1. society
2. welfare
3. healthcare
4. hospital

Agenda Item:
Board of Directors
Meeting
Subject:
Date:
Authors:
Lead Director:
Report
Monthly Quality & Safety Report
Thursday 3rd October 2013
Susan Bowler / Amanda Callow / Jacqui Tuffnell
Susan Bowler – Executive Director of Nursing & Quality
Executive Summary
This monthly report provides the Board with a summary of important quality and safety items
to note. In summary, the paper highlights the following key points:
•
Results from the most recent mortality data are encouraging. Adjusted mortality for
all inpatients is 106, which shows a marked improvement. Mortality results for key
diagnosis groups, such as sepsis, acute myocardial infarction, acute cerebrovascular
disease and pneumonia has reduced. The mortality for Acute Kidney Injury is within
range but remains a concern.
•
Pressure ulcer prevention – the reduction in avoidable grade 2 and 3 pressure ulcers
has been sustained during August. There has been zero grade 4, 1 grade 3 and 7
grade 2 pressure ulcers.
•
Improved patient flow - length of stay increased in August to 6.61 days. Analysis is
currently being undertaken to identify the cause of this. Improved patient tracking and
escalation of patients is evident, with a decrease in the percentage of patients with
four or more ward movements during their hospital stay.
•
Complaints performance has remained stable during August, with 173 complainants
receiving responses within the agreed time frame.
•
PLACE inspections – The Trust has received excellent scores in the recent PLACE
audits which are patient led assessments of the care environment.
•
Infection control - there has been a third Trust acquired MRSA case in September
2013. In terms of C Diff performance, as of 23rd September the Trust has identified
17 cases of Trust acquired C Diff against a year to date trajectory of 13 cases.
•
CQC Report – The final report from the inspection that took place following the
Keogh review has now been published. There are 5 outcomes which are not meeting
the required standards. The Trust has received a formal warning in relation to
‘assessing and monitoring the quality of service provision.’
•
Intentional Rounding – ‘Care and Comfort Rounds’ have now been introduced on 11
wards, with a plan to roll out across all inpatient wards by October 28th 2013.
•
A summary of discussions at Clinical Governance and Quality Committee on the 26th
September 2013 is included at the end of the report.
Recommendation
To note the content of the report and progress / position to date
Relevant Strategic Objectives (please mark in bold)
Achieve the best patient experience
Improve patient safety and provide high
quality care
Attract, develop and motivate effective teams
Links to the BAF and Corporate
Risk Register
Details of additional risks
associated with this paper (may
include CQC Essential Standards,
NHSLA, NHS Constitution)
Links to NHS Constitution
Financial Implications/Impact
Achieve financial sustainability
Build successful relationships with external
organisations and regulators
BAF 1.3, 2.1, 2.2 2.3, 5.3, 5.5
Mortality, C Diff & Complaints on corporate risk register
Failure to meet the Monitor regulatory requirements for
governance - remain in significant breach.
Risk of being assessed as non-compliant against the
CQC essential standards of Quality and Safety
Failure to meet 2013/14 infection control trajectories –
impacts on governance risk rating
Principle 2, 3, 4 & 7
Potential contractual penalties for C Difficile, Pressure
Ulcers, Never Event and MRSA
Legal Implications/Impact
Reputational implications of delivering sub-standard
safety and care
Partnership working & Public
This paper will be shared with the CCG Performance
Engagement Implications/Impact and Quality Group and the Patient Quality and
Experience Committee
Committees/groups where this
A number of specific items have been discussed at
item has been presented before
Infection Prevention & Control Committee, Pressure
Ulcer Strategy Group, Nursing Care Forum, Clinical
Management Team and Clinical Governance & Quality
Committee
Monitoring and Review
Monitoring via the quality contract, CCG Performance
and Quality Committee & internal processes, e.g.
Clinical management Team & relevant
committees/forums
Is a QIA required/been
No
completed? If yes provide brief
details
TRUST BOARD OF DIRECTORS - OCTOBER 2013
MONTHLY QUALITY & SAFETY REPORT
1. Introduction
This monthly report highlights to the Board of Directors key areas in relation to quality and safety. It
complements the quarterly quality report, which gives a more comprehensive review of progress against all
of the Trust’s quality and safety priorities. The monthly report will include updates on the Trust’s top 3
quality priorities for 2013/14, which are:
•
Priority 1 – Improving the effectiveness of care we deliver by achieving a reduction in mortality (HSMR,
SHMI and crude mortality)
•
Priority 2 – Delivering Harm Free Care by reducing hospital acquired pressure ulcers
•
Priority 3 - To reduce length of stay and readmissions by improving patient flows (i.e. reducing the
number of bed movements during the patients inpatient stay)
2. Mortality (Priority 1)
2.1
Overview
The most up to date information we have for HSMR is from May 2013. HSMR data from June has not been
included, due to high numbers of patients with a ‘residual code’ making the data unreliable. HSMR for the
year to May 2013 is shown in the graph below:
1
Adjusted mortality for all deaths rather than the HSMR basket of diagnoses is more accurate when the
number of residual codes is high.
The position therefore is that for the first half of 2013, adjusted mortality for all in-patient deaths is 106. This
shows a marked improvement and is within the expected range. The graph below shows that SFHFT is no
longer the highest in the East Midlands.
2
There has been a 15 point drop in HSMR at SFHFT for the period Dec 2012 – May 2013 in comparison
with the previous 6 months. .
HSMR by Acute Trust in East Midlands
140
120
HSMR
100
80
June 2012-Nov 2012
60
Dec 2012-May 2013
40
20
Le
ice
st
er
Ch
es
te
r fi
el
d
De
rb
y
Ke
tte
r in
g
No
rth
am
pt
on
UL
HT
H
NU
SF
HT
0
Trust
2.2
Trust In-House Mortality Report
These figures need to be validated as they do not correlate with the numbers of deaths in the Dr Foster
data.
However there does appear to be a reduction in the crude mortality rate in the last 4 months, meaning that
HSMR may drop further when the Dr Foster data from June-Aug becomes available.
Jan ‘13
Feb ‘13
Mar’13
Apr’13
May’13
Jun’13
Jul’13
Aug’13
Discharges
Total
Deaths
4325
3944
4201
4043
4131
3891
4193
3997
125
113
135
124
103
92
99
89
% Deaths
2.89
2.87
3.21
3.07
2.49
2.36
2.36
2.23
Discharges
3632
Emergencies
Death
125
3256
3465
3445
3444
3216
3514
3401
112
134
124
101
91
97
89
% Deaths
3.33
3.72
3.47
2.85
2.75
2.69
2.55
3.33
2012/13
Discharges – Emergencies
41057
2013/14 (YTD)
17020 (ytd)
Deaths
1461
502 (ytd)
% Deaths
3.44%
2.86%
3
2.3
Key Diagnosis Groups
The following key diagnosis groups have previously been identified for improvement because of concern
about adjusted mortality rates;
1. Sepsis and UTI
2. Acute cerebrovascular disease
3. Acute myocardial infarction
4. Acute kidney injury
5. Pneumonia
2.3.1
Sepsis
.
The improvements in mortality have been maintained
2.3.2
Acute Cerebrovascular Disease
The action plan in response to the CQC alert has been completed and submitted. There has been a
steady improvement in mortality for the last 4 quarters.
2.3.3
Acute myocardial infarction
4
Mortality from AMI is below the national average for the first two quarters of this year and is no longer a
cause for concern.
2.3.4
Acute kidney injury
Whilst HSMR is elevated at 130 over the past 3 years it is still within the expected range. However, there is
no downward trend and mortality from AKI remains a concern.
The action plan has been re-vitalised. A new Consultant Renal Physician needs to be appointed to allow
specialist in-put to in-patients at SFHT with AKI and the Emergency Care & Medicine Division are leading
discussions.
2.3.5
Pneumonia
Mortality from pneumonia dropped in the first half of this year, which is likely to be as a result of the
implementation of the sepsis action plan.
A pneumonia improvement group has been established. New care bundles and an audit tool have been
developed
5
3. Pressure Ulcer Reduction (Priority 2)
The table below demonstrates actual numbers of avoidable pressure ulcers (by grade) in comparison to the
target. We achieved the targets during August 2013. There have been zero avoidable grade 4 pressure
ulcers now for 8 months. One avoidable grade 3 pressure ulcer developed in August. Avoidable grade 2
pressure ulcers remain significantly lower in August compared to Quarter 1. The Trust completes a full
route cause analysis on all hospital acquired pressure ulcers.
Table: 2013/14 SFH Avoidable Pressure Ulcer Reduction Trajectory
Apr
13
0
May
13
0
Jun
13
0
Jul
13
0
Aug
13
0
0
0
0
0
0
Target No.
Grade 3
Actual No.
3
3
2
2
2
4
5
2
0
1
Target No.
Grade 2
Actual No.
20
15
10
8
7
13
14
16
8
7
Target No
Grade 4
Actual No.
Sep
13
0
Oct
13
0
Nov
13
0
Dec
13
0
Jan
14
0
Feb
14
0
Mar April
14 14
0
0
2
2
1
1
1
1
0
0
7
6
6
6
4
3
3
0
After reviewing the data, audit intelligence and feedback from clinical teams, there are a number of factors
that have contributed to this continued improved performance in August. These include:
•
•
•
Continued collaborative awareness and commitment to reduce pressure ulcers between clinical
teams and senior management across the trust
The on-going presence and visibility of the tissue viability team within clinical areas
Improved root cause analysis of grade 3 pressure ulcers, supported by appropriate action plans and
monitored at the Divisional Ward Leaders Quality Groups.
4. Improved Patient Flow (Priority 3)
Length of stay increased in August to 6.61 days against a Trust target of 6 days. Whilst this appears
disappointing, there was an increase in ambulatory outpatient clinics in Acute Medicine. Diverting patients
to ambulatory clinics and the clinical decisions unit could have impacted on this, as traditionally these
patients had a very low length of stay.
The 4 hour target performance in August was 97.81% with Quarter 2 to date performance at 97.11%.
Almost no additional capacity was opened during August and the deep cleaning programme is progressing
well which limits the Trusts ability to flex capacity. However it is essential that this work is undertaken
ahead of ‘winter’ commencing. The one exception was temporary staffing of additional beds on EAU to
manage some peaks in admissions for 2-3 days.
6
We are developing a suite of performance information to monitor flow through the clinical decisions unit, the
emergency outpatient’s clinics for Acute Medicine and Gastroenterology. This will enable managers to
assess any changes in casemix and severity of patient, together with aiding decision making on capacity
and escalation actions.
Length of stay is also being monitored on EAU and particularly where patients are staying on this short stay
unit longer than 48 hours. There is a cohort of short stay patient who we expect to remain on EAU longer
than 48 hours however our aim is for right patient, right ward, right specialty to ensure that all patients are
receiving care in the right place. We anticipate this suite of length of stay information being available in
September to support winter preparedness and improved decision making. It will also be used to more
accurately calculate changes in length of stay where patients use outpatient and non-admitted services.
Readmissions information is not fully reliable until all coding has concluded; and July data is therefore not
fully accurate until September. This therefore shows that readmissions was sustained at 10.2% and not
showing any significant signs of improving.
7
Hot week emergency clinics started in August as a development to prevent unnecessary admissions and
readmissions. The full effect of these is yet to be seen but it is anticipated that these services combined
with services such as the community COPD team will reduce readmissions for some chronic condition
patients.
In addition to this hot week, consultant telephone line advice and guidance in Gastroenterology and
Respiratory have now been set up with consultants taking calls internally form ED as well as GPs to
prevent admissions and readmissions. These services used in conjunction with those described up will be
monitored throughout August and September, refined and improved to ensure that maximum potential
readmission/admission reduction can be
Building on the mantra of right patient right place, we are also aiming to reduce the number of ward moves,
reduce risk and improving patient care and experience. With new data on the number of moves a target
has yet been defined but a recommendation that we should aim for 2.5% is being current being considered.
There are sound and appropriate reasons for some patients having to move four or more times during
hospital spell, such as patients who move through surgical, critical care, high dependency and rehabilitation
wards. However the reduction of inappropriate patient moves is essential.
Improved patient tracking and escalation of patients who have moved a number of times before is in the
process of being embedded in hospital duty management teams, and a series of risk assessment,
simulation and escalation tools are being piloted in September to minimise the amount of unnecessary
moves patients make.
8
5. End of Life Care & the Liverpool Care Pathway
In July 2013, the independent review of the Liverpool Care Pathway reported their findings in ‘More Care.
Less Pathway’ led by Baroness Julia Neuberger. The report was commissioned as a result of concerns that
hydration and nutrition were being denied to patients on the pathway. They recommended that the LCP be
phased out over the next 6-12 months and replaced with an individualised care plan backed up by good
practice guidance. In total there were 44 recommendations with some of the key ones described below:
•
•
•
•
A patient should be placed on the LCP only be a senior responsible clinician in consultation with the
healthcare team
Unless there is good reason a decision to withdraw or not to start life –prolonging treatment should
not be made out of hours.
An urgent call for the Nursing & Midwifery Council to issue guidance on end of life care.
A new system wide approach to improving end of life care
There is now a national programme to review the pathway. It is hoped that this review will conclude early
next year.
At SFHFT, there has been significant discussion and evaluation of the immediate findings of the report.
The guidance from national bodies has been considered and discussed locally and regionally. In light of the
current national review, we have issued immediate local guidance to clinical staff, which takes on board the
initial national recommendations.
If a patient, family and staff are happy with the care being provided, the local guidance is to continue with
the LCP. If concerns are raised by the patient or family and they are not happy to continue the LCP, staff
have been advised to listen to their concerns, stop using the LCP, and continue to provide best supportive
comfort care.
For patients in their last days of life a discussion with the most senior doctor available is advocated. Again,
if the family have concerns about the LCP, then the LCP should not be used, but best supportive care will
continue. If the family are comfortable with the LCP, then this will be commenced as usual.
The lead clinician for end of life care alongside the end of life steering group will issue further guidance
when the national programme has reported. In the meantime the newly appointed end of life care nurse will
continue to offer advice for individual patients, family members and staff.
The numbers of patients on the LCP continues to be carefully monitored. Audits of the quality of end of life
care provided to our patients are also undertaken. The graph below shows that although the LCP continues
to be used, there has been a significant reduction over the last 6 months.
9
6. Patient Experience
6.1
Complaints
6.1.1
Complaints Performance - Current Position
The numbers of complaints received by the organisation are shown in the diagram below:
This shows that the organisation has seen an increase in the numbers of complaints received in August
2013 (76) compared to July 2013 (59). The Trust currently receives an average of 2.5 complaints per day
over 7 days. As of 25 August 2013, the position is as follows:
•
All complaints received an acknowledgment within 72 hours
Emergency Care and Medicine:
•
•
•
27 new complaints were received in August, 4 were reopened
There are 41 open active complaints in total including those that have been re-opened
Of the 41 open complaints, 3 complainants were contacted to request an extension. 38 were closed
within the deadline date
Planned Care & Surgery:
•
•
•
33 complaints were received in August, 6 were re-opened
There are 50 open and active complaints in total
All complaint responses were within the deadline of responding to the complainant
Diagnostics and Rehabilitation:
•
•
•
12 complaints were received in August, 3 were re-opened
There are 29 open and active complaints in total including reopened
There are no complaints open beyond their deadline date.
10
Corporate / Central Services:
•
•
•
4 complaints were received in August 2013 and 2 reopened
There are 6 open and active complaints in total including reopened
There are no complaints open beyond their deadline date.
Overall this is an excellent and much improved position. Of the 176 complaints received from 1st April 2013,
only 3 have been sent holding letters and their responses have now been actioned.
6.1.2 Ombudsman
We currently have 4 active Ombudsman cases. Twelve further complainants have gone to the Ombudsman
and we are awaiting feedback as to whether these will be put forward for investigation.
6.1.3 Themes and Learning
Themes are reported within the Trust Quarterly Quality Report. This will be presented in November 2013.
A significant change we have introduced over the last few months is to visit complainants within their own
homes. This enables the complainant to talk through their concerns in the comfort of their own home and
the complaint is solved there and then.
One of the nurses who regularly undertakes this task along with her deputy said:
Home visits allow me to experience the emotion of the patient/family member. It allows them to share their
experience in a safe environment and they see how upset it makes me and my deputy feel. It also allows
us to see the distress we have caused as an organisation and to take the emotion back to our teams.
Words on paper just do not make a difference to them or me. I need to feel what they feel and they need to
know the person who is listening to them cares and more importantly is going to do something about it.
Every complainant / patient I have visited at home I have resolved their concerns. The complainant / patient
always say they appreciate that someone has taken the time and someone cares!
This approach can mean a much better patient experience and an improved outcome for all concerned.
Examples of specific actions in relation to some selected complaints are being tracked by the complaints
team. Three examples of lessons learnt are outlined below:
Complaint
Action Taken
No food or drink was provided in the The introduction of patient care and comfort rounds within ED,
Emergency Department
which ideally are undertaken by the nursing staff to ensure that
all patients are comfortable and any questions answered. The
rounds will ensure that patient’s needs are met.
Doctor's attitude
The specific doctor responded that they will be voluntarily
undertaking a formal patient and staff feedback survey, in order
to identify whether there are any common or reoccurring
concerns regarding their communication skills which can be
improved upon.
Concerns regarding the appointments As part of our new approach to managing outpatient
system
appointments we have also introduced a system whereby
consultants can review results and if all is well write to the
patient and their GP to advise of this. This then avoids the
need for some patients to attend where it is not clinically
necessary (to be physically present) freeing up appointments
for those patients who do need to attend.'
11
6.1.4 Sustainability of Complaints Performance
Complaints performance has been excellent. Performance is monitored daily and individual response
times monitored and tracked weekly by the Director of Nursing. A new redesigned complaints process has
been finalised and is currently being consulted upon within the Clinical Divisions. Barnsley NHS FT have
been invited to review our proposed new process and to advice on ‘ward to board’ patient experience
measures, as well as evidence of ‘lessons learnt’.
6.2
Friends & Family Test
The Trust continues to meet national CQUIN requirements and perform well in the Friends and Family test.
The organisation is currently required to ensure 15% inpatients and A & E attendances respond to the
questionnaire. In August 2013 we continue to meet this with a response rate of 17%.
Our friends of family scores in August were 4.6 starts out of 5. Analysis of comments will be included within
the November Quarterly Quality Report
Best performing wards
Score
Score
5
Lowest performing
wards
Ward 52
Ward 54
Ward 44
5
Ward 24
4.5
Ward 43
4.9
A&E
4.4
4.6
Maternity Services are preparing to implement the family & friends tests to commence in October 2013.
6.3
National Maternity Survey
The 2013 National Maternity survey has been undertaken by Quality Health for our Trust. We received our
initial report on the 10th September with a 44% response rate compared to 45% nationally. There were a
total of 76 questions to respond to which covered all aspects of pregnancy care and some demographic
data. The initial report show us how we have compared with the 2010 survey (where applicable) and with
other Maternity Hospital trusts that that were surveyed. The full Management Report will be available within
one month, containing an analysis of all the data and national trends.
6.4
PLACE (Patient Led Assessment of the Care Environment) audits
Results from the new Patient-led Assessments of the Care Environment (PLACE) published by the Health
and Social Care Information Centre show the Trust scored an impressive 99.31% for cleanliness, 86.68%
for food and hydration, 92.74% for privacy, dignity and wellbeing, and 93.75% for condition, appearance
and maintenance.
These results, combined for King’s Mill, Mansfield Community and Newark hospitals, are well above the
national averages of 95.74%, 84.98%, 88.87% and 88.75% respectively.
Several of the patient representatives who undertook the inspection visits are members of the PLACE
Steering Group and progress has been made to introduce improvements in several areas, notably in the
Emergency Department where actions have been taken in relation to the environment and cleanliness.
12
7.0 Healthcare Associated Infection
Sherwood Forest Trust is working very hard to tackle health care associated infections, but Hospitalassociated infections (HCAI) still present us with a great challenge. As a part of HCAI prevention and
control strategy the Trust has participated in the national mandatory surveillance for MRSA & MSSA
bacteraemia, E.coli bacteraemia and C.difficile infection. This report provides a overview of the current
situation in regards to these infections at the SFH Trust and also a brief comparison with the neighbouring
trusts in the East Midland region.
7.1
C.difficile Infection
As of 23rd September 2013, the Trust has identified 17 cases of Trust acquired C. difficile infection against
a year to date trajectory of 13 cases. Discussions are still underway with the Public Health England (which
replaced the Health Protection Agency in April 2013) and the commissioners in relation to the inherited
case in June 2013.
Root cause analysis of all these cases hasn’t suggested any issue with cross-infection. Most of these are
sporadic cases. Review of the Hospital Antibiotic Prudent Prescribing Indicators (HAPPI) audit has not
highlighted any concerning issues regarding the inappropriate antibiotic usage of antibiotics. We are
planning to undertake further investigations and an independent external review.
Actions instigated:
•
•
•
•
Implementation of SIGHT poster in clinical areas
Implementation of a ‘check list’ for clinical staff providing care to systematic patients
Implementation of ‘RAG’ infection clean level regime (including posters, training)
Aerosol hydrogen peroxide environment decontamination system is used at present by the Trust –
plan to review the appropriateness of moving to a hydrogen peroxide vapour environment
decontamination system
Chart 1: C. difficile infection cases against average reduction target April 2013
13
Chart 2: Number of C. difficile infection processed at Sherwood Forest Hospitals NHS Foundation Trust
split by ‘Trust apportioned’ cases and ‘All other’ cases by quarter from April 2009 to June 2013
Chart 3: Number of cases of Clostridium difficile infection in patients aged 2 years and above, split by
‘Trust apportioned’ and ‘All other cases’ processed by each Trust laboratory, by quarter from April 2010 –
June 2013
14
Table 1: Quarterly laboratory returns for Clostridium difficile testing for each of the Trusts in the East
Midlands, from April – June 2013. The table includes monthly Clostridium difficile infection numbers taken
from the HCAI Data Capture System, as there are some differences between those figures provided for
monthly mandatory surveillance and the quarterly laboratory returns
7.2
MRSA Bacteraemia:
As of 23rd of September, there has been three new cases of MRSA bacteraemia since April 2013. The
post infection review for the two cases has already been completed and is being completed for the third
case. We have requested Professor Brian Duerden, retired Microbiology Inspector for DoH, to carry a
thorough external review on the back drop of these cases. (Date to be confirmed). An internal review
team has been assembled and will be following the format highlighted in Appendix 1.
Actions• Monthly audits to be undertaken by the Infection Prevention and Control Team on key themes,
reports and actions plans to be presented to HCAI Forum
•
Review and update the Clinical Assessment packs for Naseptin-Bactroban-Chlorhexidine
•
Review the use of ChorPrep for skin preparation prior to venous cannulation
•
Regular unannounced visits to various clinical area by the internal team to observe the infection
control practices.
15
Chart 4: Monthly counts of MRSA bacteraemia (Trust acquired) since April 2010
Chart 5: Number of MRSA bacteraemia processed at Sherwood Forest Hospitals NHS Foundation Trust
split by Trust apportioned case and ‘all other’ cases by quarter from April 2009 to June 2013
Chart 6: Number of cases of MRSA bacteraemia processed by each Trust laboratory in the East Midlands,
by quarter, April 2010 to June 2013 split by ‘Trust apportioned’ and ‘All other’
16
7.3
MSSA Bacteraemia
As of 23rd September 2013, the Trust has identified 7 cases of Trust acquired MSSA bacteraemia. There is
no set national trajectory for MSSA bacteraemia .
Chart 7: Number of cases of MSSA bacteraemia processed by each Trust laboratory in the East Midlands,
by quarter, January 2011 to June 2013 split by ‘Trust apportioned’ and ‘All other cases’
7.4
E. coli Bacteraemia
As of 23rd September 2013, the Trust has identified 15 cases of Trust acquired E. coli bacteraemia.
There is no set national trajectory for E. coli bacteraemia .
Chart 8: Number of E. coli bacteraemia (All cases) processed by each Trust laboratory in the East
Midlands, per quarter from July 2011 to June 2013
17
8.
Care Quality Commission (CQC)
Following the Sir Bruce Keogh Review in June 2013, the Care Quality Commission undertook an inspection
visit. The Trust has recently received the final report (Appendix 2). Inspectors assessed eight of the
national standards of quality and safety at the hospital and found only three were being met. The
standards not being met at the trust related to; the care and welfare of people who use services, meeting
nutritional needs, staffing, assessing and monitoring the quality of service provision and complaints. As a
result of the inspection, CQC has issued a formal warning to the trust in relation to the national standard
relating to ‘assessing and monitoring the quality of service provision’. Recently the trust was placed in
special measures by Monitor following Sir Bruce Keogh’s review of hospitals with high mortality rates.
As the CQC inspection took place a week after the review by Sir Bruce Keogh’s team, similar concerns
have been highlighted, although some further areas for improvement have been advised. As a
consequence of the Keogh review the Trust has implemented many improvement actions (e.g. hydration
training, care and comfort rounds, NEWS policy, additional nurses on night duty and red tray and red jug
guidance). The Keogh action plan will be adjusted to ensure all the findings within the CQC report are
addressed.
9.
Implementation of Care & Comfort Rounds
In September 2013 ‘Care and Comfort Rounds’ were launched at
SFH. The implementation of care and comfort rounds is aimed at
creating a safer hospital environment and also aims to reduce
patient harm by proactively checking patients. All patients admitted
to SFH will have a minimum schedule for care and comfort rounds of
hourly visits between the hours of 08:00 – 22:00 and two hourly
between the hours of 22:00 – 08:00 - we do not wake patients if they
are sleeping.
It is expected that a registered nurse visits the patient every
alternate hour after receiving patient hand-over and taking
accountability for their patient’s care. They will routinely check ‘the 4
P’s’ during each visit.
A key component of the approach is for ward leaders to complete a daily leadership round to ensure
compliance with care and comfort rounds, utilising appreciative enquiry and a leadership rounding log. This
involves speaking to patients and relatives to understand if their needs are being met. Any compliments
about staff members are displayed on a staff recognition board.
We now have 11 wards participating in care and comfort rounds all of which are seeing improvements in
compliance with documentation and patient experience. All wards will have adopted this approach by 28th
October 2013.
10. Summary of Discussions at Clinical Governance and Quality Committee
This report summarises the discussions and decisions made, and the assurances received at the Clinical
Governance and Quality Committee (CGQC) held on September 26th 2013.
Present
Peter Marks
Susan Bowler
Gerry McSorley
Claire Ward
-
Non-Executive Director (Chair)
Executive Director of Nursing and Quality
Non-Executive Director
Non-Executive Director
18
In Attendance
Sarah Banks
-
Karen Fisher
Julie Fottles
-
Nigel Nice
Lee Radford
-
Sally Seeley
Fran Steele
Dr Simon Stinchcombe
-
Jacqui Tufnell
-
Assistant Nurse Director for Compliance (CQC
Inspection Report item only)
Director of Human Resources
Pathology Quality Manager (External Regulatory
Body Requirements in Pathology item only)
Public Governor
Head of Training, Education and Development
(Mandatory Training update item only)
Head of Governance (Interim)
Chief Finance Officer
Assistant Medical Director – Patient Safety (Mortality
and Coding item only)
Executive Director of Operations
Mandatory Training Update
A paper was presented to the Committee summarising the Trusts mandatory training requirements, the
current position and challenges to compliance. It was noted that the DNA (did not attend) rate for training
courses was significant and this was further increasing pressure on capacity. The Committee supported
the recommendations made within the paper and requested that further discussions took place in relation to
the approach for those staff for whom incremental pay progression does not apply.
The Committee noted the work that had been undertaken and the improvements in compliance rates and
requested that an update paper was presented in three months.
Disclosure and Baring Service Checks Update
The Committee confirmed that the interim update had been provided to members by 5 September 2013 as
requested. They received a further paper which demonstrated significant progress, reduced the number of
staff requiring DBS checks to two and stated that the outstanding information for these individuals would be
received by Monday 30 September 2013. The Committee noted the significant progress that had been
made and thanked the staff involved. They requested that verbal confirmation at the next meeting that there
zero staff remain outstanding.
CQC Inspection Report and Warning Notice
Confirmation was provided that the inspection report had been published on 25 Sept 2013 and that the
action plan in response had been sent to CQC within the timescales required. The Committee were asked
to note that as a significant number of the actions in the inspection report mirrored those required from the
Keogh review which has its own action plan, it had been agreed with CQC that the two action plans should
be linked. Members were provided with a copy of the action plan sent to CQC which reflected this
approach.
It was reported that an internal action plan had also been developed and shared with the clinical divisions
and would be led via the Clinical Management Team. The warning notice in relation to outcome 16 was
also discussed and the Committee expressed their concern about the implications of this for the Trust. It
was requested that this was discussed at the Board of Directors.
External Regulatory Body Requirements in Pathology
This paper was prepared in response to a request from members at a previous meeting for an
understanding of how the Trust assures itself of current and future compliance with external regulatory
requirements. The paper presented provided details of the current position and a summary of assessments
and actions. The Committee noted that the organisation was currently compliant against all requirements
including the Blood Safety and Quality regulations, Clinical Pathology Accreditation (CPA) and the Human
19
Tissue Act and that a new process for monitoring compliance (including key performance indicators which
were scrutinised at the Divisional Clinical Governance) had been introduced. The Committee confirmed that
they were assured by the comprehensive information presented and the oversight at Divisional level and
requested that they received updates by exception as required.
Terms of Reference
An updated version of the Committees Terms of Reference were received and discussed in detail. The
Committee requested that minor amendments were made to the Terms of Reference, that clarity was
sought on a number of points from the Director of Corporate Services and that they were submitted to the
Board of Directors for approval at the same time as the Terms of Reference for other sub-committees of the
Board of Directors to ensure consistency.
Serious Incident Log
This was presented to the Committee in the revised format as requested at the previous meeting. Members
agreed that there had been a significant improvement but that further refinements were required to provide
assurances about themes and lessons learned. Each incident was reviewed in detail and as a result of the
discussion in relation to one particular incident the Committee requested an update from the electronic
reporting project group at the November meeting. The Committee noted that a paper to supplement the
serious incident log, detailing themes, trends and actions would also be received when the next update was
provided.
Mortality and coding update
The Committee received two progress reports in these areas. The mortality report showed that between
January and May 2013 there had been a reduction in HSMR with adjusted mortality for all in patient deaths
of 106, which is now within expected range and no longer the worst in the East Midlands. Information was
also provided which showed that in the five key diagnosis groups identified for improvements because of
concerns about adjusted mortality rates; four had made or maintained these improvements. The
Committee were informed that there was confidence that this was related to improvements in care, notably
the improving sepsis programme and introduction of National Early Warning Scores (NEWS) rather than
improvements in coding.
The Committee also received a report on coding which had been escalated from the Clinical Management
Team. This highlighted concerns that the Trust may not be able to meet three national coding deadline
targets. It was noted that recruitment of coders had been difficult and although four appointments had been
made a period of training would be required. The Committee were concerned that if the expected benefits
of the appointments were not realised in December 2013 this could jeopardise achievement of the
trajectories for improvement that have been agreed with commissioners. It was noted that as this was an
area of concern it should be escalated to the Board of Directors.
Other items received included:
•
•
•
•
•
Infection Prevention and Control
Progress against milestones on the Keogh Action Plan
Progress against milestones on the Price Waterhouse Cooper Work Plan
Feedback from Clinical Management Team
Partial Booking Update
Summary prepared by Sally Seeley, Head of Governance (Interim) and Peter Marks, Chair of the Clinical
Governance & Quality Committee.
20
Appendix 1
Ward:
Date:
Check list for internal infection prevention and control observational review: four key
areas to be reviewed during observation period
Standard
Comments
Venous catheter/line management: Observe 10 instances of central line maintenance in the time period
Hands are decontaminated prior to touching the patient or their bed space
Gloves are put on just prior to touching the line/catheter – other task are not
completed prior to touching the line/catheter/dressing
Daily review of line necessity documented, along with regular VIP (min 4hly)
Dressing is intact, clean and dry
Dedicated lumen for TPN
ANTT is used for all IV administration (gloves and aprons are worn) from start to
finish (i.e. drawing up the medication to the administration)
Hand hygiene: Observe 10 instance of hand hygiene using 5 moments
Moment 1: before touching a patient
Moment 2: before clean/aseptic procedures
Moment 3: after body fluid exposure/risk
Moment 4: after touching a patient
Moment 5: after touching patient surroundings
Alcohol based hand rubs are readily available
Staff are adhering to the bare below the elbow principles
Personal Protective Equipment (PPE): Observe 10 instances of use of PPE
Hands are decontaminated after removing PPE
PPE is removed prior to leaving the bed space (i.e. staff are not walking
around the area wearing PPE)
PPE are don just prior to commencing the task were PPE is required
Gloves are worn as a ‘single use item’ i.e. staff do not wear the same pair of
gloves for several task i.e. touching the care notes then processing to
administrate IV medication
Gloves are observed to be worn for invasive procedures, contact with sterile
sites, contact with mucous membranes
Disposable aprons are worn as single use items for each clinical procedure
or episode of patient care
Disposable aprons are worn when there is a risk that clothing or uniform may
become exposed to body fluids
Respiratory protective equipment is used i.e. when clinically required
21
Environment: 15 steps. What was your impression as you entered the clinical area? Observe environment
during the observation period
Entrance/reception to the area is clean and tidy and free from clutter
The clinical areas is clean, tidy and free from clutter (first impression)
Cleaning of dedicated patient equipment is undertaken
Used and infected linen is not left in the bed space i.e. it is not left on the
floor but removed
Doors are closed i.e. ward entrance, rooms used for isolation care, storage
ages
Floor is clear of items, outside shipping containers
Linen cart is has a cover which is used when not collecting linen
Isolation rooms, appropriate sign displayed, door closed, linen not stored
within (used or clean) staff are wearing PPE when entering and removing
prior to leaving
Review Undertaken By:
Date:
Summary:
Discussed With:
22
Sherwood Forest Hospitals NHS Foundation Trust
Response to CQC Inspection Report – September 2013
Page
Judgment
Reasons for CQC Judgment
No.
Care and Welfare of people who use service – Outcome 4
6
Minor
Impact
Exec
Sponsor
Date of
Completion
Mouth Care is addressed through the Nutritional and
Hydration task force see Keogh Action K3 – fluid
management and Hydration
29.07.13
Director of
Operations
Divisional
Management
Teams
Patient locations, tracking and moves addressed
through Keogh action plan K8a-8e
30.09.13
Director of
Operations
Clinical
Director of D
& R Division
Radiology backlog addressed through Keogh action
plan K13a-13d.
st
Backlog cleared by 31 July 2013
31.07.13
Director of
Nursing
Assistant
Nurse Director
and Patient
Safety Lead
Fluid Management and Nutrition addressed through
Keogh action plans K3a-K3b
25.08.13
Director of
HR
Director of
Nursing
Addressed through Keogh Action K2a and K2c.
Report to Trust Board regarding nursing staffing
requirements and establishment
Director of
Nursing
•
a high number of patients on wards that
were not on the specialty ward specific to
their condition
a backlog of x-rays and scans which required
reporting
Meeting Nutritional Needs – Outcome 5
Moderate
Patients were not fully supported to be able to
Impact
eat and drink sufficient amounts to meet their
9
needs.
SFHFT Response Action
Deputy
Director of
Nursing
Issues included the prevention and management
of:
• poor mouth care,
•
Outcome
Lead
Staffing – Outcome 13
16
Moderate
Impact
There were not enough qualified, skilled and
experienced staff to meet people's needs
……. It's directly impacted on patients because
we're not getting to buzzers quickly enough……….
We did not see any evidence of an overarching
medical workforce strategy.
Director of
Nursing
Director of
HR
Deputy
Director of
Nursing
Medical
Director
Page 1 of 1
05.10.13
Audit of buzzer times undertaken as part of Keogh
Action K10c
05.08.13
Intentional Rounding/Care and Comfort rounds are
being implemented through Keogh action K2b.
A workforce strategy is being developed under
Keogh action K4a for submission to the Trust Board.
Sept 13
Nov 13
27
Dec 13
The trust had built up a significant backlog of
complaints. We were told that this issue had
been caused by a lack of sufficient staff. The trust
told us that there were plans in place to address
this staffing issue.
Director of
Nursing
Head of
Governance
Addressed through Keogh Action K1 and also see
CQC response – complaints outcome 17.
Oct 13
The trust had a significant backlog of x-rays and
CT scans to be reported on. We were told that
this issue had been caused by a lack of sufficient
staff. The trust told us that there were plans in
place to address this staffing issue.
Director of
Operations
Clinical
Director of D
& R Division
Addressed through Keogh Action K13a and also see
CQC response – Care and Welfare of people who use
the service – Outcome 4
July 13
Staff told us that there was a significant backlog
in post-appointment letters being sent from the
hospital to GPs. We were told that this issue had
been caused by a lack of sufficient staff. The
provider told us that plans were in place to
address this staffing issue
Director of
Operations
Divisional
Management
Teams
Addressed through Keogh Action K13e and K13f
July 13
2 Housekeepers appointed
Revised cleaning routines have been agreed
between Medirest and the Emergency dept and
implemented.
Sept 13
31.10.13
We noted concerns with the level of cleanliness
in the Emergency Department. Cleaning staff
told us there were insufficient staff to keep the
department clean. We saw that there were plans
in place to address this issue
Assessing and monitoring the quality of services provision – Outcome 16
The provider did not have an effective system to
Moderate
regularly assess and monitor the quality of
23
Impact –
service that patients received.
Enforcement
Action
Complaints –Outcome 17
Moderate
Impact
Development of the OD strategy is in process and
addressed through Keogh action K4a and is to be
submitted to Trust Board
The provider did not have an effective
complaints system.
Director of
Operations
Service
Director and
Lead Nurse for
ED
CEO
Executive
Team
Implementation of the PWC action plan to be in
place 31.10.13.
Director of
Nursing
Head of
Governance
The Complaints system and process is being
addressed through Keogh action K1.
Complaints backlog cleared.
Page 2 of 2
31.07.13
Inspection Report
We are the regulator: Our job is to check whether hospitals, care homes and care
services are meeting essential standards.
Kings Mill Hospital
Mansfield Road, Sutton In Ashfield, NG17 4JL
Tel: 01623622515
Date of Inspections:
Date of Publication:
September 2013
18 July 2013
17 July 2013
10 July 2013
09 July 2013
08 July 2013
26 June 2013
We inspected the following standards in response to concerns that standards weren't
being met. This is what we found:
Care and welfare of people who use services
Action needed
Meeting nutritional needs
Action needed
Cooperating with other providers
Met this standard
Cleanliness and infection control
Met this standard
Staffing
Action needed
Supporting workers
Met this standard
Assessing and monitoring the quality of service
provision
Enforcement action
taken
Complaints
Action needed
| Inspection Report | Kings Mill Hospital | September 2013
www.cqc.org.uk
1
Details about this location
Registered Provider
Sherwood Forest Hospitals NHS Foundation Trust
Overview of the
service
King's Mill Hospital is a location of Sherwood Forest
Hospitals NHS Foundation Trust. It provides emergency,
medical, surgical, paediatric, obstetric and gynaecological
services.
The trust is registered with the Care Quality Commission for
the following regulated activities at Kings Mill Hospital:
treatment of disease, disorder or injury, surgical procedures,
diagnostic or screening procedures, maternity and midwifery
services, termination of pregnancies, nursing care and family
planning.
Type of services
Acute services with overnight beds
Community healthcare service
Diagnostic and/or screening service
Regulated activities
Diagnostic and screening procedures
Family planning
Management of supply of blood and blood derived products
Maternity and midwifery services
Nursing care
Surgical procedures
Termination of pregnancies
Treatment of disease, disorder or injury
| Inspection Report | Kings Mill Hospital | September 2013
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2
Contents
When you read this report, you may find it useful to read the sections towards the back
called 'About CQC inspections' and 'How we define our judgements'.
Page
Summary of this inspection:
Why we carried out this inspection
4
How we carried out this inspection
4
What people told us and what we found
4
What we have told the provider to do
5
More information about the provider
5
Our judgements for each standard inspected:
Care and welfare of people who use services
6
Meeting nutritional needs
9
Cooperating with other providers
11
Cleanliness and infection control
14
Staffing
16
Supporting workers
20
Assessing and monitoring the quality of service provision
23
Complaints
27
Information primarily for the provider:
Action we have told the provider to take
30
Enforcement action we have taken
32
About CQC Inspections
33
How we define our judgements
34
Glossary of terms we use in this report
36
Contact us
38
| Inspection Report | Kings Mill Hospital | September 2013
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3
Summary of this inspection
Why we carried out this inspection
We carried out this inspection in response to concerns that one or more of the essential
standards of quality and safety were not being met.
This was an unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service,
carried out a visit on 26 June 2013, 8 July 2013, 9 July 2013, 10 July 2013, 17 July 2013
and 18 July 2013, observed how people were being cared for and checked how people
were cared for at each stage of their treatment and care. We talked with people who use
the service, talked with carers and / or family members, talked with staff and reviewed
information given to us by the provider. We reviewed information sent to us by other
regulators or the Department of Health, talked with other regulators or the Department of
Health and were accompanied by a specialist advisor.
We were supported on this inspection by an expert-by-experience. This is a person who
has personal experience of using or caring for someone who uses this type of care
service.
What people told us and what we found
We visited the Emergency Department and sixteen wards during the inspection. We spoke
with 75 patients, four relatives and approximately 100 staff. We looked at approximately 20
patient records.
Almost all patients were happy with their overall experience within the hospital. Patients
were generally positive about the quality of food provided and felt sufficient drinks were
available. They were positive about discharge processes and were generally positive
about the cleanliness of the hospital.
Patients gave us mixed feedback regarding whether staffing levels were sufficient.
Patients felt safe and trusted the staff to carry out their care. Patients did not know how to
provide feedback to the trust and most of those patients that we asked about the
complaints system were not aware of it.
We found that care and treatment was not always delivered in a way that ensured patients'
safety and welfare. Patients were not fully protected from the risks of inadequate nutrition
and dehydration. However, patients' health, safety and welfare were protected when more
than one provider was involved in their care and treatment, or when they moved between
different services.
We found that patients were protected from the risk of infection because appropriate
guidance had been followed. We also found that patients were cared for by staff who were
supported to deliver care and treatment safely and to an appropriate standard. However,
there were not enough qualified, skilled and experienced staff to meet people's needs.
| Inspection Report | Kings Mill Hospital | September 2013
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4
We also found that the provider did not have an effective system to regularly assess and
monitor the quality of service that people receive. The provider also did not have an
effective complaints system.
You can see our judgements on the front page of this report.
What we have told the provider to do
We have asked the provider to send us a report by 25 September 2013, setting out the
action they will take to meet the standards. We will check to make sure that this action is
taken.
We have taken enforcement action against Kings Mill Hospital to protect the health, safety
and welfare of people using this service.
Where providers are not meeting essential standards, we have a range of enforcement
powers we can use to protect the health, safety and welfare of people who use this service
(and others, where appropriate). When we propose to take enforcement action, our
decision is open to challenge by the provider through a variety of internal and external
appeal processes. We will publish a further report on any action we take.
More information about the provider
Please see our website www.cqc.org.uk for more information, including our most recent
judgements against the essential standards. You can contact us using the telephone
number on the back of the report if you have additional questions.
There is a glossary at the back of this report which has definitions for words and phrases
we use in the report.
| Inspection Report | Kings Mill Hospital | September 2013
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5
Our judgements for each standard inspected
Care and welfare of people who use services
Action needed
People should get safe and appropriate care that meets their needs and supports
their rights
Our judgement
The provider was not meeting this standard.
Care and treatment was not always delivered in a way that ensured patients' safety and
welfare.
We have judged that this has a minor impact on people who use the service, and have told
the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
Care and treatment was not always delivered in a way that ensured patients' safety and
welfare.
We inspected this standard due to information received regarding the quality of care
provided at the hospital. Issues included the prevention and management of pressure
ulcers, poor mouth care, a high number of patients on wards that were not on the specialty
ward specific to their condition and a backlog of x-rays and scans which required reporting
on.
Almost all patients were happy with their overall experience within the hospital. A patient
said, "Very good so far, they can't do enough for you." Another patient said, "I had to have
an emergency pacemaker fitted, everything was explained to me, everyone was very
helpful, my treatment was excellent." Another patient said, "You hear bad things about this
hospital but I haven't found them, I have been really well looked after."
We saw that the provider's friends and family test current average score was 4.7 out of a 5
star rating indicating that patients were generally happy with the care they were receiving.
We also saw the results of the provider's outpatient survey dated June 2013 showed that
patients were happy with a range of indicators with 98 of 101 patients likely or extremely
likely to recommend the trust to their family or friends.
We observed care both on the wards and in the Emergency Department. We saw that staff
generally supported patients in a caring and appropriate manner.
We looked at the pressure area care provided for three patients. All had pressure ulcer risk
assessments and appropriate plans of care in place. Staff said they could get access to
pressure relieving equipment when they needed it. We were also told that the trust had
| Inspection Report | Kings Mill Hospital | September 2013
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6
employed a tissue viability nurse consultant to address pressure area care issues.
However, we saw some examples of care that did not meet patients' needs.
We saw four patients for whom mouth care was not being provided appropriately. This
meant that patients' needs were not always being met.
We saw one patient in the emergency department who was sitting in a chair. We saw that
the patient's catheter was not correctly positioned to ensure effective drainage of urine.
We also saw the catheter bag had been left on the floor. We raised this issue with the
nurse in charge and they addressed this immediately.
We looked at the care being provided for patients who were not on the appropriate
specialty ward for their condition (outlying patients). The hospital had developed a system
to ensure continuing responsibility for medical patients on the non-medical ward, however,
junior doctors were not aware of any system for identifying those patients who were
outliers requiring review, other than visiting these wards daily. It did not appear that there
was a routine review of all outlying patients at weekends, with outliers only reviewed if
specifically requested. This was different from all other medical wards where patients
would be routinely reviewed at the weekends.
Nursing staff told us that it could be difficult for them to identify which Consultant was in
charge of an individual patient and which junior doctor to contact when required. One
nurse described part of their role as, "having to be a good detective."
We looked at patients' care records. One patient had been an inpatient for four days, with
no evidence of a consultant review in that time. Notes made by junior doctors named three
separate consultants, whilst a fourth consultant's name was on the list of outliers supplied
to us by the trust.
Another patient had been admitted on 10 July 2013 and the next entry in the records on 14
July 2013, stated, "down on board as orthopaedic, hence not reviewed until now".
However, it was clear from looking at care records that regular and appropriate medical
reviews of outlying patients were generally taking place, although frequently later in the
day than other patients. We heard that it was routine for outlying patients to be reviewed
after lunch and often not until late afternoon, instead of in the morning as would be the
case for non-outlying patients.
The trust had a backlog of x-rays and scans that needed to be reported on by a radiologist.
We were told that the backlog had been risk assessed and had been prioritised in line with
this risk assessment. We were told that patients were safe but that some of them may
have to re-attend clinics to receive reports on MRI scans as the results would not have
been ready in time for their scheduled follow up appointment.
We saw concerns had been raised by patients regarding the backlog. A Patient Advisory
Liaison Service (PALS) breakdown of concerns listed a patient concerned about a six
week delay after an x-ray for a doctor to write to them. It also listed other concerns from
patients regarding delays in reporting following diagnostic scans.
We were told during our inspection that the trust was carrying out an internal review of this
backlog and had plans in place to reduce the backlog. We saw evidence that the backlog
was reducing and we talked with the Clinical Commissioning Group who were also
| Inspection Report | Kings Mill Hospital | September 2013
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7
monitoring the trust's progress to reduce the backlog. There was no evidence to suggest
that patients had suffered actual harm as a result of this backlog at the time of the
inspection but it was clear that there was a potential risk and some patients had been
concerned regarding the delays.
| Inspection Report | Kings Mill Hospital | September 2013
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8
Meeting nutritional needs
Action needed
Food and drink should meet people's individual dietary needs
Our judgement
The provider was not meeting this standard.
Patients were not fully protected from the risks of inadequate nutrition and dehydration.
We have judged that this has a moderate impact on people who use the service, and have
told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
Patients were not fully supported to be able to eat and drink sufficient amounts to meet
their needs.
We inspected this standard due to information received regarding nutritional risk
assessments, poor fluid recording and inconsistent implementation of procedures to
support people at risk of hydration or nutrition concerns.
Patients were generally positive about the quality of food provided and felt sufficient drinks
were available. One patient said, "Can't believe how good the food is, very tasty." Another
patient said, "There is always plenty to drink. You can have anything you want, tea, water,
juice." One patient with diabetes said, "Plenty of choice, more for diabetics including
puddings."
Staff told us there was a red tray system in place to identify patients whose diet intake
needed recording. They also told us there was a red jug system in place to identify
patients who required extra encouragement to drink and the need for staff to record fluid
balance. Staff were able to describe the risk assessments and documentation that they
were required to complete and the support that they provided for patients to eat and drink
sufficient amounts to meet their needs.
However, staff told us that there was no hydration policy or effective red tray or red jug
guidance. We were also told that issues had been identified regarding the completion of
nutritional risk assessments and fluid balance documentation. We were told that formal
training on nutrition had been undertaken by both registered and non registered staff. The
training was included in the care, compassion and dignity training. Additional training also
took place in clinical areas and was undertaken by the nutritional specialist nurse. One
member of staff said, "We could do with more training on documentation and fluid charts,
for example, for new starters and healthcare assistants."
We observed mealtimes and we saw that a large print and pictorial menu was in use on
the wards. It clearly identified vegan, vegetarian, healthy choices, gluten free and high
calories meals. On one ward, we saw that patients requiring assistance were given their
| Inspection Report | Kings Mill Hospital | September 2013
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9
meals first to enable staff to be fully engaged with the particular patient they were helping.
We also saw staff encouraging patients to eat more food when they were nutritionally at
risk and observed a member of staff ensuring that a patient's denture was clean and in
place before supporting them to eat.
However, we observed some concerns regarding this standard.
We observed a patient in a side room on one ward. The patient had been left with a
plastic apron on and was asleep. They had not eaten any of their lunch and the way they
were positioned suggested they would not have been able to eat their lunch. We raised
this with a senior member of staff on the ward. They said that more was needed to be
done to identify those patients who were on the borderline of needing help with eating and
drinking. Ward staff confirmed this patient had also not eaten any breakfast.
We observed one patient who had not eaten their lunch. They said, "I've been in three
weeks and my appetite is poor." We looked at this patient's records and saw there was no
care plan in place for their poor appetite nor had there been any monitoring of their food
intake. The person had a urinary catheter. We saw there were fluid balance charts in
place. The chart dated 6 July 2013 had not been completed and the chart dated 7 July
2013 had been completed but the total input and output had not been calculated.
We found several examples of patients who had fluid balance charts in place but their
input and output had not been calculated. This meant people were at risk of fluid
imbalance not being identified.
We observed that use of the red jug system was inconsistent. Red jugs were in place for
people who were not at risk on some wards and not in place for people at risk on other
wards. Staff were not always clear about the purpose of the red jugs.
We had to escalate an issue to senior management regarding a patient whose nutritional
risk assessment had not been reviewed despite them not eating and drinking for two days.
A referral to a dietician had also not been made.
We also saw incorrect nutritional risk assessments, nutritional risk assessments which
were not always reviewed regularly and that food and fluid charts were not always
accurately completed. We also saw that a nutrition care plan was not in place for one
patient where required. Staff were not able, in all cases, to confirm whether or not a
dietician referral had been made where appropriate. This meant that effective systems
were not in place to ensure that people were protected from the risks of inadequate
nutrition and hydration.
We saw that audits were taking place regarding this standard. One audit seen stated that
reviews of nutritional assessments were not always taking place. We also saw a briefing
paper completed by the member of staff appointed as the guardian of this outcome in May
2013 (which is the trust's method of monitoring compliance with the Health and Social
Care Act 2008). Their paper stated that there had been 15 visits since September 2012
and concluded '…we are still not meeting the standard completely.'
| Inspection Report | Kings Mill Hospital | September 2013
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10
Cooperating with other providers
Met this standard
People should get safe and coordinated care when they move between different
services
Our judgement
The provider was meeting this standard.
Patients' health, safety and welfare were protected when more than one provider was
involved in their care and treatment, or when they moved between different services. This
was because the provider worked in co-operation with others.
Reasons for our judgement
Patients' health, safety and welfare were protected when more than one provider was
involved in their care and treatment, or when they moved between different services. This
was because the provider worked in co-operation with others.
We inspected this standard due to information received regarding discharges from the
hospital, ambulance turnaround times, insufficient handover times for staff and the
timeliness of letters being sent to GPs following outpatient appointments.
We spoke with four patients who were either awaiting discharge that day or were ready to
leave hospital once support was put in place. They all told us they had been informed of
discharge in an appropriate time frame. Two patients required extra help once home and
both had seen a social worker to discuss setting up or in one case re-starting domiciliary
care. One patient said, "I have carers at home and they are setting that back up for me
then I will be off."
We spoke with 14 patients in outpatient clinics. We did not receive any negative comments
about their discharge arrangements from those patients who had been an inpatient at the
hospital and discharged home.
We spoke with three staff regarding the discharge process. Staff felt that they received
sufficient training on discharge and there was appropriate guidance in place to support the
discharge process. Staff felt that they worked well with other services including pharmacy,
medical records department and ambulance services and that the discharge process
generally worked well. One member of staff told us that a discharge had been delayed that
day because an error had been made with medication, however discharges generally
worked well.
We spoke with ambulance service staff who had arrived on a ward to collect a patient who
was being discharged. The staff were happy with the way that discharges were handled by
the hospital.
We spoke with the hospital's integrated discharge advisory team who described the
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processes in place to ensure effective discharge. They had regular contact with partners
within the health and social care community to ensure effective discharge. They also
described the training staff received to support them when discharging patients. They told
us that discharge delays and length of stays for patients were both coming down.
We saw guidance documentation on the wards to support staff when discharging a patient.
We also saw examples of staff raising issues regarding the discharge process and actions
taken to address these issues.
We looked at three patient records and saw there were discharge checklists in place to
support staff when discharging patients. The provider may find it useful to note that two of
the discharge checklists had not been completed prior to the patient being discharged.
This meant that there was a greater risk that not all actions would be completed prior to a
patient's discharge. Staff told us that checklists would be completed prior to the patient's
records being stored in the records department.
We also saw that information was available for patients regarding the discharge process
on one ward. Staff told us they were able to contact the communications department if
they required this information in different languages or formats.
We looked at ambulance turnaround times. We spoke with three staff members from East
Midlands Ambulance Service (EMAS) who regularly brought patients to the Emergency
Department. They told us, "I'd say about 80% of patients get handed over and transferred
in under 15 minutes," and, "The system works well. There's a very good separation of
ambulance patients direct to majors and resus; it's a good process. We have good
communications and it's an efficient system."
We also spoke with two staff who worked in the Emergency Department. One staff
member said, "It works pretty well, as long as we have enough physical space in the
department especially if lots of patients and EMAS staff come into the department at the
same time." Another staff member told us, "We average between 14 to 19 minutes for
patient turnaround times, it's been pretty consistent. There's usually good communications
and handover between EMAS and hospital staff."
During our inspection we tracked the progress of three patients who were brought by
ambulance into the Emergency Department. One patient was handed over and booked in
by EMAS staff in less than 15 minutes. The other two patients were handed over and
booked in within 20 minutes. This meant ambulance patients were transferred from EMAS
to the Emergency Department in a timely and controlled manner. We also saw that
ambulance handover times had been reducing over the last few months.
We looked at the handover between staff. The provider may find it useful to note that there
was mixed feedback from staff regarding nursing handover times. Some staff felt that they
needed more time to handover, others were happy with the handover process. We were
told that handover times were being reviewed as part of the nursing staffing levels review.
We looked at the medical staffing handover. We saw that there was no formal handover
meeting and there was no electronic system for documenting issues or pending jobs. The
provider may find it useful to note that medical staff did not have access to an IT system
used by nursing staff to track patients' needs and dependencies. Access to this system
may better support medical staffing handover as staff told us that the IT system accessed
by medical staffing was not always fully up to date.
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The hospital had a backlog of letters being produced following outpatient appointments.
Staff told us that there was a significant backlog in post-appointment letters being sent
from the hospital to GPs. We were told that the backlog of letters was 5,172 in June 2013
but was now down to 3,344. We were told that urgent letters were produced within
appropriate timescales and that the provider had plans in place to reduce the backlog of
letters by mid-September 2013. We were told that this had not had a serious impact on
patient care as any actions identified in the letters were acted upon prior to the final letter
being sent out. One patient described their experience from a previous clinic, "I had to
attend fracture clinic last November it was a good experience but I do know my GP did not
receive a letter until February. That does seem a long time to me."
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Cleanliness and infection control
Met this standard
People should be cared for in a clean environment and protected from the risk of
infection
Our judgement
The provider was meeting this standard.
Patients were protected from the risk of infection because appropriate guidance had been
followed.
Reasons for our judgement
There were effective systems in place to reduce the risk and spread of infection.
We inspected this standard due to information received regarding infection control
practices at the hospital.
Patients were generally positive about the cleanliness of the hospital. One patient said,
"They keep everywhere clean and tidy. They come in each day and move everything
around and keep it clean. They change the bed regularly." Another patient said, "Cleaners
have been in today and they do a good job."
Staff were able to explain the steps they took to ensure the environment was kept clean
and the risk of infection was minimised. They told us that they attended infection control
training annually.
We inspected infection control practices in seven areas of the hospital.
We found that wards were clean and appropriate infection control practices were being
followed. We saw staff demonstrated good hand hygiene when they provided care. We
saw that the arms of staff were bare below the elbows and staff used personal protective
equipment.
The provider may find it useful to note that information regarding hand hygiene and the
use of alcohol gel was not always easy to see when entering the wards. This meant that
there was a greater risk that staff, patients and visitors would not follow good infection
control practices to ensure that people were protected from the risk of infection. The
provider told us that lockable alcohol gel containers had been ordered and when received
would be placed in wards with appropriate signage to indicate their location.
The provider may also find it useful to note that there were few examples of patients
washing their hands or being provided with hand wipes at mealtimes. We also saw a
number of curtains that had not been dated when they had been fitted. This meant that
there was a greater risk that curtains would not be replaced as frequently as appropriate
and there was a greater risk that patients were not protected from the risk of infection.
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The provider may find it useful to note that we saw a number of infection control issues in
the Emergency Department. These included low level dust and debris, which included
what appeared to be blood on patient trolleys, non-separation of a clean food trolley from
dirty food trolleys and hand hygiene facilities were not all fully stocked. We also observed
that there was only one member of staff responsible for cleaning all parts of the
emergency department and they were also responsible for transferring patients to wards.
We observed that the daily cleaning checklist was not fully completed on a number of
days. These issues meant that there was a greater risk that patients were not protected
from the risk of infection.
We re-inspected the Emergency Department the following day and the issues had been
addressed. The provider may find it useful to note that some treatment couch mattresses
had deteriorated and required replacing. This meant that there was a greater risk that
patients were not protected from the risk of infection. We also saw that additional cleaning
resources were being put in place for the Emergency Department.
We saw that infection control audits took place and that infection control policies and
guidance were in place. However, the provider may find it useful to note that we saw that a
large number of infection control guidance documents had passed their review dates. We
also saw that infection control audit action plans did not always identify people responsible
for actions or timescales. This meant that there was a greater risk that infection control
guidance for staff was not up to date and that appropriate actions were not taking place to
address identified infection control concerns.
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Staffing
Action needed
There should be enough members of staff to keep people safe and meet their
health and welfare needs
Our judgement
The provider was not meeting this standard.
There were not enough qualified, skilled and experienced staff to meet people's needs.
We have judged that this has a moderate impact on people who use the service, and have
told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
There were not enough qualified, skilled and experienced staff to meet patients' needs.
We inspected this standard due to information received regarding staffing levels at the
hospital.
Patients gave us mixed feedback regarding staffing levels. Some patients told us that their
buzzers were responded to quickly, however, some patients told us this depended on how
busy the ward was.
One patient said, "Staffing levels on here are abysmal, they are rushed off their feet all the
time." Another patient said, "At 10am I was still sitting in my nightie, all I needed was some
help to get my wash things into the bathroom. There are not enough nurses to help you."
A patient's relative said, "This morning my wife rang me in tears because she could not get
any one to help her, they are so busy."
We looked at nurse and healthcare assistant (HCA) staffing levels. Many staff members
we spoke with identified a need for increased numbers of staff and a higher ratio of nurses
to healthcare assistants in order to meet patients' needs.
A member of staff said, "There are times when we could do with more qualified staff. If
there were more qualified nurses there would be greater care provision for patients. I know
that other trusts have higher qualified to healthcare assistant ratios than Kings Mill."
Another staff member said, "We don't always have the number of staff working that are on
the rota. It's directly impacted on patients because we're not getting to buzzers quickly
enough. The delays can be five to ten minutes long."
One staff member said, "We're just managing but it's not always safe for patients. The new
ward layout doesn't help either because there's a lack of visibility for patients and it's
difficult to locate staff. Patients have complained of waiting for staff and for painkillers.
We've fed back our opinions but haven't heard from trust management. It feels like we're
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being told there's 'no agency, no bank [staff available] – get on with it.'"
Another member of staff said, "We have three trained and three healthcare workers on a
shift in the day, then at night it is two and two. It is not enough to care for the patients on
this ward properly." Another staff member said, "It can be horrendous at times."
Staff on the Emergency Assessment Unit (EAU) raised concerns with us about staffing
levels. There was a heavy reliance on agency staff on this ward, and we saw that on
many shifts, 50% of the staff were made up of agency nurses. Staff told us they did not get
breaks and they were concerned about the risk to patient safety on this ward. One nurse
told us, "We cannot go on, it's terrible, nurses are crying because it's so bad on here." The
provider informed us that plans were in place to address staffing levels on the EAU,
additional posts were being advertised and a number of staff had already been recruited to
start shortly.
We saw that most of the wards contained 24 beds, 50% of which were in single rooms.
This made the observation of patients more difficult for staff. Most wards had three nurses
and three healthcare assistants on duty during the day and two nurses and two healthcare
assistants at night.
The Royal College of Nursing has produced guidance on safe nursing levels in the UK. It
stated that on older people's wards there should be one nurse for seven patients to ensure
basic safe care and one nurse for five patients for ideal care. The hospital's older people's
wards had one nurse for eight patients during the day and one nurse for 12 patients at
night.
The trust monitored ward staffing levels and used a recognised dependency tool to assess
them. The trust had identified that a number of wards were below the staffing levels
identified by the dependency tool. The trust increased the ward night time staffing levels
during our inspection. We also looked at the ratios of nurses to healthcare assistants on
the wards. The trust had a 50:50 ratio on most wards. The Royal College of Nursing
guidance states that a 65:35 ratio is recommended.
The hospital monitored a number of indicators for each ward including complaints, falls,
avoidable pressure ulcers and the completeness of documentation. This information
showed some correlation between lower staffing levels/nurse ratios and negative impacts
for patients.
We saw a position paper on ward staffing levels submitted to the board by the Director of
Nursing in May 2013. This paper stated that, 'where there has been an increase in variable
pay [money spent on agency staff] due to a reduction in established levels of staff there
appears to be a deterioration in care and safety metrics such as the number of pressure
ulcers, falls and incidents.'
We also saw that nurse staffing levels had been listed as a risk on the risk register. We
saw that the dilution of nursing skill mix had also been identified on the risk register.
We saw that the nursing care forum discussed a pressure ulcers paper in June 2013. The
minutes of the forum commented in relation to the increase in hospital acquired pressure
ulcers from January to March 2013, "The reasons for this are being investigated but … the
dilution of staffing levels, along with the use of agency staff are felt to have contributed to
this."
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We looked at a breakdown of patient incidents from 1st May to 16th July 2013 provided by
the trust identified as 'adverse events that affect staffing levels' and saw that there were 26
incidents in May, 22 in June and 4 in July.
We also looked at the trust's results in the most recent NHS Staff Survey. The report listed
one of the trust's bottom five ranking scores as 'Work pressure felt by staff'. It also stated
that the trust's scores had deteriorated since the last survey in the areas of, '% working
extra hours', '% feeling satisfied with the quality of work and patient care they are able to
deliver' and '% suffering work related stress'.
We looked at medical staffing. The hospital has 635 beds, of which 289 are designated as
acute medical with an additional 46 for the Emergency Admissions Unit. We were told that
each consultant was responsible for an average of 12 inpatient beds.
We were told that the hospital also has twelve F1 doctors and thirty at "SHO grade". F1
doctors are those who are newly qualified from medical school, SHO grade doctors are
doctors who are in the second year after qualifying from medical school. There were fifteen
specialist registrars or fellows on the middle tier rota. Specialist registrars and fellows are
doctors who have completed their first two years after qualifying from medical school. The
middle tier rota contains doctors who are of a level of seniority between junior doctors and
consultants.
There were occasional gaps in the medicine middle tier rota, but the feedback from the
junior doctors working in Medicine was that considerable effort was made to ensure that
any locum staff who came in to cross-cover had worked in the hospital previously and
generally knew the hospital and its systems. It was seen as exceptional for this not to be
the case and none of the junior doctors could recollect this happening in the recent past.
There has been considerable re-working of rotas over the last year and generally the junior
doctors welcomed the changes and felt things had improved significantly. Out of hours, a
team of doctors covered the EAU and one junior doctor covered each floor of between two
and four wards. This was felt to be much more manageable by the junior doctors and had
improved their satisfaction.
We saw that the junior doctor medical staffing rota showed that in the evening, between
5pm and 9pm, one SHO covered all of the medical wards and this is a period when a
doctor's workload can increase due to investigation results being made available and new
arrivals from the EAU may be moving to wards. This meant that there was a greater risk
that there were insufficient medical staff to meet patients' needs.
Medical staffing issues in the Emergency Department (ED) and EAU were discussed with
both the Service Lead and Medical Director. These two areas function as one unit and
there was a clear vision to increase the consultant input, but in common with many sites in
the NHS, there were significant recruitment difficulties, particularly with Acute Physicians.
At present there are seven ED Consultants and two acute physicians. The trust's target is
to have 10 ED consultants and eight acute physicians. The acute cover at the EAU is
currently supplemented by all of the general physicians participating in the rota system. A
system had developed of three shifts working through the day, with consultant cover from
8am to 10pm, seven days per week. Some of the junior medical staff reported that at times
an individual shift could be particularly busy and they were expected to stay until all
patients had been dealt with. At particularly busy periods, they felt that additional medical
input would have helped.
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While junior doctors in areas like Obstetrics and Gynaecology and Anaesthetics were
positive about their roles, we did receive some significant concerns from junior doctors in
other areas. We were told that junior doctors in medicine had had to act up inappropriately
when the more senior doctors "had gone missing." We were also told that medical ward
cover at the weekend was described as "one of the worse jobs" because insufficient
numbers of junior doctors were on duty. We raised these issues with the provider who told
us that there are two doctors of CT level and one doctor of SpR level working from
midnight for the medicine team. They also told us that each floor of the hospital has a
dedicated junior doctor from 9am to 1pm, each specialty has a consultant visit all of their
wards and there are also two junior doctors on call covering the wards during the day.
They also told us that there is a medical consultant on call at all times and present in the
hospital from 8am to 10pm at the weekend.
Junior doctors in orthopaedics told us that their role was too busy in terms of the hours
expected and number of patients they were required to cover. We were told that the rota
had the bare minimum of junior doctors on it which created a risk in the event of short
notice absence. One staff member told us that junior doctors had made mistakes because
of high workloads. It was suggested that junior doctors had failed to prescribe antibiotics
for three patients who had gone on to develop an infection following an implant. They
commented that they did not always feel supported by senior staff which had led to them
being asked to make end of life decisions on behalf of the team, despite being
uncomfortable in doing so. The provider told us that there was an orthopaedic consultant
on call for night time cover and there was also consultant involvement on Saturdays and
Sundays at the hospital.
We did not see any evidence of an overarching medical workforce strategy to plan for a
future reduction in junior doctor numbers which we were told was likely to take place. This
meant that there was a risk that the trust did not have plans in place to address potential
shortfalls in staff.
We saw a number of other areas where staffing levels had been identified as a concern.
The trust had built up a significant backlog of complaints. We were told that this issue had
been caused by a lack of sufficient staff. The trust told us that there were plans in place to
address this staffing issue.
The trust had a significant backlog of x-rays and CT scans to be reported on. We were told
that this issue had been caused by a lack of sufficient staff. The trust told us that there
were plans in place to address this staffing issue.
Staff told us that there was a significant backlog in post-appointment letters being sent
from the hospital to GPs. We were told that this issue had been caused by a lack of
sufficient staff. The provider told us that plans were in place to address this staffing issue.
We noted concerns with the level of cleanliness in the Emergency Department. Cleaning
staff told us there were insufficient staff to keep the department clean. We saw that there
were plans in place to address this staffing issue.
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Supporting workers
Met this standard
Staff should be properly trained and supervised, and have the chance to develop
and improve their skills
Our judgement
The provider was meeting this standard.
People were cared for by staff who were supported to deliver care and treatment safely
and to an appropriate standard.
Reasons for our judgement
Staff received appropriate professional development.
We inspected this standard due to information received regarding staff in the Emergency
Department reception area making decisions without having received appropriate training
or support and low staff appraisal rates.
Patients felt safe and trusted the staff to carry out their care. A patient said, "The staff are
very good, they help me to help myself, I think is important as I want to go home soon."
Another patient said, "Marvellous. Everyone has worked as a team, from A&E via the
admission ward to here. They have done a great job."
We observed the Emergency Department reception and minor injuries triage area during
our inspection. We saw that reception staff did not triage patients who presented at the
Emergency Department reception but took details and booked patients in so they could be
seen and triaged by Emergency Department nursing staff.
We spoke with two staff members in the Emergency Department reception who were both
able to describe the booking in process for patients. One staff member said, "We don't
triage any patients unless we can clearly see they've got visible injuries or chest pain. If
that's the case we speak with nursing staff straight away and highlight those patients to the
nurses. I'm happy to do that and feel I've got enough support from the nurses when that
happens."
We observed that staff in the Emergency Department reception did speak with nursing
staff if they needed additional support or advice for individual patients. This meant patients
who presented at the Emergency Department reception were booked in appropriately and
were ensured of a suitable response if additional nursing assistance was required.
The majority of nursing and care staff we spoke with felt supported by their team and line
managers.
Staff members told us, "We have a daily staff meeting in the department and a Nursing
Band 6 meeting every few months. If I can't attend, colleagues feedback after the
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meeting," and, "I've always got back up if I need it; it's a very good team. My last appraisal
gave me the opportunity to discuss training needs and any issues. As a result I'm starting
my NVQ 3 training in August." A third staff member said, "I'm able to raise concerns and
speak with my ward leader. I feel supported, valued and listened to."
However other staff we spoke with had different views. One staff member told us, "Staff
meetings and team briefs are sometimes helpful but not very often. We're unable to bring
our views to the meetings because we don't have enough time. Team meetings can be
quite negative and the team's morale is quite low at the moment. I don't feel able to go to
my ward leader but I speak with other managers instead."
Another staff member said, "I'm happy to raise issues at a ward level and discuss things
with my ward leader but I don't feel listened to by the Trust. It's alright at our ward level but
I don't feel valued by the Trust."
We found that staff members were mostly positive about the support they received at a
local level. The majority of staff felt able to discuss issues of concern within their teams
and felt that they received adequate communication from team meetings and briefs.
We also spoke with junior doctors. Junior doctors highlighted their monthly junior doctors'
forum as very positive. This is a monthly meeting with junior medical staff, Consultant staff
and administrative staff to review any issues affecting them and a forum for their ideas for
improving the clinical service. Junior doctors on the medical side mentioned that their
engagement had fed into changes to their rota which was seen as very positive. Quality of
teaching for juniors by consultants was highlighted as positive.
Junior doctors were positive about a number of specialties in the hospital. They were
positive about Obstetrics and Gynaecology, GP, Anaesthetics and ITU and raised no
concerns regarding general surgery. However, the provider may find it useful to note that
they were not positive regarding the trauma and orthopaedic rotation.
Junior doctors in Orthopaedics told us that they had raised concerns about their workload
and felt ignored. They told us they were unable to attend clinics for additional experience
and were making decisions regarding end of life decisions which they felt were not
appropriate for their level. They felt that it was difficult to access support when required,
especially when on call. They told us that the orthopaedic middle tier doctor was not
resident in the hospital overnight and would often be in clinic at Newark hospital while
being on call for Kings Mill hospital.
We spoke with a consultant in orthopaedics who felt that support was available for junior
staff if they required it. They told us that they had received concerns about levels of
support in the past so had introduced team ward rounds. They felt that end of life decisions
should not be made by very junior doctors. They felt that decisions should be made by
more senior doctors supported by consultants.
The provider told us that changes had been made regarding clinical supervision of junior
doctors at the end of 2012. Feedback was obtained from junior doctors at their forum in
February 2013 and we saw a copy of these minutes which stated, "Junior doctors present
said ... that they did feel adequately supported when dealing with general orthopaedic
patients." The minutes also state, "...it is acknowledged that with the current level of JD
[junior doctor] support the dept cannot possibly place assistance into all activities or
always support the training needs of the junior." The provider told us that this area, "...is a
work in progress."
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We saw that an annual trust staff survey was completed. The trust had taken some actions
following the last survey in 2012, when staff had raised concerns about timely
communications within the trust and appraisals for staff. The trust had also completed a
mini staff survey and intended to continue this process on a quarterly basis, with survey
results to be reported within the trust.
We looked at the training records for 11 staff members and found that most of them had
completed mandatory training or were booked on courses. We also saw that staff attended
training which was relevant to their roles, including pressure ulcer awareness and care,
compassion and dignity training.
Staff we spoke with confirmed they completed mandatory training and job specific training
on an on-going basis. One staff member told us, "I've been on a dementia related study
day. I think the training opportunities have been adequate on this ward."
We also looked at appraisal records and spoke with staff members about their most recent
appraisals. Most of the staff we spoke with told us they had received an appraisal in the
last year or had one booked with their manager.
The provider may find it useful to note that we looked at 11 staff records for confirmation of
completed appraisals and a third of the staff had not had an appraisal and were identified
as overdue for an appraisal. This meant some staff had not had their appraisal and might
not be able to discuss concerns or identify training and development needs with their
manager.
We asked to see the trust's appraisal policy. Trust staff confirmed there was no existing
appraisal policy and a new policy was in the process of being ratified. The proposed policy
contained guidance on the completion of appraisal documentation and the procedure for
staff to follow if they wished to appeal against their appraisal outcomes. We were told that
the new appraisal had been piloted in clinical and non-clinical areas and training on the
new appraisal policy would be provided for Trust staff.
Trust staff confirmed that the recording and collation of completed appraisals was
managed centrally for all Trust divisions. Completed appraisal rates were reported monthly
within the Trust and showed a rate of below 60%. Although slight improvements had been
made in recent months, we were told that the Trust was still significantly short of their 79%
target for completed appraisals.
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Assessing and monitoring the quality of service
provision
Enforcement action
taken
The service should have quality checking systems to manage risks and assure
the health, welfare and safety of people who receive care
Our judgement
The provider was not meeting this standard.
The provider did not have an effective system to regularly assess and monitor the quality
of service that patients received. The provider did not have an effective system to identify,
assess and manage risks relating to the health, welfare and safety of patients.
We have judged that this has a moderate impact on people who use the service and have
taken enforcement action against this provider. Please see the 'Enforcement action'
section within this report.
Reasons for our judgement
The provider did not have an effective system to regularly assess and monitor the quality
of service that patients received.
Our inspection on 10 October 2012 found that the provider had systems in place to
identify, assess and manage risks to the health, safety and welfare of people using the
service and others. However, these systems were not sufficiently robust to ensure that
governance arrangements were managed effectively and in a timely fashion. The provider
wrote to us and provided us with an action plan. Almost all of the actions were timetabled
to be completed by 30 June 2013. We followed this up as part of our inspection.
The provider is in breach of its authorisation with Monitor and has high risk ratings for
finance and governance with Monitor. The trust has also been placed in special measures
following the Keogh review, which took place as a result of high mortality rates.
We saw that new executive and non-executive teams had taken up post in recent months.
Governance arrangements had been reviewed by an external body. The provider also
commissioned a follow up review of the board and their quality governance arrangements
in May 2013. The review found progress had been made and the foundations were in
place to underpin the governance arrangements for the provider. However it also found
that the provider needed to ensure that it received assurance over the effectiveness of
governance and that a risk management culture was embedded across the provider.
Most patients were not aware of the ways in which they could provide feedback, including
the complaints process. One patient said, "I have been in three times and wouldn't know
how to complain, I didn't know there was a booklet."
The provider had a number of processes in place to monitor the quality of services. The
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governance structure had been changed to provide direct reporting to the Board of
Directors. New terms of reference for the Clinical Governance and Quality Committee
were approved in April 2013. The committee had significant Non-Executive Director
presence and also included external membership from the Clinical Commissioning Group.
A clinical management board had also been introduced which mirrored the hospital
management board. This reported to the clinical governance committee and had
representation from the clinical teams. At a corporate level the board had an assurance
framework. This had been presented in early format to the board at the May 2013 meeting.
We were provided with a board assurance framework dated July 2013 which had been
developed from the May 2013 version.
The board minutes indicated a level of understanding and challenge by non–executive
directors. There was reference to executives being requested to provide more detail or
papers in a different format to the board.
The minutes of the board of directors and the clinical governance and quality committee
indicated that a significant amount of time was spent on discussing the quality of services.
Quality was the first agenda item at the board meeting and there was evidence of good
discussion and interaction. The Chair made a very robust declaration that quality of
services was the trust's priority despite the challenging financial situation.
We saw how the clinical governance committee was identifying learning from incidents.
For example, in response to an incident, the trust had carried out a review of the incident
and identified practices that needed to be changed as a result. We also saw an example of
a newsletter sent to all staff following an infection control audit.
The only reference to patient and public satisfaction was the friends and family test and
complaints management. There was no indication of the involvement of patients in the
planning of services and very little reference to the role of the governors in relation to the
board's function. The complaints report presented to the clinical governance and quality
committee contained only numbers and did not identify themes or trends and there did not
appear to be any indication of the relationship between complaints, litigation, incidents and
PALS issues.
The Director of Nursing had responsibility for the governance team. They had made a
number of appointments to strengthen the team. The newly appointed risk manager
informed us of their plans for training staff in risk assessment and the Director of Nursing
told us that risks were being escalated to the board more effectively now and staff were
prepared to raise their concerns.
The Director of Nursing believed that the work done at the senior level in the organisation
ensured that good systems and processes were in place to monitor the quality of services
but considered that there was still room to improve the governance arrangements at ward
and department level.
A new performance framework had been developed to provide ward and department
based information. This was still work in progress and had areas where no information was
being provided. The quality metrics were very nursing driven and there was not a similar
set for clinical team performance or consultant performance. We were told that nursing
metrics were considered by the nursing care forum and concerns and themes were taken
back to the division and followed up with specific heads of nursing.
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The trust had a senior nurse responsible for ensuring systems were in place to
demonstrate compliance with CQC standards and these were subject to regular audit.
They also co-ordinated external visits to the trust.
The trust had appointed CQC outcome guardians. Each of the main 16 outcomes had a
member of staff appointed as guardian. Each of the guardians reports to an outcome
sponsor and leads a team of people who check compliance with the outcomes across the
trust. Each month, the outcome guardian framework requires the guardian to report on
these to the outcome sponsor. The outcome sponsor is an executive member and decides
whether any themes need to be taken to a higher level. This process had been in place
since September 2012 and we saw a number of examples of visits taking place.
The trust also had an internal assurance team who also visited wards and checked
compliance in relation to CQC outcomes. We also saw examples of these visits taking
place.
We saw a number of examples where the provider's governance arrangements were not
working satisfactorily.
We looked at four risk registers. The risk register dated 28 November 2012 for the
diagnostics and rehabilitation division identified a clinical risk from a radiology backlog
within the trust. We saw another risk register for the same division dated April 2013 which
stated the trust was exploring outsourcing of radiology reporting as an action to control the
risk of the backlog. Despite this, the trust would not be in a position for the backlog of
radiology reporting to be sent to the outsourcing company until the end of July 2013.
Some of the risks identified had been on the register for a long time. For example, there
was a risk identified around an Aseptic Dispensing Unit that had been identified in January
2011 and the trust was going to tender for a new unit. This remained on the register which
would indicate that this had not been resolved. A register indicated risks around a shortage
of medical staff at the Newark Hospital in January 2011. This showed that the trust was
slow to respond to identified risks. There were a number of items on the registers where
the review dates had passed.
Most of the wards we inspected had notice boards where information about ward
performance was displayed. For example, these included items such as infection control
audit results and pressure ulcer data. There were sections on the boards identified for
learning lessons. We found several of these sections were blank. This meant that there
was a missed opportunity to share information with staff on lessons learnt from incidents or
near misses.
The clinical governance minutes dated April 2013 stated, "a radiology concern was raised
regarding a back log. The risk to patients is low." There was no description of how the trust
had assured itself that the risk to patient safety was low. We also saw that a significant
backlog had built up in post-appointment letters being sent from the hospital to GPs, we
did not find evidence that this had been addressed through the clinical governance
committee.
We saw a briefing paper completed by the member of staff appointed as the guardian of
outcome 5 in May 2013. Their paper stated that in response to audits, "Action plans are
not being submitted from wards when requested." Another statement made was,
"Although feedback appears to be taken on board by ward leaders a recent re-visit to one
ward identified that no changes had taken place."
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While checking infection control arrangements we saw that a large number of infection
control guidance documents had passed their review dates. We also saw that infection
control audit action plans did not always identify people responsible for actions or
timescales. We saw that cleanliness audits and an infection control environment audit had
no actions or timescales to remedy identified issues. We also saw that cleaning checklists
were not fully completed.
We saw on one ward that a resuscitation area equipment checklist had not been
completed for four days. This indicated that the equipment had not been checked which
could place patients at risk should it be needed in an emergency.
We saw a range of issues related to the trust's handling of complaints in that complaints
were not being handled in line with the trust's policy. In some wards and departments we
found evidence of teams learning from complaints and implementing changes as a result.
However, there was no systematic approach to this across the trust or at executive level. A
number of teams told us they did not get a copy of the final trust response letter and felt
this would be beneficial in helping them to learn. The themes emerging from complaints to
the trust were not routinely monitored or reported to the board. The director of nursing told
us that they had been looking at complaints to pick up any patient safety issues.
We spoke with staff regarding the Patient Advisory Liaison Service (PALS). We were told
that after receiving concerns from patients they sometimes identified possible areas for
service improvement. They sent these to the ward involved and asked for a response. We
were told that PALS had not received any responses from wards in the last month and
before that rarely received any responses.
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Complaints
Action needed
People should have their complaints listened to and acted on properly
Our judgement
The provider was not meeting this standard.
The provider did not have an effective complaints system.
We have judged that this has a moderate impact on people who use the service, and have
told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
The provider did not have an effective complaints system.
We inspected this standard due to information received regarding how complaints were
handled.
We spoke with 30 patients and relatives across a range of wards and departments at the
hospital about complaints. The majority of people were not aware of the complaints
system. One patient said, "I have not had to complain so far but wouldn't know who to go
to or how to go about it if I needed to". Another said, "Everything great so far, although I
wouldn't have a clue how to complain. I didn't know there was patients' information and no
one has explained anything regarding this to me."
Another patient said, "I want to make a complaint about my general experience, they are
just not sorting the problem out, don't know who to make it to." One patient said, "I have
never had a problem with staff here but if I did, I would go to reception and ask to speak to
nurse in charge. I haven't heard of PALS [Patient Advisory Liaison Service] I had seen the
poster but thought it was a support group if you had a bereavement or something". This
meant that patients were not aware of the complaints system.
Patients told us they found information was not very well displayed and was confusing.
One patient said, "I don't think the poster is big enough, wouldn't it be better to have a
notice board, or area specifically for Customer Services, Health & Safety etc that way you
could have all the information in one place which would make it easier to see". This meant
that the hospital was not providing information to people in a way that was accessible and
met their needs.
On the wards there was a patient information booklet at most, but not all, bedsides
although not all the people we spoke with were aware of it. We saw a range of information
provided to patients and visitors on giving feedback to the trust. We noted that this was
presented inconsistently across the trust. The Emergency Assessment Unit had a display
board which contained a poster, leaflets, comments card and a suggestion box. This was
in both entrance corridors to the ward area. On the stroke unit there was no evidence on
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the ward of information for patients regarding PALS or complaints, however, some leaflets
were displayed next to the ward. We did not see printed information made available in
different formats to meet patients' needs; however, the complaints leaflet and easy read
PALS leaflet stated that information was available in different formats or languages.
The complaints and PALS services functioned separately. There was mixed feedback from
staff regarding the role of PALS. Some staff found them helpful at managing patients
concerns before they developed into full complaints, others felt they just "signposted"
people to make a complaint. The letters of response we reviewed did not make any
mention of PALS or the service they offered. Complainants were given the details of the
local Independent Complaints Advocacy Service.
Patients were not always given support to make a complaint if they needed assistance.
For example, we were informed that there was a PALS office located in the main reception
area of the hospital. We saw a Customer Services Office and were told this was also the
PALS office. The door was closed and there was no suggestion that patients and relatives
were free to enter the office to discuss issues. We did not observe any leaflets or posters
encouraging patients and relatives to provide feedback in the main reception area.
The trust had a complaints policy in place dated January 2012. The policy was not being
followed or monitored by the trust. The trust told us they have plans to review the policy
but no confirmed date has been set for this. The trust board acknowledged the complaints
system was not functioning effectively but has been taking steps the remedy this. Two
interim complaint managers were employed in April 2013. They were brought in to review
and revise the system. However, they had not been able to proceed with this process as
there was a significant backlog of complaints that had not been responded to by the trust
and the information available on how many complaints there were was not up to date. The
complaints department had not been adequately staffed for three months which had also
compounded the backlog situation.
The trust was unable to confirm to us at the start of the inspection how many complaints
they were currently dealing with, or how many are still outstanding. The policy stated that
complaints should be acknowledged within three days and then responded to within 20, 40
or 60 working days depending on the complexity of the complaint. The current NHS
standard practice is for all complaints to be responded to within 20 working days. The trust
was unable to tell us what proportion of complaint letters were acknowledged within three
days and how many were responded to within 20 working days. This meant there was not
a clear comprehensive system in place for dealing with complaints.
The trust had now tasked a member of the trust board with addressing the problems with
the complaints process and they had set up a working group to develop an action plan and
monitor progress.
We looked at eight randomly selected ongoing complaints. The files contained copies of
letters and internal email correspondence. We noted that the responses used medical
terminology which may be difficult for some patients to understand. We also noted that
some of the responses did not address all of the issues raised by the complainant resulting
in follow up letters and the case being re-opened. Some had been responded to within
agreed timescales but not all. In one case the member of staff to whom the complaint
related to had written the response rather than an independent investigator. None of the
files contained investigation reports and the monitoring form was also incomplete.
Staff also told us the value of meeting with complainants and said that they would like to
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have the opportunity to do this more often.
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This section is primarily information for the provider
Action we have told the provider to take
Compliance actions
The table below shows the essential standards of quality and safety that were not being
met. The provider must send CQC a report that says what action they are going to take to
meet these essential standards.
Regulated activities
Regulation
Diagnostic and
screening
procedures
Regulation 9 HSCA 2008 (Regulated Activities) Regulations
2010
Care and welfare of people who use services
Treatment of
disease, disorder or
injury
How the regulation was not being met:
Regulated activity
Regulation
Treatment of
disease, disorder or
injury
Regulation 14 HSCA 2008 (Regulated Activities) Regulations
2010
The provider had not taken proper steps to ensure that each
service user was protected against the risks of receiving care or
treatment that was inappropriate or unsafe by the means of the
planning and delivery of care to ensure the welfare of the service
user. Regulation 9(1)(b)(ii)
Meeting nutritional needs
How the regulation was not being met:
The provider had not ensured that service users were protected
from the risks of inadequate nutrition and dehydration, by means
of the provision of support, where necessary, for the purposes of
enabling service users to eat and drink sufficient amounts for
their needs. Regulation 14(1)(c)
Regulated activities
Regulation
Diagnostic and
screening
procedures
Regulation 22 HSCA 2008 (Regulated Activities) Regulations
2010
Staffing
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This section is primarily information for the provider
Treatment of
disease, disorder or
injury
How the regulation was not being met:
Regulated activities
Regulation
Diagnostic and
screening
procedures
Regulation 19 HSCA 2008 (Regulated Activities) Regulations
2010
The provider had not taken appropriate steps to ensure that, at
all times, there were sufficient numbers of suitably qualified,
skilled and experienced persons, employed for the purposes of
carrying on the regulated activity. Regulation 22
Complaints
Treatment of
disease, disorder or
injury
How the regulation was not being met:
The provider did not have an effective system in place for
identifying, receiving, handling and responding appropriately to
complaints and comments made by service users, or persons
acting on their behalf, in relation to the carrying on of the
regulated activity. Regulation 19
This report is requested under regulation 10(3) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010.
The provider's report should be sent to us by 25 September 2013.
CQC should be informed when compliance actions are complete.
We will check to make sure that action has been taken to meet the standards and will
report on our judgements.
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This section is primarily information for the provider
Enforcement action we have taken to protect the health, safety and
welfare of people using this service
Enforcement actions we have taken
The table below shows enforcement action we have taken because the provider was not
meeting the essential standards of quality and safety (or parts of the standards) as shown
below.
We have served a warning notice to be met by 31 October 2013
This action has been taken in relation to:
Regulated activities
Regulation or section of the Act
Diagnostic and
screening
procedures
Regulation 10 HSCA 2008 (Regulated Activities) Regulations
2010
Treatment of
disease, disorder or
injury
Assessing and monitoring the quality of service provision
How the regulation was not being met:
The provider did not have an effective operation of systems to
regularly assess and monitor the quality of the services provided
in the carrying on of the regulated activity. The provider did not
have an effective operation of systems to identify, assess and
manage risks relating to the health, welfare and safety of service
users. Regulation 10(1)(a)(b)
For more information about the enforcement action we can take, please see our
Enforcement policy on our website.
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About CQC inspections
We are the regulator of health and social care in England.
All providers of regulated health and social care services have a legal responsibility to
make sure they are meeting essential standards of quality and safety. These are the
standards everyone should be able to expect when they receive care.
The essential standards are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009. We regulate against these standards, which we sometimes describe as "government
standards".
We carry out unannounced inspections of all care homes, acute hospitals and domiciliary
care services in England at least once a year to judge whether or not the essential
standards are being met. We carry out inspections of other services less often. All of our
inspections are unannounced unless there is a good reason to let the provider know we
are coming.
There are 16 essential standards that relate most directly to the quality and safety of care
and these are grouped into five key areas. When we inspect we could check all or part of
any of the 16 standards at any time depending on the individual circumstances of the
service. Because of this we often check different standards at different times.
When we inspect, we always visit and we do things like observe how people are cared for,
and we talk to people who use the service, to their carers and to staff. We also review
information we have gathered about the provider, check the service's records and check
whether the right systems and processes are in place.
We focus on whether or not the provider is meeting the standards and we are guided by
whether people are experiencing the outcomes they should be able to expect when the
standards are being met. By outcomes we mean the impact care has on the health, safety
and welfare of people who use the service, and the experience they have whilst receiving
it.
Our inspectors judge if any action is required by the provider of the service to improve the
standard of care being provided. Where providers are non-compliant with the regulations,
we take enforcement action against them. If we require a service to take action, or if we
take enforcement action, we re-inspect it before its next routine inspection was due. This
could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection.
In between inspections we continually monitor information we have about providers. The
information comes from the public, the provider, other organisations, and from care
workers.
You can tell us about your experience of this provider on our website.
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How we define our judgements
The following pages show our findings and regulatory judgement for each essential
standard or part of the standard that we inspected. Our judgements are based on the
ongoing review and analysis of the information gathered by CQC about this provider and
the evidence collected during this inspection.
We reach one of the following judgements for each essential standard inspected.
Met this standard
This means that the standard was being met in that the
provider was compliant with the regulation. If we find that
standards were met, we take no regulatory action but we
may make comments that may be useful to the provider and
to the public about minor improvements that could be made.
Action needed
This means that the standard was not being met in that the
provider was non-compliant with the regulation.
We may have set a compliance action requiring the provider
to produce a report setting out how and by when changes
will be made to make sure they comply with the standard.
We monitor the implementation of action plans in these
reports and, if necessary, take further action.
We may have identified a breach of a regulation which is
more serious, and we will make sure action is taken. We will
report on this when it is complete.
Enforcement
action taken
If the breach of the regulation was more serious, or there
have been several or continual breaches, we have a range of
actions we take using the criminal and/or civil procedures in
the Health and Social Care Act 2008 and relevant
regulations. These enforcement powers include issuing a
warning notice; restricting or suspending the services a
provider can offer, or the number of people it can care for;
issuing fines and formal cautions; in extreme cases,
cancelling a provider or managers registration or prosecuting
a manager or provider. These enforcement powers are set
out in law and mean that we can take swift, targeted action
where services are failing people.
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How we define our judgements (continued)
Where we find non-compliance with a regulation (or part of a regulation), we state which
part of the regulation has been breached. Only where there is non compliance with one or
more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a
judgement about the level of impact on people who use the service (and others, if
appropriate to the regulation). This could be a minor, moderate or major impact.
Minor impact - people who use the service experienced poor care that had an impact on
their health, safety or welfare or there was a risk of this happening. The impact was not
significant and the matter could be managed or resolved quickly.
Moderate impact - people who use the service experienced poor care that had a
significant effect on their health, safety or welfare or there was a risk of this happening.
The matter may need to be resolved quickly.
Major impact - people who use the service experienced poor care that had a serious
current or long term impact on their health, safety and welfare, or there was a risk of this
happening. The matter needs to be resolved quickly
We decide the most appropriate action to take to ensure that the necessary changes are
made. We always follow up to check whether action has been taken to meet the
standards.
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Glossary of terms we use in this report
Essential standard
The essential standards of quality and safety are described in our Guidance about
compliance: Essential standards of quality and safety. They consist of a significant number
of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the
Care Quality Commission (Registration) Regulations 2009. These regulations describe the
essential standards of quality and safety that people who use health and adult social care
services have a right to expect. A full list of the standards can be found within the
Guidance about compliance. The 16 essential standards are:
Respecting and involving people who use services - Outcome 1 (Regulation 17)
Consent to care and treatment - Outcome 2 (Regulation 18)
Care and welfare of people who use services - Outcome 4 (Regulation 9)
Meeting Nutritional Needs - Outcome 5 (Regulation 14)
Cooperating with other providers - Outcome 6 (Regulation 24)
Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)
Cleanliness and infection control - Outcome 8 (Regulation 12)
Management of medicines - Outcome 9 (Regulation 13)
Safety and suitability of premises - Outcome 10 (Regulation 15)
Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)
Requirements relating to workers - Outcome 12 (Regulation 21)
Staffing - Outcome 13 (Regulation 22)
Supporting Staff - Outcome 14 (Regulation 23)
Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)
Complaints - Outcome 17 (Regulation 19)
Records - Outcome 21 (Regulation 20)
Regulated activity
These are prescribed activities related to care and treatment that require registration with
CQC. These are set out in legislation, and reflect the services provided.
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Glossary of terms we use in this report (continued)
(Registered) Provider
There are several legal terms relating to the providers of services. These include
registered person, service provider and registered manager. The term 'provider' means
anyone with a legal responsibility for ensuring that the requirements of the law are carried
out. On our website we often refer to providers as a 'service'.
Regulations
We regulate against the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.
Responsive inspection
This is carried out at any time in relation to identified concerns.
Routine inspection
This is planned and could occur at any time. We sometimes describe this as a scheduled
inspection.
Themed inspection
This is targeted to look at specific standards, sectors or types of care.
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Contact us
Phone:
03000 616161
Email:
[email protected]
Write to us
at:
Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Website:
www.cqc.org.uk
Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may
be reproduced in whole or in part, free of charge, in any format or medium provided
that it is not used for commercial gain. This consent is subject to the material being
reproduced accurately and on proviso that it is not used in a derogatory manner or
misleading context. The material should be acknowledged as CQC copyright, with the
title and date of publication of the document specified.
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