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Inspection Summary


Overall summary & rating

Good

Updated 28 October 2016

We inspected the trust from 8 to 10 June 2016 and undertook an unannounced inspection on 21 June 2016. We carried out this inspection as part of the Care Quality Commission’s (CQC) follow-up inspection programme to look at the specific areas where the trust was previously rated as ‘requires improvement’ when it was last comprehensively inspected on the 9-12 and 16 December 2014.

At the comprehensive inspection in 2014 the trust overall was rated as requires improvement for their acute and community services. It was requires improvement for the safe and effective key questions at both hospital locations. The remaining key questions were rated good overall. Community health services were rated good overall, with requires improvement for the urgent care centre.

During this inspection, the team looked at one key question in urgent and emergency care, medicine and outpatients at both hospital locations. One key question in children’s and young people at one of the hospitals, three key questions in end of life care at both hospitals, plus two key questions in the urgent care centre and one in community inpatients at one other location. All these services had previously been rated as requires improvement, and all came out as good following the June inspections.

We included the following locations as part of the inspection:

James Cook University Hospital

  • Urgent and emergency services;
  • Medical care;
  • Services for children and young people;
  • End of life care;
  • Outpatients and diagnostic imaging.

The Friarage Hospital

  • Urgent and emergency services;
  • Medical care;
  • End of life care;
  • Outpatients and diagnostic imaging.

Redcar Primary Care Hospital

  • Urgent care centre;
  • Community inpatients (adults).

Our key findings were as follows:

  • Patients received appropriate pain relief and were able to access suitable nutrition and hydration as required.
  • There were defined and embedded systems and processes to ensure staffing levels were safe. During this inspection, we did not observe any evidence to suggest the level of nurse staffing was inadequate or caused risk to patients in the areas we visited.
  • The trust had infection prevention and control procedures, which were accessible and understood by staff. Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment. However, there were some issues with cleanliness in the discharge lounge at the Friarage Hospital.
  • Patient outcome results had improved in areas of sepsis, senior review of patients in A&E with non-traumatic chest injury, febrile children and unscheduled return of A&E patients.
  • Staff understood the basic principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and could explain how these worked in practice.

  • There was consistency in the checking and servicing of equipment. However, there was one piece of equipment used in the mortuary at the Friarage Hospital, which had not been adequately maintained.

  • Competent staff that followed nationally recognised pathways and guidelines treated patients. There was audit of records to make sure pathways and guidelines were followed correctly.
  • Arrangements for mandatory training were good and significant improvements had been made for staff to attend.
  • Medication safety was reported as a quality priority in 2016/17 and improvement targets had been set. There were improvements in the management of medicines since our last inspection particularly around effective audit and reconciliation of medicines. We found some inconsistencies in the management of medicines however, the trust nursing and pharmacy team acted promptly and these issues were addressed.
  • There was an open culture around safety, including the reporting of incidents. Staff were aware of the duty of candour and there were systems to ensure that patients were informed as soon as possible if there had been an incident that required the trust to give an explanation and apology.
  • The trust had developed action plans to improve performance of the 4 hour A&E target, 18 week referral to treatment times, c. difficile and 62 day cancer waiting times. These plans provided the necessary assurance that the trust had the actions and capacity to ensure compliance in 2016/2017.
  • The trust had commenced a significant period of transformation and organisational re-design in 2015. There was a newly established senior executive team, and there was a clear ambition from the Board to be an outstanding organisation.
  • From 1 April 2016, the trust had moved to a new clinical centre structure. There were five centres, which replaced the existing seven centres. Clinical leadership was strengthened.
  • The trust had been in breach for governance and finances; however, they had made significant progress against their enforcement undertakings for both elements.
  • The recent changes to the executive team were seen by staff to be very positive. There were improvements in the speed of decision-making and visibility of the senior team in clinical areas.
  • The trust was strengthening the patient voice and developing strategies to enhance patient and staff engagement.

We saw several areas of outstanding practice including:

  • The trust was developing a detailed programme around patient pathways/flow/out of hospital models. This included developing a detailed admission avoidance model to establish pilot schemes in acute, mental health, community and primary care services. This would ensure patients were virtually triaged earlier in their pathway rather than being admitted to A&E. This would support patients closer to home and in more appropriate facilities, and reserve acute capacity for patients who required it.
  • The Lead Nurse for End of Life Care was leading on a regional piece of work for the South Tees locality looking at embedding and standardising education around the 'Deciding Right' tools  (a Northeast initiative for making care decisions in advance).

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

In addition the trust should:

  • Ensure that processes are in place and understood by mortuary staff at the Friarage Hospital for the maintenance, moving and handling of equipment and transfer of deceased patients particularly out of hours.
  • Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.
  • Ensure that the end of life strategy is approved and implemented and move to develop a seven-day palliative care service.
  • Review arrangements for the discharge lounge at the Friarage Hospital in terms of maintaining and cleaning equipment and ensuring the environment was suitable for patients and purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 June 2015

Effective

Requires improvement

Updated 10 June 2015

Caring

Good

Updated 10 June 2015

Responsive

Good

Updated 10 June 2015

Well-led

Good

Updated 10 June 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 10 June 2015

Overall maternity services were good in all areas, with an ‘outstanding’ rating for being well-led. The service provided safe and effective care in accordance with recommended practices.

Resources, including equipment and staffing, were sufficient to meet the needs of women. Staff had the correct skills, knowledge and experience to do their jobs.

The individual needs of women were taken into account in planning the level of support throughout pregnancy. Women were treated with kindness, dignity and respect while they received care and treatment.

The maternity services were led by a highly committed, enthusiastic team, with each member sharing a passion and responsibility for delivering a high-quality service. Governance arrangements were embedded at all levels and enabled the effective identification and monitoring of risks and the review of progress on action plans. There was strong engagement with patients and a focus on gaining greater involvement from patients’ groups who represented the local population using the service.

Medical care (including older people’s care)

Good

Updated 28 October 2016

Medical care was rated as good for safe because:

There were significant improvements since the comprehensive inspection of the Friarage Hospital in December 2014.

There were processes to ensure safe staffing levels on wards and capacity had been reduced to support nurse to patient ratios being safely maintained. During this follow-up inspection, we did not find any evidence to suggest that nurse staffing was unsafe or would cause a risk to patients in the wards we visited.

Arrangements for mandatory training were good and significant improvements had been made in order for staff to attend. Trust targets were being met or plans were in place to achieve them. Resuscitation equipment was checked daily.

During our inspection, we found inconsistent storage of medicines, however the trust nursing and pharmacy team acted promptly and issues were addressed with an improvement action plan to ensure out of date drugs were not stored in wards, liquid medications were labelled to identify when they were opened and arrangements for drug fridges and temperature recordings were improved.

Urgent and emergency services (A&E)

Good

Updated 28 October 2016

Urgent and emergency care services were rated as good for effective because:

There were policies and procedures and these were evidence based. Audits took place to ensure staff were following relevant clinical pathways.

Staff were able to access information about clinical guidelines. Information about patients such as test results were readily accessible.

Patients were offered pain relief on arrival at the department and regularly during their stay. Patients’ nutrition and hydration needs were managed effectively.

There was evidence of multi-disciplinary and multi-agency working throughout the department and the department offered a full seven-day service.

Surgery

Good

Updated 10 June 2015

We rated surgery services at this hospital as ‘good’. There were effective arrangements in place for reporting patient and staff incidents and allegations of abuse. Staff were encouraged to report incidents and they received feedback on what had happened as a result. Staffing establishments and skills mix had been reviewed to maintain optimum staffing levels during shifts. Effective handovers took place between staff and included daily safety briefings to ensure continuity and safety of care.

There were arrangements for the effective prevention and control of infection and the management of medicines. Checks were carried out on equipment.

There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. Surgical services participated in national clinical audits and reviews to improve patient outcomes and had developed a number of local audits. Mortality indicators were within expected ranges.

Processes were in place to identify the learning needs of staff and opportunities for professional development. There was effective communication and collaboration between multidisciplinary teams who met regularly.

We observed positive, kind and caring interactions on the wards and between staff and patients. All patients spoke positively about the standard of care they had received. All patients we spoke with felt they understood their care options and were given enough information about their condition. There were services to ensure that patients received appropriate emotional support.

Systems existed to plan and deliver services to meet the needs of local people. Services were available to support patients, particularly those living with dementia, a learning or physical disability or those whose first language was not English. There were also systems in place to record concerns and complaints raised within the division, review these and take action to improve patients’ experience.

There was evidence that the service reviewed and acted on information about the quality of care that it received from complaints.

The trust’s vision, values and strategy were well-embedded with staff who had a clear understanding of what these involved. Staff were aware of their individual roles and responsibilities and there was effective ward leadership; staff felt supported at a local level.

Intensive/critical care

Good

Updated 10 June 2015

We rated critical services at this hospital as ‘good’. Effective arrangements were in place on the unit for reporting patient and staff incidents and allegations of abuse, which was in line with national guidance. Staff were encouraged to report incidents, and received feedback on what had happened as a result. Nurse staffing levels were determined using an acuity tool and national guidelines were followed. The complement of medical staff and the skills mix of the medical team were suitable and in line with national guidance. Arrangements were in place for the effective prevention and control of infection and the management of medicines. Checks were carried out on equipment and care records were completed accurately and clearly. The unit appropriately assessed and responded to patient risk.

Processes were used for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. The unit performed well in comparison with similar units in terms of patient outcomes, and there were no concerning patient outcome figures. Processes were in place to identify the learning needs of staff and opportunities for professional development. There was effective communication and collaboration between multidisciplinary teams who met regularly to identify patients requiring visits or to discuss any changes to patient care.

The team working on the unit were caring, compassionate and patient-focused. We observed positive, kind and caring interactions between staff and patients. Patients spoke positively about the care that they received and felt they understood their care options and were given enough information about their condition. Services were provided to ensure that patients received appropriate emotional support.

The unit was an integrated critical care unit, which meant it could easily flex between level 2 and 3 beds depending on demand. The staff group were also responsive to the changing needs of patients and worked effectively to manage the workload.

Quality indicators, including early readmissions, late readmissions and post-unit hospital deaths were within acceptable limits on this unit. The unit had a very low number of complaints. The vast majority of concerns and complaints were managed at a local level without the need for issues to be formally escalated. Any learning from complaints was disseminated to staff through staff meetings and directorate updates.

Governance processes were embedded and there were appropriate processes for managing risk. The leadership team was approachable and open, and seen positively by staff. The management team had a number of effective ways of engaging with staff. Patient engagement and feedback was actively sought on the unit.

Services for children & young people

Good

Updated 10 June 2015

We rated services for children and young people as ‘good’. The children’s services actively monitored safety, risk and cleanliness. We did not identify any concerns regarding nursing and medical staffing at the Friarage Hospital.

At Friarage Hospital there was only one young person available to talk with during our inspection visit and they were very happy with the care they received. We reviewed 63 questionnaires submitted since 1 November 2014 and these showed that parents provided positive feedback with no negative responses.

We found that a recent service reconfiguration was being closely monitored and managed in partnership with commissioners and other healthcare providers. We found access and flow was good within the hospital and its link to the main children’s services at James Cook University Hospital.

The service had a clear vision and strategy based on the National Service Framework for Children. The service was led by a positive management team who worked well together. The service regularly introduced innovative improvements with the aim of constantly improving the delivery of care for children and families.

End of life care

Good

Updated 28 October 2016

Overall end of life care was rated as good because:

Staff delivering end of life care understood their responsibilities with regard to reporting incidents and ensured information and lessons learnt were shared proactively with other colleagues within the hospital.

There were improvements made since the last inspection in documentation of individualised care of the dying documents and appropriately completed Do Not Attempt Resuscitation forms.

However:

Some equipment in the mortuary was not safe for its intended use.

Risk assessments for porters and security staff were found to be out of date.

There was no regular audit programme for infection prevention and control in the mortuary.

Outpatients

Good

Updated 28 October 2016

Outpatient and diagnostic imaging was rated for safe as good because:

Departments were clean and hygiene standards were good. Staff ensured equipment was clean and well maintained, so patients received the treatment they needed safely.

Incidents were reported using an electronic reporting system and staff knew how to report incidents. Incidents were investigated and ‘lessons learned’ were shared with staff.

Staff had received appropriate training and support through the completion of mandatory training, so that they were working to the latest up to date guidance and practices, with appropriate records maintained.