Inspection Report - Care Quality Commission · Ward 20, Ward 21, Ward 31, the Maternity Unit...

| Inspection Report | The Tunbridge Wells Hospital at Pembury | June 2013 www.cqc.org.uk 1

Inspection Report

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

The Tunbridge Wells Hospital at Pembury

Tonbridge Road, Pembury, Tunbridge Wells, TN24QJ

Date of Inspections: 19 March 201314 March 201313 March 2013

Date of Publication: June 2013

We inspected the following standards as part of a routine inspection. This is what we found:

Respecting and involving people who use services

Met this standard

Care and welfare of people who use services Met this standard

Safeguarding people who use services from abuse

Met this standard

Cleanliness and infection control Met this standard

Staffing Met this standard

Supporting workers Met this standard

Assessing and monitoring the quality of service provision

Met this standard

Complaints Met this standard


Details about this location

Registered Provider Maidstone and Tunbridge Wells NHS Trust

Overview of the service

Tunbridge Wells Hospital, Pembury has been built with 512 single rooms. Each inpatient room is equipped with its own en-suite facilities and free view flat screen television.

The hospital provides a range of complex and routine surgical and medical services. It also has a trauma centre, orthopaedic centre and women and children's centre. These centres service the whole of Maidstone and Tunbridge Wells. Other services include an Accident and Emergency (A&E) Department.

Type of service Acute services with overnight beds

Regulated activities Diagnostic and screening procedures

Family planning

Maternity and midwifery services

Surgical procedures

Termination of pregnancies

Treatment of disease, disorder or injury


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

More information about the provider 5

Our judgements for each standard inspected:

Respecting and involving people who use services 6

Care and welfare of people who use services 9

Safeguarding people who use services from abuse 13

Cleanliness and infection control 15

Staffing 17

Supporting workers 19

Assessing and monitoring the quality of service provision 20

Complaints 23

About CQC Inspections 25

How we define our judgements 26

Glossary of terms we use in this report 28

Contact us 30


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 13 March 2013, 14 March 2013 and 19 March 2013, talked with people who use the service and talked with carers and / or family members. We talked with staff, reviewed information sent to us by other regulators or the Department of Health, reviewed information sent to us by other authorities and were accompanied by a specialist advisor.

What people told us and what we found

This inspection included visits to the following wards/clinical areas: Ward 10, Ward 11, Ward 20, Ward 21, Ward 31, the Maternity Unit including ante-natal and post-natal wards, the Accident and Emergency Department (A&E) including the Medical Assessment Unit (MAU), the Paediatric Unit (PAU), the surgical holding unit (SSU), a children's ward and a gynaecology ward. As part of the inspection team we were supported by two specialist advisors. An independent Obstetrician and Gynaecologist and a Director of Nursing. We spoke with 40 patients, 15 relatives/visitors and 56 staff across the wards and clinical areas that we visited at the hospital.

All the patients we spoke to consistently told us they were treated with dignity and respect.A sample of what patients told us included "The staff treat us humanly, they extended thevisiting hours and we were able to have more visitors than usual. They have looked after us as a family", and "I didn't think I would like the single room but I get a lot more rest and Iam not worrying about other patients'. I like it".

Patients said the wards were kept clean and nurses always washed their hands. We saw that the Trust had systems and process in place to ensure that the hospital responded appropriately to incidents of hospital acquired infections (HCAI) or C. difficile.

Patients said the staff took time to discuss with them how things were going. One patient said, "They always tell me what is happening like when the consultant is due to do his rounds ". Another person told us, "It is good that they discuss everything in the open. You don't feel that they are hiding things from you".

On all the wards most people said that they were satisfied with the food provided. People spoke positively about the staff. They said the staff where polite and nice but they were busy. We saw that the hospital operated a red tray / blue tray system for meals. Red trays denoted that patients required assistance with nutrition. We observed that patients with door precautions which indicated that assistance was required with nutrition, were


provided with meals on red trays and appropriate staff assistance was given. We saw that staff were not rushed when dealing with patients and that call bells we heard were answered promptly.

All of the patients spoken with did not have any complaints about the service but did say they would speak to a member of staff or a relative if they had any concerns. One patient said "I would definitely say something if things went wrong, but I have no complaints".

You can see our judgements on the front page of this report.

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.


Our judgements for each standard inspected

Respecting and involving people who use services Met this standard

People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

Our judgement

The provider was meeting this standard.

Patient's privacy, dignity and independence were respected. Patient's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Reasons for our judgement

All the patients we spoke to consistently told us they were treated with dignity and respect.A sample of what patients told us included "The staff treat us humanly, they extended the visiting hours and we were able to have more visitors than usual. They have looked after us as a family".

Patients told us that their privacy, dignity and independence were respected. The wards consisted of single rooms. When personal care was being delivered, we saw that staff closed doors and window blinds. Some doors were kept closed for infection control purposes. We saw that staff where careful to knock before entering rooms. Staff we spokewith where aware of the possible feeling of isolation for some patients. To safeguard this, the hospital had introduced quality rounds where staff visited each room regularly and recorded this to demonstrate patient contact. In addition some patients kept their bedroom doors open.

We saw evidence of how the hospital kept patients informed about their care and treatment and the practicalities of hospital life through various methods depending upon the specialities of the wards. For example, we saw that in the A&E department waiting times were displayed electronically on a television screen, this was in real time and was also displayed on the Trust's website. One family with a teenage daughter waiting to be seen said they were told it would be an hour and a half which they confirmed that it had been.

Patients we spoke with on Ward 21 said they had been kept informed of what was happening with their treatment. They told us that they were also given information about the hospital and ward for example visiting and meal times. Most patients were happy with what they had been told although discussions highlighted a lack of understanding about the parking concessions and how to access these.

When we visited Ward 20 we saw that it cared for Acute Elderly Care / Orthopaedic-


Geriatric patients. On the day of our inspection there were 30 patients, 10 of whom were post orthopaedic surgery. We saw that there was information available in the ward reception area that included topics such as Care Visits at Home, Liverpool Care Pathway, Coping with Dying, 24 hour Kent Dementia helpline, Age UK, the Prevention of Slips, Tripsand Falls at Home, Osteoporosis, How to Make a Complaint and Car Park Concessionary Rates. We saw that there was a notice board on the ward that provided information about events such as the lunch club, and volunteer visitor services. Patients were satisfied that they understood the care and treatment choices available to them. Patients told us that they had the opportunity to speak with doctors and nurses, most patients understood why they were in hospital and the treatment they had received. For example, why fluid and nutrition charts were in place for them and why infection control precautions were in place, such as why staff were wearing gloves and aprons when they entered some patient's rooms.

We saw that on Ward 20 information provided to newly admitted patients was predominantly verbal and visual. This included an orientation of the ward and bedroom, a demonstration of the en-suite facilities and call bell. In the instance of non English speaking patients, a translation service was available although staff did not recall that there had been a need to utilise this service. Discussion with staff, patients and examination of records found that patients were asked whether they preferred male or female staff for personal care.

We saw how the hospital helped to ensure that people with dementia type symptoms weresupported to be kept informed of their care and treatment. Assessment and nursing notes recorded that explanations had been given and each patient that we spoke with felt confident that they could approach staff with any questions they had. We saw that one patient had received written instructions about physiotherapy exercises and for the care of their operation site. They had discussed this with the physiotherapist and were content with the information received.

Patients we spoke with on Ward 20 felt that they were able to express their view and were involved in making decisions about their care, treatment and support where possible. Patients told us that staff regularly spoke to them about their care and treatment and they had the opportunity to raise any questions or concerns. Patients confirmed that they had been asked their preferred name, particular dietary requirements as well as any particular cultural or religious observances. Reference to patient notes and discussion with staff confirmed this. Some people were aware that a Chaplin and Chapel were available on site.

We saw that staff spoke with patients respectfully and allowed people to undertake tasks for themselves where they could, for example eating independently, mobilising and going to the toilet. We saw that patients were asked which clothes they wanted to wear, if they preferred a wash or a shower. We saw that staff encouraged patients to walk as part of their rehabilitation which helped to develop confidence and independence.

Staff we spoke with told us that the completion of the 'This Is Me' booklet helped to ensure that patients were involved in decisions about their care and treatment because it enabled staff to understand individual patients, and provided an avenue to establish their personal preferences, which in turn formed the basis of care plans.

Capacity assessments took place as a matter of course to ensure that patients identified as having complex needs and reduced mental capacity, had decisions made in their best interest. We saw that where patients were assessed as not having capacity or had limited capacity to make decisions, arrangements were in place for decisions to be made on a


patient's behalf through best interest meetings. This meant that friends, relatives or advocates helped to ensure that decisions made about a patient's care, treatment and support were right for the individual.

In the Maternity Unit, all the patients said they were given choices about their care. For example, one person told us they had been able to decide to delay their induction to see if labour progressed naturally. Another patient told us they really wanted a water birth and their views on this were respected. Patients said they had been given leaflets to explain their treatment, for example induction. We looked at two patient's notes and saw that there were comments included about the information given to the patient and their wishes and views about their care. For example, it was recorded that a person wanted a water birth, but that the reasons why this may not be possible had been explained. The person said they had been involved in this decision. Another patient told us that they were using hypnotherapy techniques during their labour and that staff respected this and ensured the room was quiet with low lighting and music.

In the Maternity Unit we spoke with staff who told us that they had the used cards to help explain procedures to patients who may have limited capacity or language barriers. The ward manager also told us that they could access a list of interpreters available in the hospital if needed and had a translation facility on the intranet for basic translation of languages. Staff where aware of the need to seek the views of the patient in situations where their husband was speaking for them. The ward manager said there was a matron for vulnerable adults based at the hospital.

We spoke with a ward manager who told us that work was in progress to improve the information available to patients on admission. We saw that there was an information sheet in each room giving information about the ward. The manager said they wanted to include more information for people about treatment and conditions relating to pregnancy and labour and to improve the education facilities for women in pregnancy to help further support patients in making decisions about their treatment.

We were told of two examples given by patients where they said they did not feel their views were always taken seriously. These related to where a patient felt that the triage system did not take account of their previous birth experience and where despite asking for pain relief, this was not provided for some time with no explanation as why this was not forthcoming. This was fed back to the Trust management.

All patients we spoke with on the Maternity Unit said that they had been kept up to date with what was happening with their care and what the next stage was. Those that were waiting to go home knew that they were waiting for a medical check and discharge letter. Patients who were going home said they had been given information about the next stage of their care and how get advice once at home. Two patients told us that their husbands had been able to stay overnight and how important this was for them and how the staff hadmade them feel welcome.

There were many ways in which the hospital enabled patients to express their views regarding the service and their individual care. For example, in A&E we saw patient feedback cards and a post box were clearly visible at the reception desk. In addition, the Trust intends to use a "Touch Book" electronic system, and via 16 questions get feedback from at least three patients daily. We saw that on Ward 20, the ward had engaged in a patient survey which was undertaken by volunteers at a rate of 1 per day. We saw that the current patient satisfaction rate was 90%.


Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement


Patients experienced care, treatment and support that met their needs and protected their rights.


Patient's needs were assessed and care and treatment was planned. All the patients we spoke with across the wards and clinical areas told us they were happy with their care and treatment. Patients told us that the ward staff looked after them well and were always asking if they were alright, if they were comfortable or in pain and if they needed anything.

We saw that the hospital had implemented a system of hourly quality patient checks whichincluded an assessment of pain management, continence care, call bell accessibility, comfort and hydration. Written records for each patient verified whether checks had taken place and noted Achieved or Variance against each area. On the day of our inspection, wefound that hourly checks had been completed on the wards for each patient without exception. We saw that in the A&E department, a senior nurse conducted two hourly quality rounds. She reviewed every patient, talked to them and their families, checked all assessments and care was up to date and supported the nurses caring for the patients by administering analgesia if due.

In the A&E department, we saw that a registered nurse was allocated to the rapid assessment bays. We saw that within five minutes the patient received an initial assessment, which also included skin inspection documented on a body map, observations taken and pain assessed. We saw that a handover was taken from the paramedics who had brought the patient by ambulance. Family members were included, and reassured through the process. We saw that the patient was then moved to a major injuries bay and transferred from the ambulance trolley to the A&E trolley with the ambulance crew still present. We saw that a falls assessment had occurred in the ambulance handover bay, patients at high risk of falls were given a blue wrist band, a visual cue for on-going management, and a trigger for the completion of a falls record and referral to the falls clinic. These patients where possible were placed in the more visible of the majors bays.

We saw that one older patient, who had respiratory problems and was requiring admissionto the hospital had been in the A&E department for seven hours. When we spoke with them, they were very complimentary about their care and treatment and how this had improved their breathing saying that they would score their care 10 out of 10.Their relatives also spoke positively about their relatives care and how they had been treated


with respect and as an individual. Staff had identified promptly the patient's fragility and they had been moved from a trolley onto a more comfortable bed. We tracked this patient transfer into the Medical Assessment Unit (MAU) unit where they remained very complementary about their continuing care and their bedroom facilities.

On Ward 20, we saw evidence within admission assessment material that staff used a Royal College of Nursing tool 'This Is Me' which was designed to promote a positive approach in dementia care. The records gathered information about the person such as their home and family, life history and occupation, hobbies and interests and worries. It considered communication, hearing and eyesight as well as mobility, sleep, personal care,eating, drinking and medication. The purpose of this approach was to gather appropriate information to promote individual identity, to be able to connect and communicate effectively with the person and involve them in decision making. We found that this information was contained within and utilised from patient's care plans. An admission assessment was undertaken for each patient admitted to the ward which was broken downinto four main areas of: medication charts, nursing assessment, patient care plan and miscellaneous such as observation charts and patient at risk scores. This helped to make sure that staff had the guidance they needed to meet patients' needs.

Part of the admission process included establishing key information towards discharge, such as any need for specialised equipment, and the likelihood of independent or assisted home care. Such information was used to determine the involvement of other healthcare professionals in the discharge process, for example occupational therapists or social services. Of the five patients that we spoke with on Ward 20, we looked at each of their admission assessments and found that they were complete and up to date. Each assessment contained a date of admission and an estimated date of discharge together with appropriate consideration of what would be required to assist of support them when they were at home. This would then help in the planned discharge of patients.

Patients we spoke with were able to confirm that they had been involved in developing their care plan and this had taken place through discussion with staff. For some patients this had been low level, for example a preferred name, another patient had discussed with staff their preference to carry out their own personal care where able to do so.

All of the patients that we spoke with conveyed a positive impression and experience of the care they had received in the hospital. They spoke positively about the staff and the care that they had experienced. One person commented "I don't need to use the call bell, staff are always looking in on me, they are very good". Another person commented "The staff are very pleasant and efficient, they always tell me what's happening and answer any questions I have". Each patient that we spoke with confirmed that they had met with a doctor or a consultant.This was confirmed by staff and reference to records of medical assessments.

We saw that the hospital operated a red tray / blue tray system for meals. Red trays denoted that patients required assistance with nutrition. We observed that patient's with door precautions which indicated that assistance was required with nutrition, were provided with meals on red trays and appropriate staff assistance was given. Nutrition doorprecautions corresponded with Malnutrition Universal Screening Tool (MUST) assessments and dependency assessments contained within the patient's nursing assessment care plans, which helped ensure that vulnerable patients got the nutrition and support they needed.

We saw that on Ward 20 a lunch club for patients had been introduced so that patients


with dementia had to opportunity to participate in social interaction. We saw that games, books and art work were available in the lunch club room and soft music was played. We saw that the lunch club was well attended. We saw that there were arrangements in place whereby two volunteers regularly visited the ward and spent time speaking with patients. We also saw that three volunteers from the Reader Organisation also regularly visited the ward and spent time reading short stories and poems to patients individually or where possible in groups.

Patients we spoke with on Ward 21 told us they were extremely satisfied with the care andtreatment provided. Comments included, "It's brilliant, very good", "Very good indeed" and "It's second to none". They confirmed that they had been able to ask questions about their care and treatment. Comments included, "Every stage is discussed with me. They (the staff) think I need to go to the intensive care unit, but I have refused because the nurses on this ward know me so well". People said they had had the opportunity to meet with doctors and/or their consultant. Comments included, "Yes every morning". "The vascular people explain everything very well, the medical team are not so easy to follow, but I'm notunhappy". "I see them regularly. At one stage I wanted to talk to the consultant alone and she made a time and came back at the end of the day". One patient talked about how theywere trialling a new oxygen therapy. The patient felt the benefits were very good. The oxygen was administered via a nasal cannula which delivered a high flow of oxygen instead via a mask. This meant the patient was able to take their medication (nebuliser) whist having oxygen, but also could eat whilst on oxygen.

All of the patients we spoke with on the Maternity Unit said they had had a positive experience in the hospital and that their care pathway throughout their pregnancy had been good. They all said that the support they received from the community team was good and that they had regular checks and appointments. They said they knew who to callif they were concerned. All of the patients said how good the support was for breastfeeding. One patient said "They have been really fantastic, every time I've needed help they have been straight in". Another said "I haven't felt hurried when trying to learn how to feed my baby".

We saw how the various wards we visited prepared for discharge and we noted an effective communication process during and following discharge. For example in maternity services there was a system to fax the outcome of investigations to the patient's GP service and community midwife following assessment or treatment in triage and then returning home. The specific needs of patients had been recorded in their notes, for example gestational diabetes and a heart condition. There was information recorded on the postnatal notes about the birth and the specific care the mother and baby needed afterwards for example, stitches or antibiotics.

We saw that Ward 20 had piloted a patient Discharge Coordinator role. This enabled one staff member to liaise with the patient, medical teams, consultants, occupational therapist, physiotherapists, social services, families, other hospitals and care or nursing homes to facilitate patient discharges to support a person centred approach. Patients that we spoke with were aware of their discharge processes, although not necessarily their discharge date, we noted however that estimated dates of discharge were recorded within patient's notes.

Staff on Ward 21 said they ensured that everything was planned for a safe discharge. They told us that they talked to the patient and family to ensure there was enough support and treatment support to ensure they felt safe after discharge. Staff told us that patients had to be medically fit to go home. Staff told us they aimed to have patients discharged in


the morning. Patients were then taken to the departure lounge. Staff said told us that the delays to discharge were transport and medication. Staff we spoke with told us that they would not normally discharge a patient home after a certain time namely 8pm, but this would however depend on their circumstances. However, one patient told us on Ward 21 that when they were in the hospital on a previous occasion they had been discharge from the ward at 10.30am but did not leave the departure lounge until 4.40pm. We were told that the delayed discharge on this instance was waiting for the discharge letter and medication. Staff told us that there could be a delay with the EDN (electronic discharge note) which could delay a patient's discharge. That although they tried to plan this in advance the process did not always enable these notes to be generated quickly by medical staff. This was fed back to the Trust management.


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


Patients 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.


All of the patients we spoke with on the Maternity Unit said they were happy with their care. One patient said "I have felt in safe hands all the way through".

We saw that "whistle blowing" information was available to all staff on the hospital intranet and all staff had access to a computer within the wards and clinical areas. Staff we spoke with were knowledgeable, they were able to explain the "whistle blowing" process and had confidence that any concern raised would be suitably addressed. Staff spoken with had not had reason to raise any "whistle blowing" concerns.

Staff we spoke with felt able to raise concerns with the ward manager. One member of staff said, that the ward manager was very open and easy to talk to. Another staff member told us they had previously raised a concern about another member of staff's attitude whendealing with patients. They told us the ward manager resolved the issue by speaking to themember of staff.

We saw that there was an effective process in place which ensured the hospital respondedappropriately to allegations of potential adult and child abuse. Clinical staff we spoke with where clear about their roles and responsibilities to report concerns and had received training in the protection of vulnerable adults. We saw that patients identified as being at risk by staff had an AP1 (Adult Protection) form completed and uploaded on to the Trust's computer system. This triggered an email to the matron for safeguarding who would follow up each case. We saw that all paediatric attendances were reviewed the next working dayby the safeguarding team, they visited the department and reviewed the patient's notes, they also picked up any causes for concern of violence where there may be children in the home. If a child left the department without being seen, this was also followed up by the safeguarding team. However, the provider may find it useful to note that staff we spoke with commented that with regards to adults with mental health problems, the out of hours service did not always facilitate a prompt mental health review.

We tracked potential safeguarding concerns which were raised with the Care Quality Commission (CQC) prior to the inspection which related to pressure care and discharge arrangements. We saw that these had been reported and investigated and although found


to be unsubstantiated, learning points had been identified and action taken. However, we noted an example where there was a delay in a referral being made. Although the delay did not place the patient at any further risk, there was a delay in the investigation, and therefore any learning to prevent re-occurrence. The hospital identified the reason for the delay and changes to practices were being implemented to ensure that a safeguarding alert would now automatically be raised when a ward identified a hospital acquired pressure sore.

The hospital had identified that it was not meeting is own projection of the percentage of staff that needed to have received training in child protection, which we saw the hospital was in the process of addressing. The provider may find it useful to note that we identified an example whereby a potential safeguarding concern had been raised with clinical staff (Patient Advice and Liaison Service -PALS) but this had not been forwarded onto the safeguarding team for consideration. Although this issue was not pursued under safeguarding, when further information was gathered, it did raise issues around standards of recording. We were told that training was underway for PAL team members to improve knowledge around safeguarding guidelines.

The hospital took steps to ensure that safeguarding investigations undertaken by the Trustwere impartial and undertaken by staff from a different directorate/location within the hospital and who had the appropriate skills. The local authority lead on community based safeguarding referrals, with evidence of some joint working to help support impartiality, shared learning and improve patient safety. We saw data which confirmed that the hospitalhad addressed concerns around variable standards in the quality of some previous safeguarding investigations. This had included additional staff training and closer monitoring of safeguarding investigations by senior management.

There was a clear system in place to monitor safeguarding referrals through the 'safeguarding adults committee' which identified learning from each reported safeguarding referral in order to continually improve patient safety. We tracked four referrals which showed that learning from investigations resulted in: staff disciplinary action, changes to transfer of information and additional training in customer care for individual staff.

Where the Trust had identified shortfalls in its management of some historical safeguarding allegations, they had initiated an independent review of adult safeguarding processes across the Trust. We saw how the recommendations from this were included inthe hospitals safeguarding action plan, which identified who was responsible for addressing action points along with timescales. For example, the need for triangulation of complaints, incidents and safeguarding concerns to ensure a more comprehensive approach to safeguarding.


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


There were effective systems in place to reduce the risk and spread of infection.


Patients we spoke with said the wards were kept clean and nurses always washed their hands but we received consistent comments that they did not always see the doctors washtheir hands.

On the Maternity Unit, all the patients we spoke with said they were satisfied with the standards of cleaning. They said they had a cleaner in each day to clean their room and change their bed. One person said the cleaner had been great as they had only just changed the bin and they asked for it to be done again because of more dirty nappies. All patients said that staff had washed their hands before examining them or their baby and they used the hand gel at the doors. Staff we spoke with said there was always a dedicated cleaner on the ward. We spoke with a healthcare assistant who told us that theywere responsible for cleaning equipment and used special wipes. They said there was a check sheet for the cleaning of equipment on each shift and that equipment was cleaned each day and between uses. At the time of our inspection, we saw cleaners working withineach unit. Staff we spoke with where able to name the infection control lead for maternity services.

The areas we visited were clean, odour free and tidy. The ward environments, bay areas, single rooms and patient bed areas looked clean and well maintained. Alcohol hand gel was available at entrances and exits to each ward. We observed that nursing staff were cleaning their hands between patient contact and on entering and exiting the ward. They also wore appropriate personal protective clothing when undertaking care tasks with patients.

We saw that the toys in the A&E department were clean. We saw that the children's room in "see and treat" did not get much use, however, there was a process for the healthcare support workers to clean the toys, and this appeared to be working.

We walked round the wards, observed toilet, bathroom and shower areas, kitchens, sluices, treatment rooms, commodes, single rooms and bays on the ward and corridors and found them to be clean and tidy. All equipment had been regularly checked and well maintained. We checked a mattress and observed staff's practice when cleaning a mattress thoroughly. This means that due care and attention had been given to controlling infection on the wards. There were systems in place to make sure that all parts of the


wards and equipment were checked, thoroughly cleaned and replaced systematically. These were recorded in a data system which had regular audits, so that compliance with the cleaning procedures could be checked. If there were any areas of weakness, an actionplan would be produced by the infection control lead nurse, who ensured the plans were followed. During our inspection of Ward 20 we saw that the machine for disposing of body fluids and waste matter was faulty. This was brought to the attention of the ward manager and was addressed immediately.

We saw posters on the walls in each ward giving instructions on aseptic/non touch procedures and we observed that these were correctly followed. We saw door precaution information boards were in place for each individual room. These identified the name of the patient and any preferred name as well as informing staff of specific requirements suchas infection control precautions, assistance required with moving and handling, mobility or nutrition and provision of any additional nutritional supplements. During our inspection we noted that all door precaution requirements were observed by all staff, including cleaning staff. For example, wearing personal protective equipment such as gloves and plastic aprons before entering the room, and removing them before leaving the room and washingtheir hands.

All staff within the trust received regular infection control training. Documentation showed that all nursing staff completed infection control training and hand hygiene training was carried out every year. For example, we saw that for Ward 21, 95% of staff working on theward had received infection control training.

We saw that the Trust had systems and process in place to ensure that the hospital responded appropriately to incidents of hospital acquired infections (HCAI) or C. difficile. Clinical staff we spoke with were clear about their roles and responsibilities and had received training. We saw that all cases of C. difficile, both community and in-patient, weresubjected to a root cause analysis investigation. The Infection Control Team worked collaboratively with the community team to investigate community and pre-48 hour cases. We saw that outcomes from internal root cause analysis were shared with the Primary Care Trust.

The Executive Team had held risk summits with two wards in the last three weeks prior to our inspection, with another planned for the following week. These were all related to high levels of C. difficile infection and possible cross infection episodes. We were told that directorates and ward teams, including nursing and medical staff were being held to account for their infection control incidents. We were told how the Trust's None Executive Directors (NED) were undergoing additional training in infection control in order to support the Board's monitoring of performance across the hospital.

We saw that the Director of Infection Prevention and Control prepared an Infection Prevention Annual Report for September 2012. We saw that this report provided the Boardwith an overview of infection control activities within the Trust, including the Trust performance with respect to healthcare associated infections, surgical site infection surveillance for replacement hip, knee and fractured neck of femur surgery and surveillance activity for other infections. We saw that the Trust regularly reviewed the ratesof infection and that weekly updates were cascaded to all medical, nursing and allied healthcare professionals. This meant that staff were kept informed of practices, of changes, learning points and actions from incidents of HCAI or C.difficile.


Staffing Met this standard

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement


There were enough qualified, skilled and experienced staff to meet patient's needs.


Patients consistently spoke positively about the staff. They said the staff were polite and nice but they were busy. One person said "The staff are very nice, I have no problems withany of the staff, but they are too busy and don't have enough time." We saw that there was enough staff on the wards. We saw that staff were not rushed when dealing with patients and that call bells heard were answered after a couple of minutes.

As part of our inspection, we looked at the management of surgical patients with the support of an independent specialist advisor in obstetrics and gynaecology. We joined thesurgical doctors' morning handover round. We saw that there were approximately 20 to 25medical staff of all grades and appropriate nursing staff where involved with the handover.

After the handover, we continued with the acute surgical ward round consisting of the previous day's admissions plus those still considered to require consultant input. The round consisted of junior grade doctor, a middle grade doctor and a consultant accompanied by at least one nurse on each ward. We saw that patients who were not on the ward that specialised in their particular condition (outliers) were seen first, starting with patients on the children's ward, then the gynaecology ward, and then the surgical holding area (SSU).

We saw approximately 15 patients being assessed by the surgical consultant and their team. The case notes we inspected were on a random selection of approximately one thirdof these patients. There was helpful discussion of the process as the round continued. We saw that the handover process on Ward 10 was well organised, clearly structured and efficiently run. This showed that the quality of medical input into patient care, as evidencedby the handover, ensured clear information was transferred across the team. We looked atthe recruitment documentation of the covering staff and saw that they had backgrounds with a wide variety of useful skills to support their role. There were no concerns expressed by any of their more senior colleagues about the quality of care provided by any Resident Medical Officers (RMOs).

Patients we spoke with on the Maternity Unit said that they felt the staffing levels were good and that they had not had to wait for assistance. They all said that staff came straightaway when they used the buzzer. A member of staff we spoke with said that if theywere in charge they would increase staffing "numbers on the floor", but said that this was


because new mums had high expectations of their care and wanted one to one care. Stafftold us that one to one care could be provided some of the time but that it would not always be by the same person.

All the staff we spoke with said that there was a problem with staff shortages, but that there had been some recruitment and that new midwives and healthcare assistants were beginning to start work. Staff said the shortages were due to maternity leave and long termsickness.

We saw that where instances of staff shortages were identified across maternity services, in order to manage this, they had redeployed staff from across the departments. Staff we spoke with said that this had not impacted on care as the ratio of staff to patient was still maintained as they were not full.


Supporting workers Met this standard

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement


Patients were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.


In response to some concerns we received prior to the inspection about junior doctors/RMO training and supervision at the hospital we therefore focused on this staff group as part of our inspection. Junior doctors are those doctors in postgraduate training. Residential Medical Officers (RMOs) are usually resident doctors in private hospitals for emergencies and general ward work, and are doctors wishing to study whilst earning a salary.

We spoke with five RMOs who told us that they felt that they had received appropriate training and support. The RMOs felt there was a well functioning surgical team but there was room for misunderstanding by those less familiar with how the surgical unit worked.

The RMOs we spoke with told us a consultant was always available for support.They told us that they had an induction programme and that the quality of the surgical training had improved. The RMOs told us that a process for training and support had been put in place so that when the junior doctors returned to the surgical team, they could supervise them. Some of the RMOs told us that they had had the opportunity to gain skills in the operating theatre. One RMO said "I want to be a surgeon, I love it here".

The Trust had implemented an action plan to improve the training and supervision/clinical supervision of RMOs and junior doctors. We saw that the Trust had increased the number of in house surveys for the junior doctors for evidence of all issues of training. We saw thatthe Trust had ensured that two on-call surgical consultants were available at all times, to provide support to the RMOs and junior doctors.


Assessing and monitoring the quality of service provision

Met this standard

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 had an effective system to regularly assess and monitor the quality of servicethat patients receive.


The Trust had established clinical governance arrangements in place to effectively monitorstandards and performance across The Tunbridge Wells at Pembury Hospital. This included a clinical governance process which is a framework through which NHS organisations are accountable for clinical performance. It exists to safeguard high standards of care.

We looked in detail at the governance process for Women's and Sexual Health directorate which covered maternity services at the hospital. Although this was a newly merged directorate there was a clear governance structure which showed the various groups and committees in place to be able to monitor and assess clinical and operational practices, such as incidents, complaints, resources, midwife supervision.

We saw how risks were effectively identified and recorded for discussion at the Trust executive board level, including the actions being undertaken to manage or reduce risks. This included the use of an early indicator programme to identify potential failing wards so that prompt action could be taken to improve patient experience and safety. We saw how the development of Women's and Sexual Health Clinical Governance newsletter had been used to keep staff informed of practices, of changes, learning points and actions from incidents.

Clinical audits were well organised and regularly undertaken as part of the hospitals assessment of its clinical performance against National institute of Clinical Excellence (NICE) guidelines. The Trust was meeting its projection of the number of clinical audits to be undertaken across the year.

We looked in detail at head injuries clinical audit as we had received some information about poor patient experiences with head injuries prior to the inspection. The audit was detailed and identified recommendations where aspects of clinical practices were not in line with NICE guidelines. A comprehensive action plan was then put into place as to how compliance would be achieved. The action plans were then monitored through a formal process to help ensure improvements to practices were implemented in a timely way. We saw evidence of how actions from audits were discussed at senior level through a


Standards Committee. This helped ensure that learning was shared across the hospital directorates.

We saw evidence of how clinical and operational monitoring tools across the hospital wereeffectively used to help improve patient experience and safety throughout the Trust. For example clinical audits undertaken on falls assessment and prevention and the Health andSafety Committee review of accidents both fed into the development of a falls action plan.

Where the Trust had identified the need for significant clinical or operational improvements, we have seen some variable responses to addressing these in a robust and timely manner. For example, a steering group had been developed to look at ways of improving 'length of stay'. A clear structure and strategy had been put into place in order toprogress this area for improvement.This had been fed back to the Trust prior to our inspection in response to us receiving copies of the Trusts actions plans. At the inspection we looked at the Trust's actions for addressing increases in hospital acquired infections. We saw evidence of how the hospital had responded and that clear actions were being recorded as to what was being done to investigate and improve infection control at the hospital.

There was a process in place to identify key risks across the hospital and what actions were needed to mitigate these risks. For example, the establishment of 'Emergency Services Improvement Programme' to address some A & E performance risks.

We were told how the Trust's Non-Executive Directors (NED) where undergoing additional training in infection control and complaints management in order to support the Boards monitoring of performance across the hospital. We were told that the appointment of NEDs with specialist experiences and skills was also in progress.

We saw evidence how the hospital worked in partnership with other NHS organisations such as commissioning groups who buy services from the hospital and how this had helped to monitor and improve patient safety and experiences. For example partnership working had initiated changes in practices that had helped people who have a learning disability to be more easily identified through their records. This meant that the hospital could plan their support and care. We saw how an external audit of midwifes supervision had resulted in actions to further improve patient safety, through changes in supervision practices and caseloads. The Trust was working with the ambulance service to improve the handover time and experience of patients.

We saw evidence of the effective monitoring of serious incidents (SI) which identified any learning from incidents in order to minimise the risk of them happening again. For example, work had been undertaken in response to the monitoring of falls at the hospital. This had resulted in the implementation of pressure alarm mats, none slip socks, changes to bed linen and the use of wrist bands for staff to easily identify those patients at risk of falls. Data showed that this had reduced the severity of injuries from falls across the Trust.

We saw how learning from incidents was shared with other directorates across the hospitaland Trust. For example, increase in incidents involving patient violence and aggression towards staff resulted in further training in dementia care and conflict resolution being implemented. Staff we spoke with were clear about their reporting responsibilities and felt confident to report serious incidents. This was reflected in national data that showed that ahigher percentage of staff reported incidents compared to other acute trusts.

There were various opportunities for staff to be able to able to feedback their ideas and


influence practices. This included changes to the environment in response to staff concerns about patient privacy and dignity and in clinical practices such as 'manual vacuum aspiration'. National Staff Survey results also confirmed that staff felt able to contribute towards improvements at the hospital.

There were many mechanisms in place for the Trust to obtain feedback on the experiences of patients and their relatives about the quality of the services. This included national patient survey data, feedback surveys and patient groups such as 'Birth Voices'. We saw how feedback had led to initiatives such as the 'normalising births' campaign to improve the experiences of mother and baby. In response to feedback about the potential isolation through the hospital having only single rooms 'quality rounds' had been introduced to ensure patients had regular contact with staff, along with monitoring of call bells.


Complaints Met this standard

People should have their complaints listened to and acted on properly

Our judgement


There was an effective complaints system available. Comments and complaints patients made were responded to appropriately.


There was an accessible complaints process for patients and their representative to follow should they be unhappy with any aspect of their experience at the hospital.

All of the patients spoken with said that they did not have any concerns about their experiences. Patients told us they felt confident to speak to a member of staff or a relative if they had any concerns. One patient said "I would definitely say something if things went wrong, but I have no complaints".

There was a clear process for responding to formal complaints which ensured complaints were managed and any actions and learning resulting from investigations were implemented in order to improve the services provided at the hospital. Significant progresshad been made in recent months to reduce the backlog of complaints and improve overall complaints management. This included the appointment of a new complaints manager. Recent data showed an increasing number of complainants satisfied with the complaints process and improvements in the time taken to resolve complaints.

We looked in detail at four complaints that had been received by the hospital, which also included a long standing complex complaint which we had been made aware of prior to our inspection. We saw that there was a robust method to record the details of the complaint and clear chronology of actions taken to date for each complaint. Investigations were robust in their analysis and were concluded by either being substantiated or not. Complaints we saw whether they were substantiated or not also identified potential learning points which had been noted through the investigation. However, the provider may find it useful to note that there were no clear arrangements in place to ensure the appropriate staff hierarchy for investigating complaints about colleagues, to help ensure a fair and robust investigation. This was because we noted an example where a complaint about a doctor had been investigated by nursing staff, which may not have been appropriate.

In response to learning points from the complaints, changes had been implemented to the ward discharge process, post natal care, breast feeding information, along with staff disciplinary action and training.


We saw how complex complaints were appropriately escalated to the relevant senior staff for review and action. There was a robust process for monitoring complaints which ensured that any patterns or themes could be identified and responded to. This was because reports on complaints were reviewed through the Trust's governance structure. This structure reviewed data and case studies from complaints, to identify trends and develop improvement actions.


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 "governmentstandards".

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 re-inspect 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.


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 ofactions 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 prosecutinga 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.


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 ontheir 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.


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 numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential 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.


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.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 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 thetitle and date of publication of the document specified.

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Inspection Report - Care Quality Commission · Ward 20, Ward 21, Ward 31, the Maternity Unit...

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