KGH given warning notice after concerns over patient falls

Kettering General Hospital is not learning its lessons when vulnerable patients fall over despite several serious incidents caused by a lack of staff knowledge.

A highly critical report released today (Wednesday) by the Care Quality Commission (CQC) found the Rothwell Road hospital is failing to meet two of its legal care requirements, with a warning notice issued by the health regulator.

After an inspection the hospital's rating for medical services has been dropped to inadequate, the lowest possible, with a series of vital improvements ordered by the CQC.

Hospital bosses say their staff have "taken the concerns to heart", that patient falls are now at their lowest in two years and that they have taken immediate action and developed new ways of working to address the issues.

CQC inspectors visited the hospital in early May after concerns about patient falls and found mandatory training was not being undertaken until months later despite serious incidents.

Bernadette Hanney, CQC’s head of hospital inspection, said: “Our inspection of medical services run by Kettering General Hospital NHS Foundation Trust found a number of areas where improvements were needed to ensure patients are cared for in a safe and secure environment in order to prevent the risk of falls.

“There have been several serious incidents resulting in harm from falls where a lack of staff knowledge was identified as the cause, yet mandatory falls training was not undertaken until months later.

“It was also concerning that related to this, lessons weren’t being learnt and preventative actions to reduce the risk of people being hurt were not consistently implemented across the service."

Prior to the inspection the CQC reviewed serious incident investigations which had occurred between December 2019 and March 2021. They found recurrent themes in these reports which led to or contributed to harm such as poor assessment of falls risks.

During the inspection a number of patient records were examined which found flaws in assessments which could reduce the likelihood of a fall, with inspectors noting that staff did not effectively deal with specific risk issues to prevent patients from falling.

Lying and standing blood pressures were not always recorded for all patients above 65 years of age or those with a medical condition that would increase the risk of falling.

Not all patients at risk of falling wore a yellow falls risk wrist band, as required by the trust policy, with ten out of 18 patients assessed as being high risk not wearing one.

Bed rails were involved in some of the serious incidents where people had been hurt, and inspectors found they were used unnecessarily in six out of the 18 patients reviewed.

Of 18 reviewed patient records falls assessments were not fully or accurately completed in 15 of them.

Not all patients at risk of falling had a falls hazard sign on the wall above their bed, with 12 of 18 reviewed patients not having the required sign. Staff on Cranford Ward told inspectors they did not use them as they did not stick to the wall.

Two patients who were at risk of falling did not have anti-slip footwear in place. Cohort bays were being left unattended by staff leaving the bay, varying in length of time from less than a minute to 15 minutes.

The report said just one-in-three relevant staff had completed falls prevention training, which was mandated by April 1.

Nurse staffing levels during the inspection were below planned levels on five out of six wards they visited, with the service "not always having enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm".

And the hospital's ageing design and layout was also found to be an issue, with areas like corridors and bathrooms being used as storage spaces which posed a trip hazard.

Ms Hanney said: “However, inspectors did observe improvements on Naseby Ward where there had been several serious falls incidents. The number of beds had been reduced which meant staff were better able to use the space to keep eyes on people who were at a high risk of falls.

“The trust knows where we expect to see improvements. We will continue to monitor the service closely to ensure the necessary improvements are made.”

Following the inspection, CQC told the trust it must make several improvements, including:

- All staff involved in the care of patients must receive effective training in falls prevention and management.

- Staff must be competent in their roles and processes must be in place to assess staff competency.

- The trust must ensure environmental risks are appropriately assessed and mitigated.

- Effective systems must be in place to assess and mitigate individual patient safety risks, including handovers where patients are transferred.

- Effective systems must be in place to identify and share learning from incidents to prevent further incidents from occurring.

- Complete and accurate records must be maintained that support effective risk management and describe the care and treatment delivered to patients.

Kettering General Hospital’s director of nursing and quality Leanne Hackshall, who is overseeing the trust’s work in this area, said: “We welcomed the CQC’s very detailed inspection of how we try to prevent patients from falling and hurting themselves while in hospital.

“Our staff have taken the concerns to heart and we have undertaken an immense amount of focused work with our teams to address the CQC’s findings and the early indications are that there is now a much better understanding of falls safety amongst our staff, easier to follow guidance on key daily actions, and that staff are carrying out all the appropriate checks and documenting them.

“As a result, the data is suggesting that we are starting to make real progress in this area.

"Since April 2021 the total number of patient falls has decreased and is now at the lowest it has been over the past two years.”

A KGH spokesman said that over the last seven weeks they have worked to make rapid improvements in their systems and processes to better safeguard patients from harm.

They say they have:

- Revised the documentation associated with the assessment of the use of bedrails and introduced new training to ensure staff know how to effectively assess risk.

- Revised care planning documentation to enable staff to maintain continuous records of risk and action.

- Introduced “bay tagging” where nursing staff ensure someone is available in the ward bay to cover their post if they need to leave. This means, where appropriate, there is always someone present in the bay to reduce the risk of falls.

- Refreshed and reproduced yellow ‘visuals’ that clearly identify the bay that is ‘tagged’ or the patient that is at risk

- Introduced greater digitalisation of clinical information so that observations and assessments are easily accessible, and any areas of concern flagged. More written data is now being recorded on electric systems accessible through staff hand-held mobile devices, computer tablets and PCs. Some of this information is displayed on electronic ward white boards in ward areas flagging risks for particular patients.

- Introduced listening events so that staff can highlight any other aspects of our environment, practice, systems and processes that prevent them doing their best by our patients

The hospital spokesman added that they have been working with experts to look at options to rebuild clinical space to address concerns over its ageing estate.

Debbie Needham, Kettering General Hospital's chief executive, said: “As a learning organisation, the work we have carried out to improve our patient safety processes at Kettering General Hospital is a reflection of the way we are working across our hospital.

"We have introduced weekly staff engagement events. This is protected time for us to listen to our staff, address any issues or challenges they face in order for us to deliver the best patient care and exceptional patient experience.”