Kidderminster Hospital and Treatment Centre

The Care Quality Commission (CQC) previously carried out a comprehensive inspection in November 2016, which found that overall; the trust had a rating of 'inadequate'.

We carried out a focused inspection on 11 and 12 April 2017. We also visited on 25 April 2017, specifically to interview key members of the trust’s senior management team. This was in response to concerns found during our previous comprehensive inspection in November 2016 at Worcestershire Royal Hospital, the Alexandra Hospital Redditch and Kidderminster Hospital and Treatment Centre whereby the trust was served with a Section 29a Warning Notice. The Section 29a Warning Notice required the service to complete a number of actions to ensure compliance with the Health and Social Care Act 2008 Regulations and the trust had produced an action plan, which reflected these requirements as well as additional aims and objectives for the service. This inspection looked specifically at the issues identified in the warning notice and therefore no services were rated as a result of this inspection.

Focused inspections do not look at all five key questions; is it safe, is it effective, is it caring, is it responsive to people’s needs and is it well-led, they focus on the areas indicated by the information that triggered the focus inspection.

The inspection at and Kidderminster Hospital and Treatment Centre focused on the following services; minor injury unit, medical care and surgery. We inspected parts of the five key questions for these services but did not rate them.

Areas where we found improvements had been made were:

• The hospital had addressed the mixed sex accommodation breaches observed during our previous inspection.

Areas where insufficient improvements had been made were:

• The Minor Injuries Unit (MIU) had a process in place for the monitoring of fridge temperatures where medicines were stored. However, there was no evidence of follow-up processes when areas of concern had been highlighted.

Areas of improvement, that were not included in the Section 29a Warning Notice, found from the last inspection were:

• Appropriate systems were in place for the management of controlled drugs within the endoscopy unit.

Additional areas of concern, that were not included in the Section 29a Warning Notice, that we found during this inspection were:

• Resuscitation equipment in the MIU was not fit for purpose in an emergency situation. The defibrillator was not ready for use, as the electronic pads had expired at midnight on the night before our inspection.
• Not all staff had completed their medicines’ management training in the medical care service. Figures from the trust showed a completion rate of 30% against a trust target of 90%. This meant that not all staff had up-to-date knowledge relating to potential risks associated with medicines.
• The Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training was mandatory training and only 33% of medical care staff were up-to-date on this training. This was below the trust target of 90%.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure that all resuscitation equipment is fit for use.
• Ensure that effective actions are taken if medicines’ fridge temperatures are not within the required range.

• Ensure all staff are up-to-date on medicines’ management training.
• Ensure all staff are up-to-date on the Mental Capacity Act and the Deprivation of Liberty Safeguards training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire, with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire, as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection at Kidderminster Hospital on 8 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

Overall, we rated Kidderminster Hospital and Treatment Centre as inadequate, with one of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

• Managers did not have clear oversight of mixed sex breaches or the need to report them in line with national guidance
• Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
• Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
• Not all staff had had undertaken the mandatory training required, including safeguarding children’s training, Mental Capacity Act 2005, Deprivation of Liberty Safeguards and insulin management.
• Appropriate systems were in not in place for the management of controlled drugs within the endoscopy unit.
• Resuscitation equipment was not fit for purpose in an emergency situation. In the MIU we found an empty oxygen cylinder and out of date paediatric airway masks.
• Pain in children attending the MIU was not always managed effectively. We found children were not always assessed for pain and associated pain scores were not always documented.
• Medical notes were not always locked away safely.
• Medicines were not always stored safely. For example: medication fridge temperatures in the MIU were above the recommended temperatures for storing medicines and vaccines.
• Limited use of local audit meant that some outcomes with regards to patient safety, care and effectiveness were not fully understood.
• The NHS Friends and Family Test (FFT) had been suspended in children’s clinics since the service reconfiguration. Patients’ feedback could not be used to monitor and improve services.
• Nursing staff competency assessment records in the children’s clinic were all out of date.
• Examination protocols for standard x-ray examinations were not routinely reviewed and not subject to document control. Patients were unable to access the majority of services in a timely way for initial assessments, diagnoses and/or treatment.
• There was a lack of radiation protection infrastructure.
• Examination protocols for standard x-ray examinations were not routinely reviewed and not subject to document control. Patients were unable to access the majority of services in a timely way for initial assessments, diagnoses and/or treatment.
• Staff were caring and respectful towards patients. Patients’ privacy and dignity was protected and staff adapted their approach to meet the individual needs of patients
• There was an on-site Resident Medical Officer to cover services seven-days a week.
• There were areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve:

• Ensure patients privacy, dignity and confidentiality is maintained at all times.
• Establish female genital mutilation and child sexual exploitation training that is to be completed by all staff working in children and young people’s services.
• Ensure administration of controlled drugs are always documented contemporaneously with signature as appropriate.
• Ensure that medicines are always stored within the recommended temperature ranges to ensure their efficacy or safety.
• Ensure all equipment is in date and used, stored and maintained in line with manufacturers’ instructions.
• Ensure that resuscitation equipment is readily available for use when required without posing a risk.
• Ensure that there is an effective system in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
• Ensure that equipment is checked as per policy.
• Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
• Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
• Ensure they are carrying out patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
• Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
• Ensure there is a strategy in place for diagnostic and imaging services that staff are aware of.
• Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
• Ensure there is a process for collecting data regarding the effectiveness of the children’s outpatients department to recognise and plan where improvements can be made.
• Ensure mixed sex breaches are reported as required.
• Ensure patient notes are stored securely and safely.
• Increase staff awareness of the trust’s incident reporting procedures and risk matrix tool.
• Ensure staff complete the required level of safeguarding training, including safeguarding children.
• Ensure staff compliance with mandatory training meets trust target of 90%.
• Ensure all staff receive an annual appraisal.
• Ensure staff receive appropriate clinical supervision.

In addition, the trust should:

• Ensure there is a clear consistent approach to streaming patients in the minor injuries unit at all times, to ensure patients with the most urgent needs are prioritised.
• Ensure every child has a pain assessment and pain scores are documented.
• Ensure pain relief given to children is audited in the minor injuries unit.
• Ensure that guidelines are in date and are in line with national best practice guidance.
• Ensure patient outcomes are collected, monitored, analysed and used to drive service improvements.
• Ensure there is a clear minor injuries unit strategy.
• Consider developing a formal clinical audit plan, including regular, local audit of documentation, environment, equipment and hand hygiene. Then share the results with staff to improve patient care.
• Ensure all additional training identified is completed by staff.
• Ensure that World Health Organisations’ Five Steps to Safer Surgery checklists is reviewed and completed appropriately.
• Review the systems in place to ensure staff feel safe, respected and valued within the workplace.
• Ensure staff have knowledge of the key objectives within the service.
• Consider involving staff in strategic plans and developments within surgical services.
• Review the number of cancelled operations in line with the national average of 6%.
• Review the choices offered to patients about where they are discharged too for continuing care.
• Record templates should be developed that clearly identify where information should be recorded.
• Record meetings where performance in the children’s clinic is discussed.
• Ensure there are appropriate and child friendly waiting areas for children and young people and provide appropriate environments for them, including room temperatures.
• Take action to address the ‘did not attend’ appointment rate for new children and young people’s clinic appointments.
• Ensure complaints are investigated within the timescales stated in the trust’s complaints policy.
• Ensure there is a clear flow of information from the children’s clinic to the board via effective governance processes.
• Ensure there is senior oversight of the minor injury unit.
• Ensure there are suitable arrangements for the maintenance, renewal and replacement of equipment and medical consumables.
• Ensure that risks are identified, escalated and acted on without delay.
• Ensure that processes are in place to assess, monitor and mitigate risks relating to service users.
• Ensure that systems and processes are operated effectively.
• Ensure that records and information in relation to equipment is accurate, analysed and reviewed by people with the appropriate skills and competence to understand its significance.
• Ensure effective governance measures are in place to ensure staff adhere to trust policies and processes.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the section 29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

​Chief Inspector of Hospitals