Kettering hospital’s children’s services rated inadequate by CQC

Kettering General Hospital’s services for Children and Young Persons have been rated as inadequate following an inspection by the Care Quality Commission (CQC).

The CQC carried out an unannounced inspection following worrying reports from members of the public and found many of the services for children and young people were unsafe and not well-led.

The inspectors rated the service as inadequate overall after finding that:

• Not all staff had completed mandatory training, including for the highest level of life support
• The service did not always control infection risk well
• The design, maintenance, facilities, premises and equipment did not always keep people safe
• Staff did not always complete and update risk assessments for each patient
• Risks were not always removed or minimised
• Staff did not always effectively identify and quickly act upon patients at risk of deterioration
• The service did not always have enough nursing or medical staff
• Records were not stored securely
• The service did not always use systems and processes to safely prescribe, administer, record and store medicine
• Improvements following lessons learnt were not always fully embedded or sustained.

Dozens of families complained to BBC about the services at KGH

The BBC first reported about the safety concerns of KGH in February, and since then, “dozens” more families have come forward, it says.

One woman, Michaela Stevens, told the BBC, that her son Archie is “lucky to be alive” following his treatment on the on Skylark paediatric ward at the KGH. Archie, who was just 17 months old at the time, lost 1.1lbs while on the ward.

Another parent, Michelle Morrison, said she was repeatedly asked to sign a do not resuscitate (DNACPR) form, after her son was diagnosed with Menkes disease.

At four years old, her son Owen was admitted to KGH after having a seizure. She was told by staff at the hospital that he has been placed end-of-life pathway and would not survive the night. However, Owen quickly recovered when he was transferred to Leicester Royal Infirmary (LRI).

In 2018, Michelle bought Owen in to KGH after finding blood in his stools, but he was discharged after four days. Two weeks later, he suffered three cardiac arrests and died. An inquest into his death would that he probably died as a result of a perforated bowel linked to an untreated gastric bleed.

Michelle told the BBC she thinks the hospital “could have done more” to save him.

A lack of training, poor adherence to risk assessments and unclean premises

These reports from concerned and bereaved parents align with what the CQC found in their inspection. For example, the inspectors found that staff did not always keep up to date with mandatory training, such as infection control (81%), sepsis (81%) and new-born basic life support (67%).

Furthermore, staff did not always complete and update risk assessments for each patient, and risks were not always removed or minimised. For example, assessments of patient’s nutritional needs had not been completed in 70% of the records which were viewed, and only 50% of risk assessments for pressure ulcers had been completed.

Sepsis screening was not always completed in line with trust policy and there were some delays in the sepsis 6 screen being completed. For example, one patient was not screened for the first 17 hours of admission, while another, who had later been diagnosed with sepsis, was not screened for more than seven hours.

The inspectors also found that ward areas were not always cleaned and well-maintained. They found dirt in the bathrooms, dirty potties, dust on cot rails and dusty equipment. There were no stickers on any medical equipment to say when it had last been cleaned.

Many of these issues were caused or exacerbated by staffing shortages, and the report found the service “did not have enough nursing staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment.” There was also a shortage of consultants and registrars, but these gaps were mitigated by agency staff.

Parents on the ward told the inspectors that “staff were trying their best but did not have the time to provide their child with the level of care needed”, particularly where a child had complex needs.

KGH now required to improve multiple areas

The hospital has been served a warning notice and it is now required to improve multiple areas including medicines management, risk assessments, identification and treatment of sepsis, fluid balance monitoring, safeguarding processes, learning from serious incidents, and equipment and environment risks.

The trust’s chief executive has apologised to the families who felt let down.