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The James Cook University Hospital Good

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. Nurse staffing in neonates did not fully comply with British Association of Perinatal Medicine (BAPM) standards. However, there was a period of sustained improvement in recruitment and increased staffing compliance rates since April 2016. 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.
  • 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.
  • 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. However, we found some inconsistencies in the storage of medicines. 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 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 North East 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 the emergency nurse call system in wards 10 and 12 is reviewed to ensure it is fit for purpose.
  • Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.
  • Ensure medication processes are followed consistently particularly ‘do not disturb’ procedures for staff completing medicine rounds.
  • Ensure that that the frequency of controlled drug balance checks is carried out in line with national guidance.
  • Ensure that the end of life strategy is approved and implemented and move to develop a seven-day palliative care service.
  • Continue to develop plans to ensure that staffing levels particularly in the neonatal unit meet the British Association of Perinatal Medicine guidelines.

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 reviewed, with services rated as ‘outstanding' for being well-led. We observed exemplary practice in the care and treatment of women.

The service provided safe and effective care in accordance with recommended practices. Outcomes for women using the service were continuously monitored and, where improvements were required, action was taken.

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

Women’s individual needs 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 implemented action to improve the quality of care.

The maternity and gynaecology services were led by a highly committed, enthusiastic team, each 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 very strong engagement with patients and staff. There was evidence of innovation and a proactive approach to performance improvement.

Medical care (including older people’s care)

Good

Updated 28 October 2016

We rated safe for medicine as good because:

We found significant improvements since the comprehensive inspection of the 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.

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

There were some inconsistency in the 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

We rated effective for urgent and emergency care as good because:

At our last inspection in December 2014, we identified concerns about the results of Royal College of Emergency Medicine (RCEM) audits. We also identified that staff had not received training on how to safely restrain patients.

During this inspection although RCEM audits had not been repeated, the department had completed local audits based on RCEM guidance and we identified significant improvement in compliance in these areas.

Patients were able to access treatment seven days a week, 24 hours a day.

Competent staff who followed nationally recognised pathways and guidelines treated patients. Records were audited to make sure that pathways and guidelines were followed correctly.

Overall, patients received pain relief in a timely way and were able to access food and drinks as required.

Staff understood their responsibilities in relation to the Mental Capacity Act (2005), restraint of patients and the treatment of detained patients.

Surgery

Good

Updated 10 June 2015

Overall, we rated surgical services as good. There were effective arrangements for reporting patient and staff incidents and allegations of abuse. Staff were encouraged to report incidents and most received feedback on what had happened as a result. Staffing establishments and skills mix had been reviewed for the number and acuity of patients.

There were arrangements for the effective prevention and control of infection and the management of medicines. Equipment was routinely examined in the daily checks for anaesthetic equipment. However, resuscitation equipment had not been routinely checked on some wards and signatures were missing from documentation. Care records were completed accurately and clearly.

Surgical services participated in national clinical audits and reviews to improve patient outcomes. Mortality indicators were within expected ranges.

Processes were in place to identify staff’s learning needs 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 patients’ care.

We observed positive, kind and caring interactions on the wards and between staff and patients. Patients spoke positively about the standard of care they had received. Most 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.

Services were available to support patients, particularly those living with dementia, a learning disability or physical disability or those whose first language was not English. There were also systems to record concerns and complaints raised within the centre, review these and take action to improve patients’ experience.

The trust’s vision, values and strategy had been disseminated to wards and departments and staff had a clear understanding of what these involved. Staff were aware of their roles and responsibilities and there was good ward leadership. Staff felt supported and had seen positive changes to improve patient care.

The service recognised the importance of patient and public views and had mechanisms to hear and act on patients’ feedback. Staff were encouraged and knew how to identify risks and make suggestions for improvements.

Intensive/critical care

Good

Updated 10 June 2015

We rated critical care services as good. Effective arrangements were in place for reporting patient and staff incidents and allegations of abuse, which was in line with national guidance. Nurse staffing levels were determined using an acuity tool and national guidelines were followed. Although an additional coordinator was factored into staffing rotas in line with the Core Standards for Intensive Care Units 2013, this did not always happen due to staff sickness. The safety of patients was not compromised as a result of this. The complement of medical staff and the skills mix of the medical team were suitable and were in line with national guidance. There were arrangements 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.

There were processes 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 staff’s learning needs 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 patients’ care.

All the critical care units were caring. We saw people and their relatives being treated with understanding, compassion, dignity and respect. Patients spoke positively about the care that they received. Patients and their relatives felt they understood their care options and were given enough information about their conditions. Services were provided to ensure that patients received appropriate emotional support.

The staff groups 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 all units. Average length of stay for all admissions and for unit survivors were also within acceptable limits. The units 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.

The trust’s values and objectives had been communicated to all staff and they had a clear understanding of what this involved. Governance processes were embedded and there were appropriate processes for managing risk. The leadership teams were approachable and open, and were viewed positively by staff. The management teams had a number of effective ways of engaging with staff, and patient engagement and feedback was actively sought on the units.

Services for children & young people

Good

Updated 28 October 2016

We rated safe for children and young people as good because:

Staff ensured the ward environment and clinical areas were ‘child-friendly’, secure, clean and well maintained. Equipment was checked, labelled and safely stored.

Medicines and clinical records were stored securely. Documentation was good with each child and young person having an individualised plan of care.

The service had good local procedures to monitor changes in a child’s condition and arrangements with network colleagues to escalate care when a child deteriorated.

Staff followed trust mandatory training requirements. Managers were working to ensure all staff completed necessary training and to meet trust targets.

There had been an improvement in staffing levels in all paediatric areas since the inspection in December 2014. Additional recruitment was planned to re-enforce staffing in the neonatal unit to ensure compliance with national staffing guidelines. Staffing levels were managed appropriately to ensure they were safe.

Staff reported concerns and incidents where they felt this compromised a child’s safety and wellbeing. Outcomes and lessons learnt from investigations were shared with all staff.

End of life care

Good

Updated 28 October 2016

We rated safe, effective and well-led for end of life care as good because:

The service had made significant improvements in audit and completion of DNACPR forms. Nutrition and hydration assessments were included in an individualised patient assessment tool for patients at the end of life.

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.

We saw clear, well-documented and individualised care of the dying documents. The referral process was clear and responsive and staff ensured that patient’s wishes were central to the care planning process.

However, although there was a clear vision for the service, which specialist palliative care staff had developed, the trust specific strategy for end of life care was in draft and under review and it was not clear when Board approval would be finalised.

The trust did not have an overall strategic lead for palliative care but this was identified as a future development. There was no action date to implement this role but the Board were keen to ensure that this happened.

Outpatients

Good

Updated 28 October 2016

We rated safe for outpatients and diagnostic services as good because:

There had been improvements in all areas identified during the 2014 inspection. There were processes to ensure that resuscitation equipment was checked each day. Staff had enough personal protective equipment in all the areas and staff knew how to dispose of items safely and within guidelines.

There were sufficient staff of all specialties and grades to provide a good standard of care in the departments we visited.

There were processes to ensure medicines were managed safely. Practices were monitored and improvements made where required. Staff identified and responded appropriately to changing risks to patients, including deteriorating health and medical emergencies.