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Scarborough Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 February 2018

Inspection areas

Safe

Requires improvement

Updated 28 February 2018

Effective

Requires improvement

Updated 28 February 2018

Caring

Good

Updated 28 February 2018

Responsive

Requires improvement

Updated 28 February 2018

Well-led

Requires improvement

Updated 28 February 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because

  • We rated safe, effective and responsive as requires improvement. We rated caring and well-led as good.
  • There continued to be insufficient numbers of suitably skilled, qualified and experienced registered nurses, in line with best practice and national guidance, taking into account patients’ dependency levels.
  • There was a reliance on staff goodwill, bank and agency workers and ward managers relinquishing managerial shifts to support clinical work.
  • A number of registered nurse shifts remained unfilled despite escalation processes and wards worked below assessed levels based on acuity.
  • Medical staffing was reliant upon short term and long term locum support at all grades.
  • Staff did not always follow trust policy and recognised guidelines for the prescribing of antimicrobials and checking controlled drugs.
  • Staff awareness and understanding of the principles underpinning the Mental Capacity Act was variable. There was not a robust approach to the assessment of capacity and staff could not confirm who was responsible for completing such an assessment or how and where this was captured within the patient record.
  • The clinical guidance for sepsis management required updating.
  • The process for the management and completion of staff appraisals required review as there was significant variation in compliance across the wards.
  • The initiatives to support the care for patients living with dementia were not fully embedded however staff made some reasonable adjustments to support vulnerable patient groups on the wards.
  • There were a number of patient bed moves between 10pm and 6am.
  • There were a number of medical patients being cared for on non-medical wards (outliers). These patients occasionally moved between consultants and this interrupted continuity of care.
  • Staff morale and well-being was being compromised due to workforce limitations.
  • Service risk registers lacked detail regarding review and updates.

However:

  • There had been a marked improvement in mandatory training completion.
  • Infection prevention and control audits covering hand hygiene and environmental cleanliness were better than the trust target.
  • Staff ensured patients were comfortable and received pain relief in a timely manner.
  • Patients commented positively about food choice, quality and service. There were a number of made available to patients to meet individual needs.
  • Patients commented positively about the care they received and we observed genuinely kind, compassionate and warm care interactions.
  • Staff made changes to care delivery following patient feedback and concerns raised.
  • There was evidence of actions taken to account for variable outcomes in local and national audit.
  • Local leadership was good and staff reported senior managers were present in clinical areas.
  • Staff were aware of the trust vision, strategy and objectives. Staff were also aware of directorate strategies specific to their area of practice. Wards at Scarborough Hospital had developed their own ward based mission statements to reflect their patient cohort.
  • Staff reported an improved cultural shift in the previous 12 months.
  • There was evidence of service improvements and local innovations to support patient care.

Urgent and emergency services (A&E)

Requires improvement

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • We rated caring and well led as good, and safe, effective and responsive as requires improvement.
  • The department was failing to meet the majority of national standards relating to Accident and Emergency performance including: four hour waits, re-attendance rates, time from decision to admit to admission, median time to treatment and ambulance handover times (however, recent information showed that this was improving).
  • Staff were not meeting the trust’s mandatory training targets, therefore staff were not up to date with mandatory training. We also identified this at our last inspection.
  • Nursing and medical staffing in the department was not always meeting planned staffing levels. There was a heavy reliance on bank and agency nursing staff. There was a reliance on locum doctors to fill gaps in the medical rota and there were concerns about the long term sustainability of consultant cover. Consultant cover was not 16 hours per day as per Royal College of Emergency Medicine (RCEM) guidance.
  • Not all staff received annual appraisals.
  • Information in clinical records was not consistent or robust and was not subject to regular clinical audit.
  • Patients had long waits in the department once a decision to admit them had been made. This was predominantly due to the lack of beds available to admit patients in to the trust, although mental health patients were also affected.
  • Information for patients in alternative formats such as large print or braille and other languages was not available.
  • Staff in the department reported very low morale and we had concerns about the culture as some staff told us they felt undervalued.

However:

  • The department was aware of its problems and risks and had changed practice and processes in an attempt to tackle them, such as by the introduction of new nursing roles to support ambulance handovers and manage the flow of patients through the department.
  • Patients experiencing long waits were provided with hospital beds and the department were trialling new ways of working that could improve the experience of patients or improve the efficiency of the department.
  • Patients received care and treatment that was caring and compassionate from staff who were working hard to make sure that patient experience was positive and supportive.
  • The department was able to meet the physical and emotional needs of patients. Specialist equipment was available for patients with physical disability. There was access to pastoral support for patients of any or no religion.

Surgery

Requires improvement

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • We rated effective, caring and responsive as good and safe and well led as requires improvement.
  • Registered nurse and care staff were not always at optimum levels and we saw that there were a significant number of registered nursing shifts which could not be filled despite active recruitment. This was mitigated by the use of agency staff and those redeployed from other wards.
  • Medical staff vacancies were higher than the York Hospital despite active recruitment. This was mitigated by the use of locums.
  • Referral to treatment times (RTT) improved following our last inspection, however this had fallen back to below the national average during 2017 in most surgical directorates.
  • There was a significant amount of medical staff who had not received safeguarding adults and children’s training, and some mandatory training modules which included ‘do not attempt cardiopulmonary resuscitation’.
  • We saw gaps in record books of checking emergency trolleys and anaesthetic machine log books in theatre areas.
  • Staff did not always have access to clinical supervision as part of their learning and development. This was linked to professional revalidation.
  • None of the staff groups at Scarborough Hospital met the trust target for appraisals

However:

  • We saw that wards and theatre areas were visibly clean and staff observed infection prevention and control measures.
  • Nursing staff we spoke with said that there was good teamwork.
  • The trust had set up a urology ‘one stop shop’ at Malton Community Hospital where patients were seen and had appropriate tests carried out and discharged with a clear plan of care prior to going home. This prevented the patient having to attend several appointments.
  • Staff we spoke with told us that they felt well supported by local leadership who tried to address the short and long term staffing problems.
  • We observed good compassionate care and emotional support.
  • Scarborough Hospital had better than the national average for readmissions in all surgical directorates.

Intensive/critical care

Requires improvement

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • We rated safe and caring as good, and effective, responsive and well led as requires improvement.
  • The service had not taken action on some of the issues raised in the 2015 inspection. For example, the unit still did not have a clinical educator which was not in line with the guidelines for the provision of intensive care services (GPICS) standard and the service had not undertaken patient or relative surveys or any public engagement. At the time of this inspection, it was still not clear what critical care would look like across York and Scarborough hospitals, as the service strategy had not been finalised.
  • The risk register was not reflective of all the risks in the service. There was no record of the date the risks were added to the risk register, the date the risk should be reviewed and the controls and mitigating actions recorded were limited and did not always appear to address the cause of the risks.
  • The rehabilitation after critical illness service was limited and was not in line with GPICS or the National Institute for Health and Care Excellence (NICE) CG83 rehabilitation after critical illness. The service did not have access to patient and relative support groups.
  • Staff were not always supported to maintain and develop their professional skills. The number of nursing staff who had an up-to-date appraisal was worse than the trust’s target. The service did not meet GPICS recommendations for the number of nurses that had a post registration award in critical care nursing.
  • Senior staff acknowledged that service improvement and innovation was limited on the unit and the pace of change was slower at Scarborough than in critical care at York Hospital.

However:

  • The service had taken action on some of the issues raised in the 2015 inspection. For example, medical staffing was now in line with GPICS, mandatory training rates were better than the trust target and there had been a focus on cross-site working which had improved.
  • Systems and processes in safety, infection control, medicines management, equipment, patient records and the monitoring, assessing and responding to risk were reliable and appropriate.
  • Care and treatment was planned and delivered by a cohesive multidisciplinary team in line with current evidence based guidance.
  • All the feedback from patients and relatives was positive about the way staff treated them.