staff we spoke with said they had approached senior leaders following their attendance at the meeting. Staff also reported they were more confident that action would be taken if they raised concerns.
Not all staff in theatres felt supported in their roles. Some managers reported they were unclear of their roles and responsibilities. We saw evidence of nursing staff requesting support and asking for clear instructions to carry out tasks but support had not been provided. During our inspection, we observed a manager communicating with nursing staff in theatres in an unconstructive and poor manner. We were assured that action had been taken to address issues with individual staff members. The majority of medical and nursing staff we spoke with in the main theatres told us they were unhappy with staff facilities. For example, staff complained about the changing facilities and arrangements for refreshments within theatres. Staff did not escalate issues because they felt their concerns would not be listened to.
Nursing staff on surgical wards reported a good culture amongst all staff. Staff felt supported by their colleagues and matrons. They told us they were proud to work within the organisation. Most staff we spoke with said their line managers looked after their welfare. We also observed positive and supportive interactions between matrons and lead nurses. Staff teams worked collaboratively with each other and staff were able to provide examples of when they have supported a different team.
All medical staff we spoke with told us relationships were cooperative and appreciative. Staff within the trauma and orthopaedic teams told us that rare cases of conflict were resolved quickly and constructively.
Staff understood their responsibilities with regard to the duty of candour legislation. Nursing and medical staff were fully aware of the duty of candour and described a working environment in which any mistakes in patient’s care or treatment would be investigated and discussed with the patient and their representatives and an apology given whether there was any harm or not. Governance The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. The surgical service was made up of two CBUs; surgery and anaesthesia services. The surgery and anaesthesia governance meeting was held monthly and discussions were held around performance, patient safety and any issues. This included incidents, risks, complaints, finance and activity. Meetings were well attended by a range of senior medical and nursing staff as well as service leaders, human resources advisors and finance service leads. Governance and managerial staff interacted often and functioned effectively. The governance meeting discussions supported the strategy.
There was a clinical governance group who were responsible for reviewing surgical procedures. There was a clear governance structure in place for reviewing sepsis associated deaths. The management and reporting of sepsis was the responsibility of the clinical business unit director for anaesthesia.
The monitoring of service level agreements with third parties was managed by the general manager for surgery and anaesthesia and the governance lead. There were arrangements in place with partners and third parties. We found these arrangements were governed effectively and discussions were recorded.
20180222 KGHNHSFT Evidence Appendix Page 110
Leaders of the service were able to describe the systems and processes of accountability within surgery. Most staff of all levels understood their roles and what they were accountable for. However, not all staff in main theatres felt their responsibilities were clear.
There were lead nurses in post across the surgical division. They each had clearly outlined remits such as elective, non-elective, surgical services, and anaesthesia. All staff we spoke with knew who their manager was.
Nursing staff told us they attended ward meetings but they were irregular. Meeting minutes were not always available. Staff used private social media forums to share information with their colleagues but we saw no evidence of complaints being shared when we reviewed the forums. Staff confirmed learning from incidents was communicated during handover meetings. However, all junior staff we spoke with were unable to tell us about incidents or complaints that had occurred on wards they did not work on therefore we could not be assured learning was shared between wards.
Staff meetings for theatre staff were held monthly. Learning from incidents was shared at these meetings. Staff in theatres also used a communication book daily to share information about staffing shortages and equipment. However, the content of the book was inappropriate. It held detailed personal information about staff. For example, detailed explanations for staff absence. We raised this with senior managers on inspection who took action and removed the communications book. A documented detailed handover sheet was in development to ensure the relative information was not lost in the absence of a communications book. The trust’s governance structure was being reviewed and consulted on at the time of our inspection.
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. The trust did not have effective systems for monitoring life support training. Intermediate life support (ILS) and advanced life support (ALS) compliance was not monitored. The trust was unable to provide compliance levels for nursing and medical staff. They told us this was because the system used did not match life support training to job roles therefore there were no systems in place to assure the trust that staff had the required life support training for their role. There was no clear process to capture life support training data that staff had completed outside of the trust. The trust did not have effective systems in place to monitor the safety of theatre equipment. The service report for theatres was incomplete. Not all equipment had service due dates recorded and other did not have the month recorded of when the service was due for each piece of equipment. A senior member of staff told us the medical devices audit was an inaccurate reflection of the equipment in main theatres and was not confident that all devices were itemised.
Assurance systems were in place and performance issues were generally escalated appropriately. Structures and processes were being reviewed at the time of our inspection. There were clear processes to monitor current performance and ideas to monitor future performance were evident in governance meeting minutes.
There was a systematic programme of clinical and internal audit to monitor. At the time of our inspection, the audit plan showed 64 surgical audits. We reviewed the audit plan and saw that 11 audits were overdue and ten of those did not have overdue audit actions recorded. Five audits had been abandoned with a recorded rationale as to why they were no longer being completed. There were 23 completed audits and 25 that were in progress at the time of our inspection. Progress with audits was discussed at CBU governance meetings and actions to progress overdue audits were formally documented.
20180222 KGHNHSFT Evidence Appendix Page 111
There were arrangements for identifying, managing and recording risks. There were two risks registers; one for each CBU within the surgical service. All risks were clearly dated, summarised, and a named responsible person. Mitigating actions were documented and were reviewed and updated monthly. Risks recorded were clearly aligned with the risks that staff and service leaders believed to be the biggest risks to the service. The biggest risk to the service was the safety of patients waiting over 18 weeks from referral to treatment. Mitigating actions had been prioritised and actions taken. Staff we spoke with knew what the main risks were in their individual areas. Potential risks were taken into account when planning services. For example, the theatre refurbishment programme had been put on hold over the busiest period of the winter season. This was to ensure all theatres were open and could be used so that the trust could meet expected fluctuations of winter pressures.
Information management The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Leaders had a holistic understanding of performance. Information was used to measure improvements. There were clear and robust service performance measures in place, which were monitored at monthly governance meetings.
We were told by senior nurses that performance and quality was discussed at ward meetings however we did not see any evidence of this. We observed staff being informed of ward performance at nursing handovers. Quality dashboards were displayed in an easy to read format on surgical wards.
Information technology systems were used effectively to monitor and improve patient care. There were effective arrangements in place, which ensured data was submitted to external providers as required. For example, serious incidents and RTT performance.
All staff of all levels played a role in reporting changes in patients’ mental health and emotional wellbeing.
Engagement The service engaged well with patients, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Patient’s views were gathered and acted on. The patient experience and involvement steering group was attended by patient representatives. There was a standing agenda to obtain patient representatives feedback about services. The general manager was informed of surgery related feedback. The matrons and lead nurses received feedback by email if the information was ward specific.
There was a quarterly learning disability forum, which was chaired by the deputy director of nursing and the learning disability lead. Membership included people living with a learning disability and representatives from the community learning disability team. There was also a disability and sensory impairment working group which was chaired by the diversity and inclusion manager and held quarterly. The group was made up of community and voluntary sector organisations who represented patients, carers and families of patients living with a disability. Patient service managers gave presentations about different services provided by the trust. The group there are presentations by different patient service managers and these are scrutinised by the group members as to the extent to which the services meet the needs of patients, carers and family with disabilities / complex needs.
20180222 KGHNHSFT Evidence Appendix Page 112
The trust held a multi-faith group meeting twice a year. There were representatives from many faiths in attendance. Members of the group made themselves available to visit patients in hospital when requested.
Some staff felt they were engaged so that their views were reflected in the planning and delivery of services. The trust had developed a social media forum titled “What have you done for me lately” where staff suggestions and ideas could be shared. However, some staff who did not use social media felt their views were not captured in an alternative way. Staff we spoke with said they contributed to the annual staff survey. Staff were able to give examples of improvements made following the staff survey such as the development of a shared staff area and improved access to leadership training.
Learning, continuous improvement and innovation The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The “joint school” had continued to support patients who were undergoing hip and knee replacements. The service had been expanded since our last inspection so that more patients could take advantage of the programme which provided patients with educational and informative information.
The RTT recovery scheme was well embedded and progress had been made. It was recognised that the number of patients waiting over 52 weeks for a procedure had continuously decreased since our last inspection. Staff within specialities understood the importance of ensuring all patients waiting had their risk of harm reviewed. The clinical harm review process had been positively recognised and was presented to the national elective care conference in 2017. Staff had worked well throughout the theatre refurbishment programme. Lessons learnt from the programme had been recorded and staff told us the lessons learnt would be shared with teams who planned to relocate, for example, the maxillofacial service. There were also plans to make better use of space within the day case unit. A business case had been approved to convert a room into a bay of four chaired cubicles for pre-operative minor procedure admissions.
The lead nurses within surgery presented ideas for service improvements to the head of nursing. For example, the lead nurse for the pre-operative assessment service had suggested ways to improve patient flow through the clinic with the aim of being able to see a higher number of patients. Suggestions were supported by the head of nursing for surgery and plans were in place to recruit health care assistants (HCAs). Plans were in place for HCAs to complete investigations such as chest scans which were carried out by nurses at the time of our inspection.
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 across hospital and community settings. The maternity service is in the women’s and children services’ clinical business unit (CBU) and contains 52 inpatient beds. The service provides consultant-led and midwife-led care for high and low risk women. The delivery suite has eight delivery rooms, including two with birthing pools, one bereavement suite, two theatres and a recovery area shared with the gynaecology service, a four-bedded midwifery triage bay and a two bedded high-risk induction bay. The delivery suite also has a two-bedded
20180222 KGHNHSFT Evidence Appendix Page 113 high dependency observation bay for women who need higher levels of care and observation than those provided on the general maternity ward. Women who have a straightforward pregnancy can choose to have their baby at home or in the delivery suite using the low-risk birthing poolrooms. Kettering General Hospital has a 33-bedded joint antenatal and postnatal ward (Rowan ward), a two bedded early pregnancy assessment unit and a fetal health unit comprising of a fetal medicine and screening unit, and a three-bedded antenatal assessment area for women to be assessed after 20 weeks gestation without having to be admitted to hospital. Outpatient maternity services, including sonography and specialist antenatal clinics, are provided at the hospital site Monday to Friday. 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 birth service. From November 2016 to October 2017, the service reported 103 (2.9%) babies were born at home. This was above the national average of 2.3%. The community midwives are aligned to the local GP practices and children’s centres. The trust reported 3,548 births from November 2016 to October 2017. Of these, 58% were normal (non-assisted deliveries), which is lower than the England average (60%) and 8% were instrumental deliveries (ventouse or forceps). Additionally, 16% were elective caesarean section deliveries, which was higher than the England average of 12%, and 16.5% were emergency caesarean deliveries, which is higher than the England average of 15%. In the most recent four quarters, from 01/04/2016 to 31/03/2017 3,409 women delivered their babies at the trust. Trends by quarter for the last two years can be seen in the graph below. Number of babies delivered at Kettering General Hospital NHS Foundation Trust by quarter.
A comparison between the number of births at the trust and the national totals over the most recent 12 months is shown below. Number of babies delivered at Kettering General Hospital NHS Foundation Trust – Comparison with other trusts in England
20180222 KGHNHSFT Evidence Appendix Page 114
(SOURCE: HES - Deliveries (01/04/2016 - 31/03/2017))
Is the service safe? Mandatory Training
Not all staff completed their mandatory training. The mandatory training topics covered keys areas, such as basic life support, newborn basic life support, fire safety and infection control. Staff received their mandatory training through face-to- face sessions and online courses. Staff completed their mandatory training during quiet periods in their clinical area. Training was on a rolling programme so they were automatically enrolled on the training for the following year. The trust set a target of 85% for completion of mandatory training. The majority of mandatory training modules were below the trust target of 85% for medical and dental staff. Basic life support modules for adult, newborn and paediatric all had the lowest completion rates. Medical staff’s poor compliance rates with statutory and mandatory training was documented on the service’s risk register and escalated to the clinical director to address and allocate training. Staff said that the low training compliance rate for medical staff was due to a records issue with some doctors retiring and still being registered for the training. A dedicated practice development team had full oversight of the training compliance rates 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. A breakdown of compliance for mandatory courses as of July 2017 for medical/dental and nursing/midwifery staff in the maternity service is shown below:
20180222 KGHNHSFT Evidence Appendix Page 115
(Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training)
We requested the updated training compliance figures as of the end of November 2017 for basic life support for adults (BLS), which showed that:
12 out of 48 medical staff had completed this (43%).
We requested the updated training compliance figures as of the end of November 2017 for paediatric basic life support (BLS), which showed that:
2 out of 27 medical staff had completed Newborn Basic Life Support (7%). 1 out of 3 medical staff had completed Paediatric Basic Life Support (33%).
20180222 KGHNHSFT Evidence Appendix Page 116
The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register. The timescale to achieve compliance was March 2018. Nursing and midwifery staff in the maternity service met the 85% trust target for mandatory training compliance in all ten modules. On the day of our inspection, we saw evidence that all training modules still met the 85% compliance rate. The service held maternity specific education days each year, in addition to the trust’s mandatory study days. This included a maternity mandatory day specifically for midwives and a multidisciplinary ‘skills and drills’ training day. The maternity mandatory study day included training and information on antenatal screening, smoking cessation, customised growth charts (GROW), carbon monoxide testing, bereavement and mental health in midwifery. As of October 2017, 96% of midwives had attended this training. The multidisciplinary ‘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 and maternal and neonatal resuscitation. Following our previous inspection in October 2016, we reported that (as of September 2016) only 54% of midwifery staff had completed the skills and drills training. On this inspection, we saw that actions had been taken to address this, and as of October 2017, 100% of midwifery staff were compliant. The maternity service required medical staff and midwives to complete mandatory annual cardiotocography (CTG) training. Staff were also required to attend a minimum of one CTG meeting per year, which were held once a week and included individual case reviews. As of July 2017, 27% of medical staff and 89% of midwives were compliant with CTG training. The service was unable to provide us with more up to date compliance rates for this training because they produce the training figures twice a year. Senior managers encouraged and funded staff to attend a ‘CTG masterclass’ study day, delivered by a leading expert in CTG interpretation. The study day was offered to all midwives, student midwives and obstetricians. Training in the recognition, assessment and management of sepsis was included in the trust’s statutory training day. The maternity service used the adult sepsis trust policy to support them to manage and recognise sepsis in pregnant women. Staff we spoke to confirmed they were aware of this policy. The practice development team informed us that they had used a sepsis scenario in a ‘skills and drills’ training day, which required the multidisciplinary team (MDT) to recognise, assess and manage a pregnant woman with sepsis.
Safeguarding
There were clear systems, processes and practices in place to ensure that women and babies were kept safe from avoidable abuse. The staff we spoke with demonstrated a good understanding of their responsibilities in relation to safeguarding adults and children in vulnerable circumstances, and could describe the correct processes for reporting safeguarding concerns. If staff raised a safeguarding referral, the safeguarding midwife informed them of the outcome. On the trust’s electronic record system, there was a safeguarding workflow that contained prompt questions for the midwives to ask the women about mental health, domestic abuse and 20180222 KGHNHSFT Evidence Appendix Page 117
substance and alcohol abuse during their pregnancy. Staff also uploaded any safeguarding plans to the system. There was a named safeguarding midwife who provided support and supervision. The service also had a designated team of midwives who provided care, support, and treatment for women in vulnerable circumstances, such as those who had a history of substance misuse, those with perinatal mental health concerns, teenagers and women living with a learning disability. The team liaised with other professionals and agencies, such as social workers, the police and independent domestic violence advisors. All midwives, medical staff, assistant practitioners and maternity support workers had access to level three safeguarding children training. This was in line with the national recommendation (‘Working together to safeguard children’ (2015); ‘Safeguarding children and young people: roles and competences for health care staff’, Intercollegiate Document, (March 2014)). Updates were provided annually on the mandatory skills and drills training day. The trust set a target of 85% for completion of safeguarding training. Whilst medical staff met or were close to meeting the trust target of 85% across all required safeguarding training modules, safeguarding children level three training rates were lower than expected for a maternity service. Midwifery staff met the trust target of 85% across all required safeguarding training modules. On the inspection, the named safeguarding midwife told us that she recently facilitated additional safeguarding level three sessions for medical staff to improve their compliance rate. A breakdown of compliance for safeguarding courses as of July 2017 for medical/dental and nursing/midwifery staff in the maternity service is shown below:
20180222 KGHNHSFT Evidence Appendix Page 118
(Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training)
We requested the updated training compliance figures as of the end of November 2017 for safeguarding children level 3 training, which showed that:
16 out of 20 medical staff had completed this (80%). The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register. The timescale for compliance was January 2018. 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 midwife 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, and shared any learning from serious case reviews within the maternity service. We observed that FGM and CSE posters, containing relevant support contact details, were displayed in all outpatient areas within the maternity service. Although babies were not provided with electronic safety tags, the service used a baby identity tagging system to ensure the safety of babies in the maternity unit. Staff applied an identify tag to both of the baby’s ankle shortly after birth which included the baby’s name, date of birth and mother’s name. The identity tags were checked on admission to the postnatal ward and on a daily basis as part of the routine postnatal check. The trust had updated policies to include a comprehensive section on baby abduction. This included the measures that should be taken to ensure security and to prevent a baby’s abduction whilst on hospital premises. The trust had revised all ‘lockdown’ procedures following our last
20180222 KGHNHSFT Evidence Appendix Page 119 inspection. The maternity service also carried out two baby abduction simulations on Rowan ward since our last inspection. Rowan ward won the team of the year award in October 2017. This was presented to them following their excellent management of a safeguarding incident, which required involvement from the police. All staff were required to completed an online ‘Prevent strategy’ training course. The practice development midwife also attended a national Prevent training day in November and planned to cascade learning into the service’s mandatory training days. The prevent strategy is the duty on specified authorities to help prevent people from being drawn into terrorism.
Cleanliness, infection control and hygiene
The service controlled infection risk well. All areas of the maternity unit we visited were visibly clean and tidy, and women we spoke with said they found the patient areas were clean. We saw cleaning checklists in all areas we visited, which provided evidence of daily cleaning. The appropriate ‘I am clean’ stickers were on equipment to demonstrate it was clean and ready for use. Staff received training about infection prevention and control (IPC) during their initial induction and annual mandatory training. We saw that 97% of nurse and midwifery staff had completed their IPC training, which was in line with the trust target of 85%. However, only 78% of medical staff in the maternity service received this training. We requested the updated training compliance figures as of the end of November 2017 for IPC training, which showed that:
21 out of 29 medical staff had completed this (72%). The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register. Timescale for compliance was March 2018. Senior staff conducted monthly hand hygiene audits for each clinical area. From September to October 2017, the delivery suite, fetal health unit, and Rowan ward achieved a 100% compliance rate. In all areas we visited, including in community, we observed a high level of staff compliance with IPC practices such as hand washing, use of alcohol hand gel, use of personal protective equipment and ‘arms bare below the elbow’ in clinical areas. We observed staff washing their hands appropriately before and after patient contact. This was in line with the National Institute for Health and Care Excellence (NICE) ‘Infection and Prevention Control: Quality Standard 61’, (April 2014). Hand hygiene gels were available for use at the entrance and exit of all clinical areas, bays and within the community. 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 all staff using alcohol hand gel when entering and exiting the clinical areas. Side rooms were available on delivery suite and Rowan ward, which could be used to admit women with a known or suspected infection. Staff we spoke with could describe what they would do if a patient required isolation due to infection.
20180222 KGHNHSFT Evidence Appendix Page 120
In all clinical areas we visited, we saw the correct segregation of laundry, clinical and non-clinical waste into different coloured bags. We saw that staff had labelled sharp bins and the bins were not overfilled. There was a flushing schedule for taps that were not in constant use to prevent infection thriving, for example, legionella. A system was in place to ensure this was completed. From November 2016 to October 2017, one case of hospital acquired methicillin-resistant staphylococcus aureus (MRSA) was reported in November 2016 for the maternity service. For the same period, no cases of methicillin-susceptible staphylococcus aureus (MSSA) infection were reported and there was one reported case of clostridium difficile infection in April 2017. Women who were booked for elective caesarean section were not routinely screened for MRSA during their pre-operative assessment appointment. Only women who previously tested positive for MRSA were screened at this appointment. Staff told us this was a recommendation made by the IPC lead for the trust. However, women were given a hospital-strength antimicrobial skin cleanser at this appointment to wash with prior to surgery. The maternity service monitored postnatal maternal readmission rates for infections. Dashboard data showed that from November 2016 to October 2017 the service reported 20 maternal readmissions with infection as a primary or secondary diagnosis. This equated to a 0.5% readmission rate for maternal infection. Of these 20 readmissions, 11 were due to an infection of the woman’s caesarean section wound. This was significantly below the national average of 13.8% readmission rate for maternal infection (National Audit Office ‘Maternity services in England’ (2013)). Women were offered screening for infectious diseases, such as rubella and hepatitis B. Women were also offered the influenza (flu) and pertussis (whooping cough) vaccinations after 20 weeks gestation, in line with best practice recommendations. We witnessed midwives explaining the importance of these vaccinations to women during their antenatal appointments. At the time of our inspection, midwives did not administer the influenza or pertussis vaccination. However, senior managers told us the screening department recently approved funding for the maternity service to have a vaccination clinic run alongside anomaly scan appointments.
Environment and equipment
The service had suitable premises and equipment. Staff also confirmed they had sufficient equipment to meet the needs of women and babies. There was no designated low-risk birthing unit in the maternity service. 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 spoke with knew the birthing pool cleaning and evacuation procedures. The trust completed a £5 million of improvement, refurbishment work and this included an upgrade of the bathrooms and showers on the delivery suite, and Rowan ward to ensure all women had ensuite facilities. This was in line with national recommendations. The maternity service had access to one obstetric theatre, which was predominately used for elective caesarean section lists. In the event of an emergency, obstetric staff were able to use the
20180222 KGHNHSFT Evidence Appendix Page 121 gynaecology theatre. When both of these theatres were in use, the staff used a back-up theatre, which was located next to the induction bay on delivery suite. This theatre was previously the main obstetric theatre prior to the refurbishment work completed in February 2016. Staff informed us that this theatre was only used in very rare circumstances. 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 delivery suite. The CTG machines were checked daily. A fetal blood gas analyser was also available on delivery suite, in line with national recommendations. The obstetric theatres, delivery suite and neonatal intensive care unit (NICU) were all situated on the ground floor, which enabled timely transfer when required. A laboratory facility for blood and blood products was available at the hospital. A dedicated secure fridge for blood and blood products was situated on the delivery suite. All electrical equipment we checked during our inspection, apart from one, were electrical safety tested to ensure they were safe to use. We found a handheld fetal monitor device on Rowan ward where the electrical safety test was overdue (due June 2017). A fetal monitor is a hand-held ultrasound transducer used to detect the fetal heartbeat for prenatal care. We raised this with a member of staff who immediately removed the device from use. We saw checklists in theatre, which confirmed staff checked the equipment frequently. This included the difficult airway trolley. Adult resuscitation equipment was easily located on the delivery suite, the ward, theatres and the outpatient areas. We saw from checklists that registered healthcare professionals checked the resuscitation equipment daily and documented that the equipment was ready for use. From 1 August 2017 to 10 November 2017, we found eight occasions when staff on Rowan ward had not checked the resuscitation trolley. We brought this to the attention of a senior midwife who informed us she would reiterate the importance of daily resuscitation equipment checking. With staff present, we opened the resuscitation equipment and saw it was all in date and safe to use. Neonatal resuscitares were available on the ward, obstetric theatres and delivery suite, which staff checked regularly. Staff could access bariatric equipment when requested, for example bariatric beds and wheelchairs. Since our last inspection in October 2016, the maternity service introduced stricter security controls within the unit. Access to the delivery suite, the ward and the fetal health unit was by means of a hospital swipe card or an intercom buzzer system to gain both entry and exit from the wards. There were also security cameras at the entrances to these clinical areas with the footage from these cameras displayed at the midwives’ workstations. This meant staff could identify visitors and ensure women and their babies were kept safe. We observed staff challenging visitors who tailgated into the department with authorised visitors. All visitors were asked to sign in and out of the ward and were given white visiting stickers, this ensured visitors were easily identifiable.
20180222 KGHNHSFT Evidence Appendix Page 122
The maternity service provided community staff with mobile phones. These enabled them to be contacted easily during their community visits, and ensured they were able to escalate when they did not feel safe to colleagues or the police. The trust had a lone worker policy and we saw a copy of this during our inspection. 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 completed by two members of community staff until they determined whether it was safe for them to visit alone. Staff we spoke with were able to demonstrate the location of the nearest fire exit and we observed that staff kept fire exits clear and free from obstruction.
Medicines
The majority of systems in place regarding the storage and handling of medicines were effective. Medicine incidents were reported via the electronic incident reporting system. From October 2016 to September 2017, the maternity service reported 50 medication incidents. This equates to 8% of total incidents reported in the maternity service. Learning from these incidents was also cascaded to staff during handovers, emails, and through the ‘hot topics’. We saw copies of previous ‘hot topics’ which confirmed this. In all clinical areas we visited, medicines were securely stored behind locked doors or cupboards, and were only accessible to appropriate staff. Controlled drugs (CDs: a medicine that is controlled under the ‘Misuse of Drugs Act’ (2001), were stored appropriately in a locked cupboard and the keys held separately from the main keys. Two midwives checked the physical stock of the CDs against the stock level recorded in the register daily in each clinical area. CDs, brought in by women, were always securely stored alongside the ward’s stock of CDs and checked daily. Controlled medicine destruction kits were available on delivery suite and Rowan ward. Medicines that required refrigeration were kept at the correct temperature and we saw staff checked and recorded the fridge temperatures daily in all clinical areas. This ensured medicines that were temperature sensitive were stored correctly. The temperature of the treatment room on Rowan ward exceeded 35°C for four consecutive days from 11 July 2017 to 14 July 2017, and on two days staff recorded temperatures of 44°C. High temperatures reduce the shelf life of medicines, and so trust policy stated that in areas where temperatures reached up to 35°C, medicines needed a reduced shelf life of six months. The policy required ward staff to seek advice from the pharmacy department if temperatures exceeded 35°C for more than 24 hours. We did not see evidence that ward staff reported or took the appropriate action to ensure that the medicines remained safe to use. We raised these concerns with ward staff and a member of the pharmacy team, who told us they would review the arrangements as a matter of urgency. During our follow-up inspection on the 24 November 2017, staff were still unable to explain the process for escalating non-compliant ambient room temperatures. We again fed this back to the trust. The majority of prescription charts we reviewed accurately reflected the woman’s care plans. They clearly documented allergies, the dose, and route of the medication prescribed, and why the medication had been omitted. However, in eight of the 12 prescription charts we reviewed, the
20180222 KGHNHSFT Evidence Appendix Page 123 woman’s weight was not recorded. This is important because the correct dose of some medicines was determined by the woman’s weight. 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. During our inspection, we reviewed 12 prescription charts. We saw that there was a separate record chart for medicines prescribed under midwives’ exemptions. This record chart was not attached to or recorded on the main prescription chart as required by trust policy. This meant there was a risk that women received two doses of a medication. From October 2016 to September 2017, the maternity service reported three medication incidents where women received two doses of a medication because the midwives’ exemption record chart was not secured to the woman’s main prescription chart. We raised this as a concern with senior staff during the inspection. At our follow-up inspection on the 24 November 2017, we reviewed a further five prescription charts. We saw that all five midwives’ exemption record charts were stapled to and recorded on the woman’s main prescription chart in line with trust policy. We saw that prepacks of frequently used medicines were available on Rowan ward to facilitate the timely discharge of women and babies. The wards carried a stock of the routine medicines such as painkillers and antibiotics, which enabled take home medication to be dispensed out of hours. We observed that midwives were proactive in ordering this medication from pharmacy to avoid delays to women being discharged at weekends. There were local microbiology protocols for the administration of antibiotics. Prescription charts reviewed showed that they were followed by prescribers. Antimicrobial stewardship training was included in the medical staff’s induction programme. On-call community midwives carried equipment for facilitating a home birth; this included emergency equipment such as oxygen and oxygen masks, and pain relief medication, such as nitrous oxide (gas and air). The maternity service had not conducted any risk assessments to ensure midwives, their cars or premises were not a target for someone wanting to access medical gases, or other emergency medication, inappropriately. We raised this with senior managers on the inspection who told us that the on-call equipment contained a warning leaflet to alert emergency services that the vehicle contained nitrous oxide. We saw these leaflets in the two on- call equipment bags we reviewed.
Records
Staff ensured that patients’ individual care records were well managed and stored appropriately. Records seen were accurate, legible, up to date and 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 any paper notes were stored away from public view in lockable trollies. The majority of community staff spoke positively about using electronic records, which they accessed through laptop computers. However, staff said there were occasional issues with
20180222 KGHNHSFT Evidence Appendix Page 124 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. However, there was only reported one incident relating to community staff not being able to access the electronic record system over the last 12 months. 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 11 sets of records, both electronic and paper. 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. As part of monitoring staff practices, senior midwives carried out regular audits on the content and standard of recordings made by midwives. We reviewed the October 2017 nurse sensitive indicators for record keeping on delivery suite, and no areas of improvement had been identified. The delivery suite coordinator checks included whether fluid balance charts were complete and correct, pressure area assessments were complete and handover tools contained the appropriate information. If an issue was identified with the documentation, the delivery suite coordinator raised this with the midwife immediately and ensured any issues were rectified. We saw a copy of this check for 15 October 2017, which reviewed three sets of patient records. All the records were completed appropriately. Both delivery suite and Rowan ward used ‘Patient Safety at a Glance’ (PSAG) white boards to display women’s names, their location on the wards and some treatment information. Hospital wards use PSAG boards to display important information such as patient’s infection risk, discharge readiness and safeguarding concerns. The PSAG boards were located in staff areas so were out of sight of women and visitors. This meant that women’s personal data was protected. Mothers were given the national personal child health record (often called the ‘red book’), before they were discharged home. The red book is used to monitor the child’s health and development up to the first four years of life. During our inspection, we reviewed two red books and saw they were filled out correctly. On discharge, women were given written information and relevant contact details in case they needed extra support. As of July 2017, trust data showed 99% of midwives and 94% of medical staff within the maternity service had completed information governance training. This was above the trust target of 85% compliance.
Assessing and responding to patient risk
Patients received assessments, treatment and observations in a timely way. 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 these risk assessments were used to help women choose their
20180222 KGHNHSFT Evidence Appendix Page 125 preferred place of delivery, recommend further investigations and inform a plan 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 11 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 11 medical records we reviewed, venous thromboembolism (VTE) assessments were completed. A VTE is a blood clot that can form in the veins of the leg or lungs. 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. However, staff informed us they completed the assessment daily whilst the woman was an inpatient. During our inspection, we observed this in practice. This complied with NICE ‘Venous thromboembolism: reducing the risk for patients in hospital’: CG 92 (last updated June 2015). From April 2017 to July 2017, the VTE assessment audit results showed 98% of patients had a completed VTE risk assessment. Community midwives completed home birth risk assessments for women who requested a home birth. This included an assessment of the woman’s home and her mobility, and social care involvement. Women seen and assessed before the end of the twelfth week of pregnancy have been proven to have better outcomes than those seen for the first time later on in pregnancy. Data from the trust demonstrated that from January 2017 to March 2017, 77% of women attended their booking appointment by 10+6 weeks gestation and 87% of women were seen by 12+6 weeks of pregnancy. The service had implemented the ‘Saving Babies’ Lives’ care bundle (NHS England, 2016), which was designed to reduce stillbirths. This 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 women regarding fetal movements and smoking cessation. Written information about reduced fetal movements was also given to women at their initial booking appointment and again if they experienced episodes of reduced fetal movements. A referral to a stop smoking service was offered to women identified as smokers and the service had recently purchased a carbon monoxide monitor for each GP centre (where community midwives held their antenatal clinics) and each clinical area in the unit. Women were referred for further ultrasound scans if their baby was not growing as expected. These additional scans needed to be offered within three days. If this was not facilitated, the woman attended the antenatal assessment area in the fetal health unit for regular CTG monitoring. Maternity staff used the modified early obstetric warning score (MEOWS) assessment to detect signs of deterioration. This included a full set of vital signs (heart rate, respiratory rate, temperature, blood pressure and oxygen saturations, fluid charts, and a pain score). Staff plotted the observations against pre-determined parameters. There were clear actions to take when the MEOWS increased and indicated a woman was deteriorating. All medical records we reviewed contained appropriate actions taken.
20180222 KGHNHSFT Evidence Appendix Page 126
Monthly audits of MEOWS completion and escalation were undertaken for the fetal health unit, delivery suite, and Rowan ward. In August 2017, the maternity service achieved a 100% compliance rate for the correct calculation and escalation of MEOWS scores. The audit for situation, background, assessment, and recommendation (SBAR) technique, when escalation to medical staff was required showed the service achieved a 100% compliance rate. SBAR is a communication tool designed to support staff to share clear, concise and focused information when a handover is required. At our last inspection in October 2016, we were told that a group of community midwives had been developing a MEOWS tool to support earlier identification of sepsis within community. During this inspection, staff said this was still in development and we were not given a time scale for the implementation of this new tool. A sepsis-screening tool was incorporated into the maternity observation booklet. This gave clear, best practice guidance on the assessment and treatment for sepsis (the presence of harmful bacteria and their toxins in the body). Midwifery and medical staff throughout the service confidently described the signs of sepsis and what action they would take, for example, completing the ‘Sepsis Six’ pathway in the woman’s notes and immediate escalation to medical staff. Sepsis Six is the name given to a bundle of medical therapies designed to reduce the mortality and 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 had a ‘suspicion of sepsis’ box which contained all the necessary equipment for the monitoring and treatment of sepsis in an emergency. 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. 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. We found action was taken when observations were outside normal parameters. For example, a baby’s temperature was measuring below the ‘normal’ threshold. Therefore, the midwife placed the baby skin-to-skin with the mother and re-took the temperature within 30 minutes. There was a designated triage area, situated within delivery suite, which provided 24-hour assessment for pregnant women over 20 weeks gestation, and for postnatal women up to 10 days post-delivery. Women could telephone for advice or present to the triage unit if they were concerned about their welfare or the welfare of their baby. Staff told us that a midwife saw every woman who attended triage within 15 minutes of arrival for baseline observations, such as blood pressure and temperature, and fetal heart auscultation, if antenatal. Women we spoke with during the inspection, confirmed they had been seen within 15 minutes. However, there was no formal system to ensure women were assessed and reviewed within 15 minutes, as the waiting times for triage were not monitored. The maternity service completed a daily safety huddle, which was attended by the multidisciplinary team. This included the midwives-in-charge of delivery suite, Rowan ward and the fetal health unit, the obstetric consultant, registrar and senior house officer, the anaesthetic registrar, theatre staff and the nurse in charge from the neonatal intensive care unit. We observed a safety huddle during our inspection. This was well attended and organised. Staff discussed high-risk women, the number of discharges, and staffing. Each topic was addressed using the safety huddle ‘4D’s, which were define the problem, design a solution, develop a
20180222 KGHNHSFT Evidence Appendix Page 127 practical way and deliver tangible results. This ensured senior staff from each area maintained an effective oversight of the daily risks of the service. CTG monitoring was used only when it was clinically indicated as per NICE ‘Intrapartum care for healthy women and babies’; CG 190, (last updated 2017). In the all the records we reviewed, we saw that midwives followed the hourly “fresh eyes” approach for CTG interpretation and classification during labour. The ‘fresh eyes’ system required a second midwife to review the fetal heart trace and contractions to ensure there had been correct interpretation and management. Multidisciplinary CTG case reviews were held weekly to facilitate discussion and learning. The maternity service used an adapted version of the World Health Organisation’s (WHO) surgical safety checklists, which was produced in conjunction with the RCOG. 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 carrying out the modified WHO checklist. Staff completed the steps correctly and the checklist forms we reviewed were all signed, dated, and fully completed. Completion of the checklist was audited, and from August 2017 to October 2017, compliance rate for the checklist was at 98%. The audits were both observational and non-observational. Therefore, the service was 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 care and observation. The maternity service also had access to the trust’s critical care outreach team. The outreach team was available 24 hours a day, seven days a week and provided extra clinical support with deteriorating women. Any woman who required additional support to this, such as central venous lines, was transferred to the intensive care unit. We saw evidence that regular impromptu ‘live’ emergency scenarios were held to maintain and improve the skills needed in the event of an emergency. Following a ‘live’ emergency scenario, all staff involved were given written feedback about how the team dealt with the scenario, including areas of good practice and areas for improvement. Simulation training, using the service’s new simulation model mother, was also provided for obstetric emergencies, such as shoulder dystocia and sepsis. The practice development team held ‘live drills’ scenarios and all members of the multidisciplinary team (MDT) were expected to participate. Similarly, the ‘skills and drills’ annual sessions were multidisciplinary. A successful bid with Health Education England enabled the maternity service to invest and provide integrated MDT training, which also included paramedics and theatre teams. Both community midwives and paramedics attended the ‘childbirth emergencies in community’ training.
Midwifery staffing The service planned and reviewed staffing levels and skill mix to ensure that women and their babies received safe care, and at the time of our inspection, the service had enough staff to keep people safe from avoidable harm and abuse. However, from November 2016 to October 2017, the midwife-to-birth ratio was above the national recommended 1:28 for 11 out of the 12 months. 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
20180222 KGHNHSFT Evidence Appendix Page 128 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. During the inspection, actual staffing levels met the planned levels on all shifts, apart from one shift on delivery suite. The planned establishment for delivery suite was seven midwives. On this occasion, the actual establishment was six midwives. The delivery suite coordinator escalated this immediately and a text message was sent to all midwives not on shift to ask for their support. The head of midwifery completed a formal staffing review paper each year about nursing, midwifery and support staffing levels for the women’s and children clinical business unit (CBU). We reviewed the September 2017 report, which stated that the maternity service was achieving a 1:29 midwife to birth ratio as of August 2017. However, the review stated this figure would reduce to 1:28 when new midwives commenced in October 2017. All the vacancies and known retirements for the service until the end of 2017 were all recruited to. The maternity service monitored the midwifery staffing to birth ratios on a monthly basis and these were reported on the maternity dashboard. From January 2017 to October 2017, the nationally recommended workforce ratio of 1:28 was not achieved in nine out of the ten months, with the highest reported ratio of 1:30 for April 2017. The service only achieved the recommended ratio of 1:28 in September 2017. Senior managers completed quarterly audits of the provision of one-to-one care for women in established labour. The report from November 2017 demonstrated that for August, September and October 2017 the maternity service achieved a 100% compliance rate. The majority of staff we spoke with felt the service had sufficient staffing levels to provide safe care to women and their babies. There was an escalation policy for staff to follow if staffing levels fell below agreed levels. This included ensuring bank shifts were filled and deploying midwives from other areas to support delivery suite, such as ward managers and specialist midwives who were generally supernumerary. The on-call community midwives were also asked to support the unit when needed. There were four midwives on-call each day that were also responsible for facilitating homebirths. A system was in place to reorganise their caseloads should they be called out in the night. We reviewed incidents from October to September 2017, and saw that there were no incidents that referenced using the escalation policy. During our inspection, staff said that a community midwife was called to support the unit during a night shift. On the delivery suite and in the antenatal clinic the staffing levels for each shift were publically displayed. However, the staffing numbers for Rowan ward and the fetal health unit were not on display in clinical areas. The delivery suite coordinator was supernumerary and coordinated the activity for each shift. This was in line with best practice. Midwifery handovers happened at the change of each shift. We observed that the handovers were well structured and concise. The midwife in charge summarised the plan of care for each woman and baby to all of the incoming team. This included information about women waiting for an induction of labour, discharges, safeguarding concerns and allocation of workloads. The staff completed these board handovers in areas where they could not be overheard. After the main handover, the individual midwives gave a detailed handover of each woman and baby to the newly allocated midwife. We observed that these handovers occurred outside of the patient bays, which ensured patient confidentiality was maintained.
20180222 KGHNHSFT Evidence Appendix Page 129
At the inspection, senior managers told us there were no vacancies for midwifery staff. They had recently appointed a midwife but they were not due to start until December. The data provided showed trust vacancy rate for midwifery was -3.68% for midwives in the maternity service. This meant that they are over the expected WTE level, and there were no vacancies. The trust currently has a turnover rate of 9.96% for nursing and midwifery staff in the maternity service (as of September 2017). From August 2016 to July 2017, the trust reported a sickness rate of 4.8% in the maternity service. This was about the same as the trust wide sickness rate. At the inspection, senior managers told us that the maternity service did not use agency staff. They relied on bank, specialist midwives or managerial midwives to provide cover. From August 2016 to July 2017, agency nurses were used to fill 17 shifts in the EPAU. However, no agency staff were used to cover shifts within other areas of the maternity service for the same period. From August 2016 to July 2017, there were 1704 total shifts covered by nursing and midwifery bank staff within the maternity service. During the inspection, staff spoke positively about the service not using agency staff. This was because all bank staff were existing or previous colleagues. This meant staff felt confident challenging and working with them.
Medical staffing
Medical staffing levels within the maternity service were sufficient to provide safe care and treatment at the time of the inspection. There were four multidisciplinary ward rounds per day on delivery suite attended by medical staff and the delivery suite coordinator. A consultant-led ward round of Rowan ward was also undertaken once a day, seven days a week. During our inspection, senior managers told us there were no vacancies for medical staff within the maternity service. They had recently appointed three new consultants. However, one of the appointed consultants was not due to start until January 2018. The trust currently has a vacancy rate of 4.58% for medical staff in the maternity service (as of September 2017). This indicated that they were short staffed. The trust currently has a turnover rate of 31.25% for medical staff in the maternity service (as of September 2017). From August 2016 to July 2017, the trust reported a sickness rate of 3.1% in the maternity service. This was below the trust wide sickness rate. At the inspection, senior managers told us that the maternity service did not use medical agency staff. This was confirmed by trust data, which demonstrated that from January 2017 to July 2017 no shifts were filled by medical agency staff. As of June 2017, 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 higher. Staffing skill mix for the 59.3 whole time equivalent staff working in the women’s and children services’ clinical business unit at Kettering General Hospital NHS Foundation Trust. This Trust England average Consultant 28% 41% Middle career 16% 8% Registrar Group 43% 44% Junior 13% 6%
20180222 KGHNHSFT Evidence Appendix Page 130
(Source: NHS Digital Workforce Statistics)
Consultant cover on the delivery suite
The maternity service had improved consultant cover arrangements for the delivery suite, wards and elective caesarean lists. At the time of the inspection, the consultant cover was appropriate to meet patient needs. The maternity service had reorganised the medical staffing to ensure the delivery suite had an additional registrar or consultant who undertook the elective caesarean section lists. This ensured there was a consultant available to support any emergencies on the delivery suite. The maternity service monitored the weekly hours of consultant obstetric cover on the delivery suite and this was reported on their maternity dashboard. From November 2016 to October 2017, the service provided 60 hours of consultant cover per week. This was in line with RCOG ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’ (2007), which recommends that units with between 2,500 and 5000 births a year should provide at least 60 hours a week of consultant presence. This was an improvement from our last inspection in October 2016. An obstetric consultant provided on-site cover from 8am to 7pm Monday to Friday. On the weekends, a consultant provided cover from 9am to 12pm. After 7pm on weekdays and 12pm on weekends, a consultant was on-call from home for emergencies and support. Medical staff confirmed they were able to access consultant support when required. Dedicated obstetric anaesthetic cover was available on the delivery suite 24 hours a day, seven days a week. Middle grade anaesthetists provided this. From 8am to 5pm Monday to Friday, two consultant anaesthetists also covered the maternity service. Incidents
The service generally managed patient safety incidents well. The hospital used an electronic online system for reporting incidents. All staff we spoke with described the process for reporting incidents and gave examples of when they had done this. For example, a postpartum haemorrhage, shoulder dystocia (where a baby’s shoulder becomes stuck delaying the birth of the baby’s body) and transfers from home births to delivery suite. They told us their managers encouraged them to report incidents and supported them with this process. 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 September 2016 to August 2017, the trust reported no incidents which were classified as never events for maternity. In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents in the maternity service that met the reporting criteria set by NHS England from September 2016 to August 2017. One incident was categorised as surgical/invasive procedure incident meeting SI criteria, another was categorised as maternity/obstetric incident meeting SI criteria: mother and baby, and the final SI was reported as maternity/obstetric incident meeting SI criteria: mother only.
20180222 KGHNHSFT Evidence Appendix Page 131
The trust policy for serious incident reporting included a two tier reporting system where serious incidents were declared internally and externally. The maternity service declared three serious incidents externally and reported another two serious incidents internally. Of these internal serious incidents, one should have been declared externally as a serious incident. This incident related to an intrauterine death. The trust’s internal investigation identified improvements of care, which may have led to a different outcome. This would normally meet the criteria for an externally reportable serious incident. However, this was not reported and the service classified the severity of the incident as ‘no harm’. We reviewed 593 incidents reported from August 2016 to September 2017 and identified 71 (12%) incidents which had been graded as ‘no harm’. Of these, examples were where a woman who suffered a major postpartum haemorrhage (the loss of more than 1000ml of blood from a woman’s genital tract within 24 hours of a birth of a baby) on transfer to recovery, which resulted in a hysterectomy, and an admission to the intensive care unit (ICU). Another incident, which involved a woman being transferred to ICU after suffering a major postpartum haemorrhage following an emergency caesarean section, was also graded as ‘no harm’. Another incident where an emergency caesarean section was completed for suspected fetal compromise and the baby was found to be stillborn was graded as ‘no harm’. On our inspection, staff said they categorised the level of harm when they initially reported an incident. The managers for each clinical area reviewed the incidents, followed by a final sign-off review by either the head of midwifery or clinical director. At both these reviews, the categorisation of harm could be changed in line with national guidance. Following our inspection, we sought clarification that incidents were being reported and investigated appropriately. Therefore, we spoke with senior staff at the trust who supplied us with further information. This information explained that the level of harm was determined by staff’s influence into the incident. For example, postpartum haemorrhages were reviewed and if no clinical attributing factors that caused the bleeding was identified, the level of harm was graded as ‘no harm’. This was in line with national guidance for reporting of incidents under the National Patient Safety Agency (NPSA) (2009) guidance for the identification and reporting of patient safety incidents (PSI). This guidance provides a definition of a PSI: ‘Local organisations should investigate these to determine if a PSI contributed to the unexpected outcome or unexpected death. Organisations should not enter a harm grading of severe or death on a PSI report unless they believe that permanent harm or death actually resulted and was directly attributable to a PSI.’ Senior staff completed internal investigation reports for all incidents initially graded as ‘moderate harm’. We found thorough investigations were completed, including evidence of duty of candour application. Some incidents were downgraded to ‘no harm’ following an investigation where no patient safety incident had been determined. We saw that the management of both internally and externally reported serious incidents followed the same process. A senior member of staff was appointed as the lead for the serious incident investigation and conducted the root cause analysis (RCA). We reviewed the RCAs of the external and internal serious incident investigations. We saw detailed RCAs had been completed, which included recognition of care management and service delivery problems, contributory factors, lessons learned and actions to be completed to reduce the risk of further incidents. All serious incident investigation reports were presented at the serious incident review meetings and needed to be signed off by the serious incident panel (comprised of senior staff) prior to the report being shared.
20180222 KGHNHSFT Evidence Appendix Page 132
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. Staff understood their responsibilities with regard to the Duty of Candour regulation and were aware of the trigger for the application of Duty of Candour, which was for moderate harm and above. Staff described a working environment in which any errors in a woman’s or baby’s care or treatment were investigated and discussed with the woman and her relatives. We saw from both internal and external serious incident investigations reviewed that the service had applied Duty of Candour. A senior member of staff, usually a midwifery advocate, was appointed as the Duty of Candour lead to liaise with the woman or her family. The trust offered a verbal and written apology to the woman and/or family, shared the SI investigation report with them and offered a meeting to discuss the findings of the report. There was evidence of learning from incidents in all areas we visited and the majority of staff we spoke with provided us with many examples of this. For example, community staff told us that completed newborn blood spot screening tests were often not received by the laboratory in Sheffield. This meant staff repeated the test unnecessarily. As a result, the community managers implemented a new process for sending the completed tests. This included ensuring staff received a proof of posting receipt and each sample was checked by another member of staff prior to sending. All staff told us they received direct feedback when they had been involved in incidents. Staff also told us that lessons learned from incidents were cascaded to the team during ward handovers, through weekly ‘hot topic’ emails, and the ‘spotlight on quality’ newsletter, which was produced monthly by the quality matron. We saw copies of this newsletter from August, September and October 2017. The newsletter included information about the importance of incident reporting, the total number of incidents reported for the CBU, an incident theme overview and learning from incidents. For example, the October 2017 newsletter contained information about changes to documentation of blood products following a number of incidents about staff (trust wide) not complying with trust policy in relation to transfusion of blood products. The eight community staff we spoke with had an awareness of incidents that occurred within the maternity unit and described learning from these incidents. Managers told us they encouraged midwives to reflect on any incidents they were involved in, and the service held debrief sessions after serious incidents occurred. Incidents were discussed at the monthly women’s and children services CBU governance meetings and the monthly risk forum meetings. We reviewed the minutes of these meetings from August 2017 to October 2017, and found there was poor medical staff attendance. Minutes showed that the quality matron provided staff in attendance an overview of the number of incidents reported and the themes. Serious incidents were also discussed at the clinical governance meetings including lessons learnt, immediate actions taken to prevent future incidents and recommendations. 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.
20180222 KGHNHSFT Evidence Appendix Page 133
Minutes of meetings held from July 2017 to October 2017 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.
Safety Thermometer
The service used safety monitoring results well. Staff collected safety information on the maternity dashboard and shared it with staff, women and visitors. Midwives said this information was discussed at team meetings and in their monthly newsletters from the quality matron. The midwives we spoke with were aware of the main risks of the service. The maternity service did not complete the national maternity safety thermometer. The data sets collected were used on the maternity dashboard and had been agreed with the trust’s commissioners. For example, postpartum haemorrhage, perineal trauma, caesarean section and infection rates. 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 now 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.
Major incident awareness and training
There were appropriate policies in place with regard to business continuity and major incident planning. The maternity service had contingency plans in place, which included staffing, closure of the unit, abandoned and abducted baby, and senior staff were able to describe them. From November 2016 to October 2017, the maternity service had not suspended any services. We saw that regular impromptu emergency scenarios were held to maintain and improve the skills needed in the event of an obstetric emergency. These included postpartum haemorrhage, shoulder dystocia and evacuation of the birthing pool. The service had also carried out two baby abduction simulations since our last inspection in October 2016. We saw that areas of good practice, areas of improvement and learning was detailed and shared within the service after each simulation or scenario. Staff received training about fire safety during their initial induction and annual mandatory training. We saw that 97% of nurse and midwifery staff had completed this training, which was in line with the trust target of 85%. For the same period, 84% of medical staff in the maternity service received this training, which was just below the trust target. However, all staff we spoke with showed appropriate awareness of fire safety protocols throughout the department. There was also a trained fire marshal working on shift.
20180222 KGHNHSFT Evidence Appendix Page 134
Is the service effective?
Evidence-based care and treatment
The service used current evidence-based guidance and best practice standards to inform the delivery of care and treatment. There was a process to update, review and ratify policies and policies were available on the trust intranet. There was an effective system in place to ensure policies and guidelines reflected national guidance. The service allocated authors to review policies to ensure they were up-to-date. The authors took into account the publications from the National Institute of Health and Care Excellence (NICE) and guidance from other professional bodies such as the Royal Colleges. We reviewed 25 policies and these were all up-to-date and reflected the latest national guidance. However, trust data showed that as of 6 November 2017, there were 13 maternity guidelines appearing as overdue on the trust’s intranet. Of the 13 overdue, one was archived, nine were ratified, but were awaiting upload to the intranet, two were returned to the author following the October 2017 scrutiny meeting for additional amendments and one was with a new author for review. Trust guidelines were assessed to ensure guidance did not discriminate because of race, ethnic origin, nationality, gender, culture, religion or belief, sexual orientation and/or age. This was called the equality impact assessment. We saw staff were able to access policies on the trust’s intranet. A handful of the most accessed guidelines were kept in ring binders for the convenience of quick access in the clinical areas. The service was took part in national audit programmes, but local audit was limited. The service recognised that their audit schedule was not complete and this was documented on the service’s risk register. At the time of our inspection, the audit leads had started to produce an audit schedule for 2017/18. They told us that this would help to improve the oversight of all the audits completed. Antenatal, intrapartum and postnatal care was provided in line with NICE quality standards and guidelines, and the 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, as appropriate, their partner and family should expect to receive during the postnatal period. We observed staff supporting women and babies 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’: NG 3, (last updated August 2015). We reviewed four cardiotocography (CTG) traces. A CTG trace records both the fetal heart rate and uterine contractions. Its purpose is to monitor fetal wellbeing and allow early detection of fetal distress. All of the traces reviewed had a “fresh eyes” review documented and the interpretation and escalation was in line with NICE ‘Intrapartum care for healthy women and babies’; CG 190, (last updated February 2017). The ‘fresh eyes’ system required a second midwife to review the fetal heart trace and contractions to ensure there had been correct interpretation and management.
20180222 KGHNHSFT Evidence Appendix Page 135
The service had implemented the ‘Saving Babies’ Lives’ care bundle (NHS England, 2016), which was designed to reduce stillbirths. This included the use of customised fetal growth charts to help identify babies who were not growing as expected and routine symphysis-fundal height measurements from 24 weeks gestation. We observed staff asking about smoking status at antenatal appointments and women who smoked were routinely offered carbon monoxide monitoring throughout their pregnancy. This was in line with NICE ‘Smoking: acute, maternity and mental health services’: PH 48, (November 2013). The service had recently purchased a carbon monoxide monitor for each GP centre (where community midwives held their antenatal clinics) and each clinical area in the unit.
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. Midwives in the pre-operative assessment clinic routinely gave women advice on fasting before their elective caesarean section. For food, women were able to eat up until midnight the day before surgery, and for drink, women were able to drink small amounts of water up until their surgery. Elective caesarean section lists were run every weekday morning. However, if an elective caesarean section list was delayed, women’s fasting was reviewed to ensure they did not go without food for long periods. Meals were provided on the inpatient areas by a menu ordering system. Meals were varied and met both nutritional and cultural needs, for example, vegetarian, gluten-free, halal, kosher and vegan food were all available. All women who had undergone a caesarean section (emergency and elective) received intravenous (IV) fluid to ensure they were kept well hydrated. Post-operative nausea was managed through the prescribing of an antiemetic (anti-sickness medicine). There was an infant feeding specialist midwife, who was supported by an assistant practitioner. Their role was to support and provide infant feeding advice to both midwives and women. The infant feeding midwife also provided breastfeeding training to midwives, maternity support workers, healthcare assistants and assistant practitioners. As of October 2017, 87.5% of maternity staff had completed this training. Women told us that they did not feel pressurised to breastfeed and they were assisted with feeding their babies whatever method they chose. The breastfeeding rate for initiation was 88% for data submitted from July 2017 to September 2017. This had improved from 75% at the time of our last inspection. Breastfeeding information was displayed throughout the maternity service, including positioning and attachment information. We checked the breast milk refrigerator on Rowan ward for the storage of expressed breast milk. We found that this was labelled appropriately and was in date. However, the milk kitchen or refrigerator was not locked. This meant the expressed breast milk could be tampered with. We escalated this to senior managers who told us they were considering a digi-lock for the refrigerator. A range of infant formulae was available for mothers wishing to bottle-feed their baby. The formula was stored in a locked cupboard, which could be accessed by staff only.
20180222 KGHNHSFT Evidence Appendix Page 136
Pain relief
Staff assessed and managed women’s pain effectively and regularly. The patient records we reviewed confirmed this. We saw that staff assessed women’s pain regularly as part of their routine observations using the modified early obstetric warning score (MEOWS). Pharmacological 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 was offered 24-hours a day. The maternity service did not audit the time from women requesting an epidural to the time the anaesthetist attended. National guidance from OAA/AAGBI ‘Guidelines for Obstetric Anaesthetic Services’ (2013) recommends that the length of time should not normally exceed 30 minutes. This meant the service could not determine whether women were provided pain relief in a timely manner. This audit was not documented on the audit schedule for 2017/18. However, the audit schedule was not complete at the time of our inspection. All staff we spoke with on delivery suite informed us that they believed anaesthetists responded promptly to requests for epidurals. However, one woman told us that staff informed her there was a long wait for an epidural. Staff did not tell the woman how long she would have to wait. All the other women we asked, did not have any concerns with the timeliness of pain relief. From May 2017 to October 2017, 91% of women received regional anaesthesia for elective caesarean section and emergency caesarean sections. This was better than the national target (OAA/AAGBI ‘Guidelines for Obstetric Anaesthetic Services’, (2013)). Midwives told us that regular analgesia was prescribed for post-operative women, including opioids, paracetamol and ibuprofen. Women were routinely offered adequate pain relief prior to perineal suturing, this included local anaesthetic. Non-pharmacological methods of pain relief were also available. The delivery suite had two birthing pools, which were available for women to use in labour and/or birth. From November 2016 to October 2017, the maternity service facilitated 121 water births; this equated to 3.4% of all deliveries on the delivery suite. During this period a further 196 women used a birthing pool during their labour.
Patient outcomes
The maternity service did not adequately monitor the effectiveness of care so was not able to use findings to consistently improve practice. We reviewed the audit programme for 2016/2017 and found 13 audits were documented. These included the maternal, newborn and infant clinical outcome review programme (MBRRACE audit), a home birth audit and an audit on the prevention, identification and management of third and fourth degree perineal tears. Of the 13 audits documented on the audit programme, the home birth audit was overdue. We were not provided an explanation as to why this audit was overdue. The management of their local audit programme was not effective. The audit programme did not include all the local audits completed in the maternity service. For example, modified early obstetric warning scores (MEOWS) audits, hand hygiene audits and the audits of labour ward epidural chart documentation were not included. This meant the audit team did not have oversight over the audits being completed in the maternity service, their results, and whether improvements to practice had been implemented appropriately.
20180222 KGHNHSFT Evidence Appendix Page 137
A total of 49 performance measures were detailed on the maternity dashboard, covering birth activity, workforce, and obstetric and neonatal clinical indicators. A traffic light system was used to flag performance against the agreed thresholds. The lead midwife completed a monthly exception report to address any indicators rated as amber or red to demonstrate learning from themes and trends, identifying audits and ensure appropriate action was taken. However, we were not assured that timely action was taken to address problematic areas. For example, induction of labour flagged as amber or red for the whole 12 month period. It was only in August 2017 that the service decided they needed to complete an audit to review the clinical indications. The audit findings were due to be presented in December 2017. According to the maternity dashboard from November 2016 to October 2017, the service did not meet the agreed threshold of 11 major postpartum haemorrhages (the loss of more than 1000ml of blood from a woman’s genital tract within 24 hours of a birth of a baby) for five of the 12 months. The highest number of incidents was reported in August 2017, with 19 postpartum haemorrhages recorded. The service’s threshold for blood loss greater than 1000ml was set according to the RCOG national indicator of 3.7%. We would have expected the maternity service to have completed a regular quality review to determine the causes behind these reported major postpartum haemorrhages, and to determine if lessons needed to be learnt. After our inspection, we made a request for the service to provide us with copies of any audits or quality reviews completed in response to the postpartum haemorrhage rate. The service had only completed a thematic overview of the relevant incidents in only the months of September 2016 and August 2017. Therefore, we were not assured that all of the incidents from November 2016 to July 2017 and September to October 2017, were unavoidable. Without completing regular audits or quality reviews, the service could not be assured learning from these incidents were identified or shared to help prevent future reoccurrence. In the 2016, National Neonatal Audit performance for Kettering General Hospital was as follows: Do all babies of less than 32 weeks gestation have their temperature taken within an hour of birth? 93% of eligible babies had their temperature taken within an hour of birth. This is slightly lower than the unit level comparison where 97% of local neonatal units (LNU) nationally took the temperature of eligible babies within an hour of birth.
Are all mothers who deliver babies between 24 and 34 weeks gestation inclusive given any dose of antenatal steroids? 87% of eligible mothers at Kettering General Hospital received antenatal steroids. This is the same as the LNU unit level comparison.
What proportion of babies < 33 weeks gestation at birth were receiving any of their own mother’s milk at discharge to home from a neonatal unit? 30% of eligible babies at the trust were receiving any of their mother’s milk when discharged home. This is slightly lower than the LNU unit level average of 33%.
The results of the audit were presented to the women’s and children service clinical business unit (CBU) clinical governance meeting. We saw a copy of this report and found that the service raised awareness of the trust’s neonatal thermoregulation guidelines at midwifery mandatory training days. This included neonatal temperature regulation in medical staffs’ teaching sessions and raised the incident-reporting threshold for babies with a temperature of less than 36°C to 36.5°C. From April 2016 to March 2017, the total number of caesarean sections was higher than expected. The standardised caesarean section rates for elective sections higher than expected and rates for emergency sections similar to expected. 20180222 KGHNHSFT Evidence Appendix Page 138
The standardised elective caesarean section rate has increased slightly since our last inspection. From March 2015 to April 2016, the elective caesarean section rate was 13%. This has increased to 14.4% for period April 2016 to March 2017. The standardised emergency caesarean section rate has remained unchanged at 17%. Standardised caesarean section rates England Kettering General Hospital NHS Foundation Trust Type of Caesarean Caesareans Caesarean Standardised caesarean RAG rate (n) rate Ratio Elective Higher than 11.9% 490 14.4% 129.6 (z=2.4) caesareans expected Emergency Similar to 15.4% 578 17.0% 111.7 (z=0.9) caesareans expected Total Higher than 27.4% 1,068 31.3% 119.3 (z=2.5) caesareans expected Note: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries.
In relation to other modes of delivery from April 2016 to March 2017, the table below shows the proportions of deliveries recorded by method in comparison to the England average. Proportions of deliveries by recorded delivery method Kettering General Hospital NHS England Delivery method Foundation Trust Deliveries (n) Deliveries (%) Deliveries (%) Total caesarean sections1 1,068 31.3% 27.4% Instrumental deliveries2 349 10.2% 12.5% Non-interventional deliveries3 1,963 57.6% 59.8% Other/unrecorded method of 29 0.9% 0.2% delivery 100% Total deliveries 3,409 100% (n=614,199) ¹Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Inlcudes breech and normal (non-assisted) deliveries
According to the maternity dashboard from November 2016 to October 2017, the service did not meet the agreed threshold of 14% for elective caesarean sections for ten of the 12 months. The highest reported rate was in December 2016 at 20.6%. The service also did not meet the threshold of 15% for emergency caesarean sections for nine of the 12 months, with the highest reported rate in June 2017 at 20.6%. No action plans were in place to address the rise in the elective caesarean section rates. We would expect the maternity service to complete a quality review and audits to determine if caesarean sections were clinically indicated and to help highlight any improvements to practice. However, at the time of our inspection a quality review had not been undertaken. The October 2017 maternity dashboard exception report explained that two senior registrars were going to complete an audit on all caesarean sections to help identify any necessary changes to practice. The audit findings were due to be presented in December 2017 to senior managers.
20180222 KGHNHSFT Evidence Appendix Page 139
Senior managers recognised that the rate was above national average and had took a range of actions to help address it. This included contacting their legal representative to check their legal position on whether they could deny a woman a caesarean section, when it was not clinically indicated. The service was informed that they needed to give women informed choice, as recommended in national guidance. The service provided a birth options clinic, called ‘Choices’. The clinic provided an opportunity for women, who have previously had a caesarean section or traumatic birth, to explore the birth choices for their current pregnancy. Midwives running the clinic promoted vaginal birth, where appropriate. Senior managers told us this clinic was well attended. In addition, the maternity service offered ward-based debrief sessions to help address the caesarean section rates. This service was run by the midwifery advocates, who visited the inpatient areas between 9am to 1pm, Monday to Friday. They spoke to any women who had difficult births or emergency caesarean sections. At the time of the inspection, the service did not audit the compliance of category one emergency caesarean sections (baby should be delivered within 30 minutes of the decision), or category two emergency sections (baby should be delivered within 75 minutes of the decision). This meant that they were not aware if babies were at risk due to not being delivered within the recommended time. As of October 2017, the trust reported no active Maternity outliers. An outlier is an indication of care or outcomes that are statistically higher or lower than would be expected. They can provide a useful indicator of concerns regarding the care that people receive. Maternity outliers include puerperal sepsis and other puerperal infections, elective caesarean section, emergency caesarean section, neonatal readmissions and maternal readmissions. The trust took part in the 2017 Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE) audit and their stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) was 5.32. This was much worse than the comparator group average of 4.73 and meant the trust reported up to 10% higher than average stillbirth, neonatal and extended perinatal mortality rates. The 2017 result was also worse than the 2016 MBRRACE audit. In 2016, the service’s stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) was 5.17. During the inspection, senior managers told us they produced an action plan in response to the MBRRACE audit and its recommendations. We reviewed a copy of the action plan and saw that all of the actions had been completed or were on track to complete within the allotted timescale. The action plan included training an additional two midwives to become midwife sonographers. At the time of our inspection, we saw evidence that two midwives were currently completing their training. The service had implemented the ‘Saving Babies’ Lives’ care bundle (NHS England, 2016) in response to the findings from the MBRRACE audit. In addition, ‘predict to prevent’ training was provided to staff on the annual maternity mandatory study day. This training provided midwives with an overview of the Saving Babies’ Lives care bundle, still birth rates for the trust, information on increasing the detection rates of small for gestational age babies and smoking cessation training. Growth assessment protocol (GAP) e-training produced by the Perinatal Institute was now mandatory for all midwives and medical staff. The practice development team completed uterus measurement assessments of all midwives to ensure all midwives were using the same technique. As of October 2017, 96% of all midwives had been assessed and were competent. The practice
20180222 KGHNHSFT Evidence Appendix Page 140 development team told us that every single midwife employed at the trust would be assessed by the end of December 2017. As part of the trust’s Maternity Safety Improvement plan 2016-2020, published in January 2017, the CBU committed to reduce neonatal term admissions to the neonatal intensive care unit (NICU). Therefore, the CBU developed a multidisciplinary forum to identify themes, lessons learnt and recommendations. The quality matron, a member of the forum, completed a thematic review of all term admissions (babies born before 37 weeks gestation) for April 2017 to August 2017. We saw a copy of this report which stated 50 term baby (babies born from 37 weeks gestation) were admitted to NICU in this period. However, only 41 of the 50 were unexpected admissions, as some babies had known congenital anomalies and others were admitted whilst foster care placements were secured. The reasons for admission to NICU for these 41 babies included suspected sepsis, respiratory distress, jaundice, hypoglycaemia and infection. The report also collated the learning established from the forum. This included ensuring all women having a caesarean section before 39 weeks gestation were administered prophylactic (preventative treatment) steroids. From November 2016 to October 2017, the trust reported 19 stillbirths. This was lower than the agreed trust’s threshold of 36 for the same period. All stillbirths and neonatal deaths were reviewed to identify areas of good practice and areas for improvement. However, the reports did not determine whether the deaths were expected or avoidable. Therefore, we were not assured the deaths were comprehensively reviewed. Senior managers informed us they were extremely confident that their results in the next MBRRACE audit would have significantly improved because of all the changes and initiatives they have introduced following the results of the 2017 MBRRACE audit. The service audited its compliance with the UK National Screening Committee’s ‘Standards for screening programmes’. During our inspection, staff said the service met all of these standards. However, in the trust’s annual antenatal and new-born screening programme report for 2016-17, we saw that the maternity service did not achieve the national achievable (100%) or acceptable standard (95% or more) for the new-born screening timely assessment standard; the trust achieved 73.3%. The trust audited the prevention, identification and management of third and fourth degree perineal tears. Findings from this audit demonstrated that the trust’s incidence rate was below the England average. However, documentation, referrals to the physiotherapy and outpatient follow-up appointments within the recommended time needed to be improved. The maternity dashboard showed that in October 2017 the service reported five third and fourth degree perineal tears, which was below the agreed threshold of seven per month. The maternity dashboard showed the number of home births. From November 2016 to October 2017, there were 103 home births, which was 2.9% of all births. The number of actual home births was much higher than the agreed threshold of 60 home births per 12 months for the service, and the national average of 2.3%. This demonstrated that the service promoted ‘low risk’ births despite not having a midwife-led birthing unit. The maternity service told us they actively engaged with the ‘Each Baby Counts’ Royal College of Obstetricians and Gynaecologists (RCOG) project and the ‘Saving Babies Lives’ NHS England initiative, both of which raise the profile of babies at risk of harm at the time of childbirth, identified as small for gestational age and babies that are stillborn. From November 2016 to October 2017, the trust reported 22 antenatal and intrapartum stillbirths, which was lower than the trust’s threshold. 20180222 KGHNHSFT Evidence Appendix Page 141
The maternity service reported all premature births from 22+0 to 23+6 weeks gestational age, who did not survive the neonatal period, in line with national recommendations (MBRRACE-UK, 2015). 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.
Competent staff
The maternity service made sure staff were competent for their roles to deliver effective care and treatment to women and their babies. The service had processes in place to identify training needs and compliance, and address any issues identified. Newly qualified midwives completed a comprehensive preceptorship programme to support their development from band five to band six midwives. They received a supernumerary period in each of the clinical areas and then rotated to work on the delivery suite, the fetal health unit and Rowan ward during their 12-month programme. Newly qualified midwives completed a competency booklet, which prompted reflection on their practice. Midwives were able to carry out tasks, such as venepuncture, cannulation and perineal suturing when they had received training and demonstrated competency. There was a structured induction and mandatory training programme for all new staff. This included any required local training. All midwives who were new to the trust worked in a supernumerary capacity alongside an experienced midwife until they were competent to work alone. A practice development team of midwives supported qualified midwives and student midwives in the maternity service. The service also provided development opportunities for staff at various grades. This included supporting midwives to move to the next band, the development of specialist midwifery roles and funding additional training, such as high-dependency and sonography training. The service funded aspiring delivery suite coordinators to attend the Royal College of Midwives’ (RCM) delivery suite leadership course. In addition, a lead midwife told us that the service supported her to complete the head of midwifery masterclass, run by the RCM. All trainee doctors (foundation, core and specialist) had an educational supervisor. They met the trainee at the start of the placement, middle of their placement and at the end of their placement. Junior doctors attended protected weekly teaching sessions. Midwives rotated around the clinical areas every six months to help maintain their clinical skills. All specialist midwives and lead midwives regularly worked clinically. Minutes from various meetings confirmed that apologies for the meeting were sent when the midwives were completing a clinical shift. For example, at the October 2017 scrutiny meeting, the infant feeding specialist midwife was working a clinical shift. The role of the supervisor of midwives (SoM) was discontinued on 1 April 2017 following changes to legislation. The trust implemented a bespoke model of midwifery advocacy supervision, with professional midwifery advocates (PMAs). The existing SoMs all agreed to complete additional training to become midwifery advocates and were providing supervision to midwives at the time of our inspection. This service had presented this bespoke model to the regional maternity lead nurse for NHS England. The delivery suite coordinator was supernumerary and coordinated the activity for each shift. This was in line with best practice. At the time of our inspection, 14 midwives were trained to coordinate delivery suite. Senior managers told us that some of these midwives were due to retire. Therefore,
20180222 KGHNHSFT Evidence Appendix Page 142 the service had funded aspiring Band 7 midwives to attend the RCM delivery suite leadership course in anticipation. As of July 2017, 92% of staff within Maternity at the trust had received an appraisal compared to a trust target of 85%. All staff groups met the trust target for appraisal completion. A split by staff group can be seen in the graph below:
(Source: Routine Provider Information Request (RPIR) P43 Appraisals)
All staff we spoke with on the inspection told us they were up-to-date with their appraisals. They told us they found them beneficial and could suggest additional training they wanted to complete. For example, all healthcare assistants on delivery suite and Rowan ward were trained in taking neonatal observations after one healthcare assistant mentioned they wanted to become competent in this during their appraisal.
Multidisciplinary working
Staff worked together as a team for the benefit of patients. Medical staff, nurses, midwives and other healthcare professionals supported each other to provide 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 of the trust. We observed good interactions between medical staff and midwives on delivery suite during the daily safety huddle and multidisciplinary handovers. A multidisciplinary handover took place twice daily on the delivery suite. The handover included discussions regarding women who were on the delivery suite and women who were on the antenatal ward who may later require care on delivery suite, for example, induction of labours. Relevant information about the women and their babies, including risks and emotional and social needs were shared. Community midwives told us there were good relationships between the community teams and the hospital staff. They described effective MDT working between health visitors, GPs and social services. Multidisciplinary CTG case reviews were held weekly to facilitate discussion and learning. We observed a CTG review meeting during the inspection and saw positive and respectful interactions between the staff groups. The meeting was well attended by all grades of staff, including band 5
20180222 KGHNHSFT Evidence Appendix Page 143 and band 6 midwives, senior midwives, consultants and junior doctors. Every attendee was given the opportunity to contribute and challenge, and the consultants promoted junior doctors to consider interpretation and action. The maternity service held multidisciplinary antenatal clinics. These included specialist medical clinics. For example, the service held a weekly diabetes clinic where a specialist midwife, nurse, consultant obstetrician and consultant endocrinologist saw the women. In addition, the service offered a joint community mental health clinic with a consultant obstetrician and a psychiatrist. The service held monthly local neonatal unit forum meetings. Representatives from both NICU and the maternity service attended. The forum reviewed all term admissions to NICU and implemented any training or learning as a result. However, staff told us that there was generally poor attendance of obstetricians at this forum. The maternity service set up an infant feeding implementation group that met monthly. The group was comprised of the infant feeding specialist midwife, senior midwives, healthcare professionals, maternity support workers, community and hospital midwives and staff from NICU. The purpose of the group was to improve infant feeding within the trust. The group discussed any local updates, training needs and supplementation rates. Staff who attended disseminated any learning to the rest of their teams.
Seven-day services
Seven-day medical support was provided with the minimum of a resident middle grade doctors. A dedicated obstetric consultant was on-call out of hours. Anaesthetic cover was available for emergencies on delivery suite and/or within the maternity service 24 hours a day, seven days a week. There was 24-hour access to a dedicated obstetric theatre and a theatre team was available 24 hours a day, seven days a week. The maternity triage unit on delivery suite was available to women 24 hours a day, seven days a week. Women (or their partners/relatives) could telephone for advice or present to the unit if they had any concerns or health issues. The antenatal assessment unit, which was part of fetal health unit, was open from 7am to 7.30pm Monday to Friday and from 8.30am to 4.30pm on a Saturday. Out of these hours, women could self-refer to the maternity triage or delivery suite. The early pregnancy assessment unit (EPAU) was open Monday to Friday 8.30am to 4.30pm, and on a Saturday 8.30am to either 2.30pm or 4.30pm depending on the midwife on shift. Sonography services were available Monday to Friday, and additional weekend clinics were arranged on the weekend. The home birth service was staffed by the community midwives who were on call over a 24 hour period, seven days a week. Pharmacy operated a weekday service 8.30am to 18.30pm, with an evening and weekend pharmacist available for dispensing urgent medicines. However, staff told us pharmacy only physically visited Rowan ward once a fortnight unless the midwives required additional ‘top-ups’ of medication. The chaplaincy team was available 24 hours a day, seven days a week.
Health promotion
20180222 KGHNHSFT Evidence Appendix Page 144
The service achieved the United Nations Children’s Fund (UNICEF) Baby Friendly full accreditation in 2016, and there was due to be a re-assessment in April 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 means the organisation is committed to supporting mothers to initiate breastfeeding and encourages them to exclusively breastfeed for the first six months while at the same time also supporting parents who choose to bottle feed. We observed staff asking about smoking status at antenatal appointments and women who smoked were routinely offered carbon monoxide monitoring throughout their pregnancy. The service recently purchased a carbon monoxide monitor for each GP centre (where community midwives held their antenatal clinics) and each clinical area in the unit. In November 2017, the maternity service hosted its 28th bi-annual pregnancy and baby roadshow. The roadshow helped parents-to-be prepare for the birth of their baby and care for their baby at home. The event was led by the trust’s midwifery advocates and included support from health visitors, the infant feeding specialist midwife and physiotherapists. Information provided included water births, home and hospital births, safe sleeping, hypnobirthing, fire safety and antenatal massage. Women were offered the influenza (flu) and pertussis (whooping cough) vaccinations after 20 weeks gestation. We witnessed midwives explaining the importance of the vaccines to women during their antenatal appointments. The trust’s campaign to promote the flu vaccination for their staff was outlined in the trust’s infection prevention and control (IPC) report for 2016-2017. The trust implemented a media campaign called ‘Fludeo-who killed Fluella’. During the inspection, we saw this campaign displayed on computer screen savers and posters.
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 women experiencing mental ill health and those who lacked the capacity to make decisions about their care. Medical staff informed women about the risks and benefits of obstetric procedures, such as emergency caesarean sections. Written consent was obtained from women prior to surgery and this was documented in all 11 relevant women’s records we reviewed. 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. The audit team told us they conducted a review of how verbal consent for induction of labour (IOL) was recorded in women’s notes. They found the process was inconsistently documented. As a result, the service introduced an IOL sticker. When a woman was booked for IOL, she was provided with an information booklet and evidence-based advice. The healthcare professional signed the sticker to say this was completed. When the woman attended the unit for her IOL, her consent was checked and the sticker was signed again. We saw staff used this sticker in the intrapartum records we reviewed.
20180222 KGHNHSFT Evidence Appendix Page 145
Post-mortem examinations were offered in all cases of stillbirth and neonatal death in order to enhance future pregnancy counselling. Consultants or registrars took gained consent from women for all post-mortem examinations. The trust reported that as of July 2017, Mental Capacity Act (MCA) training had been completed by 83.1% of staff in within Maternity. Medical and dental staff had the lowest completion rate of 56.3% with 18 out of 32 required staff having completed the training. Eight of the ten staff we asked demonstrated a clear understanding of the Fraser Guideline and Gillick competencies. These are used to help decide whether a child is mature enough to make their own decisions. The Gillick competency and the Fraser guideline help to balance children’s rights and wishes with the hospital’s responsibility to keep children safe from harm. Gillick competency is concerned with determining a child’s capacity to consent. The Fraser guideline is used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment. Staff had access to specialist midwives who had particular expertise in dealing with women in vulnerable circumstances, such as those with learning disabilities or girls under the age of 18.
Is the service caring?
Compassionate care
Staff cared for women and babies with compassion, treating them with dignity and respect. Feedback from women confirmed that staff treated them well and with kindness. We observed staff treating and assisting women and their babies in a caring and compassionate manner. We spoke with 12 women post-delivery, three women attending the antenatal outpatient areas and four relatives. All spoke positively about the kindness and care they received. One woman described her care as “outstanding” on delivery suite and told us she “rated it five stars”. Women also told us that staff were extremely friendly and introduced themselves appropriately when greeting them and their families. The trust obtained patient feedback via the Friends and Family Test (FFT), which allowed women to give feedback on their experiences and state whether they would recommend the service to others. This feedback confirmed that the number of women recommending this service was similar to the England average. From September 2016 to August 2017, the trust’s Maternity Friends and Family Test (antenatal) performance (% recommended) was generally similar to the England average.
From September 2016 to August 2017, the trust’s Maternity Friends and Family Test (birth) performance (% recommended) was generally similar to and slightly above the England average. 20180222 KGHNHSFT Evidence Appendix Page 146
From September 2016 to August 2017, the trust’s Maternity Friends and Family Test (postnatal ward) performance (% recommended) was generally similar to the England average. The drop in the trust’s performance in October 2016 is due to having only two respondents in that month.
From September 2016 to August 2017, the trust’s Maternity Friends and Family Test (postnatal community) performance (% recommended) was generally similar to the England average. The drop in the trust’s performance in April 2017 is due to having no respondents in that month.
(Source: NHS England Friends and Family Test)
The CQC maternity survey for December 2015 surveyed women who gave birth in February 2015. A total of 102 women returned a completed questionnaire for Kettering General Hospital. Results showed that the trust performed similar to other trusts for 15 out of 16 questions. This included being kind and understanding, being treated with respect and dignity and for having confidence and trust in the staff caring for them during labour and birth. The trust performed worse than other trusts in the following question: “Thinking about the care you received in hospital after the birth of your baby, were you given the information or explanations you needed?” Since the publication of this survey, the maternity service introduced a ‘listen to me campaign’ which they implemented 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. Area Question RAG Score
20180222 KGHNHSFT Evidence Appendix Page 147
Labour and At the very start of your labour, did you feel that you About the 8.94 birth were given appropriate advice and support same when you contacted a midwife or the hospital? During your labour, were you able to move around About the 8.42 and choose the position that made you most same comfortable? If your partner or someone else close to you was About the 9.76 involved in your care during labour and birth, same were they able to be involved as much as they wanted? Did you have skin-to-skin contact (baby naked, About the 8.84 directly on your chest or tummy) with your baby same shortly after the birth? Staff during Did the staff treating and examining you introduce About the 9.42 labour themselves? same and birth Were you and/or your partner or a companion left About the 7.36 alone by midwives or doctors at a time when it same worried you? If you raised a concern during labour and birth, did About the 8.03 you feel that it was taken seriously? same Thinking about your care during labour and birth, About the 9.41 were you spoken to in a way you could same understand? If you used the call button how long did it usually take before you got the help you needed? Thinking about your care during labour and birth, About the 8.24 were you involved enough in decisions about same your care? Thinking about your care during labour and birth, About the 9.03 were you treated with respect and dignity? same Did you have confidence and trust in the staff About the 8.56 caring for you during your labour and birth? same Care in Looking back, do you feel that the length of your About the 6.88 hospital stay in hospital after the birth was appropriate? same after the Thinking about the care you received in hospital Worst 5.93 birth after the birth of your baby, were you given the performi information or explanations you needed? ng trusts Thinking about your stay in hospital, how clean was About the 7.60 the hospital room or ward you were in? same Thinking about the care you received in hospital About the 7.26 after the birth of your baby, were you treated same with kindness and understanding? Thinking about your stay in hospital, how clean About the 4.63 were the toilets and bathrooms you used? same
(Source: CQC Survey of Women’s Experiences of Maternity Services 2015)
Midwives placed a teardrop sticker on women’s notes to identify those who previously suffered a pregnancy loss. This ensured that all healthcare professionals were made aware of a woman’s obstetric history. Similarly, a purple butterfly was placed on notes for when one twin had passed away. These ‘stickers’ were also electronically available on the electronic record system. Even when the unit was busy, we saw that staff took the time to check on women and provided them with the support and care they needed. We observed staff responding to call bells promptly.
20180222 KGHNHSFT Evidence Appendix Page 148
Staff respected women’s privacy and dignity. For example, we observed that all staff knocked before entering the rooms. Delivery suite coordinators created a campaign called ‘back to basics’ following the publication of the Francis inquiry report (2013) (a national report that examined the causes of the failings in care at another NHS trust). The aim of the campaign was to improve the ‘basic’ care for women and families. An initiative implemented was the production of the ‘stop and knock’ signs on the delivery suite room doors. These acted as a reminder for staff to knock and wait for a response before entering the rooms. Curtains were also available around the bays in the fetal health unit, triage and Rowan ward, and we saw staff pulled the curtains when providing care to protect women’s privacy. All women we spoke with felt their privacy and dignity was maintained.
Emotional support
Staff provided emotional support to women and their families to minimise their distress. All staff we spoke with had an awareness of women with complex needs and when to provide them with additional support to minimise the potential of them becoming anxious or distressed. The maternity 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. Community visits from the bereavement midwife had recently been introduced and provided additional support for families once they were discharged from hospital. Staff offered ‘post-loss’ appointments to families who experienced a pregnancy loss. This appointment was held with the consultant who cared for the women and provided the opportunity for families to discuss what had happened with a healthcare professional. Staff followed the bereavement policies and guidelines in place to support mothers and their family in the event of a pregnancy loss, such as miscarriage, stillbirth or neonatal death. Midwives supported families to collect keep sakes such as photographs and imprints of the baby’s hands and feet after they experienced a loss. Staff provided spiritual care and religious support for women and relatives as needed. For example, women could be referred to the chaplaincy service for support 24 hours a day, seven days a week. Multi-faith options were also available. Staff signposted women and their relatives to national and local advisory groups, when required. This included charities that provide practical advice and emotional support to families who have experienced a pregnancy loss. During our inspection, we observed staff on the delivery suite providing excellent emotional support for a family who had recently experienced a loss.
Understanding and involvement of patients and those close to them
Staff generally involved women and those close to them in decisions about their care and treatment. Sixteen out of the 19 women and relatives we spoke with all felt involved in their care and received the information they needed to understand their treatment to allow them to make informed decisions. However, three women we spoke with felt that their community midwife did not always
20180222 KGHNHSFT Evidence Appendix Page 149 give them the information and advice they needed in a timely manner. For example, they told us their community midwife often did not respond to their text messages or phone calls. However, all three women said that the support they received when they phoned or attended the unit was exemplary. We observed a pre-operative assessment appointment, with the woman’s permission, and observed the midwife communicating well, and answering questions clearly and precisely. Women were involved in their choice of birth at booking and throughout the antenatal period. One woman told us that medical staff had recommended her to have a caesarean section due to complications in her pregnancy. Despite their recommendations, they provided information about all the options available and because of this, the woman told us she “felt in control” of her care and would be supported regardless of the choice she made. Staff included birthing partners involved them in the care of their partner and newborn baby, including being offered the option to cut their baby’s cord at delivery. Staff ensured that birthing partners could attend caesarean section deliveries carried out under regional anaesthesia (epidural and/or spinal) and so were able to sit beside their partner and support them throughout the procedure. Following patient feedback, staff made provisions for extended visiting hours on Rowan ward for birthing partners. Partners were also allowed to stay on the ward overnight.
Is the service responsive?
Service delivery to meet the needs of local people
The maternity planned and provided services in a way that met the needs of local people. They worked closely with commissioners, the local authority, clinical networks and other stakeholders to plan delivery of care and treatment for the local population. This collaborative working ensured future planning covered recommendations laid out in ‘Better Births’ (NHS England, 2016) and ‘Safer Maternity Care’ (Department of Health, 2016), and also linked with the Northamptonshire’s sustainability and transformation plan 2016-2021. Women’s needs in community were met in accordance with the following National Institute for Health and Care Excellence (NICE) guidance: NICE ‘Antenatal Care’: QS22, (last updated April 2016) Statement 2: ‘Pregnancy women were cared for by a named midwife throughout their pregnancy’. NICE ‘Antenatal care for uncomplicated pregnancies’: CG62, (last updated January 2017): ‘Antenatal care was readily and easily accessible to all pregnant women and was sensitive to the needs of individual women and the local community’. The service provided community-based, consultant-led antenatal clinics in Kettering, Corby and Wellingborough; this included a clinic for vulnerable women and a joint mental health clinic with a consultant obstetrician and a consultant psychiatrist. These appointments enabled women to access timely care and treatment closer to home. Community midwives had their bases at local GP or children’s centres. During the inspection, staff informed us that these consultant-led community clinics had reduced the number of women not attending their antenatal appointments.
20180222 KGHNHSFT Evidence Appendix Page 150
The service recognised that there was a high stillbirth rate in Corby, a more deprived area. As a result, additional community staff were placed in Corby to better support the women and families living in this area. The needs of the local population were also used to inform how services were delivered within the hospital. For example, the service recently commenced a joint antenatal clinic with a consultant obstetrician and a consultant haematologist. Pregnant women with a large body mass index (BMI) were referred to the clinic to commence preventative venous thromboembolism (VTE) treatment. A VTE is a blood clot that can form in the veins of the leg or lungs. The maternity service introduced this clinic because national research showed women with a large BMI were at increased risk of developing a deep vein thrombosis (DVT) during the first trimester of pregnancy. Medical staff told us that the prevalence of obesity among the local population, accessing antenatal care through Kettering General Hospital was high. Therefore, the clinic aimed to reduce any adverse VTE complications. The health profile for Northamptonshire, published by the Public Health England in 2017, also indicated that the county was significantly worse than the England average for adult obesity. A consultant from a specialist hospital held a clinic in the antenatal screening department twice a week. This clinic was for women who required additional ultrasound scans because concerns with their baby were identified during their routine scans and appointments. For example, heart problems and talipes. The maternity service introduced this clinic because it recognised that women struggled to attend their appointments at the tertiary centre because of poor public transport availability. There was no midwife led unit (MLU) at the hospital. At the time of the inspection, feasibility studies were being completed to investigate the options available to the service to create a MLU. However, women were given an informed choice about where they gave birth, in conjunction with consideration of their potential risk. Midwifery-led models of care were offered to women with an uncomplicated pregnancy. This included a home birth or the facilitation of a low-risk birth on the delivery suite. As part of its operational plan 2017-2018, the maternity service was reviewing the feasibility of creating a midwife-led birthing unit. As a response to patient feedback, partners were able to stay overnight on the delivery suite and Rowan ward if they wished. However, there were limited facilities for them to rest comfortably on the ward. All partners staying overnight signed a ‘visitor charter’ to ensure they were aware of the limited facilities. Representatives from the service attended the local Maternity Voices partnership (MVP; formerly known as Maternity Northants or the Maternity Services Liaison Committee) 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.
Meeting people’s individual needs
The maternity service generally took account of women’s individual needs. The maternity service employed specialist midwives, such as the bereavement midwife, infant feeding lead midwife, safeguarding midwife, midwife sonographers and a clinical quality and safety midwife. The service also employed four assistant practitioners. These new roles were developed to bridge the gap between healthcare assistants and registered midwives. The assistant practitioners supported specialist midwives, for example, bereavement, screening and
20180222 KGHNHSFT Evidence Appendix Page 151 safeguarding. Midwives at all levels spoke very positively of the assistant practitioners and told us they played an important role in managing women and their babies. An interpreting service was available for non-English speaking women and for women who used British sign language. All of the staff we spoke with knew how to access this service. Information leaflets were generally provided in English and staff told us they could get the leaflets printed in different languages. However, they told us this was challenging and difficult. This meant that women, whose first language was not English, might not have been fully informed about their care and treatment. We saw that the induction of labour information leaflets were available in alternative languages. The service had processes in place to support women with a learning disability. This included a flagging on the electronic record system, a specific learning disability pathway, and a ‘passport’ that highlighted the women’s specific communication needs and preferences. A midwife from the vulnerable community team also met with women and their families in the antenatal period. This meeting ensured that the service had the appropriate equipment required to support the woman during her labour. In addition, there was a learning disability lead within the trust that supported both patients and staff. Staff could access bariatric equipment when requested, for example bariatric beds and wheelchairs. The service employed a bereavement midwife, whose role was to develop bereavement care, provide support for parents and training and education for staff. There was a special counselling room in the fetal health unit to enable sensitive discussions to take place in privacy. It was also used by women who received bad news or were distressed, to allow them privacy and time alone or with a professional. During our last inspection in October 2016, we found that women attending for antenatal and gynaecology outpatient appointments shared the same waiting room and clinic times. This meant that women who had difficulty in conceiving were sharing the same area with pregnant women. At this inspection, we found that there was a separate gynaecology waiting area at the bottom of the maternity outpatient area. The fetal health unit shared the same waiting area as the early pregnancy assessment unit (EPAU). There were signs displayed in the reception area to warn women that there were shared waiting areas. This meant that women who may have experienced a miscarriage were sharing the same area with women who were much later on in their pregnancy, and this was not sensitive to their needs. Due to limited space within the maternity service, staff told us they were not able to move the reception areas. There was a dedicated room used for bereaved mothers and families, which was accessed through the delivery suite. This meant that women were cared for in a room next to other women delivering healthy babies and therefore, was not responsive to the woman and families’ needs. The service recognised this and it was documented on their risk register. The service planned to create a separate entrance to the bereavement room through a designated bereavement garden and a charity that focused on stillbirth and neonatal deaths had agreed to fund the garden. At the time of the inspection, the service was in the process of agreeing a pricing quote for the construction of the garden. Memory boxes, which included photographs and hand and footprints, were made up for parents who suffered a pregnancy loss. The boxes could be stored on the delivery suite until the family was ready to take it home.
20180222 KGHNHSFT Evidence Appendix Page 152
Cold cots (cooling units that allows families to spend extra time with their baby by regulating its temperature) were available to ensure babies could stay longer with their parents. The service also provided a cold cot to a local funeral home. This allowed families to take their baby home with them for a short period before their funeral. Parents were supported with making funeral arrangements where necessary. The hospital had a chaplaincy service, which offered support to parents who faced the loss of their baby. Chaplains of various denominations and faiths were available on request. Post-mortem examinations were offered in all cases of stillbirth and neonatal death in order to enhance future pregnancy counselling. Placental histology was also offered for all stillbirths. Women who had miscarried were cared for in dedicated areas that were dependent on their gestation. However, we were not assured that women experiencing a miscarriage were always provided care in a single room. This meant that women’s privacy and dignity was not always maintained. For example, women who miscarried from 14 to 20 weeks gestation were often cared for on the gynaecology ward, which did not have any single rooms. This was not documented on the service’s risk register. When we raised this with staff on the inspection, they told us that the delivery suite tried to facilitate and care for these women in its dedicated bereavement suite when it was available but this was still near women in labour and therefore, not responsive. The trust told us that women that miscarried were cared for in a side room on either the early pregnancy unit or on the delivery suite There was a named midwife for diabetes who supported women with diabetes from preconception to the postnatal period to help improve outcomes for women and their babies. Women with pre- existing diabetes and those with a history of gestational diabetes are at a greater risk of serious complications and morbidity. The service provided a birth options clinic, called ‘Choices’. The clinic provided an opportunity for women, who have previously had a caesarean section or traumatic birth, to explore the birth choices for their current pregnancy. At 34 weeks gestation, a maternity support worker offered all women and their families a pre-birth educational session. These sessions included information about safe sleeping, including optimum room temperatures and infant feeding. They also ensured the environment was suitable for a newborn baby. Women on Rowan ward and delivery suite were able to have drinks and snacks when they wanted them. The inpatient areas had communal areas, where women and their relatives could help themselves to tea, coffee, and water, and women who had recently given birth were offered toast and cereal. A water fountain was also available in the outpatient clinics. There were arrangements in place to support pregnant women and new mothers with mental health concerns. Staff referred women to their GP and the team of community midwives who provided care to vulnerable women. If urgent mental health concerns were identified, staff had access to a 24/7 mental health crisis team. In addition, if the woman was an inpatient on delivery suite or the ward, a psychiatric nurse provided one-to-one support. Community midwives had set up a Great Expectation Group. This group was held once per week in the Corby area and provided support and guidance to women who had been identified as being at risk of suffering with anxiety and depression during their pregnancy and the postnatal period.
Access and flow
Women could access the service when they needed it.
20180222 KGHNHSFT Evidence Appendix Page 153
The maternity service had not closed the unit on any occasions from November 2016 to October 2017. There was an escalation guideline to support staff during peaks in activity, which staff said was extremely comprehensive and gave clear and concise guidance. From Q4 2015/16 to Q1 2017/18, the bed occupancy levels for the maternity service were generally higher than the England average, with the trust having 66% occupancy in Quarter Q1 2016/17 compared to the England average of 59%. The chart below shows the occupancy levels compared to the England average over the period.
(Source: NHS England)
The service did not have a dedicated transitional care ward. This meant that babies who required more specialised neonatal care, such as phototherapy treatment for jaundice, were cared for on Rowan ward. During the inspection, senior managers told us that this was the reason why the service’s bed occupancy rates were higher than the national average. 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 also automatically sent to the women’s GPs. NICE guidance recommends that women should ideally be able to access antenatal care by 10 weeks gestation. From January to March 2017, a midwife saw 77% of women for their booking appointment by 10+6 weeks of pregnancy and 87% were seen by 12+6 weeks of pregnancy. This was slightly worse than our findings at our last inspection in October 2016 where 88% to 94% of women were seen by 12+6 weeks of pregnancy. It was not clear what action the service had taken to address this. During our inspection, staff said that the service had a historical problem with providing women their dating scan within the appropriate time range. This meant they could not always receive the recommended method of screening for Down’s syndrome, which was the combined test (a blood test and ultrasound scan). The service’s risk register also confirmed that there were delays in diagnostic testing. However, the screening midwife told us that this had drastically improved, and the number of quadruple tests (a blood test) for Down’s syndrome screening had reduced by 50% from July 2017 and September 2017. 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 20180222 KGHNHSFT Evidence Appendix Page 154
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. 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. It was a busy unit and we were told from 24 to 44 women could access it in a day. 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. However, there was no formal system to ensure women were assessed and reviewed in a timely way, as the waiting times for triage were not monitored. Elective caesarean section lists for theatre ran five times a week (Monday to Friday), with a maximum of three caesarean sections scheduled on a list. There was one designated obstetric theatre, which was predominately used for the elective caesarean section lists. Staff told us there could be delays in accessing a paediatrician to complete a newborn infant physical examination (NIPE) on the weekend. This often caused delays in discharges. Therefore, the service trained nine midwives to complete this examination. 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. Community midwives told us they struggled to contact the delivery suite when they needed to transfer a woman to the hospital from a homebirth. As a result, the service introduced a separate phone on the delivery suite for community midwives to contact. Feedback from community midwives during the inspection confirmed that the separate phone had improved this. 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.
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. Data from the maternity dashboard indicated that the service had received fifteen complaints from November 2016 to October 2017. The trust took an average of 29 days to investigate and close complaints and noted that all complaints were closed within agreed timescales. This was in line with trust policy, which stated that a response to a complaint should be within 25 days or 30 days if the complaint was complex. There were no open Parliamentary Health Service Ombudsman (PHSO) complaints at the time of our inspection.
20180222 KGHNHSFT Evidence Appendix Page 155
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. Meeting minutes confirmed that complaints and patient feedback were discussed at the monthly clinical governance meetings. Staff told us that information and learning from formal complaints were shared in the ‘spotlight on quality’ newsletter. This was confirmed when we reviewed the October 2017 newsletter. 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. However, staff did not record any issues and/or complaints raised through the listen to me campaign. Twelve out of the sixteen women and relatives we asked were aware of the ‘listen to me’ campaign and confirmed staff explained the process to them. 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
The maternity service had strong leadership at ward manager and lead midwife level to run a service providing high-quality care. However, leadership at the clinical business unit (CBU) level needed improvement. The maternity service was under the women’s and children services CBU. However, the trust planned to reconfigure its CBU structure in December 2017. At the time of the inspection, the senior management team for maternity consisted of a head of midwifery, two lead midwives, and a clinical director who was a consultant obstetrician. We met with the senior management team who demonstrated an awareness of the service’s performance and the challenges they faced. We saw there had been improvements with trust board oversight of the maternity service since our last inspection in October 2016. For example, the head of midwifery presented the maternity risk register to senior staff at the risk management steering group in November 2017, and presented the Maternity Safety Improvement Plan to the trust board in March 2017. The head of midwifery was also due to attend the trust board meeting in December 2017. The service did not have a non-executive director representative at board level. The director of nursing and quality was the service’s direct link to the trust board. We asked the senior team whom the nominated board level maternity champion was, as recommended in ‘Safer Maternity Care’ (2016). There was not a defined member of staff with this responsibility.
20180222 KGHNHSFT Evidence Appendix Page 156
The current patient safety lead was a registrar and therefore, struggled to attend the meetings due to their work rota. The service planned to reinstate a consultant into this position in January 2018. Not all staff could name the chief executive or members of the trust’s senior management team. However, they said the director of nursing and quality was visible, approachable and often attended meetings. For example, we were told that she regularly attended the infant feeding implementation group. All staff spoke very positively about the head of midwifery and the two lead midwives, with one member of staff telling us that the lead midwife “has fought for midwifery and what is right, she is amazing”. All staff we spoke with told us that the service’s senior management team were visible and regularly visited the clinical areas. During our inspection, we observed the lead midwives attending the clinical areas to support staff, discuss activity and any issues that had arisen. 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. We saw limited evidence of improvements with medical leadership and service oversight. We were not assured that medical staff had a clear awareness of risk, learning, and action plans due to poor attendance at the service’s risk, governance, and audit meetings. We observed clear and strong midwifery leadership at a local level with wards, units and community teams being well managed. All staff spoken with said they felt well supported by their line manager and were able to raise any worries they had. Junior doctors also confirmed they felt supported by the consultants. 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. At the time of our inspection, 14 midwives were trained to coordinate delivery suite. Senior managers told us that some of these midwives were due to retire. Therefore, the service had funded aspiring band 7 midwives to attend the RCM delivery suite leadership course in anticipation. There were consultant leads for specific services, such as diabetes, audit, and the delivery suite.
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, women, and key groups representing the local community. 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 launched a ‘Maternity Safety Improvement Plan, 2016 to 2020’ in January 2017 to respond to the recommendations laid out ‘Better Births’ (NHS England, 2016) and ‘Safer Maternity Care’ (Department of Health, 2016). The plan also linked with the Northamptonshire’s sustainability and transformation plan 2016- 2021. Progress against delivering the Maternity Safety Improvement Plan was regularly monitored and reviewed. A traffic light system was used to flag performance against the estimated delivery date. The maternity service did not have a midwife-led birthing unit (MLU) at the hospital. The head of midwifery told us that the service wanted to invest £30,000 in scoping the feasibility in building a
20180222 KGHNHSFT Evidence Appendix Page 157
four bedded MLU, which would be attached to the delivery suite. At the time of the inspection, feasibility studies were being completed to investigate the options available to the service to create a MLU. Staff in all areas we visited emphasised their commitment to providing safe care and improve women’s experience of care. They demonstrated they understood the trust’s 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 trust 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, and 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 lead midwives had an ‘open-door’ policy and encouraged staff to voice any concerns. Staff gave us examples of the support they had received from senior managers during times of personal difficulty. For example, the service offered assistant practitioner roles to staff that had been unsuccessful in the last module of their midwifery degree. This ensured the staff maintained their clinical skills and were able to earn a wage whilst they retook the final module. 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. However, we were concerned that not all incidents were being recognised in terms of severity and therefore opportunities to meet the Duty of Candour requirement may not be fully met. The maternity service celebrated staff success and we were provided with many examples during our inspection. For example, Rowan ward won the team of the year award in October 2017. The community midwives were nominated for the trust’s smile award in July 2017. They were nominated by the lead midwife for the way they dealt with the NHS cyber-attack. The trust had appointed a Freedom to Speak Up Guardian. The majority of staff we spoke with were unaware of this role or the trust’s whistleblowing policy. However, staff told us the local managers, the head of midwifery and the two lead midwives were approachable. They all had an ‘open-door’ policy and encouraged staff to voice any concerns.
Governance
The maternity service did not use a systematic approach to continually improving the quality of its services. It did not always safeguard high standards of care by creating an environment in which excellence in clinical care would flourish.
20180222 KGHNHSFT Evidence Appendix Page 158
Monthly clinical governance meetings were held by the service, which discussed service performance, incidents, complaints, clinical audit outcomes, and guidelines. We reviewed the minutes of these meetings from August 2017 to October 2017, and found they were detailed and contained copies of relevant reports, action plans, and lessons learned. The governance meetings were frequently attended by all grades of midwifery staff. However, there was limited representation from medical staff within the service. We attended the November 2017 clinical governance meeting and noted there was no medical staff from the maternity service present. There was also no medical staff in attendance at the October 2017 clinical governance. We corroborated this with medical staff who told us that they did not have the time to attend governance or risk meetings. We raised this with senior managers, who said that emails were sent to consultants after the meeting containing a copy of the meeting minutes. The clinical governance meeting terms of reference confirmed this. However, the consultants we spoke with informed us that they did not have enough time to read the minutes. Therefore, we were not assured medical staff had an adequate understanding of the risks and performance of the service. The terms of reference for the meeting also stated that all consultant obstetricians, gynaecologists, and paediatricians were members. However, they were not quorate so were not required to attend every meeting. 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, we observed this during the November 2017 governance meeting, and in meeting minutes, we reviewed. However, we were not always assured that timely and appropriate actions were taken to address areas where performance was not met. For example, induction of labour flagged as amber or red for a whole 12-month period on the maternity dashboard. It was only in August 2017 that the service decided they needed to complete an audit to review the clinical indications. The audit findings were due to be presented in December 2017. 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. We reviewed the meeting minutes from July, September, and October 2017 and found that there was medical representation at the September meeting only. The August 2017 scrutiny meeting was cancelled due to non-attendance of both midwifery and medical staff. However, the minutes confirmed that guidelines were not ratified until all of the comments made prior to and at the meetings were amended. The quality matron referenced updated guidelines in her monthly ‘spotlight on quality’ newsletter, which was emailed to staff. We saw evidence of this in the October 2017 newsletter. A senior manager had implemented a campaign called ‘listen to me’. The campaign was initially implemented on the delivery suite and ensured women felt listened to during their stay. 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. Since our last inspection in October 2016, the campaign has now also been introduced on Rowan ward. Senior
20180222 KGHNHSFT Evidence Appendix Page 159
managers told us this campaign helped to reduce the number of formal complaints raised. However, staff did not record any issues and/or complaints raised through the ‘listen to me’ campaign. Therefore, we were not assured that lessons learnt from all issues raised were disseminated to staff and used to improve quality of care.
Management of risk, issues, and performance
The maternity service systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were not always effective. A risk register was used to identify and manage risk to the service, and a senior staff member owned each risk. The risk register contained 21 risks, with the majority of risks added in the last 12 months. We saw an improvement in the identification and recording of risk on the risk register since our last inspection in October 2016 and the senior leads were able to clearly articulate the risks in the service and was to be done about them. However, we identified risks that were not documented on the risk register. These were women experiencing a miscarriage, not always being provided care in a single room, and poor medical staff engagement with both clinical governance and risk. At the time of our inspection, the service had not completed risk assessments for lone-working community staff carrying medical gases. We were concerned that senior managers had not recognised this as a potential risk and it was not documented on the service’s risk register. The quality matron implemented a monthly ‘risk meeting’ for the service. This was in response to the concerns we identified about risk management during our inspection in October 2016. This meeting helped to identify risks, agree the acceptable level of risk, and approve actions to mitigate the risk. Midwifery staff spoke positively of the new risk meeting because it enabled them to have an oversight over the risks of the entire service. Staff said medical staff attendance at these meetings was “non-existent”. We reviewed three sets of meeting meetings from July, August, and October 2017, and there were no medical staff representatives from the maternity service. This meant we were not assured that medical staff had an awareness of risk, learning and action plans, and that medical and midwifery senior staff worked collaboratively to improve service provision. The consultants had a monthly ‘cabinet meeting’. Meeting minutes from September, October and November 2017 showed these meetings were well attended by obstetric consultants and discussed operational and clinical issues, such as outstanding incident reports. However, there was no evidence that service performance, its challenges, and risks were discussed. Midwifery staff confirmed that the quality matron distributed a monthly ‘spotlight on quality’ newsletter. We reviewed a copy of the October 2017 newsletter and saw it 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 July 2017 to October 2017 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.
20180222 KGHNHSFT Evidence Appendix Page 160
The service held monthly local neonatal unit forum meetings. Representatives from both the neonatal intensive care unit (NICU) and the maternity service attended. The forum reviewed all term admissions to NICU and implemented any training or learning as a result. However, staff told us that there was generally poor attendance of obstetricians at this forum. 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. There was poor escalation and management of the ambient room temperature levels in treatment rooms on Rowan ward. We saw that the temperature of the treatment room on Rowan ward exceeded 35°C for four consecutive days from 11 July 2017 to 14 July 2017, and on two days staff recorded temperatures of 44°C. There was no evidence that ward staff reported or took the appropriate action to ensure that the medicines remained safe to use.
Information Management
The maternity 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 outcomes. However, 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. For example, modified early obstetric warning score (MEOWS), hand hygiene audits and the audit of labour ward epidural chart documentation was not documented on the audit programme. The audit leads told us they were in the process of completing an audit schedule for 2017/18 and we saw a draft version of this during the inspection. The medical staff audit lead had recently changed, and the audit team were hopeful that this change would help to improve the audit management of the service. 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 and we observed this when we attended a clinical governance meeting during the inspection.
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, partners could now stay overnight with women on Rowan ward.
20180222 KGHNHSFT Evidence Appendix Page 161
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. There was a Maternity Voices Partnership (MVP: formerly known as Maternity Northants or the Maternity Services Liaison Committee) which held meetings 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. Representatives from the midwifery team at Kettering General Hospital also attended the MVP forums. Regular newsletters, emails, notices in staff areas and ‘hot topics’ ensured ongoing staff engagement took place, this included a “you said, we did” notice board in the handover room on delivery suite. The community teams held monthly team meetings. Staff told us they had the opportunity to provide feedback to their managers during team meetings or appraisals and felt listened to when they raised concerns. Community midwives were part of the overall maternity team and felt they had good contact and communication with the hospital service. Staff felt actively engaged and involved in the planning and delivering of services. An example of this was the way the community midwives were instrumental in setting up the ‘Great Expectations Group’, which provided support and guidance for women who had been identified as being at risk of suffering with mental health concerns during their pregnancy and the postnatal period. There was a staff recognition scheme called the smile awards. Patients, relatives, staff, and visitors were invited to recognise staff that went the extra mile by nominating them for a smile award.
Learning, continuous improvement and innovation
There was a variable approach to whole service improvement. However, we saw many examples of promoting training, research, and innovation during our inspection. Staff spoke very positively about the practice development team and said they were encouraged and supported to complete additional training. This included a midwifery sonography course, high-dependency training, and the newborn infant physical examination training. A staff member also told us that the service funded them to complete their assistant practitioner training. A successful bid with Health Education England enabled the maternity service to invest and provide integrated multidisciplinary training, which also included paramedics and theatre teams. Both community midwives and paramedics attended the ‘childbirth emergencies in community’ training. The service developed new assistant practitioner roles to bridge the gap between healthcare assistants and registered midwives. The hospital achieved the United Nations Children’s Fund (UNICEF) Baby Friendly full accreditation in 2016. Community midwives had set up a Great Expectation Group. This group ran once a week in the Corby area and provided support and guidance to women who were identified as being at risk of suffering with anxiety and depression during their pregnancy and the postnatal period.
20180222 KGHNHSFT Evidence Appendix Page 162
The ‘listen to me’ campaign was implemented by the lead midwife for delivery suite following a neonatal death where the mother felt staff did not listen to her, and also from emerging themes from the service’s complaints, and the results from the CQC maternity survey 2015. The lead midwife presented the campaign to other healthcare professionals in a webinar hosted by NHS Improvement in May 2017. The Nursing Times also wrote an article about the campaign in March 2017. The maternity multidisciplinary safety huddle was awarded second prize at the RCOG and RCM safety leadership project awards. The service’s ‘Back to basics’ initiative was presented at the Maternity Midwifery and Baby conference in April 2017. The service implemented the campaign following the publication of the Francis report (2013). The aim of the campaign was to improve the ‘basic’ care for women and families. This included infection and prevention control standards, respecting patients’ dignity and ensuring women and families received equity of information. At this inspection, we found the following improvements since our last inspection in October 2016: Women’s privacy and dignity was protected on the delivery suite. The local maternity dashboard met the RCOG ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’, (2007). The service met the required level of consultant obstetrician presence on the delivery suite. The security systems on Rowan ward had been reviewed and appropriate actions taken to minimise the risk of visitors accessing the ward without being challenged. The service had reviewed the current practice where women who were having a termination due to abnormalities were cared for on the delivery suite in rooms next to women delivering healthy babies, and gynaecology and obstetrics women attending for these appointments, shared the same waiting room. Mandatory training compliance for midwifery staff had improved, particularly concerning ‘skills and drills’ training. A separate ‘risk’ meeting had been introduced to ensure the service recognised and documented all their risks on the local risk register. The majority of the risks we identified during our inspection were documented on the risk register. Formal complaints were handled in line with trust policy. Progress against the service’s strategy was regularly monitored and reviewed. The service had recently recruited three additional consultant obstetricians.
However, there were areas where they had not been any changes since our inspection in October 2016. 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. The staffing in maternity did not consistently meet the nationally recommended midwife-to- birth ratio of 1:28. Medical staff compliance with the trust’s mandatory training target. Eight of the ten mandatory training modules were below the trust target of 85%. The service did not have a non-executive director with responsibility for the maternity
20180222 KGHNHSFT Evidence Appendix Page 163
service. Therefore, we were concerned the trust board was still not fully aware of all the risks within the service.
Services for children and young people
Facts and data about this service The children’s and young people’s service at Kettering General Hospital consists of a Neonatal Intensive Care Unit (NICU) and a paediatric ward (Skylark ward) as well as an outpatient centre. The NICU had 18 cots. There were four cots for babies who required intensive care, six cots for babies who required higher dependency care, and eight cots for babies who required special care The paediatric ward has 26 inpatient beds; all 26 beds are open from Tuesday to Friday evenings, when the elective (non-emergency) lists were running. From Friday evenings until Tuesday mornings, only 18 beds are open. There were two beds for children who required closer observation in cubicles, which could be used for isolation. There also are 16 beds in cubicles as well as two four bedded bays.
The paediatric assessment unit (PAU) is co-located on the ward and consists of six beds in total and is open Monday to Friday from 9am to 9.30pm. There were two single cubicles and one four bedded bay.
Services for children and young people have a dedicated outpatients’ area for patients attending some appointments. Some patients are seen in adult areas, for example at the dedicated diabetes centre, ear, nose, and throat (ENT) and maxillofacial clinics.
We visited the service on 8 to 10 November 2017 and carried out an unannounced inspection to Skylark ward on 24 November 2017. We spoke with 43 staff, 11 young people, and their parents. We reviewed a variety of documentation, including 15 patients’ notes.
The trust has between 36 and 44 inpatient paediatric beds across two wards: Local Neonatal Unit: 18 beds.
Skylark Ward: 26 beds from Tuesday morning to Friday evening: 18 beds from Friday night to Tuesday morning. (Source: Routine Trust Provider Information Return (RPIR) – Sites Acute tab) The trust had 5,162 spells between 01 July 2016 and 30 June 2017. Emergency spells accounted for 95% (4880 spells), 5% (252 spells) were day case spells, and the remaining 1% (30 spells) were elective. Percentage of spells in children’s services by type of appointment and site, 01 July 2016 and 30 June 2017
20180222 KGHNHSFT Evidence Appendix Page 164
Total number of children’s spells by Site, Kettering General Hospital NHS Foundation Trust Site name Total spells Kettering General Hospital 5,162 This trust 5,162 England average 1,100,097 (Source: Hospital Episode statistics) Is the service safe?
Mandatory Training
The service provided mandatory training in key skills to most staff but did not always make sure everyone completed it. Medical staff mandatory training compliance was poor.
Mandatory training was an annual cycle for all staff. There was a structured induction programme in place for all new staff. All trust staff were expected to complete mandatory training modules. Some of the mandatory training was completed e-learning modules and it was expected that staff complete these during working hours when the ward was quiet. Staff were allocated dedicated time to complete ‘face to face’ mandatory training. In addition, staff on Skylark Ward had received training in working with children and your people with mental health needs.
A new staff member’s mandatory training profile was identified at their induction to meet the needs of their role, using the trust’s standard matrix. Any individual specific requirements were identified and this training profile added. Staff were informed as to their requirements through relevant staff handbooks and could see their own training profiles via their own electronic training records. Training was completed and entered onto the trust’s electronic system where any competences achieved through training completion could then be awarded.
The induction process for each new staff member was reviewed monthly as part of the service’s routine reporting process. Individual service area reports were sent to managers for validation and action and overview shared at clinical business unit meetings for local action. There had been an increase in e-learning modules and availability to offer alternative learning opportunities and widen access. Trust training was both face-to-face and e-learning. Senior staff said there had been a considerable amount of work undertaken to improve the compliance rates across the mandatory training portfolio with steady progress being made. The diversity and inclusion mandatory training for staff included information about protected groups, and what needs to be taken into account to provide high quality services.
20180222 KGHNHSFT Evidence Appendix Page 165
The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory courses as of July 2017 for medical/dental and nursing/midwifery staff in children’s services care is shown below:
Only manual handling (patient) met the trust target of 85% for medical and dental staff. Newborn basic life support had the lowest completion rate at 34% with 10 of 34 required staff having completed the training. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) We requested the training compliance figures as of the end of November 2017, which showed that out of all 19 mandatory training modules, medical staff had met the trust target of 85% in just two (infection control at 87% and paediatric basic life support at 87%). For basic life support (Adult) training, only 23 out of 31 medical staff had completed this (74%). For newborn basic life support training, 4 out of 27 medical staff had completed this (15%). For health and safety training, 19 out of 31 medical staff had completed this (61%). (Source: DR201a)
The service had an action plan in place to improve compliance with this mandatory training. This was also on the service risk register. Actions included: Progress was to be reviewed monthly at the paediatric divisional meeting with actions linked to medical staff appraisals. The clinical director and junior doctors’ college tutor would review training records for accuracy each month. The service was to record departmental European Paediatric Advanced Life Support (EPALS) training compliance (which covers basic life support and paediatric life support); this was to be communicated to the trust’s staff development team. Some doctors had completed EPALS but the trust’s workforce training reports did not reflect this. The European Paediatric Advanced Life Support (EPALS) course is collaboration between the European Resuscitation Council and the Resuscitation Council (UK).
20180222 KGHNHSFT Evidence Appendix Page 166
Training completion rates were generally higher for nursing and midwifery staff than medical and dental staff group. Only the modules relating to basic life support were below the trust target of 85% with newborn life support scoring the lowest. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
We requested the training compliance figures as of the end of November 2017, which showed that out of all 21 mandatory training modules, nursing staff had met the trust target of 85% in 16 (overall compliance with 76% of the modules). For basic life support (Adult) training, 58 out of 77 nursing staff had completed this (75%). For newborn basic life support training, 31 out of 39 nursing staff had completed this (80%). For paediatric basic life support training, 26 out of 38 nursing staff had completed this (68%). (Source: DR201a)
The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the paediatric divisional meeting. This was also on the service risk register. Each month the staff training board was updated to show who was out of date and due to expire in next three months. The service provided information of the actions being taken that included: Dates of basic life support drop-in sessions had been publicised to staff and staff were encouraged to attend in their own time if possible with the understanding that their hours attended will be logged on the trust’s payroll system. Dates of basic life support sessions were also highlighted on the staff rota and the ward diary as a reminder and were staff encouraged to attend whilst on duty. The practice development nurse and lead nurse were to provide ward support whenever possible support on ward to allow staff to attend sessions. Trained staff being booked onto Paediatric Immediate Life Support (PILS) full day and PILS recertification training sessions (as these sessions incorporated both adult and paediatric BLS). The practice development nurse was also to meet with the resuscitation team to arrange some bespoke BLS sessions for staff.
Safeguarding
20180222 KGHNHSFT Evidence Appendix Page 167
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Medical staff did not always have current training on how to recognise and report abuse. 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 intranet, including out of hours contact details for hospital staff. There were posters displayed with contact details of the hospital’s safeguarding team. 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. Relevant information and relevant contact numbers for safeguarding were seen on staff noticeboards and in public areas.
Nursing staff described how they identified children at risk of harm and how they made a safeguarding referral. We reviewed a sample of patient files and found that safeguarding referrals had been made appropriately and in accordance with hospital policy. They took appropriate actions to safeguard children. For example, we saw evidence that nurses escalated concerns about the safety of a child when they felt the plan for returning home was not appropriate. This led to a case conference to discuss the plan. The service made 25 safeguarding referrals about children in the year from August 2016 to July 2017. The service was not involved in any serious case reviews in the past year. Most safeguarding referrals, which related to self-harm were made by the emergency department (ED) prior to the child being admitted to Skylark ward and this was recorded in the child’s notes. Staff who worked on the paediatric ward checked to ensure a referral had been made in ED, and completed a referral if not. We reviewed a sample of four files and found that a safeguarding referral had been made as appropriate in each case
There was a named safeguarding nurse for children and a named safeguarding doctor for children (one of the paediatric consultants). The Director of Nursing and Quality was the hospital lead for safeguarding adults and children. Some nurses were shortly to attend a course in providing training to other staff for ‘Prevent’, which is part of the government policy to safeguard children and vulnerable people from being radicalised to supporting terrorism. The safeguarding lead reported a good working relationship with the local Child and Adolescent Mental Health Service (CAMHS), which was provided by another NHS trust.
Female Genital Mutilation (FGM) was included in level two safeguarding training, which all clinical staff attended. Staff were aware that they have a mandatory reporting duty to report any cases of FGM in females under the age of 18 years of age, including those females who have given birth to a female infant. This awareness may come from physical examination or from a verbal disclosure. Staff knew their responsibility to report this to the Police within 24 hours ideally but certainly within 28 days after being made aware of the FGM. FGM cases in children would be reported to children's social care using the interagency referral form, and an appropriate alert (red flag) placed on the electronic patient record.
Child Sex Exploitation (CSE) was included in level two and three safeguarding training. CSE is a form of child abuse and reportable to children’s social services in line with safeguarding procedures. Staff were aware of the potential indicators of abuse, the toolkit to use and how to complete an interagency referral. When a child was referred or CSE is suspected, an alert (red flag) flag was placed on the patient’s electronic record to alert staff to possible CSE concerns, detailing who to contact and how. The hospital policy for safeguarding children included FGM and CSE. Safeguarding supervision is a Department of Health requirement, as detailed in ‘Working Together to Safeguard Children’ (2010). A safeguarding case supervision policy was in date and staff had access to safeguarding supervision in line with hospital policy.
Following our October 2016 inspection, the hospital had introduced a separate missing child/abduction policy. This policy included the measures that should be taken to ensure security and to prevent a child’s abduction whilst on hospital premises, as defined under the Child 20180222 KGHNHSFT Evidence Appendix Page 168
Abduction Act 1984. There was a flowchart on what action to take on display at the nurses’ station. All staff we spoke with were able to tell us how they would respond to an abduction or attempted abduction. They described a lockdown procedure with main doors to the ward being closed following the alarm and a member of staff on guard. This was an improvement from the October 2016 inspection.
Staff knew how to make referrals to other agencies in cases of domestic abuse disclosure. Staff we spoke with were confident in talking about the types of concerns that would prompt them to make a safeguarding referral as well as the referral process. We reviewed a sample of records and found these contained relevant information such as reason for concern and previous information known.
An identity tagging system was in use to ensure the safety of children on the ward. The identity tags were checked on admission to the ward following transfer from ED and on a daily basis, as part of the routine wards check. We checked identity tags for seven patients and found three had no identity band. We raised this with senior staff, who took actions to address this. We checked another ten patients’ the next day, and the identity bands were present in accordance with trust policy. The hospital had a chaperone policy, which made specific reference to chaperone arrangements for children under the age of 16.
There are four levels of safeguarding training, levels 1, 2, 3 and 4. The Intercollegiate Document, ‘Safeguarding children and young people: roles and competences for health care staff (2014)’ states that, ‘all clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/ child protection concerns must be trained to level 3. Named lead professionals must be trained to level 4. Safeguarding training and refresher training was part of the mandatory annual training programme. We were told by senior staff that all the service was reviewing training requirements this is in line with national recommendations. Updates were provided annually on the mandatory maternity study day. We saw evidence that training covered all aspects of safeguarding children and included professional responsibilities, categories of abuse, safeguarding processes and child protection. The study day also included guidance and responsibilities regarding domestic violence, child sexual exploitation, parental drug and alcohol misuse, perinatal mental health and female genital mutilation (FGM). Staff were also encouraged to access e-learning courses.
In the women’s and children’s health division two practice ‘live’ drills were undertaken on the maternity unit and Skylark ward in the past year. Scenarios of an abducted child and missing child tested staff understanding and compliance with the internal security (abduction) policy and flow chart. Learning from the debriefing sessions identified: switchboard to be part of the information cascade to ensure notification of all parties and staff to be encouraged to use the emergency call bell on the ward. This had been incorporated into the abduction flow chart that was displayed at the nurse’s station.
The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding courses as of July 2017 for medical/dental and nursing/midwifery staff in children’s services is shown below:
20180222 KGHNHSFT Evidence Appendix Page 169
(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) The medical and dental staff group failed to meet the trust target of 85% for completion of any of the required safeguarding training modules.
We requested the training compliance figures as of the end of November 2017, which showed: For safeguarding adults’ level 2 training, only 11 out of 31 medical staff had completed this (35%). For safeguarding children level two training, 4 out of 6 medical staff had completed this (67%). For safeguarding children’ level three training, only 12 out of 25 medical staff had completed this (48%). (Source: DR201a)
The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the paediatric divisional meeting with actions linked to medical staff appraisals. This was on the service’s risk register.
Nursing and midwifery staff met the trust target for both of the required safeguarding training modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
20180222 KGHNHSFT Evidence Appendix Page 170
We requested the training compliance figures as of the end of November 2017, which showed: For safeguarding adults’ level two training, 68 out of 77 nursing staff had completed this (88%). For safeguarding children’ level three training, 70 out of 77 nursing staff had completed this (91%). (Source: DR201a)
Cleanliness, infection control, and hygiene
The service generally controlled infection risk well. Staff usually kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Standards of cleanliness and hygiene were generally well maintained on the Skylark ward and NICU. We observed the paediatric ward, outpatients’ department, and NICU to be visibly clean during our inspection. There were cleaning schedules, which outlined the frequency each area required cleaning. Nursing and support staff we spoke with told us that the cleaners did a great job and that they had no concerns.
All staff were required to compete infection control training. Medical staff training figures showed 87% compliance with infection, prevention, and control training as of November 2017, which met the trust target of 85%. Administrative and clerical staff training figures showed 100% compliance. Nursing staff training figures showed 90% compliance. (Source: DR 201a).
We saw that toys were cleaned as required and they did not use soft toys in the children’s play areas. There was a sticker system in place, which indicated equipment had been cleaned and we observed that stickers had been placed on equipment.
We observed that staff were ‘arms bare below the elbows’ and that they wore personal protective equipment as required and this was available throughout the ward areas. Hand gel was available at each doorway on the ward and clinical areas and we observed almost all staff using these. All taps were sensor operated. However, on one day of the inspection, we did see that five visitors and two staff did not gel their hands on entry and exit to Skylark ward. We also noted that not all nurses complied with the trust’s dress code by having ‘hair on collars and on the face’. We raised this with the senior nurse on duty, who took actions to address this. The staff that we had observed not following trust policy did not work on Skylark ward and senior staff agreed this highlighted the issue at a trust wide level.
The flooring on wards was smooth and curved around the wall to minimise the risk of bacteria collection. Isolation facilities were available on both the paediatric ward and NICU. Signs to inform staff of the need for isolation procedures were visible. The service had carried out a risk assessment and managed the risk for pseudomonas (pseudomonas is a bacterium commonly found in soil or water and can cause infections in people with a weakened or under developed immune system). Monitoring was ongoing to ensure a sustained period of no bacterium. There had been no infections reported because of pseudomonas.
Monthly hand hygiene audits were undertaken in each clinical area: the paediatric ward and NICU achieved 100% in June, July, August, September, and October 2017. Cleaning audits were also carried out for each area and both units consistently achieved compliance of 95% or above.
There had been no reported cases of MRSA, clostridium difficile or E.coli in the preceding 12 months. Clinical waste was appropriately stored and disposed of.
CQC Children’s Survey 2014 – Q26 In the CQC children’s survey 2014, the trust scored 9.23 out of ten for the question ‘How clean do you think the hospital room or ward was that your child was in?’ This was about the same as
20180222 KGHNHSFT Evidence Appendix Page 171 other trusts. (Source: CQC Children’s Survey, RCPCH)
Environment and equipment
The service generally had suitable premises and equipment and looked after them well. Skylark Ward was spacious, tidy and appeared very well maintained. It was a large ward and there was a long corridor from the entrance doors to the reception desk. Some staff said the layout presented challenges because of the long corridors and there was not always ‘line of sight’ on the main doors. There were nursing stations on each side of the ward, but there was not always a nurse present. During office hours, ward receptionists monitored who was requesting to enter the ward via a CCTV system.
Skylark ward was on level two of the main hospital site. Outside the ward was a balcony, which overlooked the ground floor. At the October 2016 inspection, this presented a risk to patients admitted to the ward with mental health concerns who may abscond from Skylark ward. We had raised concerns about the potential risks the balcony presented, and the trust carried out risk assessments urgently. The service had taken actions to improve the security of the ward since this inspection. These included: Placing netting above the balcony in the atrium. Placing the surveillance cameras at the optimum angle for covering the area outside the entry doors. Reinforcing with trust staff the importance of challenging anyone entering the ward without appropriate clearance. Extending the hours of security staff to 24 hours a day, seven days a week in November 2016. Senior staff confirmed there remained a problem of unauthorised people entering behind other people allowed entry onto the ward (‘tailgating’). The ward clerk kept an eye on the surveillance camera during the day but was not able to keep watch at all times. Senior nursing staff told us they worked closely with security staff and alerted them when there was a young person on the ward who might abscond or who might be violent. Staff told us, and we saw examples in the incident reports, of a prompt response when they alerted security staff. In an emergency, they used the ‘fast bleep’ and we were told security arrived in less than two minutes.
Whilst the staff on Skylark ward were very aware of security issues, we observed visitors and trust staff allowing other people to follow them into and out of the ward unchallenged. We also observed visitors were able to enter the ward by ‘tailgating’ through the double doors, once the original requesting visitor had entered the department. We raised this with senior staff, who took actions to remind all staff of the risk, as well as improving signage on the main ward entrance doors. A message was also sent out to all trust staff reminding them of the need to maintain security of paediatric areas. On our unannounced inspection, we saw that this had improved and we did not observe any ‘tailgating’.
The ward doors remained open for a period of 10 to15 seconds. This had been risk assessed in October 2016 and the original time of 20 seconds reduced to fifteen seconds. The lead nurse told us this enabled children in their beds or with equipment to enter and exit the ward safely. We reviewed the risk assessment undertaken in October 2016 and noted it was reviewed in December 2016 and the risk score had been downgraded. The risk was reviewed again and the risk scores maintained in April 2017 and May 2017. The risk was identified as a corporate risk and had been entered onto the trust risk register and clinical business unit risk register (CBU) in October 2016.
At our October 2016 inspection, we found that some environmental aspects of the paediatric ward (Skylark) were unsafe and not monitored or managed: we raised this with the trust urgently who took immediate actions. There had been ligature risks within the department, for example, shower
20180222 KGHNHSFT Evidence Appendix Page 172 rails, that had not been risk assessed appropriately. We had raised this as an urgent concern with the trust, which had provided us with assurance promptly to mitigate the risks.
The service had carried out a ligature and anchor point audit of Skylark ward and PAU in June 2017. This audit was to reduce the ‘obvious’, ‘attractive’ or ‘opportunistic’ ligature anchor points and ligature items that might enable or provide a young person in distress an opportunity to act upon their thoughts and feelings. Actions highlighted had been addressed. The service planned to carry out another full audit annually. A ligature can be defined as anything a person can use to hang or strangle themselves with. It can be made from anything that can be used to form a noose that may be used for self-strangulation, leading to asphyxiation and not necessarily obviously able to support body weight. Staff carried out a daily safety audit on Skylark ward. We saw five days’ audit forms that included all bays areas and rooms. Actions required were recorded. Staff also carried out a monthly audit for the ‘risk of self-harm’ on the ward.
During our inspection, we found that some staff-only storerooms containing equipment and potential ligature risks were not locked. We found the general store and equipment store both unlocked so there was a risk that visitors or unauthorised people could access equipment, ligature points, and oxygen cylinders. We raised this immediately as potential risks to the safety of patients and visitors to the senior nurses. We discussed the concern that learning from previous inspection findings had not been sustained throughout all the staff team on Skylark ward. Following our feedback about the environmental risks we found, a new senior staff environmental check, called the ‘Skylark Environmental Management Audit Walkabout’, was introduced in early November 2017 and was in place by our unannounced inspection. We saw that some environmental risks had been recognised and actioned immediately. We also saw improved signage on the storerooms to remind staff to ensure these were locked when not in use.
During this inspection, we also reviewed information as to how the safety of all patients being cared for on Skylark ward was being ensured. Comprehensive risk assessments and associated risk management plans were in place for CAMHS patients and children at risk of self-harm behaviour. Risk assessments contained an environmental risk assessment and there was evidence of effective plans of care including the appropriate level of observation and supervision required for children and young people. Nurses and assistant practitioners had undertaken training on how to complete the self-harm risk assessment tool and a competency based assessment package. This demonstrated staff on Skylark ward were assessing, monitoring, and managing the risks to prevent or minimise harm to children and young people with mental health conditions.
Staff on Skylark ward had completed competency training on using the self-harm risk assessment tool and was able to assess the appropriate level of supervision required by the child or young person. The level of supervision was clearly documented on the six self-harm risk assessments we reviewed. Staff had their competence assessed. The lead paediatric nurse told us consideration for the safety needs of other patients and staff on the ward would be dependent on individual circumstances. When required security staff would be deployed to observe the exit to Skylark ward on a 24-hour basis. This would be reviewed in light of the patient’s clinical condition.
Nurses, assistant practitioners, play specialists, and administrative staff were clear about the policies and protocols to follow when a child was found to be missing. Staff were able to explain a clear “lockdown” procedure to be operated immediately in all cases when a child was found to be missing. The flowchart displayed at the nurses’ station was specific to the ward environment and was reflective of the needs of the patients being cared for on the ward.
Storage space was generally sufficient. Storage facilities in the NICU were untidy and poorly organised. One storage room contained equipment, such as syringes, domestic supplies, alongside portable cots and Christmas decorations. The area was cluttered and there were boxes on the floor. This was brought to attention of staff, who said it would be actioned.
20180222 KGHNHSFT Evidence Appendix Page 173
Equipment was generally fit for purpose and had essential service and maintenance checks carried out in accordance with trust policy. Portable appliances had been checked. However, when checking resuscitation equipment, we found gaps in the records of daily checks that should have been carried out. We also found in one resuscitation trolley that some items of equipment had passed their expiry date. Audit results showed 94% compliance in August 2017, 98% compliance in September 2017 and 88% compliance in October 2017. (Source: DR212a). We immediately brought this to the attention of senior nurse, who replaced the out of date equipment. We saw on our unannounced inspection that additional daily senior staff checks had been implemented to ensure all resuscitation equipment was fit for purpose.
CQC Children’s Survey 2014 – Q2, Q7, Q25 In the CQC children’s survey 2014, the trust scored 9.49 out of ten for the question ‘Did you feel safe on the hospital ward?’ This was about the same as other trusts. The trust scored 9.46 out of ten for the question ‘Did you feel that your child was safe on the hospital ward?’ This was about the same as other trusts. The trust scored 9.39 out of ten for the question ‘Did the ward where your child stayed have appropriate equipment or adaptions for your child?’ This was better than other trusts. A list of all scores from the survey which fall under the safe domain are listed below. CQC Children’s Survey questions, safe domain, Kettering General Hospital NHS Foundation Trust Question KLOE Sub- Trust RAG group Score 25. Did the ward where your child S3 0-15 9.39 Better than other stayed have appropriate equipment Adults trusts or adaptions for your child? 26. How clean do you think the S3 0-15 9.23 About the same as hospital room or ward was that your Adults other trusts child was in? 53. For most of their stay in hospital S3 0-15 9.87 About the same as what type of ward did your child stay Adults other trusts on? 7. Did you feel that your child was S3 0-7 9.46 About the same as safe on the hospital ward? Adults other trusts 2. Did you feel safe on the hospital S3 8-15 9.49 About the same as ward? CYP other trusts
(Source: CQC Children’s Survey, RCPCH)
National Paediatric Diabetes Audit Patient and Parent Experience Measures (PREMS) Children and young people survey 2015/16
The National Paediatric Diabetes Audit (NPDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Paediatrics and Child Health (RCPCH). The PREM report helped clinic staff to consider whether their perception of the care delivered corresponded with the experience fed back by patients, that it would support them to share best practice across regional networks, and to provide a basis for quality improvement activity. Overall, the outcomes for the service were better than regional and national comparators.
20180222 KGHNHSFT Evidence Appendix Page 174
Question 1e: ‘The environment at my clinic is right for my age and it’s a pleasant place to wait’: the service scored a combined 93.4% for ‘strongly agree’ and ‘agree’ responses, much better than the regional comparator of 75.1% and the national comparator of 83%.
(Source: DR44d)
Assessing and responding to patient risk
The assessment and management of risks to patient safety had generally improved but some risks remained.
Risk assessments required completion for all patients on admission to the wards. We reviewed a sample of patient records and generally found these to be completed for their medical condition. However, two patients out of 10 did not have a fully completed risk assessment in their records: we raised this with senior staff, who took action to address this immediately. There was not a risk assessment tool in use for the risk of skin damage caused by continuous positive airway pressure devices (CPAP). No nutritional risk assessment had been competed at all for seven patients in 10 sets of records seen. There was no risk assessment tool in use for the risk of development of pressure ulcers. At our unannounced inspection, we saw that a new risk assessment tools had been introduced and a patient documentation audit daily check was being carried out by senior nurses.
When we inspected in June 2017, we found there had been improvements in risk assessment of young people at risk of self-harm. Staff we spoke with on this inspection told us they felt these improvements had been maintained. Staff in the hospital’s emergency department undertook an initial risk assessment, with ward staff reassessing on admission to Skylark and then every day.
From our review of records, the risk assessment for patients who had mental health needs was generally consistently completed and contained sufficient detail required to give guidance for staff providing care. Patients who were admitted to the ward with mental health concerns, for example, if the patient had self-harmed or attempted suicide, were routinely provided with one to one care in accordance with hospital policy. There was a formal risk assessment to determine whether one to one care was required, if the environment was suitable, and whether adjustments were needed. Six out of seven patients’ notes reviewed had a detailed and appropriate risk assessment in place. One risk assessment did not contain sufficient details as the patient had been off the ward (with a staff escort) three times and a formal risk assessment for this had not been completed. We raised with the lead nurse, who took immediate actions to address this.
20180222 KGHNHSFT Evidence Appendix Page 175
The ward was an acute paediatric ward so it was not designed or commissioned to provide a completely ligature-free environment. However, this was mitigated by thorough risk assessments being carried out. At our unannounced inspection, we saw that the lead nurse had implemented a daily ward environmental and risk assessment check.
The paediatric lead nurse reviewed the enhanced risk assessment tool daily and incorporated the findings into a monthly audit. Compliance for the completion of the enhanced risk assessment tool was 100% for the period January 2017 to October 2017, apart from June 2017, when it was 96% and September 2017, when it 94%. This demonstrated patients were receiving the appropriate level of care and the tool was becoming embedded in practice.
Following the October 2016 inspection, the service had taken a series of actions to support staff in the management of younger people who presented with mental health conditions. This included provision of specific risk awareness training for ward staff. We requested the training compliance figures as of the end of November 2017, which showed that overall 81% of staff had had this training, just below the trust target of 85%. 19 out of 31 medical staff had completed this (61%). 66 out of 77 nursing staff had completed this (86%). (Source: DR201a)
The training compliance figures as of the end of November 2017 also showed that overall 87% of staff had had conflict resolution training, above the trust target of 85%. 20 out of 31 medical staff had completed this (65%). 71 out of 77 nursing staff had completed this (92%). (Source: DR201a)
From training data provided, 47 out of 47 eligible nursing staff had training on the service’s mental health risk assessment tool and CAMHS awareness. All but four staff (all new starters) had had signed off in being competent to use the risk assessment tool. 50 out of an eligible 62 ward staff had had paediatric conflict training (81%) and we saw further training dates had been arranged. This represented an improvement on the October 2016 inspection. Staff spoke with felt confident in assessing risks to patients’ safety.
When one to one care was required, it was provided by ward staff who had received mental health training, or by the child’s parent or carer. If the parent or carer provided one to one support, nursing staff provided care and treatment for any medical health needs.
Trust security staff had been provided training sessions on managing violence and aggression including safe breakaway and conflict resolution called the ‘PACT Programme’: which covered proactive and responsive strategies to prevent or manage challenging, aggressive and violent behaviours. All 44 security staff had had this training in 2017.
Staff told us they were confident following their risk management and mental health awareness training in caring for these patients. However, some staff expressed concerns around the appropriateness of Skylark ward to care for children and young people who exhibited violent and aggressive behaviour. The ward was not a designated secure mental health unit and patients had previously absconded from the ward. Patients assessed by the medical team and deemed as medically fit waited on Skylark ward until an in-patient specialist mental health bed became available. There was ongoing limited availability of specialist in-patient mental health beds in Northamptonshire and nationally. This was reflective of system-wide pressures. Senior staff said there were good, open relationships with CAMHS team in the local NHS mental health trust that were always responsive to the needs of patients with mental health issues. Waiting times for assessments were usually on the day of referral to the ward. However, if admission occurred after midday the assessment was likely to be delayed until the next day.
20180222 KGHNHSFT Evidence Appendix Page 176
During this inspection, we reviewed the monthly self-harm audit of children and young people admitted to Skylark ward. There were 114 CAMHS patients and children at risk of self-harming behaviours admitted to Skylark ward from June 2017 to November 2017. This was a slight reduction from January 2017 to May 2017 when 138 CAMHS patients and children at risk of self- harming behaviours were admitted to Skylark ward. In the period June to November 2017, children and young people with deliberate self-harm behaviours were risk assessed and this identified 51% (58) were high risk and required 1:1 supervision from staff. (Source: DR209)
Skylark ward had two beds in a shared room which they used to care for patients who had ‘higher dependency needs’ although the hospital were not commissioned to provide high dependency care. There was set criteria for which patients could be admitted to the higher dependency room. The service did not have a paediatric intensive care unit (ICU) bed, so patients who required ICU level care were stabilised in the adult intensive care unit and transferred to a suitable tertiary centre. We were told that if a patient was admitted a children’s nurse would be requested from the paediatric ward. Children who required intensive care were transferred to a tertiary centre. Paediatric patients were collected by another NHS acute hospital retrieval team and neonates transferred by the neonatal network retrieval team. There was a policy on care management of the critically ill child or transfer of critically ill child. NICU had four intensive care cots, six HDU cots and eight special care cots. There were formal criteria for which babies could be admitted to each cot.
A paediatric early warning score (PEWS) tool was used to monitor and manage deteriorating patients on the paediatric ward. A separate tool was used according to the child’s age and we saw evidence of these used. Each patient’s PEWS score had to be calculated on admission and subsequently at the agreed frequency in accordance with their latest score. We noted that observations were consistently completed in line with the determined frequency and the age related PEWS chart had been used. The paediatric department carried out monthly audits on completion of PEWS, the results for July 2017 indicated that 100% of patients had a correctly added PEWS score. We saw from patient notes seen that ward staff used PEWS and took action when there was evidence of deterioration. For example, we saw that a junior doctor reviewed a patient and contacting a more senior doctor.
We also noted that a situation, background assessment recommendation (SBAR) communication tool had been used consistently in records reviewed. The SBAR tool was used to ensure accurate information is escalated as required.
Nursing staff told us of improvement in the awareness of the signs of sepsis in babies and children. Staff had received specific training in ‘sepsis six’ and everyone was aware of the importance of prompt escalation to medical staff. The paediatric sepsis screening and immediate action tool was implemented in the service in April 2017. KGH had a collaborative arrangement with another local NHS trust sharing their sepsis screening and immediate action tool. This eased the burden on junior doctors who often rotated between the two trusts and so will be familiar with the tool. The sepsis screening and immediate action tool (Sepsis 6) were available to staff. The sepsis screening and immediate action tool is a two-sided page with the sepsis screening tool on one side and the sepsis six on the other. Sepsis screening was prompted by a PEWS of three or more. In the service as of November 2017, 30 of the required 38 staff had received paediatric sepsis training since March 2017. The newly appointed practice development nurse on Skylark ward was to be involved in ongoing training. (Source: DR205). There were three separate screening tools for patients of ages 0 to 4 years, 5 to11 years, and 12 to 17 years.
Commissioning for Quality and Innovation (CQUIN) national goals. CQUIN stands for commissioning for quality and innovation. The system was introduced in 2009 to make a proportion of healthcare providers' income conditional on demonstrating improvements in quality and innovation in specified areas of patient care. The hospital was taking part in the ‘Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis) 2017/19’ CQUIN. The purpose of this CQUIN in 2017 to 2019 is to embed a systematic approach to the prompt
20180222 KGHNHSFT Evidence Appendix Page 177 identification and appropriate treatment of life threatening infections, while at the same time reducing the chance of the development of strains of bacteria that are resistant to antibiotics. In the hospital, an audit methodology had been agreed with local commissioners to achieve the CQUIN indicator reporting the percentage of patients who met the criteria for sepsis screening and were screened for sepsis. The indicator applies to adult and child patients arriving in hospital as emergency admissions and to all patients on acute in-patient wards. Data was not separated specific to children and young people. For the hospital overall, quarter two 2017/2018 outcomes were
CQUIN 2a – Timely identification of sepsis in emergency departments and acute inpatient settings. In the ED, 63% patients of patients who met the criteria for screening in Q2 were screened for sepsis. Therefore this target was been achieved in Q2. The data was not separated between adults and children. In the inpatient wards, 77% of patients that met the criteria for screening in quarter two were screened for sepsis in KGH. Therefore, for the available cases, this target was achieved. CQUIN 2b – Timely treatment for sepsis in emergency departments and acute inpatient settings. In the ED, 60% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. Therefore, this target was achieved in quarter two. In the inpatient wards, 78% of patients prescribed antibiotics for red flag sepsis were administered these within one hour. Therefore, for the available cases this target was achieved. (Source: DR45)
A paediatric diabetes service was available for urgent referrals, Monday to Friday and on call at weekends. There was a dedicated inpatient diabetes specialist nurse with responsibility to visit the wards daily (on weekdays).The nurse routinely visited the admissions wards and in addition those areas that have requested a review based on a priority ‘traffic light’ system.
The service used the World Health organisation (WHO) ‘Five steps to safer surgery’ checklist for all surgical procedures. This had been audited on a daily basis since its introduction into the trust. For the last 12 months, the findings varied between 70% to 100% compliance. July's 2017 audit figures showed 100% compliance.
Nurse staffing
The service did not always have enough 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. Staffing levels were generally planned and reviewed in advance based on an agreed number of staff per shift and patients’ needs were met at the time of the inspection. An acuity tool was now used to determine staffing levels for paediatric inpatients. The trust had identified that staffing levels were a pressure in the service and this was recorded on their risk register for the wards but not for outpatients. Staffing levels for NICU had also been identified as a risk. This was monitored on a daily basis. The potential impact on safety because of nursing shortfalls was on the service risk register. Control measures listed on the risk register including planning rotas in advance and filling gaps by offering shifts to staff to work as additional hours or bank shifts. The newly appointed head of service was in the process of identifying all paediatric nursing staff at the trust, for example, those working at outpatient clinics at the hospital and at satellite units. This would ensure they were supported professionally, and widen the pool of nurses available. The senior nurse had recently emailed paediatric nurses to ask for their interest in working additional hours when there were gaps in the rota. Senior staff in children’s services were authorised to use agency staff up to a cost ceiling when there were no bank staff available.
The service had carried out a staffing needs analysis and determined that they were not always meeting the recommended level of nurses in accordance with the Royal College of Nursing (RCN)
20180222 KGHNHSFT Evidence Appendix Page 178 safer staffing guidance. RCN guidance states that there should be a ratio of one nurse to three patients for children under the age of two years, a ratio of one to four for patients over the age of two years, during the day and night shifts, and that an experienced band 6 should be on duty over the full 24 hour period. The guidance also stated that, ‘the standard for a general inpatient ward should reflect the age of the child as well as acuity. Hospitals should therefore use a proven methodology to assess acuity of patient care that clearly reflects the needs of children, not adults. The service had introduced an acuity tool prior to the inspection. Staffing levels had increased since the October 2016 inspection. On the days of the inspection, we saw actual planning levels met planned staffing levels.
The trust had introduced an electronic staff rota system that took into account patient numbers, and their acuity and or dependency to ensure that the right staff with the right skills were in the right place at the right time. This system also demonstrates the service was using evidence-based tools to inform decisions on setting appropriate establishments. Daily staffing issues were identified quickly, and the system used to identify other areas from where it may be possible to move staff. Senior managers quickly identified whether wards, units, and teams were staffed safely, and intervened where necessary. Staffing was discussed at every capacity meeting and safety huddle, moving staff and escalating to bank and agency for cover. There were an agreed number of nurses and assistant practitioners (assistant practitioners are highly skilled healthcare assistants who have undergone additional training) working each shift and this varied depending on the number of beds open on the unit. At weekends and from Friday evenings until Tuesday mornings, there were 18 beds open and from Tuesday mornings until Friday evenings, there were 26 beds open. When there were 18 beds open, there were six nurses per shift during the day and five at night with one assistant practitioner. When there were 26 beds open, there were seven nurses and two practitioners. PAU had two nurses on duty whenever it was open. The service provided information that staffing levels were based on the Royal College of Paediatrics and Child Health (RCPCH) ‘High Dependency Care for Children – Time to Move On’ (October 2014). This document recommended that there should be a minimum of one nurse on every shift, who is directly involved with caring for the critically ill child who must have completed a recognised paediatric resuscitation course (Resuscitation Council UK 2010/ALSG 2011). The service was working towards this but did not always meet this for every shift. The lead nurse informed us that the rota did flag this when it occurred and that appropriate support would be available from the matron and the lead nurse who would work on the ward.
We saw 66% of neonatal nurses had completed their post registration qualification, which did not meet the British Association of Perinatal Medicine (BAPM) of 70%. We were told that there were additional staff completing the qualification.
Senior staff moved paediatric nursing staff between ED and Skylark Ward when one area was under pressure. Neonatal staff were also expected to come to Skylark Ward when there were sick babies to care for and the ward was under pressure. However, we were told staff were reluctant to move from the neonatal unit. Senior staff regularly reviewed staffing on Skylark Ward. Nursing staff commented on the challenges of managing the care of babies and children with high needs. For example, in winter there might be four or five babies at any one time who required help with breathing through heated humidified high-flow (HHHF) therapy. There were young people at risk of self-harm, who required one to one care. The head of service informed us that they had decided to close some beds on the ward one day in the week before our inspection because of the number of children with high care needs on the ward. We saw a completed staffing acuity tool, used to assess the appropriate level of staffing for the patients in the ward for 8 November 2017. However, this tool was not routinely used. There were two high dependency beds, with at least one nurse to care for two patients.
20180222 KGHNHSFT Evidence Appendix Page 179
We observed nursing handovers on NICU as well as the paediatric ward, which were detailed and effective. We observed that each child or baby on the unit/ward was discussed by the nurse in charge and each patient was allocated to a nurse for their shift. We saw that there were induction processes in place for when temporary staff were used.
The trust advised that as of the 30 September 2017 there was a 9.66% vacancy rate for nursing staff in children and young people. (Source: Additional request DR37). The trust advised that as of the 30t September 2017 there was a 14.90% vacancy rate for health care assistants in children and young people. (Source: Additional request DR37). The trust advised that as of the 30 September 2017 there is a 12.7% turnover rate for nursing staff in children and young people. (Source: Additional request DR38). Between August 2016 and July 2017, the trust reported a sickness rate of 5.7% in children’s services. This is higher than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness). The trust has provided the total number of shifts filled by agency staff (80) and bank staff (263) over the last 12 months: however, they have not supplied the total number of shifts available so we are unable to provide percentage usage. (Source: Additional request DR39). Five nurses staffed NICU during the day and night shifts. The service planned to have a minimum of three neonatal nurses qualified in speciality (QIS). The unit recognised that they were not always compliant with the BAPM guidance if the unit was at full capacity. BAPM guidance recommends a ratio of 1:1 for ITU cots, 1:2 HDU cots and 1:4 SCBU cots. This had been identified as a risk on the paediatric risk register and staffing levels and acuity of babies was monitored and reported on a daily basis. It is also recommends the number of nurses who should be (QIS) and this was monitored daily. We saw that incident forms were completed when staffing levels and skill mix did not meet BAPM guidance. Staff we spoke with that the unit was adequately staffed and that staff usually had time to take breaks.
The paediatric outpatient department was run by adult nurses and was part of a different clinical business unit and now worked closely with paediatric inpatients staff. There was a main paediatric outpatient department who saw the children and young people for most specialities. There was also a specialist diabetes centre. Children seen by the ear, nose and throat, ophthalmology and maxillofacial teams, were seen within the main adult outpatient department. A paediatric nurse from Skylark ward did attend clinics including the paediatric asthma and allergy clinics, the paediatric gynaecology clinic and paediatric murmur clinics. The trust had also recruited a paediatric nurse to support the general paediatric clinics to meet RCN guidance, which states that, ‘a minimum of one registered children’s nurse must be available at all times to assist, supervise, support and chaperone children’.
The lead nurse told us of the service’s plans to recruit more nurses to allow Skylark ward to open to 26 beds at the weekends. Recruitment was ongoing and it was anticipated this change would take effect from April 2018.
Medical staffing
The service did not always have enough 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. Consultant cover had improved since the October 2016 inspection. There were ten consultants employed for children and young people’s services. Consultants told us there was a flexible rota that provided appropriate cover at consultant, middle grade, and junior doctor levels. There had been two recent consultant appointments, including a locum. There was a consultant of the week
20180222 KGHNHSFT Evidence Appendix Page 180 who had the overview of children on Skylark ward. There was a consultant on site until 7.30pm (summer) and 9pm (winter) who was then on call. There were two middle grade doctors on site from 9am to 9pm, one covering Skylark ward and the PAU and one supporting the NICU and reviewing emergency department referrals.
The clinical leads for ED and paediatrics were working closely to provide rotation programmes to support staff competency and provision of expertise.
All grades (junior, middle grade and senior/consultant grade) were available 24 hours a day, seven days a week. The junior and middle grades were on site. There was onsite consultant cover until 7.30pm hours (and extended to 9pm in winter months), thereafter the on-call consultant was available to advise or attend the hospital, as required. Specialist advice (by telephone) could be accessed 24 hours day, seven days a week by the middle grade or duty consultant. Emergency advice for acutely unwell patients was obtained from the relevant on call tertiary consultant (at a specialist NHS hospital). The service had access to six specialist tertiary centres in the central region. The trust have advised that as of the 30 September 2017 there is a current vacancy rate of 15.76% for medical staff in children and young people. (Source: Additional request DR40). The trust have advised that as of the 30 September 2017 there is a current turnover rate of 41.55% for medical staff in children and young people. (Source: Additional request DR41). Between August 2016 and July 2017, the trust reported a sickness rate of 3.2% in children’s services. (Source: Routine Provider Information Request (RPIR) P19 Sickness). The trust has provided the total number of shifts filled by agency staff (218) and bank staff (181) over the last 12 months: however, they have not supplied the total number of shifts available so we are unable to provide percentage usage. (Source: Additional request DR42). A review of a sample of rotas confirmed that the actual medical cover agreed to the planned staffing arrangements. Locums were used as required to ensure gaps in the rota were filled, for example, to cover sickness or annual leave. A standard checklist was used to induct locums into the service. Locums who worked for the service long term accessed the hospital induction as well as mandatory training.
Handovers took place twice each day and were led by a consultant paediatrician. We observed a handover and found that these were appropriate, relevant and appropriate information was discussed.
Consultant cover was provided ten hours a day Monday to Friday in the summer months and on- call arrangements were in place. This was an improvement on the October 2016 inspection. This did not meet the recommended BAPM guidance of 12 hours daily cover and meant there was a risk that not all children admitted to the ward with an acute medical condition could be seen by a consultant within 14 hours of admission as recommended by Royal College of Paediatrics and Child Health (RCPCH), ‘Facing the Future’ guidance. This was on the service’s risk register. We reviewed five sets of notes and saw that all patients had been reviewed by a consultant within 14 hours.
As of June 2017, 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 higher than the England average.
20180222 KGHNHSFT Evidence Appendix Page 181
Staffing skill mix for the 29 whole time equivalent staff working in Children’s services
This England Trust average Consultant 31% 42% Middle career 3% 7% Registrar Group 50% 44% Junior 16% 7%
(Source: NHS Digital Workforce Statistics)
Records
Staff did not always keep appropriate records of patients’ care and treatment. Not all records were clear, up-to-date, and available to all staff providing care.
The trust had mostly a paper based clinical records system. The nursing notes were not always completed contemporaneously and there were entries from play staff as well as nursing staff. In three sets of notes, we found gaps in assessments and a lack of contemporaneous notes. There were gaps in some records as staff said they updated at end of shift when they were busy. Fluid input and output were recorded on a fluid chart. However, there was no daily balance recorded. We raised this with senior staff, who took actions to remind staff of the need to ensure accurate recording. At our unannounced inspection, we saw that a patient documentation audit daily check was being carried out by senior nurses.
We reviewed nine sets of medical notes and found these were legible, signed and dated. However, seven of these sets of notes were not stored in a file and were loose. Nursing notes were kept separately from medical notes. Nursing notes were kept in a discrete wall mounted holder at the entrance to the patient bays or rooms and medical notes were kept in the office, some distance away.
The medical records department was based at an off-site building approximately one mile from the main site. Notes were transported between the off-site facility and the main site using a dedicated courier service. Compliance for notes in outpatient clinics, including children’s clinics, was 97%.
Regular quality visits were made by managers to check that staff were compliant with the confidentiality of records in clinical areas and lockable records cabinets were now in place. All records were stored confidentiality during out inspection. Monthly record audits took place on the quality of patient notes for both neonates and paediatric patients. Findings were reported as part of the monthly nursing indicator dashboard.
The monthly nursing indicator audit included quality measures to ensure documentation had been adequately completed for paediatric early warning scores (PEWS). For the three months prior to the inspection, audits showed 100% compliance. PEWS is a tool used to monitor and manage deteriorating paediatric patients. Some of the measures audited were; checking vital signs,
20180222 KGHNHSFT Evidence Appendix Page 182 checking for tissue damage, baby discharges notified to the midwife or health visitor, hospital passports completed for patients living with a learning disability, allergy status and medication errors.
Some children and young people had ‘open access’ to the ward and were able to contact the ward directly for admission. We looked at the open access folders, which were filed appropriately. Of these files, the last dated entries were as follows: 83 dated 2017. 40 dated 2016. 132 dated 2015. 61 had last been updated before 2015, with 13 of these update before 2010. 18 had no review date.
We saw that one patient with a complex medical condition who had open access to the ward came to PAU via the main ED. Staff were not able to locate the open access plan for this child. Medical staff therefore used their clinical judgement to rely on parents’ history to make a care plan based on experience. We raised this immediately with senior staff, who were able to retrieve the patients’ medical notes, which did not contain an open access plan. At our unannounced inspection, we saw that the service had plans in place to review all open access patients’ notes to ensure a formal plan was in place. The trust plans included the lead nurse to review all of the patient open access information, which was kept on the ward, to ensure it was up to date. They would also be working with the medical consultants to develop a proforma which will be completed by the consultants when offering patients open access to the ward or PAU, which will then be sent to the ward, along with a copy being kept with the patient. This process was to be undertaken by the end of January 2018.
Medicines
The service generally prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. Medicines were generally available when needed, and a member of the pharmacy team reviewed prescriptions and was available for advice. There were suitable arrangements in place for management of medicines, which included the safe ordering, prescribing, dispensing, recording, handling, and storage of medicines.
We found that medicines were securely stored in the ward and NICU and that controlled drugs were stored in accordance with the required legislation. A controlled drug (CD) register was used to record the details of the CDs received, administered as well as CDs that had been disposed. Some prescription medicines are controlled under the Misuse of Drugs Act (1971). These medicines 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. We reviewed a sample of controlled drugs and found that accurate records had been maintained.
We saw that room and fridge temperatures were checked and that these had all been within the required range and we noted that checks had been performed consistently on the Skylark ward. This was an improvement on the last inspection.
Medicine records were completed for patients. A medicine administration record specific for children was used to record medication prescribed and administered and we saw that these had been completed appropriately for the patient files we reviewed. Each patient had their weight checked and prescriptions were written accordingly. If patients were allergic to any medicines, this was recorded on their prescription chart.
20180222 KGHNHSFT Evidence Appendix Page 183
There was a dedicated pharmacist for Skylark ward and NICU who came to the ward daily Monday to Friday. Checks were made on stock levels as well as audits of the controlled drugs registers; pharmacists also undertook checks on patient drug records.
We saw that on one occasion a nurse prepared the medicines for a child and signed the chart but did not administer the medicines straight away. If something had happened to prevent them administering the medicines, the chart would not have accurately reflected the situation. Five out of six medicine charts wen reviewed had been completed accurately. However, one medicine chart had several blank spaces meaning that it was unclear whether medicines had been given at those times. A nurse told us that the child was at home at that time and was given medicines by their parents. Neither the chart nor the patient notes included a record of medicines administration while away from the ward. The code on the chart for ‘not on the ward’ had not been used. Parents were involved in giving medicines to their children while on the ward, but staff were not aware of a policy to cover how this was managed safely. We saw the trust’s Medicines Code, which included a section on medicine self-administration. The policy covered self-administration by carers but did not specifically reference parents and children. The policy required patients / carers to be assessed by a trained assessor to determine whether it’s appropriate for them to administer medicines but there were no records to show that the parents were giving medicines.
CQC Children’s Survey 2014 Data – Q53 In the CQC children’s survey 2014, the trust scored 9.87 out of ten for the question ‘For most of their stay in hospital what type of ward did your child stay on?’ The measure is if children spent most of their time of a children’s ward rather than an adult ward. This was about the same as other trusts. (Source: CQC Children’s Survey, RCPCH) In the period 1 November 2016 to 25 October 2017, the service reported 45 incidents relating to medicines. For Skylark ward, there were 31 medication errors/incomplete drug records. We saw that appropriate actions had been taken to reduce risks to patients for individual incidents and learning identified where appropriate. For NICU, there were 13 medication errors/incomplete drug records incidents reported in this period. (Source: DR49)
Incidents
The service generally managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated individual incidents but there was a lack of sharing lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Staff generally understood their responsibilities to raise concerns, record and report safety incidents, concerns and near misses, and how to report them. When things did went wrong, thorough and effective reviews were carried out. The service was focused on learning lessons to make sure action was taken to improve safety. The service used the hospital wide electronic incident reporting system to report incidents. Staff we spoke to were all aware of the system and how to use it and found it easy to manage. Nursing and other clinical staff we spoke with described the system they used and the investigating process and externally to the National Reporting and Learning System (NRLS). The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports. Staff told us they were encouraged to report incidents even when these did not result in harm. Nurses said the matron acknowledged their reports. Senior nursing or medical staff reviewed all incidents and decided on any action. We saw that incidents reported included ‘near misses’, providing an opportunity to learn from errors that did not result in harm to the patient. However, we found limited evidence of the overarching themes from these individual incident reports being used to improve the holistic understanding of potential
20180222 KGHNHSFT Evidence Appendix Page 184 risks to patient safety. There was little analysis of incidents to identify themes or to track whether the same incident continued to happen. Staff were not consistently able to describe how learning was cascaded and how it was used to drive improvements in the service.
Senior staff told us that learning was shared across the hospital by staff learning bulletins, briefings at the daily trustwide safety huddles and at the lessons learned forum presentations. The measurement of sustained learning was checked through quality visits.
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. Between September 2016 and August 2017, the trust reported no incidents classified as never events for children’s’ services. (Source: Strategic Executive Information System (STEIS))
In accordance with the Serious Incident Framework 2015, the trust reported one serious incident (SIs) in children’s services, which met the reporting criteria set by NHS England between September 2016 and August 2017. (Source: Strategic Executive Information System (STEIS))
This incident related to a diagnostic incident including a delay (including a failure to act on test results) that met SI reporting criteria. There had been a detailed investigation and actions implemented following learning identified. Senior managers had also arranged training to individuals and groups of staff delivered by the trust’s patient safety team. Root cause analysis training was scheduled as part of the trust’s continuing training programme delivered by the patient safety manager. There had not been any identified internal or external serious incidents within the service the past six months prior to the inspection. (Source: DR2017a)
In the period 1 November 2016 to 25 October 2017, the service reported 276 incidents. (Source: DR49) For Skylark ward, there were 135 incidents reported in this period. The main themes were staffing pressures (13), medication errors/incomplete drug records (31), missing documents/delayed results (13) and incidents of aggression and behavioural challenges to staff (24). We saw that appropriate actions had been taken to reduce risks to patients for individual incidents and learning identified where appropriate. For NICU, there were 66 incidents reported in this period. The main themes were incorrect documentation (6), medication errors/incomplete drug records (13) and staffing pressures (9). We saw that appropriate actions had been taken to reduce risks to patients and learning identified for each incident where appropriate. For PAU, there were 18 incidents reported in this period. The main themes were communication issues, equipment issues and the presenting behaviours of the patients. We saw that appropriate actions had been taken to reduce risks to patients and learning identified for each incident where appropriate.
In the period May 2017 to November 2017, the service reported 148 incidents. The main themes were staffing and infrastructure (18), documentation and results (10) and medication issues (20). The service had identified the themes. (Source: DR208a). Lessons learned were displayed on the staff room noticeboard.
There were weekly paediatric/perinatal mortality and morbidity meetings, which were attended by medical staff as well as those presenting a case investigation. Discussions were held around each case presented. Patient safety alerts were presented to the women and children’s clinical business unit paediatric divisional meeting and cascaded to staff as necessary.
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. 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 20180222 KGHNHSFT Evidence Appendix Page 185 notifiable safety incidents and provide reasonable support to that person. All of the staff we spoke with understood what duty of candour meant and told us that they would share information with patients and their parents or carers as soon as practicable following an incident. They knew what the trigger was for application of duty of candour, in line with the trust’s policy. We saw where duty of candour had been put into practice in the records we reviewed. Duty of candour was mandatory training delivered as part of risk and safety training on the trust induction and annual refresher training for all staff.
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 care delivered. 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 suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, falls with harm or new catheter urinary tract infections between September 2016 and September 2017 for children’s services. (Source: NHS Digital)
Skylark ward did not undertake the Safety Thermometer as this was not adapted to paediatrics. The trust used data collected to inform the Nurse Sensitive Indicators it used to provide some of the aspects covered in the adult Safety Thermometer. In August, September and October 2017, the ward achieved 100% compliance with the nurse sensitive indicators being measured.
Major incident awareness and training The hospital had a service contingency plan (dated April 2017) in place for staff to use in the event of interruption to essential services such as electricity and water supply. There was an effective understanding amongst nursing and medical staff about their roles and responsibilities during a major incident. Staff were aware of the service’s fire evacuation procedures.
There was regular testing of generators occurred 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. A trained fire warden was present on each shift. We requested the fire safety training compliance figures as of the end of November 2017, which showed: 22 out of 31 medical staff had completed this (71%). 72 out of 77 nursing staff had completed this (94%). For all 149 staff working in the service, 132 had completed fire safety training (89%) which met the trust target of 85%. (Source: DR201a)
We saw that fire safety audits had been carried out on both Skylark ward and NICU in October 2017. A fire drill was planned for NICU on 14 November 2017. Fire drills had not been carried out on Skylark ward, staff told us.
20180222 KGHNHSFT Evidence Appendix Page 186
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. There were a range of hospital wide policies as well as those specific to neonates and paediatrics. We reviewed a sample of policies including ‘early care of the pre-term infant, ‘neonatal jaundice’, ‘neonatal sepsis’, ‘gastroenteritis in children younger than five years’ and paediatric early warning system and found that they reflected relevant national guidance, for example, National Institute for Health and Care Excellence (NICE) and Resuscitation Council guidance.
Staff had access to guidelines on the intranet to follow evidenced-based care and treatment. These and were developed using appropriate national and professional guidance and standards. We saw there were 156 guidelines relevant to the care and treatment of children and neonates. Of these 14 were in in the process of being updated at the time of the inspection and we saw that most were awaiting formal ratification following review. Only two of these had not been updated without clear plans to do so. The service had improved the way it monitored compliance with NICE guidance by implementation in July 2017 of an electronic system designed to do this. Overall, this was an improvement on the October 2016 inspection, when we had found a large number of polices has not been reviewed by their intended date.
The service had an annual audit programme in place with 16 audits planned or in progress. This included six new audits this year being carried out, including audits for bronchiolitis, jaundice, pain, and PAU performance. Again, this increase in audit activity represented an improvement on the findings of the October 2016 inspection.
Care pathways were in place, and from records seen were completed in accordance with trust guidance. Pathways included a diabetes pathway, a cystic fibryosis pathway, and a pathway for children with complex needs.
Play therapists were available on the ward, Monday to Saturday. Play therapists provided communication between medical and nursing staff and patients and their parents to ensure the child’s needs were catered for during procedures. Play therapists also provided additional support in distraction for younger children whilst undergoing procedures.
The trust had implemented a sepsis policy that was compliant to the NICE Guideline NG51 ‘Sepsis: recognition, diagnosis and early management’ (2016).
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural, and other preferences. Patients’ nutritional and hydration needs were met during their stay in hospital. There was a multidisciplinary approach to provide support for children with their long-term nutritional needs to ensure well balanced meals were provided. Nutritional needs assessed were recorded in the care plan document as there was no separate nutritional assessment tool. Food and fluid charts were generally used as necessary, monitored appropriately and used effectively.
The patients and parents we spoke with told us they were satisfied with the food and hydration provided. Foods to meet specialist dietary requirements were available on request, including gluten free and low allergen. Meals were also available to meet patient’s cultural and religious
20180222 KGHNHSFT Evidence Appendix Page 187 needs. Staff said they could order specific foods if required and there were no problems obtaining them. This showed a variety of nutritional needs were catered for adequately. Staff who worked on NICU promoted breast-feeding. They offered support and advice and provided equipment to help mothers as much as possible. On both units, patients were weighed on admission and their weight assessed for their specific condition. Patients had access to speech and language therapists for swallowing assessments, advice, and support. Parents and carers could also make their own food in a designated kitchen so they could eat with their child.
Pain relief Patients’ pain was assessed and managed well. Assessments were made of patient’s pain levels and arrangements were generally made to ensure their pain was managed effectively. For paediatric patients, pain assessments formed part of the paediatric early warning system (PEWS). Neonates’ pain assessments were recorded on their observation charts. Children were encouraged to score their pain levels using a smiley face system to indicate the degree of pain they felt from zero to three, zero being no pain and three being severe.
From patient notes, we saw that pain assessments had been completed for most patients where it was applicable to do so. Pain relief was prescribed and administered as appropriate when pain assessments had been completed. Distraction techniques were used to distract children from painful procedures and anaesthetic cream was used when taking blood from children. Parents and young people said the staff made sure pain was discussed and pain relief given when needed.
Effectiveness of pain relief was assessed using the pain assessment tool following administration of pain relief. This was recorded in the nursing notes and further assessment undertaken as part of the Paediatric Early Warning Score (PEWS).
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. Outcomes were generally better than national averages.
Outcomes regarding patient’s care and treatment were collected and monitored in line with national requirements. Intended outcomes for some patients were generally better than the national average. National Paediatric diabetes audit 2015/16. Senior staff told us the paediatric diabetic outcomes were second best in the East Midlands regions and significantly better than the national average. HbA1c levels are an indicator of how well an individual’s blood glucose levels are controlled over time. The NICE Quality Standard QS6 states “People with diabetes agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%)”. The data below shows that in the 2015/16 diabetes audit Kettering General Hospital performed better the England average. The proportion of patients receiving all key care processes annually was 69.1% which was a positive outlier compared to a national aggregate of 35.5%. The previous year’s score was 71.2%. The average HbA1c value (adjusted by case-mix) at the trust was 62.0 which was a positive outlier compared to a national aggregate of 68.3. The previous year’s score was also a positive outlier. The median HbA1c value recorded amongst the 2015/16 sample was 60.0, which showed no clinically significant change from the previous year’s median which was 61.0. (Source: National Paediatric Diabetes Audit 2015/16)
20180222 KGHNHSFT Evidence Appendix Page 188
The National Paediatric Diabetes Audit (NPDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Paediatrics and Child Health (RCPCH). In addition to auditing the quality of care received by children and young people in England and Wales, the NPDA has developed Patient and Parent Experience Measures (PREMS). These surveys for children and young people with diabetes and their parents provide feedback to their diabetes team about their experience of using the service. The results will help their teams to understand what they are doing well, and to identify what improvements they could make to their service. This was the second annual survey completed by children and young people with diabetes for services across England and Wales reported by the NPDA. 62 children and young people using the service at this hospital completed a questionnaire. The results were compared to those from the whole regional network and nationally for England and Wales, as well as comparison to previous year's results from 2013/14. The PREM report helped clinics to consider whether their perception of the care delivered corresponded with the experience fed back by patients, that it would support them to share best practice across regional networks, and to provide a basis for quality improvement activity. Overall, the outcomes for the service were better than regional and national comparators.
National Paediatric Diabetes Audit Patient and Parent Experience Measures (PREMS) Children and young people survey 2015/16
Question 1a: ‘I get helpful advice from members of the team’: the service scored a combined 100% for ‘strongly agree’ and ‘agree’ responses, better than the regional comparator of 98.1% and the national comparator of 98.2%.
Question 1b: ‘My HbA1c result is used by clinic staff to help me find positive and useful solutions’: the service scored a combined 96.7% for ‘strongly agree’ and ‘agree’ responses, better than the regional comparator of 95.9% and the same as the national comparator of 96.8%.
20180222 KGHNHSFT Evidence Appendix Page 189
(Source: DR44d)
Emergency readmission rates within two days of discharge. The data shows that from March 2016 to February 2017, there were no emergency readmissions of under ones following an elective admission. Patients aged one to 17 at the trust had a higher readmission rate following an elective admission for ear, nose and throat (ENT) compared to the England average. We saw senior had were monitoring an action plan for this. Emergency readmissions within two days of discharge following elective admission among the under 1 age group, by treatment specialty (March 2016 to February 2017) There were no emergency readmissions after elective admission at Kettering General Hospital NHS Foundation Trust among patients in the under 1 age group between March 2016 and February 2017.
Emergency readmissions within two days of discharge following elective admission among the 1-17 age group, by treatment specialty (March 2016 to February 2017) Kettering General Hospital NHS FT England Specialty Readmission Discharge Readmission Readmission rate s (n) s (n) rate ENT 1.3% 447 6 0.6% No other specialty at the trust had six or more readmissions The tables below show the percentage of patients (by age group) who were readmitted following an emergency admission. The tables show the three specialties with the highest volume of readmissions and only those specialties where six or more readmissions recorded are shown in the table. The data shows that between March 2016 and February 2017 there was a similar percentage of under ones readmitted following an emergency admission compared to the England average. The trust had a similar percentage of patients aged one to 17 years old readmitted following an emergency admission for paediatrics but a lower readmission rate for general surgery compared to the England average. Emergency readmissions within two days of discharge following emergency admission among the under 1 age group, by treatment specialty (March 2016 to February 2017) [Trust name] England Specialty Readmission Discharges Readmissions Readmission rate (n) (n) rate Paediatrics 3.0% 1,623 49 3.3% No other specialty at the trust had six or more readmissions
Emergency readmissions within two days of discharge following emergency admission among the 1-17 age group, by treatment specialty (March 2016 to February 2017) [Trust name] England Specialty Readmission Discharges Readmissions Readmission rate (n) (n) rate Paediatrics 2.6% 3,342 83 2.7% General 2.7% 330 9 3.4% Surgery No other specialty at the trust had six or more readmissions
(Source: Hospital Episode Statistics, provided by CQC Outliers team)
20180222 KGHNHSFT Evidence Appendix Page 190
Rate of multiple emergency admissions within 12 months among children and young people for asthma, epilepsy and diabetes. From April 2016 to March 2017, the trust had limited data for the percentage of patients under the age of one who had multiple readmissions for asthma, diabetes, or epilepsy. The trust performed better the England average for the percentage of patients aged one to17 years old who had multiple readmissions for either asthma or epilepsy. Rate of multiple (two or more) emergency admissions within 12 months among children and young people for asthma, epilepsy and diabetes (April 2016 to March 2017) [Trust name] England Long term Multiple Two or more Multiple condition admission At least one admissions admission rate admission (n) (n) rate Asthma Under 1 - - - 19.2% 1-17 12.7% 102 13 16.4% Diabetes Under 1 - - - 27.3% 1-17 * 22 * 12.8% Epilepsy Under 1 * * * 32.6% 1-17 20.5% 39 8 26.6% Note - For reasons of confidentiality, numbers below 6 and their associated proportions have been removed and replaced with ‘*’.
(Source: Hospital Episode Statistics, provided by CQC Outliers team)
National Neonatal Audit Programme. In the 2016 National Neonatal Audit, the trust’s performance was better than the England average:
Do all babies less than 1501g or a gestational age of over 32 weeks at birth undergo the first Retinopathy of Prematurity (ROP) screening in accordance with the current guideline recommendations? The unit at Kettering General Hospital scored 100% for this measure compared to an average of 98% for Local Neonatal Units nationally. Is there a documented consultation with parents by a senior member of the neonatal team within 24 hours of admission? Kettering General Hospital scored 97% for this measure, compared to an average of 92% for LNU units nationally. Are rates of normal survival at two years comparable in similar babies from similar neonatal units? Information submitted by the trust for this metric was not able to be compared to other similar neonatal units. What is the proportion of babies born less 32 weeks who develop Bronchopulmonary Dysplasia? 45% of eligible babies developed either mild or significant BPD. This is higher than the average for LNU units nationally, which had a score of 39%. (Source: National Neonatal Audit Programme, Royal College of Physicians and Child Health)
Head injuries in children audit. The service provided information that showed this audit was completed in September 2016. Positive outcomes were shown in 80% of cases where the CT scan had been requested in line
20180222 KGHNHSFT Evidence Appendix Page 191 with NICE Guidelines. The main negative finding was that in 23% of cases, the hospital’s head injury leaflet was not given. Action plans were in place following this audit with the plan to re-audit in the next year.
Diabetes admission audit. The service provided information that showed this audit was completed in May 2017. The positive outcome shown was that effective multi-service involvement had been completed. There were 13 admissions were related to a new diagnosis of diabetes and further five patients were transfers in from other services. Diabetes-related admissions were 17 in total that was 50% less than last year. Action plans were in place following this audit to monitor and enhance control of patients’ diabetes with the plan to re-audit in the next year. (Source DR44c)
Timely recognition and management of Paediatric Sepsis using guidelines and the Sepsis six pathway audit. The service provided information that showed this audit was completed in August 2017. Positive findings were that: 21 out of 23 (91%) patient’s notes contained a PEWS chart that clearly documented a PEWS score of three or above. 100% of the case notes reviewed were documented correctly for query sepsis on admission. The main areas of weakness identified within the audit were the need for clear detailed documentation in all cases and for all aspects of the Sepsis Six Pathway to be followed and documented. Action plans were in place following this audit with the plan to re-audit in the next year.
Child Protection Audit This audit had been completed in September 2017 and the clinical audit team were awaiting the completed internal summary form and evidence of presentation to relevant internal trust committee.
Competent staff
The service did not always 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. Ward staff were expected to be competent in the care of all patients on the ward, including surgical and medical patients and those with mental health conditions. Nursing staff told us they were supported to develop their skills. A practice development nurse for children was appointed in August 2017 and was putting in place systems to understand the training development needs of staff. Staff told us the nurse held regular meetings and asked for suggestions. However, we found the current systems for assessing staff competencies to be underdeveloped. The service risk register included the lack of assurance that nursing staff were competent in tracheostomy care.
Staff who worked on Skylark ward had received training in caring for patients with mental health needs. Patients with mental health needs were regularly admitted to the ward through the emergency care pathway. There was ongoing contact with the Child and Adolescent Mental Health Service (CAMHS) team in the training programme. This was an improvement on the findings of the October 2016 inspection. There were competency assessments for some key skills and use of certain equipment and these had been completed by some staff. Staff competencies assessed were recorded on the electronic rostering system. However, there was no defined list of what competencies were required for each staff group, for example, training for all relevant equipment and essential clinical skills. We found there was no competency assessment for looking after a patient with a tracheostomy (a tracheostomy is an incision in the windpipe made to relieve an obstruction to breathing); therefore, we could not be assured that this group of patients were cared for appropriately. There were no
20180222 KGHNHSFT Evidence Appendix Page 192 competencies for continuous positive airway pressure devices, nasogastric feeding, suctioning, gastrostomy care, or vapothermy. Senior staff said the service had focused on risk assessment competencies, intravenous treatment, and PEWS. A practice develop nurse had been appointed to the service and was in the process of devising a whole service competency framework. We raised this concern as to how the trust assured itself that all nurses had the competency to meet patient needs each shift. Senior staff said that assurance was taken that the new practice development nurse was leading on this and was working with all of the nursing staff and associate practitioners to ensure that staff will have training and support in self-assessment and then peer assessment to meet the competencies. Further competency packages were being written and would form part of the wider competency training for all staff. After the inspection, the trust provided newly developed tracheostomy tube care and tube change, suctioning, and nasogastric tube feeding competency assessments. Doctors provided teaching sessions that were open to all staff in the service. Some staff were trained in European Paediatric Life Support (EPLS). However, there were not enough trained staff to ensure there was always a nurse trained to this level on duty every shift. The hospital had developed a bespoke paediatric competency package for outpatients’ staff and were seeking Resuscitation Council (UK) accreditation for in house EPLS with the first course running in November 2017.
The full implementation of the formal process of clinical supervision for the wider workforce was in progress at the time of the inspection. A documented process for clinical supervision for staff nurses and matrons was not yet fully embedded and progress on this was considered at the Nursing Midwifery Strategy Steering Group in September 2017.
All the trainee doctors (foundation, core, and specialist) had an educational or clinical supervisor. They met the trainee at the start of the placement, the 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 or clinical lead/educational lead for the department. They had regular meetings with the clinical supervisor in a similar pattern to the training grade doctors in the trust.
A revalidation process had been implemented and close monitoring of staff due to revalidate had been established. There was a process in place to ensure all medical and nursing professionals had their registration status checked, we confirmed through review that all staff listed as employed and registered had a valid registration.
As of July 2017, 92% of staff within children’s services at the trust had received an appraisal compared to a trust target of 85%. All staff groups either met or were near to the trust target for appraisal completion. A split by staff group can be seen in the graph below:
20180222 KGHNHSFT Evidence Appendix Page 193
(Source: Trust Provider Information Request P46)
The trust also provided an update as of November 2017, which showed that 92% of medical staff and 86% of nurses had their appraisal. (Source: DR218a). All consultants within paediatrics had been revalidated and were now in their second cycle of revalidation. All Nursing and Midwifery Council registered nurses that were due to revalidate since April 2016, had done so successfully.
Multidisciplinary working Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. All necessary staff, including those in different teams and services were involved in assessing, planning, and delivering patients’ care and treatment.
Nursing and medical staff described good relations and a focus on patient care. Nursing staff told us they felt valued and respected by medical staff. We observed a multidisciplinary handover on Skylark Ward, with the members of the consultant team and nursing staff present. The consultant led the discussion, with contributions from others present, and considered the plan for each patient. Mental health and social issues were discussed.
There was a brief joint safety meeting each morning on the maternity unit for neonatal unit and midwifery staff. Handover at the change of nursing shift provided key items of information about patients. There was a medical handover at 5pm and at 9pm to the night team.
The service worked well with the Hospital and Outreach Education (HOE) local authority service, which catered mainly for pupils with diagnosed medical conditions, including mental health issues. All attendance, engagement, and interaction were recorded and teaching plans for individual pupils were completed and kept on record for the local authority staff. The designated teacher recorded all interactions on patients’ hospital records.
There was effective support from other services, including physiotherapy and dietetics. Staff said support from the speech and language therapy (SALT) team was rarely needed but that they came on request. There was psychological support for patients diagnosed with mental health conditions but support was limited out of hours.
20180222 KGHNHSFT Evidence Appendix Page 194
There was a weekly multidisciplinary diabetic ‘foot round’ consisting of consultant diabetologist, podiatrist, vascular surgeon, microbiologist, vascular nurse specialist and pharmacist.
Senior staff played an active part in the East Midlands Diabetes Network with seven other acute NHS trusts. The service, as part of this multidisciplinary network, was continuing to make progress with all the trusts in the region to optimise teams with required personnel and expertise in providing outcomes to a high standard. Regional quality improvement projects were being planned to continue to drive improvements in diabetes care and treatment throughout the region.
The CAMHS team staff, provided by another NHS trust, called the ward each morning Monday to Friday to ask whether anyone had been admitted overnight. The CAMHS team attended the ward as required to conduct assessments on patients. Out of hours, the adult crisis team made assessments if it was assessed that a child could not wait to be seen by a member of the CAMHS team within their working hours. Staff said there was much better integrated working with CAMHS and with the community nursing team.
The infant feeding leads from the service met with staff from the other two local NHS trusts at the infant feeding action group to drive the breast-feeding agenda within the county.
Multidisciplinary team involvement in care and treatment was documented in patients’ notes. A dedicated pharmacist came to each ward to check supplies and review drug charts for patients on the ward.
CQC Children’s survey 2014 – Q36 In the CQC children’s survey 2014, the trust scored 8.32 out of ten for the question ‘Did the members of staff caring for your child work well together?’ This was about the same as other trusts other trusts. (Source: CQC Children’s Survey, RCPCH)
Seven-day services The service was working towards a seven-day service but resource challenges remained a concern for senior staff.
Patients had access to most services seven days a week; some services had a reduced level of service provided by out of hours and there were sometimes delays for some radiology reports, but arrangements were in place to keep patients safe. The trust had in October 2017 decided to open all 26 beds throughout the week and had agreed additional nursing staff allocation to enable this. Plans were in place to implement this increase in the service. The paediatric assessment unit (PAU) was open Monday to Friday from 9am to 9.30pm.
The consultants provided seven day a week cover for up to 10 hours, although this was not for 12 hours per day in accordance with ‘Facing the Future: Standards for Acute Paediatrics’ guidance, which recommends that there is consultant cover seven days per week, 12 hours per day and during hours of peak activity. There were on-call arrangements out of hours during the week and weekends.
Pharmacy support was available on the ward each day of the week; out of hours arrangements were in place. The hospital did not employ a paediatric radiologist; arrangements were in place with another NHS hospital to report on x-rays. This had been recorded as a risk on the service’s risk register. Pathology services were provided seven days a week, 24 hours a day. Paediatric physiotherapy was available on weekdays. This service was provided by another local hospital. The physiotherapist attended the ward twice each day and assessed any new patients. An out of hour’s service was provided by adult physiotherapists as required.
Access to information
20180222 KGHNHSFT Evidence Appendix Page 195
Staff generally had access to up-to-date, accurate, and comprehensive information on patients’ care and treatment. Staff had access to the trust’s electronic records system. Information to deliver effective care and treatment to patients was consistently documented or available. Patient records were requested as needed on admission or in advance for outpatient appointments. The trust reported low incidence of notes not been available in outpatients’ clinics and staff followed the temporary notes procedure in these cases. This had been identified as a risk on the service risk register wand was being monitored by senior staff.
There were effective transition arrangements for patients with diabetes as there was a joint diabetes clinic. Other transition arrangements varied depending on individual requirements but there were some formal pathways for renal patients, and there were joint arrangements with another local hospital for patients with cystic fibrosis or sickle cell. Transition arrangements for patients with other conditions were not always structured.
A copy of the patient’s discharge summary was given to the patient as well as sent to the patient’s GP. Staff reported there had been delays and a backlog of GP letters being sent following a patient’s discharge and that some delays were a number of weeks. Additional resources had been dedicated to address the backlog and there had been significant improvements and that this was now being monitored closely; it remained a risk on the risk register.
GPs were able to contact the service for telephone advice if they needed to. Test results were obtained promptly from the relevant departments to ensure clinical decisions could be made based on supporting pathology results.
Health Promotion CQC Children’s survey 2014 – Q28 In the CQC children’s survey 2014, the trust scored 9.07 out of ten for the question ‘Did a member of staff agree a plan for your child’s care with you?’ This was about the same as other trusts other trusts. (Source: CQC Children’s Survey, RCPCH)
Staff in the service spoke about interventions to maximize health promotion opportunities. We saw smoking cessation advice was available and patients had access to a smoking cessation nurse. Staff were able to signpost patients to relevant support services in the community and via patients’ own GPs. We observed poster and leaflets throughout all areas advising patients on the importance of a healthy lifestyle, exercise, and ways to reduce health risks.
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. Not all staff had received annual mandatory training. Staff we spoke with had an effective understanding of gaining consent from children and the guidance around this with regard to a child’s capacity to consent, including Gillick and Fraser competency. Gillick and Fraser competency is used to help decide whether a child is mature enough to make their own decisions. The Gillick competency and Fraser guidelines helps to balance children’s rights and wishes with the hospital’s responsibility to keep children safe from harm. Gillick competence is concerned with determining a child’s capacity to consent. Fraser guidelines are used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment. Staff understood the Mental Capacity Act 2005 and explained how they would assess a child’s mental capacity and a decision would be made in their best interest and recorded in their notes.
20180222 KGHNHSFT Evidence Appendix Page 196
Patients and their parents were supported by staff to make decisions. Staff and patients we spoke with told us how the procedures and treatment were explained to them and that they were told about different options available. Written consent could be obtained by the child and/or their parents for certain medical and surgical procedures and we saw examples of these in the patient’s notes we reviewed. The trust reported that as of July 2017, Mental Capacity Act (MCA) training had been completed by 63.6% of staff in within children’s service. 75% of nursing and midwifery staff had completed this training compared to 42% for medical and dental staff. (Source: Trust Provider Information Return P14/P49) We requested the MCA training compliance figures as of the end of November 2017, which showed that: 7 out of 22 medical staff had completed this (32%). 32 out of 41 nursing staff had completed this (78%). For all 66 staff working in the service required to have this training, 40 had completed it (61%) which did not meet the trust target of 85%. (Source: DR201a)
The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the paediatric divisional meeting. This was also on the service risk register. The head of the service was also planning to start carrying out audits for Gillick and Fraser assessments in the New Year.
CQC Children’s Survey Data The trust performed about the same as other trusts in the majority of questions relating to effective in the CQC children’s survey 2014 (five out of six available questions). One question scored better than other trusts, this was regarding whether the child liked the hospital food provided. CQC Children’s Survey questions, effective domain, Kettering General Hospital NHS Foundation Trust Sub- Trust Question KLOE RAG group Score 28. Did a member of staff agree a plan for E1 0-15 9.07 About the same as other your child’s care with you? adults trusts 41. Do you think the hospital staff did E1 0-15 8.19 About the same as other everything they could to help ease your adults trusts child’s pain? 34. Did you feel that staff looking after your E3 0-15 8.19 About the same as other child knew how to care for their individual adults trusts or special needs? 36. Did the members of staff caring for E4 0-15 8.32 About the same as other your child work well together? adults trusts 33. Were the different members of staff E5 0-15 7.12 About the same as other caring for and treating your child aware of adults trusts their medical history? 24. Did your child like the hospital food E1 0-7 7.09 Better than other trusts provided? adults 11. Do you think the hospital staff did E1 8-15 NA NA everything they could to help your pain? CYP 4. Did you like the hospital food? E1 8-15 NA NA CYP
(Source: CQC Children’s Survey, RCPCH)
20180222 KGHNHSFT Evidence Appendix Page 197
Is the service caring?
Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. All interactions we observed between staff, children and young people, and their carers, were caring, compassionate, respectful, and friendly. We saw staff, including nurses, doctors, and pay staff, interacting with children and their parents in a kind and caring way. We observed a member of play staff interacting with a child who was having a procedure. A mother told us how caring the staff were. A young person said the nurses and play therapists were ‘brilliant’. All staff took the time to interact with patients and their parents in a manner, which was respectful and supportive. Parents and children were extremely positive about the care and treatment they received regarding inpatient and outpatient services at the hospital. Nurses, consultants, and support staff were friendly and welcoming to children and their families and were skilled in communicating with children and young people. Children and their relatives told us how happy they were with the care throughout the hospital. They said staff were very caring; one relative said they were always fully informed.
CQC Children’s survey 2014. The trust performed about the same as the England average for all 14 questions relating to compassionate care in the CQC children’s survey 2014. CQC Children’s Survey questions, compassionate care. Sub- Trust Question KLOE RAG group Score 16. Overall… (please circle a number) C1 0-15 8.73 About the same as other adults trusts 35. Were members of staff available when C1 0-15 7.96 About the same as other you or your child needed attention? adults trusts 8. Was your child given enough privacy C1 0-7 9.01 About the same as other when receiving care and treatment? adults trusts 9. Did you think there were appropriate C1 0-7 8.65 About the same as other things for your child to play with on the adults trusts ward? 10. Did staff play with your child at all while C1 0-7 7.91 About the same as other they were in hospital? adults trusts 11. Did new members of staff treating your C1 0-7 8.62 About the same as other child introduce themselves? adults trusts 40. Do you feel that the people looking C1 0-7 8.32 About the same as other after your child listened to you? adults trusts 41. Do you feel that the people looking C1 0-7 8.90 About the same as other after your child were friendly? adults trusts 42. Do you feel that your child was well C1 0-7 9.08 About the same as other looked after by the hospital staff? adults trusts 43. Were you treated with dignity and C1 0-7 9.22 About the same as other respect by the people looking after your adults trusts child? 9. Were you given enough privacy when C1 8-15 9.11 About the same as other you were receiving care and treatment? CYP trusts 18. Do you feel that the people looking C1 8-15 8.78 About the same as other after you listened to you? CYP trusts 19. Do you feel that the people looking C1 8-15 9.35 About the same as other after you were friendly? CYP trusts 20. Overall… (please circle a number) C1 8-15 8.73 About the same as other CYP trusts
20180222 KGHNHSFT Evidence Appendix Page 198
(Source: CQC Children’s Survey, RCPCH) Feedback was provided through the Friends and Family Test, NHS Choices, patient surveys in addition to comment made to the patient experience team. Patient feedback was obtained using the NHS Friends and Family Test (FFT). The NHS ‘Friends and Family’ test is a method used to gauge patient’s perceptions of the care they received and how likely patients would be to recommend the service to their friends and family. This is a widely used tool across all NHS hospitals. For the last three months, the results of the FFT were: For August 2017, the FFT response rate was very low at 9% compared to the England average of 26% and 97% of the people that did take part (32 out of 357 eligible patients) would recommend the ward. For September 2017, the FFT response rate was very low at 6% compared to the England average of 25% and 96% of the people that did take part (27 out of 442 eligible patients) would recommend the ward. In October 2017, the response rate was too low at 0.7% (3 out of 439 eligible patients) to be able to provide a meaningful sample.
We were told that comment cards were available to patients and their parents about the care they had received. Senior managers told us of the trust’s plan to improve the way patient and relative feedback was collected and the patient experience team were planning to introduce different ways of collecting patient feedback, including the use of tablet devices in some areas.
Emotional support Staff provided emotional support to patients to minimise their distress. Staff were able to provide appropriate support to children and young people and their families and signposted them to appropriate services outside the hospital. Staff understood the impact that a patient’s care, treatment, and condition had on them and those close to them. Staff provided emotional support whilst caring for patients. Staff said there was a professional psychologist available to provide counselling to patients with diabetes. For other patients and families, who may be distressed, support was provided by the medical and nursing team. Staff said the ongoing support from the local Child and Adolescent Mental Health Services (CAMHS) service was really helpful to them and the patient. CQC Children’s survey 2014. The trust performed about the same as other trusts for both of the eligible questions relating to emotional support in the CQC children’s survey 2014. CQC Children’s Survey questions, emotional support. Sub- Trust Question KLOE RAG group Score 37. Did a member of staff tell you what to C3 0-7 8.73 About the same as other do or who to talk to if you were worried Adults trusts about your child when you got home? 7. If you had any worries, did someone at C3 8-15 NA NA the hospital talk with you about them? CYP 15. Did hospital staff tell you what to do or C3 8-15 8.26 About the same as other who to talk to if you were worried about CYP trusts anything when you got home?
(Source: CQC Children’s Survey, RCPCH)
Understanding and involvement of patients and those close to them
20180222 KGHNHSFT Evidence Appendix Page 199
Staff involved patients and those close to them in decisions about their care and treatment. Children and their parents we spoke with felt well informed about their care and treatment. Parents and children told us the ward staff generally went out of their way to include them in the planning and delivery of their care. Parents told us they were given sufficient advice following their child’s discharge from hospital and knew who to contact if their child became unwell. Parents understood when they would need to attend the hospital for repeat investigations or when to expect a follow- up outpatient appointment. Parents were included in the escort of young children to and from theatre to reduce the distress to the child. The play therapist also supported younger children with this. A mother said doctors explained her child’s care and treatment in a way she could understand. One young person of 17 years was concerned that doctors gave information, such as the results of tests, to their parents rather than to them. They said, “If I had been on an adult ward, they (the doctors) would have spoken to me rather than over me”.
CQC Children’s survey 2014. The trust performed about the same as other trusts for all 17 available relating to understanding and involvement of patients and those close to them in the CQC children’s survey 2014. CQC Children’s Survey questions, understanding and involvement of patients. Sub- Trust Question KLOE RAG group Score 24. Did hospital staff tell you what was C2 0-15 8.07 About the same as other going to happen to your child while they adults trusts were in hospital? 27. Did members of staff treating your C2 0-15 8.66 About the same as other child, give you information about their care adults trusts and treatment in a way that you could understand? 29. Did you have confidence and trust in C2 0-15 8.96 About the same as other the members of staff treating your child? adults trusts 30. Were you encouraged to be involved in C2 0-15 7.64 About the same as other decisions about your child’s care and adults trusts treatment? 31. Did hospital staff keep you informed C2 0-15 8.04 About the same as other about what was happening whilst your child adults trusts was in hospital? 32. Did staff ask if you had any questions C2 0-15 7.81 About the same as other about your child’s care? adults trusts 38. Did a member of staff tell you what C2 0-15 7.71 About the same as other would happen next after your child left adults trusts hospital? 43. Before the operation or procedure did a C2 0-15 9.27 About the same as other member of staff explain to you what would adults trusts be done during the operation or procedure? 44. Before the operation or procedure, did C2 0-15 8.86 About the same as other a member of staff answer your questions adults trusts about the operation or procedure in a way you could understand? 45. After the operation or procedure, did C2 0-15 8.91 About the same as other someone explain to you how the operation adults trusts or procedure had gone in a way you could understand? 47. Were you given enough information C2 0-15 9.48 About the same as other about how your child should use the adults trusts medicine(s) (e.g. when to take it, or whether it should be taken with food)? 48. Did a member of staff give you advice C2 0-15 7.94 About the same as other about caring for your child after you went adults trusts home? 50. Were you given any written information C2 0-15 6.50 Worse than other trusts (such as leaflets) about your child’s adults condition or treatment to take home with you?
20180222 KGHNHSFT Evidence Appendix Page 200
13. Did members of staff treating your child C2 0-7 7.72 About the same as other communicate with them in a way that your adults trusts child could understand? 19. Were you told different things by C2 0-7 7.49 About the same as other different people, which left you feeling adults trusts confused? 1. When you first arrived at hospital, did C2 8-15 8.25 About the same as other people working at the hospital tell you what CYP trusts was going to happen to you while you were there? 5. Did hospital staff talk to you about how C2 8-15 8.78 About the same as other they were going to care for you in a way CYP trusts that you could understand? 13. Before the operation or procedure, did C2 8-15 NA NA someone tell you what would be done? CYP 14. Afterwards, did someone from the C2 8-15 NA NA hospital explain to you how the operation or CYP procedure had gone in a way you could understand
(Source: CQC Children’s Survey, RCPCH) National Paediatric Diabetes Audit Patient and Parent Experience Measures (PREMS) Children and young people survey 2015/16
The National Paediatric Diabetes Audit (NPDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Paediatrics and Child Health (RCPCH). The PREM report helped clinic staff to consider whether their perception of the care delivered corresponded with the experience fed back by patients, that it would support them to share best practice across regional networks, and to provide a basis for quality improvement activity. Overall, the outcomes for the service were better than regional and national comparators.
Question 1c: ‘My clinic appointments are well organised and give me enough time to discuss everything I would like to talk about’: the service scored a combined 98.3% for ‘strongly agree’ and ‘agree’ responses, better than the regional comparator of 95.8% and the national comparator of 96.3%.
Question 1d: ‘I have the opportunity to provide feedback on my clinic experiences and any improvements that could be made’: the service scored a combined 98.4% for ‘strongly agree’ and ‘agree’ responses, better than the regional comparator of 90.2% and the national comparator of 92.1%. 20180222 KGHNHSFT Evidence Appendix Page 201
Question 2c: ‘I feel heard, respected and understood by all members of my diabetes team’: the service scored a combined 96.7% for ‘strongly agree’ and ‘agree’ responses, better than the regional comparator of 93.5% and the national comparator of 94.8%.
(Source: DR44d) National Paediatric Diabetes Audit Patient and Parent Experience Measures (PREMS) Parent and carers survey 2015/16
Responses were provided by parents and carers in 2015/16 as well as by children and young people. 41 parents and carers from this service completed a questionnaire. Overall, the outcomes for the service were better than regional and national comparators.
Question 2c: ‘over the last 6 to 12 months, please rate whether you felt you were given enough time to discuss your questions and concerns with your dietician’: the service scored a 94.7% for ‘always’ responses, much better than the regional comparator of 74.9% and the national comparator of 82.4%.
20180222 KGHNHSFT Evidence Appendix Page 202
(Source: DR44e) Is the service responsive?
Service delivery to meet the needs of local people
The service had not always planned and provided services in a way that met the needs of local people. Paediatric radiology provision was limited but arrangements were in place with another NHS trust to mitigate this. Paediatric services at this hospital were located on Skylark ward in the Foundation Wing Care with care provided to children from the age of 0 to18 years and included inpatient and outpatient services and end of life care, along the with Local Neonatal Unit (LNU) and close working with maternity services. Care was provided for emergency admissions, medical day case admissions, surgical day cases, and in-patient surgical cases. The paediatric assessment unit (PAU) operated in a separate contained area on Skylark ward and had six beds to support flow within the children's service and with the emergency department (ED). The service offered support to children attending the ED through direct access to paediatricians. The service provided care for newborn babies requiring treatment in the LNU and for those babies over 26 weeks of age. Care was provided via 18 cots of which four were intensive care, six were high dependency cots, and eight were special care cots. The hospital provided the following dedicated paediatric surgical services over a month: Ear, nose, and throat (ENT): seven elective theatre sessions. Orthopaedic: one elective theatre session. Maxillofacial: eight and a half elective theatre sessions. Urology: two elective theatre sessions. General surgery: one elective theatre session. Ophthalmology: three elective theatre sessions. Plastic: one elective theatre session. Emergency cases for paediatric and trauma surgery are carried out as and when required.
The service worked with commissioners and other providers to support young people in their transition to adult services. There were pathways for young people with cystic fibrosis, diabetes and haematology conditions. The recently appointed head of services was taking a lead in mapping the gaps in transitional services, for example in neurological conditions, and liaising with commissioners to help inform future planning. The service saw young people up to the age of 18, if this was appropriate. Patients and stakeholders were not consistently involved in service development during the year. There was some patient involvement to provide feedback to the
20180222 KGHNHSFT Evidence Appendix Page 203 service. Services were planned using operational performance data and priorities had been identified. Information about the needs of the local population had been considered.
Skylark Ward was designed as a children’s ward and was light and a spacious. The ward had been purpose built and designed and was opened in 2013. Relevant stakeholders, including patients who regularly used the service at that time, and their parents, had been involved in its development. There was a playroom for young children and a ‘den’ for adolescents with age appropriate computer games and books. There was also a sensory room and a quiet room. The bays and individual patient rooms and had pull-down beds so that parents could stay overnight. A mother who was with her child on the ward described the facilities as ‘fantastic’.
The ward had 26 inpatient beds open Tuesday to Friday evenings and 18 beds open from Friday night until Tuesday mornings. There were an additional six beds in the paediatric assessment unit, which was co-located. Paediatric patients were admitted to the ward, either via a planned admission process, or through an emergency admission from a direct referral via their GP or through the emergency department (ED).
Facilities were generally appropriate for children and young people. Some children had appointments in the main adult outpatient department. This department had a small play area and some books and toys available. There was also a specialist diabetes centre, with a nurse to support children and their parents. A post of paediatric epilepsy nurse specialist had been created for a year. The nurse was working in outpatient clinics to provide information and support to children and their parents and to link with services in the community.
Hospital and Outreach Education (HOE) is a local authority service, which catered mainly for pupils with diagnosed medical conditions, including mental health issues. HOE provided a hospital service at the hospital for inpatients aged 3 to 19 years during academic term times. In addition, HOE operated an outreach service for pupils who are recovering from major operations or who are too ill to attend.
Senior staff said there was a growing number of patients (adults and children) with psychological needs with a lack of primary care provision in the county, challenges with cross-county partnership working and commissioning and the resource challenges relating to the implementation of seven- day services. Ongoing system-wide challenges with looked after children and those with mental health conditions continuing to present challenges for the service, and the wider health economy. Effective partnership work was ongoing with other local NHS trusts, commissioners, GPs, and social services to redevelop the care pathways available, with particular emphasis on enhanced out of hospital support to deliver pathway changes for those children requiring psychological support.
In 2016, there was an additional middle grade doctor provided during the winter to help address increased demand, and it was expected this would be agreed again for this year.
The business plan for the paediatric ward and the neonatal intensive care unit (NICU) formed part of the wider women and children’s clinical business unit (CBU) business plan. The plan had four main sections, vision and objectives, current position, strategic priorities and actions to ensure delivery. The plan included a review of performance from 2015/16 and 2016/17. A separate business case had been developed to expand the current paediatric service and open all available beds throughout the year. The business case identified the need for an additional consultant to support current activity and also identified there was a shortage of middle grade doctors. The plan included details of current nursing shortages as well as additional staffing requirements for the unit expansion. In October 2017, the trust had decided to open all 26 beds on Skylark throughout the week and had agreed additional nursing staff allocation to enable this. Plans were in place to implement this increase in the service.
20180222 KGHNHSFT Evidence Appendix Page 204
Arrangements were in place across the trust for end of life care. A ‘Guide for Parents Following the Death of Their Child’ was given to parents by ward staff when their child had died. The guide contained information about post mortems, registering the death, arranging funerals and what support was available. The guide was being reviewed and updated by the end of life lead nurse. The chaplaincy service was available to do whatever was appropriate in offering care for dying children and their families.
Paediatric radiology provision was limited. The department had not employed a consultant radiologist specialising in paediatric radiology. Currently there was one consultant radiologist being trained in paediatric radiology. The trust had made arrangements in 2014 with another local NHS acute trust for one of their paediatric radiologists to be on site one day a week on a collaborative basis. Complex paediatric cases requiring radiology would be referred to the specialist unit at another local NHS acute trust. Between November 2016 and October 2017, 58 paediatric patients were referred to the other NHS acute trust for imaging or scanning. The referrals had been recorded along with the type of imaging or scanning required. Processes were in place to monitor timeliness of reports and the service had arrangements in place with the other trust for 24 hour access to off-site reporting in accordance with their prioritisation policy.
CQC Children’s survey 2014 The trust performed better than other trusts for one of the two available questions relating to responsiveness in the CQC children’s survey 2014 and about the same for the remaining question. CQC Children’s Survey questions, responsive domain. KLO Sub- Trust Question RAG E group Score 37. Did you have access to hot drinks R1 0-15 9.60 About the same as other facilities in the hospital? Adults trusts 39. How would you rate the facilities for R1 0-15 8.59 Better than other trusts parents or carers staying overnight? Adults 2. Did the hospital give you a choice of R2 0-7 NA NA admission dates? Adults 3. Did the hospital change your child’s R3 0-7 NA NA admission date at all? Adults
(Source: CQC Children’s Survey, RCPCH)
Meeting people’s individual needs
The service took account of patients’ individual needs. Arrangements for children requiring psychological support had improved. Services were planned which took into account the needs of different people. Consideration had been given to the patients’ age and gender as well as disabilities. There were suitable bathroom facilities for patients with physical disabilities and adequate space on the ward to accommodate patients who used wheelchairs. The ward had a dedicated sensory room, which was used for patients with visual impairment as well as other patients who may benefit from this. We saw children and their parents in this room and staff said feedback was very positive about this facility. There was also a playroom for young children, which contained toys and books and a separate room for adolescents with DVDs, books and a computer gaming system.
There was a dedicated diabetes centre, which was run by a multidisciplinary team, which included joint working with staff from another local hospital. The doctors in the service ran clinics at the centre supported by nurses from another hospital. 20180222 KGHNHSFT Evidence Appendix Page 205
The hospital used a ‘patient passport’: these were completed for patients who had complex health needs and may require support with communicating their needs. The passports were used to record information about a patient’s communication preferences, equipment they may require, sleeping preferences and daily routines as well as details about their mobility, general health and eating arrangements. From the ones we reviewed, they generally were well completed and reflective of patients’ needs. A communication booklet and flashcards had been developed to support patients who may be unable to verbalise their needs. The communication book consisted of advice and pictures for certain illnesses and simple instructions, for example, cough, ear, constipation, stop, more, help, look. Whilst all patients had an individual care plan in place, not all were personalized for the individual.
There was a specific learning disability admission checklist and discharge planning tool and additional support risk assessments and processes for engaging staff one to ones if required. There were dedicated admission pathways through ED. Learning disability training was provided as part of the extended induction process for all qualified nurses and healthcare assistants. Regular learning disability awareness training was provided for all staff on the trust’s mandatory refresher days as part of level two safeguarding training. There was access to a qualified learning disability nurse for advice and expertise (employed by the local commissioners but based in the hospital for 26 hours a week).
Translation services were available, although we were told that these were rarely needed. There were some staff members who spoke other languages and were happy to translate for patients and parents. ‘Language line’ was also used and worked sufficiently well, although this was not the preferred option. Leaflets were available in other languages. The Patient Advice and Liaison Service (PALS) team could produce different leaflets in other languages when requested. Patients and carers used the main hospital chaplaincy for support in the event of bereavement. Staff used bereavement boxes for parents to save memories of their baby or child. There were two prayer rooms within the main hospital, the main chapel of peace as well as a small multi-faith prayer room.
The trust had two dedicated spiritual/religious rooms: the chapel of peace and the multi-faith prayer room. Both were always open and available for quiet reflection. In addition, the chapel of peace was used formally for Christian worship on Sundays and Tuesdays, Buddhist meditation on Thursdays, and Muslim prayers on Fridays. The service could arrange support for patients and parents from the trust chaplaincy team consisting of 2.7 (whole time equivalent posts) chaplains and about 60 chaplaincy volunteers who helped in various ways during the week. Chaplaincy also provided a 24 hour a day, seven day a week on call service and was able to provide help and reassurance within 30 minutes of receiving a call.
There were generally effective arrangements in place with the Child and Adolescent Mental Health Service (CAMHS), which was provided by another local NHS hospital. CAMHS telephoned the ward each to see whether children had been admitted overnight or during the weekend. A member of CAMHS staff then visited the ward to make a psychological assessment of the young person. The ward staff worked closely with the specialist CAMHS service to provide appropriate care and treatment for children and young people who had severe, enduring, and complex mental health difficulties, emotional or behavioural problems, including anxiety/depressive disorders, attachment disorder, attention deficit disorder, autistic spectrum disorders, eating disorders and self- harm/attempted suicide. The majority of children who were referred to CAMHS in the hospital setting were those who had presented to hospital (to ED normally) following a self-harm episode or with suicidal thoughts or intent. The child or young person was initially assessed and then, if deemed to be physically medically fit, they were referred to CAMHS for assessment. CAMHS provided a seven day a week service for acute services from 8am to 5pm, then an out of hours service from 5pm to 10pm. Referrals were made either electronically or via the telephone support line. As the CAMHS team collated all new referrals each morning and then allocated a mental health practitioner to each young person who had been referred. The team endeavoured to see all
20180222 KGHNHSFT Evidence Appendix Page 206 young people who were inpatients on the day of referral but at times of high demand, there was a prioritisation process and some assessments were carried out the following day.
All children and young people admitted to Skylark ward following a self-harm episode were managed using the countywide self-harm pathway. The pathway incorporated the self-harm risk assessment tool to identify if they were low, medium, or high risk of further self-harm behaviours. Children and young people assessed as being a medium risk were kept in sight of the nurse / assistant practitioner who recorded observations hourly. Children and young people assessed as being high risk required 1:1 supervision and were kept within arm’s length at all times and observations were recorded hourly or more frequently and were dependent on clinical need. An additional staff member was required for the 1:1 supervision of a vulnerable child.
Parents had the option to stay overnight with their child and on the paediatric ward, there were pull-down beds in each side room with the exception of the HDU room and the shared bays; there were chair beds available for parents whose child was admitted to an HDU bed or bay. There was also a parents’ room on paediatric to accommodate parent. The parents’ room had a toilet and shower as well as tea and coffee making facilities and a fridge and microwave. NICU had parent bedrooms; there were three designated bedrooms, as well as a quiet room /counselling room, which could be used as a fourth bedroom in an emergency.
There was a hot meal served as an evening meal, the choices included healthy options as well as more traditional children’s foods. The meals were designed to cater for a variety of ages. A choice of sandwiches was available as a lunchtime meal and choices were available for breakfast such as toast or cereal. Snacks were available on the ward 24 hours a day. These included fruit, sandwiches, crisps, and cereals. This meant that patients could have food outside of meal times.
Hospital and Outreach Education (HOE) is a local authority service, which catered mainly for pupils with diagnosed medical conditions, including mental health issues. HOE provided a hospital service at the hospital for inpatients aged 3 to 19 years during academic term times. In addition, HOE operated an outreach service for pupils who are recovering from major operations or who are too ill to attend. Teaching /engagement activities were offered on day one of a hospital stay to a young person who had a Special Educational Need (SEN), was a looked after child (LAC) or had a mental health issue, or if they had a medical condition that means they have more than one admission a year. For the remaining children and young people on the ward, teaching and engagement activities were offered on day three of admission unless they have a planned discharge on that day. Any child or young person who was transferred from other hospitals is offered activities from day one of admission. In the event that a young person was in hospital on the day that they are due to sit an exam, the ward staff and HOE would enable the young person to sit the exam, if they are well enough to do so, and invigilate accordingly.
Access and flow
People could generally access the service when they needed it. Waiting times for treatment were not meeting national standards but were improving. Arrangements to admit, treat and discharge patients were generally in line with good practice. Patients admitted to the ward generally had access to timely assessment and treatment. Some patients experienced delays waiting for treatment, specifically for urology, maxillofacial and ear, nose and throat (ENT) but this had improved since the October 2016 inspection. Arrangements with the children and adolescents mental health service (CAMHS) provided by the local community NHS trust were responsive to the needs of children and young people with mental health issues. From 1 July 2016 to 30 June 2017, there were 4,880 admissions to the paediatric ward. This accounted for accounted for 95% of the service’s reported activity with 5% (252) day case cases.
20180222 KGHNHSFT Evidence Appendix Page 207
There were 1,721 elective admissions for patients aged less than 18 years of age December 2016 to November 2017. (Source: DR222a) From April 2017 to October 2017, the average length of stay (LOS) for the paediatric ward was less than one day for elective admissions for all age groups and one day for emergency admissions for all age groups, which was similar to the England average. There was close liaison with the scheduling team for planned surgery, and a manager attended the weekly scheduling meeting. There was a rapid turnover of patients, with an average length of stay of 1.1 days. Senior staff reviewed ward activity throughout the day. The number of admission to the paediatric assessment unit (PAU) from 1 July 2017 to 30 November 2017 was 810, an average of 162 per month. (Source: DR224). The service had plans to formally commence monitoring the time to treatment in PAU in the New Year. Some patients with mental health needs could remain on the ward longer than planned if they were waiting for a bed in a mental health unit, but most patients were discharged back to the community team. There were 114 CAMHS patients and children at risk of self-harming behaviours admitted to Skylark ward from June 2017 to November 2017, at an average of 19 per month. This was a slight reduction from January 2017 to May 2017 when the monthly average was 23 admissions. As in previous inspections, there was an effective response from the local CAMHS team and system-wide work regarding appropriate out of hospital pathways were being undertaken by all three local trusts and local commissioners.
In the period January 2017 to August 2017, there were 15 children and young people waiting for in-patient specialist mental health beds. The average waiting time was between one and seven days with the average being two days. In the same period, eight children and young people waited on the ward for four days or more due to a lack of specialist social care placements in Northamptonshire.
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 publically 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.
The data for RTT for incomplete pathways were worse than the national 92% target and there were delays for children waiting for surgery, particularly for ENT, urology and maxillofacial. As of the end of 12 December 2017, waiting times performance for patients less than 18 years of age on an RTT pathway was 82%. This had improved over the past year and since our last inspection. No patients were waiting more than 52 weeks. The service worked to the trust’s access to care policy to priortise those patients waiting beyond 18 weeks. There were 4,947 patients waiting for an outpatient appointment (85% of whom were within the 18 week standard). For admitted pathways, 55% of patients were seen within 18 weeks.
RTT performance
0-9 10-14 15-17 18-24 25-31 32-38 39-45 46-51 Total weeks weeks weeks weeks weeks weeks weeks weeks Admitted 160 72 54 137 65 26 12 2 528 pathways Non- 3,050 770 362 424 234 61 34 12 4,947 admitted pathways Total 3,210 842 416 561 299 87 46 14 5,475 (Source: DR225)
20180222 KGHNHSFT Evidence Appendix Page 208
Did Not Attend rates The service monitored those patients that did not attend (DNA) clinic appointments and, alongside the adults’ outpatient department, had introduced improved ways to remind people of appointments, including a text messaging service. DNA rates had reduced by 2.5% since the October 2016 inspection.
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Total 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 Attended 2,475 2,864 2,710 3,176 2,951 3,434 3,497 3,130 3,097 3,263 3,338 3,50 37,435 0 Did Not 386 392 316 405 383 383 399 420 417 373 408 327 4,609 Attend Total 2,861 3,256 3,026 3,581 3,334 3,817 3,896 3,550 3,514 3,636 3,746 3,82 42,044 7 DNA 13.5 12.0 10.4 11.3 11.5 10.0 10.2 11.8 11.9 10.3 10.9 8.5 11.0% rate % % % % % % % % % % % % (Source: DR226) In the period December 2016 to November 2017, the number of clinics cancelled within six weeks of the clinic date was 59. Staff followed the trust process to rebook patients at the next available clinic. In total for this period, that meant 658 patients had clinic appointments changed due to clinic cancellations. Most of these were for general paediatric clinics. (Source: DR227)
There are no waiting times for inpatient occupational therapy or physiotherapy services with 100% of patients seen on the same day as requiring therapy. Fracture clinic trauma patients did not have any waiting times with 100% patients seen within the required clinical timeframe.
In the period from April to March 2017, the Kettering children’s diabetes team had a caseload of 168 children and young people with diabetes under its care.
National Paediatric Diabetes Audit Patient and Parent Experience Measures (PREMS) parent and carers survey 2015/16
The National Paediatric Diabetes Audit (NPDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Paediatrics and Child Health (RCPCH). The PREM report helped clinic staff to consider whether their perception of the care delivered corresponded with the experience fed back by patients, that it would support them to share best practice across regional networks, and to provide a basis for quality improvement activity. Responses were provided by parents and carers in 2015/16 as well as by children and young people. 41 parents and carers from this service completed a questionnaire. Overall, the outcomes for the service were better than regional and national comparators.
Question 1: ‘over the last 6 to 12 months, how quickly were you usually seen in your clinic?’: the service scored a 65% for ‘being seen within 15 minutes’ responses, much better than the regional comparator of 36.7% and the national comparator of 56.7%.
20180222 KGHNHSFT Evidence Appendix Page 209
(Source: DR44e)
NICU had 18 cots. There were four cots for babies who required intensive care, six cots for babies who required higher dependency care, and eight cots for babies who required special care. Neonates were admitted via maternity as a planned or emergency admission. Transfers from other hospital were also accepted as well as some neonates who had returned from the community. The average length of stay for neonates for the period was 10 days at the time of the inspection. Neonatal Critical Care Bed Occupancy From September 2016 to August 2017, the trust’s neonatal bed occupancy has fluctuated but has predominantly been below the England average.
Note data relating to the number of occupied critical care beds is a monthly snapshot taken at midnight on the last Thursday of each month. (Source: NHS England)
Learning from complaints and concerns
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were usually shared with staff. From August 2016 to July 2017, there were six complaints about children’s services, three of which were currently open. The trust took an average of 29 days to investigate and close complaints with one breaching the agreed trust target for closing complaints. This included some complicated complaints. The timescale for response was three working days. The timescale for responding to a complaint was 25 working days: more complicated complaints had a timescale of 30 days, or longer, if agreed with the complainant. Themes seen were referral delays to social services and communication. Response letters seen were detailed and address the concerns raised. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
20180222 KGHNHSFT Evidence Appendix Page 210
There had been 12 formal compliments about Skylark ward staff in the same period and we saw numerous thank you cards on display on noticeboards on the ward.
There was a process in place for responding to complaints and information was available to make patients aware of how to complain. Leaflets informing patients how to make a complaint or contact the Patient Advice and Liaison service (PALS) service were available on the ward and NICU. Most complaints were resolved and responded to immediately and that these were mostly due to communication issues from nursing and medical staff. Formal complaints were rarely received. Staff were aware of the process for supporting patients in making complaints.
Complaints formed part of the monthly paediatric report, which was circulated, with the minutes of the Women and Children’s clinical business unit’s divisional meeting for paediatrics. The monthly report detailed the number of complaints received in month, the number ongoing and detailed if there had been any delays in responding to the complainant; no delays were reported. Details of the complaint were shared and there was some evidence of lessons learned. Staff said information and learning from complaints was discussed at the ward huddle meeting and themes were including on posters in the staff office. The hospital daily safety huddle had been revised and this included daily safety messages cascaded to staff including learning messages from the patient experience team so that learning from complaints was shared with all services.
Parents spoken with were aware of how to make a complaint or contact PALS. We saw PALS posters and leaflets available in the ward and outpatient areas.
Is the service well-led?
Leadership
The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Sustainability of improvements was to be an ongoing focus for the leadership team. Leaders recognised the significance of most risks in the service and generally identified weaknesses as part of audits and reviews.
The department had a documented accountability structure. Ward matrons reported to the lead nurse, medical staff reported to the clinical director; there was a general manager for the clinical business unit (CBU). The lead nurse, clinical director, and general manger reported to the CBU director, who in turn reported to the medical director and director of nursing. The trust had recently appointed a head of service to have a strategic overview of children. The lead nurse for children continued to have an operational lead. Nursing staff told us both leads were visible and approachable and that they felt well supported. Leaders were seeking to ensure that active governance and risk processes were in place and understood by all staff in the service. The hospital had an established leadership programme, which included for those staff at a supervisory level an essential skills course, an advanced course for managers at staff band 6, 7, and 8a and a strategic level course for senior managers. A one-day management induction course commenced from October 2017 for all newly promoted managers and new starters with its purpose being to cover the essential elements of a manager role, relevant policies, where to find support and seek advice. Job plans were in place for all consultants; the number of programmed activities for each consultant was between 10 and 12. Programmed activities (PA) are a way of informing and monitoring the allocated time a consultant has for direct clinical care, additional NHS responsibilities, external duties, supporting professional activities as well as additional activities (time which exceeds the standard 10 PAs).
Staff told us that they had good working relationships with their managers and felt able to raise concerns if they needed to and that on the wards they regularly saw their local managers. There
20180222 KGHNHSFT Evidence Appendix Page 211 were clear lines of responsibility and accountability. Staff told us that they felt supported by their immediate line managers and that the senior management team were visible within the department.
Leaders had made significant improvements in the way that risks were assessed and managed following our October 2016 inspection. However, at this inspection, we found that some ward processes and safety systems had not been consistently followed by all staff. When we raised these concerns during the inspection, leaders took urgent actions to address them. Sustainability of improvements was to be an ongoing focus for the leadership team.
Vision and strategy
The service had a vision for what it wanted to achieve but workable plans to turn it into action were not yet in place. There was not a clearly defined strategy specific for the children and young people’s service in place to drive improvement and innovation. The vision and strategy for the service had not changed since our last inspection in June 2017. The service vision and strategy was part of the CBU’s Women and Children’s Clinical Business Unit Operational Plan (2017 to 2018). The main aims of this plan were to: To have the provision of outstanding care that reflects patient needs and delivers a quality service repeatedly. To address CQC concerns and recommendations. To be the provider of choice for the local and surrounding areas. Safe Responsive Quality service, which is Family Friendly that continually delivers and puts women and children’s services on the map. Clinically Led service that is responsive to patient needs/choices delivered by an empowered skilled workforce. Provide efficient service with positive contribution both clinically and financially that patients can feel. Improve and sustain operational performance including RTT.
Senior managers told us of plans to improve and develop the service, but these were in the formative stage at the time of the inspection. After the inspection, the service provided us with a copy of the Paediatric Action Plan 2017/2018, which set out clear aims and objectives across the service to provide safe and high quality care and treatment. Timescales were realistic.
The trust had a vision for what it wanted to achieve, and there were workable plans to turn it into action. The trust’s vision was to provide high quality care to its communities. The four strategic aims described within the trust’s 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.
The trust had a clear set of values, which were ‘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. Staff were aware of the CARE values and felt that they reflected the organisation and the care provided to patients. Staff were familiar with the trust wide vision and values and felt part of the trust as a whole.
20180222 KGHNHSFT Evidence Appendix Page 212
Culture
Managers across the service were promoting a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with said that morale was continuing to improve after the comprehensive inspection report was published in April 2017. They were proud that their hard work in making improvements had been recognised in our June 2017 inspection (report published in August 2017). All staff were committed to ensuring the service delivered the best possible care for all patients. Staff said they were well supported by local and senior managers of the trust. Staff told us there were effective working relationships amongst their peers as well as other disciplines. Staff at all levels told us how there was excellent teamwork throughout. Nursing and support staff told us that medical staff always took time to listen to their concerns. There was positive teamwork between medical, nursing and support staff and staff were patient focused. Most staff felt supported by senior management when things went wrong. Staff told us that local leadership worked well and staff felt listened to. Staff generally reported improvements in how supportive senior management was and that there was a much better focus and response when concerns were escalated. Many staff spoke of the benefits of their staff only ‘closed’ social media page and how it helped communication across the service. We saw that there was a positive, friendly, and professional working relationship between staff.
Staff told us that they were encouraged to report incidents and that they felt confident in doing so and the importance of sharing information with patients and families when an incident occurred which involved them. We saw that learning from incidents and complaints as well as the patient outcomes were recorded on the staff notice board.
Induction for new staff included information about the support available from other staff, by a trust system called ‘link listeners’, whom staff could talk to about concerns in confidence. They were aware about the freedom to speak up guardian at the trust so that they knew who to go to if they had a concern and felt their line manager was not dealing with the issue. Senior staff said they were invited to take part in investigations about issues raised by staff ‘speaking up’ in other parts of the trust. Staff were aware of their responsibilities under Duty of Candour and the trust’s ‘speaking up’ policy.
Staff were generally positive about the service’s appraisal process and how it met their ongoing developmental needs. Senior staff told us of plans to enhance the trust’s appraisal process to provide clarity for staff on how the organisational objectives link to theirs, reinforce the trust’s CARE values and link back to the overall assessment of the individual staff member. This was designed so individual and organisational performance was considered together to better determining pay progression and future talent. This would provide a more structured and organisational approach which would be transparent and give staff career pathways over the longer term.
Staff were committed to providing a fully inclusive service. We requested the equality, dignity, and respect training compliance figures as of the end of November 2017, which showed that: 23 out of 31 medical staff had completed this (74%). 74 out of 77 nursing staff had completed this (96%). For all 149 staff working in the service required to have this training, 136 had completed it (91%) which was better than the trust target of 85%. (Source: DR201a)
20180222 KGHNHSFT Evidence Appendix Page 213
Governance The service was embedding a systematic approach to improving the quality of its services and safeguarding high standards of care by aiming to create an environment in which excellence in clinical care would flourish. Governance structures were in place to support the functions of the services. Monthly governance meetings were conducted to allow oversight of the service. All senior 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 the service and with the rest of the trust. The governance systems in place had improved to allow better oversight at board level of the potential risk to patients.
Governance systems in place had improved so that most staff, at all levels, from ward to board, understood the areas of risk within the service, and we saw that a series of actions had been implemented but not always embedded in the service to minimise risk to patients. There was an improved focus on patient safety, effective risk assessment and management throughout the service, but this was not yet fully embedded in the service by all staff. Procedures and guidance available to staff was comprehensive and up-to-date, which was an improvement on the October 2016 inspection. Staff were able to respond appropriately to internal security arrangements that kept children and young people safe.
Staff were able to demonstrate their competence in caring for children and young people with mental health issues due the training delivered because of our last inspection. Security measures now in place were being monitored and reviewed on a regular basis by the service. However, we found significant ‘tailgated’ into the ward was still occurring. We also found environmental risks posed by unlocked storerooms so staff had not understood the risks to patients’ safety this presented.
Care was generally planned and delivered in line with evidence-based practice. Nursing audits were monitoring care provided against agreed standards but these audits had not recognised some of the gaps in documentation and risk assessments that we found on this inspection.
Senior staff told us that the trust was redesigning its assurance, risk, and governance processes to build on its existing methods. At the time of the inspection, the trust was carrying out a restructure of the CBUs, moving to a three divisional structure in the New Year. Governance systems and processes would then be restructured to develop a holistic risk management and reporting culture with streamlining data for ease of use and analysis for action.
We spoke with the head of the service regarding the issues we had found on the inspection. Whilst the service had some informal ways of communicating change and sharing learning (such as staff notices on the wall of the staff room, and a ‘closed’ social media page), it was apparent there was not a formalised structure of regular staff meetings on Skylark ward. NICU did have regular staff meetings. Standing agendas, referencing incidents, learning and patient outcomes, and minutes were not consistently produced over the past few months Skylark ward staff told us. The service therefore committed to ensuring there was an enhanced level of formality and consistency regarding staff meetings and made plans to commence this.
Managing risks, issues and performance The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected, but these were not always effective. Fully effective arrangements for identifying, recording, and managing risks, issues, and taking mitigating actions were not yet in place. We found that risk management processes that were now in place had improved and were sufficient to recognise, assess, monitor, review, and therefore reduce most risks.
20180222 KGHNHSFT Evidence Appendix Page 214
Risks were recorded on the trust’s incident reporting system and paper copies printed and added to the risk register folder on Skylark ward. When new risks were identified, a risk assessment was undertaken and approved through the paediatric division senior management team and uploaded onto the risk register. Depending on how high the risk was, it would be escalated to the CBU governance meeting and to trust directors as necessary.
The service had a comprehensive risk register in place that detailed accurately risks to the service, actions taken to mitigate risks, a risk level, and a review date. The highest-level risks to the service were: Insufficient staffing to facilitate service delivery. Insufficient numbers of paediatric staff/staff with paediatric competencies. Low level of training compliance in mandatory training. Continuing pressures on the service due to admission of CAMHS patients.
Clear actions, mitigations, timescales for action, and risk owners were in place for the risks identified. We observed that some risks had reduced by the time of our inspection as staff training and recruitment had occurred in line with actions on the risk register. Managers and senior staff had an effective knowledge of the risk register and said it was reviewed frequently, with any high level risks being escalated to corporate level for review. However, awareness of the main risks in the service was variable with other grades of staff, particularly new staff. Also, a number of risks that we found during the inspection had not been fully recognised and addressed by the service (for example, the lack of assurance regarding nursing competencies, the lack of ‘open access’ patients records, the gaps in nursing notes and incomplete patient risks assessments). The service risk register reflected the risks associated with the children and the adolescents mental health service (CAMHS) patients and children experiencing self-harm behaviour and was reviewed and updated as required. Nursing audits were monitoring care provided against expected standards but they were not always thorough as our findings regarding the lack of completed patient risks assessments showed.
Managers in the service now had an effective oversight of the service’s RTT performance and could show how the recording system worked and the number of patients waiting to be seen. Our inspection identified that the risk register reflected the level of risk regarding environmental factors and concerns regarding risk assessment and care provision of CAMHS patients and children experiencing deliberate self-harm behaviours. However, staff were not always following the service’s procedures and policies to reduce risks and this had not been effectively recognised by senior staff.
Managing information The service had improved the way it collected, analysed, managed, and used information well to support all its activities. Leaders said the hospital had some considerable concerns about the quality of its data that it had been collecting and reporting in the past, and had been working with subject specialists and external companies to ensure that this position was improved. However, the leaders were not complacent about this and continued to work to improve the quality of the data collection systems and data. Referral to treatment (RTT) data was now reliable and accurate and it gave leaders and staff the assurance of knowing the day-to-day position for those patients awaiting an appointment. Nurse sensitive indicator information was reviewed and used to highlight areas to develop.
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. We requested the information governance training compliance figures as of the end of November 2017, which showed that: 12 out of 31 medical staff had completed this (68%).
20180222 KGHNHSFT Evidence Appendix Page 215
71 out of 77 nursing staff had completed this (92%). For all 149 staff working in the service required to have this training, 130 had completed it (87%) which was better than the trust target of 85%. (Source: DR201a)
Engagement The service engaged with patients, staff, the public and local organisations to plan and manage appropriate services, but this could be improved. There was some evidence that the views and experiences of patients and those close to them were gathered and acted on to shape and improve the service. Leaders knew this was an area to develop. Leaders recognised that there were weaknesses in capturing public feedback from the engagement activities undertaken to help shape services at the hospital. However, steps were being put into place with the trust’s patient experience team to incorporate a more structured approach to ensure that patient feedback was captured and acted upon.
Patients and relatives were given the opportunity to provide feedback using the NHS Friends and Family Test (FFT). In April 2015, it became compulsory for patients under the age of 16 in line with those over the age of 16 to be offered the opportunity to provide feedback via the NHS Friends and Family test. The FFT is an important feedback tool that gives patients the opportunity to feedback on the service and ask whether they would recommend the service to their friends and family. Response rates were very low overall and the service was looking at ways in which meaningful patient feedback could be captured and used to continually develop the service.
The service used comment cards, which we saw were available to patients and relatives. Patients could also provide feedback using NHS Choices. Child friendly comment cards were also handed out to children to gauge their perception of the care and treatment they had received. The service had also engaged with Young people’s Healthwatch had undertaken a review of the paediatric ward. Healthwatch is an external consumer champion for health and social care. A report was produced in 2016, which included some suggestions for actions, for example more comfy chairs for parents and carers as well as magazines for adults. Another review was being planned to help capture the voice of young people using the service.
Kettering children and young person’s diabetes service had undertaken the National Paediatric Diabetes Audit (NPDA) /PREM questionnaire in 2014, 2015, and 2016 good. The needs identified were around patient empowerment and actions plans were developed to further improve the service. The diabetes team produced a newsletter which is distributed to the families updating them on service developments, education and important diary dates. Education and information evenings had been arranged. Communication via texting and email was frequently used by staff to promote better communication. A local parent support group had recently been established and is supported by the team as requested. There were multiple events organised by the team for interaction and education and team family days with excellent feedback and appreciation.
The service gathered feedback from staff through staff meetings and discussions. Staff told us they would not hesitate to give feedback and discuss any concerns or issues with colleagues and management. The head of service held staff ‘huddles’ twice a week to share information and highlight risks with ward staff. These were held at different times of day so that as many staff as possible attended. Three whole team days were organised over the summer, but only one took place because the service was so busy. These were intended to strengthen staff engagement for greater resilience and more opportunity to share experiences internally. CARE ‘Smile’ awards were held monthly as a celebration and recognition of staff from all levels; staff that have ‘gone the extra mile’ and shared via the trust’s intranet screen saver. Leaders also were embedding CARE values through activities such as ‘Random Acts of Kindness Campaign’ and encouraging staff to be kind to themselves and others.
20180222 KGHNHSFT Evidence Appendix Page 216
Learning, continuous improvement and innovation The service had improved its commitment to developing services by learning from when things go well and when they go wrong, promoting training, research, and innovation, but further work was required. There was limited innovation in the service development. The service, and all staff, had been focused on addressing the significant safety and risk management concerns that we had found, and escalated, at the October 2016 inspection. Many improvements had been made to provide an effective, safe, high quality service, but ongoing work was required to fully embed all the improvements. There were two paediatric hot clinics each week, which were held on the paediatric outpatient unit. Referrals could be made by the patient’s GP into the hot clinics, which were used for rapid access including one emergency slot at each clinic. The lead paediatrician used the clinics for both clinical and teaching purposes. There was now an established process of undertaken monthly audits of young people admitted with self-harm behaviours. This information was being used to help monitor the overall safety and quality of care provisions, as well as informing the system wide changes that were being developed at the time of the inspection. Integrated working with CAMHS and community nursing teams was significantly improved. Paediatric diabetic outcomes were the second best in the East Midlands with 50% better than the national average. The service had appointed a practice development nurse who was developing a comprehensive set of nursing staff competencies.
Outpatients
Facts and data about this service Kettering General Hospital NHS Trust provides its main outpatients services at Kettering General Hospital. It also has three satellite services, which are based at Nene Park outpatients’ clinic, Nuffield centre and Isebrook outpatient’s clinic. These satellite services are managed by the same team who oversee main outpatients. Each year this hospital facilitates over 250,000 outpatient appointments. Outpatient appointments on the main site are held in various locations across the site: Main outpatients (general medical and surgical clinics), fracture clinic (trauma and orthopaedics). Foundation Wing (paediatrics). Cave Block (Ophthalmology, ENT, rheumatology . Jubilee wing (Dermatology). Centenary wing (Oncology). Diabetes centre. Rockingham wing (obstetrics and gynaecology).
On average, there are 627 physical healthcare outpatient clinics per week. There was a separate children’s main outpatient department, which is reported on under children and young people core service; however, some children were seen in regular outpatient clinics dependant on specialty including ENT and ophthalmology. 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 appointments are provided dependant on specialty.
20180222 KGHNHSFT Evidence Appendix Page 217
The trust had 311,916 first and follow up outpatient appointments from July 2016 to June 2017. The graph below represents how this compares to other trusts:
(Source: Hospital Episode Statistics)
The following table shows the number of Outpatient appointments by site, the total for the trust and the total for England, from July 2016 to June 2017. Site Name Number of Spells Kettering General Hospital 270,842 East Northants Outpatient 34,360 Department Nuffield Diagnostic Centre 20,832 Isebrook Hospital 8,896 Waendell Leisure Centre 912 This Trust 337,664 England 104,275,113 (Source: Hospital Episode Statistics)
The chart below shows the percentage breakdown of the type of outpatient appointments from July 2016 to June 2017 by site and appointment.
(Source: Hospital Episode Statistics)
20180222 KGHNHSFT Evidence Appendix Page 218
Is the service safe?
Mandatory Training
The service provided mandatory training in key skills to all staff and made sure everyone completed it. The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory training courses between July 2016 and July 2017 for nursing/midwifery staff in outpatients is shown below:
Kettering General Hospital had a 92% mandatory training completion rate. Isebrook hospital had a 91% mandatory training completion rate. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
The trust confirmed that no medical staff worked in directly outpatients as they all worked in other clinical business units, so medical staff training figures will be reported in other core services.
Staff received effective mandatory training in the safety systems, processes, and practices. For example, staff told us they completed training in a range of mandatory subjects, including fire safety awareness, safeguarding (both adult and children), basic life support, infection prevention and control, information governance, mental capacity act (MCA), deprivation of liberty safeguards and equality, diversity and human rights. We saw examples of staff training records showing completed training. We also saw examples of the monitoring, which showed staff had undertaken all mandatory training, such as health and safety, infection prevention and control, moving and handling, safeguarding and basic life support. Staff knew how to access mandatory training and told us they could find out when they were next due for an update. Staff spoke positively of mandatory training modules and felt able to access further assistance if required. Staff were positive about their training and were confident they would be supported to attend additional training if required. Paediatric intermediate life support (PILS) training had been introduced for staff involved in paediatric clinics. At the time of our inspection, 50% of staff needing this training had completed it. The service did not have a specific target for this, as it was not a requirement for all staff. During
20180222 KGHNHSFT Evidence Appendix Page 219 our inspection, we saw there was enough staff trained to ensure one PILS trained member of staff was on duty during clinics seeing children. This was in accordance with the trust’s policy.
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. 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 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. Staff generally understood their responsibilities and were aware of safeguarding policies and procedures.
Staff had regular training in safeguarding of vulnerable adults and child protection. Those interviewed were able to provide definitions of different forms of abuse and were aware of safeguarding procedures, how to escalate concerns and relevant contact information. Information on safeguarding was seen on staff noticeboards and in public areas with relevant contact numbers. Staff said they received feedback from the hospital’s safeguarding team if they made a safeguarding referral. Clinical leads were aware of the guidance for safeguarding level three training for children and told us that safeguarding level three was required for all nursing staff dealing with children. During our inspection in 2016, nurses and healthcare assistants who were involved in the assessment and treatment of children did not all have the appropriate level of safeguarding children training. For example, ophthalmology clinics were conducted for adults and children with full paediatric clinics running but staff only had level two safeguarding children training. During this inspection, 86% of clinical staff had received level three safeguarding children training. This was in line with the ‘Intercollegiate document on safeguarding children and young people’ (March 2014), which recommends that all nursing and medical staff who have direct contact with children and young people should attain level three safeguarding training. Outpatient areas had a paediatric nurse to facilitate care and treatment delivered to children. Female genital mutilation (FGM) and child sexual exploitation (CSE) training was included in level two safeguarding training. Concerns would be reported using the interagency referral form, and an appropriate alert/red flag placed on the trust IT systems. Cases would also be reported through the trust’s safeguarding steering group on a monthly basis for interrogation and discussion, identifying trends and themes if possible. Staff we spoke with 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. The trust set a target of 85% for completion of safeguarding training. A breakdown of compliance for safeguarding courses between July 2016 and July 2017 for nursing/midwifery staff in outpatients is shown below:
20180222 KGHNHSFT Evidence Appendix Page 220
Kettering General Hospital had a 95% safeguarding training completion rate. Isebrook had an 89% safeguarding training completion rate. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
The trust confirmed that no medical staff worked in directly outpatients as they all worked in other clinical business units, so medical staff training figures will be reported in other core services.
We requested the updated training compliance figures as of the end of November 2017 for safeguarding children level 3 training, which showed that: 33 out of 35 nursing staff had this training (94%).
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. Effective standards of cleanliness were maintained across outpatient areas, with reliable systems in place to prevent healthcare-associated infections. Whilst most areas of outpatient services were dated in appearance, the environment and equipment were visibly clean. Some areas stored equipment and boxes on storeroom floors which increased the risk of contamination. We raised this in each area we found concerns and staff advised this would be rectified. Staff had received training about infection, prevention, and control (IPC) during their initial induction and annual mandatory training. We saw that 97% of nursing staff and 94% of medical staff across outpatient services had completed their IPC training. This exceeded the trust target of 85%. Audits were carried out monthly in relation to hand hygiene and environmental cleanliness. We observed that in August, September and October 2017, compliance ranged from 89% to 100%, which was within acceptable levels according to trust policy. Staff told us that where compliance did not meet trust targets, or areas of consistent non-compliance were identified, action plans would be put in place to ensure improvements. There were specific environmental cleaning schedules in place throughout all outpatient areas. Domestic staff understood their responsibilities for keeping all areas clean and 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. Each item of equipment was cleaned after patient use. We saw clean equipment was labelled with 'I am clean' stickers so staff knew the items were clean and ready for use. However, we did not observe these being used for examination couches or trolleys.
20180222 KGHNHSFT Evidence Appendix Page 221
We saw that staff followed the trust’s policy regarding infection prevention and control. This included staff being ‘arms bare below the elbow’, adhering to uniform guidelines and hand washing between patient contact and clinical tasks. We observed personal protective equipment such as gloves and aprons being used appropriately and were available in sufficient quantities in all areas. Hand washing facilities and sanitising gel was available throughout the department and we observed staff using these regularly. There was sufficient personal protective equipment throughout the department and it was used appropriately. Hand hygiene gel was available at the entrance to all areas. We observed staff washing their hands before and after patient contact during our inspection. Although there were no designated waiting areas for patients with communicable diseases, senior staff informed us that these patients would be seen in a separate treatment room, which would be deep cleaned after use. Precautions were taken in the outpatients for patients with either known or suspected communicable diseases like infectious diarrhoea, tuberculosis, or seasonal flu were placed at the end of the lists and deep cleaning was carried out when they left the room.
Environment and equipment
The service did not always have suitable premises. Equipment was looked after well. The design, maintenance, and use of facilities were not always suitable for their intended use. Whilst risks had been identified by the service, there were no long-term plans in place to rectify them only to temporarily mitigate them. The maintenance and use of equipment generally kept people safe from avoidable harm. Some waiting areas in outpatients’ services were not suitable for the volume of patients attending. We observed this was a problem in dermatology outpatients and some patients had to stand whilst waiting for their appointment. The waiting area for fracture clinic was shared with the minor injury waiting room for the emergency department (ED). This caused problems with patients being unsure where to present/book in, and meant outpatient reception staff spent time directing and advising ED patients. Staff also advised us that patients attending the ED would often see patients being called in to outpatient clinics and complained they were not being seen in time order. This meant staff had to explain that two services were being run out of the area and waiting times were different for each service. All staff within fracture clinic spoke of the poor environment as their main concern and felt this affected patient experience and care. A part of the waiting area had a small screen to separate outpatient children; however, this was not always sufficient to avoid them seeing patients attending the emergency department who often had visible injuries in the same area. There were toys available in this area for children to use whilst waiting for appointments. The ophthalmology outpatient area was cramped for the volume of patients that attended clinics. Due to space limitations, patients were sometimes receiving treatment in corridor areas such as receiving eye drops: this was also found during our previous two inspections. Visual acuity tests were carried out in small gaps next to the reception and waiting areas, which were very noisy and crowded with constant disruption. Ophthalmology staff told us they believed estate changes were being considered to improve this service but had not been given any timeframes or definitive plans for this. Managers also did not have any definitive plans for any developments in this area. We raised this as a concern and the trust have provided a risk assessment dated 17 November 2014, which was reviewed In September 2017: mitigations had been put in place for staff to use a quiet room to provide eye drops. We also saw that the estates department had been requested to consider options for changes in the environment as a priority.
20180222 KGHNHSFT Evidence Appendix Page 222
The audiology outpatient area had suitable and up to date facilities to carry out examinations and treatment. Staff in these areas felt happy with these facilities. Some clinics such as audiology and ear, nose and throat (ENT) had separate children’s waiting areas, which was an improvement since the previous inspection. These waiting areas had toys suitable for children. There were resuscitation trolleys or grab bags available in all outpatient areas. We observed that these were accessible and had received the necessary daily and weekly checks from August 2017 to November 2017. All equipment stored within resuscitation trolleys and grab bags was within expiration dates and in sealed packaging ready for use. Automatic external defibrillators within resuscitation trolleys and grab bags had received suitable device testing to confirm their safety for use. We reviewed portable equipment within outpatient’s services and found most items to have received appropriate safety checks to ensure their suitability for use. However, two computers in main outpatients and an observation machine in ophthalmology had not received a safety check within the previous 12 months. We raised this with staff in the department. Disposable equipment was stored appropriately and all items were inspected were found to be within their expiration date. Staff told us they could access bariatric equipment 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. 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. We found that sharps containers were not always utilised in line with national and trust guidance. In main outpatients, we observed 12 full sharps containers being stored on the floor of the utility room. These containers did not have written detail on the front to advise where they originated from or the date that they were opened and closed. We raised this with the matron who advised they were from another department and immediately arranged for their collection. Sharps containers in treatment areas were stored appropriately.
Assessing and responding to patient risk
Systems and procedures were in place to assess, monitor, and manage risks to patients. During our last inspection, we found there was a system in place to monitor and manage the risk to patients on the waiting list. We saw that the hospital had ceased reporting the Referral to Treatment Time (RTT) in November 2015 due to the hospital’s data quality concerns. The trust had had significant problems with a large number of patients waiting over 52 weeks since November 2015. We observed during our inspection in June 2017 that improvements had been made. During this inspection, there was a further reduction in the number of patients waiting over 52 weeks, with figures (based on unvalidated information provided by the trust during the inspection) showing that 46 patients had been waiting over 52 weeks, in comparison to 413 during October 2016. This was a continuing improvement. RTT data was monitored weekly within the trust, with a new designated team and lead in place to manage this. The trust had a clinical harm review (CHR) process in place to assess those waiting. The trust had implemented a ‘Clinical Harm Process and Governance process for patients experiencing delay in treatment on the 18 week RTT pathway’ at the start of July 2016, which reflected agreed amendments from the external RTT assurance group meeting held in May 2016,
20180222 KGHNHSFT Evidence Appendix Page 223 where NHS England, NHS Improvement (NHSI) and the clinical commissioning group were present. Feedback from NHSI’s Intensive Support Team had also been reflected in this policy. Other NHS organisations with RTT problems had completed the RTT data validation process prior to commencing any clinical harm reviews, however, for a timely response the trust had commenced clinical harm reviews (CHRs) in parallel with the ongoing data validation process. A five-phase approach for CHRs was implemented and this process was underpinned by risk-based prioritisation of specialities. The trust’s process was that if any clinical speciality pathway identified an increased frequency of harm or high levels of harm, then the clinical harm review process would be extended to those patients waiting before 46 weeks. This was still occurring within outpatient services. The CHRs ensured that all patients who had waited for greater than 46 weeks or longer for treatment had their clinical record reviewed to ascertain if harm had occurred. If 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 patient’s notes instances where outpatient appointments had been brought forward as a matter of urgency due to the possibility of the patients experiencing harm. Any patients deemed to be at risk of moderate or severe harm were reviewed by the trust’s medical director. At the time of our inspection, 513 patients who had waited over 52 weeks had not received a CHR. Reviews were ongoing and the number of outstanding CHRs was reviewed each week by senior managers. Information provided by the trust showed that as of August 2017, 2,109 patients had waited over 52 weeks for an appointment (both non-admitted and admitted RTT pathways) and 1,595 patients had had a CHR carried out. Of these, 90.2% had suffered no harm, 9.7% had suffered low harm, and 0.1% had suffered moderate harm. Evidence provided by the trust showed that of the 513 waiting for CHRs to be completed, 98 were in progress and 415 were waiting for clinical records. We looked at records of patients and saw that clinical harm reviews had been carried out on all the patients. The medical director and a clinical harm coordinator oversaw the reviews. Patient medical notes were sent to relevant consultants who were required to ensure that patient reviews were conducted. Patients who were found to have been caused potential harm as a result of any delays in treatment were identified. The outcomes of this process were included in the reports to the external RTT assurance group and the trust’s board. An external monitoring process by the clinical commissioning group was also in place, which involved the review of a sample of ‘no harms’ and ‘low harms’. The process involved an independent review of the patient record in primary care and the secondary care harm review. At the time of our inspection there had not been any ‘no harms’ upgraded to a higher harm level, but some ‘low harms’ had been downgraded to ‘no harm’. The hospital relied on patients to contact their GP in case of any concerns. The trust had written to all primary care providers to make them aware of the RTT position and requested that if any GP had concerns about a particular patient they should bring it to the attention of the relevant consultant. A range of information had been sent to all local GPs, and the trust had raised the waiting list issue in the local media and on their public website, to raise public awareness of the delays in receiving treatment for patients on RTT pathways.
20180222 KGHNHSFT Evidence Appendix Page 224
The trust had an ‘elective care access policy’, which gave guidance for the prioritisation of patients. During the initial phases of CHRs, the hospital had contacted local GP practices to make them aware of the long waits identified. If a GP had concerns about a specific patient who was waiting for either an appointment or treatment, they were advised to contact the relevant specialty consultant. Patients who were at risk of breaching cancer waiting times were reviewed and prioritised by the cancer services team. Patients who were not on the two-week waiting list but had a positive diagnosis from a routine or urgent investigation were flagged to the cancer team in daily emails. There was a clear process in place in outpatients to check the identity of the patient by using name, address, and date of birth. We observed staff obtaining this information from patients that attended for appointments. Patient appointments were managed through a central electronic booking system (hospital wide). The service used the trust’s electronic booking system and prioritised appointments according to referral requests from GPs with urgent requests and cancer referrals booked within two weeks. Risk assessments were completed for patients undergoing minor procedures in the outpatient department, including World Health Organisation ‘Five Steps to Safer Surgery’. Patient records we reviewed contained appropriate risk assessments. If a patient became clinically unwell in an outpatient area, staff would monitor them and check their vital signs then request emergency assistance from on call medical staff if needed. There were clear procedures in place for the care of patients who became unwell or patients who deteriorated while waiting at the clinic. Staff could clearly articulate emergency procedures and the escalation process for unwell and deteriorating patients using the national early warning scores (NEWS). However, they stated these had not been used often, as the department did not often have acutely unwell patients. There was a protocol in place to manage deteriorating patients in the outlying clinics and a system was in place to transport unwell patients to the emergency department at Kettering hospital if required Staff in Nene Park, Corby and Isebrook outpatient clinics could call 999 when required to transfer unwell patients to Kettering general hospital. If a patient had a cardiac arrest, the process was to call the on-site emergency team and 999. They then managed the patient using basic life support training 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.
Nurse staffing
The service had enough 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. There are no agreed national guidelines as to what constitutes ‘safe’ nursing staffing levels in outpatient departments. Staffing levels and skill mix were planned based on the number of clinics and patients attending. Nurses were flexed to provide cover within other outpatient clinics. At the time of our inspection, nurse staffing met the needs of patients. We found across the outpatient departments that agency and bank staff were not frequently used to fill vacancies. In the event where agency staff was required, a local induction would be given to the agency staff. New staff were inducted locally using a checklist with an additional competency pack for substantive staff. An example of this was seen during our inspection. We looked at nursing rotas up to two months before our announced inspection and no gaps were identified. Where additional staffing
20180222 KGHNHSFT Evidence Appendix Page 225 was required to cover extra clinics, sickness or annual leave, this was covered by bank staff or permanent staff who volunteered to work over and above their contracted hours. Hospital bank employed staff on an ad hoc basis. The outpatient clinics were staffed by registered nurses and health care assistants. Each clinic was consultant led and was run by registered nurses supported by health care assistants. Overall, as at November 2017, staff vacancies were 3.46% of the staffing establishment. Nursing and healthcare assistant staffing levels were displayed in waiting areas. We observed that nursing staff figures were displayed in ophthalmology department and met planned levels during our inspection. The areas that we visited displayed the required and actual staffing numbers: these staffing levels met patient needs. Nursing staff in urology felt that nursing levels did not meet the necessary requirements for the patient volumes being seen. The consultant numbers had increased from two to five over the past 12 months but there had not been a nursing staff increase to match this. Managers told us that nursing levels in this area were not planned for a review. The nurse in charge of each area was identified by a red “nurse in charge” badge. This meant they were easily identifiable to staff, visitors and patients. As of November 2017, the trust reported:- The vacancy rate of 3.82% for nursing staff in outpatients. This was not split by site. Managers told us that the main nursing vacancies were in main outpatients. The turnover rate of 3.62% for nursing staff in outpatients. This was not split by site. The sickness rate of 2.77% for nursing staff in outpatients. This was not split by site.
The trust provided the number of shifts completed by bank and agency staff by site however; it did not provide the total number of shifts so it was unable to provide the percentage of shifts covered by bank or agency staff. No agency staff were used within outpatient areas. Bank staff were used to fill vacant shifts when required, these were usually staff familiar with the service and its processes. The trust reported their staffing numbers for outpatients as of 30th September 2017 thus: No. in post September Ward/Site WTE Staff 2017 Corby OPD (5740) 3.97 5 Fracture Clinic (2730) 4.51 6 Isebrook OPD (5735) 2.69 3 Kettering General Hospital OPD 12.68 18 (5750) Nene Park OPD (5745) 3.48 4 Total 27.33 36 (Source: Additional request DR110) In the period from October 2016 to October 2017, 1,082 shifts across all outpatients sites were filled by bank staff. At Kettering General Hospital, 532 shifts were covered by bank staff (49%), and Nene Park Outpatient Centre had 97 (9%) shifts covered by bank staff. Medical staffing The service had enough 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.
20180222 KGHNHSFT Evidence Appendix Page 226
No medical staff worked directly in the outpatient service as they all worked in other clinical business units. Staffing levels and skill mix were planned based on the number of clinics run within the service. Medical staffing was provided by the specific specialities that were holding the clinics such as rheumatology, cardiology, ophthalmology, and ear, nose, and throat (ENT). Consultants had job plans and reviewed patients in clinics from 8am until 8pm from Monday until Friday. No clinics were covered by locum consultants on the days of the inspection. We saw evidence of the service’s policies and systems for local induction and training. Consultants arranged outpatient clinics directly with the outpatients department to meet the needs of their speciality. Where appropriate, consultants were supported by junior doctors in some clinics. The trust had advised that there were no medical staff reporting directly to outpatients. No locum doctors had been used in outpatients in the past year.
Records
Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to- date and available to all staff providing care. Patients’ individual care records were generally written and managed in a way that kept people safe from avoidable harm. Records seen were accurate, complete, legible, and up to date. Patient records were stored securely in accordance with hospital policy. Medical notes were in good order and information was easy to access. All records were consistent, with risk assessments and medical notes being stored in the same place throughout patient records. We reviewed 14 sets of medical records, which were fully completed, legible with entries timed, dated and signed for. We observed patients’ medical notes were in locked notes trolleys to ensure patients’ details were kept confidentiality. Some clinics stored medical records in the main nursing room initially to allow access for basic height and weight checks to be recorded. We found these nursing rooms were not left unattended at any point to ensure records were not accessible to the public. Records were stored at an off-site building approximately one mile from the main hospital site. Records were transported between the off-site facility and the main site using a dedicated courier service. Records were paper based and required a large volume of administrative staff to maintain them and ensure their availability. At the time of our inspection, notes availability within outpatients’ service was 97%; this had been improving over the previous 12 months. 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 tried, where time allowed, reviewing ahead of time the records available, but this often resulted in a healthcare assistant using their shift chasing up notes and travelling around the hospital to locate them. Main outpatients was in the process of recruiting an extra administrative member of staff whose sole responsibility would be notes availability, however this was at the cost of a healthcare assistant post. During our inspection we found eight bags of confidential waste stored in an unlocked utility room, one of these bags was in use and open. We raised this with the matron who advised they had been placed in the room from another department and immediately arranged for the collection of these bags. Staff said that confidential waste was stored in this room regularly and the need for a key lock had been escalated to the estates’ team.
20180222 KGHNHSFT Evidence Appendix Page 227
Medicines
The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. Arrangements for managing medicines in outpatient services were suitable to ensure patients were kept safe from avoidable harm. During our previous inspection in 2016, concerns were identified in relation to safe storage and management of medicines. We found there had been improvements made during this inspection. During our inspection in 2016, we noticed that temperatures checks were missed for one to two days in the main outpatients unit. During this inspection, we saw fridges used to store medications were checked by staff in line with hospital policies and procedures. Temperature records were complete and contained minimum and maximum temperatures to alert staff when they were not within the required range. All medicines we saw at the ophthalmology department and fracture clinic were in date and FP10 prescription pads were stored appropriately in locked cupboards. Pharmacy support was available during clinic hours and staff advised that they were accessible and were happy to answer any queries. There were processes and procedures in place to complete weekly checks and reconciliation of medicines as well as monthly audits to check stock and utilisation by pharmacy. We saw in clinics that stock medication was checked regularly by a pharmacist. Nursing and medical staff were aware of policies on administration of controlled drugs as per the Nursing and Midwifery Council (NMC) – ‘Standards for Medicine Management’. Most medicines were prescribed to patients for them to then collect from pharmacy, with the exception of some items such as eye drops, which were given to patients within clinics. If a patient required long-term medicines, the consultant would contact the GP and send a recommendation to prescribe to enable this to be managed in conjunction with their GP. Patient group directives (PGDs) were used in the ophthalmology service to cover the supply and/or administration of eye drops and eye 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 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. We saw that these had been authorised and signed appropriately. A record was kept of all instances where a medicine was administered under a PGD within the department.
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 this 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 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. Staff understood their responsibilities to raise concerns, record and report safety incidents, concerns and near misses, and how to report them. When things did went wrong, thorough and
20180222 KGHNHSFT Evidence Appendix Page 228 effective reviews were carried out. Staff were focused on learning lessons to make sure action was taken to improve safety. From September 2016 to August 2017, the trust reported no incidents classified as never events for outpatients. 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. In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in outpatients, which met the reporting criteria set by NHS England between September 2016 and August 2017. From October 2016 to September 2017, 852 incidents were reported across outpatient and diagnostic services. This data was not provided separately for both of these core services. Of the incidents reported, 689 resulted in no harm, 124 in low harm, 34 in moderate harm and five in severe harm. Common themes of incidents reported were around waiting times, poor care, and lack of communication. Where a serious incidents had occurred, we saw written evidence from the trust to the relevant person in correspondence containing information that had been discussed. The majority of incidents related to documentation/records (248 incidents), clinical assessment (174 incidents), and access/admission (159 incidents). Most incidents were investigated and closed within 30 days (72%). Clinical governance and departmental meetings provided staff with the opportunity for discussion of incidents. All incidents were investigated using a root cause analysis tool, taking into account the factors, which may have contributed to the incident. Managers confirmed information relating to reported incidents was collated and discussed during clinical governance meetings. We reviewed the minutes of governance meetings from June 2017 to August 2017 and this was confirmed. We saw evidence of the harm review process for patients who died whilst on the waiting list for an appointment had commenced. No harms had been identified as result of waiting for an appointment. Staff said they also relied on GPs informing the trust of deaths of patients who were on a waiting list. The trust had not been informed of any such cases. 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. Staff were aware of the Duty of Candour regulation (to be open and honest) ensuring patients received a timely apology when there had been a defined notifiable safety incident resulting in moderate or severe harm. Staff could give us examples of where they had used this in practice or instances where they would use it. We checked some recent incidents reported and saw that staff had followed the hospital policy and staff we spoke with could clearly articulate when to trigger the Duty of Candour to patients and their relatives.
Major incident awareness
The service planned for emergencies and staff understood their roles if one should happen. The hospital had a service contingency plan in place for staff to use in the event of interruption to essential services such as electricity and water supply. There was regular testing of generators
20180222 KGHNHSFT Evidence Appendix Page 229 occurred 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. There was an effective understanding amongst nursing and medical staff about their roles and responsibilities during a major incident. Staff were up to date on fire safety training. The service planned for emergencies and staff understood their roles if one should happen. Staff could describe the outpatient department’s role in a major incident. Staff in outpatient had carried out a vast amount of work at the time of and following a recent cyber-attack. Staff actions ensured that all patients were kept informed of appointments and any delays/cancellations, along with updates on their personal information availability. Appropriate fire safety equipment was available in all outpatient areas, including fire extinguishers that had received a safety check. Fire exits were clearly signposted and fire doors were clear of obstruction. Staff were up to date on fire safety training. 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. Specialities within outpatient services delivered care and treatment in line with the National Institute for Health and Care Excellence (NICE) and national guidelines where appropriate. 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 this guidance when delivering care and treatment for patients. Staff were aware of how to access policies and procedures. Staff could also locate further guidance on the hospital’s computer system, which was demonstrated to us. Overall, staff were positive about the hospital’s intranet and reported that their managers communicated effectively with them via e-mail. At the time of our inspection there were no audits registered for compliance with NICE guidelines for outpatients. However, managers advised us that this this issue was on the agenda for the December 2017 Quality Governance Steering Group.
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural, and other preferences. People’s nutrition and hydration needs were risk assessed when required using the malnutrition universal screening tool (MUST). Glucose preparations, drinks, and biscuits were available in the outpatient department for patients with diabetes if their blood sugars were found to be low. We observed staff offering food and drinks to people who had been waiting for long periods of time.
Pain relief
Pain of individual patients was assessed using a pain management tool and managed well.
20180222 KGHNHSFT Evidence Appendix Page 230
Pain relief could be prescribed within the outpatient department and subsequently dispensed by the pharmacy as required. Staff had access to analgesia in areas where patients were undergoing minor procedures. For example, ophthalmology stored paracetamol for patients who attended clinics for eye injections. The ophthalmology clinic also had access to local anaesthesia preparations, which were used if prescribed by a doctor. There was a dedicated chronic pain clinic, which took referrals from GPs, consultants and other departments within the hospital. The chronic pain service involved nurses, physiotherapists, occupational therapists, clinical psychologists, and pharmacy input to provide a complete approach to pain management. Outcomes of this service were monitored by patient self- assessments. In the chronic pain department, patients were given a diary to record their individual pain scores and this was further used to carry out an effective patient centred pain assessment to ensure that evidenced based care and treatment was delivered. The pain of individuals was assessed and managed well. Nursing staff administered simple pain relief medication and they maintained records to show medication given to each patient. Patients we spoke with had not required pain relief during their attendance at the outpatient departments.
Patient outcomes The service did not consistently monitor the effectiveness of care and treatment to use the findings to improve them. Follow-up to new rate. Between July 2016 and June 2017, The follow-up to new rate for Kettering General Hospital was similar to the England average. The follow-up to new rate for East Northants Outpatient Department was similar to the England average. The follow-up to new rate for Nuffield Diagnostic Centre was similar to the England average. The follow-up to new rate for Waendell Leisure Centre was worse than the England average, with two notable spikes noticeably worse than the England average in December 2016 and March 2017. The follow-up to new rate for Isebrook Hospital was similar to the England average.
(Source: Hospital Episode Statistics)
20180222 KGHNHSFT Evidence Appendix Page 231
Clinical audits were not conducted within outpatient services. This meant there was not full oversight of patient outcomes across specialties. The service intended to create and begin an audit schedule from February 2018. Competent staff
Generally, 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. Between July 2016 and July 2017, 79% of staff within outpatients at the trust had received an appraisal compared to a trust target of 85%. A split by staff group can be seen in the graph below:
(Source: Routine Provider Information Request (RPIR) P43 Appraisals)
We requested the updated appraisal compliance figures as of the end of November 2017 for safeguarding children level 3 training, which showed that across the service 88 staff had had an appraisal (84%) and plans were in place for the other staff to have theirs.
The hospital’s appraisal policy stated that all staff were required to have an annual appraisal using the job description and person specification for their post. There was a process for identifying any training and development needs. Staff had opportunities for development and received an annual appraisal. Staff said the trust had an electronic appraisal system assessable to all. There were appraisal leads for medical staff and a 360-degree appraisal system was available. Staff received feedback electronically. Staff told us they were encouraged to develop professionally and supported to attend internal and external training programmes.
The ophthalmology department had recently recruited a paediatric nurse to oversee paediatric care within the department. This was an improvement from the last inspection. The outpatient service planned to recruit a paediatric nurse within all outpatient clinics. Staff nurses we spoke with said the outpatient department had rolled out paediatric competencies and all nurses and health care assistants were required to be competent by January 2018. Following our previous inspection, designated paediatric nurses had been recruited to ensure each specialty had a paediatric nurse available during clinics.
A fully documented process for clinical supervision for staff nurses and matrons was not yet fully embedded. The trust wide policy and project to embed clinical supervision for all grades of nurses was presented to the Nursing Midwifery Strategy Steering Group in September 2017. The nursing staff revalidation process had been implemented and there was close monitoring of staff due to revalidate had been established.
20180222 KGHNHSFT Evidence Appendix Page 232
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.
Multidisciplinary working
Staff in different teams worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
Outpatient teams worked together to plan and deliver care and treatment. Staff in different teams and services worked together to assess, plan and deliver co-ordinated care. There were multidisciplinary team (MDT) meetings held across the specialties to provide effective assessment and treatment.
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 hand therapy for patients who had suffered a hand fracture/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. Audiology staff often assisted in ad-hoc ENT clinics and felt that working relationships between the two areas were productive and beneficial to patient care.
Booking and clinic co-ordinators were based at within Kettering General Hospital. They worked together with divisional managers and the individual specialties to continuously manage waiting lists for outpatient services. Staff in the booking and scheduling offices described improved communication with the clinical specialties since our last inspection. Discharge summaries were sent to patients’ GPs after their appointment or treatment within outpatient services. Data provided by the trust showed that 102,535 discharge summaries were sent to GPs in the current year; with an average turnaround from appointment to letter dispatch of six days. The average time to complete these discharge letters in October 2017 was 120 hours or five days. This was an improvement on the previous year when the average was seven days (or 154 hours to complete the discharge letter).
Managers and senior staff in all outpatient departments held regular staff meetings. All members of the multidisciplinary team attended and staff reported that they were a good method to communicate important information to the whole team. Regular meetings were held with consultants from nearby acute hospitals to discuss complex cases. There was a dedicated diabetes centre, which was run by a multidisciplinary team, which included joint working with staff from another local hospital. Medical staff ran clinics at the centre supported by specialist nurses from another trust. Chronic pain clinicians were part of the Midlands Pain Group that was comprised of staff from neighbouring hospitals. They met quarterly to discuss service designs and improvements. There were multidisciplinary one-stop clinics, such as in urology and the breast clinic, where patients could access consultations, diagnostics, results, and clinical nurse specialists in one appointment.
Seven-day services
Outpatient services were provided across sites from 8.30am to 6pm, Monday to Friday. Most clinics in the main outpatient department did not routinely provide a seven day a week service. In order to deal with appointment backlogs some outpatient services running clinics on Saturdays. Some specialities were carrying out ad-hoc Saturday clinics to attempt to reduce the number of patients on waiting lists but this was not a standard clinic day. Some clinics had trialled 20180222 KGHNHSFT Evidence Appendix Page 233 evening appointments previously but these had not been successful due to difficulties in arranging appropriate staffing levels.
There were no long-term plans in place to work towards seven-day services within outpatients.
Health Promotion
Staff in outpatient services spoke about using the trust’s ‘Every Contact Counts’ methodology and interventions to maximise health promotion opportunities. We saw smoking cessation advice was available and patients had access to a smoking cessation nurse. The matron for outpatient service conducted audits to review if patients were asked about their alcohol and cigarette consumption. If these questions were not asked feedback was provided to the relevant specialty to follow up. Staff were able to signpost patients to relevant support services in the community and via patients’ own GPs. We observed poster and leaflets throughout all outpatient areas advising patients on the importance of a healthy lifestyle, exercise, and ways to reduce health risks.
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 (MCA) 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. The trust has reported that 91.3% of staff in outpatients has completed MCA awareness training. This indicated they were meeting the target of 85%. There was a hospital policy to ensure that staff were meeting their responsibilities under the MCA and Deprivation of Liberty Safeguards (DoLS). Staff said that they had had training in MCA and DoLS as part of their safeguarding training. Nursing, therapy, and medical staff understood their roles and responsibilities regarding consent and were aware of how to obtain consent from patients. 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. Patients told us that staff were very good at explaining what was happening to them prior to asking for consent to carry out procedures or examinations. The service used different consent forms, depending on the patients’ capacity to make the decision. This was in line with Department of Health guidance. All patients we spoke with felt that their care and treatment was fully explained. They described having treatment options explained so that they were informed to make their own decisions. Is the service caring?
Compassionate care
Staff generally cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients were treated with respect and compassion throughout their care within outpatient services. Staff responded sympathetically to queries in a timely and appropriate way. We observed caring interactions with patients whilst they were having observations taken or being assisted in the departments. During our inspection, we saw patients were treated with 20180222 KGHNHSFT Evidence Appendix Page 234 compassion, kindness, and respect. Staff respected patients’ social, cultural, and religious needs. We observed positive interactions between staff, patients, and relatives. Staff introduced themselves and took time to interact in a considerate and sensitive manner. Patients were directed to separate waiting areas and discreet changing facilities for appointments that required hospital gowns, to protect their dignity. Patients were given the opportunity to be accompanied by a friend or relative and there were chaperones available when personal care was provided. For example, female nurses or healthcare assistants were available to act as chaperones when required. We saw staff respecting patients’ privacy and dignity, for example by knocking on doors to consultation rooms. All patients we spoke with were highly complementary of the care they had received in outpatient services and many had used the services for a number of years. Patients and their relatives told us staff were extremely friendly despite working under pressure and being very busy. The main concerns patients had were the delays in appointments and car parking. All staff introduced themselves appropriately when greeting patients and throughout their care. Staff recognised and mostly took action in areas where the environment did not always maintain patients’ privacy and dignity. The ophthalmology outpatient area was cramped for the volume of patients that attended clinics. Due to space limitations, staff gave patients treatment such as receiving eye drops in corridor areas with other people around: this was also found during our previous two inspections. This did not respect patients’ privacy and dignity. We raised this with the trust, who said that there was a quiet room available for staff to use, rather than give medicines in open areas. The trust obtained patient feedback via the Friends and Family Test (FFT), which allowed patients to state whether they would recommend the service and give feedback on their experiences. From May 2017 to October 2017, outpatient services had 7,592 FFT responses. Out of these responses, 82% of patients said they were extremely likely to recommend the service and 17% said they were likely to recommend the service. The trust did not provide us with a response rate but advised it was very low in some areas of outpatients, with work underway to improve this.
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 we spoke with told us they knew who to contact if they had any worries about their care and said staff had supported them emotionally as well as physically where there had been bad news following diagnostic results. Some specialties had clinical nurse specialists available who could provide in depth knowledge and support to patients about their particular condition. Staff in the chronic pain service were in contact with a local independent chronic pain support group and encouraged patients to contact them.
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.
20180222 KGHNHSFT Evidence Appendix Page 235
Patients and relatives said they felt involved in their care. They had been given the opportunity to speak with the staff looking after them. Relatives we spoke with said they had been given time with the nurses and doctors to ask questions. 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 patients care. Patients we spoke with felt well informed about their care and treatment. 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. Staff communicated with patients and families in ways they could understand and patients felt they had been encouraged to make their own decisions. Patients could be escorted by their relatives or friends if they wished. Staff could give examples of when they had used face-to-face and telephone interpreters to ensure patients fully understood their treatment. We saw letters sent to patients informing them when there had been a change to their planned consultant. Patients we spoke with whose planned consultant had changed confirmed that they had received such letters before their appointment. Is the service responsive?
Service delivery to meet the needs of local people
The trust generally planned and provided services in a way that met the needs of local people. Improvements in service delivery had been made since the last inspection. We saw that services were generally planned 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. The audiology department provided some specialist services to the community, which would otherwise require long travel to either Peterborough or Leicestershire. The audiology teams were pleased to be able to provide these services and support the care needs of the local population. Most outpatient areas we visited advised us that they tried to help patients receive care closest to their home address. Administrative and clinic staff often reviewed patient addresses and checked whether a closer clinic was available to them 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 with reduced means of travel. Car parking facilities were available at each site; however, the number of parking bays did not always meet demand. There were building works taking place at Kettering General Hospital to improve parking capacity, which would increase capacity by up to 250 car park spaces. At the time of our inspection, these were being completed. Some patients we spoke with told us they had found parking difficult. There had previously been drop-off bays outside the main outpatient area but these had been closed. Some relatives and patients who had mobility issues told us that they found it difficult getting to the department due to this. Some patients also advised that the lack of parking space increased their anxiety prior to appointments and clinic staff told us patients often came in agitated and frustrated due to this. Parking was raised as an issue in the CQC inspections in both 2014 and 2016. Signposting in the department had been improved in 2016 to make it easier for patients to find the correct outpatient area. However, some signposting was still confusing and some patients had to 20180222 KGHNHSFT Evidence Appendix Page 236 ask staff for directions. There was a mixture of old signs and new lettered signs. For areas such as ENT and ophthalmology, it was unclear how to access these areas without asking at reception upon entry. Main outpatient administrative staff told us that providing directions was constantly required and this took away some of their concentration and time on inputting data to systems that was required to be accurate. Managers advised us they would like to have a separate ‘meet and greet’ reception to avoid administrative staff having to provide directions and allow them to focus on their role. Volunteers on the main receptions desk also gave patients and relatives advice on finding the right clinic areas. Since the previous inspection in 2016, several specialities had introduced separate waiting areas for children, these included ENT, and ophthalmology. These areas had suitable toys, books and seating for children. Fracture clinic did not have a suitable separate children’s area, due to this a screen was used to designate some seats for children but there was no signage to advise other patients this was a children’s area and patient from the emergency department and other outpatient could sit in this area. 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. Between July 2016 and June 2017, the ‘did not attend’ rate for all sites within the trust were worse than the England average. Waendell Leisure Centre shows notable fluctuation, and briefly performed better than the England average in December 2016 and February 2017. The chart below shows the ‘did not attend’ rate over time.
Proportion of patients who did not attend appointments
(Source: Hospital Episode Statistics) At the time of our inspection, these rates had improved to 7.2%, which was in line with the national average of 7.4%. 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 list. The exceptions to this were paediatric patients and cancer patients. Information regarding DNA rates was displayed on 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.
20180222 KGHNHSFT Evidence Appendix Page 237
Managers within outpatient service were aware that further 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 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.
Meeting people’s individual needs
The service took account of patients’ individual needs. 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. Information was available in accessible formats. For example, ophthalmology staff could request information to be sent in large text for patients who were visually impaired. Hearing loops were available in all outpatient areas and were clearly visible to assist patients with hearing difficulties. Some outpatient services, such as audiology, provided a text service, which allowed patients to contact if they had any questions about their care or treatment. A member of staff would contact the patient following the receipt of a text message. Most outpatient areas had a room that could be utilised for breaking bad news to patients. Information packs with details of organisations that could help following a poor diagnosis were available and staff gave out contact details of clinical nurse specialists (CNS) and Macmillan staff that could provide support to these patients. However, if rooms were not available, or were already being utilised it meant that conversations with patient had to be held in regular clinic areas where they may be overheard. Staff we spoke with told us that if a patient living with dementia or a learning disability attended a clinic they would be prioritised to ensure least disturbance to them and enable them to spend minimal time in the department. We also observed that children were prioritised when attending outpatient areas. Some staff could not recall receiving dementia specific training to enable them to provide the best care to this patient group. Translation services were accessible across outpatient services, either via telephone or face to face. Staff told us that GP referrals usually stated if translation services were required, or that this would be picked up by the booking department. Some signage was in languages other than English and information leaflets could be accessed in other languages upon request. Patients were allocated appointment lengths based on the need for the appointment. If a patient was going to be given bad news following diagnostics they would be provided with a longer appointment to ensure there was time for staff to answer all questions they had. During our previous inspection in 2016, we identified concerns that patients in wheelchairs could not access all outpatient areas. Clinic rooms did not always allow space for wheelchairs to fit in. This had not changed during this inspection and some areas were still inaccessible to patient in wheelchairs. There were also areas that were problematic for patients on trolleys as there were not facilities to hoist in the main outpatient department. However, some improvements had been made for patients who were immobile and were bought in by patient transport services, including handovers to patient transport staff.
20180222 KGHNHSFT Evidence Appendix Page 238
We also found similar issues that were identified during the 2016 inspection in that due to insufficient space and seating, waiting areas in ophthalmology and the fracture clinic were overcrowded causing difficulties for people with mobility problems.
Access and flow
People could not always access the service when they needed it. Waiting times from treatment were not in line with good practice but were improving in line with the trust’s recovery plan. 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 publically 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. During our inspection in October 2016, we found that patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses, or treatment. There were long waiting lists with many patients waiting up to 52 weeks for outpatient services. At October 2016, the service had 18,816 patients on the waiting list for new appointments in outpatient services. Trust data showed 413 patients had been waiting over 52 weeks. They had not reported RTT performance nationally since November 2015. The trust had returned to national reporting of its RTT figures at the end of March 2017 following significant support from NHS Improvement’s Intensive Support team. ‘RTT Confirm and Challenge’ meetings regarding RTT performance were held every two weeks. Data from April 2017 to October 2017 showed actions by speciality, current RTT performance, additional resource updates, and harm reviews carried out. From September 2016 to August 2017, the trust’s referral to treatment time (RTT) for non-admitted pathways has been worse than the England overall performance. The figures for August 17, showed 83.8% of this group of patients were treated within 18 weeks, compared to the England average of 89.6%. Despite this, there is a notable uplift in performance in January 2017 that was then maintained to the end of the reporting period. Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways.
(Source: NHS England) Two specialties were above the England average for non-admitted RTT (percentage within 18 weeks).
20180222 KGHNHSFT Evidence Appendix Page 239
Specialty grouping Result England average Rheumatology 93.7% 91.0% Dermatology 91.9% 89.5% Fifteen specialties were below the England average for non-admitted RTT (percentage within 18 weeks). Specialty grouping Result England average General Surgery 86.3% 89.8% Gynaecology 85.4% 93.9% Other 83.0% 91.4% Ophthalmology 83.0% 90.5% ENT 82.1% 88.9% Neurology 81.9% 83.0% Cardiology 81.8% 87.9% Thoracic Medicine 78.8% 89.0% Trauma & Orthopaedics 77.9% 87.5% Plastic Surgery 77.4% 92.2% Oral Surgery 76.0% 85.5% General Medicine 75.0% 92.8% Geriatric Medicine 73.6% 95.6% Gastroenterology 69.6% 84.9% Urology 56.2% 88.1% (Source: NHS England)
From September 2016 to August 2017, the trust’s referral to treatment time (RTT) for incomplete pathways has been worse than the England overall performance. There is a marked increase in trust performance from February 2017 to July 2017, although a trend of decline could be seen at the end of the reporting period, mirroring the England average. Referral to treatment rates (percentage within 18 weeks) for incomplete pathways.
(Source: NHS England)
Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty
One specialty was above the England average for incomplete pathways RTT (percentage within 18 weeks). Specialty grouping Result England average Rheumatology 96.7% 94.7%
16 specialties were below the England average for incomplete pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average General Surgery 57.8% 86.9% Gynaecology 87.2% 90.9%
20180222 KGHNHSFT Evidence Appendix Page 240
Other 81% 91.5% Ophthalmology 65.5% 91% ENT 81.2% 89% Neurology 86.5% 89.3% Cardiology 78.1% 91.9% Thoracic Medicine 80.5% 92.4% Trauma & Orthopaedics 71.4% 84.7% Plastic Surgery 82.9% 86.5% Oral Surgery 77.7% 88.1% General Medicine 81.8% 94.6% Geriatric Medicine 78.8% 96.5% Gastroenterology 73% 91.3% Urology 53.3% 88.7% Dermatology 92.2% 92.5% (Source: NHS England) As of 5 November 2017, the total number of patients waiting for an appointment was 22,214 with 5,319 patients on an admitted pathway (for a procedure requiring admission to hospital) and 16,895 patients on a non-admitted pathway. 17,603 patients had been waiting less than 18 weeks (79.2%). There were, as of 5 November 2017, 4,611 patients waiting more than 18 weeks (20.8%). This demonstrated an improvement from the 5,702 patients (25%) that had been waiting over 18 weeks as of 20 June 2017, when we last inspected. This improvement in performance indicated the trust was achieving steady improvements generally in line with its trajectory and RTT recovery plan to return to the overarching target of 92% (for both admitted and non-admitted RTT pathways) in early 2018. There were 46 patients (for both admitted and non-admitted RTT pathways) waiting over 52 weeks. This again was an improvement from the last inspection in June 2017 when the total was 178 patients. The trust was working to reduce this total to 20 patients waiting more than 52 weeks by the end of November 2017. For non-admitted RTT pathways, there were 486 patients waiting over 31 weeks (2.9%) and nine patients waiting more than 52 weeks (0.1%). This was an improvement from the June 2017 inspection, when we found that there were 751 patients waiting over 31 weeks (4.1%) and 28 patients waiting more than 52 weeks (0.2%). For admitted RTT pathways, there were 678 patients waiting more than 31 weeks (12.7%) and 37 waiting more than 52 weeks (0.7%). This was an improvement from the June 2017 inspection, when we found that there were 1,059 patients waiting more than 31 weeks (22.9%) and 150 waiting more than 52 weeks (3.2%).
From quarter two 2016/17 to quarter one 2018/18, the trust performed consistently better than both the England average and 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)
20180222 KGHNHSFT Evidence Appendix Page 241
(Source: NHS England – Cancer Waits) Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers). From quarter two 2016/17 to quarter one 2018/18, the trust performed consistently better than both the England average and 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)
From quarter two 2016/17 and quarter one 2017/18, the trust performed better than both the England average and the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral, with the exception of quarter four 2016/17, where the trust did not meet the standard. The performance over time is shown in the graph below. Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment.
(Source: NHS England – Cancer Waits)
Referrals were prioritised by clinical urgency: suspected cancer referrals first, then urgent referrals and then routine referrals on a ‘next in turn’ basis. Suspected cancer and urgent referrals did not experience any delays in accessing appointments. The maximum waiting time for suspected
20180222 KGHNHSFT Evidence Appendix Page 242 cancer referrals is two 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. The trust’s policy for prioritisation showed the RTT clock started on the date the trust received the referral and stopped when a patient had either received treatment in an outpatient setting or was admitted for treatment. The RTT clock stopped for non-treatment when a decision was made and communicated to the patient and their GP that; a clinical decision had been made not to treat, a patient did not attend their appointment which resulted in the patient being discharged, a patient declined treatment after being offered it, or a patient died before treatment. However, we noted senior staff were to review the process to ensure it was being followed correctly. In order to help teams reduce waiting times, an elective care e-learning programme to help teams reduce waiting times and improve access was launched by the trust in June 2017. Data provided by the trust showed 93% of staff had attended this training by July 2017, with the other staff booked onto this training. The trust’s RTT training for 2017 covered basic navigation to the electronic recording system (Patient Administration System) and included how to search for patient records, check key demographic information and alerts with the aim of having all staff complete this by the end of December 2017. During our inspection, we spoke to the lead staff for monitoring and managing RTT data. This team had been set up since our previous inspection to ensure robust processes were put in place to improve processes and performance. Lead RTT staff said that without significant investment or a reduction in patient volume it was unlike the trust would meet its RTT targets in the near future. From April 2017 to August 2017, there had been an increase in referrals by 7.2%; staff felt that if referrals continued to increase rather than decrease this would further affect RTT performance. Senior managers were aware of this rise and were taking actions to deal with this increase via the ‘RTT Confirm and Challenge’ meetings, where performance was reviewed and the actions agreed to continue to improve performance. This included the use of an external organisation to undertake some appointments and treatments required as well as weekend clinics in some specialties. Senior managers were speaking with the local commissioners about the increase on referrals and had recognised this risk on the service’s risk register. A new electronic room booking system had been introduced within outpatient services. This system allowed nursing and operational managers to view which rooms were available at certain times. This system replaced a manual system, which took excessive administrative time and reduced flexibility. Managers hoped this system would continue to evolve and provide a more streamlined system for ensure the appropriate rooms were used for each clinic, and improve utilisation following cancellations of clinics. Managers within the department felt that there were areas that could be altered or added to improve flow and efficiencies. They felt that the provision of electronic kiosks that allowed patients to book in and directed them to the correct area would be beneficial. This would also ease the workload of the two administrative staff that sat within the main reception booked patients into clinic and were often required to provide directions. At the time of our inspection, there were no plans to introduce electronic kiosks due to financial constraints. From November 2016 to October 2017, 446 additional ad-hoc clinics were carried out across outpatient services, this allowed over 2,600 additional patients to be seen. These clinics were generally in working hours and during Saturdays. However, ophthalmology had completed some evening clinics are the Isebrook satellite clinic. 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
20180222 KGHNHSFT Evidence Appendix Page 243 alternative appointment or to rebook an appointment. Patients felt these methods were all convenient and saved time. There had been high abandoned call rates within the appointment centre prior to our inspection. Staff told us that we observed that abandoned call rates had improved from over 19% to 2% since changes were made to earlier in the year. Managers advised there had been a restructure within the appointment centre, along with additional staff provided and improved equipment to facilitate this improvement. 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 reduce the impact on clinics. They were liaising with the local commissioners and the private ambulance service. Staff were aware of this problem and reported all patient transport issues via the electronic incident reporting system. There were examples of patients waiting up to three hours for return transport. Staff tried to mitigate this by making requests for return transport as far in advance as they could. They chased any late pick-ups and logged all phone calls to the transport provider. Patients were kept comfortable while they waited. Within the 12 months prior to our inspection, 4,839 clinics in total had been cancelled. Out of the 4,839 clinics that were cancelled, the majority related to ‘clinician on holiday’ (32%), ‘clinic rules change’ (16%) and ‘no consultant’ (13%). The target for cancelled clinics was 2% or below. For the week commencing 2 October 2017, cancelled clinic rates were 2.43% and for the week commencing 15 October 2017 cancelled clinic rates were 3.17%. A standard operating procedure (SOP) had been introduced in relation to clinic cancellations. If appointments were required to be cancelled at short notice (within six weeks) the SOP detailed this had to be signed off by the outpatients’ general manager. Managers told us this had helped to improve unnecessary cancellations and ensure those that needed to be cancelled were done so in a timely way. The service measured the number of patients who were seen within 30 minutes of their appointment time. Over the last 12 months to October 2017, 19% of patients waited over 30 minutes to see a clinician after their appointment time. The best performing specialties were respiratory (1% over 30 minutes), pain management (0.5% over 30 minutes) and audiology (2% over 30 minutes). The worst performing specialities were oncology (38% over 30 minutes), ENT (36% over 30 minutes), and urology (40% over 30 minutes). There did not appear to be correlation between high patient volumes and increased waits across these specialties. This trust did not advise what their target was for the performance measure. Managers within outpatient services were aware late running clinics were a problem and a programme of work was being conducted with the transformation team. There had been recent work to review clinic templates to ensure slot times were realistic to maximise utilisation. Audits were carried out twice yearly in relation to notes availability in clinics. The most recent audit was carried out in April 2017, with the next due in November 2017. The results of the April 2017 audit showed that on average, across outpatient sites, notes were available for 97% of clinic appointments against a target of 100%. All patients sampled during this audit could be seen in the clinic without their full clinical by utilising previous referral or appointment letters. We did not observe any instances where notes were not available on the days of the inspection.
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.
20180222 KGHNHSFT Evidence Appendix Page 244
The service had patient experience leaflets available across the hospital and its external sites as well as displaying posters on how to contact the patient experience team. These details were also available on the public website. The Patient Advice and Liaison Service (PALS) office had a visible presence within the main entrance to the hospital with a banner to advertise the service. Patient information/welcome packs included information on how to raise concerns with staff. All publicity material emphasised that the service welcomed feedback as a valuable opportunity to improve services. Staff were trained and actively worked to resolve concerns at source. Staff ensured that they make people aware of the various ways they can raise concerns if they wish to contact PALS or the complaints team. The trust was investing in an electronic patient feedback system that will enable people to give feedback via various routes including email, text, input into tablet devices on site and voicemail. The trust’s electronic incident recording system was being developed so that staff could also report on locally resolved concerns to enable better learning and reporting, including identification of risks. Between August 2016 and July 2017, there were eight complaints about outpatients with the themes of delayed appointment and waiting times, lack of communication and not receiving test results. We looked at these complaints and saw all had been investigated within the trust timescales. This was in line with their complaints policy, which stated non-complex complaints should be completed within 25 days and complaints that were more complicated would have an agreed extended deadline. Between August 2016 and July 2017, there were 28 compliments about outpatients. Themes for compliments received related to the care provided, cleanliness of environment, and no delayed waiting times. Compliments that were received by the patient experience team were shared with the ward/ department and were reported in monthly clinical business unit reports. 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. We observed leaflets were available throughout all outpatient areas on how to make a complaint to the trust and the complaints’ process. Staff told us of examples where procedures and process had changed in light of feedback from patients and their relatives. These included: Changing the telephone system in waiting list office so calls were answered in sequence. Signage in some outpatient areas had been improved. Introduction of text reminders for appointments for the majority of outpatients. Patient information leaflets on results reporting introduced. More staff provided in the waiting list team to improve the management of referrals.
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. Outpatient services were managed by both operational and clinical managers. The general
20180222 KGHNHSFT Evidence Appendix Page 245 manager had responsibility for a number of specialties within the hospital including outpatients, obstetrics, gynaecology, and paediatrics. A service manager was in place along with a lead nurse. These staff all understood the pressures present within outpatient services and could explain the journey the service had made since the previous CQC inspections. Service leaders fully understood the challenges to high quality care and identified actions needed to address them and were focused on driving improvements in a timely way. Staff we spoke with felt that their divisional and immediate managers were visible and approachable. We observed that managers worked effectively with the executive team in the trust in relation to the transformation programme that was ongoing. We observed positive leadership from department managers, sisters, and matrons across all outpatient areas. These staff showed enthusiasm for their role and in supporting staff to provide the best patient care for their outpatient area. Some staff we spoke with had not seen anyone from an executive level within outpatient services, and felt that this created a divide between the outpatient’s service and the trust as a whole.
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 trust had a vision for what it wanted to achieve, and there were workable plans to turn it into action. The trust’s vision was to provide high quality care to its communities. The four strategic aims described within the trust’s 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.
The outpatients’ service had set up a five-year outpatient transformation programme in September 2016 aligned with the trust’s strategy. This plan was in place during our previous inspection with work focused on do not attend rates, clinic template changes and cancellation of clinics. 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 (two way-text service implementation). Clinic template optimisation achieved through the introduction of new tools.
During this inspection, we found there had been improvements in all of these key deliverables with positive outcomes on flow and patient care. A structured, well-defined service and quality improvement plan was in place, which linked risk, performance, and delivery and the service’s financial position to clearly defined key performance indicators.
20180222 KGHNHSFT Evidence Appendix Page 246
Managers were clear on what progress had been made and what needed further investment and time to embed. Staff working in outpatients felt that whilst they heard from their managers about plans for outpatients, they did not hear anything definitive from a trustwide level. Staff felt that visions and strategies often involved other areas of the trust and not outpatients. Some staff had been told that there were going to be improvements to the environment, but no timescale or set plans had been provided for this. The trust had a clear set of values, which were ‘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 audiology, where staff had received them. Staff were aware of the CARE values and felt that they truly reflected the organisation and the care provided to patients.
Culture
Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. All staff felt that there was a positive working culture and a good sense of teamwork and good staff morale was evident. All staff we spoke with felt respected and valued. There was positive feedback from the recognition staff received from their divisional managers, service managers, matrons, and senior nurses. Managers spoke very highly of the clinical and support staff that worked within the outpatient departments they told us they were flexible and highly motivated to provide a positive patient experience and best patient care. Some managers felt that medical engagement could be improved within the service and this would help to support a team working culture. The trust had introduced a Freedom to Speak Up Guardian since our previous inspection; however, some staff we spoke with were unaware who this was or what their role was.
Governance
The service used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by aiming to create an environment in which excellence in clinical care would flourish. Governance structures were in place to support the functions of outpatient services. Monthly governance meetings were conducted to allow oversight of the 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 outpatients and with the rest of the trust.
Managers in the service had an effective oversight of the hospital’s RTT performance and could clearly show how the recording system worked and the number of patients waiting to be seen. This continued improvement in understanding the hospital’s RTT position and performance was continually checked performance at the service’s two weekly ‘RTT Confirm and Challenge’
20180222 KGHNHSFT Evidence Appendix Page 247 meetings. Clear, ongoing communication with NHS improvement (NHSI) and the local clinical commissioning groups was evident.
Senior staff said that the service was well represented at board level. The chief operating officer was the executive lead for the outpatient quality improvement programme. We saw evidence that regular reviews were held to monitor and improve progress against the quality improvements initiated by the trust for the outpatient department. Clinical staff carried out clinical harm reviews (CHRs) for patients who had been waiting over 52 weeks. Data provided by the trust showed CHRs were carried out in high-risk specialties after 46 weeks. Senior staff we spoke with said there was a weekly report for patients waiting over 46 weeks and for the trust’s executive team. RTT executive assurance groups were held every two weeks between RTT leads and executive trust leaders. We reviewed minutes of the last three meetings and found these to detail necessary areas of risk and performance relating to RTT. Governance and risk oversight had continued to improve so that the trust’s Board of Directors and all external stakeholders could be assured as to the trust’s ongoing RTT performance and potential risks to patient safety. Following the introduction of a transformation lead into the service, steering groups were held every two weeks. 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. Staff attended the hospital’s daily safety huddle and took part in daily discussions. Regular staff meetings were held where learning from incidents and complaints was cascaded swiftly. Staff told us they always received any local learning and feedback relevant to outpatients, but were not always aware of learning from other parts of the trust. Service level agreements were in place with other providers where necessary. The diabetic centre at the hospital was run by another NHS trust but the oversight of the facilities and equipment was the responsibility of Kettering General Hospital. 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. 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 service had a comprehensive risk register in place that detailed accurately risks to the service, actions taken to mitigate risks, a risk level, and a review date. The highest-level risks to the service were: Insufficient staffing to facilitate service delivery and to support the RTT pressures over more than 42 weeks of the year with current activity. Insufficient numbers of paediatric staff/staff with paediatric competencies across all outpatient sites. Low level of training compliance in level three children’s safeguarding training. Lack of assurance on actual number of patients who require a follow-up appointment. Lack of robust electronic room scheduling system to enable the effective management of outpatient clinic capacity and utilisation.
Clear actions, mitigations, timescales for action, and risk owners were in place. We observed that some risks had reduced by the time of our inspection as staff training and recruitment had occurred in line with actions on the risk register. Managers and senior staff had a detailed and effective knowledge of the risk register and said it was reviewed weekly, with any high level risks being escalated to corporate level for review.
20180222 KGHNHSFT Evidence Appendix Page 248
We reviewed the quality and performance dashboard for the service. It gave clear information as to the overall RTT performance position, individual speciality performance, the number of patients on a waiting list and for how long, the number of clinical harm reviews carried out, and those yet to be done (with the rationale as to why there was any delay).
Managers in the service now had an effective oversight of the hospital’s RTT performance and could clearly show how the recording system worked and the number of patients waiting to be seen. There was continued improvement in understanding the hospital’s RTT position and all managers drove improvements and checked performance against agreed actions at the service’s two weekly ‘RTT Confirm and Challenge’ meetings.
Information Management
The service collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards. There were effective arrangements to ensure the information used to monitor, manage, and report on quality and performance was accurate, valid, reliable, timely, and relevant. The data quality team and data validators were integral to ensuring outpatient referral to treatment performance data was accurate. The trust had recruited its own team of data validators. They removed duplicate patients added in error, and provided weekly reports to managers to help drive improvements in meeting targets and patient flow. Senior managers felt confident that the quality of RTT data had significantly improved and accurately reflected the trust’s position. The service had recruited a clinical harm coordinator in January 2017 and their role was to lead the harm review process. Patient pathway managers and service support managers were newly recruited to support service delivery and to sustain improvements. Service support managers were now trained to validate patient records and RTT data. Staff generally had access to up-to-date, accurate, and comprehensive information on patients’ care and treatment. Records were required for clinics at other sites and not always provided on time. Consultants would see patients without records but interim notes comprising of test results and correspondence were printed out to make a temporary set of notes. These would be stored in the full patient record. If there was any risk to the patient, the appointment was cancelled and rearranged.
Engagement
The service generally engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. 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. There was limited patient engagement outside of these feedback mechanisms. Outpatient 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. As part of this project, there would be trustwide promotion and newly branded material. The new system would allow patients to provide feedback electronically as well as traditional methods such as comment card. The system would
20180222 KGHNHSFT Evidence Appendix Page 249 allow feedback for all the various areas and departments of the trust and the intention was to design this system in conjunction with patient representatives. The anticipated implementation for this system was April 2018. As an interim measure, the patient experience team were engaging with outpatient staff to support improved completion of paper forms by patients. All outpatient specialties scheduled monthly team meetings; however, these were often changed due to increased demand or staffing shortages. Staff forums had been put in place since our last inspection and allowed staff to engage with trust executives and share ideas.
Learning, continuous improvement and innovation
The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research, and innovation, but further work was required to embed this practice. Almost all staff we spoke with had ideas of how they could improve their area of the outpatient service, including in audiology and urology. However, staff felt that the trust’s financial status was potentially hindering improvements being carried out or piloted. This led to frustration with some staff, especially those working in poorly performing areas where staff felt efficiencies could be made. Some staff told us they did not actively raise ideas any more due to lack of progression with them previously. Diagnostic imaging
Facts and data about this service
Kettering General Hospital NHS Foundation Trust provides a Diagnostic Imaging service, which is within the clinical support services business unit of the hospital. The diagnostic imaging department provides a full range of diagnostic imaging modalities, including general radiography, computerised tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and ultrasound. The service also performs dental x-rays, including orthopantomograms (OPG) which give a panoramic scan of the jaw, and cephalostat scans providing accurate measures of dentofacial morphology. There were several modern portable x-ray machines and four new image intensifiers for theatre work. The department performed approximately 20,000 examinations each month. This is the first CQC inspection of diagnostic imaging at Kettering General Hospital as a core service. We carried out our inspection from 8 November to 10 November 2017. During our inspection, we visited all the modalities, including the cardiac investigation unit and the cardiac catheter laboratory. We spoke with19 patients and relatives, and 32 members of staff, including radiologists, radiographers, nurses, unit managers, and health care support workers. We reviewed eight patients’ care notes and medical records and observed care being delivered.
20180222 KGHNHSFT Evidence Appendix Page 250
Is the service safe?
Mandatory training The service provided mandatory training in key skills to all staff and made sure everyone completed it. However, training given was not always recorded for all staff. The trust set a target of 85% for completion of mandatory training. A breakdown of compliance for mandatory courses between July 2016 and July 2017 for medical/dental and nursing/midwifery staff in diagnostics is shown below: Nursing staff:
Module name July 2017 Equality, Dignity & Respect 97.0% Fire Safety 87.9% Health and Safety 93.9% Infection Control 87.9% Risk Management 87.9% Basic Life Support (Adult) 90.6% Information Governance 93.9% Manual Handling Patient 93.9% MCA Awareness 93.8%
Medical staff:
Module name July 2017 Equality, Dignity & Respect 91.7% Fire Safety 91.7% Health and Safety 91.7% Infection Control 91.7% Risk Management 91.7% Basic Life Support (Adult) 75.0% Information Governance 91.7% Manual Handling Patient 91.7% MCA Awareness 91.7% Paediatric Basic Life Support 37.5% (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) Staff received effective mandatory training in the safety systems, processes, and practices. For example, staff told us they completed training in a range of mandatory subjects, including fire safety awareness, safeguarding (both adult and children), basic life support, infection prevention, and control, information governance, Mental Capacity Act 2005 (MCA), deprivation of liberty safeguards and equality, diversity and human rights. At the time of our inspection, we saw that 43 out of the total number of 44 radiographers in the main radiography unit had received basic life support (BLS) training. The one remaining member of staff had been booked for training on 13 November 2017. Radiologists we spoke with said they had had BLS training by other institutions and this was not recorded in the trust spreadsheets. The trust should ensure that all mandatory training staff had been given was recorded correctly. We requested the updated training compliance figures as of the end of November 2017 for basic life support for adults (BLS) and paediatric basic life support (PBLS), which showed that: 20180222 KGHNHSFT Evidence Appendix Page 251
10 out of 13 medical staff had completed BLS (77%). 5 out of 9 medical staff had completed PBLS (56%). The service had an action plan in place to improve compliance with this mandatory training and progress was to be reviewed monthly at the divisional meetings. This was also on the service risk register. The timescale to achieve compliance was March 2018. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Not all staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 85% for completion of safeguarding training level 2. A breakdown of compliance for safeguarding courses between July 2016 and July 2017 for medical/dental and nursing/midwifery staff in diagnostics is shown below: Nursing staff: Module name July 2017 Safeguarding Adults - Level 2 100.0% Safeguarding Children Level 2 100.0%
Medical staff: Module name July 2017 Safeguarding Adults - Level 2 91.7% Safeguarding Children Level 2 91.7% (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) Staff understood their responsibilities and were aware of safeguarding policies and procedures. Staff had regular training in safeguarding of vulnerable adults and child protection. Those interviewed were able to provide definitions of different forms of abuse and were aware of safeguarding procedures, how to escalate concerns and relevant contact information. Information on safeguarding was seen on staff noticeboards and in public areas with relevant contact numbers. Staff said they received feedback from the hospital’s safeguarding team if they made a safeguarding referral. Staff had access to the trust’s adult and children safeguarding policies. The trust safeguarding team was available to provide advice and guidance when required. We spoke with four radiographers and they were able to identify the potential signs of abuse and they knew the process for raising concerns and making a referral. Staff adhered to the safeguarding procedure if they encountered a non-accidental injury. Radiographers knew about the non-accidental injury policy. Staff would seek the advice of a consultant radiologist on site and if necessary contact a paediatric radiologist from another trust for advice, as the department had no paediatric radiologist at the present time. We were told arrangements had been made with another trust for a paediatric radiologist to be on site one day a week from 13 November 2017. Staff said the non-accidental injury policy was in the process of being updated. Safeguarding training was mandatory for all staff and different levels of training were provided, according to job role. All radiographers and nursing staff had had adult and children safeguarding level 2 training. 91.7% of medical staff had had adult and children safeguarding level 2 training. Managers were waiting for clarification from the trust if all staff should have adult and children safeguarding level 3 training. Meanwhile, the management had arranged for all trained staff to have safeguarding level 3 training. Two radiographers said they had recently attended safeguarding level 3 training and arrangements had been made to roll out level 3 training for all trained staff in the diagnostic service. We raised this with the trust who said that level 3 training was required for all clinical staff working with children or young people and/or their parents who 20180222 KGHNHSFT Evidence Appendix Page 252 could potentially contribute to the assessment, planning, intervention and evaluation of the needs of a child or young person and parenting capacity where there are child protection concerns. Several staff had chosen to undertake level 3 training in addition to the competency matched level two requirements. However, no training compliance figures were provided.
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. The radiology areas that we visited were visibly clean. We saw cleaning schedules had been completed and domestic staff were visible across the department. Staff working in clinics where specialised equipment was used, such as the cardiac unit and ultrasound, cleaned and maintained their own equipment to ensure safety. The diagnostic department was visibly clean. Staff wore appropriate personal protective equipment. We saw staff wearing lead aprons during procedures. Staff wore aprons and gloves before giving personal care to patients in recovery and these were changed in-between patients. Hand washing facilities and sanitising gel was available throughout the department and we observed staff using these regularly. All staff we saw were ‘arms bare below the elbow’ in clinical areas, in line with national guidance. We observed staff washing their hands before attending to patients. There were adequate hand washing facilities and hand gel for use at the entrance to the modalities and clinical areas. There was prominent signage reminding people of the importance of hand washing. The display boards in the staff room had key infection prevention and control messages. Colour-coded cleaning equipment was used for different areas, such as the toilet and kitchen facilities. The trolleys for various procedures were visibly clean and were labelled appropriately to indicate if they had been cleaned. Staff said they had training on infection control and compliance was above the trust target of 85%. The service had access to infection prevention and control nurses and we observed that “I am clean labels” were used on equipment and daily cleaning checks were documented. We saw that hand hygiene audit compliance was 94% in September 2017, 90% in October 2017 and 94% in November 2017. This was above the trust target of 85%.
Environment and equipment The diagnostic and imaging department generally had suitable premises and equipment and looked after them well. However, the cardiac investigation unit was cramped, cluttered, and contained potential risks to staff and patients. The trust took action to address this once we had raised it as a concern. Clear signage and safety warning lights were in place in the x-ray department to warn people about potential radiation exposure. The design of the environment within diagnostic imaging kept people safe from avoidable harm. Waiting and clinical areas were clean. There were radiation warning signs outside any areas that were used for diagnostic imaging. Illuminated imaging treatment room no entry signs were clearly visible and in use throughout the departments at the time of our inspection. The imaging service ensured that ionising radiation in plain film and fluoroscopy rooms had arrangements in place to control the area and restricted access. The environment in each area visited was clean and generally uncluttered. However, the nuclear medicine area was small. The corridor leading to the nuclear medicine area was wide and accessible for wheelchairs and patients’ trolleys. However, there were unused clinical waste
20180222 KGHNHSFT Evidence Appendix Page 253 trolleys and several items of decommissioned equipment in the corridor by the nuclear medicine area. Staff said the equipment was waiting to be removed but there was no timeline for this. 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, the patients were redirected to the various modality areas. There were electronic keypads at the entrance to each modality. The cardiac investigation unit had a comfortable sized waiting area but the actual clinical area was cluttered. It had a very short and narrow corridor leading to a number of cramped clinical rooms where patients were being treated. The manager’s office was blocked by a large photocopying machine and there were boxes of paper on the corridor floor by the photocopier, which was also next to the staff room. Staff 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. We raised this with senior managers who took urgent action to address this. The risk assessment was updated and the department decluttered as much as possible. In addition, a business case was developed for a feasibility study to be completed by end of January 2018 to look at environmental works to address the concern.
All diagnostic equipment was serviced and tested regularly according to the manufacturers’ specifications. Equipment that needed to be repaired was dealt with in a timely manner. The imaging department had installed two new magnetic resonance imaging (MRI) scanners before the October 2016 inspection. All equipment was in working order and fully functioning. Regular quality assurance and servicing was in place to ensure that the equipment was functioning safely. The MRI scanners were kept secure behind coded doors. Radiographers performed safety questionnaires to ensure anybody entering these areas were kept safe from the high magnetic field. Risk assessments had been carried out on all imaging equipment. Staff wore radiation badges to monitor any occupational doses. The 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 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 tagged. The cardiac investigation unit had paediatric and adult resuscitation trolleys. They were tagged when not in use. All resuscitation equipment was checked every day and the nurse who checked these updated the logbook daily. All the contents of the resuscitation equipment were checked every Monday, when the tag was broken and replaced when all the contents had been checked. The arrangements for managing waste kept people safe from avoidable harm. Cleaning materials were stored securely 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.
Assessing and responding to patient risk The service did not have safe systems in place for recognising and responding to patient risk. The service was not managing the potential risks to patient safety due to significant concerns about the unreported images. The trust took urgent action to address this once we raised it as a concern. Staff assessed and responded to patient risk by undertaking comprehensive risk assessments and safety checklists. The World Health Organisation (WHO) ‘Five Steps to Safer Surgery’ checklist, designed to prevent avoidable harm, was used for patients undergoing invasive procedures and diagnostics. These checklists were used for patients undergoing angiography (procedures involving the injection of contrast into a major vessel) and image guided biopsies and drainages.
20180222 KGHNHSFT Evidence Appendix Page 254
In the cardiac catheter laboratory, there were 12 recovery beds and three cubicles for day cases. The unit was part of a 24-hour percutaneous coronary intervention service. This had its own nursing and medical staff during the day and medical staff on call out of hours. Staff showed us the National Early Warning Score (NEWS) chart that was used to assess a patient’s condition before and after cardiac catheter procedures. The NEWS charts we saw had been filled in appropriately as specified. Nursing staff said there was an escalation policy which staff had to follow. Staff said they were able to seek help if they had concerns about a patient. The consultant cardiologists and their medical team were on site throughout the day. In the MRI unit, staff used the MRI safety questionnaire to risk assess a patient before they had MRI scanning. In the cardiac catheter laboratory, we were shown a patient’s nursing/medical record booklet. This contained the patient’s personal details and a section for nursing staff to check for allergies, nutritional requirements, history of falls, and other medical history. There was a pre-procedure risk assessment form, which included the patient’s medical history and whether the patient was suitable as a day case or required a hospital stay. We saw details of vital signs checks and blood results. The booklet included post procedure medical and nursing care plans, including a falls risk assessment, a tissue viability assessment and a nutritional assessment using the Malnutrition Universal Screening Tool (MUST) and an action plan if required. We saw the patient pre-procedure checklists had been correctly filled in, signed, and dated by the nurse. The checklist included a section on allergies and all patients were asked if they had had a previous reaction to contrast media. When a patient arrived for the procedure, staff checked that the results of blood tests had been reported and that they were in the patient’s records. The diagnostics department had a number of methods of taking an image, termed modalities, which include x-rays, CT, MRI, and ultrasound. There are two waiting periods involved. First, there is 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’. There was therefore a second delay waiting for the image to be reported. In some cases, the trust may judge it adequate for an image to be interpreted by a non-radiologist clinician, which is termed ‘reviewing’, either alone, or prior to reporting. In many cases, though, the image will not be useful to guide the patient’s treatment until it has been reported by a radiologist to the patient’s clinician. Delays in image reporting 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. We found no evidence of impact of the reporting delays on patient care. Staff we spoke with were very aware that the backlog of unreported images might be compromising patient safety. Staff said they would book patients an appointment for imaging within a reasonable time but then the report may be delayed due to lack of reporting capacity. 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. During our inspection, we saw that there had been 10,723 unreported images on 27 October 2017. Routine outpatient tests, GP plain films, and A&E plain films were part of the backlog. The trust had improved this from 20,000 backlog of plain films from October 2016. The number of delayed unreported images varied markedly from month to month (see the Responsive section for further details). There was not a formal process for prioritisation of those images on this backlog. There was not a formal individual assessment of risk that this delayed reporting may have for a patient. From information provided by the trust, 25,228 patients out of a total of 189,250 waited longer than four weeks for their report (13%). Images reported within two weeks were 77.8%. Images reported within four weeks = 86.6%.
20180222 KGHNHSFT Evidence Appendix Page 255
Longest patient waits for a report were: 40 41 42 43 44 45 46 weeks weeks weeks weeks weeks weeks weeks 34 12 24 29 8 16 2
Delays in Image Reporting by Modality from November 2016 to October 2017: Ultrasound GP access – one patient waited 33 weeks. Inpatients – one waited 41 weeks. Plain film Outpatients – seven patients waited 45 weeks. GP access – one patient waited 40 weeks. A&E - five patients waited 44 weeks. Inpatients – nine patients waited 45 weeks and one patient 46 weeks. Day case – two patients waited 34 weeks. MRI Outpatients – one waited 44 weeks. GP access – one patient waited 31 weeks. A&E - one patient waited four weeks. Inpatients – four patients waited four weeks. CT Outpatients – two waited 34 weeks. GP access – one patient waited 29 weeks. A&E - one patient waited six weeks. Inpatients – one patient waited 21 weeks. Fluoroscopy: Outpatients – three patients waited 34 weeks. A&E - one patient waited 34 weeks. Inpatients – One patient waited 37 weeks. Day case - one patient waited 36 weeks.
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. At the time of the well-led part of this inspection, this backlog of images not yet reported within 10 days had reduced to just over 8,000. In June 2016, the department had installed a Radiology Information System (RIS) at the same time as the Picture Archiving and Communication System (PACS) was installed when the trust joined the East Midlands Radiology consortium (EMRAD). EMRAD is a vanguard consortium designed for sharing radiology workloads between the trusts in the consortium in order to work efficiently and safely. Following the transfer to the new systems, the service found in the RIS there were approximately 220,000 historic studies for which no formal report had been produced. Work
20180222 KGHNHSFT Evidence Appendix Page 256 was being undertaken to update these records with a ‘no formal report status’ but this work had not been completed. We raised this as a concern with the trust’s senior managers. One of the actions the trust was taking at the time of the inspection was a validation and removal of historic data from the PACS for examinations that would not be reported as per the trust’s policy. The trust took urgent actions to develop a detailed action plan with clear timescales to address this concern by the end of January 2018. The trust had carried out a specific clinical harm review of 85 unreported cases in 2016. This was related to potential harms arising due to the transition period when the service moved to the new PACS and RIS. However, not all case reviews had not been completed. It seemed there had been no monitoring of the progress of this harm review. The department was not able to produce any report to that effect. No further harm reviews had been planned or carried out since October 2016. Whilst there was an ongoing backlog of unreported images, there had been no risk assessment undertaken to protect that group of patients whose x-ray images or scans were waiting to be reported and the delay might have had an impact on patient management. Inpatient plain films were not included in these figures because these were reviewed by non- radiology clinicians but they were not reported by radiologists. The trust had made the decision in 2012 not to report these low risk images due to ongoing capacity issues. The trust had relied on non-radiology clinicians to review these images. A risk assessment had been presented to the trust’s management committee on that basis but not reviewed since. However, 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. The reviews of the images should be recorded in the patients’ notes, but there had been no audit that this was being done. The department radiology manager was unaware of any radiology training given to clinicians who were reviewing images. The Royal College of Radiology (RCR) has made clear that clinicians could give an interim interpretation of an image, but, to give the final interpretation, specific training and assessment in each type of diagnosis was essential. The Royal College of Radiologists has published ‘Standards for the reporting of imaging investigations by non-radiologist medically qualified practitioners’, (July 2016). Standard 4 states: ‘When interpretation of radiological investigations is delegated to non-radiologist medically qualified practitioners, hospitals and healthcare providers are jointly responsible for ensuring the expertise of the practitioners and for obtaining their agreement to provide a record of the results of each investigation.’ We raised this as a concern and senior managers took urgent actions to develop and implement an ongoing action plan to continue to revise the risk assessments, as well as planning devising a support programme for non-radiology clinicians in reviewing these images.
Nurse Staffing The service did not have enough 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. In the main radiology department, the established number of nursing staff was three but the nursing capacity had been limited to one full time nurse (Band 5) for the last three months. The matron had retired earlier this year and the vacant position had not been filled. We were told a new matron would be starting in the New Year. The nurse who resigned had returned recently as a bank nurse working part-time two days a week, namely, Mondays and Fridays. This meant that
20180222 KGHNHSFT Evidence Appendix Page 257 there was only one trained nurse in the whole department on Tuesdays, Wednesdays, and Thursdays.
Medical staffing The service did not have enough 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. Much like the rest of the NHS acute sector, recruiting radiographers and sonographers (specialist ultrasound staff) to the department was an on-going challenge and despite numerous attempts to advertise and interview radiographers, the hospital continued to struggle in recruiting and filling vacancies and radiologist workforce. The diagnostic department had an insufficient number of consultant radiologists. There had been multiple recruitment rounds for consultant radiologists. One new consultant had been appointed and was due to start in January 2018. We raised this as a concern with the trust’s senior managers. The trust took urgent actions to develop a detailed action plan to address this concern, which included use of locum doctors as an interim measure. From August 2017 to October 2017, the average consultant radiologist staffing was 9.97 whole time equivalent (WTE), compared with an establishment level of 12.55 WTE, so the service was 20.6% understaffed. Over this period, no bank or locum radiologists had been used. Radiologists provided onsite cover from 8am until 8pm weekdays and 10am until 4pm at a weekend with an additional out of hours cover. During our inspection, we were told the number of consultant radiologists in post was 10 but the actual number of consultants working in the department was only eight. Two out of the ten consultants were on sabbatical leave for a year and they were not due back to work until the beginning of 2018. This made the department in effect 36.5% understaffed at the time of the inspection. The department had no paediatric radiologist. Arrangements had been made with another local NHS acute trust for a paediatric radiologist to be on site one day (10am to 4.30pm) a week commencing the week beginning 13 November 2017. The service had outsourced some of the image reporting and had also been engaged in training reporting radiographers to improve the backlog. The hospital had undertaken some actions to improve radiology staffing, the service provision offered and the reporting backlog. The department employed three reporting radiographers for x-ray reporting totalling 2.2 WTE. However, one full time radiographer was on maternity leave and a part-time (0.6 WTE) was on a career break. Therefore there was only one part time reporting radiographer (0.6 WTE) working at the time of the inspection.
Radiographer staffing The number of radiographers working in the department are shown below by modalities.
20180222 KGHNHSFT Evidence Appendix Page 258
40.00
35.00
30.00
25.00
20.00 X-ray CT/MRI 15.00 Ultrasound 10.00
5.00
0.00 Nov '16 - Oct Feb '17 - Apr May '17 - Jul Aug '17 - Oct '17 '17 '17 '17
Staff (radiographers) (WTE)
Additional information received from the trust showed the number of radiographers for the period from November 2016 to October 2017 was as described below. X-ray Modality In November 2016, the established radiographer WTE was 35.37 and the WTE of radiographers in post was 35.85, showing the modality as somewhat overstaffed (101.37%). By October 2017, the trust had decreased the establishment WTE to 34.83 (1.53%). The WTE of radiographers in post had decreased to 35.10 (1.56%). This meant that the modality was slightly more than fully staffed (100.78%). The service had recruited six more radiographers since March 2017. CT and MRI Modalities In November 2016, the established radiographer WTE was 10.77 and the WTE of radiographers in post was 14.06, showing the modality as substantially overstaffed (130.5%). By October 2017, the trust had made a large increase in the established WTE to 21.37 (+98.4%). There were then 20.76 WTE of radiographers in post, so the modality was now understaffed (97.1%), even though many more radiographers were in post (+47.7%). Ultrasound Modality In November 2016, the established radiographer WTE was 7.16 and the WTE of radiographers in post was 6.55, so the modality was understaffed in comparison with the then establishment (91.48%). By October 2017, the trust had increased the established WTE considerably to 10.16 (+41.89%). The WTE of radiographers in post had increased considerably (+30.23%), but overall the modality was understaffed compared with the new establishment (83.96%).
Radiographer Bank and Agency Usage
20180222 KGHNHSFT Evidence Appendix Page 259
Total Agency and bank radiographer shifts worked, by month, between November 2016 and October 2017
1000 900 800 700 600 500 Agency 400 Bank 300 Totals 200 100 0 Cardiac MRI/CT Radiography Ultrasound Investigation Unit
Agency and bank radiographer shifts worked, by modality between November 2016 and October 2017
Modality Agency Bank Totals Cardiac Investigation Unit 707 212 919 MRI/CT 499 263 762 Radiography 2 760 762 Ultrasound 234 158 392 Totals 1442 1393 2835
Agency and bank shifts worked, by modality between November 2016 and October 2017 The modality making heaviest use of agency and bank radiographers was the cardiac investigation unit. MRI/CT and ultrasound modalities used a high number of agency staff. The radiography unit used bank staff rather than agency staff. We saw local induction processes were in place for temporary staff new to the department.
20180222 KGHNHSFT Evidence Appendix Page 260
Records Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to- date, and available to all staff providing care. However, in the cardiac investigation unit, some patients’ medical notes had not been kept securely and confidentiality had not been maintained, breaching the Data Protection Act 1998. Patients’ individual care records were generally written and managed in a way that kept patients safe from avoidable harm. Records seen were accurate, complete, legible, and up to date. Nursing staff showed us the care plan forms in use for specific procedures. For example, there were separate care plan forms for the angiogram procedure and for liver biopsy, both with post procedure instructions. There was no patient in the unit at the time of our visit. In the cardiac catheter laboratory, patients’ nursing/medical record booklets contained the patient’s personal details and a section for nursing staff to check for allergies, nutritional requirements, history of falls, and other medical history. All seen had been completed appropriately. We saw that the National Early Warning Score (NEWS) chart used to assess a patient’s condition before and after cardiac catheter procedures had been correctly filled in and appropriately maintained.
The hospital used a radiology information system (RIS) and picture archiving and communication system (PACS). This meant patients radiological images and records were stored securely and access was password protected.
In the cardiac investigation unit, patients’ medical notes had not been kept securely. All the medical notes of patients waiting to be seen on the day were placed in two open wheeled baskets that were left in the corridor outside the ECG room. This was in breach of the Data Protection Act 1998. We raised this as a concern with the trust who took action to address this. The service reviewed its risk assessment and ensured staff knew that notes are to be left secured, doors were to be closed when staff not in the office, and that patients should not be in rooms alone with patient notes. The service was also looking into alternative location for clinic and notes as a priority.
Medicines The service generally prescribed, gave, and stored medicines well. Patients received the right medication at the right dose at the right time. Nursing staff checked the controlled drugs daily to make sure they were correct and the check was recorded in a logbook. There was a weekly check that was recorded in the controlled drug register. The pharmacy team made periodic checks and these were recorded in the controlled drug register. When disposing of controlled drugs, staff ensured part-used ampoules of controlled drugs were destroyed appropriately using a denaturing kit and the waste was recorded appropriately in the book for drug disposal. There was a sample signature sheet of staff for controlled drug orders. We saw a recording error in the controlled drug register in the cardiac catheter laboratory. The author had corrected an entry by crossing out the written item so that the original entry was no longer legible. This was not in line with the trust policy. We pointed this out to the nurse in charge who stated they would address the issue with the member of staff. However, the stock balances were checked regularly and we saw that they agreed with the stock in the cupboard. We checked the logbook and saw that the medication storage room temperature had been recorded. We noted that the temperature was slightly over 25 degrees Celsius between 14 to17 August 2017 and the record of action section showed ‘Nil’ during this four-day period. The trust policy stated that the ward should notify the medicines information team if temperatures exceeded
20180222 KGHNHSFT Evidence Appendix Page 261
35 degrees for more than 48 hours. On this occasion, the room temperature was well below this and therefore staff did not have to take any action. Patients were asked to bring in their own medicines so the doctor could check if the medicines were safe to take on the day of the procedure. We saw the cardiac centre prescription chart, which was completed by a nurse during the procedure following verbal instructions from the doctor. Two nurses signed the medication record chart when the medicines were administered; the doctor signed the record chart afterwards. This was in line with the operation medication policy for the unit. Currently, the unit had not used patient group directions. Following best practice guidance, contrast media was prescribed by radiologists before administration avoiding the need to utilise Patient Group Directives. However, radiographers were still able to inject contrast in CT and MRI because radiologists prescribed the contrast when justifying the imaging requests and recorded the prescription of contrast media on the request cards, which was subsequently scanned on to Radiology Information System (RIS). Contrast media were stored securely. These were ordered directly from the manufacturer. The working stock was kept in a warmer with an on/off switch only and a light to show it was on. There was no temperature gauge. A radiographer said they regularly checked whether the light was on and if it was not, the staff would report it as a fault to the trust estate. We checked the medicines, including controlled drugs that were stored in the unit. Medicines were appropriately managed and recorded. Nursing and medical staff were aware of policies on administration of controlled drugs as per the Nursing and Midwifery Council ‘Standards for Medicine Management’. Radiation Dose The dosage of radiation given to a patient was recorded manually. The medical physics service at the Radiation Protection Service in Northamptonshire then analysed these and provided graphs. Dose charts for each month were sent back to the department on a monthly basis. We reported in October 2016 that the radiographers had not been aware of dose reference levels. Since that inspection, work had been done on this in conjunction with the Radiation Protection Service. All x- ray rooms now had room-specific dose reference levels (DRLs) displayed together with the national DRLs. These provide the starting point in arriving at the optimum radiation dose to achieve the diagnostic aims of a procedure for a particular patient. Radiographers’ awareness of the importance of DRLs had now been raised through training sessions. The trust training department was in the process of producing a central archive for radiation protection information. Information for staff was usually sent by email but this central repository would be accessible on the trust’s secure internal computer system for all staff to access.
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. All incidents were reported through the trust’s online incident reporting system. Any radiation incidents would be reported using the correct procedures. Staff would report to the team lead who would then 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. The radiologists held a discrepancy meeting monthly. The minutes of these meetings were widely circulated. The Royal College of Radiologists
20180222 KGHNHSFT Evidence Appendix Page 262 recommends that there should be such a meeting to discuss errors that have been reported for learning and reflective purposes. 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 happen for an incident to be a never event. Between September 2016 and August 2017, the trust reported no incidents classified as never events for diagnostics. In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in diagnostics, which met the reporting criteria set by NHS England between September 2016 and August 2017. (Source: Strategic Executive Information System (STEIS)) 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 November 2016 and October 2017, there had been two serious incidents in the diagnostics department. Both these incidents involved IR(ME)R investigations and were reported to CQC at the time. These incidents were discussed at the trust’s Serious Untoward Incident Review Group meeting on 9 November 2017. One of these had now been closed with actions implemented to prevent reoccurrence. The first incident occurred in July 2017. The patient was referred for a CT scan of the head. This was done, but an unnecessary CT scan of the chest was also done. The incident was reported and a root cause analysis was carried out. The cause of the incident was misread handwriting. It was planned to introduce an electronic system for these referrals. The incident had been discussed at team meetings and lessons had been learnt. The second incident occurred in October 2017. A CT scan of the chest, abdomen, and pelvis was carried out. It was found that the patient was pregnant. The checklist which included checking the identification (ID) and the last menstrual period (LMP) for a female patient had not been done. A root cause analysis was carried out. The root cause was found to be that the referring clinician had not checked the patient’s pregnancy status. The incident was discussed at team meetings and lessons were learnt. Staff we spoke with 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. A senior radiographer told us that, in two recent incidents, when mistakes were made, the patients were informed immediately. Following the investigations, the patients were given feedback. Staff told us information regarding duty of candour was available on the trust intranet.
Major incident awareness The service planned for emergencies and staff understood their roles if one should happen. The hospital had a service contingency plan in place for staff to use in the event of interruption to essential services such as electricity and water supply. There was regular testing of generators occurred 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. Staff were up to date on fire safety training.
20180222 KGHNHSFT Evidence Appendix Page 263
In the event of a radiation or radioactive incident, there were effective arrangements in place. For example, training had been provided to staff and most staff who spoke with us about this were aware of the procedures to follow in the event of a radioactive incident. There was an effective understanding amongst nursing and medical staff about their roles and responsibilities during a major incident. Is the service effective?
Evidence-based care and treatment The service had not always provided care and treatment based on national guidance and evidence of its effectiveness. The service had not followed the guidelines issued by the Royal College of Radiology on non-radiology clinicians reviewing images. Managers failed to make sure staff followed guidance. The service was subject to the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R) and guidelines from the National Institute for Health and Care Excellence (NICE), the Royal College of Radiologists (RCR), the College of Radiographers and other national bodies. Our inspection showed that the service had not followed the guidelines issued by the RCR on non- radiology clinicians reviewing images. We raised this as a concern with the trust’s senior managers. The trust took urgent actions to develop a detailed action plan to address this concern. Specialities within diagnostic services generally delivered care and treatment in line with the National Institute for Health and Care Excellence (NICE) and national guidelines where appropriate. All radiation protection policies and procedures were on the trust’s secure internal computer system and accessible to all staff. Staff we spoke with said they had access to policies, procedures, national and specialist guidance through the hospital’s intranet. Overall, staff were positive about the hospital’s intranet and reported that their managers communicated effectively with them via e-mail. Imaging protocols were in date until 2018 but were being reviewed in line with another hospital that has Imaging Services Accreditation Scheme (ISAS) accreditation by the College of Radiographers and the Royal College of Radiologists. ISAS carried out checks on the quality of the service provided and instigated continuous improvements to ensure patients received a high quality service. The trust had a service agreement with two other hospitals to provide medical physics support, namely, a radiation protection adviser, a magnetic resonance expert and a medical physics expert, 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 (HSE) are the Ionising Radiations Regulations 1999 (IRR99). In line with IRR99, the diagnostics department appointed three radiation protection supervisors, one for the main x- ray unit, one for the computerised tomography (CT) unit and one for the cardiac catheter laboratory. The supervisors’ 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.
20180222 KGHNHSFT Evidence Appendix Page 264
We saw ‘Pause and Check’ posters 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. 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 could also locate further guidance on the hospital’s computer system, which was demonstrated to us.
Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. There was a water dispenser available in the department’s waiting area for patients and visitors to help themselves. This meant that patients were able to keep themselves hydrated while waiting to be seen. Patients in the cardiac catheter centre were provided with light refreshments if they had to stay a few hours. We observed staff offering food and drinks to patients who had been waiting for long periods.
Pain relief Pain of individual patients was assessed using a pain management tool and managed accordingly. Nursing staff observed patients recovering from a procedure using the trust’s pain score chart and if required gave patients pain relief. Patients we spoke with had not required pain relief during their attendance at the outpatient departments. Diagnostic imaging and breast screening staff carried out pre-assessment checks on patients prior to carrying out procedures. Staff assessed pain relief for patients undergoing procedures such as biopsies through pain assessment criteria.
Patient outcomes The service had not always monitored the effectiveness of care and treatment in order to use the findings to improve. Appropriate audits had not been done to ensure quality of practice was maintained. We were told that 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. The service planned to conduct two extensive programmes of image quality audits throughout 2018 for x-rays and CT scans respectively. These would concentrate on one type of image at a time. 95% of satisfactory images would be regarded as a success. The findings and steps for improvement would be discussed at ongoing team meetings. We saw a specification for how audits of chest x-rays would be conducted. Radiographers were not conducting reject analysis at the time of the inspection. (Sometimes 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). They had been no peer review by radiologists to maintain clinical practice. There were some audits undertaken which included a radiation dose audit and a cross-injection audit. Quality checks were carried out regularly on all diagnostic and X-ray equipment. Lead
20180222 KGHNHSFT Evidence Appendix Page 265 aprons were checked yearly in line with good practice to ensure they were fit for purpose and not damaged.
Competent staff The service had not always made sure that staff were competent for their roles. Reviewing of images by non-radiology staff was not in accordance with Royal College of Radiology guidelines. Between July 2016 and July 2017, 80.5% of staff in diagnostic imaging services at the trust had received an appraisal, compared to a trust target of 85%. A split by staff group can be seen in the table below: Staff Group Completion Add Prof Scientific and Technic 87.5% Additional Clinical Services 86.7% Administrative and Clerical 76.6% Allied Health Professionals 67.5% Medical and Dental 100.0% Nursing and Midwifery Registered 96.0% Students 100.0%
Isebrook hospital and Nuffield Diagnostic both had a 100% appraisal completion rate. Kettering General Hospital had a 79.4% appraisal completion rate. This was due to 51 staff members not completing appraisal. (Source: Routine Provider Information Request (RPIR) P43 Appraisals) The department arranged for staff to have relevant training to enhance their skills and staff had the opportunity to attend training by external organisations. In September 2017, two members of staff who were interested in paediatrics radiology attended a day course on ‘New Guidance on Radiological Investigations of Suspected Child Abuse.’ Staff training was a mixture of online and face to face and was organised by a designated member of staff. We saw evidence of some development opportunities for radiographers. The department had three reporting radiographers for plain film appendicular acute injuries (limb injury x-rays from A&E) and radiographers in MRI were trained in reporting MRI pre-orbital x-rays. Team leaders provided induction training packs and ensured staff were competent to operate each type of equipment. Two designated members of staff supervised and trained newly qualified radiographers. Each new member was given induction training on each x-ray machine and scanner. The equipment had different manufacturers and had differing operating systems. The department was a training site for radiography students. They trained three students from each year of the three-year course. Radiography students from a local university rotate through the diagnostic department. One student said they were very happy with their placement at Kettering and would apply for a job at the hospital. An advertisement went live on the day of our inspection. We observed a final year student radiographer taking an x-ray of a patient and they were supervised when they entered the information into the CRIS. Since 2012, the trust had a policy not to report inpatient plain films apart from those requested by A&E and the Intensive therapy unit (ITU). Radiologists were not reporting on inpatient plain films as the image had been seen by the clinician. This meant that any inpatient plain film (apart from A&E and ITU) would be seen and reviewed by the referrer doctor of the ward the patient came from. There was no way of telling if the reviewer was competent to review images as they may have had limited radiology training. The referrer had to record in the patient’s notes that they had
20180222 KGHNHSFT Evidence Appendix Page 266 reviewed the image. However, these reviews had not been audited. The impact of the trust decision had also not being audited. The department radiology manager was unaware of any training or written guidance for the clinical teams who were expected to review images. We raised this as a concern with the trust’s senior managers. The trust took urgent actions to develop a detailed action plan to address this concern and provided assurance that the human resources department of the trust would develop and implement an appropriate training programme for medical staff.
Multidisciplinary working Staff in different teams worked together to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Managers and senior staff held regular staff meetings with colleagues from outpatients departments. All members of the multidisciplinary team attended and staff reported that they were a good method to communicate important information to the whole team. There was effective multidisciplinary working, both internally and externally. The IR(ME)R group held their first meeting to discuss the implications of the new IR(ME)R regulations that would come into force in early 2018. It also provided a forum for reporting and learning from radiation incidents. Radiographers attended a monthly team meeting where issues of concern were discussed and lessons learnt were shared. Staff we spoke with were aware of two recent incidents and they discussed the lessons learnt. Managers and senior staff attended regular multidisciplinary management meetings, at which important information was shared which would be cascaded down to frontline staff in their team meetings. Consultant radiologists had weekly team meetings and a weekly one-hour business meeting followed by a rolling audit, education, and academic programme. Prior to discharge, a member of staff checked through the discharge form with the patient and their carer; the patient was given a discharge advice leaflet and signed the discharge form specifying the name of the carer/relative. There were multidisciplinary one-stop clinics, such as in urology and the breast clinic, where patients could access consultations, diagnostics, results, and clinical nurse specialists in one appointment.
Seven-day services The service generally made sure patients had access to the main diagnostic services seven days a week. Radiologists worked from 09:00 hrs to 17:00 hrs Monday to Friday and they took part in an extended hours’ session on call from 17:00 hrs to 20:00 hrs. 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, theatre fluoroscopy and CT x-rays for both inpatients and A&E patients. Plain film x-rays for GP patients and outpatient clinics were available from 9am until 5pm 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 a tele-radiology company who provided reporting services for CT and MRI scans performed overnight.
20180222 KGHNHSFT Evidence Appendix Page 267
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. The trust reported that between July 2016 and July 2017, Mental Capacity Act (MCA) awareness training had been completed by 86.5% of staff within Diagnostic Imaging. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) Staff said they had had received training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Staff knew and had knowledge of the MCA and the deprivation of Liberty safeguards. Nursing, diagnostic imaging, and medical staff understood their roles and responsibilities regarding consent and were aware of how to obtain consent from patients. Patients told us that staff were very good at explaining what was happening to them prior to asking for consent to carry out procedures or examinations. Patients’ consent was obtained prior to a diagnostic procedure. Both radiologist and staff ensured patients had given informed consent. Staff explained to each patient the type of procedure the patient would be having and the patient’s consent was sought. We saw evidence of the consent form being signed and dated by a patient in the cardiac catheter laboratory. Consent was taken from patients appropriately. A patient told us their consent was obtained after staff had explained the procedure. We observed staff explaining what they were about to do and checking patients’ wishes prior to providing care. We checked two patients’ nursing records and saw that each patient had signed the patient declaration form to indicate that they understood the information given about the procedure and the aftercare.
Is the service caring?
Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Throughout our inspection, we saw patients were treated with compassion, kindness, dignity, and respect. Staff respected patients’ social, cultural, and religious needs. We observed positive interactions between staff, patients, and relatives. We spoke with 36 patients and relatives and they gave positive feedback about the staff and the service they received. They all felt well cared for. A patient waiting commented that every time they attended the radiology department they had received good service. Patients waiting in the main x-ray waiting area said the staff were kind and respectful and treated them with dignity. We observed staff interacted well with patients and their relatives. A patient commented the radiographer was polite and caring. Patients said they were very happy with the service and felt well cared for. They said the staff were friendly and the radiologists were approachable. Staff in the department cared for people in wheelchairs appropriately. In the main x-ray waiting area, there was room for wheelchair users and an extended room for in-house hospital patients on trolleys or wheelchairs. These patients were accompanied by health care assistants from the respective wards.
Emotional support
20180222 KGHNHSFT Evidence Appendix Page 268
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. We observed staff providing additional support to patients who seemed anxious. Staff had an effective awareness of patients with complex needs and those patients who may require additional support should they display challenging behaviour during their visit to the service. Patients we spoke with said that they had been encouraged by staff to contact external agencies for further support outside of the hospital. Patients said staff gave them full information and explained the procedure in a clear and unhurried manner. If non-accidental injury was suspected, staff used distraction boxes which made it easier to take the images required. This was called a skeletal survey. The use of distraction boxes designed by the ‘Starlight’ charity was good practice.
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 felt involved with their care and knew what to expect. Patients we spoke with felt well informed about their care and treatment. Patients said staff gave them full information and explained the procedure in a clear and unhurried manner. We observed staff to be caring and considerate in their interactions with patients and in most cases staff ensured they gave the patient adequate time to discuss any concerns they had. Staff communicated with patients and families in ways they could understand and patients felt they had been encouraged to make their own decisions. Patients were able to be escorted by their relatives or friends if they wished. Staff could give examples of when they had used face-to-face and telephone interpreters to ensure patients fully understood their treatment.
Is the service responsive?
Service delivery to meet the needs of local people The service had not always planned and provided services in a way that met the needs of local people. The reception area in the main x-ray department now included a recently converted waiting room to accommodate inpatients waiting on trolleys or in wheelchairs. Staff felt they had worked well with local GPs, other healthcare providers and local authorities to meet the needs of the local population. The trust is one of eight 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. This initiative requires 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 share information with other NHS organisations and private contractors. NHS England has chosen EMRAD as an NHS vanguard project. This means that the project is 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 is 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 20180222 KGHNHSFT Evidence Appendix Page 269 lower cost. This is 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 can be provided to patients closer to home, because the imaging data is now available at more local sites. Radiographers worked a shift system (8am to 4pm, 12 noon to 8pm, 12 midnight to 8am). 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.
Meeting people’s individual needs The service took account of patients’ individual needs. Services were generally planned and delivered to take into account the needs of different people, for example on the grounds of age, disability, or religion. The department was accessible to wheelchair users and there was a large waiting room for inpatients waiting on trolleys. Wheelchairs were available at the main reception. We saw staff assisting wheelchair users to the x-ray room when it was their turn to have an x-ray taken. Bariatric equipment could be accessed if required. We saw bariatric seating, examination couches, and wide-bore MRI scanners that were compatible with heavy weights. Wide-bore MRI scanners were also used for claustrophobic patients. There was a system to notify staff if patients required additional support, such as patients living with a learning disability, dementia, or mental health problems. This information was added to patients’ notes so that the department could make necessary adjustments prior to their appointment, for example fast-tracking patients to avoid unnecessary distress. Staff said butterfly stickers were put on the medical notes of patients living with a dementia to make staff aware so that appropriate support could be given to these patients. Similarly, additional support was given to people with a learning disability. Staff were aware of how to support people living with dementia and had accessed the hospital training programme in order to understand the condition and how to be able to help patients experiencing dementia. There was a multifaith prayer room and a chapel of peace that patients and relatives could access and services were held for all faiths. There was written information in treatment rooms and waiting areas on a variety of conditions and treatments. Examples included ‘Helping you decide for breast screening’. Information leaflets were available in different languages, representing local cultural groups. Arrangements were made for patients who required an interpreter to have one when they attended an appointment or if they needed one over the phone. Hearing loops were in place at reception desks across the department. There was a water dispenser in the waiting area for all patients to help themselves.
Access and flow Patients could not always access the service when they needed it. Waiting times for some patients exceeded six weeks before diagnostic imaging was carried out and this had not consistently improved over the past year. The department had no monitoring system in place for patients who did not attend (DNA) an arranged appointment. We were told it was possible to print off a DNA report from the Clinical Radiology Information System (CRIS) but this was never done. Staff said they were aware that the
20180222 KGHNHSFT Evidence Appendix Page 270
DNA figures in the MRI modality may be an issue but this had not been monitored. The service had no record of the ‘did not attend’ performance rate. We spoke with patients in the ultrasound waiting room. The patients were seen on time and had not waited long for their appointment. Waiting Time for diagnostic imaging 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. Diagnostic waiting times (percent waiting 6+ weeks) Between September 2016 and January 2017, the trust did not submit any data for the percentage of patients waiting more than six weeks to see a clinician due to concerns around data validation. Since February 2017, performance has been generally better than the England average. The trust’s performance was worse than the England average in May 2017 and August 2017. The England average is the mean value from NHS Trusts, NHS Foundation Trusts and Independent Sector Providers in England. The chart below shows over six weeks percentages over time.
( Source: NHS England – Diagnostic Waits) 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 from November 2016 to October 2017. The trust supplied data for CT, MRI, and ultrasound modalities, but not for the x-ray modality. The three modalities for which we received data had similar characteristics. In March 2017, many images were taken without undue delay, but there was a relatively small number that were delayed for considerable periods of up to 40 weeks. By September 2017, this problem had virtually been eliminated. (See graphs below.) The following charts indicate the waiting time for patients waiting less than six weeks for imaging in March, June, and September 2017 for each modality. The charts also show the lesser number of patients waiting over six weeks for imaging to be undertaken in the same periods.
20180222 KGHNHSFT Evidence Appendix Page 271
Computer Tomography
Images waiting under 6 weeks to be taken by CT imaging in March, June and September 2017.
Images waiting 6 weeks or more to be taken by CT imaging in March, June and September 2017. In these charts, two weeks stands for two weeks and 0 days to two weeks and six days onwards. The majority of patients had been seen for CT imaging in less than six weeks. However, in March 2017 there were a small number of patients who had to wait for a substantially longer time, up to 35 weeks. In June 2017 and September 2017 there were far fewer patients having longer waits.
20180222 KGHNHSFT Evidence Appendix Page 272
Magnetic Resonance Imaging (MRI)
Images waiting under 6 weeks to be taken by MRI imaging in March, June and September 2017.
Images waiting 6 weeks or more to be taken by MRI imaging in March, June and September 2017.
The majority of patients had been seen for MRI imaging in less than six weeks. However, in March 2017 there were a small number of patients who had to wait for a substantially longer time, up to 41 weeks. In June 2017 and September 2017 there were far fewer patients having longer waits.
20180222 KGHNHSFT Evidence Appendix Page 273
Ultrasound
Images waiting under 6 weeks to be taken by ultrasound imaging in March, June and September 2017.
Images waiting 6 weeks or more to be taken by ultrasound imaging in March, June and September 2017. The majority of patients had been seen for ultrasound imaging in less than 6 weeks. However, in March 2017 there were a small number of patients who had had to wait for a substantially longer time, up to 41 weeks. In June 2017 and September 2017 there were far fewer patients having longer waits.
Backlog of Unreported Images 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. The charts below demonstrate the number of unreported images following the installation of the new PACS. On 1 May 2017, prior to the installation of the new PACS in July 2016, Kettering General Hospital had decreased the number of unreported images to 4,000. Also prior to the change, the trust had outsourced to two private teleradiology companies, (Company A and Company B) to resolve the high number of unreported images. When the new installation experienced repeated downtimes,
20180222 KGHNHSFT Evidence Appendix Page 274 the trust was unable to transfer images to the outsourcing companies and this led to a substantial increase in unreported images as patients continued to use the diagnostic service daily. By 27 October 2017, the total number of unreported images was 10,723. Routine outpatient tests, GP plain films, and A&E plain films were part of the backlog. However, some of these routine outpatients tests, GP plain films and A&E plain films were being outsourced to help clear the backlog.
14,000
12,000 12,362 11,209 10,991 10,723
10,000 9,375 9,606 8,717 8,000 8,0187,903 6,905 6,000 4,675
4,000 4,000 Number of Images of Number 2,000
0
9/7/16 4/2/17 2/9/17
Date
15/4/17 20/2/16 30/4/16 17/9/16 24/6/17 20/1/18
26/11/16 11/11/17
Backlog of Unreported Images
Date Backlog Status of Company P System 1/5/16 4,000 Approx. date. Low point. Weekly addition. 1/6/16 Approx. date. Start of new PACS System installation.
2/6/16 4,675 1/11/16 System more stable but 30% slower. 3/11/16 12,362 High point. Outsourcing. 10/11/16 9,375
1/12/16 8,717 Low point. Winter pressures, Christmas, New Year. 12/12/16 11,209 High point.
26/1/17 10,991
30/3/17 8,018
13/4/17 7,903
25/5/17 6,905 Low point. 1/8/17 Approx. date. Start of PACS System upgrade. System unstable. Freezing. Errors. Frequent reboot. 24/8/17 9,606
27/10/17 10,723 High point.
Time sequence of events
20180222 KGHNHSFT Evidence Appendix Page 275
The backlog of unreported images graph shows very prominent peaks and troughs. The first peak is clearly identified with problems following the installation of the new PACS system, replacing the legacy PAC system. The second peak is the usual heavy demand in the winter period. Up to the end of October 2017, the backlog rose dramatically. This is clearly identified with problems following the installation of the update to the PACS. The first trough shows the effect of the introduction of outsourcing to private companies. The second trough shows that the system has been operating relatively normally and much of the winter load has been reported. The ‘Time Sequence of Events’ table shows in detail the impact of these events. As part of the transition to the new PACS EMRAD, all historical diagnostic imaging data was to be transferred to the new system. Between June 2016 and July 2016, five million patient records had been transferred. These did not require any reporting and did not contribute to the backlog of unreported images. Between 1 May 2016 and the 2 June 2016, the reporting backlog had increased by 675. If this rate of growth of the backlog had continued, one would expect a backlog of 8,050 by 3 November 2016, but in fact it was 12,362. This showed the impact of the problems with the PACS. This also showed that the reporting was not totally keeping up with new patient images, even when the system was working properly. Nevertheless, the impact of the problems the PACS system was significant; instead of an additional backlog of 3,375 images over five months from 1 June 2016 to 3 November 2017, there was an additional backlog of 7,087 images: a 128% increase.
Delays in Image Reporting The departmental radiology staff were being asked to concentrate on reporting cancer pathway patients, urgent CT and MRI scans and urgent outpatient tests. The department aimed to report A&E images and CT and MRI scans within 24 hours and outpatient images within two weeks. These objectives were not always being met, with plain films from A&E taking much longer than 24 hours and outpatient images taking on average four weeks to be reported. Information received from the trust stated that 25,228 patients out of a total of 189,250 waited longer than four weeks for their report (13%). 77.8% were reported within 2 weeks and 86.6% were reported within four weeks. The service had ensured patients with suspected cancer had images done 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 percentages of images reported in less than five weeks for some modalities were as given in the table below:
Percentage of Modality images reported in under 5 weeks Nuclear Medicine 100%
Obstetrics 99.97%
Ultrasound 99.91%
Breast Scan 99.87%
Endoscopy 94.4%
20180222 KGHNHSFT Evidence Appendix Page 276
Delays in Image Reporting by Modality from November 2016 to October 2017 X-rays (Plain Films)
80000
70000
60000
50000
40000 Images 30000
20000
10000
0 Weeks 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Average waiting time for reporting of x-rays November 2016 to October 2017
10000 9000 8000 7000
6000 5000
Images 4000 3000 2000 1000 0 Weeks 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
Average waiting time for reporting of x-rays, 5 weeks and over November 2016 to October 2017
Of 94,413 x-rays: 72,106 (76.4%) had been reported in under five weeks. 92,395 (97.9%) had been reported in under 20 weeks. 2,018 (2.1%) had taken between 20 and 46 weeks to be reported.
Longest waits were: Day case – two patients waited 34 weeks GP access – one patient waited 40 weeks A&E - five patients waited 44 weeks Outpatients - seven waited 45 weeks Inpatients – nine patients waited 45 weeks and one patient 46 weeks
20180222 KGHNHSFT Evidence Appendix Page 277
Magnetic Resonance Imaging (MRI)
16000
14000
12000
10000
8000 Images 6000
4000
2000
0 Weeks 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44
Average waiting time for reporting of MRI November 2016 to October 2017
350
300
250
200
Images 150
100
50
0 Weeks 10-14 15-19 20-24 25-29 30-34 35-39 40-44
Average waiting time for reporting of MRI, 10 weeks or more November 2016 to October 2017 Of 15,120 MRI images: 13,596 (89.9%) had been reported in under five weeks. 14,743 (97.5%) had been reported in under 10 weeks. 377 (2.5%) had taken between 10 and 44 weeks to be reported.
Longest waits were: A&E - one patient waited four weeks Inpatients – four patients waited four weeks GP access – one patient waited 31 weeks Outpatients – one waited 44 weeks
20180222 KGHNHSFT Evidence Appendix Page 278
Computer Tomography (CT)
30000
25000
20000
15000 Images 10000
5000
0 Weeks 0-4 5-9 10-14 15-19 20-24 25-29 30-34
Average waiting time for reporting of CT November 2016 to October 2017
140
120
100
80
Images 60
40
20
0 Weeks 10-14 15-19 20-24 25-29 30-34
Average waiting time for reporting of CT, 10 weeks or more November 2016 to October 2017
Of 26,251 CT images: 25,277 (96.3%) had been reported in under five weeks. 26,079 (99.3%) had been reported in under 10 weeks. 172 (0.7%) had taken between 10 and 33 weeks to be reported.
Longest waits were: A&E - one patient waited six weeks Inpatients – one patient waited 21 weeks GP access – one patient waited 29 weeks Outpatients – two patients waited 34 weeks
20180222 KGHNHSFT Evidence Appendix Page 279
Fluoroscopy
3000
2500
2000
1500 Images 1000
500
0 Weeks 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35+
Average waiting time for reporting of fluoroscopy November 2016 to October 2017
100 90 80 70
60 50
Images 40 30 20 10 0 Weeks 10-14 15-19 20-24 25-29 30-34 35+
Average waiting time for reporting of fluoroscopy, 10 weeks or more, November 2016 to October 2017
Of 3,076 fluoroscopy images: 2,681 (87.2%) had been reported in under five weeks. 2,815 (91.5%) had been reported in under 10 weeks. 261 (8.5%) had taken between 10 and 37 weeks to be reported.
The longest waits were: Outpatients – three waited 34 weeks A&E - one patient waited 34 weeks Day case - one patient waited 36 weeks Inpatients – one patients waited 37 weeks
Ultrasound Of 31,447 ultrasound images: 31,422 (99.9%) of ultrasound images had been reported in under five weeks. 22 (0.1%) had been reported in between five and 13 weeks.
20180222 KGHNHSFT Evidence Appendix Page 280
There were three outliers at 25 weeks (one GP access), 33 weeks (one GP access) and 41weeks (one Inpatient) respectively.
Endoscopy Of 180 endoscopy images: 170 (94.4%) had been reported in under five weeks. 10 (5.6%) had taken between five and nine weeks to be reported, and one image took 32 week.
Nuclear Medicine All 2,099 nuclear medicine images had been reported in less than 5 weeks (100%)
Breast Scans Of 7,870 breast scan images: 7,860 (99.9%) had been reported in under five weeks. 10 (0.1%) had been reported in under 12 weeks.
Obstetrics Of 8,791 obstetrics images, all had been reported in under a week, except for two outliers at four and seven weeks respectively.
Patients’ Images Outsourced for Radiological Reporting
8000 7000 6000
5000 4000 Company A
Images 3000 Company B 2000 Total 1000
0
Jul-17
Apr-17 Oct-17
Jan-17 Jun-17
Mar-17
Feb-17
Nov-16 Dec-16 Aug-17 Sep-17 May-17
Reporting outsourced to Company A and Company B and the Total
Between November 2016 and October 2017, 43,770 images and scans were outsourced for reporting, 25,915 to one teleradiology company (company A) and 17,855 to a second teleradiology company (company B). Outsourcing reached a peak of 6,747 images in March 2017 then tailed off sharply to 1,228 images by October 2017. Routine outpatient tests, GP plain films, and A&E plain films were being outsourced and were part of the backlog. During our inspection, we were told that company A was facing capacity problems at the present time. The radiology manager told us a meeting was being arranged with company A to resolve this problem. Staff told us that often they had been asked to give a second opinion or re-report on some of the scans and images that had been outsourced to private companies. This is inefficient, as the studies had been reported at cost to the department. The department had a policy for notification of unexpected findings to the referring clinicians, for example, unexpected lung cancer shown on an x-ray. However, reports from the outsourcing company were sent back to the
20180222 KGHNHSFT Evidence Appendix Page 281 radiology department which meant that, unless an urgent notification was picked up by a member of staff, the clinician or the GP would not be aware, thus causing further delay in notifying them. Specialities such as urology and the breast clinic had set up one-stop clinics to reduce the number of appointments patients had to attend and facilitate timely access to care. One-stop clinics combined consultations, diagnostics, and results. 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 recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery. The radiology recovery plan set out the key areas of work, which the trust would undertake to address the removal of the radiology reporting backlog. Included were the trustwide formal training programme for junior medical staff regarding maintaining competencies in basic image evaluation, confirmation of the process for documentation in notes of non-radiological evaluation of any imaging study, audits of image review process by non-radiological staff and to review capacity of workforce both radiologists and radiographers to maintain timely reporting. At the time of the well-led part of this inspection, this backlog of images not yet reported within 10 days had reduced to just over 8,000.
Learning from complaints and concerns The service generally treated complaints and concerns seriously, investigated them and learned lessons from the results, which were shared with all staff. Between August 2016 and July 2017, there were ten complaints about the service with the themes of delayed reporting of scans the main theme. We looked at these complaints and saw all had been investigated within the trust timescales. This was in line with their complaints policy, which stated non-complex complaints should be completed within 25 days and complaints that were more complicated would have an agreed extended deadline. (Source: Routine Provider Information Request (RPIR) P61 Complaints) Between August 2016 and July 2017, there were ten compliments about the service. Themes for compliments received related to the care provided, staff attitude and cleanliness of environment. Compliments that were received by the patient experience team were shared with the ward/ department and were reported in monthly clinical business unit reports. Staff were aware of the trust complaints procedure and were confident in dealing with complaints and knew who to report complaints to. Patients we spoke with knew how to complain. The complaints policy was updated in 2016, together with supporting publicity materials, such as a leaflet, an easy read leaflet, and a poster. All public materials had been reviewed by the patient experience steering group before publication. Information on how to complain was accessible on the hospital intranet website and throughout the hospital, which provided details of how patients could raise complaints about the care they had received. Feedback forms and information leaflets on the patient advice and liaison service (PALS) were available and accessible. The PALS office was in the same corridor as the diagnostic department. Feedback forms were available and accessible across the service. Information on PALS was included. Patients we spoke with knew how to complain. Staff said lessons learnt from complaints and concerns raised were discussed at team meetings. Lessons learnt were also reported on through patient experience reports to the
20180222 KGHNHSFT Evidence Appendix Page 282 patient experience steering group and the governance committee. The hospital’s ‘Learning Leaflet’ included learning points from complaints so that all staff could benefit from lessons learnt and improve the service. Is the service well-led?
Leadership The service lacked leadership capacity to run a service providing high-quality sustainable care. The general manager of the clinical support business unit was accountable for all services within the business unit such as therapy, and endoscopy but also acted as the service manager for imaging and the radiation protection for plain film. Since May 2016, they felt much of their time was consumed by managing large risks within radiology such as the reporting backlog and staffing issues. The other services in the business unit had service managers who reported into the general manager. The clinical director of radiology started in post in June 2016. The radiologist had previously been in the hospital for several years as a consultant radiologist. The general manager and superintendents of each modality in the diagnostic and imaging service were seen to be present and easily accessible to staff during the inspection.
We did not see clear evidence that the leadership team had driven sustainable improvements in the service since our last inspection. 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.
Senior managers had not been monitoring the diagnostic service appropriately, despite knowing that there had been a continual backlog of unreported images for a number of years. There was continuing staffing pressures due to recruitment difficulties: despite these pressures, leaders had agreed staff career leave and sabbaticals, without realistic plans to manage the operational pressures this had created in the service.
The diagnostic team covering various disciplines were not able to tell us who had overall responsibility at trust level to ensure actions were being taken in a timely manner. At a local level, the radiology manager had 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.
Vision and strategy The service did not have a clear strategy and vision for what it wanted to achieve and lacked workable plans to turn it into action. 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. 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 Radiology (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 surrounding the safety of this change had not been audited. The trust vision was to provide safe, high quality care to the communities. Most staff knew the trust vision and were able to tell us the CARE values which were:
20180222 KGHNHSFT Evidence Appendix Page 283
Compassionate: to take the time to be empathetic and open, treating each other and patients as individuals that matter. Accountable: to take responsibility and ownership both individually and collectively for decisions and actions Respectful: to value the experience and contribution of others: respecting others’ thoughts, feelings, beliefs, and behaviours. Engaging: asking for and listening to the opinions of others and facilitating an open environment for dialogue.
Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff within the department were confident about the service and care they provided for patients. They told us that a high quality of service and good patient experiences were seen as priorities. However, 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 observed staff were considerate, helpful and unhurried in their interactions with patients. Staff ensured a patient understood the procedure they were undergoing and explained each step before it was carried out.
During the inspection, staff said there was a strong emphasis promoting the safety and wellbeing of staff. Most staff told us they felt respected, valued and were treated fairly, with equal opportunities for training and development, career progression. The culture in radiology was centred on the needs and experience of patients. All staff we spoke with were proud to work at the hospital; they were passionate about the care they provided for their patients. Staff and teams always aimed to work collaboratively, resolved conflicts quickly and constructively and shared responsibility to deliver good quality of care. Staff said the managers and consultants were supportive. Staff supported each other and kept the department functioning smoothly.
Governance 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. Monthly governance meetings were held with action plans discussed. Diagnostic imaging risks fed into the clinical business unit’s risk register. This was regularly reviewed at the business unit’s governance meetings. There was also a radiation protection committee annual meeting. The radiation protection committee (RPC) met to discuss any issues relating to radiation protection. The RPC 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.
The trust had introduced reviewing of images by non-radiology clinicians in 2012, but had not followed the guidelines issued by the 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 surrounding the safety of this change had not been audited. This process had been risk assessed in 2012, but not reviewed regularly since.
The risk ascribed to this reporting backlog had been reduced by the trust managers from 25 (very high) to 16 (medium). This meant that the backlog problem was no longer on the trust’s corporate risk register. This would have meant that the backlog had received less attention at trust level. We noted that the trust board did not have the numbers of unreported images or the staffing shortages in radiology on the corporate risk register.
20180222 KGHNHSFT Evidence Appendix Page 284
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 recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery. The radiology recovery plan set out the key areas of work, which the trust would undertake to address the removal of the radiology reporting backlog. This included ensuring the service had adequate reporting capacity to remove the current backlog and to meet service needs in the future, to ensure there was a robust governance structure and processes were in place to manage the risks associated with any reporting delays and that a clear harm review process was developed. In addition a further work stream was to identify training needs within the trust regarding interpretation of images by non- radiological staff and processes for audit to monitor this. The trust’s plan included:
Work stream 1: performance data. Appropriate validation and removal of historic data from the PACS for examinations that were not to be reported. Validation of current information regarding the reporting backlog on PACS and RIS. Data quality and management linked to multiple body part examinations. Agreement of the data extract requirements for weekly reports.
Work stream 2: additional capacity to reduce backlog and meet key performance indicators (KPIs) on a continual basis. Determine evidence base for a set of fully risk assessed options to reduce the backlog further. Agreement of forma KPIs for reporting turnaround times and how this will be captured for reporting purposes. Carry out a capacity and demand study to identify reporting capacity gap that needed to be addressed. The operational recovery plan to include plans for staffing levels and develop a trajectory for reduction of the reporting backlog. Communication to service users regarding reporting turnaround times. Work steam 3: additional capacity to reduce backlog and meet KPIs on continual basis. Trustwide formal training programme for junior medical staff regarding maintaining competencies in basic image evaluation. Confirmation of process for documentation in notes of non-radiological evaluation of any imaging study. Audit of image review process by non-radiological staff. To review capacity of workforce both radiologists and radiographers to maintain timely reporting.
Work stream 4: clear governance system linked to identification of harms Formal harm review process to be established and followed for all examinations reported outside agreed turnaround times. Clear process for Duty of Candour to any affected patients in the case of harm.
20180222 KGHNHSFT Evidence Appendix Page 285
Management of risk, issues, and performance The service had not been managing and monitoring the service effectively to drive improvement or to mitigate risks to patients. The trust had a system for identifying risks, planning to eliminate or reduce them and coping with both the expected and unexpected. However, 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. The image backlog was formerly on the corporate risk register but was downgraded to the departmental risk register alone. This would have meant that the backlog had only been dealt with at local level. Staff we spoke with were very aware that the high number of unreported images might be compromising patient safety. The size of the backlog may have presented potential risks to patient care in a number of ways. Patients may have received inappropriate care because the diagnostic information was not available when it was needed. By the time the diagnostic information was responded to, a patient’s condition may have changed or worsened so that the treatment given would be inappropriate. If the diagnostic information was eventually discarded, the patient had received a dose of ionising radiation carrying a known risk of cancer without gaining any benefit. A risk assessment was undertaken by the trust in 2012 and it was agreed that inpatient imaging would not be reported on by a radiologist as the image had been seen by another clinician. This meant that any inpatient plain film would be seen and reviewed by the referrer doctor of the ward the patient came from. There was no way of telling if the reviewer was competent to review images as they may have had limited radiology training. The referrer had to record in the patient’s notes that they had reviewed the image. There had been no audit of the quality of the reviews of the images. No audit had been carried out on the abilities of individual clinicians to carry out these reviews effectively. When images were reviewed the details were recorded in the patient’s notes, but there was no clear overall view of the number of images reviewed, so it remained unknown the percentage of images that had been reviewed and the impact on patient management. We were told that trust guidelines stipulated that films taken in the emergency department should be reported within 24 hours. The trust had undertaken a specific clinical harm review but some of the 85 case reviews that were undertaken in 2016 had not been completed. There was a not clear monitoring process to determine the progress of this review. There was no ongoing harm review process specific to delayed reporting of images, beyond the trust’s standard incident reporting system. 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 the radiology recovery plan was also devised following our findings with clear work streams, actions, named owners for each action and timescales for delivery. The radiology recovery plan set out the key areas of work which the trust would urgently undertake to address the removal of the radiology reporting backlog as well as revising the risk assessment for non-reporting of images. Previous CQC reports mentioned that radiographers had not been aware of dose reference levels. Work had since been done to highlight awareness of the dose reference levels in conjunction with the Radiation Protection Service. All x-ray rooms had room-specific dose reference levels (DRLs). These were now displayed and national DRLs were also available. 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.
20180222 KGHNHSFT Evidence Appendix Page 286
Information management The service did not consistently collect, analyse, manage, and use information well to support all its activities. Staff were generally able to access patient information such as diagnostic imaging records and reports, medical records and referral letters appropriately through electronic records. The hospital joined the EMRAD radiology consortium with six 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 (Picture Archiving and Communications System) 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. During the installation and the four months following the change over to the new PACS and RIS, the service had been experiencing severe issues with the stability of the PACS, RIS and reporting systems. This had meant the IT systems at times were unavailable to various members of staff across the hospital to review or report upon images in a timely manner. At the time of this inspection, this had appeared to be mostly resolved due to a software upgrade carried out by the supplier and the upgrade of the hospitals network connection. System reliability had improved, staff reported. The service had installed a Clinical Radiology Information System (CRIS) at the same time as the PACS system was installed under the East Midlands Radiology consortium (EMRAD). This had caused some issues with the speed and usability of the system. Radiographers’ awareness of the importance of the DRLs had been raised by training and the department was in the process of producing a central archive for radiation protection information. Information was usually sent by email but this central repository would be accessible on the trust’s secure internal computer system. Staff could access trust policies and procedures through this internal computer system. Between September 2016 and January 2017, the trust did not submit any data for the percentage of patients waiting more than six weeks to see a clinician due to concerns around data validation. Reporting had recommenced following a data validation exercise. One of the urgent actions the service took following our findings was to establish, by January 2018, a new reporting template for all images per modality and length of time to report, as well as formally recording those images not reported.
Engagement There was limited engagement with patients, staff, the public and local organisations to plan and manage appropriate services, and to collaborate with partner organisations effectively. There was limited evidence of meaningful engagement with patients and the local community. Staff said they supported each other. Staff said the managers and consultants were supportive. Staff said the lead radiographers (superintendents) were hands-on and staff felt well supported by them. Student radiographers were positive about the training they had received and said they would apply to work in the department when there was a vacancy. A new member of staff felt they
20180222 KGHNHSFT Evidence Appendix Page 287 had received good mentoring and that they had integrated effectively in the department. Staff meetings took place with monthly newspapers and leadership briefings.
Learning, continuous improvement and innovation The service was not improving services by learning from when things go well and when they go wrong, nor promoting training, research, and innovation. There was a lack of continuous improvement and innovation There was limited evidence of innovation or improvement. During the inspection in 2016, we found high numbers of images with delayed reporting. During this inspection, we found that this had not improved. The service was working closely with the other trusts in the EMRAD consortium. The clinical director had received an award for innovation related to the fact that any endoscopy patient with a positive cancer diagnosis could now be 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. 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.
20180222 KGHNHSFT Evidence Appendix Page 288