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University Hospital North Durham Requires improvement

We are carrying out checks at University Hospital North Durham 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 29 September 2015

The University Hospital of North Durham was one of two acute hospitals forming County Durham and Darlington NHS Foundation Trust. This trust was one of the largest hospital and community healthcare providers in the NHS. County Durham and Darlington NHS Foundation Trust served around 600,000 people across County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside, with services including health and wellbeing services, community-based services, and acute and planned hospital services.

In total the trust had 1,331 beds across two acute hospitals and the community, and employed around 7,555 staff. The University Hospital of North Durham had 460 beds.

The University Hospital of North Durham provided medical, surgical, critical care and maternity services, and services for children and young people in County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside. The hospital also provided emergency and urgent care (A&E) and outpatient services.

We inspected the University Hospital of North Durham as part of the comprehensive inspection of County Durham and Darlington NHS Foundation Trust, which included this hospital, Darlington Memorial Hospital and the trust's community services. We inspected the University Hospital of North Durham on 3, 4 and 25 February 2015.

Overall, we rated the University Hospital of North Durham as ‘requires improvement’. We rated it ‘good’ for being caring and responsive, but it required improvement in providing safe, effective and well-led care.

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

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. Rates of Methicillin-resistant staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the 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 processes for implementing, and monitoring the use of, evidence-based guidelines and standards to meet patients’ care needs.
  • There was effective communication and collaboration between multidisciplinary teams.
  • There were staff shortages, particularly on some medical wards and in the maternity and gynaecology service, mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank, agency and locum staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.
  • Mortality rates were within acceptable limits for a hospital of this size.

There were areas of poor practice where the trust needed to make improvements.

Importantly, the trust must:

  • Review the achievements and actions taken to address national targets within A&E.
  • Review consultant levels against CEM guidance.
  • Ensure the A&E department meets cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors. Chairs and equipment that have deteriorated must be removed and replaced.
  • Ensure all toys are cleaned properly to reduce the risk of infection within the A&E department.
  • Ensure sharps bins are managed appropriately to reduce the risk of needle stick injury within the A&E department.
  • Ensure that all resuscitation drugs and equipment within the A&E department are regularly checked, cleaned and in date. This should include all grab bags and anaphylaxis kits.
  • Ensure that all relevant staff know where the difficult airway kit is kept.
  • Ensure that there are robust risk assessments in place for the paediatric environment within the A&E department. These must be readily accessible and available to all staff in the department. Risk mitigation must be outlined and an action plan to improve the area must be written.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance and taking into account patients’ dependency levels on medical wards, particularly where patients are receiving non-invasive ventilation (NIV) and require Level 2 intervention.
  • Undertake a review of current documentation relating to the care and management of patients receiving NIV to ensure that it is consistent across both the University Hospital of North Durham and Darlington Memorial Hospital.
  • Have arrangements in place for patients who are in receipt of NIV that comply with the British Thoracic Society guidelines (2008) for the use of NIV for acute exacerbation of chronic obstructive pulmonary disease.
  • Undertake a regular audit of the provision of services to patients requiring NIV to ensure that the service is safe and to the appropriate quality.
  • Ensure that patients are placed on the most appropriate ward to meet their needs, including a review of the care of patients requiring NIV to ensure that they are admitted to a suitable ward with appropriately skilled and experienced staff in line with best practice guidance.
  • Ensure that patient records are maintained up to date, are patient-centred and contain the relevant information about their treatment and care, including patients awaiting discharge to eliminate unnecessary delays.
  • Ensure that staff know the syringe driver policy and carry out/record syringe driver checks in line with this policy.
  • Add audits of syringe driver administration safety checks to the annual end of life audit programme.
  • Ensure medical staff record mental capacity assessments for patients who are unable to participate in decisions about do not attempt cardiopulmonary resuscitation (DNACPR).
  • Ensure audits of mental capacity assessments are incorporated into audits of DNACPR forms.
  • Ensure robust implementation of structural changes to the specialist palliative care team to support the development of the end of life care services.
  • Ensure data are available to identify and demonstrate the effectiveness of the end of life service.

In addition the trust should:

  • Continue to review College of Emergency Medicine (CEM) audit data to ensure patient outcomes are met.
  • Direct medical staff to check resuscitation equipment and drugs before the start of their shift even when nursing staff have completed the checks.
  • Encourage all relevant staff within the A&E department to attend violence and aggression training.
  • Ensure that patients have their medicines reconciled in accordance with trust targets.
  • Review access to patient information in languages other than English.
  • Review dedicated management time allocated to ward managers.
  • Review the patient flow of higher dependency patients throughout the hospital to ensure care was given in the most appropriate setting.
  • Have an up-to-date standard operating procedure (SOP) which clearly sets out the management of patients requiring NIV who are admitted to the University Hospital of North Durham.
  • Ensure that this guidance/SOP includes clarity on the setting/specific ward in which patients can be managed.
  • Ensure that this guidance/SOP includes staffing to patient ratios that are in line with current guidance.
  • Ensure that there is a training plan in place, which is delivered to all staff involved in the care of patients receiving NIV, and that it is competency-based and in sufficient detail to demonstrate competence in all aspects of NIV.
  • Ensure that any guidance/SOP includes an escalation plan that includes action to be taken when a bed is unavailable in an appropriate setting and when patient numbers do not match agreed staffing ratios.
  • Ensure that the intensive care unit has an outreach team to identify and monitor deteriorating patients.
  • Ensure that there is clinical pharmacist input in the intensive care unit in line with Core Standards for Intensive Care guidelines.
  • Consider ways of improving engagement between staff and managers within the care closer to home directorate with a view to achieving a joined up approach within maternity and gynaecology services. Also, consider ways of improving responsiveness and efficiency in respect to service-level decisions within this service.
  • Consider ways in which it can identify the required standards within the maternity service dashboard.
  • Consider within the maternity and gynaecology services clinical and quality strategy for 2014–16 timelines for review and achievement.
  • Consider ways of developing a coherent plan for joint working on improvements in maternity and gynaecology services.
  • Consider ways of improving timely and responsive human resource management processes, including personnel issues that impact on service delivery in maternity and gynaecology services.
  • Ensure that the paediatric high dependency unit room has specific standard operating procedures or protocols available to guide suitably trained staff.
  • Ensure that advanced paediatric nurse practitioners have a set of standard operating procedures available to guide their practice and care.
  • Formally nominate an executive or non-executive director to represent children at board level, separate from the safeguarding children executive lead role.
  • Ensure that actions against the National Care of the Dying Audit and other identified actions to develop the service are carried out in a planned and timely way with continued evaluation.
  • Ensure that systems support ways of identifying when incidents and complaints relate to end of life care so that specialist input can be provided and recorded in terms of investigation and learning.
  • Ensure that any out of date medication is removed from stock cupboards once it has expired, in line with the trust medication management policy, and have a process for monitoring this within outpatients.
  • Ensure that all fridge temperatures are checked daily and that there is a system in place to monitor that checks are taking place within the outpatient department.
  • Ensure that all resuscitation equipment is checked daily, stored securely and introduce a monitoring system to ensure that checks take place within the outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 September 2015

Effective

Requires improvement

Updated 29 September 2015

Caring

Good

Updated 29 September 2015

Responsive

Good

Updated 29 September 2015

Well-led

Requires improvement

Updated 29 September 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 1 December 2016

Medical care (including older people’s care)

Requires improvement

Updated 29 September 2015

Overall, the medical care and treatment received by patients within the hospital was responsive, caring and well-led, with some areas of patient safety and effectiveness requiring improvement.

Medical staffing was made up of a higher proportion of junior doctors and was higher than the England average. The proportion of consultants, middle career and registrars were all lower than the England averages. The trust was working towards compliance with the National Institute for Health and Care Excellence (NICE) draft guidance for safe nurse staffing. Nurse staffing establishments were determined using the safer nursing care tool (SNCT), however, actual staffing numbers on duty were sometimes below the planned level. We were particularly concerned about the staff to patient ratios for patients requiring non-invasive ventilation (NIV) who were being nursed in general ward areas. We found examples of patient care records that were not fully completed or kept up to date. We also found that supportive documentation on some wards, such as fluid balance charts and risk assessments were not consistently completed in all cases. We found during the unannounced inspection that care planning was not robust and this was reflected in the ward documentation audits.

Policies and guidelines were available to staff and the medical directorate participated in local and national audits. Indicators from some national audits showed mixed performance with some indicators being better than the England average, while others were below the national average. There was no evidence to support any detailed competency based assessment for nursing staff regarding the initiation and ongoing management of patients requiring NIV.

Wards were visibly clean and cleaning schedules were in place. A recent patient-led assessment of the care environment (PLACE) rated the hospital as achieving over 90% compliance in all of the four areas of: cleanliness, food, privacy/dignity and wellbeing and condition/appearance and maintenance. Systems were in place to report incidents and wards were monitored for safety and ‘harm-free’ care. Results were positive, overall, and were prominently displayed at the entrance to wards for staff, patients and visitors to view. Planned and actual nurse staffing levels were also clearly displayed.

Staff were well trained, provided with good support and worked within locally or nationally agreed guidance to ensure that patients received appropriate care and treatment for their conditions. Patients were protected from the risk of harm by adherence to policies and procedures which ensured care needs were managed appropriately.

Patients were happy with the care they received and found the service to be caring and compassionate. Most patients and relatives spoke very highly of staff and told us that they, or their relatives, had been treated with dignity and respect, had been listened to and given enough information in a way they could understand. Nutrition, hydration and comfort needs were met.

The trust had consistently achieved its referral-to-treatment times (RTT) for all care groupings with the exception of gastroenterology. RTT was better than the England average. The trust had consistently achieved their performance targets for national cancer waiting times.Services were delivered in a way that responded to patients’ needs and ensured the departments worked effectively and efficiently.

Clear governance structures were in place to facilitate analysis of information from incidents and complaints, identify themes and ensure communication from ward to board. Key messages from incidents and complaints were communicated across the trust via staff meetings, training and newsletters. There had been a number of developments made and there were projects ongoing to improve services, outcomes and patient experience. Most staff were clear about the vision and strategy for the service.

Urgent and emergency services (A&E)

Requires improvement

Updated 29 September 2015

Overall, urgent and emergency services at this hospital required improvement. Some areas in the department were not visibly clean when we completed our announced inspection visit. We found high level and low level dust on cupboards, curtain rails, equipment and floors. Spilled blood was found around equipment and some staff did not always observe good hand hygiene. We found some resuscitation medication was out of date and not all resuscitation drugs, equipment and fridge temperatures were checked regularly. We reviewed these issues during our unannounced inspection visit and found all equipment in the department was clean and free from dust and resuscitation medication was in date. Fridge temperatures were regularly checked, however, there were some missing entries in the resuscitation equipment checklist in the resuscitation and monitoring bay areas. There were appropriate nurse staffing numbers but consultant numbers were lower than the recommended level. Systems were in place for investigating incidents, learning the lessons of those incidents and communicating those lessons to staff. A programme of mandatory training was in place and managers were working towards training targets.

Policy and protocols were underpinned by national guidelines but the department did not meet several patient outcome targets. The trust had a clinical audit programme and categorised its centrally coordinated clinical audit activity according to priorities. We saw evidence that further clinical audits had been carried out and the results and actions were awaited. Some patients told us they were not provided with adequate pain relief. There were good arrangements in place for patients to obtain food and drinks. There was a rolling programme of regular training and appraisal for staff. Multidisciplinary team arrangements were in place.

Patients received a caring service in the department. We observed respectful and courteous interactions with patients that showed patients were treated well and with compassion.

Between October 2013 and October 2014 the department did not meet national targets. It did not meet the standard of admitting, transferring or discharging 95% of patients within 4 hours. The trust also had a higher than England percentage average for patients waiting 4–12 hours in the department from the decision to admit until being admitted into an inpatient bed. In addition, the standard that 95% of ambulance patients should be handed over within 15 minutes of arrival was not met. It was evident that staff understood that access and flow was a top priority and they worked well together to try to comply with national standards. Paediatric facilities were severely limited and children often used the adult waiting area; ambulatory paediatric patients were treated in areas where adults were cared for. Systems were in place for investigating complaints, learning the lessons of those complaints and communicating lessons to staff.

There was clear management structure in the department and senior managers worked closely together to meet strategic objectives, monitor and improve care. Regular governance and information-sharing meetings were held and staff told us the felt empowered to take responsibility for issues. However, there was a lack of monitoring systems and processes which had resulted in issues with cleanliness, equipment and medication checks. Staff were focused on giving patients a positive experience.

Surgery

Good

Updated 29 September 2015

Surgery at this hospital was good. There were effective arrangements in place for reporting patient and staff incidents and allegations of abuse, which was in line with national guidance. Staff told us they were encouraged to report incidents and most received feedback on what had happened as a result. Staffing establishments and skill mix had been reviewed to maintain optimum staffing levels during shifts and effective handovers took place between staff shifts and included daily safety briefings to ensure continuity and safety of care. Care records were completed accurately and clearly and in line with patients’ needs.

There were arrangements in place for the effective prevention and control of infection and the management of medicines.

Processes were in place for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. Mortality indicators were within expected ranges.

The learning needs of staff and opportunities for professional development were identified. There was effective communication and collaboration between multidisciplinary teams. We observed positive, kind and caring interactions on the wards between staff and patients. All patients we spoke with felt they understood their care options and were given enough information. There were services to ensure patients received appropriate emotional support.

Systems were in place to plan and deliver services to meet the needs of local people, particularly those with dementia, a learning disability or a physical disability. There were also systems in place to capture concerns and complaints raised within the division, review these and take action to improve the experience of patients. There was evidence that the service reviewed and acted on information about the quality of care that it received from complaints.

The trust vision, values and strategy had been communicated 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.

Intensive/critical care

Good

Updated 29 September 2015

Overall the services within critical care were good. However, some aspects of safety required improvement. The intensive care unit did not have an outreach team to identify and monitor deteriorating patients. The purpose of the service would be to assess the critically ill or deteriorating patient on wards and to stabilise them at ward level and so avoid the need to escalate to the unit. There was no clinical pharmacist input to the daily multidisciplinary ward rounds. This was not in line with the national Core Standards for Intensive Care Units 2013. The unit had just started to have its own mortality and morbidity meetings, which were still to be further embedded. Medical and nursing staffing levels were adequate, but there was no supernumerary sister or charge nurse to cover areas such as peak activity times, facilitating admissions and discharges or coordinating nurse staffing on the unit.

Patients received treatment and care according to national guidelines and the unit used an audit programme to check whether their practice was up to date and based on sound evidence. The unit was obtaining good-quality outcomes as shown by its Intensive Care National Audit and Research Centre (ICNARC) data. We found there was good multidisciplinary team working across the unit. However, the full multidisciplinary team did not attend the ward rounds.

Staff cared for patients in a compassionate manner with dignity and respect. Relatives we spoke with told us their loved ones had all their care needs met by dedicated staff. Relatives told us they were involved with their loved ones’ care and felt supported in making decisions as a family.

Bed occupancy rate within the unit was 92% which enabled it to plan admissions and accept emergencies. The unit experienced some delay in discharges, often due to the lack of available beds and due to delays in determining what the parent team was when patients were admitted via the A&E department; this also caused delays in discharges to a ward.

Staff felt well supported within an open, positive culture.  The governance processes still needed time to become embedded, with medical and nursing leadership within the unit needing further development.

Services for children & young people

Good

Updated 29 September 2015

Overall, services for children and young people were good at this hospital. Staff demonstrated awareness of how to report incidents using the trust’s reporting mechanisms and we saw these were reviewed and acted upon by the management team. We found risks were assessed and monitored, and control measures were put in place. We found all children’s clinical areas were kept clean and were regularly monitored for standards of cleanliness. Medicines were stored and administered correctly. Medical records were handled safely and protected.

Members of staff of all grades confirmed they received a range of mandatory training, although training records did not always accurately reflect training uptake. Medical staffing had some gaps but these were being managed and addressed.

The levels of nursing staff were adequate to meet the needs of children and young people.

Children’s services had made improvements to care and treatment where needs had been identified using programmes of assessment or in response to national guidelines.

Children, young people and parents told us they received compassionate care with good emotional support. Parents felt fully informed and involved in decisions relating to their child’s treatment and care.

The service was responsive to children’s and young people’s needs and was well led. The service had a clear vision and strategy. The service was led by a positive management team who worked together. The service had introduced innovative improvements with the aim of improving the delivery of care for children and families.

End of life care

Requires improvement

Updated 29 September 2015

End of life care services at this hospital required improvement. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were not always being completed accurately and comprehensively with clinical information relating to the decision, and discussions with patients and relatives not always being recorded. Mental capacity assessments were not being recorded when there was an indication that patients did not have capacity to be involved in decision making. The trust had taken part in the 2013/14 NCDAH, where it had not achieved six out of seven organisational key performance indicators. The trust performed below the England average and failed to meet all of the 10 clinical key performance indicators. The trust had an action plan in place to address areas identified as part of the National Care of the Dying Audit (NCDAH), including the implementation of training and staff surveys.

Staff were seen to be caring and compassionate and we saw that the development of pastoral and spiritual services were planned for. The specialist palliative care team provided support for patients at the end of life and for the ward staff caring for them. We observed specialist nurses and medical staff providing specialist support in a timely way, and this was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care for patients at the end of life wishing to be at home.

The specialist palliative care team had addressed issues around staff attending specialist training by attending the wards on a regular basis every day and supporting staff to develop the skills needed to care for people at the end of life through a mentoring programme. Education had been identified as a priority area by the trust and recruitment to a dedicated end of life educator post had been included in service action plans. Structural development of the services had begun in terms of the identification of workforce needs and plans being developed to address these needs, but at the time of our inspection we saw that staffing difficulties had impacted on the ability of the specialist palliative care team to take action to develop the service. Examples included taking timely action to develop the service and address issues identified, the development of out of hours consultant cover and the use of data to monitor the effectiveness of the service.

Outpatients

Good

Updated 29 September 2015

Overall the care and treatment received by patients in the University Hospital of North Durham outpatient and imaging departments was safe, effective, caring, responsive and well led. Patients were very happy with the care they received and found it to be caring and compassionate. Staff were supported and 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 took part in the NHS Friends and Family Test and another satisfaction scheme called ‘I want great care’. There were comment boxes in waiting areas.

On the whole, the services offered were delivered in an innovative way to respond to patient needs and ensure that the departments worked effectively and efficiently.

Other CQC inspections of services

Community & mental health inspection reports for University Hospital North Durham can be found at County Durham and Darlington NHS Foundation Trust.