Kingston and Richmond NHS Foundation Trust

Kingston Hospital NHS Foundation Trust provides local services, primarily for people living in and around Kingston-Upon-Thames. The trust provides services to approximately 350,000 people and provides a full range of diagnostic and treatment services, including emergency care, day surgery and maternity services. Our key findings were as follows:

Safe

• Improvements were required for the safe storage of medicines in outpatients, theatres, some wards, and the emergency department. In particular with regard to recording of fridge temperatures, and restricting accessibility to storage facilities.
• Improvements were required to ensure equipment used for patient treatment and care had routine safety and maintenance checks.
• Improvements were required to ensure there was enough surgical instrumentation available in theatres.
• Staff understood their responsibilities to raise concerns, to record safety incidents, and near misses, and to report them. However, incident reporting was not fully embedded in everyday practice within the emergency department.
• Safety goals were set and performance was monitored using information from a range of sources.
• People who used the services were told when they were affected by something that went wrong, and were informed of any actions taken as a result. However, letters written to people did not always contain a formal apology.
• Staff and relevant individuals were involved in thorough and robust investigative reviews, where incidents or adverse events arose.
• With the exception of the emergency department, lessons learned and action taken as a result of investigations were shared with staff and changes in practice implemented.
• The environment in which people received treatment and care was clean and there were reliable systems to prevent and protect people from a healthcare-associated infection. Despite this, staff working in the emergency department did not always follow recommended hand hygiene practices.
• The majority of staff had received effective mandatory training in the safety systems, processes and practices. 
• Risk management activities and procedures used by staff helped to ensure peoples safety needs were identified and responded to.
• There were sufficient staff with appropriate skills to ensure the safe delivery of treatment and care in most areas. 
• There was a high number of new and inexperienced nursing staff in the emergency department and not enough permanent shift leaders or doctors to cover the rota.

Effective

• People's consent to treatment and care was sought in line with legislation and guidance. People were supported to make decisions and where a person lacked mental capacity to consent to treatment or care staff made 'best interest' decisions. However, mental capacity assessment were not always carried out where patients required mechanical restraint on medical wards. Best interest decisions had not always been recorded for the interventions taken.
• Staff generally had an understanding and awareness of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS), but some staff reported not having formal training in either subject.
• People’s needs were assessed and care and treatment was delivered in line with legislation, standards and evidence based guidance.
• A multidisciplinary team of staff worked collaboratively, and were supported to deliver effective treatment and care by relevant and current evidence-based guidance, standards, best practice and legislation.
• Monitoring of the effectiveness of services was taking place and outcomes from such activities were generally used to improve standards and quality.
• People receiving treatment and care were not discriminated against. Individual care needs took into account; age, disability, gender, pregnancy and maternity status, race, religion or belief and sexual orientation.
• People’s nutrition, hydration and pain needs were assessed and action was taken by staff to meet their immediate and changing needs.
• Technological equipment was generally available and used by staff to monitor and deliver treatment and care.
• Staff had the right qualifications, skills, knowledge and experience to undertake their roles and responsibilities. They had access to appropriate developmental training and were supported by senior staff through a range of approaches. Staff had opportunities to receive feedback on their performance.

Caring

• People were treated with kindness, dignity, respect and compassion whilst they received care and treatment from staff.
• Staff took into account and respected people’s personal, cultural, social and religious needs.
• Staff were observed to take the time to interact with people who used the service and those close to them in a respectful and considerate manner. They showed an encouraging, sensitive and supportive attitude towards people receiving treatment and care, and those close to them.
• People who used the services and those close to them were involved as partners in their care. Staff communicated with people so they understood their care, treatment and condition. They recognised when people needed additional information and support to help them understand and be involved in their care and treatment and facilitated access to this.
• People were given appropriate and timely support and information to cope emotionally with their care, treatment or condition.
• Staff encouraged participation from those close to people who used the services, including carers and dependents. People were encouraged and supported to manage their own health, care and wellbeing and to be as independent as able.

Responsive

• Services had been planned and delivered to meet the needs of people within the local population. Stakeholders and other providers were involved in planning and delivering services.
• The emergency department was not meeting the national target of seeing and treating 95% of patients within four hours of arrival. Ambulance hand over times were not always achieved.
• The facilities and environment were being developed in some areas in order to meet the changing needs of the population using the services. Further improvements were needed in some areas to ensure privacy was not compromised and to meet the needs of particular groups of people. This including patients attending the emergency department with mental health related matters. The Critical Care Unit environment was not conducive to meeting the needs of patients, visitors and staff.
• Services were accessible and took into account the individual needs of people who used them. This included vulnerable individuals and people with a physical disability, learning disabilities, and those living with dementia. Some environmental improvements were needed to areas where people living with dementia were receiving treatment and care.
• People were given the help and support they needed to make a complaint. With the exception of the emergency department, complaints were handled effectively and confidentially, with a regular update for the complainant and a formal record was kept. The outcome was explained appropriately to the individual in an open and transparent manner. Lessons learned from concerns and complaints were acted upon by staff.

Well-led

• There was a clear vision and a set of values, with quality and safety the top priority, which was understood by staff. Core services had robust, realistic strategies targeted towards achieving the clinical priorities set by the trust and aimed at delivering good quality care; staff knew what their responsibilities were for delivering this. Targets were continuously reviewed.
• The majority of clinical areas were well led, with strong and effective governance arrangements to oversee quality, safety and risk management.
• Most staff reported effective leadership, with approachable and supportive line managers, who operated in an open and responsive culture. Some theatre staff reported challenges with visibility and direction of the main theatres leadership, with a need for more constructive engagement. Theatre leaders had recognised staff morale was an area for improvement and had put in place a number of interventions.
• Staff in the majority of areas reported feeling respected and valued, and were enabled to contribute to service delivery and improvements.
• There was a systematic programme of clinical and internal audit, which was used to monitor quality and systems to identify where action should be taken. There were arrangements for identifying, recording and managing the majority of risks, along with mitigating actions.

We saw several areas of outstanding practice including:

• The Wolverton Centre, for providing comprehensive sexual health services; for provision of service alerts for vulnerable patients, including young people, and those with a learning disability.
• A comprehensive dementia strategy, which enabled staff to support people living with dementia. A dedicated dementia improvement lead provided visibility and support to staff, ensuring positive interventions were implemented. The carer’s support pack, therapeutic activities and a memory café contributed to the enhancement of services.
• The trust’s engagement with ‘John’s campaign’, promoted the rights of people living with dementia to be supported by their carers in hospital. To facilitate this, there was open visiting and a free car park for respective carers and relatives. Family members and carers were offered beds to stay overnight if needed.
• The specialist palliative care (SPC) team stood out as highly skilled and effective. They supported staff to provide good quality, sensitive care to patients at the end of life and to the people close to them.
• Staff of all disciplines demonstrated an impressive understanding of their role in addressing the needs of people at the end of life and of providing sensitive and compassionate care.
• The paediatric diabetes team were a top performer in the National Paediatric Diabetes audit 2014 to 2015 due to HbA1C rates being better than the England average.
• The trust participated in the Sentinel Stroke National Audit Programme (SSNAP), and achieved an A rating for the period January 2015 to March 2015.
• The Physiotherapists in the critical care unit had reduced the length of stay for their patients through the early implementation of rehabilitation.
• The engagement and involvement of volunteers was recognised as an invaluable team to support service delivery.
• Patient pathway co-ordinators in outpatients had impacted positively on the effectiveness of appointment arrangements.

However, there were also areas of where the trust needs to make improvements. Importantly, the trust must:

• Ensure that individuals who lack capacity are subjected to a mental capacity assessment and best interest decisions where they require restraint. Such information must be recorded in the patient record.
• Make improvements to ensure medicines are not accessible to unauthorised persons; are stored safely, and in accordance with recommended temperatures.
• Make improvements to the systems for monitoring of equipment maintenance and safety checks in order to assure a responsive service.
• Ensure that the Duty of Candour is adhered to by including a formal apology within correspondence to relevant persons and that such a record is retained.
• Ensure the management, governance and culture in ED, supports the delivery of high quality care.
• Improve the quality and accuracy of performance data in ED, and increase its use in identifying poor performance and areas for improvement.
• Ensure all identified risks are reflected on the ED risk register and timely action is taken to manage risks.

In addition the trust should:

• Review patient outcome measures to consider how performance can be improved.
• Staff should have timely access to regular training with respect to the Mental Capacity act (2005) and Deprivation of Liberties Safeguarding.
• Review length of stay and ways of decreasing this in care of the elderly and cardiology services.
• Take steps to embed debriefings after operating lists across all surgery services, as part of the World Health Organization (WHO) Surgical Safety Checklist.
• Ensure better compliance with hand hygiene and cleaning of clinical equipment in the emergency department.
• Review the skill mix and flexibility of staff within ED in order to respond to changes in activity levels and demand surges.
• Improve ED staffs understanding and compliance with the trust's incident reporting procedures, complaints handling and application of learning from these.
• Ensure there is accurate performance information in the ED.
• Seek ways of consistently improving patient flow through the ED.
• Ensure the systems for routine safety processes such as recording timely observations of patients, checking resuscitation equipment, and making sure medicines and cleaning chemicals were stored safely.
• Ensure adequate and safe facilities for patients with mental health needs.
• Ensure staff use computers securely in ED and do not share login cards
• Improve staff engagement in main operating theatres.
• Establish a robust system for ensuring required surgical instruments are readily available.
• Increase visibility and leadership engagement within theatres.
• Optimise pre-assessment procedures in order to limit cancellations on the day of scheduled surgery.
• Take steps to ensure all nursing staff understand how to communicate with vulnerable and elderly patients in an appropriate way.
• Improve responsiveness of nursing staff to patient call bells at weekends.
• Consider how the environment and facilities in the CCU could be improved.
• Review CCU records in order that capacity assessments can be documented.
• Explore the benefits of having a follow up services available for patients who have used CCU so they are able to reflect upon their stay and can address long term psychological concerns.
• Review maternity service bed capacity in order to address the increasing activity.
• Ensure midwifery staff have access to required equipment.
• Review staffing levels in maternity services in order to avoid delays of induction and elective caesarean sections.
• Ensure children have an appropriate waiting area in the fracture clinic.
• Review areas used by children and young people with a focus on age appropriate décor.
• Ensure staff working in children's and young people's services have access to up to date editions of the British National Formulary (BNF).
• Ensure registered nursing staff levels in children's and young people's services are in accordance with RCN and BAPM guidelines.
• Review the specialist palliative consultant and nursing presence at the hospital in order to maintain progress towards meeting the provision of excellent end of life care.
• Review the environment of the chapel and multi-faith facilities.
• Consider how the environment on medical wards and in outpatients can be developed to enhance the experiences of people living with dementia.
• Provide greater privacy for inpatients who attend the CT scanning unit.
• Reinforce best practice around the use of appropriate interpreters.
• Ensure information about chaperones is made easily available in all OPD clinics.
• Ensure waiting times and clinic delays are appropriately displayed and communicated to waiting patients.
• Have a consistent approach to sending reminders to patients about their appointments, to minimised non attendance.
• Ensure that patient examination couches are checked and maintained as appropriate in the general outpatient area.
• Address recommendations made by the Anti-Terrorism Squad for the safe monitoring of radionuclide medicine delivery.
• Ensure proper systems are in place to facilitate governance meetings in each outpatient service.
• Consider how daily cleaning schedules can be completed and quality checks and sign off of these are routinely undertaken.
• Arrangements around equipment storage should be reviewed so that shower rooms are not used.
• Utility rooms containing hazardous chemicals should be locked, with additional provision for secure storage of such products.
• Fire safety precautions should be reinforced with staff to ensure fire doors are not propped open.
• The policy for medicines management is followed to support the use of patients own medicines.
• Review existing arrangements to ensure that suitable governance and assurances mechanisms are in place with regards to the trust's statutory duty to ensure that directors are fit and proper.

Professor Sir Mike Richards

Chief Inspector of Hospitals