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Darlington Memorial Hospital Requires improvement

We are carrying out checks at Darlington Memorial Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 September 2015

Darlington Memorial 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. It served around 600,000 people across County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside 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 7555 staff. Darlington Memorial Hospital had 410 beds.

Darlington Memorial Hospital provided medical, surgical, critical care and maternity services, and services for children and young people, for 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 Darlington Memorial Hospital as part of the comprehensive inspection of County Durham and Darlington NHS Foundation Trust, which included this hospital, University Hospital of North Durham and the trust's community services. We inspected Darlington Memorial Hospital on 5 and 6 February 2015.

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

We rated medical care, surgical services, critical care, services for children and young people, maternity and gynaecology, and outpatient and diagnostic imaging services as ‘good’, with A&E, 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, 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 working overtime.
  • Mortality rates were within acceptable limits for a hospital of this size.

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

Importantly, the trust must:

  • Review the achievements and actions taken to address the targets set nationally within A&E.
  • Review consultant levels against CEM guidance.
  • Ensure that the A&E department meets cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors.
  • Ensure that the area outside the accident and emergency decontamination facility is free from dirt, litter and debris.
  • Be able to demonstrate that all toys are cleaned properly to reduce the risk of infection within the A&E department.
  • Ensure that staff regularly check all resuscitation drugs and equipment within the A&E department.
  • Ensure medicine fridges are locked and temperatures are checked regularly within the A&E department; this will include recording maximum and minimum fridge temperatures.
  • Ensure that medical gases are stored in a secure facility within the A&E department.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff on medical wards, in line with best practice and national guidance; taking into account patients’ dependency levels, particularly where patients are receiving non-invasive ventilation (NIV) and require Level 2 intervention. Also, ensure that actual staffing levels meet planned staffing levels.
  • 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, including those for patients awaiting discharge, are maintained and up to date, are patient-centred, contain the relevant information about their treatment and care, and serve to eliminate unnecessary delays.
  • Ensure that staff are conversant with the syringe driver policy and carrying out/recording 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 that medical staff record mental capacity assessments for patients who are unable to participate in decisions about do not attempt cardiopulmonary resuscitation (DNACPR).
  • Ensure that 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 that data is 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 within the A&E department.
  • Extend its safeguarding assessment processes and consider child sexual exploitation for all age appropriate children.
  • 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 through the hospital to ensure care is given in the most appropriate setting.
  • 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 timelines for review and achievement within the maternity and gynaecology services clinical and quality strategy for 2014–16 .
  • Consider ways of developing a coherent plan for joint working on improvements to maternity and gynaecology services.
  • Consider ways for improving timely and responsive human resource management processes, including personnel issues that affect service delivery in maternity and gynaecology services.
  • Ensure that the paediatric high dependency room has specific standard operating procedures or protocols available to guide the suitably trained staff required to deliver high dependency care.
  • 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. This should be separate from the safeguarding children executive lead role.
  • Review access and security arrangements to theatres and recovery areas.
  • Review the servicing of all equipment within the theatre and recovery areas to ensure maintenance and service arrangements are within required timescales.
  • Improve the systems in place to remove out of date stock or stock no longer used from store cupboards in the outpatient department.
  • 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 September 2015

Effective

Good

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)

Good

Updated 29 September 2015

We rated medical care at this hospital as good. However safety required 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.

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 as well as condition/appearance and maintenance.

Systems were in place to report incidents and wards monitored 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.

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. It was reported that patients felt safe and relatives said that their loved ones were well cared for. Nutrition, hydration and comfort needs were met. Ward 44 had recently been awarded the “Quality Mark for Elder-Friendly Hospital Wards”.

The trust had consistently achieved its referral-to-treatment times (RTT) for all care groupings with the exception of gastroenterology. RTT were better than the England average. The trust had consistently achieved their performance targets for national cancer waiting times.

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

Urgent and emergency services (A&E)

Requires improvement

Updated 29 September 2015

Overall, emergency and urgent care services at this hospital required improvement. Some areas of the department were not visibly clean and we found high and low level dust around the department. We found resuscitation equipment and fridge temperatures were not checked regularly and some types of medication were not stored securely. 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. 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.

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. Systems were in place for investigating complaints, learning the lessons of those complaints and communicating lessons to staff.

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.

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 they felt empowered to take responsibility for issues. We found a number of risks in the department and found no evidence that they had been effectively mitigated. Staff were focused on giving patients a positive experience.

Surgery

Good

Updated 29 September 2015

Overall, surgical services at this hospital were good. We saw effective arrangements in place for reporting patient and staff incidents and allegations of abuse, which was in line with national guidance. Staff 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. Effective handovers took place between staff to ensure continuity and safety of care.

There were arrangements in place for the prevention and control of infection and the management of medicines, but we saw that not all equipment had been serviced within required timescales and issues were identified with the kitchen on the theatre corridor.

Care records were completed accurately and clearly and in line with patients’ needs.

There were processes in place 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.

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.

There were kind and caring interactions on the wards and between staff and patients. 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.

Services were available to support patients, 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 and we saw effective arrangements in place for collaborative working between surgical teams.

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. The service recognised the importance of patient and public views and there were mechanisms in place to hear and act on patient feedback. Staff were encouraged and knew how to identify risks and make suggestions for improvement.

Intensive/critical care

Good

Updated 29 September 2015

Overall we rated the intensive care unit as good. The environment was clean and the unit complied with the trust’s infection control policy. Medical and nursing staffing levels were adequate and there was evidence of a cohesive team working approach to patient care. The senior sisters on the unit were supernumerary so staff working on a 1:1 basis with patients could rely on the sister’s individual support when needed. Staff told us this made them feel safe. Staff were aware of the systems and processes in place for reporting patient and staff incidents. Staff we spoke with told us they were encouraged to report incidents and we were given examples where staff demonstrated an open and transparent culture of doing so. Staff regularly received feedback from an incident either by email or through staff huddles.

All aspects of care delivered in the unit were audited and reviewed and could demonstrate continuous improvement. The unit had an outreach team to identify and monitor deteriorating patients, although this was not well resourced. Patients received treatment and care according to national guidelines. The unit was obtaining good-quality outcomes as evidenced by its Intensive Care National Audit and Research Centre data. We found there was good multidisciplinary team working across the unit. Staff were actively engaged in reviewing patient outcomes through research and audit activities, peer review and benchmarking.

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 that ‘went the extra mile’. For those patients who were on the unit for exceptionally long periods of time due to their illness, we observed some very special relationships which had developed over time. We observed individualised care and attention to detail given to patients and relatives, evidenced by their work with the end of life team, their visitor’s charter, care of patients with learning disabilities and implementation and consideration of the deprivation of liberty safeguards standards.

The unit was responsive to patients’ needs. Staff worked across the ITU1 and ITU2 wards to ensure the required patient-to-nurse ratio was met. They also had a bed occupancy rate of 80–85% which enabled them to plan admissions and accept emergencies. The unit occasionally experienced a delay in discharges, often due to the lack of available beds on a ward, but also because of difficulties determining who the parent team was when patients were admitted via the emergency department.

We found there was a real commitment to working as a multidisciplinary team delivering a high quality and safe service. Feedback was valued as a way of improving the service. On a number of occasions the team went over and above what would be expected in order to keep patients feeling safe and at ease. There was strong medical and nursing leadership within the unit. Staff felt well supported within an open, positive culture. However, the process for governance was still to be embedded. The trust had recently identified a designated executive director to take lead responsibility for critical care services and a critical care delivery group (CCDG) had been set up. The first meeting of the CCDG took place in January 2015.

Services for children & young people

Good

Updated 29 September 2015

Overall, services for children and young people at this hospital were good.

The children’s services actively monitored safety, risk and cleanliness. 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 the need 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. Monitoring of the safe use of syringe drivers for end of life medication was not being recorded consistently or in line with the trust’s policy. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were generally being completed accurately and comprehensively, but mental capacity assessments were not being recorded when there was an indication that patients did not have capacity to be involved in decision making.

Staff were seen to be caring and compassionate and we saw that the development of pastoral and spiritual services were planned for as part of the end of life care steering group. We saw that 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 were being developed to address these needs, but at the time of our inspection we saw that staffing difficulties had affected the ability of the specialist palliative care team to take action to develop the service.

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 that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. 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 the preferred place of care for patients at the end of life wishing to be at home.

Outpatients

Good

Updated 29 September 2015

Overall the care and treatment received by patients in the Darlington Memorial Hospital 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.

There were some areas for improvement, such as the systems in place for checking storage cupboards for expired equipment. A number of patient information leaflets across the departments were past their review date.

The departments took part in the NHS Friends and Family Test (a satisfaction survey that measures patients’ satisfaction with the healthcare they have received) 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 Darlington Memorial Hospital can be found at County Durham and Darlington NHS Foundation Trust.