The Kent and Canterbury Hospital (K&C) is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT). EKUHFT provides local services primarily for the people
living in Kent. The Trust serves a population of approximately 759,000 and employs approximately 6,779 whole time equivalent staff.
The Kent and Canterbury Hospital is an acute hospital providing a range of elective and emergency services including an Urgent care (UCC). Thishospital provides a central base for many specialistservices in East Kent such as renal, vascular,interventional radiology, urology, dermatology, neurology and haemophilia services.
We carried out an announced inspection between 5th and 7th September 2016, and an unannounced insection on 21st September 2016.
This is the third inspection of this hospital. This inspection was specifically designed to test the
requirement for the continued application of special measures to the trust. Prior to inspection we risk
assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection.
We rated The Kent and Canterbury Hospital as Requires Improvement overall
Safe
We rated The Kent and Canterbury Hospital as Requiring improvement for safe because:
- There was a shortage of junior grade doctors and consultants across the medical services at the hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service, particularly out of hours and at night.
- The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day-basis.
- We found poor records management in some areas. Staff did not always complete care records according to the best practice guidance
- We found there were nursing shortages across the hospital.
- The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.
However
- Staff reported incidents and adverse events that were investigated through robust quality and clinical governance systems. Lessons arising from these events were learned and improvements had been made when needed.
- Staff followed cleanliness and infection control procedures. Potential infection risks during the building works were anticipated and appropriate responses implemented and measured
Effective
We rated The Kent and Canterbury Hospital as Requiring improvement for effective because:
- Documents and records supporting the learning needs of staff were not always competed and there were gaps in the records of training achieved.
- The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision
- Appraisial rates across the hospital needed to be improved.
- There was poor compliance in the use of the end of life documentation across the wards we visited which was reflected in the May 2016 documentation audit undertaken by the SPC team.
However
- We saw good examples of multidisciplinary working between doctors, nurses, ENPs and other healthcare professionals, including colleagues from the other emergency departments.
- Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
- Comfort rounds had been performed and audited. These provided good assurance that pain assessments had been performed, analgesia administered.
Caring
We rated The Kent and Canterbury Hospital as Good for caring because:
- Staff treated patients with kindness and compassion.
- Patients and relatives we spoke with were complimentary about the nursing and medical staff.
- Patients were given appropriate information and support regarding their care or treatment and understood the choices available to them.
- Staff we observed were consistently respectful towards patients and mindful of their privacy and dignity.
Responsive
We rated The Kent and Canterbury Hospital as Requiring improvement for responsive because:
- Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.
- We found the hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
- Admission criteria for the UCC appears to be an ongoing issue of confusion to some parts of the local community, as evidenced by inappropriate ‘walk in’ patients arriving at the department.
However
- There was an average of 17 60-minute breaches in ambulance handover times per month over the last four months. This represented 2.2% of the total number of patient handovers and was better than the regional average of 3%.
- The trust employed specialist nurses to support the ward staff. This included dementia nurses and learning difficulty link nurses who provided support, training and had developed resource files for staff to reference. Wards also had ‘champions’ who acted as additional resources to promote best practice.
Well led
We rated The Kent and Canterbury Hospital as Requiring improvement for well led because:
- In some areas risk management and quality measurement were not always dealt with appropriately or in a timely way. Risks and issues described by staff did not correspond to those
- Where changes were made, appropriate processes were not always followed and the impact was not fully monitored in maternity and gynaecology services
- No separate risk register was available for palliative /end of life care. A separate risk register would allow the risks to this patient group be discussed regularly at the end of life board, and allow plans to be made to alleviate any identified risks.
- Changes in leadership in end of life care had only recently been realised and as a result had yet to fully address the issues relating to these services.
- Although there were measures in place to promote positive behaviour and eliminate bullying, staff still reported incidents of poor behaviour from colleagues.
However
- The hospital had well-documented and publicised vision and values. Their vision was to provide ‘Great healthcare from great people’, with the mission statement ‘together we care: Improving health and lives’. These were readily available for staff, patients and the public on the trust’s internet pages, posters around the hospitals and on the trust’s internal intranet.
We saw several areas of outstanding practice including:
- Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.
- Have systems established to ensure that there are accurate, complete and contemporaneous records kept and held securely in respect of each patient.
- Ensure that all staff have attended mandatory training and address gaps in training records that make it difficult to determine if training meets hospital policy requirements.
- Ensure generalist nurses caring for end of life patients undergo training in end of life care and the use of end of life care documentation.
- Take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.
- Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.
- Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.
Action the hospital should take to improve
- Ensure the administration of pain relief medication is provided to patients in a timely manner in the urgent care unit and minor injury unit.
There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.
Professor Sir Mike Richards
Chief Inspector of Hospitals