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University Hospital of North Tees Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 February 2016

University Hospital North Tees provides acute care services for North Tees and Hartlepool NHS Foundation Trust. The hospital has 563 beds and provides urgent and emergency care services, critical care services, medical services, surgical services, maternity services, outpatient services and children and young people’s services.

The trust gained foundation status in 2007. It has a workforce of approximately 5500 staff and serves a population of around 400,000 in Hartlepool, Stockton and parts of County Durham. The trust also provides services in a number of community facilities across the areas supported, including Peterlee Community Hospital and the One Life Centre, Hartlepool.

We inspected University Hospital North Tees as part of the comprehensive inspection of North Tees and Hartlepool NHS Foundation Trust, which included this hospital and community services. We inspected University Hospital North Tees on 7-10 July and 29 July 2015.

Overall, we rated University Hospital North Tees as requires improvement. We rated it as requires improvement for safe, effective and well-led services and good for caring and responsive services.

We rated emergency and urgent care, medical services and maternity and gynaecology services as requires improvement and surgery, end of life care, children and young people’s services and critical care as good.

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection. A dedicated infection control team to supported staff and ensured policies and procedures were implemented and adhered to. We found that areas we visited were clean. In the A&E department we saw that infection control procedures were not always being followed.
  • At the time of inspection, infection rates for methicillin resistant Staphylococcus aureus (MRSA) and Clostridium Difficile (C Difficile) were within an acceptable range for this size of hospital.
  • The trust had not met the A&E four hour target between January 2015 to March 2015 however performance had started to improve
  • Patients were able to access suitable nutrition and hydration, including special diets. We observed the use of red trays for at risk patients who required support with feeding and coloured plates and bowls for patients living with dementia. Patients reported the food provided during their stay was satisfactory and valued the opportunity to choose the size of their meal.
  • 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 the hospital.
  • There were a significant number of policies on the intranet for medicine and maternity services that were out of date and required reviewing and revising.
  • There were processes in place for the reporting of incidents and there was learning from incidents; however the root cause analyses and related action plans lacked detail. Governance processes were not fully developed or embedded across the divisions and there were concerns in some areas regarding the maintenance and use of risk registers.
  • The trust was reported in July 2015 (Health and Social Care Information Centre) as among the 11 worst performing trusts in England for mortality performance. The trust had implemented actions to improve the trust position for both mortality indicators and been open to external scrutiny.
  • There was concern regarding leadership capacity within midwifery services and the impact that had on professional development and clinical standards.

We saw several areas of good practice including:

  • The development of advanced nurse practitioners had enabled the hospital to respond to patient needs appropriately and mitigated difficulties recruiting junior doctors.
  • The bariatric service had been developed as part of a consortium arrangement with neighbouring NHS trusts to ensure the local population had access to this service.
  • A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment.
  • The critical care team achieved a network award, which recognised excellent work in relation to “target” training. The team had also achieved recognition for their work related to critical care competencies, difficult airway and skills drills.
  • The critical care team achieved 58% for its consideration of patients for tissue donation. The team were the second highest achiever for corneal donations. Overall the team’s approach to tissue and organ donation was impressive, demonstrating a compassionate and sensitive approach to patients and relatives.
  • The paediatric and neonatal departments participated in a number of national and local research studies and were involved in a large number of clinical trials. The management team and several other staff told us the department had recently obtained a £3.5 million grant for an ‘OSCAR study.’ This study is for high frequency Oscillation in Acute Respiratory distress syndrome, comparing conventional positive pressure ventilation with high frequency oscillatory ventilation.
  • The neonatal unit had implemented the ‘Small Wonders’ initiative for premature babies; this was designed by the charity Best Beginnings. Small Wonders supports parents in their baby’s care in ways shown to improve health outcomes for their babies.
  • Staff in the maternity day assessment unit attended training on Gestation Related Optimal Weight (GROW) software which aims to reduce the number of stillbirths by using customised growth charts.
  • ‘NIPE Smart’ had recently been implemented within the maternity directorate. This is an information technology screening management system which has a robust system of capturing data on newborn and infant screening examinations with the aim of reducing the number of babies diagnosed with a medical congenital condition at a late stage.

  • Outpatient department staff produced posters and delivered presentations at the International Society of Orthopaedic and Trauma nurses on the development of virtual fracture clinics and on the roles of speciality nurses.
  • A number of staff within the outpatients department completed modules on service improvement including one current project to improve the staff engagement and sustainability in clinical supervision.
  • Staff worked on the development of health promotion packs within main outpatients to be rolled out within the orthopaedic department as a pilot to explore how this can be sustained.

  • The lead consultant radiologist for the specialist procedure known as CTPA (CT pulmonary angiography) presented the experiences of staff and patient outcomes to a panel at a major CT equipment manufacturer.

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

Importantly, the trust must:

  • Ensure there are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist.

  • Ensure staff follow trust policies and procedures for managing medicines, including controlled drugs. Ensure that medicines are stored according to storage requirements to maintain their efficacy in maternity services.
  • Ensure that risk assessments are documented along with personal care and support needs and evidence that a capacity assessment has been carried out where required.
  • Ensure pain in children and young people is assessed and managed effectively.
  • Ensure that the competency criteria for staff who are triaging patients are clearly documented and include recognised competency–based triage training.
  • Ensure that infection control procedures are followed in relation to hand hygiene and use of personal protective equipment.
  • Ensure that resuscitation and emergency equipment is checked on a daily basis in line with trust guidelines.
  • Ensure cleanliness standards are maintained.
  • Ensure effective systems are in place which enable staff to assess, monitor and mitigate risks relating to the health, safety and welfare of people who use the service.
  • Ensure that all policies and procedures in the In-Hospital care directorate are reviewed and brought up to date.
  • Midwifery policies, guidelines and procedural documents must be up to date and evidence based.
  • Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
  • Ensure that all annual reviews for midwives take place on a timely basis.
  • Ensure all staff attend the relevant resuscitation training.

In addition the trust should:

  • Consider strengthening the senior nurse capacity in the A&E department.
  • Consider reviewing the system for documenting the follow-up of admitted head injury patients by the A&E department
  • Consider a system in A&E to enable patients with allergies to be recognised quickly and easily without the presence of medical records
  • Ensure that staff are following the correct procedure when dispensing medication using the Omnicell including checking the prescription at the time of dispensing.
  • Consider a continuous audit of all MCA and DoLs assessments and referrals and share lessons learned.
  • Consider assessing the access to the emergency resuscitation trolley on the haematology day unit.
  • Consider putting engaged notices on toilet doors to protect dignity if the door is kept unlocked for staff to gain access to vulnerable patients.
  • Send electronic communication to the patient’s GP on discharge from the critical care unit.
  • Ensure handover meetings are held in a private and confidential area in children’s services.
  • Ensure that all patient documentation remains confidential during patient visits to the outpatients department.
  • Ensure that all outpatient treatment rooms are cleaned before use.
  • Ensure that formal drugs audits and stock checks carried out regularly in outpatients.
  • Ensure that medicines are stored appropriately to ensure their quality is maintained.
  • Ensure that overall communication, outpatient clinic planning, room utilisation and staffing is formally managed and controlled, including clinics involving staff from other trusts.
  • Ensure that patients in the children’s outpatient department are afforded privacy when speaking with reception staff.
  • Update the risk assessment related to paediatric resuscitation in the children’s outpatient department.
  • Ensure that some clean and safe methods for entertaining or distracting children are provided within the diagnostic imaging department.
  • Ensure that staff adhere to the coding system for recording on medication charts
  • Ensure that staff fully adhere to infection control policies and close doors on side rooms where patients are being barrier nursed.
  • Ensure the processes and documentation used for appraisal of non-medical staff monitors their performance and meets their personal development needs.
  • Review the process for storage of post-transfusion blood bags while retained on ward areas.
  • Review whether documentation for patients living with dementia are completed and comprehensive.
  • Ensure that within outpatient services, action plans from audits, risk registers and meetings are maintained, regularly revisited and amended to show where actions have been completed or remain outstanding.
  • Ensure that established models of regular nursing clinical supervision are implemented for all staff involved in patient care in outpatient services.
  • Ensure that patients and staff are informed if clinics are cancelled, including those involving clinicians and staff from other trusts.
  • Ensure that strategy and management plans regarding transforming the outpatients departments are communicated to all staff.
  • Consider recording decision made at the evening medical ward rounds on the critical care unit.
  • Consider how the critical outreach service will be maintained.
  • Review the recruitment of medical staff, particularly junior doctors in the surgical unit.
  • File maternity healthcare documentation according to the trust records management policy to avoid loss or misplacement of information
  • Indicate benchmark data on the maternity performance dashboard to measure performance.
  • Ensure that ‘fresh eyes’ checks are recorded when undertaken.
  • Review the senior midwifery structure and experience resource to ensure that all the midwifery roles needed for coordination and oversight of each service are appropriately covered.
  • Monitor and internally report the level of provision of 1:1 maternity care
  • Hold staff handovers in maternity services in an environment that reduces the possibility of distraction and interruption.
  • Have a competency based framework in place for all grades of midwives.
  • Have systems in place to achieve the nationally recommended ratio of 1:15 for supervision of midwives.
  • Consider safety briefings as part of daily communication with staff in maternity services.
  • Include describing the reporting arrangements for Supervisors of Midwives following investigations, audits or reviews in the maternity services risk management strategy.
  • Provide simulation training exercises to prevent the abduction of an infant

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 February 2016

Effective

Requires improvement

Updated 3 February 2016

Caring

Good

Updated 3 February 2016

Responsive

Good

Updated 3 February 2016

Well-led

Requires improvement

Updated 3 February 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 3 February 2016

Overall the maternity and gynaecology services at University Hospital North Tees were rated as requires improvement; this was due to concerns in the areas of safe, effective and well-led. We found the service to be caring and responsive and rated these as good.

We lacked assurance around the consistent checking of emergency equipment and full completion and management of patient records in maternity services. We observed a staff handover on the delivery suite that was not comprehensive or inclusive of matters relating potential safety issues. We also had concerns about staffing and skills mix on the maternity unit.

The lack of a competency framework for midwives, out of date guidelines and the failure to achieve the recommended midwife to supervisor ratio led us to a rating of requires improvement for effective. Although we were informed the out of date guidelines had been updated on our return visit, we lacked assurance that the guidelines and learning from serious incidents were embedded with all staff.

Although some areas were well-led overall, the current risk register did not give assurance that risk within the department was being managed appropriately. The staff we spoke with and observed in practice were compassionate and patient focused and patients were very happy with the care they received.

Medical care (including older people’s care)

Requires improvement

Updated 3 February 2016

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

Areas of concern included management of risk registers, management of clinical policies and the continuing worse than expected performance related to mortality ratio. Hospital Standardised Mortality Ratio (HSMR) compares the number of deaths in a trust with the number expected given age and sex distribution. HSMR adjusts for a number of other factors including deprivation, palliative care and case mix. HSMR is usually expressed using ‘100’ as the expected figure based on national rates. In 2014/15 the Trust had an increased HSMR of 124.5 (year to May 2015); this was higher than expected. The Summary Hospital-level Mortality Indicator (SHMI) was 123.5 (year to May 2015). The trust was among the 11 worst performing trusts in England for mortality performance but had implemented plans to improve the trust position for both mortality indicators including being open to expert scrutiny.

Systems were in place to report incidents, analysis and feedback was provided to staff. Wards monitored safety and harm free care and results were positive, overall. Wards were clean and staff adhered to infection control principles, however, we did observe some doors left open on side-rooms where patients were in isolation. Some of the ward areas were cluttered and cramped. Patients’ records and observations were recorded appropriately and concerns were escalated in accordance with the trust guidance. The trust had highlighted the high number of nursing vacancies as a concern and plans were in place to improve this, staffing was reviewed on a day by day and shift by shift basis, using agency staff as required. Attendance at mandatory training and safeguarding was good in all specialities.

Almost all patients and relatives told us that they or their relatives had been treated with compassion and that staff were polite and respectful. Patients were aware of what treatment they were having and understood the reasons for this and, in many cases, had been involved in the decisions. The trust had prioritised and developed a number of initiatives to improve the care of people living with dementia, including the use of therapeutic volunteer workers.

The In-Hospital care directorate had a clear vision and strategy; we spoke with staff who demonstrated pride and compassion in the care that they provided. Medical and nursing staff told us there was a positive cultural and management genuinely listened about issues. At the time of the inspection 88% of staff in the In-Hospital care directorate had received an annual appraisal. The trust was proactive in planning discharges and utilised step down wards to manage those medically fit, but not therapy fit for discharge.

Urgent and emergency services (A&E)

Requires improvement

Updated 3 February 2016

We rated the Accident and Emergency department as requires improvement for safety, effectiveness and well-led and good for caring and responsive. Overall we rated the service as requires improvement.

We had concerns about safety in the department. We observed that policies and procedures were not always being followed. We also had concerns about the triage process. Safeguarding processes to protect vulnerable adults and children were in place and referrals were made when necessary however this was not always done in a timely manner. There were sufficient medical and nursing staff employed by the department and on the whole staffing levels were acceptable. Most staff were up to date with mandatory training however there were some areas where the department was not meeting the trust expected compliance rate. Staff underwent annual appraisal although some staff had not been appraised in the past 12 months. Their competencies were checked regularly.

There were evidence based policies and procedures in place which were easily accessible to staff. These were audited to ensure staff were following relevant clinical pathways. Information about patients such as test results were readily accessible. There was evidence of multi-disciplinary working throughout the department and the department offered a full seven day service. Staff understood their responsibilities in relation to taking consent from patients and the principles of the Mental Capacity Act 2005 however documentation to evidence this was not always present.

The care given to patients by the department was good. Privacy and dignity were maintained and people were dealt with in a kind and compassionate way. Patients and families were involved in decisions about their care and emotional support was given during difficult situations.

Patients who visited the department had their individual needs met. Interpreters were available and there were facilities available to assist patients with disabilities or specific needs. Pain relief and nutrition and hydration needs of patients were met. Four hour target waiting times had improved since March 2015 and most patients were discharged within three hours of admission. The trust was performing better than the England average for a number of other performance measures relating to the flow of patients. There were however some delays in the triage of patients which had associated risks. Patient complaints were managed in line with trust policy and feedback was given to staff. Lessons were learned and where applicable, practice was changed to minimise the likelihood of recurrence.

Although staff felt they were well-led at departmental and trust level, we were concerned about the strength and visibility of nursing leadership. There were processes in place to manage governance and measure quality. Additionally we had some concerns about the type and number of risks on the risk register.

Surgery

Good

Updated 3 February 2016

We rated surgery services to be good for safe, effective, caring, responsive and well-led.

Staff were aware and familiar with the process for reporting and investigating incidents using the trust’s reporting system. Staff told us feedback on reported incidents was given and felt they were appropriately supported. A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment. Care records showed risk assessments were being appropriately completed for all patients on admission to the hospital. Infection control information was visible in all ward and patient areas. Monthly cleanliness audits were undertaken and results were displayed through the Nursing Dashboard in ward areas.

Staffing levels for wards were calculated using a recognised tool and trust ‘template’. We reviewed the nurse staffing levels on all wards visited and within theatres and found that levels were compliant with the required establishment and skill mix. We reviewed patient records and saw medical patients had been placed on surgical wards (‘boarders’) when beds were not available on medical wards. Although medical ‘boarders’ were under the care of medical clinicians, surgical staff told us they did not feel able to provide the same level of care to medical patients.

We observed patients being treated with compassion, dignity and respect throughout our inspection at this hospital. We saw ward managers and matrons were available on the wards so that relatives and patients could speak with them. We saw information leaflets and posters available for patients explaining their procedure and after care arrangements. Patients were able to access counselling services and the mental health team. Therapists worked closely with the nursing teams on the wards and staff told us they had good access to physiotherapists, occupational therapists and speech and language therapists.

The service was responsive to the needs of patients living with dementia and learning disabilities. All wards had dementia champions as well as a learning disability liaison nurse. There was access to an independent mental capacity advocate (IMCA) for when best interest decision meetings were required. Complaints were handled in line with the trust policy and were discussed at monthly staff meetings where training needs and learning was identified as appropriate.

Senior managers had a clear vision and strategy for the division and staff were able to repeat this vision and discuss its meaning with us during individual interviews. Joint clinical governance and directorate meetings were held each month. The directorate risk register was updated following these meetings and we saw that action plans were monitored across the division. Records for 2014 showed that staff across all wards in surgery and theatres had received an appraisal or had an appraisal planned. Staff said speciality managers were available, visible within the division and approachable; leadership of the service was good.

Intensive/critical care

Good

Updated 3 February 2016

We found critical care services to be good for safe, effective, caring, responsive and well-led.

There was a real commitment to work as a multidisciplinary team delivering a patient centred and high quality service. Patients were at the centre of the service and high quality care was a priority for staff. There was a good track record on safety with lessons learned and improvements made when things went wrong. Staff knew how to report incidents. The environment was clean but there was a lack of space due to the position of the unit within the hospital. The service had recently put in place a Critical Care Outreach Team (CCOT) to identify and monitor the deteriorating patient. The purpose of this service was to assess the critically ill or deteriorating patient on wards and to stabilise the patient at ward level and so avoid the need to escalate to the unit.

Medical and nursing staffing levels were adequate and there was evidence of a cohesive team working approach to patient care. The unit was staffed according to the Core Standards for Intensive Care Units and nursing and support staff provided flexibility within the department to provide the level of care that met patients’ care needs.

Patients received treatment and care according to national guidelines and the service used an audit programme to check whether their practice was up to date and based on sound evidence. The service was obtaining good-quality outcomes as evidenced by its Intensive Care National Audit and Research Centre (ICNARC) data. We found there was good multidisciplinary team working across the service.

There was a clear open, transparent culture which had been established with the new leadership team. Staff felt valued and supported by their managers and received the appropriate training and supervision to enable them to meet patients’ individual needs. Both medical and nursing staff we spoke with were passionate about providing a holistic and multidisciplinary approach to assessing, planning and treating patients. This was demonstrated by regular multidisciplinary meetings and excellent communication with the patients and relatives.

We observed individualised care and attention to detail given to patients and relatives evidenced by their work with the end of life team, care of patients with learning disabilities and implementation and consideration of the Deprivation of Liberty Standards (DoLS)

Services for children & young people

Good

Updated 3 February 2016

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

Staff knew how to report incidents and these were followed up appropriately. Lessons learned were shared and preventive measures put in place. Staff of all grades confirmed they received appropriate mandatory training to enable them to carry out their roles effectively and safely; training included awareness of safeguarding procedures. There were sufficient well-trained and competent nursing and medical staff to ensure children and young people were treated safely. There were some gaps in the medical staffing establishment; however, several new doctors were due to start in post. Children and young people did not always have access to appropriate pain relief as and when required, there was no evidence of the use of pain assessment tools in the care records reviewed.

Children, young people, and their families told us they received supportive care. They said the staff were kind and provided them with compassionate care and emotional support. They also felt well informed and involved. Staff and families both told us they would recommend the service to their families and friends and feedback from surveys carried out by the children’s service was all positive.

The children’s service was responsive to the individual needs of the children and young people who used it and there were effective systems and processes in place for dealing with complaints from people using the service. The management team were committed to the vision and strategy for the children’s service and feedback from staff about the culture within the service, teamwork, staff support and morale was positive.

However, systems and processes for risk management within the service were not effective and timely. The need to improve risk register management was known by the trust board and a plan was in place but not yet implemented. The risk register was not regularly reviewed at the patient safety and risk management meetings and risks were not actively managed by using the risk register. There was no resuscitation trolley in the children’s outpatient department. Staff were able to describe the procedure they would follow but the trust response to mitigate this risk was not clearly documented in the risk assessment or on the risk register and both documents required updating.

End of life care

Good

Updated 3 February 2016

We rated End of Life Care services as good. Patients were provided with an end of life care service that was safe and caring. We found the specialist palliative care team, mortuary and chaplaincy team were effective, responsive and well led and delivered safe and caring services. The local teams were very responsive to patient requests with evidence of end of life patients able to be discharged under the trust’s Fast Track Rapid Discharge process. We saw good links with the community services, General Practitioners and care and nursing homes within the trust’s geographical area.

The service provided good and effective person-centred care to patients through support of patients and their families, for example, the introduction of the Family Voice project. The Family’s Voice is a diary given to relatives or friends of dying patients inviting them to be a part of care planning. By use of the diary relatives are invited to assess if the care provided by the ward achieves the expected standard. The Family Voice project and its outcomes were now being disseminated to trusts nationwide.

The staff throughout the hospital knew how to make referrals and people were appropriately referred to and assessed by the specialist palliative care team in a timely fashion, therefore individual needs were met. The hospital’s new integrated technology system had improved efficiency within the specialist palliative care team and given staff better access to patient information.

The mortuary was clean and well-maintained; infection control risks were managed with clear reporting procedures in place. Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care. An out-of-hours system was in place for hospital staff community colleagues to access appropriate equipment, for example, syringe drivers. The chaplaincy and bereavement service supported families’ emotional needs when patients were at the end of life and continued to provide support to families afterwards.

Outpatients

Good

Updated 3 February 2016

Overall the care and treatment received by patients in the University Hospital of North Tees outpatient and diagnostic imaging departments was safe, caring and responsive. Patients were very happy with the care they received and found it to be caring and compassionate. 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 there were policies in place to make sure that any additional support needs were met. Staff were aware of these policies and how to follow them. The departments learned from complaints and incidents and put systems in place to avoid recurrences.

Senior managers were familiar with the trust’s vision for the future of the outpatients department and were aware of the risks and challenges. However staff told us they felt the service was fragmented and changes to meet current and future departmental needs could not be considered because there was no clear departmental strategy following a pause in plans for a new hospital at Stockton. It was not always possible to see from the risk register which risks had been managed and which were still waiting to be actioned. The diagnostic imaging department had good leadership and management and staff told us they were kept informed and involved in strategic working and plans for the future.

Other CQC inspections of services

Community & mental health inspection reports for University Hospital of North Tees can be found at North Tees and Hartlepool NHS Foundation Trust.