Dartford and Gravesham NHS Trust

Updated 22 August 2019

Dartford and Gravesham National Health Service Trust provides a range of acute services across Kent to approximately 350,000 people a year.

The trust has around 463 inpatient beds and provides specialty services including day-care surgery, general surgery, trauma, orthopaedics, cardiology, maternity and general medicine.

The trust has a team of around 3,400 staff.

This trust has five registered locations:

• Darent Valley Hospital
• Gravesham Community Hospital
• Queen Mary's Hospital
• Erith & District Hospital
• Elm Court

Updated 22 August 2019

Our rating of the trust improved. We rated it as good because:

• Effective, caring, responsive and well led were good.
• Safe was rated as requires improvement overall.
• Services had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
• The trust managed patient safety incidents well. Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support in line with the duty of candour.
• The trust provided care and treatment based on national guidance and evidence of its effectiveness. The trust had a programme of internal audits and participated in national audits and research projects. Trust policies and clinical guidelines reflected national guidance from the National Institute for Health and Care Excellence and other national bodies.
• There was effective multidisciplinary working to improve patient care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• The trust planned and provided services in a way that met the needs of local people. They worked collaboratively with commissioners, local authorities and other partner organisations.
• The service treated concerns and complaints seriously. Complaints were investigated, the trust was candid with complainants and they learned lessons from their complaint investigation findings.
• The trust had an effective system for identifying strategic risks or planning to eliminate or reduce those risks. Robust arrangements were in place for identifying, recording and managing risks, issues and mitigating actions. The trust board had sight of the most significant risks.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The workforce strategy reinforced the trust’s values with the core message ‘Our Family, Caring for Yours’. The development of the trust’s values involved focus groups with over 300 staff involved. Staff developed the values and they were aligned to the core knowledge and skills framework, national leadership standards and codes of professional conduct.

However:

• The urgent and emergency care service did not mirror the general findings of the hospitals services. The leadership of the service did not have sufficient oversight of the quality and safety of the service provided.
• While the trust had controlled infection risk well and there had been a significant improvement in practice, we observed poor practice in relation to the use of personal protective equipment and that several staff were not ‘bare below the elbow’ in the emergency department.
• In urgent and emergency care, patients did not always receive treatment within agreed time frames and national targets.
• In urgent and emergency care, staff treated patients with compassion and kindness. However, because of the constraints of the physical environment, it was not always possible for staff to respect patients’ privacy and dignity and maintain their confidentiality.
• The average length of stay for non-elective surgery at the trust was worse than the England average and showed little improvement since our last inspection.
• There was poor compliance to safeguarding adults training for nursing and medical staff.
• There was no Mental Capacity Act specific training at the time of the reporting period. The trust advised that a new course was introduced on 1 April 2019.

Updated 22 August 2019

Updated 22 August 2019

Updated 2 July 2014

We found that A&E had the potential to be unsafe as there were insufficient numbers of appropriately skilled staff to deliver care. This was because there were not enough nurses qualified in the care of children and the medical staff team was not staffed to the agreed capacity and skill mix. The triage system in the minors area led to some patients’ needs not being assessed in a timely manner as it was not clear that patients were required to wait to attend triage in one area and then book in and wait in another area. Staff were not always able to access current national and best practice guidelines to deliver safe effective care. Staff were caring and responsive about patients’ needs but did not always maintain patient privacy. We observed examples of good individual leadership at department level but there was evidence that ongoing safety issues, for example insufficient substantive staffing, had not been resolved at a higher level.

Updated 2 July 2014

Overall, the standard of care and treatment in medical care was good. Teams were well-led and supported by leaders at all levels in the service. Staff were listened to and had access to specialist training. There was positive feedback from the patients, relatives and visitors who we spoke with. They described caring and responsive staff who met their treatment needs. On a number of wards changes had been introduced in October 2013. These included increased staffing numbers. During our visit we could see that improvements were taking place. However, there had been insufficient time for many changes to have become embedded. This meant that the hospital was still improving against current performance indicators. Patient records were generally up to date with full details available to ensure that staff could provide safe and consistent care. The use of window bays, witnessed during the unannounced visit, showed that there was pressure on the hospital to cope with the level of demand. Staff were concerned about the use of ‘window bay beds’ and the potential impact on quality and safety.

Updated 2 July 2014

In the main children’s department parents told us that staff were responsive to their needs and that they listened to them. They were included in decisions about the care and treatment of their children. They said staff responded quickly to requests for assistance. Patients received safe and effective care and treatment. The environment was well maintained and engaging for young people. There were sufficient numbers of staff on the wards and in the outpatient area, and there was a system for the management of staffing levels and skill mix to ensure children were cared for safely. 

This was not the case in the A&E department where there was an insufficient number of nurses qualified in the care of children. We also found in the A&E department that national guidance was not being followed in relation to the management of pain in children. 

The trust was monitoring the quality of the service and making changes were they were needed. The views of children and families were being used to inform the service provision in the main children’s department. There was a team in place to monitor and address any safeguarding concerns, and the trust had planned further developments.

Updated 2 July 2014

We found that the intensive care and critical care service was safe and effective, performing within expectations for a unit of its size according to the Intensive Care National Audit and Research Centre data. It was responsive to the needs of patients and had caring and attentive staff. We found that the unit was well-led. Pressure was placed on the unit when transfer of patients was delayed due to bed occupancy challenges faced by the trust. Though the unit coped with the situation, these patients were cared for in a mixed sex environment and had to use the bathroom and toilet facilities in the adjacent ward.

Updated 2 July 2014

We found that end of life care provided at the trust was safe, effective, caring, responsive and well-led. The trust no longer used the Liverpool Care Pathway and was in the process of reviewing its end of life pathway. The palliative care team worked closely with staff on wards to ensure that patients had individualised end of life care provided in a positive, supportive environment. The team also had close links to community services. Patients and their families were involved in decisions about care and treatment in a dignified, respectful manner. Staff spoke positively about the support they received from the team. They felt this improved the patient experience and ensured patients received choices regarding end of life care and treatment.

Updated 2 July 2014

We found that the midwifery unit provided safe and effective care for women. Feedback from women using the service was positive. They told us that staff were kind and sensitive to their needs and that they were given effective advice and support in their chosen method of feeding their babies. The service was well-led with clear shared goals and objectives which were known to all staff we spoke with. Women said they had been well supported throughout their stay in the maternity services.

Updated 2 July 2014

The main outpatients department was a large area, with good access and seating for patients. Patients received effective treatment and information and felt happy with the care they received. The trust was monitoring appointment targets for waiting times and clinic start and finish times. It had sought the views of patients, and we saw that it had listened and responded to patient feedback by changing the layout of the department. Clinics were well managed and organised. When unavoidable delays occurred and clinics ran late, staff kept patients informed and provided them with information. Staff told us that they received training and supervision to enable them to provide effective care. All staff we spoke with told us that outpatients was a positive environment to work in.

Updated 2 July 2014

Patients generally received safe and effective surgical care. We saw that some wards worked with fewer staff than needed. However the trust was aware of this and recruitment had taken place. A number of staff were due to commence employment in the new year. There was a multidisciplinary approach to providing effective patient care. 

Staff we observed were caring. However, patients’ privacy and dignity were not always maintained. Staff responded appropriately to changes in patients’ care and treatment. Staff told us how they responded to the increased workload when admission numbers increased, particularly when extra beds were placed on the ward. However, actions the trust was taking to respond to fluctuating demands of the organisation did not prevent these situations reoccurring. Staff told us they worked in a well-led organisation. They told us the culture was open and transparent, and there was a clear willingness by all staff to learn.