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St Hugh's Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 May 2019

St Hugh’s Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 05 and 06 March 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the surgery service level report.

Services we rate

Our rating of this hospital stayed the same. We rated the hospital as requires improvement overall. This was because we rated well led as inadequate, we rated safe as requires improvement and we rated effective, caring and responsive as good.

We rated the surgical services as requires improvement. This was because we rated safe as requires improvement. We rated effective, caring and responsive as good. We rated well led as inadequate.

Although the hospital had made some improvements since our previous inspection, there was still work to do in terms of safety and leadership. This was because staff did not always recognise and report concerns, incidents or near-misses. We identified some discrepancies in medicines governance and were not assured there was a consistent approach to reporting medicines incidents and escalating patient risk. Mandatory training compliance remained low in some subjects, for example, safeguarding training. Not all consultants were completing care records in line with the hospitals record keeping policy.

There was no formalised and consistent system of clinical supervision in place. We had concerns formal complaints were not always managed in accordance with hospital policy. We had concerns that the senior leadership team were not proactively managing the concerns identified in some consultants practice, behaviour and record keeping. We also found some the concerns identified at our previous inspection were not fully addressed and some controls were not fully embedded, for example, issues relating to medicines governance, which breached hospital policy. We were concerned that there was not an equitable awareness of safety and risks across all services. Staff across all services raised concerns about low morale and the culture at the hospital since our previous inspection.

However, we found the surgical care areas, equipment and facilities were well maintained and safe. We found robust infection prevention and control processes were in place, audits took place and compliance rates were high. The hospital had reported two never events following our previous inspection. These were in October and November 2017, we found following these incidents the patients were fully informed and duty of candour (DoC) applied. Root cause analysis investigations were completed, learning identified and action plans put in to place to prevent recurrence.

We saw patients were treated with care, compassion, and respect by all staff during their treatment and patients told us they were fully involved in their care.

The hospital worked with other care providers to improve services and to meet the needs of the local population. Patients could access treatment quickly. Referral to treatment performance was good with 90 to 95% of patients being treated within 18 weeks. On average patients completed their treatment within 10 weeks. There were low numbers of complaints. Staff told us the senior managers were visible and supportive. The hospital had a clear set of principles, goals and values. Despite the challenges of the previous year most staff said the hospital was a good place to work with good teamwork in their departments.

Overall, we rated the outpatient’s department as good because we rated safe, caring, responsive and well led as good. We do not rate effective for outpatients.

This was because the department was clean and tidy. All equipment had been serviced in line with requirements. Records were stored securely. Staff were aware of their safeguarding responsibilities, how to assess patients for risks and respond appropriately if any were identified. When incidents occurred, staff knew their responsibilities to report incidents and near misses. There was adequate nursing and medical staffing available in the department to meet the needs of patients.

Patients received evidence-based care delivered by competent staff from a number of different disciplines who understood their responsibilities in relation to mental capacity and consent and focused on providing good quality care and treatment. Patients could access drinks and food if their clinical condition necessitated it however, pain relief was only accessible via a prescription from the consultants working in the department.

Outpatient clinics were offered during the day, evenings and some weekends depending upon demand. Patients we spoke with were happy with the care and treatment they received. Staff were kind, courteous, patient and understanding. Patients were offered support if they needed it and provided with information about their condition presented in terms that were understandable and avoided medical jargon. Services were delivered in a way that met the needs of local people by staff who understood patients had individual needs. The hospital provided support to patients who had sensory, language, physical disability and mental health support needs.

Patients could access appointments quickly. Complaints were few however all staff took complaints seriously and aimed to provide a good quality service for patients.

The department was managed by staff who were experienced in the management of an outpatient department. There was a strategy in place to develop the services delivered by the department in line with local needs and the requirements of local services the hospital engaged with such as the local NHS trust and Clinical Commissioning Group (CCG).

The department collected information about services and had governance processes in place to monitor the quality of services delivered. Risks faced by the department were assessed, recorded and managed. Staff mostly felt well led although some had concerns about their line managers occasionally being unsupportive.

Overall, we rated the diagnostic imaging department as requires improvement. We rated well led as inadequate and safe as requires improvement. We rated caring and responsive as good. We do not rate effective in diagnostic imaging.

This was because during our time on site, the management team were unable to provide us with assurance that equipment being used had been appropriately safety checked and calibrated. This posed a potential risk to both patients and staff. Staff were not wearing appropriate safety equipment and there was no evidence of safety equipment having mandatory safety checks.

Although the hospital had received a safety assessment from their local radiation protection advisor (RPA) in November 2018 highlighting many breaches of IR(ME)R (ionising radiation medication exposure regulations), we found no evidence whilst we were on site and managers could not provide us with any evidence of how these breaches had been addressed other than with an out of date action plan showing no prioritisation and only one action completed.

Whilst on site, we were unable to find, and the hospital was unable to provide us with up to date information about safety and quality checks carried out in the department to ensure ionising radiation procedures were performed in line with national guidance and local procedures. When we arrived at the department, local rules were out of date however these were updated and replaced during the inspection.

The department did not have an established safety checklist for carrying out interventional radiology as highlighted at the hospital’s previous CQC inspection.

We were concerned about the safety of patients and staff visiting the department because the hospital could not provide us with immediate assurance that the department was safe.

The hospital was unable to provide us with evidence of how they were assured they provided evidence-based treatment. Documentation relating to evidence-based care was out of date and had not been updated to reflect the latest IR(ME)R regulations issued in 2018.

The process for quality checking the work of individuals was unclear and there was no evidence that quality assurance of images took place. We found no evidence of discrepancy meetings taking place.

We identified concerns about the senior management of the diagnostic imaging department. They were unclear about the quality assurance and safety processes involved in managing a service that uses ionising radiation. There were no robust embedded systems of governance in place and the department was reliant on one person to oversee governance and quality assurance. Staff were unclear about the governance processes in place to safeguard both them and patients.

Management and leadership was remote. Staff were unaware of any strategies or future plans for the department.

We wrote to the hospital director immediately after our inspection and told him the Care Quality Commission was considering action under section 31 of the Health and Social Care Act 2008. We told the hospital they must provide us with information which showed that patients and staff working in the diagnostic imaging department were safe from harm. The hospital voluntarily suspended diagnostic imaging services until this information was provided. CQC received this information within the required timescales and therefore the hospital was able to resume diagnostic imaging services.

However, we also found the following good practice in the diagnostic imaging department. Staff were aware of their responsibilities relating to consent and mental capacity of patients requiring x-rays or ultrasound.

Patients received care from staff who were kind and compassionate. They were given information in terms they understood and were given emotional support if it was needed. Patient feedback was positive and we were assured the hospital had carried out due diligence to ensure radiology and radiography staff were suitable qualified.

The service was planned to meet the needs of people attending the hospital and x-ray imaging was available whilst clinics were running as well as when required by inpatients. Patients did not have long waits for appointments and could be seen quickly if needed.

Services were designed to meet the needs of individuals and support was available for people living with sensory impairment, physical and learning disabilities, mental health problems and dementia.

The department had received no complaints however complaints received across the hospital were discussed with staff and lessons learned shared to improve services and prevent future complaints.

Following this inspection, we told the provider it must take some actions to comply with the regulations and it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with two requirement notices. These were related to regulation 12, safe care and treatment and regulation 17, good governance that affected surgery and the diagnostic imaging departments. Details are at the end of the report.

Name of signatory

Ellen Armistead

Deputy Chief Inspector of Hospitals North Region

Inspection areas

Safe

Requires improvement

Updated 31 May 2019

Our rating of safe stayed the same. We rated it as Requires improvement because:

  • Mandatory training compliance was low in some subjects, for example, safeguarding training was low in endoscopy, theatres and the ward.

  • In surgery staff did not always recognise and report concerns, incidents or near-misses. Therefore, we were not assured safety and risk concerns were consistently identified or addressed quickly enough.

  • We identified some discrepancies in medicines governance and were not assured there was a consistent approach to reporting medicines incidents and escalating patient risk.

  • Consultants did not always keep contemporaneous records which breached the hospital’s record keeping policy.

  • We were concerned about the safety of patients and staff visiting the diagnostic imaging department because the hospital could not provide us with immediate assurance that the department was safe.

  • We were not assured that equipment being used for diagnostic imaging had been appropriately safety checked and calibrated. This posed a potential risk to both patients and staff.

  • Staff in the diagnostic imaging department were not wearing appropriate safety equipment and there was no evidence of safety equipment, such as lead aprons, having mandatory safety checks or that they were stored in a way that maintained their efficacy to keep patients and staff safe.

  • The diagnostic imaging department did not have an established process for completion of a safety checklist for carrying out interventional radiology as highlighted at the hospital’s previous CQC inspection.

  • When we arrived at the diagnostic imaging department, local rules were out of date however these were updated and replaced during the inspection.

However, we also found:

  • The surgical and outpatient department equipment and facilities were visibly clean and safe.

  • We found robust infection prevention and control processes were in place, audits took place and compliance rates were high.

  • Staff were aware of their safeguarding responsibilities, how to assess patients for risks and respond appropriately if any were identified.

  • In the outpatient department staff knew their responsibilities to report incidents and near misses.

  • There was adequate nursing and medical staffing available in the departments to meet the needs of patients.

Effective

Good

Updated 31 May 2019

Our rating of effective improved. We rated it as Good because:

  • In the surgical services patients received care in line with evidence-based best practice.

  • At this inspection we saw improvement in provision of up to date policies and guidance.

  • The services carried out local audits, participated in national audits and collated patient outcomes. They used the data to improve services for patients.

  • Surgical site infection rates were low at less than 0.1%.

  • Care was delivered by competent staff from a number of different disciplines.

  • Patients on the ward were assessed for their nutritional needs and supported if they were at risk of malnutrition.

  • Patients pain relief was managed well. Staff assessed patients and provided pain relief in a timely manner.

  • Staff across all services understood their responsibilities in relation to mental capacity and consent and focused on providing good quality care and treatment.

However, we also found the following issues that the service provider needs to improve:

  • We had concerns there was no formalised and consistent system of clinical supervision in place.

  • We had some concerns, that some consultants were not practicing in accordance with national institute for health and care excellence (NICE) guidance.

  • Although the hospital had received a safety assessment from their local radiation protection advisor (RPA) in November 2018 highlighting many breaches of IR(ME)R (ionising radiation medication exposure regulations), we found no evidence of how these breaches had been addressed other than an out of date action plan showing no prioritisation and only one action completed.

  • The hospital director was unable to provide us with evidence of how they were assured they provided evidence-based treatment in the diagnostic imaging department. Documentation relating to evidence-based care was out of date and had not been updated to reflect the latest IR(ME)R regulations issued in 2018.

  • The hospital’s consent policy indicated a two-stage process. However, this was not reflected in the consent forms we reviewed as these were only signed and dated on the day of surgery.

Caring

Good

Updated 31 May 2019

Our rating of caring stayed the same. We rated it as Good because:

  • We saw patients being treated with care, compassion, and respect by all staff during their treatment and patients told us they were fully involved in their care. Staff were kind, courteous, patient and understanding.

  • Patients we spoke with were happy with the care and treatment they received.

  • Patients were offered support if they needed it and provided with information about their condition.

  • Patients were given information in terms they understood and were given emotional support if it was needed.

  • Patient feedback was positive across all of the services provided by the hospital.

Responsive

Good

Updated 31 May 2019

Our rating of responsive stayed the same. We rated it as Good because:

  • Services were delivered in a way that met the needs of local people by staff who understood patients had individual needs.

  • The director was also establishing close working relationships with other health providers in the area to improve services for the local population.

  • The hospital provided support to patients who had sensory, language, physical disability and mental health support needs.

  • Patients could access treatment quickly. Referral to treatment performance was good with 90-95% of patient being treated within 18 weeks. On average patients completed their treatment within 10 weeks.

However, we also found the following issues that the service provider needs to improve:

  • We had concerns formal complaints were not always managed in accordance with hospital policy.

Well-led

Inadequate

Updated 31 May 2019

Our rating of well-led went down. We rated it as Inadequate because:

  • Following our inspection in 2017, we told the provider it should ensure leadership is embedded in all clinical areas to drive quality improvements.

  • At this inspection we were concerned managers did not have an equitable awareness of safety and risks for their services.

  • We were not assured there was a consistent approach to governance across all services. We did not find all current risks documented on the risk register.

  • We had concerns that the senior leadership team was not proactively managing the concerns identified in some consultants practice, behaviour and record keeping.

  • Staff across all services talked about low morale and the culture at the hospital since our last inspection. They said they felt different staff groups had not been treated equitably.

  • Staff we spoke with at focus groups told us the low morale had not affected patient experience. However, 75% of complaints relating to surgery were about staff attitude and behaviours.

  • We identified concerns about the senior management of the diagnostic imaging department. Management and leadership was remote.

  • The managers and senior leadership team were unclear about the quality assurance and safety processes involved in managing a service that uses ionising radiation.

  • There were no robust embedded systems of governance in place in the diagnostic imaging department. The department was reliant on one person to oversee governance and quality assurance. Staff were unclear about the governance processes in place to safeguard both them and patients.

  • The diagnostic imaging staff were unaware of any strategies or future plans for the diagnostic department. The leadership team was unable to provide us with evidence of how they were assured they provided evidence-based treatment.

However, we also found the following:

  • Most staff told us their immediate line managers were visible and supportive.

  • The hospital had a clear set of principles, goals and values. The goals were to improve patient and user experience, improve outcomes for patients and to support the community.

  • The hospital’s 2019 business plan included a comprehensive action plan to achieve the five-year strategic objectives. However, we noted there were no timescales for completion of the identified actions.

  • Despite the challenges of the previous year most staff said the hospital was a good place to work with good teamwork in their departments.

  • There was a strategy in place to develop the services delivered by the outpatient department in line with local needs and the requirements of local services the hospital engaged with such as the local NHS trust and Clinical Commissioning Group (CCG).

  • The outpatient department collected information about services and had governance processes in place to monitor the quality of services delivered. Risks faced by the outpatient department were assessed, recorded and managed.
Checks on specific services

Surgery

Requires improvement

Updated 31 May 2019

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated the surgical services as requires improvement. This was because we rated well led as inadequate and safe as requires improvement. However, it was effective, caring and responsive.

Diagnostic imaging

Requires improvement

Updated 31 May 2019

We rated the diagnostic imaging department as requires improvement. This was because we rated the leadership as inadequate and we rated safe as requires improvement. However, the department was caring and responsive. We do not rate the effectiveness of diagnostic imaging departments.

Outpatients

Good

Updated 31 May 2019

We rated the outpatient department as good because it was safe, caring, responsive and well led. We do not rate the effectiveness of outpatient departments.

Medical care (including older people’s care)

Requires improvement

Updated 17 May 2017

We rated the medical care (specifically endoscopy services) as requires improvement for safe and well led and requires improvement overall. We did not inspect or rate the domains effective, caring or responsive as this was a focused inspection.

We rated endoscopy services as requires improvement because:

  • Staff in the department did not always demonstrate awareness of when to submit an incident report.
  • The introduction of the surgical safety checklist was planned but not in use at the time of inspection.
  • There was an inconsistent approach to managing the risk of diabetes, pacemaker implantation or anti-coagulation treatment for patients being prepared for endoscopy procedures.
  • The quality of consent, procedure reporting and discharge documentation was inconsistent and in some cases illegible.
  • The overall approach to clinical governance in endoscopy needed strengthening and lacked proactive management oversight.
  • There was no evidence of a training needs analysis or competency framework in use for all endoscopy staff.
  • There was limited evidence that development of skills and knowledge to update and increase clinical expertise was achieved.
  • Endoscopy policies and procedural documents required updating.
  • There was a lack of audit of the quality and clinical effectiveness of the service.
  • There was no tool in place to obtain patient experience feedback from endoscopy patients.
  • Staff team meetings were infrequent.

However:

  • Patients received comprehensive written information about the risks and benefits of the procedure and received clear instructions about after-care.
  • We reviewed eleven sets of patient records and endoscope traceability records were complete in each.
  • The endoscopy department was visibly clean and tidy in all areas visited.
  • A risk register was in place for the hospital and each department within the hospital. This was under continuous review as it was still under development and staff had received training in risk management.
  • The endoscopy nurse manager regularly attended the Clinical Governance Committee.
  • Mandatory training compliance levels were good and all staff in the department had received appraisals in the past year.