We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Kingston Hospital Galsworthy Road, Kingston Upon Thames, KT2 7QB Date of Inspections: 19 July July 2013 Tel: Date of Publication: September 2013 We inspected the following standards as part of a routine inspection. This is what we found: Care and welfare of people who use services Safeguarding people who use services from abuse Staffing Supporting workers Complaints Records Action needed Met this standard Met this standard Met this standard Met this standard Met this standard Inspection Report Kingston Hospital September

2 Details about this location Registered Provider Overview of the service Type of services Regulated activities Kingston Hospital NHS Foundation Trust Kingston Hospital is part of Kingston Hospital NHS Foundation Trust. It offers all major medical, surgical maternity and diagnostic services to the people Kingston, Richmond, Roehampton and surrounding areas. The hospital has an accident and emergency department (A&E). The areas we visited were A&E, Acute Admission Unit (AAU), Ambulatory Emergency Care (AEC), medical wards, main out-patients, astor ward (emergency surgery), day surgery unit and the maternity unit. Acute services with overnight beds Community healthcare service Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Family planning Maternity and midwifery services Surgical procedures Termination of pregnancies Treatment of disease, disorder or injury Inspection Report Kingston Hospital September

3 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'. Summary of this inspection: Page 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 Safeguarding people who use services from abuse 11 Staffing 13 Supporting workers 16 Complaints 18 Records 20 Information primarily for the provider: Action we have told the provider to take 22 About CQC Inspections 23 How we define our judgements 24 Glossary of terms we use in this report 26 Contact us 28 Inspection Report Kingston Hospital September

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. 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 18 July 2013 and 19 July 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and talked with local groups of people in the community or voluntary sector. We were accompanied by a specialist advisor and used information from local Healthwatch to inform our inspection. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. 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 During our inspection most patients said they were treated with respect and staff maintained their privacy and dignity. Most patients were positive about the treatment they received. Staff attitude was reported as being friendly and helpful. Comments included "Staff are attentive and understanding". We saw patients being treated with dignity and respect although their privacy was not maintained in some instances. Most patients told us that they were "satisfied" with their care and that staff had "taken good care of them". Some told us that they got the assistance required and that staff responded to their requests as appropriate. The quality of care and treatment, staffing numbers and skill mix was good on all areas we visited apart from the medical wards. One patient said "I came in as an emergency and was seen straight away", "Happy with the service, they do their best". Another said "To be honest this hospital is reasonably good, a lot better than it was two and a half years ago". Concerns were raised by patients, relatives and staff about the staffing levels and skills mix during the evenings and night on the medical wards. Patients' comments about the medical wards included "The treatment is fair but not the greatest". ''I'm well happy, staff are always friendly", "I think it's fantastic, you could not Inspection Report Kingston Hospital September

5 wish for better" and "they (staff) are polite to you". A relative said "There is huge use of agency staff, different personnel day after day". Another relative said that they had to help other patients on a medical ward whilst they were visiting their family member during the night, because staff were unavailable at the time. The relative reported that a staff member had thanked them by saying "I don't have time". Staff on a medical ward said "On my ward there were three staff nurses with no healthcare assistants, fortunately there were two student nurses who helped". This was a 24 bedded ward. Patients we spoke with were aware of how to make a complaint if they were dissatisfied with the service they received. Complaints were acknowledged, investigated and followed up by the trust, although not all complainants were satisfied with the outcome and had voiced their concerns to the Care Quality Commission. Staff were aware of the safeguarding procedures and knew how to raise an alert if they had concerns for a patient's welfare. Staff said that they felt well supported by their line managers. Most patient records we reviewed were accurately maintained, although there were some gaps related to incomplete fluid intake charts on the medical wards. This was particularly important as there was a heatwave at the time. The trust's heatwave plan was not meeting people's needs, because people were being cared for in wards that were uncomfortably hot with no visible air conditioning and insufficient working fans. 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 24 September 2013, setting out the action they will take to meet the standards. We will check to make sure that this action is taken. 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 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 Kingston Hospital September

6 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. People did not experience care, treatment and support that met their needs and protected their rights on medical wards. 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 A&E There was a clear protocol for triaging people's medical needs in the A&E. Patients, apart from those arriving by 'blue light' ambulance were registered at reception before being triaged by nurses. Based on the outcome of triage, patients were either treated and discharged or admitted to another part of the hospital. Records for June 2013 showed the four-hour A&E waiting time target was not breached. We saw patients being treated with dignity and respect. Staff used privacy screens for personal care and call buzzers were responded to quickly. Staff told us that they were "very satisfied" with the quality of care provided. Patients and relatives were very satisfied with the care they received in A&E. Patients said they were assessed "straight away" and described staff' as "professional". One relative said that they were "Lucky to have Kingston as their hospital". AAU Staff provided appropriate care for patients and evaluated their care regularly. The patient discharge survey between 1st and 15th July 2013 showed that 82.5% of respondents were involved as they wished in decisions about their care and treatment. Nurses said they had attended Intermediate Life Support (ILS) training and explained the procedure in a medical emergency. The unit emergency trolley included the required equipment and was checked daily by nurses. There was an emergency green bag next to the emergency trolley that had expired Inspection Report Kingston Hospital September

7 equipment in it. The nurse discarded the expired equipment immediately. Main Out-patients One patient said that they were very pleased with their care and treatment. They said "This was a good hospital", and doctors spent ample time with them during appointments. However, this meant sometimes there were delays to patients being seen on time. Staff said clinics were also overbooked to allow for non-attenders. This meant sometimes there were sometimes further delays to patients being seen on time Staff attitude was described as "good, informative and helpful" by one patient. All nurses had done ILS training and healthcare assistants Basic Life Support (BLS) training as part of mandatory training. Staff said the paediatric emergency trolley was checked weekly, but there were no record of this for the past month. Astor ward (emergency surgery) We saw nurses updating standardised risk assessments for all patients. Care plans were related to risk assessments and evaluated by staff regularly. Patients' progress was recorded by staff each shift. There was good pain control management and fluid balance charts were accurately maintained. Feedback from the "Friends and family" system showed respondents were very happy with the care they received. Comments included "Very caring staff, always trying hard to make me comfortable" and "Excellent treatment and services". We saw that call buzzers were within reach of patients and appropriately responded to. Nurses knocked before entering patients side rooms and engaged them in conversation whilst delivering care. During the night shift, we saw nurses taking appropriate action in response to the deteriorating health of patients. There were arrangements in place to deal with foreseeable emergencies. Most nurses had attended ILS training and healthcare assistants had attended BLS training in the past two years. Some staff had not attended in the past year due to workload pressures. Staff explained what to do in the event of a medical emergency. The emergency trolley was being checked and recorded daily. Day surgery unit Patients attended the unit for pre-booked appointments. After surgery, patients were cared for in the recovery area, until they returned to the unit. Patients said that they were satisfied with their care and described their treatment as "First class". They were given clear instructions and seen and treated on time. A relative said that they were treated with respect by staff. Maternity Patients were complimentary about the care they received during pregnancy and their stay in hospital. Records of their care were that were satisfactory. Antenatal unit Inspection Report Kingston Hospital September

8 Most antenatal care was provided in the community with Obstetric (high risk) care provided at Kingston hospital. There was a midwife led service available for women who had a previous caesarean section. There was also a consultant midwife clinic based at the hospital. Patients were able to self-refer to the maternity service through the website or their GP. There was a dedicated booking telephone line and patients did not need a GP referral letter to book with the maternity service. Obstetric ultrasound was undertaken by ultra-sonographers as per the National Screening Committee recommendations. There was a midwife & two radiographers currently in training to carry out this task. There was an ISIS team who provided perinatal mental health care to women by a specialist midwife. This involved supporting staff, risk assessment, training, audit, developing guidelines and providing direct patient care. Referrals were normally made to the ISIS team following a booking. There was a named specialist midwife for safeguarding who worked closely with the ISIS team. Malden Suite (Labour ward) There were four delivery rooms, two with pools and three postnatal beds staffed by midwives 24 hours a day. The midwives rotate to the community on alternate months to maintain their skills. 98% of expectant mothers received 1:1 care from a midwife whilst in labour. We saw resuscitation equipment in a cupboard in each delivery room. The provider may find it useful to note that audits showed that there were high levels of 3rd & 4th degree perineal tears during June 2013 of women who delivered on the suite. The provider was aware and has an action plan in place. Worcester Ward (Post natal ward) Mothers brought newborn babies to the ward for their examination if this did not occur whilst they were in hospital. Staff ensured that there was a midwife on duty during the day shift who was trained to examine a baby prior to discharge. The nurse-call system was activated several times whilst we were on the ward and it was answered immediately by staff. The provider may find it useful to note that we saw a baby in a resuscitaire in a corridor on the ward. There were staff near the nurse's station but not near the baby. We asked staff why the baby was being cared for in the corridor and was told that there was no room for the resuscitaire in the mother's room. When later discussed with a senior manager, we were advised that a baby should not be cared for in the corridor. They said that the resuscitaire could be moved into the mother's room if the reclining chair was removed. We advised another manager of our concerns as staff appeared unconcerned and said it did not occur very often. Babies at Kingston hospital were not security tagged. However the maternity, neonatal and paediatric departments had recently updated their entry system to a swipe card only system. Maternity also had a 24 hour maternity reception desk to vet access to and from the maternity unit. There were security cameras at the entry and exit to the maternity unit. If there were concerns security were on site to support. In Worcester postnatal ward, patients could access and exit by using the buzzer system only. Inspection Report Kingston Hospital September

9 A hospital records review took place in relation to a maternity outlier for maternal nonelective readmissions within 42 days of delivery. This did not find evidence of adverse outcomes or concerns for patient safety for women either prior to or during readmission. We saw that post-natal readmissions had predominately been self-referred and had arrived out-of-hours. This may reflect issues surrounding when and whom to access for care and difficulty in accessing primary care or community midwives. An action plan has been put in place to address the problems identified. We noted that the ward receptionist had an incorrect name badge with the title volunteer on it. They said they were in post for some time but the title on their name badge was not changed. Medical Wards Most patients we spoke with said that they were treated with dignity and respect by staff. Their comments included ''I'm well happy, staff are always friendly", "I think it's fantastic, you could not wish for better" and "they (staff) are polite to you". A visitor said "Everything is fine but that is probably because I am here" and "They've been very good kept me informed". Most patients said communication from the medical teams was very good. However they sometimes struggled to get information from the ward nursing staff as they were "very busy". One patient said that they would not have a particular staff member move them again because they did not carry out the task "gently". They continued, "I could get more dignity and respect but it's not built into them" and "I am like a piece on a chessboard to be moved around". Another said "Treatment not the greatest". Other comments from patients included "One nurse told me 'I don't know' and did not offer to find out when I asked a question" and "The attitude of some staff is "I know nothing". One patient said "I have never been given a name (of a named nurse), that would make a huge difference". We saw information about each ward displayed on noticeboards including photographs of staff working there. Other information emphasised the importance of privacy and dignity on the ward and gave information about important areas being focused on such as communication, and falls prevention. We saw that staff were generally courteous, patient, friendly and attentive during the inspection. Several concerns were reported or observed by us. One person informed us that their relative was lying in a soiled pad in bed and that the patient's hearing aid was broken. Another patient was left unattended on a commode for 20 minutes which they felt was unsafe given their physical condition. We saw that one patient couldn't be discharged due to their patient transport not arriving and staff said this was a common occurrence. We saw instances where medicines were left in front of patients and staff returned up to 30 minutes later to prompt patients to take them. Twice we observed that medicine trolleys were left unlocked and unattended for short periods of time. Staff comments about the care being provided included "Good care when the staffing is right", "We are struggling a bit", "It's alright" and "We do our best". Staff said felt that they upheld the privacy and dignity of patients. Inspection Report Kingston Hospital September

10 Relatives said "It's too hot (on the ward)" and "There are not enough fans". One visitor brought a fan for a patient as there weren't enough on the ward. Staff said "We need more fans on the ward" and "There is no air conditioning, freezing in Winter, boiling in Summer". A number of windows in bays and side rooms on one ward could not be opened. Four new boxed fans were supplied to this ward but staff said that they were not allowed to put them together and were waiting for maintenance staff to do so. The recorded temperature in one office on this ward was 32C. For safety reasons the Maintenance Team were responsible for building and electrically testing fans before they could be commissioned for use. The heat wave plan in wards specified that temperatures would be monitored, minimised in all patient areas and fans and air cooling systems used as appropriate. We did not see air-conditioners in use on the medical wards. One nurse told a patient that they had a nightdress on back to front and went to attend to another patient. The first patient took off their nightdress in full view of everyone. We had to get the nurse to get the patient to put their nightdress back on. The nurse quickly closed the curtains. Whilst this was happening another patient wanted a pillow whilst seated. They were told by a nurse that there were no more pillows on the ward and that they would go and get one. Fifteen minutes had expired and the nurse had not return with a pillow for the patient. A nurse-call alarm went off three times by a patient's bed and was not responded to in a timely manner by a staff member. We observed one patient asked for help and the nurse replied "There is only one of me you will have to wait". On one ward, water jugs and glasses were out of some patients reach. We asked a nurse if patients were given enough fluids. They checked one patient's file and nothing was recorded for that morning or for the previous day. We saw the use of volunteers on a ward to help facilitate the mealtime and two instances where staff spent time encouraging people to eat in a very sensitive way. On one ward staff worked short shifts with a crossover time between midday and 3pm. There were far more staff available to support patients with their meals than on other wards. However, there were less staff during the evening meal on this ward and some patients had to wait for up to 25 minutes for help with their meals. Inspection Report Kingston Hospital September

11 Safeguarding people who use services from abuse Met this standard People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The trust had policies in place on safeguarding vulnerable adults and child protection. Most staff had attended safeguarding training in the past two years. This was part of their annual mandatory training, but some staff had not attended in the past year due to lack of time related to workload pressures. Staff we spoke with knew how to recognise the signs of abuse and how to report them internally. There was a written procedure on how to escalate concerns about a patient's welfare that included details of how to contact the safeguarding vulnerable adults' and child protection teams at the local authority. There were lead practitioners for safeguarding vulnerable adults and children. Staff knew who they were and raised concerns with them as appropriate. The trust had good links with the local Social Services Department and staff attended case conferences if they were required and able to. Staff gave examples of when they raised safeguarding concerns with the trust's safeguarding leads that resulted in alerts being raised with Social Services. We were told of a safeguarding concern on one ward that was appropriately escalated to the Deputy Director of Nursing and the safeguarding vulnerable adults lead. This was when a patient with epilepsy had their medication omitted in error by nursing staff. The patient later had a seizure. Staff said that lessons were learned and staff practice was altered as a result. A senior staff member highlighted another incident that occurred in February 2013 regarding a patient that came onto the ward via A&E and AAU. A safeguarding alert was raised by the care home after the patient had been discharged and bruises and marks on their body were identified. The safeguarding investigation concluded that the documentation and record keeping was poor and the marks were not identified satisfactorily by staff during the patient's admission. As a result, the ward improved body Inspection Report Kingston Hospital September

12 map recordings and documentation when patients were admitted and transferred between different units and wards. Information on safeguarding was available on each ward with posters displayed in corridors to raise awareness. Staff said that they felt able to raise concerns, would report them to their line manager and were aware of their professional duty to do so. We met with the Director of Nursing and Patient Experience, the Deputy Director of Nursing, the Head of Quality and Risk Assurance and the Named Nurse for Child Protection. They told us about the reporting pathways for safeguarding alerts, never events and serious incidents. They said that all staff were responsible for reporting any concerns on the Ulysses system. Ulysses was the local risk management system used by Kingston Hospital to record any events. All staff had access to this system via the Intranet and new staff were given training on it at induction. All serious incidents logged on the system were identified as either Grade I or Grade II depending on severity. The grade determined how long it would take to investigate incidents as well as who would chair the investigation. Grade I incidents had a time limit of 45 days and were chaired by a senior member of staff. Grade II incidents had a limit of 60 days and were chaired by a member of the executive team and signed off by the trust board. All serious untoward incidents (SUIs) that were reported on Ulysses were recorded on the STEIS (Strategic Executive Information System) which is the National System for reporting SUIs. Commissioning groups all had access to STEIS and therefore full visibility of all SUIs at the trust. The trust board and the Clinical Commissioning Group (CCG) reviewed the outcome of all SUIs. Inspection Report Kingston Hospital September

13 Staffing Met this standard There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet people's needs. Reasons for our judgement There were enough qualified, skilled and experienced staff to meet people's needs. Overall We saw that there was a collective nursing vacancy rate of over 10% in the medical and surgical areas. There was a recruitment campaign for qualified nurses and health care assistants focusing on all wards. The purpose of the campaign was to increase permanent nursing staff numbers and had recruited 146 new roles since 1st April Medical Wards Some patients told us that there were enough staff on duty during the bulk of the day. Comments included "There are enough staff, when I needed them, they came", "If you ask for anything it is provided" and "I have used the call alarm and they (staff) came quickly". We saw that there was a significant difference in the staffing levels and skill mixes during the evening and at night that had the potential for a drop in the quality of the care provided. This meant that staff were stretched during periods of high activity where patients had particularly complex needs. Staff told us that a patient had passed away during a night shift and they had to spend most of the shift with the patient. This meant that other patients in the bay they were responsible for did not get the quality and level of care they should have. The rotas were difficult to follow as they indicated staff had been allocated to one ward when they had been transferred to another during the course of a shift. The provider may find it useful to note that staff were not happy with the current staffing levels on the medical wards. Staff comments to us included "I felt like crying, we are losing good nurses because of work pressures". "There are not enough staff on the wards during the evening and at night". "On some wards there have been no team assistants". The hospital management team told us this was because some wards had been recently made 100% qualified on the night shifts to increase the ratios of qualified nurses. In the opinion of some staff spoken with they were particularly concerned about staffing Inspection Report Kingston Hospital September

14 levels on evenings and overnight. Comments included "Only three nurses on here at night", "It's too much for the nurses", "I would not want my relative here" and "We need more staff. We witnessed one agency nurse telling patients "We are short staffed" during the morning shift. We asked them about this and they stated that the other nurse was administering medication which left them on their own in their allocated bay. A&E Senior nursing staff said that there were enough qualified, skilled and experienced staff to meet patient's needs. A&E nurses and healthcare assistants worked 12 hour shifts. It was staffed by 10 registered nurses and one healthcare assistant on the day shift and nine registered nurses and one healthcare assistant on the night shift. The duty rota showed that there was a skill mix of registered nurses ranging between Bands 5 and 7. There were also physician assistants and administrative staff. Temporary nursing cover was available for staffing shortfalls to ensure that the department was adequately staffed. There were seven whole time equivalent (WTE) consultants in emergency medicine. Other medical staffing in the department included trainees, senior house officers (SHOs), registrars and staff grades. A consultant said the medical staffing in the department was "adequate" and they provided a "safe and effective" workforce. Acute Assessment Unit (AAU) Nurses and healthcare assistants worked 12 hour shifts. The unit was staffed by 10 registered nurses and two healthcare assistants on the day shift and eight to ten registered nurses (depending on need) on the night shift. We were told that there was a high turnover of junior nurses. The unit was actively recruiting for more staff. Temporary bank and agency nurses were used to back fill staff shortages on a daily basis. Main Out-patients Senior nursing staff told us that there were not many vacancies for nursing staff in the department and had just recruited two junior nurses. Astor ward (emergency surgery) This ward had 20 beds and there were two registered nurses and two healthcare assistants on the night we visited. Normally there would be three staff on duty, but one healthcare assistant was employed to care for a patient on a one-to-one basis. Staff said that there were usually enough staff on duty to meet the needs of patients. Staff also told us that their managers supported them to book additional staff if it was required. Day surgery unit Senior nursing staff said that there were enough staff to carry out care and associated activities for patients. There was only one vacancy for an anaesthetic nurse and staffing turnover was minimal on the unit. Nurses were employed between Bands 5 and 7 Inspection Report Kingston Hospital September

15 demonstrating the skill mix required to deliver the care required. Patients were cared for on a one-to-one basis in the unit. Maternity The overall staffing ratio in maternity was 1:32.5 and where necessary staff were used to backfill gaps to maintain quality. possible staff undertook extra bank shifts in order to maintain the quality of care. There were four community midwifery teams providing antenatal, home birth services and postnatal care in the community. The Trust provided 1:1 care for women in labour. Inspection Report Kingston Hospital September

16 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. Medical Wards Staff spoken to were positive about the training they received and said that their mandatory training was up to date. Some staff said that they felt well supported by their line manager. Staff stated that they felt well connected to the more immediate management on the wards but not to the senior staff within the trust. One staff member felt strongly that senior staff should work on the wards occasionally to see how things were and another person thought that staff would appreciate personal thanks, particularly when they had been working during the heatwave. Staff told us they received annual appraisals on their performance. Records confirmed that staff had annual appraisals in order to identify their development needs and progress. The provider may wish to note that that we could not find records that individual supervision was taking place with nursing staff during the course of the year. Staff confirmed that they did not receive formal one to one supervision sessions with their line manager. Other areas visited Doctors in A&E maintained e-portfolios and documented their continuing professional development (CPD). Consultants gave educational and clinical supervision to junior doctors and all had ring-fenced time for attending CPD courses. We were told that there was a "rigorous" process for recruiting doctors, support and advice was available and poor performance was addressed. Doctors received annual appraisals on their performance. All other staff also received appraisal and supervision. They were appraised on their performance as part of the Performance Development and Review (PDR) process. Most were supervised by their immediate line manager. This was not always recorded, Inspection Report Kingston Hospital September

17 particularly for junior nursing staff. Staff said that they felt supported in their role by managers. Team meetings occurred on the various wards and departments where operational matters were discussed. Most staff received a corporate induction to the trust and a local induction to their ward or department. There was mandatory training for staff to attend which included safeguarding vulnerable adults and children, basic and intermediate life support and infection control. A mixture of online and classroom training was available to staff. We saw that staff training attendance was monitored and data showed that mandatory training attendance was "significantly under the trust's target". Less than 65% of all staff had completed mandatory training in the past 12 months. The figures improved when measured over a two year period. Staff said that this was because some staff could not attend mandatory training this year due to workload pressures. Inspection Report Kingston Hospital September

18 Complaints Met this standard People should have their complaints listened to and acted on properly Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately. Reasons for our judgement Patients were made aware of the complaints system. This was provided in a format that met their needs. Patients and relatives told us they were aware of how to make complaints and said they would speak to staff if they had any concerns about their care. One patient said "They look after me but if I was not happy I would speak to the sister". We saw that there were complaint leaflets on the wards and information throughout the hospital providing details of how to complain. These were available in different languages or could be translated for patients whose first language was not English. Staff told us they tried to address any concerns or complaints straightaway. One staff member told us "Most concerns can be dealt with quite quickly". We spoke with the Head of Litigation, Complaints and PALS (Patient Advice and Liaison Service) who explained the complaints process to us and also showed us a record of complaints for the previous two months. There were a number of ways that patients were able to raise concerns, either directly to staff, via PALS, or the complaints department. Most concerns were resolved at ward level and if not patients were encouraged to approach the PALS team to see if they could help. The PALS team dealt with informal complaints such as missed appointments. We were told the PALS team provided a "support structure and advised patients". More formal complaints raised by or in writing were seen by the chief executive or a member of the executive team. The complaints team were aware of providing extra support for patients with diminished mental capacity or learning disabilities and gave advocacy advice to them. The Head of Complaints was on the learning disability safeguarding committee and we were given examples of how patients were enabled to make complaints. All complaints that were received were graded as low, moderate or high and assigned to the division that the concerns related to. An acknowledgement letter was sent to the complainant and the expectation was that all complaints would be investigated within 25 Inspection Report Kingston Hospital September

19 days of receipt. After the investigation, a response would be returned to the complaints department for review and for the chief executive to sign off. If complaints related to safeguarding they were graded as high risk and in addition to the Divisional Manager of the relevant division, would be sent to the Deputy Director of Nursing, Head of Nursing of the relevant division and safeguarding lead. All complaints and concerns raised were recorded on the Ulysses risk management system. The complaints breakdown we saw included information according to division, location, subject matter and date. This enabled the trust to identify trends and implement learning or action plans based on the information recorded. The trust had a whistle-blowing policy and procedure that some staff said they had used. Some patients and relatives had raised concerns with the Care Quality Commission regarding the time, manner and outcome of complaints investigations made by hospital. Inspection Report Kingston Hospital September

20 Records Met this standard People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Reasons for our judgement Patient's personal records including medical records were accurate and fit for purpose. A&E We saw the creation and transfer of A&E case notes from arrival at A&E until discharge or admission. Information was attached to the A&E case notes and placed in the relevant tray. Doctors checked the trays for their patients and following assessment, the patient was either discharged or admitted. On admission, the A&E case notes were photocopied and kept with the patient. Original notes stayed in the A&E reception office. If patients were discharged, their case notes were placed in a 'discharge tray' and removed to the office. Staff were trained to use a process for managing case notes and said that the process was easy to follow. Common issues identified were staff forgetting to photocopy notes, sending originals with the patient or completed notes being removed from the office without notification. Case notes, for the previous four weeks were kept in pigeon holes in A&E's reception office and filed by date and time. An inventory was kept of the location of all old notes. The case notes we saw were correctly completed and contained patient demographics, NHS status assessment, triage form and doctor's assessment. The triage forms were signed and dated by a nurse. Doctors' assessment forms were completed with date, signature, bleep number and outcome of assessment. On admission patient health records were requested from the Health Records department. When a patient transferred to a different ward, they were "tracked on the CRS IT system" showing where they were located and the records were delivered. AAU staff said the expectation was for health records to be delivered within 12 hours of their request. One staff stated "Health records delivery has improved". We saw that some health records were delivered after patients' had been transferred. When this occurred, staff took them to the new ward. Inspection Report Kingston Hospital September

21 AEC staff said patients stayed for a short time, never overnight and timely delivery was important, although not always the case. The health record delivery times spreadsheet showed some patients were discharged without health records being delivered the ward. Ward staff said "Notes were mostly delivered on time". Health records were appropriately and securely stored by the Health Records Department. Requests from A&E for patients' notes were provided within 8 hours if they were on-site and 24 hours if off-site. We noted that 2% of health records had gone missing and 98% of notes were located and delivered on time. The business intelligence team identified process gaps to improve service delivery. Quality assurance checks took place for correct labelling, tracking, full demographics, security and correct binding. Medical wards We saw notices about the new patient information storage system called the 'Nursing Documentation Folder (NDF). We checked 16 records on four wards. The NDF was divided into nursing assessment, intentional rounds, skin, nutrition & hydration, falls, pain, elimination, weight chart, and glucose monitoring. Staff said the NDF was used throughout the hospital and they were trained to complete it. Comments included "Everything is easy to find" and "It helps with consistency". We noted that most folders were well completed and nurses had signed and dated their entries. A nurse said that if a person scored highly on their risk for falls, they would complete the relevant section in the NFD or make a referral to an appropriate clinician. There were two hourly intentional round checks by staff on patients. They asked patients 5 questions about pain, hydration, comfort, bathroom and explanation of their treatment. We noted that these records were incomplete meaning staff were not carrying out checks or not recording them. Staff told us that the checks were only carried out for patients in side rooms as they were "More out of sight than patients in bays" or for people that were identified as being high risk. Comments also included "It's not always practical to carry out checks on patients in bays as we are with them all the time", "We don't want it to become a tick box exercise" and "If a patient is self-caring they get annoyed if you keep asking them".. Some hydration and nutrition charts for patients had not been fully completed. A nurse said "We must have missed it". Staff expressed difficulty completing the records due to time constraints. Comments included "It is good as a guide, but not always practical to complete" and "We do not have enough staff to complete the charts for every single patient". Patient medical records were kept behind the nurses' station or in the sister's office depending access requirements and confidentiality. Inspection Report Kingston Hospital September

22 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 Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Family planning Regulation Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of people who use services How the regulation was not being met: On the medical wards, the care, treatment and support for patients was not consistently meeting their individual needs. Regulation 9 (1) (b) (i) Maternity and midwifery services Surgical procedures Termination of pregnancies This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us by 24 September 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. Inspection Report Kingston Hospital September

23 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 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. Inspection Report Kingston Hospital September

24 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. Inspection Report Kingston Hospital September

25 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. Inspection Report Kingston Hospital September