A summary of our findings about this service appears in the Overall summary.

Kettering General Hospital is an established 576 bed general hospital, which provides healthcare services to North Northamptonshire, South Leicestershire and Rutland. The trust provides a comprehensive range of specialist, acute, obstetrics and community-based services. The trust also provides regional cardiology services to the wider Northamptonshire and surrounding areas.

The Care Quality Commission (CQC) previously carried out a comprehensive inspection between the 2 and 4 September 2014 which found that overall, the trust had a rating of 'requires improvement'.

We carried out a focused inspection on 10 February 2016 due to information of concern regarding the hospital’s emergency department (ED) and also the use of escalation areas. These escalation areas are reported in the medical care section of this report. These are clinical areas in the hospital not normally used for caring for patients overnight however are opened to accommodate patients due to high demand for beds and patient flow pressures across the hospital. Concerns had been raised regarding the quality and safety of patients being cared for in the corridor area of the ED and also in some of the escalation areas being used at times of peak demand for beds in the hospital. During the past year, attendances at the ED had risen by 6%. The inspection was conducted during the evening of one of the days of the junior doctors’ strikes which had run from 8am on 10 February 2016 to 8am the next day.

Our key findings were as follows:

• Staff were caring and considerate towards patients and their families during our inspection.
• Patients who required prioritisation of treatment in the emergency department (ED) were not always identified in a timely way, leading to delays in care. We escalated this immediately to the executive on call, who took immediate actions to address this on the day of the visit and the trust then took a series of actions following the visit to put systems in place to maintain oversight of this concern.
• Patient records lacked sufficient detail to ensure all aspects of their care was clear. Risk assessments, including skin damage assessments, were not always completed and there was a lack of recording of the care and treatment given whilst patients were within the ED.
• Patient records within the paediatric area of ED were not always stored securely and were accessible to anyone who entered.
• Staffing within the paediatric ED was not always sufficient to ensure a paediatric trained nurse was present to care for children. We escalated this immediately to the executive on call, who took immediate action to ensure a qualified nurse was present in the paediatric ED whenever it was open. Following the inspection, the trust put in place a series of actions to address this concern.
• The entrance to the paediatric ED was not restricted and could be accessed by all hospital staff, patients and the public. We escalated this immediately to the executive on call, who took immediate action to ensure a qualified nurse was present in the paediatric ED whenever it was open. Following the inspection, the trust put in place a series of actions to address this concern.
• Patients’ privacy and dignity was not always respected whilst being cared for in the corridor of the ED.
• The department was not meeting the national performance measure to admit, transfer or discharge 95% of patients within four hours, with performance consistently below the national average since October 2014.
• There was a lack of effective risk management oversight governing the use of the corridor area in the adult ED, with a lack of clear policies and effective risk assessments for this area being used to provide care and treatment for patients. During our inspection, the trust took immediate actions to ensure the safety of patients in ED and immediately following the inspection provided a detailed action plan to deliver a programme of actions designed to sustain and embed the required improvements.
• Escalation areas in medical care areas and wards were being used at peak times of demand for beds to facilitate patient flow through the hospital.
• Nurse staffing levels and skill mix had been managed to meet the needs of the patients in these escalation areas. Extra nurses were booked for each shift to manage patients in escalation areas.
• Clinical operations managers reviewed every patient in an escalation area at the start of each night shift to ensure the placement was appropriate.
• Patients in escalation areas were reviewed by a consultant-delivered ward round, at least once every 24 hours, seven days a week.
• Emergency equipment, including equipment used for resuscitation was checked daily in escalation areas.
• Assessments for patients in escalation areas were generally comprehensive, covering all patients’ health needs.
• Patients’ pain was assessed and reviewed regularly. Appropriate pain relief was given as prescribed when required.
• The trust had been working with Commissioners and external providers to determine new ways of working to reduce demands upon the trust. At the time of the inspection these measures had not yet delivered improvements.
• Numbers of patients with a delayed transfer of care had remained high over the past two months, however, the number of patients outlying on other speciality wards had reduced in the past two months, due to change in bed management processes.
• Generally, effective systems were in place regarding the use of escalation areas in the hospital and senior staff had an effective oversight of the risks to patient safety.
• Most staff had an understanding of the escalation area usage and admission criteria. They understood the need to move staff to meet patient needs, but some staff felt under pressure due to this.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure effective systems are in place to monitor and address risks to the safety and quality of patient care in the ED.
• Ensure that all patients presenting to ED receive appropriate and timely assessments of needs and that effective care and treatment is provided in a timely way.
• Review nurse staffing within the paediatric ED to ensure a paediatric trained nurse is present to care for children.

In addition the trust should:

• Ensure patient records including risk assessments in ED contain sufficient detail to ensure all aspects of their care is clear.
• Ensure all records in the paediatric ED are always stored securely.
• Ensure patients’ privacy and dignity is respected whilst being cared for in all areas of the ED.
• Review and monitor the security and access to the paediatric area to ensure risks of unauthorised entry are addressed.
• Ensure effective systems are in place to monitor the risks to the quality and safety of patient care in the ED and fully embedded throughout the whole staff team to ensure effective oversight and management of risks.
• Ensure data is collected and monitored regarding patients transferred under the ‘Early Flow Discharge policy’ to maintain an oversight of potential risks.
• Review the storage patients’ records in escalation areas to ensure they are stored securely.
• Ensure medicine fridge temperatures are checked regularly in all escalation areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We visited wards throughout the hospital over two and a half days. The wards we visited included those that specialised in medical, surgical, and orthopaedic treatments. We also visited the accident and emergency department, outpatients departments, and a ward for children.

Patients told us that staff were invariably polite, friendly, and despite often being very busy the nurses and healthcare assistants responded in a timely way to requests for assistance.

We were told that people felt safe on the wards because security was taken seriously by staff and there were practical precautionary measures in place, such as electronically locked doors that could only be opened from the outside by someone who had been issued with an authorised ‘swipe card’.

We observed some instances where patients could have been treated with more consideration when they were still awaiting treatment. We also found that some visitors were unhappy that information they had shared with staff, and which had been relevant to the care of their relative, had not always been effectively passed on to the next shift of staff arriving for duty.

The majority of patients we spoke with, however, had no complaints about the way they had been treated or cared for and praised the staff for their “good work."

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

• We rated safe, effective and responsive as requires improvement and caring as good.
• The overall rating for well led at the core service level was requires improvement. However, we rated well led trust wide, which is a separate rating, as good.
• We rated four of the trust’s core services as requires improvement and four as good. Diagnostic imaging is considered an additional service and was rated as good.
• During this inspection we did not inspect surgery, critical care, children and young people or end of life care. The ratings published following previous inspections are part of the overall rating awarded to the trust at this time.