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The York Hospital Requires improvement

We are carrying out checks at The York Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 October 2015

The York Hospital was one of three main hospitals forming York Teaching Hospital NHS Foundation Trust. The trust provided acute hospital services to the local population. The trust also provided a range of other acute services from Scarborough and Bridlington hospitals to people in the wider York area, the north-eastern part of North Yorkshire and parts of the East Riding of Yorkshire. In total, the trust had approximately 1170 beds, over 8700 staff and a turnover of approximately £442,612m in 2013/14. The York Hospital had over 700 beds.

The York Hospital provided urgent and emergency services, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people primarily to the York and surrounding area, but also served the people in the Scarborough, Whitby and Ryedale areas of North Yorkshire for some services.

We inspected the York Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, Scarborough and Bridlington hospitals and community services. We inspected York hospital on 17 – 20, 30 – 31 March 2015.

Overall, we rated the York Hospital as ‘requires improvement’. We rated it ‘good’ for being effective and caring, but it requires improvement in providing safe and responsive care and in being well-led.

We rated urgent and emergency service and critical care as ‘requires improvement’, with medical care, surgery, maternity and gynaecological service, children & young people, outpatient and diagnostic services and, end of life care as ‘good’.

Our key findings were as follows:

  • Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
  • Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
  • We found the hospital was visibly clean, hand-washing facilities and hand cleaning gels were available throughout the department and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
  • There were concerns that patients arriving in the A & E department did not receive a timely clinical assessment of their condition.
  • At the time of the inspection, in the majority of services the Trust was below its own target of 75% for mandatory training including safeguarding training. The Trust’s target was to achieve 75% minimum compliance for the year ending August 2015. We have since been informed by the Trust that the figures provided to the CQC only included the training provided for the period of six months prior to the inspection as this was the time the Trust implemented a new system to capture and record training carried out. We were told the compliance levels did not include any training staff may have had prior to the 1 September 2014 and we were not provided with evidence to reflect this in the overall training levels.
  • There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. However, we found that some maternity services policies and guidelines were out of date.
  • The trust had no mortality outliers and mortality rates were as expected when compared with other trusts. The Summary Hospital-level Mortality Indicator (SHMI) of 98 was lower than both the Trust overall (102) the England average (100) in June 2014. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  • Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical areas; and radiologists. The trust was actively recruiting to the majority of these roles.
  • Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
  • The trust was half way through its five year plan to integrate services following the acquisition of Scarborough & North East Yorkshire NHS Trust in 2013.Services within all three of the acute hospitals were at differing stages of integration.
  • Seven of the eight core services we inspected had good local leadership within the service.

We saw several areas of outstanding practice including:

  • The appointment of a senior paediatric specialty trainee ‘quality improvement fellow’ for one year has led to improvements such as the use of technology in handover sessions, with further plans for development of electronic recording of clinical observations and the PAWS assessment.
  • We saw positive partnership working with and support from CAMHS in York, which ensured that the acute inpatient wards had seven-day support. The community nursing team also had a CAMHS nurse specialist allocated to the team who provided psychological support for families and staff.
  • The innovative way in which central lines were monitored, which included a central line clinical pathway. The critical care unit were finalists for an Institute for Healthcare Improvement (IHI) safety award.
  • The medical service had an innovative facilitating rapid elderly discharge again (FREDA) team, which provided multidisciplinary support and rehabilitation to elderly outlying patients.
  • Ward 25, an integrated orthopaedic and geriatric ward, worked closely with the A&E department, and actively identified elderly patients with a fractured neck of femur, to speed up flow to the ward and on to theatre, had demonstrated positive outcomes of speedier rehabilitation and reduced length of stay, with the majority of patients returning to their usual place of residence.
  • Phlebotomy outreach clinics in the local community, which have led to improved access to the service.
  • Availability of pathology services in the oncology outpatient department, meaning that up-to-date blood results are available for patients when they see the consultant in clinic. Treatment changes are based on up-to-date information.

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

Importantly, the trust must:

  • Ensure all patients have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011.
  • Ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical area; and radiologists.
  • Ensure there are suitable arrangements in place for staff within the medicine and surgery, outpatient and diagnostic services to receive appropriate training and appraisals in line with Trust policy, including the completion of mandatory training, particularly the relevant level of children and adult safeguarding training and basic life support so that they are working to the up to date requirements and good practice.

  • The provider must address the breaches to the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets to protect patients from the risks of delayed treatment and care.

  • The provider must ensure that patients’ privacy and dignity is maintained when being cared for in the bays in the nursing enhanced unit based on ward 16.
  • The provider must ensure effective plans are in place and implemented to eliminate the non-clinical delayed discharges and delayed admissions on the critical care unit.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 8 October 2015

Effective

Good

Updated 8 October 2015

Caring

Good

Updated 8 October 2015

Responsive

Requires improvement

Updated 8 October 2015

Well-led

Requires improvement

Updated 8 October 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 8 October 2015

Staff were caring and treated women with respect. The services were responsive and delivered in a way that met the needs of the women accessing them. The service was well led.

There were policies and guidelines on the intranet. However, there were some guidelines in maternity services, relating separately to Scarborough Hospital and York Hospital, which were out of date and did not adhere to national guidance. Monitoring of performance was difficult to review.

Medical care (including older people’s care)

Good

Updated 8 October 2015

Overall, we judged this service as good, with safety requiring improvement. In the main, patients were protected from avoidable harm and abuse. However, the provider was unable to consistently provide safe staffing levels. There was poor compliance with mandatory training requirements. Policies and pathways were based on national good practice and were accessible to staff. National audits were completed and acted upon.

Patients were happy with the care they received, and found the service to be caring and compassionate. Most patients, and their friends and families, spoke very highly of staff and told us that they, or their relatives, had been treated with dignity and respect. Staff worked to meet the needs of individual patients.

Managers and senior clinicians had a vision for the future of their services, and were aware of the risks and challenges faced by the service. Staff told us that they were well supported by their ward managers and clinical matrons, and were encouraged to develop to improve their practice. However, staff did not always feel that their views or ideas were listened to or acted upon. There were a number of examples of innovation and service improvements.

Urgent and emergency services (A&E)

Requires improvement

Updated 8 October 2015

The environment did not always enhance patient safety, particularly for young children. At the time of the inspection patients were seldom clinically assessed as soon as they arrived in the department. Some patients waited up to two hours for a clinical assessment and some did not receive an initial clinical assessment at all. It was therefore possible for their condition to deteriorate while they were waiting to be seen. There were not enough senior doctors or nurses.

The majority of care and treatment was effective and delivered in line with current evidence-based guidance and standards. There was participation in national clinical audits. Feedback from people who used the service was very positive regarding the way they were treated by staff. They thought that staff went the extra mile and the care they received exceeded their expectations.

The A&E department needed to improve its responsiveness to the needs of people using the service. In the year leading up to our inspection, the department had been unable to meet the national target of admitting or discharging 95% of patients within four hours. There was little evidence of a hospital-wide approach to improving patient flow through A&E.

The department itself was well led. The leadership actively shaped the culture through effective engagement with staff and patients. They demonstrated the skills, knowledge and experience needed for their roles.

Surgery

Good

Updated 8 October 2015

Services were responsive to patients’ individual needs, but there were concerns over waiting times, such as the 18-week referral-to-treatment time (RTT) targets, the achievement of cancer waiting time targets, and the high number of non-surgical patients being cared for on surgical wards, which was having an impact on access and flow.

Optimum staffing levels and skill mix across surgical services were not being sustained at all times of the day and night. However, the trust was mitigating some of this risk by the use of bank/agency staff and the redeployment of other staff. Pressures on the wards had an impact on staff being able to attend statutory and mandatory training.

The service provided effective and evidence-based care and treatment. Staff were seen to be caring and compassionate while delivering care. Patients’ privacy and dignity were maintained, although some concerns were raised from patients about being cared for in mixed-sex accommodation on the nursing enhanced unit on ward 16.

Work was continuing to integrate surgical services and deliver common standards of care across the three hospital sites (York, Scarborough and Bridlington). Directorate-level governance arrangements were in place but protocols, guidelines and pathways of care in all three hospital sites were variable and not yet fully established.

Intensive/critical care

Requires improvement

Updated 8 October 2015

Overall critical care services required improvement. Safeguarding training figures for the unit, across all levels of training, were under the target of 75%. Mandatory training figures for the directorate presented a mixed picture and, overall, compliance levels were well below the Trust’s target of 75%.

There were suitable processes in place in relation to incidents, safeguarding and assessing and responding to patient risk. Medical and nurse staffing levels were adequate. Staff worked to best practice guidance and overall, safety outcome data was good. The support provided from other services, such as the pain team, dietetics and physiotherapy was adequate, but in terms of dedicated hours for the unit some services fell short of best practice guidelines. Access to training was an issue and the lack of a clinical nurse educator was having a negative impact on educational progress. Staff were caring and professional, patients, relatives and friends spoke highly of the care provided on the unit.

Service and strategic planning was at an early stage and there was a lack of certainty in terms of the future design of the service and the immediate mitigating actions in terms of delayed discharge, delayed admissions and high capacity. There were positive comments from staff regarding culture and team work. However, it was felt by some staff that issues could be discussed in a more collaborative way and service planning could be more inclusive of others.

Services for children & young people

Good

Updated 8 October 2015

Overall the service was good. However, there were not always adequate numbers of registered children’s nurses available to meet the needs of children, young people and parents within the inpatient areas. Children’s services did not have all the necessary individual risk assessment tools in place so that members of staff could conduct a robust, individualised risk assessment if required. We found that all children’s clinical areas were kept clean and were regularly monitored for standards of cleanliness. Training records submitted by the trust prior to the inspection showed varying levels of training uptake by members of staff, but not all were achieving the 75% compliance set by the Trust.

Children’s services had made improvements to care and treatment where a need had been identified using assessment programmes or in response to national guidelines.

Children, young people and parents told us that they received compassionate care with good emotional support. Parents felt informed and involved in decisions relating to their child’s treatment and care.

The service was responsive to children’s and young people’s needs and was well led. The service had a clear vision and strategy and was led by a positive leadership team.

End of life care

Good

Updated 8 October 2015

We saw that end of life care services were safe, effective, caring and responsive, with elements of outstanding practice in terms of being well led. Staff were caring and compassionate and we saw the service was responsive to patients’ needs.

There was good use of auditing to identify and improve patient outcomes and we saw measures in place to monitor key areas that had been identified. The trust had a clear vision and strategy for end of life care services and participated in regional and locality groups in relation to strategic planning and implementation. There was consistent leadership relating to end of life care and a number of positive developments had been implemented, for example, non-cancer end of life care and the development of training to improve advance care planning discussions, including those relating to DNA CPR.

Outpatients

Good

Updated 8 October 2015

Overall the care and treatment received by patients in York Hospital outpatients and diagnostic imaging departments was effective, caring, responsive and well led. However the safe domain required improvement.

The managers told us that they continued to report any radiation incidents to the Care Quality Commission under Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). We requested information about IR(ME)R reportable incidents from York Hospital, but this was not provided to us. This meant we were unable to judge the outcomes for the incidents and whether corrective action had been taken by the unit to promote safety. The trust did not provide at the inspection evidence that it was consulting and receiving regular advice and reporting from its radiation protection adviser (RPA) to comply with the Ionising Radiations Regulations 1999 (IRR99). Post inspection the trust informed us they had an RPA and issues were discussed.

The information on staff training especially on mandatory training was kept as departmental records. This meant outpatients staff training records were with theatres, anaesthetics and critical care unit training records. Therefore we were unable to separate out and report on the compliance within the outpatients department. Data indicated that the diagnostic imaging services staff training were not compliant with training.

There was a 14% vacancy rate for consultant and registrar radiologists in York. Some of the vacancies were covered by locumsThe trust informed us that there were 3.5 WTE specialist registrar vacancies. There was no formal tool or mechanism used to decide on staffing levels.

Staff worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm because staff were aware of the policies and how to follow them.

Patients told us that staff working in the outpatients and radiology departments were caring and compassionate at every stage of their journey. People were treated respectfully and their dignity and privacy was maintained at all times by staff. We found the services were well led and care and treatment was delivered in response to patients’ needs and to ensure that the departments ran effectively and efficiently.