This inspection included visits to the following wards: Cambridge K, L and M1, the Clinical Decisions Unit (Male and Female) and Richard Stevens Stroke Unit. We observed and talked with eight patients on the wards and spoke to 14 staff of different levels, including ward managers and junior Drs. We focused on patients in the wards who had reduced mental capacity and needed additional support to understand their treatments and care in the hospital, for example people who had dementia or learning disabilities. Patients told us that they felt well supported by the staff and we observed polite, unrushed interactions between patients and staff when people were being helped to make a decision.

All the staff we spoke to were aware of their responsibilities to support people to make decisions about their care and treatment, if they had reduced capacity and had direct access to the guidance and policies to follow. The trust had increased the level of training and support provided so that staff were able to obtain further advice if needed.

We spoke with eight patients on Cambridge J, five patients on Cambridge K, three patients and two visitors on Cambridge M1. On Kings A2 we talked with nine patients, on Kings C1 we talked with four patients and two relatives, and on Kings D1 we talked with four patients.

Everyone said that their privacy and dignity was protected and promoted. People said staff always pulled the curtain around their bed before any treatment. On Cambridge J a person said. ‘They treat me with respect here’. On Cambridge K a person said, "They always pull the curtain around and knock on the toilet and shower doors". On Cambridge M1 a person commented, "Staff speak loudly and clearly enough. Always draw the curtains. They come quickly and they don’t rush me if I need to use the commode". On Kings C1 a person said "Yes, staff always speak with kindness and care. Always pull curtains etc". On Kings A2 a person said, "Yes, curtains always drawn and they help with the toilet." On Kings D1 a person commented, "Yes staff are always respectful. They always pull curtains but often forget to pull them back again!"

People said they had been given sufficient information to make a decision and consent to their care and treatment.

Relatives of people who had dementia or confusion commented, "there is a lack of awareness of advanced dementia." They were referring to staff asking the person questions and not being aware of when the person had capacity or not.

People spoke very positively about the care and treatment they had received. On Cambridge J a person said, ‘This ward is top dog, I have no complaints at all. They don’t rush me and they keep me informed, they show me my records and results’. On Cambridge K people said, ‘They have been brilliant, nothing has been too much trouble’. On Kings A2 people said they were given the information they needed about their care and treatment. On Kings C1 one of the relatives said that the staff communicated with them because they were the next of kin and they had been given good information, "The risks and benefits were explained before surgery."

Some people on Cambridge M1 said that they were not given enough information about their care and treatment because staff did not have the time to speak to them. However, despite saying that the staff were busy, one person said, "The care I have always received at William Harvey Hospital is world class and I've never felt unsafe here. There have been hospitals in the UK where I have felt unsafe but not here."

On all the wards people said they were satisfied with the food provided. One person said, "The food is brilliant and I am looked after well... you can have extra if you want it." Another person said, "The food is served hot, I have no complaints about the food. There is a choice and I am given time, I am never rushed." People said that there was a good range of choices of food. One person commented, "The food is pretty good. There are three choices. The last two mornings I have had a cooked breakfast."

People said the food was good but it was not always hot. People also commented that by the time they got "…the ice-cream it had turned to liquid."

People said they were impressed with the standard of hygiene and cleanliness in the wards. They said that the wards were clean and that they saw cleaners come everyday and the care staff cleaned too. They commented "…cleaning staff come round two or three times a day cleaning." "The sheets are changed every day, the ward is very clean." There was only one negative comment and that was on Cambridge M1 and again related to there not being enough staff to carry out tasks in a timely way.

A person on Kings A2 said, "Staff are straightaway your friend when you come in. There are plenty of them too." They said staff were available to help when they needed assistance. One comment was "…yes they are, sometimes have to wait a little, they are run off their feet." One person on Cambridge J commented, "The staff are pretty good." "Sometimes they rush, but usually they are good."

People we spoke to said that their call bells were answered quickly apart from people on Cambridge M1.

On Cambridge M1 people were concerned about the lack of staff. They said this had meant that some people had to wait for assistance.

People said, "The staff are very nice, very pleasant". "The nurses are happy, I do not know how they manage it and stay happy as they are very busy".

People said they felt confident in the staff who were supporting them.

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.

People told us that they “were not given a lot of information prior to or soon after admission to the ward”. They said that “The nursing care has been very good”, and that “Nurses were so patient”.

They also said that sometimes care staff can be rushed, and perhaps there should be more care staff on the ward. We spoke with two people who both told us that care staff treated them with kindness and respect at all times, and that they felt safe on the ward.

Everyone we spoke to on Bethersden ward said that they were satisfied with their care and treatment. People told us that even though the staff appeared busy, they always had time to talk to patients and ask how they were.

People said that they felt safe and that their privacy and dignity was respected. People said that they were kept informed about their care and treatment and had been given choices and options of treatment when available.

We inspected services for children and young people at the William Harvey Hospital on 24 and 25 October 2018. The inspection visit on 24 October was unannounced and began at approximately 8.30pm.

This responsive inspection was undertaken because we had received concerning information from members of the public and staff about the Emergency department and children’s inpatient wards. We had also identified concerns about the care of children during our May 2018 inspection when we inspected the emergency department and operating theatres but did not review services for children and young people as a separate core service.

As part of this inspection, we reviewed the care and treatment of children and young people from birth to 18 years in the two acute hospital sites with children’s inpatient units. Some outpatient services for children are provided at the Kent and Canterbury Hospital site and from Buckland Hospital in Dover, but there are no inpatient services there. We did not inspect clinics or community services as the inspection was focused on the areas of concern.

We rated the children and young people’s services at William Harvey Hospital as Inadequate overall. We fed back our immediate concerns to the chief executive officer, the director of nursing and quality, the medical director and the quality improvement programme lead.

The services for children and young people were not safe.

• Staff do not recognise concerns, incidents or near misses. When concerns were raised or things went wrong, the approach to reviewing and investigating causes was insufficient or too slow. There was little evidence of learning from events or action taken to improve safety.
• Frequent staff shortages increased risks to children and young people who used the services.
• There were inconsistent infection, prevention and control practice.
• Medical records were not stored securely.
• There was poor oversight of medicines management.
• Staff did not have assurance all equipment was clean, fit for purpose and ready for patient use.
• Staff did not assess, monitor or manage risks to people who use the services. Opportunities to prevent or minimise harm were missed.

The services for children and young people were not effective.

• Clinical audits were not being completed within the scheduled timeframes which meant there were no current performance indicators for the trust against national standards.
• There was confusion amongst staff on how to access policies and guidelines.
• There were gaps in the seven-day service provision that meant children had to be treated in adult environments by adult staff.
• The compliance rates for appraisals were worse than the trust target.
• Staff had limited training in the management of children with mental health needs.
• Ward rounds were not multidisciplinary which was a missed opportunity to plan and co-ordinate patient care and treatment.
• Fasting times before surgery did not follow current best practice and put the needs of the service before the needs of the children.
• There was no recognition of the psychological needs of children and young people in the operating theatre environment.
• Pain thresholds were not assessed in a timely manner.

Improvements were needed in the care and compassion shown to children and families.

• People were not always treated with kindness or respect.
• Staff did not see people’s privacy and dignity as a priority.
• There was an inadequate psychology service for children with diabetes.
• There was poor provision of paediatric mental health advice and assessment.

The services for children and young people were not responsive.

• Minimal effort was made to understand the needs of the local population. The services were planned and delivered without consideration of people’s needs.
• The provision of service to meet the needs of children with mental health or learning disabilities was insufficient.
• The facilities and premises used do not meet people’s needs.
• Children and their families were frequently and consistently unable to access services in a timely way for an initial assessment, diagnosis or treatment. They experienced unacceptable waits for some services.
• Staff did not understand the pathway for children within the emergency department.
• There was little evidence to show concerns and complaints led to improvements in the quality of care.
• Lack of children services 24 hours a day led to children being cared for in adult designated areas within the emergency department.

The services for children and young people were not well led.

• The services did not have a clear vision or strategy.
• Continuous improvement, and learning from when things go wrong was not evident across all areas.
• Governance and risk management processes were ineffective and provided false assurance to the board.
• Significant issues that threaten the delivery of safe and effective care were not identified or adequate action to manage them was not always taken.
• There was little evidence of innovation or service development. There was minimal evidence of learning and reflective practice and the impact of service changes on the quality of care is not understood.
• The NHS Staff Survey results for 2017 showed that overall the trust was in the worst 20% of trusts nationally for staff engagement. The results had worsened for many key findings since 2016.

We saw several areas of good practice including:

• Staff interacted well with babies and used different methods of distraction to keep them calm.
• Children and young people services did consistently well in the friends and family test.
• Staff had a clear understanding of their safeguarding role and responsibilities and there was an effective system to provide prompt child protection medicals when needed.
• The trust had a flagging system for children with learning disabilities so patients arriving in accident and emergency departments would be identifiable.
• Staff had a sound understanding of the need for informed consent to be obtained before providing care or treatment.
• There was good teamwork amongst staff and staff strived to support their peers.

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

Importantly, the trust must:

• Provide suitable accommodation for children and young people with mental health problems.
• Review their booking and triage processes to ensure all staff are clear about the pathway children take through the emergency department and to minimise the time before they are assessed by a qualified children’s nurse.
• Ensure that equipment checks required by trust policies are carried-out.
• Ensure the safe management of medicines.
• Ensure that clinicians are aware and follow trust policy and national guidance on the safe management of deteriorating children, sepsis identification and management.
• Ensure that children wait in the children’s waiting area at all times. They must not be exposed to volatile behaviour, inappropriate television programmes and unpleasant sights and sounds in the adult waiting area.
• Review the care of children aged 16 years to 19 years and ensure that their needs are fully considered.
• Ensure submission of data to national audit programmes to allow benchmarking against other children’s services and to drive improvements.
• Ensure that they adhere to a local audit plan and use the results to drive service improvements.
• Carry out a learning needs analysis for nursing staff working with children and young people to assist in identifying what training is necessary and where there are gaps in staff skills and knowledge.
• Ensure that staff are provided with the necessary training and support to ensure they can carry out their work competently.
• Ensure compliance with the Health and Social Care Act 2008: code of practice on the prevention and control of infections. To include ensuring there are appropriate isolation facilities in the children’s emergency department for children with communicable diseases.
• Review their policy and usual practice on pre-operative fasting for children to ensure it is aligned to national guidance.
• Ensure that up to date policies and protocols are available to staff.
• Ensure that the needs of children and young people presenting in mental health crisis are considered and met.
• Ensure the views of children and young people are taken into consideration to aid service provision and make sure the care and treatment meets their needs and reflects their preferences.
• Ensure that there are no breaches of the four-hour admission to treatment target for children attending the emergency department.
• Develop a clear vision for children’s services that is recognised and shared by all staff caring for children and young people.
• Ensure that data and information provided to the board is an accurate reflection of the services being provided to avoid the risk of false assurance.
• Undertake an assurance review of their children’s service to identify gaps in their assurance and governance processes.
• Ensure that there is clear, accountable leadership of services for all children from birth to 18 years (and beyond 18 years for looked after children and children in need).

In addition, the trust should:

• Provide staff with training in the care of children and young people with autism and learning disabilities.
• Ensure that the pathway for providing care when a child dies is known and understood by all staff likely to be affected.
• Provide all staff including senior leaders with training in equality and diversity.
• Consider providing customer service training for reception staff in the emergency department.

Professor Edward Baker

Inspector of Hospitals