Kettering General Hospital NHS Foundation Trust

Kettering General Hospital NHS Foundation Trust provides acute healthcare services to a population of around 320,000 in north Northamptonshire, South Leicestershire and Rutland.

This was the second comprehensive inspection of the trust with the first taking place in September 2014, when it was rated as requires improvement overall. We also carried out an unannounced inspection to the emergency department and some medical care wards in February 2016. As this was a focused inspection, we did not rate the services inspected.

Part of the inspection was announced taking place between 12 and 14 October 2016, with an unannounced inspection taking place 24 October 2016.

Overall, 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.

Three core services were rated as inadequate: urgent and emergency care, children and young people and outpatients and diagnostic imaging. Three services were rated as requires improvement: medical care, surgery and maternity and gynaecology. Two services, which showed improvements since the last inspection, were rated as good: critical care and end of life care.

Our key findings were as follows:

• The board was still relatively new but had seen more stability since the last inspection. There was a lack of capacity to recognise and respond proactively to emerging risks given the focus on urgent priorities
• There was a lack of capacity in the leadership team to consistently embed learning from incidents and audits throughout services to drive improvements. There had not been sufficient improvement in areas of concerns highlighted during our February 2016 inspection. The requirements of the fit and proper person’s regulations had not been met.
• Safety was not a sufficient priority. Opportunities to prevent or minimise harm were missed. Risk assessments were not being carried out in line with hospital policy. There was not a holistic approach to the monitoring of safety and performance data, supported and informed by effective, ongoing clinical audits. Action plans had not always been developed to address areas of risk or poor performance and those that were in place were not always effectively monitored.
• Risks identified by the service were not being assessed, monitored and mitigated via effective, comprehensive risk registers. Risk assessments were not being carried out in line with hospital policy.
• Services’ risk registers were not comprehensive and many of the risks did not have sufficient assurance that mitigating actions were being monitored. Ward dashboards referred to some local risks but these were not systematically escalated to the service risk register.
• Significant issues that threatened the delivery of safe and effective care were not identified. Risks we identified on inspection were not recognised by the service, including the failure to escalate deteriorating patients, poor junior doctor cover for medical wards, security and access to the children’s ward, paediatric nurse competent in the children’s ED and the poor completion and storage of patients’ records. We were therefore not assured staff at every level in the service had an effective understanding of all the risks to patient safety and were able to assess, mitigate and monitor all known risks.
• The hospital had serious concerns around the accuracy and quality of its referral to treatment (RTT) data and reported position, with the correction of this being a hospital priority. The hospital was working on a plan of data improvement including education, training, changes to systems and process and validation of patient pathways. Some patients also experienced long delays waiting for treatment, specifically for urology, maxillofacial and ear, nose and throat (ENT). In some cases, waits were in excess of 52 weeks. The service did not have the capacity to meet the needs of patients and to run additional clinics to manage waiting lists. There were long waiting lists for the majority of specialities, including medical oncology. The services’ own figures from October 2016 showed that 69% of patients were seen within 18 weeks against the national standard of 92% (based on the trust’s unvalidated data). The hospital was not nationally reporting referral to treatment time (RTT) performance at the time of inspection due to historical problems with the validity of data.
• The hospital had taken action to minimise the delays in diagnostics and imaging reporting by outsourcing their radiology reporting. At the time of inspection, there were 11,733 images awaiting a radiology report. These were classified as non-urgent images.
• Generally, staff understood their responsibility to report incidents both internally and externally. Feedback received was variable. Learning from incidents was not always effectively embedded throughout services.
• Complaints were not always handled in a timely manner in almost all services.
• There were not enough registrars and junior doctors to cover the medical wards out of hours and at weekends. Doctors told us there was no electronic handover system and no electronic list of priority patients to alert them to problems out of hours and at weekends in the medical wards. The hospital did not operate a multi-speciality hospital at night team and handover was focused on medical care wards. Working to seven day working in the service was variable.
• There were inadequate numbers of nursing and medical staff to meet the needs of patient’s in adults and children’s ED. There were not effective processes in place to ensure that all staff were competent to carry out the roles they were tasked within the ED. The coronary care unit had nurse staffing numbers that were below the recommended number stipulated by the British Cardiovascular Society. There was inadequate medical staffing cover in the children and young people’s service. The maternity service did not always have sufficient staff, of an appropriate skill mix, to enable the effective delivery of care and treatment. There were times the consultant obstetrician was not present on the labour ward as they would be covering obstetrics and gynaecology and undertaking elective caesarean section lists. The critical care outreach team was not fully established to provide the necessary support and education to the rest of the hospital. The neonatal unit did not always operate in accordance with the required staffing levels. The paediatric outpatient department was not always staffed by registered children’s nurses. Nursing staff in both fracture and ophthalmology clinics treated children but did not have level three safeguarding training in line with national recommendations. The trust took action to address this after the inspection.
• The children’s waiting area did not provide adequate space for patients waiting to be seen and staff in the children’s ED were not able to observe patients waiting at all times in line with guidance. The ED did not have adequate facilities or processes in place to manage patients who presented with mental health illness and were a significant risk to themselves and others.
• The dedicated room for patients who had mental health illness and posed risks to themselves and others was not in line with Royal College of Emergency Medicine (RCEM, 2013) guidelines. The facilities for these patients were not safe. The children’s waiting area did not provide adequate space for patients waiting to be seen and staff in the children’s ED were not able to observe patients waiting at all times in line with guidance.
• Staff were not always completing safeguarding processes in line with hospital policy and had not received the appropriate level of training. In the ED, staff did not always follow safeguarding processes and safeguarding training levels did not meet the hospital’s target or national recommendations. Risks to patients had not been actioned. Only 37% of nursing staff and 29% of medical staff had completed safeguarding level three training at the time of the inspection. Not all staff had completed the required level of children’s safeguarding training.
• The hospital did not have a baby abduction policy; it had a flowchart for staff to follow in an event of an abduction. The trust took actions to address this after our inspection. The environment on Skylark ward was not safe, particularly for patients who may be at risk of self-harm or suicide. The trust took actions to address this once we had raised it as an urgent concern.
• The ED was not consistently meeting national targets for service delivery but it had shown improvements in the last three months with performance better that the England average. From July 2016 to October 2016, the average performance against the target was 88%.
• There was a substantial number of delayed ambulance handovers in the ED. This meant that patients were not always receiving an initial clinical assessment in a timely manner and ambulance crews were not made available to respond to 999 calls. From April 2016 to September 2016, there were 15,604 ambulance handovers of over 15 minutes. This included 2,202 handovers of over 30 minutes and 323 ‘black breaches’.
• There was no effective process in place to ensure that patients waiting for up to three hours after streaming were safe to wait and that all patients with ‘red flag’ symptoms or category two patients were seen by an appropriate clinician for an initial clinical assessment within 15 minutes.
• Nurses on medical care wards had not always followed the escalation process for high-risk patients by informing a doctor when a patient’s NEWS score was raised or when the patient’s oxygen saturation showed a downward trend. There were NEWS charts which showed dates and times that were not clearly stated and some were not legible.
• Patients were exposed to the risk of receiving inappropriate care and treatment due to poorly written and incomplete care plans. For some patients, there were no individualised care plans; in some cases, the same written care needs were simply copied to a new sheet and changing needs had not been reflected or incorporated.
• Patients’ individual care records were not always written and managed in a way that kept patients safe from avoidable harm. Confidential information was not always kept in accordance with the Data Protection Act 1998.
• Medicine storage was not always in line with the national guidance in outpatient areas. For example, fridge temperatures were not checked regularly in some outpatient areas. Expired medication was found in the cardiac unit. Patient’s medical notes were not always stored securely in some outpatient areas. Medicine reconciliations had not always been done. Patients had not always been assessed for needing prophylactic medication to combat venous thromboembolisms (VTEs).
• Outcomes for patients were variable in medical care. The hospital had produced poor results in two national audits that the hospital recently participated in the Sentinel Stroke National Audit Programme (SSNAP) audit showed a poor score of D and E in all four quarters of the reporting year. The hospital participated in the 2015 National Diabetes Inpatient Audit: the hospital was worse for 13 out of 15 indicators. There were mixed patient outcomes in surgery and not always an action plan to ensure improvements. Examples included the hip fracture audit and the bowel cancer audit.
• Patient flow and bed capacity to meet demand had been a significant pressure for the hospital for a number of months. Senior managers were in ongoing discussions with commissioners and stakeholders regarding the most appropriate ways of managing the DTOC position as the medical care beds being used were placing a significant pressure on the effective patient flow through the service. Discharges were sometimes delayed due to patients having to wait for ongoing care packages.
• All staff were passionate about providing high quality patient care. Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
• Most areas of the hospital were visibly clean and were cleaned regularly. Generally, effective infection control procedures were in place.
• Despite significant staffing pressures, generally patients’ needs were met at the time of the inspection in some areas. Actual staffing levels were comparable to the planned levels for most of the wards we visited.
• Pain of individual patients were assessed and managed appropriately. Patients’ nutritional and hydration needs were generally appropriately assessed and the food and fluid charts were well maintained.
• Staff understood and respected patients’ personal, cultural, social and religious needs, and took these into account and services were generally planned and delivered in a way that took account of the needs of different patients.
• Local leaders within services were generally visible and approachable. Staff told us that the senior leadership team, including both senior management and lead clinicians and nurses, were generally visible and effective.
• Most staff felt involved in the hospital’s CARE values which brought staff together to discuss ways to improve services and provide quality care to patients. Staff felt supported and able to speak with the lead nurse if they had concerns.
• There were clear processes and procedures in place regarding the completion of the Five Steps to Safer Surgery checklist. Intensive Care National Audit and Research Centre data showed the intensive care unit to be in line with the England average for all areas except delayed discharges. The hospital had received the United Nations Children's Fund (UNICEF) Baby Friendly Initiative full accreditation for its maternity department.
• The hospital had a replacement for the Liverpool Care Pathway (LCP) called the ‘Guidance to implement care for the dying patient, and their family and friends’. The document was embedded in practice on the wards we visited. Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff. There were clear documented reasons for the decisions recorded.

We saw several areas of outstanding practice including:

• The hospital had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• Sixty volunteers supported the chaplaincy service through a programme of daily and weekly visits to wards and clinical departments. Volunteers attended a 10-week training programme, which included awareness sessions on end of life care, dementia, and hearing and visual impairment.
• There was a well-embedded play worker team, funding was sourced through donations from local businesses as well as fund raising activities. This was used to pay for new equipment as well as weekly visits from a music therapist, pet therapist and magician. The unit had modern toys and facilities for the children including a new projector, which projected moving images onto the floor, which entertained children under the supervision of a play worker.
• The hospital had launched a “Joint School” education session for hip and knee replacement patients. The aim was to give patients a clear indication of what to expect from their operation and what was expected form them by the hospital.
• The hospital had launched a new laser operation to support patients who required treatment for benign enlargement of the prostate by using a light laser to reduce the size of the prostate. This process had reduced the surgical time and the length of stay was no more than one day.

However, there were also areas of poor practice where the hospital needs to make improvements.

Importantly, the hospital must take action:

• Ensure that there are sufficient numbers of nursing and medical staff in adults and children’s ED to meet the demands of the population and ensure safe care is delivered. To ensure that staff working in children’s emergency department (ED) have the correct skills, competence and support to care for children.
• Ensure there is a sufficient number of medical registrars and junior doctors to cover out of hours and weekend shifts at all times across medical care wards. To ensure there is the required level of consultant obstetrician presence on the delivery suite.
• To ensure care and treatment are provided in a safe way for service users by following the British Cardiovascular Society guidance on nurse staffing numbers in the Coronary Care Unit. Ensure there is a sufficient number of nurses working in the Coronary Care Unit at all times.
• To ensure a qualified children’s nurse works in the outpatient department in accordance with Royal College of Nursing guidance, ‘Defining staffing levels for children and young people’s services’ which states that, ‘a minimum of one registered children’s nurse must be available at all times to assist, supervise, support and chaperone children’.
• To ensure that suitably qualified staff in accordance with the agreed numbers set by the hospital and taking into account national policy are employed to cover each shift. In the children’s and young people service. There must be suitable numbers of staff trained in Advanced Paediatric Life Support and / or European Paediatric Life Support.
• Ensure that there are effective systems in place to prioritise, assess and treat all patients attending the ED. Ensure that there are effective processes in place to measure time to initial clinical assessment for ambulance handovers and self-presenting patients.
• To review the streaming competency framework and ensure that staff in this position have the necessary skills to identify a deteriorating or seriously ill patient in adult and children’s ED. To ensure that all staff in outpatients who have direct contact and assess and treat children have the appropriate level of paediatric competencies to provide safe care and treatment.
• To ensure the security of the paediatric ward and Rowan ward at all times and review security system on the postnatal ward to minimise the risk of visitors accessing the ward without being challenged.
• Ensure staff in medical care follow the hospital’s medication policy in the safe prescribing, cancelling, handling, storage, recording and administration of medicines. Ensure staff follow the hospital’s medication procedure for obtaining medicines for patients out of hours. The disposal of controlled drug ampules which have only been partially administered to patients must be recorded in the controlled drug register in the children’s and young people service. To ensure that all medications are stored in outpatients areas in line with hospital policy and national guidelines.
• Ensure that the safeguarding children and vulnerable adult policies include all relevant information, specifically, details about female genital mutilation, child sexual exploitation as well as the referrals process for vulnerable adults. Ensure that all staff are trained to the required level of safeguarding children’s training and adhere to hospital safeguarding policies.
• To ensure all staff have the required statutory and mandatory training and effective systems are in place to monitor this. To ensure that staff in the radiology department are up-to-date on basic life support training. To ensure that radiation dose awareness in plain film by the radiographers is in line with national standards.
• To ensure staff in ED and medical care have had sufficient training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
• To ensure there are processes and procedures for staff in surgery to adhere to the Food Safety Act 1990 and the Food Hygiene (England) Regulations 2006 (Temperature Control Schedule 4 EU Regulation No.852/2004).
• To ensure that theatre staff comply with the Standards and Recommendations for Safe Perioperative Practice 2011 by the Association of Perioperative Practice or the hospital’s operating theatre policy and the theatre standard operating procedure regarding the wearing of cover gowns and footwear when leaving and entering the theatre area.
• To ensure staff are aware of the escalation policy including triggers for escalation in ED and medical care and that these process and reviewed and monitored. Ensure National Early Warning Score (NEWS) charts are filled in clearly, accurately and legibly.
• Ensure that patients’ records are completed with appropriate information to understand their care plans. Ensure all patients have person-centred care plans that are well maintained and reflect appropriately patients’ changing needs and treatment.
• Ensure all confidential patient information in medical care, surgery and gynaecology and outpatients and diagnostics are stored in accordance with the Data Protection Act 1998.
• To ensure complaints are handled in line with hospital policy and effective systems are in place to monitor this.
• To monitor patients’ referral to treatment times, and assess and monitor the risk to patients on the waiting list in surgery, children and young people’s service and outpatients and diagnostic services.
• To develop an effective programme of cyclical audits to measure performance with evidence-based protocols and guidance in the ED. To establish a system for continuous monitoring of action plans developed in response to local and national audits. To ensure all clinical guidelines are up to date and reviewed in a timely manner in the maternity and gynaecology service. To ensure the local maternity dashboard meets RCOG good practice No.7 Maternity dashboard, clinical performance and governance scorecard standards.
• To ensure all staff are supported to recognise and escalate potential risks to the safety and quality of care and treatment for all patients and to ensure effective systems are in place to assess, mitigate and monitor these risks. The hospital should ensure that the risk registers are accurate and reflective of risks in series.
• To review the incident reporting processes in children’s and young people service to ensure all incidents are reported and investigated and that actions agreed correlate to the concerns identified, are acted on and lessons learned are shared accordingly. Ensure ligature audits are undertaken and acted upon in the children’s and young people’s service
• Ensure recruitment procedures reflect the fit and proper person’s requirements.

In addition the hospital should take action to improve:

• To review the environment in reception area in ED so that patients’ privacy and confidentiality can be respected.
• To monitor the dedicated mental health room so that it meets national recommendations and poses minimum risks to patients and staff.
• Review ways to improve the ‘whole system approach’ to managing overcrowding in the ED.
• To provide training to staff in dementia awareness, learning disabilities and complex needs in ED.
• Review staff training and awareness of major incident policy and equipment.
• To monitor that equipment in ED is properly maintained and checks for resuscitation equipment are completed in line with trust policy.
• Consider ways to meet the standards in the intercollegiate document ‘Standards for children and young people in emergency care settings, 2012’.
• To review the function and use of the emergency decisions unit to ensure that the eligibility criteria are being adhered to.
• To review medical cover for the Discharge Lounge.
• To continue to work to recruit full time staff in an effort to reduce the reliance on agency staff in medical care.
• To monitor that fabric chairs and privacy curtains within the breast pre-assessment clinic have the date of cleaning identified.
• To monitor that the processes and procedures in place to manage the medicines stored in all clinical rooms which exceed the required temperature.
• To support all staff to understand the trust’s vision and strategy so that it is embedded within the service.
• To review systems and processes that are in place to ensure the cleanliness of surgical wards.
• To review pharmacy provision to meet the needs of the ICU and be in line with national guidance.
• Review systems for staff in ICU to provide level three safeguarding children’s training.
• To review the provision of the outreach service to allow effective utilisation of this service.
• To review processes so that patients are discharged from the ICU within four hours of the decision to discharge to improve the access and flow of patients within the critical care unit.
• To review processes so that the hospital meets the needs of patient requiring admission to ICU at all times.
• To review the data collecting methods to monitor the length of time patients are nursed in recovery whilst either waiting for a bed in ICU or following discharge from ICU.
• To record ambient room temperatures where fluids are stored that requires this, taking action when required.
• Steps should be taken to improve multidisciplinary working within the department between medical staff, nursing staff and allied healthcare professionals.
• To review seven day services in medical are and critical care to ensure patient needs are met.
• To review assessment and screening of delirium for patients cared for in the ICU.
• To review systems for recording essential checks on equipment, including resuscitation equipment in critical care.
• To review facilities so women’s privacy and dignity is always protected on the delivery suite.
• To review staffing in maternity so that sufficient staff to ensure midwife-to-birth ratio is at the national average of 1:28.
• To review 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 patients and women attending for these appointments shared the same waiting room.
• Monitor processes for patients who present with mental health needs are suitably risk assessed when admitted to the children and young people’s service to ensure care and support provided meets their needs and that staff are competent to manage difficult behaviours, including restraint.
• Monitor staff training in mental health needs of patients and in the use of tracheostomy in the children and young people’s service.
• A comprehensive clinical audit plan should be developed, completed and monitored in the children’s and young people service. Policies which are out of date should be reviewed and revised.
• A dashboard should be developed in the children’s and young people service to report on and monitor operational performance data each month. Business plans should be developed which consider accurate operational activity data and performance. Objectives should be clearly defined and supported with effective action plans.
• To review the provision of a face-to-face specialist palliative care service, aiming to achieve as Monday to Sunday service, including bank holidays.
• To review the data collected for patients so that the hospital can assess the number of referrals for patients with or without cancer.
• To review the collection of data in order to assess the percentage of patients at end of life who were discharged within 24 hours to their preferred location.
• To review the processes to in the mortuary so that medicines for coroner’s inquests are recorded on receipt and transfer to pharmacy for disposal.
• To consider increasing the education and training provision in the SPCT in line with national guidance.
• To monitor the safety of patients who wait over 40 weeks for non-urgent outpatient appointments.
• To review how clinic waiting times and clinic delays are appropriately displayed and communicated to waiting patients.
• To review facilities so that consultation rooms in all outpatient areas can accommodate wheelchair users when needed.
• To review and monitor all patients on waiting lists to ensure effective prioritisation systems are in place to identify and minimise patient harm.
• Review how the standard operating procedure for managing outpatient clinics cancelled within six weeks is implemented and embedded.

Due to level of concerns found across a number of services and because the quality of health care provided required significant improvement, we served the trust with a warning notice under Section 29A of the Health and Social Care Act 2008.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals