• Organisation
  • SERVICE PROVIDER

South Tees Hospitals NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

8th, 9th, 10th and 17th November 2022 and 10th January 2023

During a routine inspection

We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse. Each report explains the reason for the inspection.

This report describes our judgement of the quality of care provided by this trust. We base it on a combination of what we found when we inspected and other information available to us. It includes information given to us from staff at the trust, people who use the service, the public and other organisations.

We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement.

Overall summary

South Tees NHS Foundation Trust provides acute and community health services to a population of around 1.5 million people living in Middlesbrough, Northallerton and surrounding areas. There are two main hospital sites, The James Cook University Hospital, a regional major trauma centre and tertiary hospital offering a wide range of specialist services, and Friarage Hospital, a busy acute hospital serving a mainly rural population of 135,000. The trust also operates from several primary care hospitals and community locations.

The trust provides urgent and emergency care, medical care, surgery, critical care, maternity, gynaecology, children and young people’s services, end of life and outpatient services alongside a range of community services delivered in people’s homes and local community settings.

We carried out this unannounced inspection of four of the acute services provided by this trust to check that the trust had made improvements since our last inspection in February 2022. We looked at all key lines of enquiry in the core services we inspected. We checked that the trust had taken action to comply with the Warning Notice we served under Section 29A of the Health and Social Care Act following the last inspection which told the trust to make significant improvements in the quality of healthcare provided.

We inspected urgent and emergency care and critical care services at The James Cook University Hospital, and medical wards (including services for older people) and surgery at both The James Cook University Hospital and Friarage Hospital. We also inspected the well-led key question for the trust overall.

We did not inspect end of life care, maternity, gynaecology, services for children and young people, outpatients, diagnostics, or community services at this trust during this inspection. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

Our rating of services ​improved​. We rated them as ​good​ because:

Overall, we rated safe, effective, caring, responsive and well led as good. The trust had made significant improvement since the last CQC inspection and throughout the pandemic, particularly in critical care.

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

We rated medical care as requires improvement. We rated safe and effective as requires improvement and rated caring responsive and well-led as good at both hospitals.

We rated surgery as good overall at both hospital sites. We rated safe, effective, caring, responsive and well-led as good at both hospital sites.

We rated critical care as good overall and in all domains. The safe domain had improved significantly since our last inspection.

In rating the trust, we took into account the current ratings of the five services we did not inspect at this time.

What we found

Leaders had the skills and abilities to run the service. They understood the priorities and issues that the trust faced and had plans in place for these. They were visible and approachable in the trust and were well known to staff. They supported staff to develop their skills and take on more senior roles.

Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

Leaders operated largely effective governance processes, throughout the service and with partner organisations, although there was more to do to strengthen this. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified risks had actions taken to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.

Leaders and staff actively and openly engaged with patients and those closest to them, staff and the public to plan and manage services. They acknowledged that wider engagement with equality groups, the public and local organisations was needed. They collaborated with partner organisations to help improve services for patients.

All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

In medical care, there was not always enough nursing staff to care for patients and keep them safe.

In the emergency and urgent care service, there was no clear flagging system for risks associated with patients experiencing mental health crisis and people could not always access the service when they needed it and could experience long delays waiting for treatment.

The trust faced ongoing challenges with access and flow in the emergency department, which meant that they could not ensure people were able to access the department and receive the right care promptly. Despite these pressures, staff worked hard to keep patients safe.

Whilst the trust provided mandatory training in key skills, medical staff compliance was below the trust target.

Substances hazardous to health were not always stored securely in areas where there were vulnerable people.

How we carried out the inspection

The team that carried out the inspection included two inspection managers, 11 inspectors, one assistant inspector and an inspection planner. In addition, there was an executive reviewer plus three specialist advisors experienced in executive leadership of NHS trusts, including the CQC national professional advisor for ambulance services. The inspection team was overseen by Sarah Dronsfield, Deputy Director of Operations.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

15 to 17 Jan 2019

During a routine inspection

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated well-led at the trust level as requires improvement.
  • At trust level we rated safe, effective and well-led as requires improvement with caring and responsive as good.
  • The ratings went down for some services and domains. Both James Cook and Friarage hospitals were rated as Requires improvement overall.
  • Critical care services had deteriorated significantly since the last inspection. We found them to be inadequate in Safe at both acute hospitals and requiring improvement in effective, responsive and well led. Caring remained Good at James Cook University hospital. We did not have enough evidence to rate caring at the Friarage hospital.
  • The overall rating for urgent and emergency care at the Friarage deteriorated to requires improvement overall.
  • The well led rating in surgery at both sites went down to requires improvement.
  • The safe domain in medicine and urgent and emergency care at James Cook hospital went down one rating to requires improvement.
  • Diagnostic imaging services at both acute sites were rated as requires improvement overall.
  • Patients and carers gave positive feedback about the care they received.
  • Community services were not inspected; their previous rating was Good overall.
  • In rating the trust, we took into account the current ratings of the other services not inspected this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

8 -10 June and 21 June 2016

During an inspection looking at part of the service

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 this 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

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. However, there were some issues with cleanliness in the discharge lounge at the Friarage Hospital.
  • Patient outcome results had improved in areas of sepsis, senior review of patients in A&E with non-traumatic chest injury, febrile children and unscheduled return of A&E patients.
  • Staff understood the basic principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and could explain how these worked in practice.
  • There was consistency in the checking and servicing of equipment. However, there was one piece of equipment used in the mortuary at the Friarage Hospital, which had not been adequately maintained.
  • Competent staff that followed nationally recognised pathways and guidelines treated patients. There was audit of records to make sure pathways and guidelines were followed correctly.
  • Arrangements for mandatory training were good and significant improvements had been made for staff to attend.
  • Medication safety was reported as a quality priority in 2016/17 and improvement targets had been set. There were improvements in the management of medicines since our last inspection particularly around effective audit and reconciliation of medicines. 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 developed action plans to improve performance of the 4 hour A&E target, 18 week referral to treatment times, c. difficile and 62 day cancer waiting times. These plans provided the necessary assurance that the trust had the actions and capacity to ensure compliance in 2016/2017.
  • The trust had commenced a significant period of transformation and organisational redesign 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.

Importantly, the trust should:

  • Ensure that processes are in place and understood by mortuary staff at the Friarage Hospital for the maintenance, moving and handling of equipment and transfer of deceased patients particularly out of hours.
  • Ensure that the emergency nurse call bell 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 are 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 appropriate staffing levels on wards, particularly in the neonatal unit to meet the British Association of Perinatal Medicine guidelines.
  • Review arrangements for the discharge lounge at the Friarage Hospital in terms of maintaining and cleaning equipment and ensuring the environment was suitable for patients and purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals

8-10 June and 21 June 2016

During an inspection of Community health inpatient services

At our last inspection in December 2014, we identified concerns around staff not receiving appropriate training and support through the completion of mandatory training, particularly the relevant level of safeguarding training. Additionally we found that patient records were not always accurate and complete.

During this inspection risks to patients were assessed and managed to ensure safe delivery of care.

Staff responded appropriately to safeguarding concerns. There were systems and processes for the monitoring of medicines and infection control.

Staffing levels were adequate to meet patient demands; staffing was monitored and reviewed daily.

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

Staff understood their responsibilities to raise concerns and to record safety incidents. There were systems for reporting and learning from incidents.

Opportunities were available to learn from investigations and the service was aware of areas in which it needed to improve.

9-12 December 2014

During an inspection of Community health inpatient services

Incidents were reported and investigated. There was evidence of learning and that changes had been implemented. The rate of harm-free care, from April to October 2014, was between 95% and 100% for all community hospital wards. Staff applied the principles of the recently introduced Duty of Candour legislation.

There were safeguarding policies and procedures which were understood and implemented by staff. Compliance with safeguarding training was inconsistent; the number of staff who had received safeguarding children level 2 training and safeguarding adults level 1 training was below the trust’s targets. There was some evidence that training records were not accurate. The compliance with mandatory training ranged from 67% to 83%.

Medicines were stored and managed appropriately. Medication errors were monitored monthly. The clinical environments were visibly clean. Staff applied infection control principles. There had been one reported incident of Clostridium difficile (C. difficile) and no hospital-acquired Methicillin-resistant or Methicillin-Sensitive Staphylococcus Aureus (MRSA or MSSA) year to date (2014/15).

Records were stored appropriately and most were appropriately completed, however, we identified gaps or errors in some locations, particularly in the fluid balance records, venous thromboembolism (VTE or blood clot) assessments and malnutrition universal screening tool (MUST) scores. We found that nursing assessments and risk assessments were undertaken and, where risks were identified, appropriate action plans were mostly in place.

Staffing levels were planned according to patient need with a registered nurse to patient ratio of at least 1:8 during the day and 2:12 at night. This was achieved most of the time. Where issues with staffing levels that could affect patient safety were identified, we saw there was a positive response by managers to maintain safe levels. Adequate medical cover arrangements were in place at all community hospitals.

Staff had access to evidence-based policies and guidance and we saw evidence that these were implemented in most cases. Clinical audits were carried out regularly with good levels of compliance recorded. Action plans were in place to address areas for improvement. Information was shared across the teams.

Data showed that between 33% and 89% of staff had received an annual appraisal. Plans were in place to address the areas where there were shortfalls.

We found effective multidisciplinary working across the hospitals. There were systems in place to support information-sharing, such as team meetings and multidisciplinary board rounds (meetings usually held, with a white board, away from the bedside so that teams can prioritise patient reviews and other issues, such as discharge planning).

Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff understood their responsibilities regarding consent for patients who may lack mental capacity.

We spoke with 45 patients and 11 relatives during our inspection. They all spoke positively about the care they had received while at the community hospitals. Most patients understood the care that was planned and felt involved in decision-making. We saw evidence that staff provided emotional support in response to patient need.

Patients were treated as individuals and we saw examples of patients’ diverse needs being met. We saw that systems and equipment were put in place to support individuals’ needs.

Admission and discharge were organised and managed by the single point of contact within the Integrated Medical Care Centre in liaison with ward consultants and local GPs. Clear admission criteria were used and staff told us these were applied to ensure that patients received the right care at the right time. We saw evidence of delayed transfers of care. Trust-wide data showed that 32% (6,248) of the delays from April 2013 to July 2014 were attributed to the completion of assessments, against an England average of 19% for completion of assessments.

There was evidence that complaints and concerns were responded to, monitored and that lessons were learned and shared.

There were planned ward closures and service changes in Middlesbrough and Redcar and Cleveland which had caused some uncertainty. In North Yorkshire, staff had a clear vision for their current service. However, staff at Lambert Memorial Community Hospital were less clear about the longer-term vision and strategy for the service.

There were effective governance, risk management and quality measurement processes in place which were consistent across the community hospitals as part of the wider care centres. Staff were positive about the clear management structure. However, there remained uncertainty around the future direction and leadership roles at one location.

There was an apparent open, honest and transparent culture. Where concerns were raised, managers were quick to act and support staff.

There was good staff engagement. Patients were encouraged to provide feedback and results were displayed on the wards.

9-12 & 16 December 2014

During a routine inspection

We inspected the trust from 9 to 12 December 2014 and undertook an unannounced inspection on 16 December 2014. We carried out this comprehensive inspection as part of the CQC’s comprehensive inspection programme.

We inspected the following core services:

  • James Cook University Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care, outpatient services and diagnostic imaging.
  • The Friarage Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care and outpatient services and diagnostic imaging.
  • Community Health Services – including:
    • Community health inpatient services at Carter Bequest Primary Care Hospital, East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital, Friary Community Hospital, Lambert Memorial Community Hospital and Redcar Primary Care Hospital.
    • Community end of life care
    • Community health services for children, young people and families
    • Urgent care centres at East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital and Redcar Primary Care Hospital
    • Community health services for adults

Overall, the trust was rated as requires improvement. Safety and effectiveness were rated as requires improvement. Well led, responsiveness and caring were rated as good.

The trust leadership had generally been stable over the last few years; in 2013 the director of nursing, who had previously worked in the trust for a number of years, had been appointed to the post of Chief Executive. Some further changes were expected with the retirement of the medical director and appointments to additional roles to strengthen the delivery of quality and safety within the trust. The trust was working with staff groups, local stakeholders and consulting with the general public on the development of its services and where they were best located and how to improve the effectiveness of delivery. The trust was in the process of reviewing its governance and reporting arrangements and many of the issues identified through the risk assessment of operational delivery or the impact of the transformation of services was still work in progress. The trust was facing a particularly challenging financial position with a deficit to address, entailing significant cost improvement plans. Staff were aware of the situation and had been consulted and informed of decisions about where saving should occur. Where there had been an identified risk to quality or safety, plans had been rejected or refined. It was too early to assess at the time of the inspection whether cost savings would impact on quality and safety in the next financial year. Consultation with staff was seen as a priority and work was in progress to improve on engagement with patients and the general public.

Our key findings were as follows:

  • There was a transformation programme in place to reconfigure and re-structure services in order to operate more effectively, which entailed centralising and moving some services. The maternity, children’s and young people services had been re-organised so that the main service delivery was located at James Cook University Hospital. This was an ongoing programme, which included reviewing the community services and the trust was engaging with staff, the local commissioners of services and local communities as part of its development.
  • There were areas of excellent practice across the trust, particularly in the maternity services, where we found the leadership to be outstanding. The service was managed by a strong, cohesive leadership team who understood the challenges of providing good quality care and had identified effective strategies and actions needed to address these. This was particularly evident with the reconfiguration of services, which were well-developed and understood throughout the department.
  • Staff felt engaged and were passionate about the quality of care given to patients. Staff reported pride at working in the trust and felt encouraged and able to introduce innovative ideas to improve service development and delivery.
  • Care and treatment was delivered with compassion and patients reported that they felt treated with dignity and respect.
  • Across the acute hospitals and within the community services, 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 visibly clean. Rates of Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. difficile) were within an expected range for the size of the trust, although the trust was aware of and was taking action to address concerns over the increasing cases of C. difficile.
  • 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 across the acute services and within the community.
  • There were  nursing staff shortages across wards and departments, particularly at the James Cook University Hospital and Friarage Hospital in urgent and emergency care and in children’s services. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.
  • The composite of the Hospital Standardised Mortality Ratio (HSMR) indicators was slightly higher than expected in this trust. The Summary Hospital-level Mortality Indicator (SHMI) was as expected. The trust actively reviewed mortality cases on an ongoing basis and held regular meeting with clinicians to identify issues when data was available.
  • The trust was performing worse than the national average for the development of pressure sores. The prevalence rate for grade 3/4 pressure ulcers was consistently above the national average accounting for 79% of all serious incidents reported, although there had been a steady decrease throughout the year.
  • There was still much more work to be done to ensure that the premises and the arrangements in place were suitable for the children’s services.
  • Attendance at mandatory training and specific subject area training, particularly for safeguarding and mental capacity assessment, was low across some areas.
  • Not all records were consistently completed across the acute and the community services, including the updating of care records such as assessments, fluid balance charts, risk assessments and decisions over whether to attempt to resuscitate a patient. There were also concerns over the completion of safeguarding records, particularly in the see and treat area within the accident and emergency department.

We saw several areas of outstanding practice including:

For James Cook University Hospital:

  • In medical care services, a team of therapeutic volunteers had been created which was led by a therapeutic nursing sister who had been in place for 18 months. The volunteers had mandatory and dementia training and were in operation 24hours a day. The role of the volunteers was to support patients who may be living with dementia or other illnesses which affected their behaviour and level of supervision required. This included engaging with patients, such as playing board games or other interests patients may have. They also supported patients who required help with eating or wanted to explore their environment. This included supporting them overnight if they were disorientated. The volunteers predominantly worked on wards 10, 12 and 26. The team had been regionally recognised for its work.
  • We found examples of outstanding leadership within Maternity services.
  • In maternity services, the Families and Birth Forum was involved in the design of the induction of labour suite and championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
  • In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits used as part of the productive care work stream. The toolkits helped look at care in a variety of settings through the eyes of patients and service users, to help determine what good quality care looks, sounds and feels like.
  • In maternity services, a ‘baby buddy’ mobile phone app was being piloted by the community midwives to inform women of pregnancy issues, common ailments and reasons to seek advice.
  • We found outstanding areas of practice in the care and involvement of young people, including a young people’s unit, participation and accreditation in the You’re Welcome toolkit in four clinical areas, the development of a young person’s advisory group, inspections of services by young people and the involvement of young people in staff interviews.

For The Friarage Hospital:

  • We found examples of outstanding leadership within Maternity services
  • In maternity services, the families and birth forum was involved in the design of the induction of labour suite and in championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
  • In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits which are part of the productive care work stream. The toolkits help look at care in a variety of settings through the eyes of patients and service users, to help investigate what good quality care looks, sounds and feels like.

For the community services:

  • Diabetes specialist nurses provided telephone support and advice and clinic sessions for patients with diabetes supported by a dietician and ran the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) programme which was accessible to patients with diabetes or the risk of developing Type 2 diabetes to provide learning and support for the patient and the health care professionals involved with them

There were several areas of good practice in the community services:

  • In community end of life services a Sources of Information and Support service directory had been developed by the Hambleton and Richmondshire Palliative Care Partnership, a health and wellbeing clinic was held at Redcar Primary Care Hospital, community specialist palliative care nurses supported the National Gold Standard Framework coordination in GP practices and supported nursing and residential homes for people with cancer and other life-limiting conditions in the Middlesbrough, Redcar and Cleveland locality.
  • Within community children’s, young people’s and families services a Baby Stars programme was in place to promote the social, emotional and physical development of infants, the school nursing service held weekly drop-ins for children and young people, there was a breastfeeding group with trained peer supporters and facilitators, there were good transition arrangements for young people transferring to adult services and services enabled good accessibility for children and young people by offering different clinics and opening times.
  • Within the community services for adults, the community respiratory service focused proactively on preventing admissions through meeting patient’s needs and reviewing the quality and cost effectiveness of the service through audit, the falls and osteoporosis service received an award for its inpatient work in community hospitals. The tissue viability service had developed several examples of innovative practice such as a chronic oedema project and leg ulcer collaborative to support prevention of these conditions and specialist and maintenance clinics were held for patients with lymphedema.

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

Importantly, the trust must:

For James Cook University Hospital:

  • Ensure that there are sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical and surgical wards, children’s wards and the paediatric intensive care unit (PICU).
  • Ensure that staff have received an appraisal and appropriate supervision so that the trust can be assured they staff are competent to undertake their role.
  • Ensure staff receive appropriate training, including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity Act 2005/assessment training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
  • Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are carried out and decisions made.
  • Ensure that all patients’ records are maintained up to date, including the recording of identification and stored confidentially in accordance with legislative requirements, particularly ensuring that paediatric care records are contemporaneous, appropriately completed and regularly audited to monitor staff compliance.
  • Ensure that there are appropriate arrangements in place for the safe handling and administration of medication, including the reconciliation of patients’ medications, that all controlled drugs are appropriately checked particularly on Coronary Care Unit and that medication omissions are monitored, investigated and reported in line with trust policy.
  • Ensure that ward-based nursing staff are educated in the use of syringe drivers, including best practice in the use of continuous administration of medication for the management of key symptoms at the end of life.
  • Ensure the paediatric environment in A&E is reviewed so it is fit for purpose; including a process to make sure that robust risk assessments are readily accessible and available to all staff in the department.
  • Ensure all toys in A&E are cleaned regularly to reduce the risk of infection.
  • Ensure that there are sufficient assisted bathing facilities and moving and handling aides within the children’s and young people’s ward areas.
  • Ensure the timely completion of the refurbishment of the medical block, especially wards 10 and 12, to enable people living with dementia to be cared for in a safe environment.
  • Ensure that the system for nurse calls is reviewed to ensure that there is no confusion over patients calling for assistance and the emergency alert for cardiac arrest potentially causing delays in treatment.
  • Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
  • Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
  • Ensure robust monitoring of the safe use of syringe drivers, with sharing of results and learning from safety audits.
  • Ensure that an appropriate concealment trolley is in use for the transfer of the deceased, that risks have been assessed, and that all staff using the trolleys are aware of safe moving and handling practices.
  • Ensure that resuscitation equipment in surgical wards and in outpatients and diagnostic imaging areas is checked in accordance with trust policies and procedures and that this is monitored.

For  The Friarage Hospital:

  • Ensure that there is sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical wards, and outpatients department.
  • Ensure staff receive appropriate training and support through appraisal including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
  • Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are being carried out and how decisions are made.
  • Ensure that patients records are appropriately up dated and stored to ensure confidentially is maintain at all times in line with legislative requirements.
  • Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
  • Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
  • Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
  • Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
  • Ensure that resuscitation equipment and medication fridge temperatures in the diagnostic and imaging department are checked in accordance with trust policies and procedures.

For the Urgent Care Centres services:

  • Ensure that staff have attended mandatory training in accordance with trust policy.
  • Review the quality monitoring arrangements within the urgent care centres, including patient outcomes.
  • Review the provision of pain relief to ensure that there are no unnecessary delays when treating patients.
  • Ensure that evidence-based guidance is available for staff working in urgent care centres and that policies are appropriately reviewed and up to date.

For the Community Inpatient Services the trust must:

  • Ensure that the number of staff who received safeguarding children level 2 training and safeguarding adult level 1 training meets trust targets.
  • Ensure that staff have received mandatory training.
  • Ensure that patient records are accurate and complete, particularly fluid balance records, venous thromboembolism (VTE or blood clot) assessments and malnutrition universal screening tool (MUST) scores.
  • Ensure that staff have received an annual appraisal.
  • Ensure that hazardous substances are secured, particularly at Lambert Memorial Community Hospital.
  • Ensure that staff follow the escalation policy when a patient’s condition deteriorates.

In addition, the trust should consider other actions these are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

9-12 December 2014

During an inspection of Community health services for children, young people and families

Community health services for children, young people and families at this trust had well-established systems for incident reporting and analysis using the Datix healthcare software system. Staff told us, and we saw evidence in team meeting notes, that incidents were analysed at a local level and learning was discussed within teams. Staff understood their responsibilities to raise concerns, and report incidents and near misses.

There were effective arrangements in place to manage and monitor the prevention and control of infection, and safeguard people from abuse.

Outcome monitoring for children, young people and their families using the service varied. Staff assessed and delivered treatment in line with current legislation, standards and recognised evidence-based guidance. There was evidence that performance was reviewed and actions were in place to improve outcomes.

The service followed local policies and national guidance to achieve the best outcomes for young people using the service. The service was actively engaged with regional and national networks. Staff were trained and competent to give specialist advice and treatments.

Health promotion work and advice was given to young people to assist them in making safe choices and keeping themselves safe.

Children, young people and their carers said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions. Information was provided to help children and young people understand the care available to them.

Children, young people and their carers were treated with kindness and respect, ensuring that confidentiality was maintained.

Children, young people and their carers felt included in decision-making. They were listened to and able to express their opinions, which they felt were taken into account.

People were able to access care and treatment close to home in local clinics and treatment centres.

Services were flexible and worked across professional and organisational boundaries.

There were systems within all teams for learning from experiences, concerns and complaints.

Staff knew the vision, strategy and objectives for the trust. There were service and team meetings which included items on risk, safety and quality. There were systems for recording and managing risks; managers were approachable and visible.

Staff and teams worked collaboratively to deliver quality care. The services sought out and acted on feedback from patients.

9-12 December

During an inspection of End of life care

The community specialist palliative care service is part of an integrated service working together with the hospital service provided at the James Cook University Hospital as part of the South Tees Hospitals NHS Foundation Trust.

We found the community specialist palliative care teams provided a safe, high-quality service for people with a life-limiting illness or at the end of life.

The service followed evidence-based guidelines which had been developed by the Specialist Palliative Care Multidisciplinary Team (SPCMDT) and the North of England Cancer Network. The guidelines incorporated the latest guidance from the National Institute for Health and Care Excellence (NICE) and other professional organisations.

There were effective arrangements in place for managing people’s pain and the service had made improvements, for example, monitoring people’s hydration and nutrition.

Staff were competent and well-qualified to meet people’s needs. All staff had completed advanced communications skills training, were able to support people’s psychological needs and provide access to services which specialised in helping people cope with the psychological aspects of their condition.

The community specialised palliative teams had developed good working relationships with GP practices, community nurses and nursing homes. In addition to caring for people, staff provided palliative care training for other healthcare professionals.

Throughout our visit we observed that the service was well-led. Staff we spoke with were clear about the development priorities for the service. They told us they felt involved in shaping the future direction of the service and were encouraged to contribute ideas for service development and innovation.

9-12 December 2014

During an inspection of Community urgent care services

Staff reported incidents and processes were in place to ensure that lessons were learned.

Trust-wide, evidence-based guidance was available on the trust’s intranet; however, there was limited information on evidence-based care and treatment specific to urgent care. We saw hard copies of policies and standard operating procedures for the urgent care centres that had not been reviewed for several years. We were informed that guidance was being updated, but was not yet available.

There was limited audit undertaken to monitor quality and patients’ outcomes.

We were informed that 64% of staff were compliant with mandatory training. We saw that staff had been booked to attend update training.

Staff had received training in relation to urgent care and were supported to develop their skills further. The emergency care practitioners received informal supervision. There were no formal clinical supervision sessions held with staff, including those working on their own.

Appropriate systems ensured that staff were made aware of safeguarding concerns and that information was shared with other professionals. Medicines and equipment were managed appropriately.

We saw that patients and their relatives were treated with dignity and respect. Information about who was suitable to be seen at urgent care centres was displayed on site and on the trust’s website.

Patients at all centres were seen within four hours.

The management and leadership of the urgent care centres had moved to the trauma and theatres clinical centre as part of the trust’s reorganisation in April 2014. There were plans to amalgamate the three urgent care centres to one location at Redcar Primary Care Hospital from April 2015. The intention was to develop the service once on one site, however the current focus was on amalgamating the service.

The governance and risk management of the urgent care centres was managed through the trust’s trauma and theatres clinical centre. There was limited management information or quality review undertaken to enable the leadership to fully understand and develop the service.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.