Source · CQC inspection
Kettering General Hospital
Provider Kettering General Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region East Midlands
Last inspected 23 May 2024
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (37)
Must-do action 1 of 37
Must do
Caring
The servicemust ensure patients are treated with dignity and respect.
Must-do action 2 of 37
Must do
Safe
The servicemust ensure there is appropriate sight and supervision of patients at all times in the emergency department waiting areas.
Must-do action 3 of 37
Must do
Safe
The servicemust ensure patient risks are fully assessed and mitigated in a timely manner. This includes but is not limited to; tissue viability, falls and deterioration.
Must-do action 4 of 37
Must do
Safe
The servicemust ensure effective systems are in place and fully implemented to treat paediatric and adult patients at risk of sepsis in a timely manner and in line with national guidance.
Must-do action 5 of 37
Must do
Safe
The servicemust ensure national guidance is followed and patients arriving by ambulance receive a face-to-face triage and assessment of their clinical needs.
Must-do action 6 of 37
Must do
Safe
The servicemust ensure that where a patient requires fluid balance monitoring this is effectively implemented.
Must-do action 7 of 37
Must do
Safe
The servicemust ensure that staff reconcile medicines in line with trust policy.
Must-do action 8 of 37
Must do
Safe
The servicemust introduce a system to maintain patient confidentiality in public waiting areas.
Must-do action 9 of 37
Must do
Safe
The servicemust continue the work to ensure patients can access treatment in a timely way and in line with national standards. This includes but is not limited to undergo timely assessments, time to triage, first set of observations, medical assessments and senior reviews.
Must-do action 10 of 37
Must do
Safe
The servicemust ensure staff consistently complete safeguarding documentation in the emergency department and make external safeguarding referrals in a timely manner in line with trust policy.
Must-do action 11 of 37
Must do
Safe
The servicemust ensure the paediatric emergency department is safely managed. This includes but is not limited to ensuring waiting areas are safe and risks are assessed and mitigated; ensuring there is appropriate visual supervision of patients at all times.
Must-do action 12 of 37
Must do
Well-led
The servicemust continue to address previous breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must-do action 13 of 37
Must do
Well-led
The servicemust ensure it introduces a system to improve the security of patient paper notes.
Must-do action 14 of 37
Must do
Well-led
The servicemust maintain secure, accurate, complete, and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user in relation to the care and treatment provided.
Must-do action 15 of 37
Must do
Well-led
The servicemust ensure that there is a clear prescribing audit trail for the supply of over labelled take home medicines.
Must-do action 16 of 37
Must do
Safe
The servicemust ensure a staffing tool that correctly calculates the number of patients in the emergency department, and adequately reflects acuity is used.
Must-do action 17 of 37
Must do
Safe
The servicemust ensure there are enough nursing staff to ensure safe staffing levels are maintained across the service in line with establishment reviews, trust policy and staffing requirements which meet the Royal College of Paediatrics and Child Health standards. This should include but not limited to consideration of demand, acuity and number of staff required.
Must-do action 18 of 37
Must do
Safe
The servicemust ensure all relevant nursing and medical staff are trained to the highest-level of life support and there is an adequate level of staff trained on each shift with these skills. This includes both the adult and paediatric service.
Must-do action 19 of 37
Must do
Effective
The servicemust ensure the needs of patients with a learning disability or autistic people are regularly assessed and they are provided with person centred care.
Must-do action 20 of 37
Must do
Effective
The servicemust ensure that discharge passports are issued for all people with complex mental health and social care needs.
Must-do action 21 of 37
Must do
Caring
The servicemust ensure all mixed sex breaches are reported and appropriate action taken.
Must-do action 22 of 37
Must do
Caring
The servicemust ensure appropriate bathroom facilities are readily available to patients.
Must-do action 23 of 37
Must do
Safe
All staffmust ensure that medication is correct and appropriate to the patient’s situation and needs.
Must-do action 24 of 37
Must do
Well-led
The servicemust ensure any patient record data held electronically is stored on devices which are kept securely within the service.
Must-do action 25 of 37
Must do
Safe
The servicemust ensure there are sufficient numbers of suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs.
Must-do action 26 of 37
Must do
Safe
The servicemust ensure patient observations are completed in a timely manner in line with National Early Warning Score frequency rules to ensure deteriorating patients can be quickly identified and escalated.
Must-do action 27 of 37
Must do
Safe
The servicemust ensure patients showing signs of deterioration or those at risk of sepsis are reviewed by an appropriate grade clinician and treated in a timely manner in line with Sepsis 6 pathways and trust deteriorating patient policies.
Must-do action 28 of 37
Must do
Safe
The servicemust ensure the proper and safe management of medicines. This includes but is not limited to ensuring medication is correct and appropriate to the patient’s situation and needs; ensuring staff follow policies and procedures in managing medicines; weights are recorded when prescribing medicines; staff record the number of controlled drugs administered to patients in the controlled drug register in line with trust policy.
Must-do action 29 of 37
Must do
Well-led
The servicemust ensure effective systems and processes are in place to consistently assess, monitor and improve patient safety and the quality of care provided. This includes but is not limited to ensuring effective processes are in place across all specialistswithin surgery to follow up patients scans and abnormal findings in a timely manner or where quality and/or safety are being compromised.
Must-do action 30 of 37
Must do
Responsive
The servicemust ensure patients receive timely access to treatment. This includes but is not limited to ensuring waiting times from referral to treatment and arrangements to admit, treat and discharge patients are in line national standards.
Must-do action 31 of 37
Must do
Safe
The servicemust ensure there are sufficient numbers of suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs. This includes medical, registered nursing and non-registered nursing staff.
Must-do action 32 of 37
Must do
Safe
The servicemust ensure effective systems are in place and fully implemented to assess and treat patients at risk of sepsis in a timely manner. This includes but is not limited to ensuring antibiotics are administered within 1 hour of suspecting sepsis in line with guidance and to keep patients safe from avoidable harm.
Must-do action 33 of 37
Must do
Safe
The servicemust ensure children and young people have their observation taken as per risk scoring and clinical condition.
Must-do action 34 of 37
Must do
Responsive
The servicemust ensure people have timely access to services such as first definitive tretament for paediatric services and promptly receive the right treatment in line with national guidance.
Must-do action 35 of 37
Must do
Well-led
The servicemust ensure an effective system in place to ensure consistent recording and referrals following child and adolescent mental health service assessments.
Must-do action 36 of 37
Must do
Well-led
The servicemust ensure robust systems and processes are in place to ensure key safety and safeguarding information is handed over when transferring patients between departments.
Must-do action 37 of 37
Must do
Well-led
The servicemust ensure there is a robust process in place to effectively review and update policies in line with national guidance.
Should-do actions (37)
Should-do action 1 of 37
Should do
Safe
The service should ensure it introduces a ligature managed and confidential environment for patients experiencing mental health crisis.
Should-do action 2 of 37
Should do
Safe
The service should ensure there is a clear documented and risk assessed procedure in place for transferring a paediatric patient from the paediatric emergency department to the resuscitation area in the event of an emergency where required.
Should-do action 3 of 37
Should do
Safe
The service should ensure all patients are issued with an identity band at the earliest opportunity.
Should-do action 4 of 37
Should do
Safe
The service should ensure staff follow guidance and provide worsening advice to patients leaving the emergency department before being seen.
Should-do action 5 of 37
Should do
Safe
The service should ensure they introduce a system for prescribing medicines that does not have an over reliance on staff for its safety.
Should-do action 6 of 37
Should do
Responsive
The service should consider how to introduce additional seating for patients waiting for treatment.
Should-do action 7 of 37
Should do
Caring
The service should consider how it improves the relative’s room and signposting to support services.
Should-do action 8 of 37
Should do
Responsive
The service should continue to explore how it improves speciality response times in the urgent and emergency care department.
Should-do action 9 of 37
Should do
Responsive
The service should consider introducing a system to improve the supply of wheelchairs in the department.
Should-do action 10 of 37
Should do
Safe
The service should continue its recruitment campaign to increase the number of registered children's nurses it employs.
Should-do action 11 of 37
Should do
Well-led
The service should ensure that appraisal completion for all medical staff meets trust targets.
Should-do action 12 of 37
Should do
Safe
The service should ensure that basic life support training completion meets trust targets.
Should-do action 13 of 37
Should do
Safe
The service should ensure that 1:1 enhanced care is provided continuously and consistently in line with trust policy and procedure.
Should-do action 14 of 37
Should do
Safe
The service should ensure that clinical waste items should be removed and disposed of promptly.
Should-do action 15 of 37
Should do
Safe
The service should ensure patient privacy curtains are clean, well maintained and replaced in a timely manner.
Should-do action 16 of 37
Should do
Responsive
The service should review the discharge process, including staffing levels, facilities, and flow to ensure the safety of patients.
Should-do action 17 of 37
Should do
Safe
The service should ensure that observation rounds are undertaken in a timely manner to minimise delay in identifying deteriorating patients.
Should-do action 18 of 37
Should do
Safe
The service should ensure treatment for sepsis is done so in line with timescales set out within trust policy and procedure and national guidance.
Should-do action 19 of 37
Should do
Safe
The servicemust ensure staff always follow the correct processes when administering and storing medicines.
Should-do action 20 of 37
Should do
Safe
The service should ensure systems for reconciling patients medicines are embedded to ensure patients are provided with their usual medicines and these are considered when making medication decisions.
Should-do action 21 of 37
Should do
Effective
The service should ensure that staff have adequate dementia and learning disability and autism training to ensure appropriate care is provided at times when specialists are not available.
Should-do action 22 of 37
Should do
Caring
The service should ensure electronic patient data boards on wards protects patient confidentiality.
Should-do action 23 of 37
Should do
Effective
The service should review patient outcomes and ensure they have action plans in place where they do not meet national standards.
Should-do action 24 of 37
Should do
Well-led
The service should ensure that records trolleys on wards are always kept closed and locked when not in use.
Should-do action 25 of 37
Should do
Well-led
The service should ensure that trust managers are visible on wards.
Should-do action 26 of 37
Should do
Responsive
The service should consider engaging more pro-actively with equality groups and other stakeholders in the wider community to improve patients’ experience.
Should-do action 27 of 37
Should do
Safe
The service should ensure clinical areas consistently meet expected infection and prevention control measures.
Should-do action 28 of 37
Should do
Responsive
The service should ensure processes are in place to re-book cancelled operations within set timeframes.
Should-do action 29 of 37
Should do
Well-led
The service should ensure systems and processes are in place to ensure staff are reporting incidents so that learning can be identified, and improvements made.
Should-do action 30 of 37
Should do
Safe
The service should ensure staff complete mandatory training, including but not limited to life support training, safeguarding and learning disability training and to ensure there are effective systems to monitor compliance with trust targets.
Should-do action 31 of 37
Should do
Well-led
The service should ensure all staff receive a yearly appraisal.
Should-do action 32 of 37
Should do
Safe
The service should ensure sterile water is safely stored in all areas.
Should-do action 33 of 37
Should do
Responsive
The service should ensure children and young people receive the right care in a timely manner.
Should-do action 34 of 37
Should do
Well-led
The service should ensure there is a system in place to monitor actions taken where compliance of cleaning reusable items does not meet the target.
Should-do action 35 of 37
Should do
Well-led
The service should ensure managers have effective governance arrangements in place to identify risks to quality and safety and take action to mitigate them.
Should-do action 36 of 37
Should do
Responsive
The service should implement a system to ensure children and their families are kept informed when surgical procedures are running late.
Should-do action 37 of 37
Should do
Well-led
The service should consider implementing a system to ensure an effective storage of patient records. This includes but is not limited to accessible medical and nursing records.