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South Tyneside District Hospital Requires improvement

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

We are carrying out checks at South Tyneside District 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 1 December 2015

South Tyneside District Hospital provides acute services for South Tyneside NHS Foundation Trust.

The trust gained foundation status in January 2005. From the 1st July 2011, community health services in Gateshead, South Tyneside and Sunderland transferred to South Tyneside NHS Foundation Trust from NHS South of Tyne and Wear as part of the Government’s Transforming Community Services programme. The trust has a workforce of approximately 5000 staff and serves a population of around 154,000 in South Tyneside, 275,700 in Sunderland and 191,000 in Gateshead. South Tyneside District Hospital provided medical services, surgical services, critical care services, maternity services, and children and young people’s services and has 321 beds.

We inspected South Tyneside District Hospital as part of the comprehensive inspection of South Tyneside NHS Foundation Trust, which included this hospital and community services on 5 to 8 May and 3 June 2015.

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

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

Our key findings were as follows:

  • Across the acute hospital arrangements were in place to manage and monitor the prevention and control of infection. There was a dedicated infection control team to support staff and ensure policies and procedures were implemented and adhered to. We found that the areas we visited were clean. Infection rates for Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C Difficile) were within an acceptable range for this size of trust.
  • Patients were able to access suitable nutrition and hydration, including special diets and they reported that, on the whole, they were content with the quality and quantity of food.
  • There were staffing shortages in some areas across both nursing and medical professions with some wards unable to meet the safer staffing requirements. The trust used agency nurses and locum doctors to address the staffing requirements.
  • There were processes for implementing and monitoring the use of evidence based guidelines and standards to meet the needs of differing patient groups across both the hospital and community services.
  • There were processes in place from ward and department level through to Board level for the reporting of incidents.
  • There were long waits in the Emergency Department through the winter period with patients being cared for in the department. It was noted that patients were placed on a bed after being in the department for six hours.
  • There was on occasion a lack of critical care capacity which resulted in patients being cared for in the theatre recovery unit rather than in the intensive care unit.
  • Governance processes were not fully developed or embedded across the divisions.
  • The staff engagement was set out in the overarching trust strategy and we saw examples of staff engagement such as team brief and the Chief Executive ‘cheer up Friday’ email message.
  • There was a clear strategic development plan which included both community and hospital services.
  • There were concerns regarding leadership of some services.

We saw several areas of outstanding practice including:

  • The children’s diabetic team used a computer system that allowed uploading of information from glucose meters, insulin pumps, and mobile apps. The system consolidated and presented the information in reports which allowed the clinicians to see a more accurate picture of the patient’s health over a period of time.
  • The staff from the Endoscopy Unit won the 2015 ‘Study Team of the Year’ category awarded by the National Institute for Health Research North East and North Cumbria Clinical Research Network.
  • The Endoscopy Unit had participated in an international programme ‘Endo-live’ where live investigations were carried out and transmitted via satellite to conferences. The event in 2014 was opened by a professor from the endoscopy unit at South Tyneside District Hospital.
  • Ward 19 had received a quality mark in 2014 from the Royal College of Psychiatrists as a result of positive work in the delivery of good quality, essential care for older people.
  • The IT department is working collaboratively with the community IT team to ensure both the acute and community electronic patient systems will be compatible.
  • Maternity services used a telehealth system (the delivery of health information using telecommunications technology). This system enabled women to monitor their blood glucose levels and blood pressure in their own homes, avoiding unnecessary visits to the clinic.
  • A new form of renal replacement therapy which improved outcomes for patients with renal failure and meant that they could be stabilised prior to transfer to a hospital with a renal service (South Tyneside does not have a renal service).

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

Importantly, the trust must:

  • Review compliance with mandatory training and in particular training in safeguarding, medical device management, medicines management and Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Ensure that medical staff receive mandatory training including on fire prevention and child and adult safeguarding.
  • Ensure all necessary patient risk assessments for example, venous thromboembolism (VTE) and early warning scores for deteriorating patients are completed and recorded appropriately.
  • Ensure assurance processes are in place to confirm the five steps to safer surgery (part of the WHO surgical safety checklist) is being consistently completed.
  • Review the policy, processes, procedures, training, and support arrangements for the safe care and treatment of medical ‘boarders’ within surgical wards and the impact on services.
  • Review the arrangements for the provision of a care pathway and formal medical rota for the management of patients with gastrointestinal bleeds.
  • Review how the flow of patients is managed through the emergency department (ED) and ensure that there is a documented escalation plan that is implemented when required to deal with patients waiting for more than four hours for transfer to a ward. This should include action to avoid patients staying in ED for longer than 12 hours.
  • Review the quality of record keeping in the emergency department to ensure that records accurately reflect the standard of care provided including risk assessments, nutrition and hydration and provision of nursing care.
  • Ensure that when patients complain about their care, there is an effective process in place for staff to receive feedback and learning.
  • Conduct a full environmental risk assessment for the Intensive Therapy / High Dependency Unit (ITU) and take action to mitigate the risks posed by lack of storage space.
  • Develop and implement an escalation plan approved by the operating theatre and critical care nursing and clinical leads that ensures that appropriate support systems are available on a timely basis if critical care patients are nursed in the recovery room
  • Ensure that all theatre staff caring for Level 2 and Level 3 ITU patients have received the appropriate training and that training records are retained.
  • Implement dedicated pharmacy support for ITU.
  • Ensure appropriate staffing on all children’s inpatient areas particularly the special care baby unit.
  • Ensure that all medical devices receive portable appliance testing as required.
  • Ensure that COSHH risk assessments are completed for all areas storing substances hazardous to health to ensure that these are stored securely.
  • Ensure that effective control measures are in place to monitor exposure levels of nitrous oxide and the checking of ventilation and scavenging systems on the delivery suite.
  • Ensure resuscitation equipment checks are carried out regularly and consistently across all areas of the department.
  • Ensure that all employees receive an annual appraisal.
  • Ensure that there is a formal strategy for maternity and gynaecology services which sets out how the service is to achieve its priorities and that staff understand their role in achieving service objectives

In addition the trust should:

  • Review the concerns raised by staff of bullying and harassment and the difficult working environment within theatres.
  • Review the concerns raised by medical staff from the trauma and orthopaedics department about individual bullying and harassment leading to concerns about patient care.
  • Develop a strategy to support dedicated educational support for critical care staff.
  • Develop a formal process for safeguarding supervision in maternity services.
  • Develop processes to ensure that there is an audit trail for submission of HSA4 (abortion notification) forms to the Department of Health.
  • Consider improving facilities for children waiting within the main outpatients department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 1 December 2015

Effective

Requires improvement

Updated 1 December 2015

Caring

Good

Updated 1 December 2015

Responsive

Requires improvement

Updated 1 December 2015

Well-led

Requires improvement

Updated 1 December 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 1 December 2015

Overall, we rated maternity and gynaecology services as good for being safe, caring, responsive and effective and requiring improvement for well-led.

The service provided safe and effective care in accordance with recommended practices. Outcomes for women using the service were monitored and where improvements were required action was taken. Care and treatment was planned and delivered in a way to ensure women’s safety and welfare. Resources, including equipment and staffing, were sufficient to meet the needs of women. Staff had the correct skills, knowledge and experience to do their job.

The individual needs of women were taken into account in planning the level of support throughout their pregnancy. Women were treated with kindness, dignity and respect. The service took account of complaints and concerns and took action to improve the quality of care. A positive culture of openness and candour was evident and senior managers were visible and approachable. Although the senior management team were aware of the challenges to the service and had a vision for the future there was no formal strategy for maternity or gynaecology services, which set out how the service was to achieve its priorities or to ensure that staff understood their role in achieving the services objectives.

Medical care (including older people’s care)

Requires improvement

Updated 1 December 2015

Overall we rated medical services as requires improvement. We rated caring as good and safe, effective, responsive and well-led as requires improvement.

The key risks related to: learning from incidents, medicines management, staffing levels, lack of equipment maintenance and insecure storage of chemical products and razors in the sluice areas. We observed inaccurate prescribing and medication errors including missed doses and delays in administration. There had been difficulty in recruiting to a vacant consultant post for the stroke service since January 2014; this post was covered by a locum consultant.  There was difficulty in recruiting to registrar posts across medical services. Nurse staffing levels were affected by high sickness rates and vacancies and were regularly supported by use of bank and agency staff. We observed equipment ready for use with out-of-date service test dates including a suction pump and an electrocardiograph machine.

As a result of an audit on the use of the nutrition and hydration assessment tool, ward based training and competency assessments were introduced.Also the screening tool and dietetic referral forms were amended to enable an accurate audit to take place. Further, there was monitoring by the nutrition and hydration steering group and the development of individual ward based action plans. Patients we spoke with told us they had received good pain relief and nurses had asked them regularly if their pain was controlled.

The hospital appraisal data showed great variability in the rate of compliance with annual appraisals, these ranged from 25% - 100% for nursing staff.However when we visited individual clinical areas, we were shown different data and told that there were problems with the way appraisal and training compliance was centrally recorded. Ward managers showed us compliance of over 90%.

We found that senior leaders in medicine and elderly care were not able to clearly communicate the five year plan or vision for the specialties. Governance systems were in place but staff reported there was a lack of sharing of the learning from incidents and complaints across the directorate. The role of assurance matron supported the patient safety and quality agenda but these were not based at South Tyneside District Hospital. Most staff we spoke with felt engaged and valued by ward managers, the clinical operations manager and clinical business manager.However they said more senior leaders were not visible. There were excellent examples of innovation in the endoscopy unit

.

Urgent and emergency services (A&E)

Requires improvement

Updated 1 December 2015

Overall we rated urgent and emergency services as requires improvement. We rated safe, responsive and well-led as requiring improvement and caring and effective as good.

There were occasions when patients had to be accommodated in the ED for long periods because of a lack of beds in the hospital. It was customary  practice to place patients staying in the department over six hours onto a bed, and we were informed that this action in combination with the patient being nursed in the individual treatment rooms met the requirements of the Weekly Trust A&E Sitreps Guidance Version 1.04. Information on nursing care (such as evidence of when the patient had been transferred to a bed if required, received pressure area care and was offered nutrition and hydration) were inconsistently recorded. There was virtually no incident reporting of the occasions when patients had lodged in ED longer than 12 hours.

The escalation process to prevent patients from staying in ED longer than 12 hours was not documented and ineffective. The quality of ED documentation to reflect the nursing care provided and minimal internal reporting of patients lodging over 12 hours was poor.

We observed positive interactions between staff, patients and /or their relatives. Staff consistently demonstrated caring attitudes towards patients throughout the inspection. The majority of patients spoke positively about their care and treatment.

Surgery

Requires improvement

Updated 1 December 2015

Overall, we rated surgical services as requiring improvement. Surgical services were caring and effective but required improvement in order to be safe and responsive. We rated well-led as inadequate.

There was no medical rota for the management of patients with gastrointestinal bleeds. Staff identified this as a major risk to the safety of patients. We reviewed care records within surgical wards and saw these did not all contain a completed risk assessment for early warning scores for deteriorating patients. Staff were aware of safeguarding policies and procedures but information provided by the trust showed low compliance with safeguarding training.

Nursing staff said they did not have the experience or skills to give appropriate and safe care to ITU patients when nursed within the surgical recovery area. We were unable to find evidence surgical staff had been trained to look after the needs of ITU patients. We raised this issue with the division’s management team. It was subsequently reported staff had been berated for sharing this concern with us.

Staff said divisional managers were not always available, visible nor approachable; leadership of the service was remote and morale, particularly within theatres, was not good. Members of nursing and healthcare staff from theatres raised specific concerns with us about individual bullying and harassment leading to concerns about patient care. Staff said incidents had been raised through the department’s management structure and on occasions through the human resources department but had not been addressed and difficult working conditions continued.

We observed patients being treated with compassion, dignity and respect throughout our inspection at this hospital and saw that patients were spoken and listened to promptly. Patients commented positively on the dedication and professionalism of staff and the quality of care and treatment received. The Friends and Family response rate within surgery varied from 30% to 34% and scored similarly with the England average across all areas.

Intensive/critical care

Requires improvement

Updated 1 December 2015

We rated critical care as good for caring and requires improvement for safe, effective, responsive and well-led.

There were known risks posed by the limitations of the infrastructure and environment of the Intensive Therapy Unit (ITU). An outline business case had been approved by the trust executive team to refurbish and expand the critical care services.However the final business case was not yet finalised or agreed and there was no evidence of a contingency plan should the final business case not be approved.

There were known capacity issues regarding the number of Level 2 ITU beds during periods of hospital-wide bed pressures. This posed potential risks to the safety and welfare of patients as, when demand exceeded capacity, it was necessary on occasion to care for patients within the surgical recovery area. Critical care management were confident that patients were cared for appropriately in the surgical recovery area but the recovery nurses said they did not have the experience or skills to give appropriate and safe care to ITU patients when nursed within the surgical recovery area. Additionally patients were discharged to ward areas during the night, which national data and guidance have associated with increased mortality.

Patients were also remaining in critical care beds when they no longer needed them due to bed pressures on the wards, which could result in mixed-sex breaches and lack of privacy and dignity.

The unit was not meeting the requirements of the Core Standards for Intensive Care Units (2013) particularly in relation to educational support and management arrangements. The unit manager spent most of their hours giving direct patient care and had little or no time for management or leadership activities.

There were areas of good practice in the Intensive Therapy High Dependency Unit (ITU). These included fully and comprehensively completed care documentation, well maintained and serviced equipment, evidence in investment in new equipment, an increase in nursing, medical and critical care outreach establishments and the introduction of new renal replacement therapy for patients with renal failure.

Patients and their relatives were treated by staff with compassion, dignity and respect. Feedback from patients and their relatives showed that there was a caring and supportive, person-centred culture in the unit and thank-you cards and letters praised the unit highly for their care.

Services for children & young people

Requires improvement

Updated 28 October 2016

End of life care

Good

Updated 1 December 2015

We rated end of life services as good for safe, effective,  responsive and well-led. Caring was rated as  outstanding.

The trust came top of the league for best performing hospitals in England in The Cancer Patient Experience Survey: Insight Report and League Table 2014 and was in the top three in the same survey in 2013. The survey covers all 153 acute and specialist NHS Trusts in England that provide adult acute cancer services. Areas of excellent performance in the survey included emotional support from nursing and medical staff, clear explanations of what was wrong and what to expect, involvement of family members and easy contact with the cancer specialist nurse. Staff treated patients with dignity and respect and patients told us they felt well cared for. Staff supported patients and their families in a timely and appropriate way and involved patients and their families in planning care and treatment. Patients and their families were supported to cope emotionally with their care and treatment and there were systems in place to provide emotional support to staff when required.

Incident reporting was effective and embedded across the service. When things went wrong incidents were investigated, and lessons learned were shared. Staff responded appropriately to safeguarding concerns.

There were systems and processes for the monitoring of medication, infection control and they were regularly reviewed and improvements made. Staffing levels were monitored and reviewed to keep patients safe and meet their needs. Documentation and care records were completed appropriately. Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were completed consistently. Equipment was available for patients and appropriate safety checks were in place.

End of life care was evidence based and followed national guidance. There was a multi-disciplinary approach to care and treatment. Palliative care staff were appropriately qualified and competent to carry out their role.

Patients’ needs and preferences were important in the planning and delivery of services. An end of life strategy was not in place but a steering group was established to develop a trust-wide strategy across acute and community services. Patients could access services in a way that suited them. Any complaints were dealt with appropriately and any lessons learnt were shared with staff. There were governance arrangements in place and the service monitored and audited the quality of the service. Clinical governance arrangements provided assurance that end of life care was being well managed and information about patient experience was collected, reviewed and acted upon.

Outpatients

Good

Updated 1 December 2015

Overall, we rated outpatient and diagnostic services as good for being safe, caring, responsive and well-led.

The level of care and treatment delivered by the outpatient and imaging services was good. Arrangements were in place for managing radiation risks and incidents within the comprehensive local rules. Staffing levels were based on the knowledge and expertise of department managers and were flexible to meet the varied demands of clinics and patients.

Referral to treatment times met national targets but the rate for patients not attending appointments was slightly higher than the national average. Outpatient clinics ran every day, including some evenings and occasionally at weekends. Imaging services for inpatients were available seven days a week and service availability was increasing and continuously improving.

During the inspection, we saw and were told by patients that the staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their journey and patients were given sufficient time for explanations about their care and were encouraged to ask questions

The Trust vision and strategy were well embedded and discussed at staff meetings. There were strong governance arrangements of which staff were aware and we observed good, positive and friendly interactions between staff and managers.

Other CQC inspections of services

Community & mental health inspection reports for South Tyneside District Hospital can be found at South Tyneside NHS Foundation Trust.