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Maidstone and Tunbridge Wells NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

1 March to 17 April 2023

During a routine inspection

Maidstone and Tunbridge Wells NHS Trust provides a full range of general hospital services and some aspects of specialist complex care to around 590,000 people living in the south of West Kent and the north of East Sussex. The trust has a team of over 5000 full and part-time staff. The trust provides specialist cancer services to around 1.8 million people across Kent and East Sussex via the Kent Oncology Centre, which is sited at Maidstone Hospital, and at Kent and Canterbury Hospital in Canterbury. They also provide outpatient clinics across a wide range of locations in Kent and East Sussex.

Maidstone and Tunbridge Wells NHS Trust is part of the Kent and Medway wide Integrated Care System. This partnership has been formulated to bring health and social care together across Kent with the aim of providing the best possible care for their population in the most appropriate place.

We carried out an unannounced inspection of the end of life services provided by this trust

as part of our continual checks on the safety and quality of healthcare services. This service is provided by one team across both acute sites.

We also inspected the well-led key question for the trust overall.

We did not inspect any other core services, we are continuing to monitor the progress of improvements to all services.

Our rating of services stayed the same. We rated them as requires improvement because:

  • We rated end of life care services as requires improvement.
  • We rated the trust well-led as good.
  • In rating the trust, we took into account the current ratings of the services not inspected this time.
  • The trust overall rating for caring and well-led was good, and safe, effective, responsive was requires improvement.
  • Not all staff had completed their safeguarding training. Patients’ personalised needs and preferences were not always recorded in a timely way, particularly when there was a delay in recognising a patient was approaching the end of their life. Some services were not available seven days a week.
  • There was a reliance on limited information in some areas to measure the responsiveness, effectiveness and quality of a service. Risks were not always identified and recorded for all services.
  • The impact of the delivery of the equality and diversity and inclusion strategy was reported to be variable with middle managers reported to not be fully engaged.

However:

  • There was enough staff to care for patients and keep them safe. Staff had training in most key skills, understood how to protect patients from abuse, and managed safety well. Infection risks were well controlled. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. Safety incidents were well managed and lessons learned from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Services were planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran the trust well using reliable information systems and supported leaders to develop their skills. The trust’s vision and values were well understood, and people were clear their role in making the trust strategy work. Staff felt respected, supported and valued. The trust engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

How we carried out the inspection

During the inspection we visited wards and departments across both Tunbridge Wells Hospital and Maidstone Hospital where end of life care was provided. This included wards, mortuary, bereavement office and the chaplaincy to assess how EOLC was delivered. We spoke with staff including palliative care leads, medical and nursing staff, patient liaison officers, porters, mortuary staff, and hospital chaplains. We reviewed the medical records of 11 patients who were receiving EOLC and observed care provided by medical and nursing staff on the wards. We spoke with family members whose relative was receiving EOLC and we also spoke with 4 patients.

We spoke with members of the trust board and executive team along with senior leaders, and those with key roles such as risk and quality leads. We reviewed meeting minutes, strategy documents, governance documents, performance reports and other documents provided by the trust. We also reviewed the information we hold about the organisation.

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

18 October 2017

During a routine inspection

We found there had been significant and sustained improvement throughout the trust. Overall, the trust rating stayed the same. We rated it as requires improvement because:

  • At our last inspection in 2015, we rated safe as requires improvement at Maidstone Hospital and The Tunbridge Wells Hospital at Pembury. At this inspection, the rating stayed the same.
  • We rated effective as requires improvement in 2015 at Maidstone Hospital and The Tunbridge Wells Hospital at Pembury. At this inspection, the rating stayed the same.
  • The trust was rated as good for caring at both locations and remained unchanged from the last inspection.
  • The rating for responsive had stayed the same at requires improvement at both locations.
  • There was improvement in the well led domain at one site and overall for the trust. At the last inspection, we rated the trust as inadequate for well led, but it had improved to requires improvement at The Tunbridge Well Hospital at Pembury and improved to good at Maidstone Hospital at this inspection.
  • We did not inspect maternity and gynaecology, end of life care or outpatients and diagnostic imaging. We are monitoring the progress of improvements to these services and will re-inspect them as required.

To Be Confirmed

During a routine inspection

Maidstone and Tunbridge Wells NHS Trust is a medium sized acute trust with two main clinical sites and other small community and satellite services. The trust underwent a reconfiguration of services in maternity, gynaecology, paediatrics, trauma and orthopaedics and surgery in 2011. The trust has around 700 beds across two sites and employs around 4,700 staff. The trust is working towards achieving foundation status, however predicts a 12million deficit in 2014/15.

We carried out an announced inspection of Maidstone and Tunbridge Wells NHS Trust between 14 and 16 October 2014. We also undertook two unannounced visits of the trust on 23 and 28 October 2014.

Overall, the trust requires improvement. We rated the trust as good for caring, however we rated the trust as requires improvement for providing safe care, providing effective care, being responsive to people’s needs. We rated the trust inadequate for being well-led.

Our key findings were as follows:

Safe:

  • The concept of learning from incidents varied from service to service. Whilst some departments had grasped the important role that incident reporting and investigation had in improving patient safety, this ethos was not replicated throughout the trust.
  • The anaesthetic department utilised an independent incident reporting tool which fell outside the auspices of the trust’s quality and risk strategy; there was a lack of robust oversight of this reporting tool into the overarching trust-wide governance structure.
  • The hospitals were found to be visibly clean. Infection rates across the trust were noted to be falling when compared to previous years. There was however, some localised poor performance of hand hygiene practices which had been identified through audit data and the trusts performance for surgical site infection rates for those undergoing total hip replacements was worse than the national benchmark standard.
  • Medicines management required improvement in some areas including, but not limited to the provisions for the storage and administration of medicines.
  • Medical cover within the Intensive Care unit was not consistent with national core standards; this posed a potential risk to patients. In the lead up to the publication of this report, we have written to the trust’s medical director to advise them of our concerns in this area in order that they can start to address the issues we have discussed within this report.
  • The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied. The use of early warning systems was embedded within the medicines directorate, whilst in A&E and the children’s and young people’s service, its use was inconsistent.
  • Nursing levels were generally found to be good, This was not always the case for the children’s and young person’s service, which had a nursing establishment based on historical activity. Every mother in active labour could expect to receive 1:1 support from a qualified midwife.
  • Patient records were not always found to be kept securely, nor were they always well organised or accessible.
  • Some junior medical staff were not aware of their statutory duty of candour; this had been recognised as an area of risk by the trust and there was a plan in place to heighten staff awareness.

Effective:

  • The use of national clinical guidelines was evident throughout the majority of services. However, there was lack of clinical guidelines within the ICU setting and staff were not routinely using national guidance for the care and treatment of critically ill patients.
  • The Specialist Palliative Care Team had introduced an end of life pathway to replace the existing Liverpool Care Pathway.
  • The pre-operative management of children and adults was not consistent with national guidance. There were inconsistencies in the advice patients were offered with regards to nil-by-mouth times, with some patients experiencing excessively long fasting periods.
  • Whilst staff were afforded training in understanding the concepts of, and the application of the Mental Capacity Act (MCA), we found that staff were not routinely implementing the MCA policy into their practice.

Caring:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The Accident and Emergency and the maternity service at Maidstone hospital consistently scored better than the national average in the Friends and Family test. Responses to the friends and family test for patients undergoing surgery was varied, however, it was noted that overall, the hospital scored better than the national average.
  • Patients considered that they had been given sufficient information and counselling by qualified healthcare professionals to enable them to make informed decisions about their care and treatment.

Responsive:

  • Patient flow across the trust was poor. Patients deemed fit to be discharged from intensive care units frequently experienced significant delays in being transferred to a ward and elective surgical patients were cancelled due to a lack of available beds.
  • The provision of interpreting services across the trust was poor.
  • There were insufficient numbers of single rooms at Maidstone hospital to meet people’s needs which impacted on the privacy and dignity of patients, especially for those patients who were on an end of life pathway.
  • Capacity issues within the trust led to a high proportion of medical “outliers”. The result of this included patients being moved from ward to ward on more than one occasion, alongside late night transfers.
  • All medical specialities were meeting national standards for referral-to-treatment times, including all national cancer care waiting time standards. However, some surgical patients were experiencing delays of more than 18 weeks from referral to treatment. The trust had responded to this by introducing additional surgical lists on Saturday mornings.

Well-led:

  • High quality care was not assured by the governance processes or the culture in place in some areas of the trust.
  • The governance and risk management systems used throughout the trust were unclear, not robust and did not demonstrate consistent and effective management of the risks throughout the organisation.
  • The ability of the senior directorate management teams to effectively lead their respective service was varied. Whilst the directorates of medicine, maternity and end of life were rated to be well-led, the same could not be said for the remaining five services.
  • The application of clinical governance was varied, with some services lacking any formal, robust oversight.
  • The system for identifying, capturing and managing issues and risks at team, directorate and organisation level through risk registers was not consistent or effective. Risk registers were poorly applied in some clinical areas which led to some risks not being escalated to the executive board.
  • There were examples where there were isolated specialities who demonstrated values and behaviours which were not aligned to the trusts values and despite this being an ongoing issue, there was not clear action being taken by the trust to address this effectively.
  • Some staff did not feel there was an open culture that allowed them to express themselves freely in raising concerns. The CEO was beginning to take steps to ensure all staff felt able to raise concerns in a proactive manner.
  • Staff engagement was something that was recognised that required improvement in the trust and the executive team described how they were engaging with staff in relation to the future strategy of the trust to ensure it was ‘owned’ by staff.
  • Innovation was seen to be encouraged in the trust; however there was some confusion among staff about how innovation combined with the cost improvement plan and sustainability of the services in the longer term.

We saw areas of outstanding practice including:

  • The Maidstone Birth Centre had developed, designed and produced the Maidstone birth couch, which was used by women in labour.
  • On Mercer Ward, the role of dementia care worker had been created to focus on the needs of people with dementia and their families. An activities room had been designed, furnished and equipped to meet the specific needs of people with dementia, and was widely used. This project was the subject of an article published in the professional nursing literature.
  • The breast care service provided very good care from before the initial diagnosis of cancer through to completion of treatment. Good support and holistic care was provided to patients requiring breast surgery.
  • On Ward 20 there was a focus on dementia care. Staff had bid and won funds from the Dementia Challenge fund to create a Dementia Café for use by people living with dementia, their friends and families. This area was designed using current guidance to be dementia friendly and was equipped to meet the special needs of people living with dementia.

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

Importantly, the trust must:

Tunbridge Wells Hospital

  • Ensure that care and treatment provided to service users has due regard to their cultural and linguistic background and any disability they may have.
  • Ensure that people who use the service are protected against the risks associated with unsafe or unsuitable premises.
  • Improve the environment in the Intensive Care Unit with regards to toilet/shower facilities for patients.
  • Have adequate Consultant cover at weekends for ICU
  • Ensure patients are not delayed more than 4 hours once a decision has been made to admit them to the intensive care unit (ICU).
  • Ensure discharge from the ICU takes place within 4 hours of decision.
  • Ensure that where possible, patients are not discharged from the ICU during the night.
  • Ensure outreach service meets current guidelines. (NCEPOD, 2011)
  • Ensure that level 3 intensive care patients are observed in line with their needs.
  • Make arrangements to ensure that contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.
  • Make suitable arrangements to ensure the dignity and privacy of patients accommodated in the Clinical Decisions Unit.
  • Ensure that service users are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them by means of the maintenance of an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care and treatment provided to each service user.
  • Ensure that staff and patients have access to a competent and independent translator when necessary.
  • Review the process for incident reporting to ensure that staff are aware of and act in accordance with the trust quality and risk policy.
  • Review the clinical governance strategy within children’s services to ensure there is engagement and involvement with the surgical directorate.
  • Review the arrangement for the management and administration of topical anaesthetics
  • Review the children’s directorate risk register to ensure that risks are recorded and resolved in a timely manner.
  • Review the current PEWS system to ensure that it has been appropriately validated, is supported by a robust escalation protocol and is fit for purpose. Its use must be standardised across the children’s directorate (excluding neonates).

Maidstone Hospital

  • Make arrangements to make sure contracted security staff have appropriate knowledge and skills to work safely with vulnerable patients with a range of physical and mental ill health needs.
  • Ensure that intensivist consultant cover at weekends is adequate.
  • Ensure that sufficient numbers of ward rounds take place in the intensive care unit (ICU) to ensure the department complies with national standards.
  • Ensure that once a decision to admit a patient to the ICU is taken, the patient is admitted within four hours.
  • Ensure that patients are discharged from the ICU within four hours of a decision being made.
  • Ensure that discharges from the ICU to other wards do not take place at night.
  • Ensure that the governance structure within the ICU supports a framework to ensure clinical improvements using a multidisciplinary approach.
  • Review the existing management arrangements for the Riverbank Unit to ensure that the unit operates effectively and efficiently.
  • Take action to ensure that medical and nursing records are accurate, complete and fit for purpose.
  • Ensure that staff and patients have access to a competent and independent translator when necessary.
  • Ensure that the water supply is tested for pathogens and that appropriate systems are in place for monitoring water quality and water safety.
  • Take action to ensure that all patient clinic letters are sent out in a timely manner.

In addition the trust should:

Tunbridge Wells Hospital

  • Consider collating performance information on individual consultants. Where exceptions are identified these should be investigated and recorded.
  • Provide written information in a format that is accessible to people with learning difficulties or learning disabilities.
  • Ensure the protocol for monitoring patients at risk is embedded and used effectively to make sure patients are escalated in a timely manner if their condition deteriorates.
  • Ensure that all medical staff in the ED have completed training in safeguarding children at the level appropriate to their grade.
  • Make appropriate arrangements for recording and storing patients’ own medicines in the CDU to minimise the risk of medicine misuse.
  • Respond to the outcome of their own audits and CEM audits to improve outcomes for patients using the service.
  • Review the arrangements for meeting the needs of patients presenting with mental ill health so they are seen in a timely manner.
  • Review the management of patient flow in the ED to improve the number of patients who are treated and admitted or discharged within timescales which meet national targets
  • Review the systems in place in the ED for developing, implementing and reviewing plans on quality, risk and improvement.
  • Review the way complaints are managed in the ED to improve the response time for closing complaints.
  • Ensure there is strategic oversight and plan for driving improvement.
  • Review the quality of root cause analysis investigations and action plans following a serious incident or complaint and improve systems for the dissemination of learning from incidents and complaints.
  • On the Medical Assessment unit the trust should ensure that point of care blood glucose monitoring equipment is checked. It should also consider how this checking should be managed to be integrated as part of an overall policy that forms part of a pathology quality assurance system.
  • Develop systems to ensure the competence of medical staff is assessed for key procedures.
  • Develop systems to ensure that medicines are stored at temperatures that keep them in optimal condition.
  • Ensure that patients’ clinical records are stored securely in ward areas.
  • Review the ways in which staff can refer to current clinical guidance to ensure that it is easily accessible and from a reputable source.
  • Review current nil-by-mouth guidance to ensure that it is consistent with national standards; patient information leaflets should be standardised and reflect national guidance.
  • Review the process for the management of patients presenting with febrile neutropenia to ensure they are managed in a timely and effective manner.
  • Standardise the post-operative management and guidance of children undergoing urology surgery
  • Review the process for the hand-over of pre-operative children to ensure they have support from a health care professional with whom the child and family are familiar with.
  • Ensure that all staff introduce themselves and wear name badges at appropriate times.
  • Review the location of the vending machine currently located between Hedgehog ward and the Woodlands Unit.
  • Review the managerial oversight of staff working in children’s outpatients.
  • Review the current clinic provision to ensure that women who have recently miscarried or who are under review for ante-natal complications are seen in a separate area to children who are also awaiting their appointment
  • Review the facilities and admission process for elective surgical patients.
  • Monitor the transfers between sites, for both clinical and non-clinical reasons. The monitoring process should include the age of the patients transferring and the time they arrived after transfer
  • Have clarity about the definition of what constitutes an SI or Never Event in relation to the retained swabs.
  • Ensure policies that have not been reviewed and impact on current evidenced-based knowledge/care are updated.
  • Address staffing levels and recruitment On the gynaecology ward/unit
  • Ensure appropriate reporting and recording of incidents on the trust system on the gynaecology ward.
  • Implement actions for the findings of the gynaecology ward audit undertaken in June 2014.
  • Improve management of non-gynaecology outliers placed on the ward, including review by consultants, ward rounds and patient discharges.

Maidstone Hospital

  • Arrange for the safe storage of medicines so that unauthorised access is restricted.
  • Make sure that all medical staff in the A&E department have completed training in safeguarding children at the level appropriate to their grade and job role.
  • Make sure that a sufficient number of consultants are in post to provide the necessary cover for the ED.
  • Ensure that up-to-date clinical guidelines are available in the ED
  • Review the arrangements for meeting the needs of patients presenting with mental health conditions, so they are seen in a timely manner.
  • Review the way complaints are managed in the ED to improve the response time for closing complaints.
  • Review the governance arrangements for nursing staff in the ED to ensure effective leadership and devolution of responsibilities.
  • Review the current provisions of the ICU outreach service, to ensure that the service operates both day and night, in line with National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommendations.
  • Ensure that medical care services comply with its infection prevention and control policies.
  • Develop robust arrangements to ensure that agency staff have the necessary competency before administering intravenous medicines in medical care services.
  • Develop systems within the directorate of speciality and elderly medicine to ensure that the competence of medical staff for key procedures is assessed.
  • Ensure that systems are in place to ensure that the system of digital locks used to secure medicines storage keys can be accessed only by authorised people.
  • Develop systems to ensure that medicines are stored at temperatures that are in line with manufacturers’ recommendations.
  • Ensure within medical care services that patients’ clinical records used in ward areas are stored securely.
  • Ensure that the directorate of speciality and elderly medicine further monitors and embeds a robust system of medical handover that ensures patients’ safe care and treatment.
  • Review the ways in which staff working in medical care services can access current clinical guidance to ensure it is easily accessible for them to refer to.
  • Review the way in which in medical care services it authorises and manages urgent applications under the Deprivation of Liberty Safeguards.
  • Ensure that patients have access to appropriate interpreting services when required.
  • Ensure that the directorate of speciality and elderly medicine reviews its capacity in medical care services to ensure capacity is sufficient to meet demand, including the provision of single rooms.
  • Consider reviewing the processes for the capturing information to help the service better understand and measure its overall clinical effectiveness.
  • Consider reviewing the current arrangements for the providing elective day case surgical services to ensure parity of services across the hospital campus.
  • Ensure that the provider reviews the quality of root cause analysis investigations and action plans following a serious incident or complaint and improves systems for disseminating learning from incidents and complaints.
  • Ensure that the provider monitors transfers between sites for both clinical and non-clinical reasons. The monitoring process should include the age of the patients transferred and the time they arrived after transfer.
  • Consider collating performance information on individual consultants. Where exceptions are identified, these should be investigated and recorded.
  • Provide written information in a format that is accessible to people with learning difficulties.
  • Reduce delays for clinics and reduce patient waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.