The Tunbridge Wells Hospital at Pembury

Updated 16 February 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at The Tunbridge Wells Hospital at Pembury.

We inspected the maternity service at The Tunbridge Wells Hospital at Pembury (TWHP) as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Tunbridge Wells Hospital at Pembury provides maternity services to the population of 500,000.

Maternity services include an early pregnancy unit, maternal and fetal medicine, outpatient department, Maternity Day Unit, the Maternity assessment unit (triage), Antenatal ward, Delivery suite, Midwifery led birthing centre (Birthing Centre), two maternity theatres, the Postnatal ward (including Transitional care), an obstetric close observation area (OCOA), ultrasound department and an obstetric physiotherapy department. Between April 2021 and March 2022 5712 babies were born at The Tunbridge Wells Hospital, Pembury.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

This location was last inspected under the maternity and gynaecology framework in 2015. Following a consultation process CQC split the assessment of maternity and gynaecology in 2018. As such the historical maternity and gynaecology rating is not comparable to the current maternity inspection and is therefore retired. This means that the resulting rating for Safe and Well-led from this inspection will be the first rating of maternity services for the location. This does not affect the overall trust level rating.

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so. 

Our rating of this hospital stayed the same. We rated it as Requires Improvement because:

• Our rating of Inadequate for maternity services did not change ratings for the hospital overall. We rated safe as Inadequate and well-led as Requires Improvement.

We have since inspected 2 stand-alone birth centres run by Maidstone and Tunbridge Wells NHS Trust maternity services and the reports can be found here:

Crowborough Birthing Centre - https://www.cqc.org.uk/location/RWFX1

Maidstone Birth Centre - https://www.cqc.org.uk/location/RWF03

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the Maternity Assessment Unit (Triage), Maternity Day Assessment Unit, Antenatal Clinic, Delivery Suite, obstetric theatres, the Antenatal and Postnatal ward which included transitional care.

We spoke with 15 midwives, 7 support workers including administrative administration workers, 4 Doctors, 5 women and birthing people and 2 birthing partners and or relatives. We received no responses to our give feedback on care posters which were in place during the inspection.

We reviewed 9 patient care records, 9 observation and escalation charts and 9 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 9 March 2018

• Since our last inspection in 2015, we saw a number of changes.
• There was an improved culture of incident reporting. Incidents were recorded on electronic systems that incorporated fail-safes about aspects such as duty of candour.
• Patients and relatives we spoke with gave positive feedback about the care they received on the unit.
• Staff showed compassion when dealing with patients and protected their privacy and dignity.

However:

• Although medicines were better managed and more available, some aspects of medicines management still needed improvement.

Updated 9 March 2018

• Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learn with the paediatric directorate.
• There was comprehensive assessment of children, including a history of any past or current mental health problems alongside the assessment of their physical health needs. This included age-related pain assessments and children’s pain levels were regularly assessed and acted upon.
• Children had individualised care pathways for their care and risk assessments were completed for all patients including National Paediatric Early Warning Scores in order to rapidly detect any child whose health was of deteriorating.
• Staff had training in the assessment and management of sepsis antibiotics were given in line with guidance. Reports on antimicrobial prescribing and sepsis management were escalated to the board through the trusts governance framework.
• Staff demonstrated an understanding of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005, with regard to children over 16 years and the Children Acts 1989 and 2004.
• There was evidence of good multidisciplinary working both within the trust and with external stakeholders.
• The service was responsive to children, young people and their family’s needs. They delivered personalised care and took into account needs and choices of different people.
• There was a children’s strategy in place that staff we spoke to knew about and were committed to improving child health experiences and outcomes. There was a clear governance framework in place that was led by the chief nurse.
• Staff told us they were supported and felt valued; they thought highly of the matron who they said was very visible supportive and kept them well informed.

However:

• Although it was evident that lessons learned in the children’s services was shared within the directorate and practice changed as a result, it was less clear how learning was systematically identified, disseminated or audited across the trust.
• There were no safeguarding level 3 trained staff on adult wards where 16-18-year-old patients were cared for.

Updated 9 March 2018

Since our last inspection in 2015, we saw a vast number of improvements in critical care.

• There was a good culture of incident reporting and learning, and all incidents were recorded on the trust wide electronic reporting system.
• Medicines were well managed.
• Patient outcomes were mostly in line with or better than other similar critical care units.
• Compliance with national guidelines had improved.
• Patients and relatives we spoke to gave positive feedback about the care they received on the unit.
• Staff showed compassion when dealing with patients and protected their privacy and dignity.

However:

• It was not clear if all intensive care unit deaths were discussed at the morbidity and mortality meetings.
• Delayed discharges from the unit remained an issue.

Updated 31 August 2023

Updated 16 February 2024

Updated 3 February 2015

All the patients we spoke with told us that they had been treated with dignity and their privacy protected. They spoke highly of the staff in outpatients and radiology. They found staff polite and caring. However, many patients complained to us about the waiting times in the outpatient clinics.

Staff were reporting incidents and these were discussed at the clinical governance meetings within the directorates. There were systems in place to reduce the risk and spread of infection. Medicines were stored and administered safely. The department held its own training records which were up to date and demonstrated that most staff had attended mandatory training.

The trust had met their national targets and consistently performed higher than the national average in regard to radiology waiting times. There had been a backlog in reporting CT and MRI scans for several months but there was evidence at the visit that these were reaching resolution. There was an ongoing backlog in clinic letters being sent out that was not resolved. There was risk to patients receiving delayed or inappropriate treatment and considerable stress caused to the staff.

Staff demonstrated a commitment to patient centred care and we found many examples of such care and attention to patient conditions and preferences.

Updated 9 March 2018

• While the service improved in some areas, it stayed the same or became worse in others.
• The escalated short stay surgery unit created risks to patient safety and dignity.
• The hospital had had two never events during the reporting period and one additional never event in the week before this inspection.
• Learning from incidents had not significantly improved since the prior inspection. Information about learning was not always complete and there was not a system to ensure learning was shared with staff.
• Capacity to manage the number of patients being admitted led to significant shortfalls in the responsiveness of the service. This issue was identified at the previous inspection and continued to require improvement.
• Some senior staff did not reflect an understanding of the risks in their departments.
• Significant challenges to recruiting caused gaps in rota coverage and high reliance on bank and agency staff. This issue was identified at the previous inspection and continued to require improvement.
• Resuscitation trolleys in the department were not tamper evident which meant items could be taken from the trolley or tampered with without staff knowledge. We raised this issue with the trust. The trust reported that it reacted throughout the trust immediately and effectively to rectify the issue by putting tamper-evident security on resuscitation trolleys.

However:

• The hospital had improved its supplication of World Health Organisation Safer Surgery Checklists. This was an improvement since our last inspection.
• The department had improved staff retention.

Updated 9 March 2018

• Between October 2016 and September 2017 there was an upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Maidstone Hospital.
• Over the period an average of 42% of ambulance journeys had a turnaround time over 30 minutes.
• From August 2016 to July 2017 the trust reported 364 “black breaches”, with an upward trend over the period. A black breach occurs when a patient spends more than 60 minutes on an ambulance waiting to be seen in the emergency department.
• A significant backlog of incident investigations and limited evidence of learning from incidents meant we were not assured safety improved as a result.
• Triage processes were inconsistent and did not always keep people safe. In addition, the results of triage records indicated a need for improved quality.
• Audits identified a need for improvement in the quality of patient records.
• There was very limited evidence of health promotion work or intervention despite a significant number of patients presenting with alcohol or drug overdoses, or with suicidal intent.

However:

• 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 met the standard for all months over the 12-month period between September 2016 and August 2017 although this did not include patients who arrived by ambulance.
• The unit performed consistently well in the national patient-led assessment of the care environment (PLACE) and in weekly environmental audits. In the previous 12 months, the unit performed better than national and trust averages in all categories.
• From September 2016 to August 2017, the trust reported no incidents classified as never events for urgent and emergency care.
• The recruitment of practice development nurses had significantly improved the training and professional development opportunities for staff. This improved tracking and assessment of staff competencies and enabled individuals in different roles to work and develop together.
• There was a demonstrable track record of well-coordinated multidisciplinary working that contributed to patient outcomes.
• From January 2017 the trust showed a general trend of improvement in performance against Department of Health access and flow metrics, including the national standard to be seen, discharged or admitted within four hours.
• There were clear and demonstrable improvements in clinical governance and leadership, and this was reflected in the morale of staff and initiatives to improve performance and risk management.