Nuffield Health York Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Managers encouraged staff to raise concerns when things went wrong. There was a safety culture where events were identified and investigated. Learning was identified, shared, used and embedded to promote good practice. Hospital staff provided continuity of safe care and treatment to young patients. Hospital staff fulfilled and understood safeguarding requirements regarding young people. Hospital staff managed and involved young patients in discussions around risks, including clinical. The hospital recruited safely with the relevant checks such as disclosure and barring service (DBS). Staffing levels met the needs of young people. The environment was safe and well maintained. The premises and equipment were appropriate for the CYP services being delivered. All hospital areas were clean, rated, audited for cleanliness and free from clutter. Medicines were stored, and disposed of suitably.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Hospital leads encouraged a learning-orientated open culture. The hospital had fully adopted NHS England’s patient safety incident response framework (PSIRF). Staff had received PSIRF training. All staff could report incidents using their incident management system. All incidents were linked to learning from patient safety events (LFPSE). We saw evidence of After Action Reviews, though none related to CYP. Ward staff knew about incidents discussed in meetings, their level of harm and any related learning. Senior staff also shared learning through quarterly governance meetings, as well as quality and safety meetings. Other provider locations shared their governance minutes including incident learning with the hospital. This meant managers disseminated learning to staff from national incidents within the Nuffield group. Staff felt the hospital had an open culture, and that safety was a top priority. Staff completed After Action Reviews (AARs) and swarms as per PSIRF guidance. Swarms or huddles are used to help staff identify learning from patient safety incidents. Staff had held a related AAR to discuss and agree learning. They considered external environmental impacts on the hospital, as well as the current financial and economic climate to help decide a replacement schedule. This helped them feedback lessons learnt and make key recommendations for patient safety. CQC reviewed two AARs for young patients. Staff had completed these appropriately. Both reviews had three planned actions implemented within timescales. The governance lead planned to devise a feedback template for their AARs to use and encourage the correct terminology.

Managers encouraged staff to raise concerns when things went wrong. Staff could take time out their diaries to discuss topics for learning and address any concerns. For example, on the day of our inspection, staff were discussing physiotherapy topics. Hospital staff’s overall mandatory compliance was 90% as of June 2024. This met the provider target. However, individual training areas did not all meet compliance target. The lowest module compliance was Porter's vocational medical gases with 50%. Two of the four porters had not completed the course. Staff kept up to date with training, and were aware of its importance. They were sent a reminder when their training was due which appeared red on the training matrix. Staff use their online academy for any training specific to their role. Staff could allocate themselves respective courses, pull reports, and add additional courses which they could select separately to mandatory training. Managers monitored staff’s mandatory training compliance using a dashboard matrix showing all percentages at a glance. The registered manager held quarterly staff updates in person at staff meetings with hand-picked topics. Their latest topic was civility saves lives. The registered manager also held daily safety huddles with all their departmental representatives, along with mini staff updates of key issues, concerns, and learning. All staff had completed e-learning training on incident reporting. This was tailored according to what level staff had reached, and their role. Staff reported incidents on their incident management system. The clinical governance lead and Director of Clinical Services (DCS) were alerted to review this information, adhering to duty of candour. The DCS would then assign to the relevant manager. The provider’s incident management system would not let staff close incidents until they had been fully investigated and resolved.

Staff we asked had all necessary training required to treat CYP. All staff including recovery nurses were trained in paediatric basic life support (PBLS). Some nurses were advanced life support (ALS) trained. The resident medical officer (RMO) was emergency paediatric advanced life support (EPALS) trained and always onsite. However, nursing staff were not paediatric intermediate (PILS) or advanced (APLS) trained. This training was not required, as staff would risk assess patients pre-operatively to ensure there was no risk of deterioration. They could refer patients inappropriate for surgery to registered children’s nurses (RCNs) with this training at their local type A provider hospital. CQC reviewed one nurse, one resuscitation lead and two RMO training certificates which confirmed this. We saw some paediatric specific training modules staff could complete, such as a respiratory surge course for children. Staff with paediatric specific training ensured they were involved with sufficient numbers of CYP procedures to maintain competence. The hospital shared all relevant information with GPs about children and young patients.

Staff we asked had all necessary training required to treat CYP. All staff including recovery nurses were trained in paediatric basic life support (PBLS). Some nurses were advanced life support (ALS) trained. The resident medical officer (RMO) was emergency paediatric advanced life support (EPALS) trained and always onsite. However, nursing staff were not paediatric intermediate (PILS) or advanced (APLS) trained. This training was not required, as staff would risk assess patients pre-operatively to ensure there was no risk of deterioration. They could refer patients inappropriate for surgery to registered children’s nurses (RCNs) with this training at their local type A provider hospital. CQC reviewed one nurse, one resuscitation lead and two RMO training certificates which confirmed this. We saw some paediatric specific training modules staff could complete, such as a respiratory surge course for children. Staff with paediatric specific training ensured they were involved with sufficient numbers of CYP procedures to maintain competence. The hospital shared all relevant information with GPs about children and young patients.

The provider used an Electronic Patient Records (EPR) system. This helped staff review patient’s confidential personal information at each stage of their journey to ensure this was correct. This system had a teddy bear icon for staff to easily identify when children were being seen at the hospital. Staff carried out observational checks on patients in the timeframes set out in national guidance. We reviewed ten set of patient notes and found no gaps, errors or issues. All patient’s early warning scores (EWS) were triggered, to help staff identify any alerts. EWS is a tool to assess the degree of illness of a patient and trigger critical care intervention. It helped staff recognise and respond to signs of patient deterioration. The EPR auto generated a response. For example, the system would alert the user if the young patient had high blood pressure. CQC reviewed EWS records for ten young patients. Records showed staff monitored all patients’ vital signs in line with national guidance. The hospital had processes in place to ensure anaesthetists stayed with the patient after surgery. They ensured patients were well enough to return to the ward. Radiographers and other diagnostics staff could review young patient’s images using the picture archiving and communication system (PACS). The service reported two adverse incidents in March and April 2024 involving diagnostic imaging. These incidents found lessons learnt related to pause and check were not being embedded or effective. As a result, the pause and check process was reviewed to devise a specific standard all radiographers could clearly follow to prevent errors.

All safeguarding pathways were in place across the service. All staff had received adult and children safeguarding training. This met the provider target of 90% for levels 1 and 3. For level 2 staff achieved 89%. This narrowly missed compliance. The hospital registered manager, director of clinical services (DCS) and the governance lead were all trained to safeguarding adults and children level 3. At least one of them was onsite at all times during business hours, and on-call out of hours. The paediatric consultant in outpatients was level 3 trained. The hospital met the intercollegiate document which recommended staff in regular contact with children and young people in both inpatient and outpatient clinics should be level 3 safeguarding trained. All staff could readily contact an offsite level 4 trained provider safeguarding lead. Managers was confident in staff’s understanding and knowledge of safeguarding. They felt staff were good at raising any related issues. Managers told staff on induction their door was always open if they wanted to discuss these. Hospital staff knew about systems and policies in place for the identification and management of children at risk of abuse. They could readily access safeguarding flowcharts, policies, procedures and processes for identifying concerns, and any helpful guidance. Staff knew the hospital had a designated safeguarding lead and where to access information available, for example in the staff room. The hospital registered manager, DCS and the governance lead were all trained to safeguarding adults and children level 3. At least one of them was onsite at all times during business hours, and on-call out of hours.

All staff completed Oliver McGowan training to better recognise and respond to the needs of people with a learning disability or autism. Ten ward staff we asked had all completed this training, and staff compliance was 92%. Staff covered both female genital mutilation (FGM) and child sexual exploitation (CSE) as part of their safeguarding training. They also undertook prevent anti-radicalisation training. The provider had specific related policies, procedures and guidance staff could access on their intranet which included processes for identifying concerns. For example, appendix 03 FGM information had a flowchart with a prompt sheet for staff, and appendix 1: Prevent escalation concerning a colleague at risk of extremism and terrorism. Staff received mandatory training and were compliant in Gillick competency and parental rights. This formed part of their consent to examination and treatment for adults and children module. The provider had a related policy and standard operating procedure (SOP). Governance leads planned to fully review hospital documentation around young patients between 12-15 years old. This meant governance for CYP attending service appointments and procedures alone would be in line with Gillick competence. Staff would then provide feedback to consultant surgeons through the general medical council (GMC). All the service’s young patients aged 16 or 17 could give their own consent on an adult pathway. All hospital departments had ‘actions to take’ concerns about a child (acute services) process flowcharts. The governance system detailed safeguarding contacts, and what staff should do outside working hours. The recovery room was kept locked. Staff felt the ward area was secure enough with sufficient oversight for less vulnerable 16-17 year old patients. This area had no mixed bays, all post-operative young patients were given side rooms with en suite facilities.

The hospital held emergency simulation sessions with an external training provider to better prepare and refresh staff’s skills for children. Simulations included major haemorrhage, cardiac arrest, sepsis and anaphylaxis. One simulation recently entailed a paediatric unannounced scenario involving a deteriorating patient. The hospital held a paediatric resuscitation simulation on 27 June 2024. This noted 16 positive points and three areas for improvement, two of which concerned team response. One area for improvement was ring 999 sooner. Another was the resident medical officer (RMO) needing some assistance with WETFLAG which they would revise; this is a web tool that helps estimate weight, energy, tube length, fluids and drugs for paediatric patients. The service planned further in-house simulations for adults and paediatrics to capture all staff. For simulation scenarios the resuscitation bleep was allocated to any staff in the department, theatres, radiology, outpatients, or on the ward. From previous learning staff held a daily morning resuscitation huddle. The hospital governance or IPC leads would attend and describe what staff’s roles should be in an emergency. Leads received a follow up report and shared the learning in governance and resuscitation meetings open to all staff. The heads of department would also embed any learning. This could result in additional staff training. Any staff unable to attend could access the minutes.

We reviewed the provider’s children in hospital policy (CL20). This identified the hospital as a type B location in respect of CYP services. Type B hospitals were non-invasive sites which saw 0 – 17-year-olds in the outpatient departments including therapies and provided inpatient or day case facilities for surgery and invasive care in outpatients for 16-17-year-olds. Hospital staff did not carry out invasive procedures on young patients under 16 years old. Accountabilities of staff groups was also clearly defined in the policy. Hospital staff completed risk assessments for children and young people (CYP). They audited against any risks which could be CYP related. Staff had pre-operative assessment (POA) guiding principles which clearly outlined the POA purpose and process. Staff used clinical point of care testing (POCT) and monitoring to inform their decision making at POA. POCT is diagnostic testing performed at or near the patient to ensure care is appropriate and changed as needed. Young patients admitted for day case procedures were put in side rooms post operatively for easier monitoring. The hospital had an agreement with their local type A provider hospital, so staff had contact numbers for all the registered children’s nurses (RCNs). Before any procedures went ahead, staff contacted the RCNs pre-assessment to confirm young patients were eligible to go on the adult pathway. The provider reviewed service provision at all their locations. They gave each location a letter to identify the type of service they could safely provide. For example, this hospital was identified as a B service. This meant staff at the York location were supported by staff working at an A location who had additional skills and training in CYP care. This meant the team had additional specialist support should they require it. All CYP had their clinical assessments reviewed by a registered children's nurse before being placed on an operating list.

The hospital had some appropriate provision for children. For example, a corner of the outpatients waiting area had recently installed a child’s play area with small tables, drawing materials, chalkboards, books, toys and games. We saw families using this and staff told us it was well used. A QR code on the child’s table linked to a helpful video using simple language of what children can expect during X-ray. Children admitted to the ward could bring in their own devices or games from home. All areas of the hospital providing services to children and young people were visibly clean, spacious, free from clutter, well lit and well maintained. There was also a weekly cleaning checklist on the wall of this area dated 1 July 2024 which confirmed staff cleaned all areas. An important notice outside outpatients reminded parents or guardians of children they were responsible for their child’s safety and welfare during their hospital visit. The service did not need much bespoke equipment for children as they mostly saw 16 and 17 year olds assessed as being suitable for the adult pathway. Children in outpatient clinics were not onsite very long. The hospital had appropriate facilities to manage clinical waste. CQC saw the hospital’s monthly clinical waste compliance. They had greatly reduced the amount of infectious waste by quarter. The provider met their 2024 offensive waste compliance target. The theatre department clearly displayed warning signs about lasers, X-rays, and mobile phones, authorised access only, and which PPE must be worn. CQC reviewed evidence of quarterly and annual service checks for equipment. This comprised maintenance records for both the magnetic resonance imaging (MRI) and diagnostic imaging. Machines past their expiry were decommissioned, no longer in use and replaced with new models. A service was scheduled for the hospital’s electrical treatment couch.

The hospital had sufficient numbers of suitably trained staff to meet the needs of the CYP. This included nursing staff and ODPs in theatre, recovery and outpatient areas as well as surgeons, anaesthetists and a suitably trained RMO. The hospital used some regular bank staff well orientated to CYP areas. No agency staff were used in outpatient departments which delivered CYP services. All hospital staff were competent to provide care and treatment for children. No staff were recruited to CYP specific roles, as most young patients they cared for or treated were seen on an adult pathway. The theatre team staffing establishment for the service’s very low number of young patient procedures was governed by the association for perioperative practice (AfPP) guidelines. The provider was complaint with the Royal College of Anaesthetists (RCOA) guidelines. This related to their provision of anaesthesia services for day surgery, as they cared for young patients on an adult pathway. Anaesthetists had received appropriate training, appraisal and experience. They were present throughout any procedures involving anaesthesia. Hospital leads did not use any CYP specific staffing acuity or dependency tools or assessments to help them determine safe staffing levels. Clinical staff involved in young patient’s care used their professional judgement. Ward nursing staff easily met the Royal College of Nursing’s (RCN) occupied bed to staff ratio of one nurse to every four children (over two years old). The hospital only admitted patients aged 16 years or older to the ward, and for any surgical procedure on an adult pathway.

All young patients were day case, and rarely needed to stay at the hospital overnight. The surgeon and anaesthetist stayed until any CYP were stabilised in recovery and discharged. The hospital always had a theatre manager or deputy theatre manager onsite.

The hospital had a new cleaning audit in place where staff reviewed all room equipment and furniture. However, a few areas were marked down for improvement. Their central action plan had a section for all audits. This included the 9 May 2024 cleaning audit in which compliance declined in diagnostic imaging. Their head of department was sent an email with actions for identified areas of improvement and additional work required. CQC confirmed all actions had since been implemented and signed off.

All areas were clean and rated five out of five stars for cleanliness. We saw ‘I am clean’ stickers on equipment such as patient beds and trolleys. We saw appropriate flooring with no carpets in clinical areas. Housekeeping staff routinely cleaned the blood pressure monitoring machines, and sealed toilet seats in patient areas and ensuites. We saw the service had all available surgical equipment with one set for each young patient. The theatre department always kept a standby set of surgical equipment. The hospital had two sepsis box locations in the ward and outpatient department both next to the emergency trolleys. Staff followed the sepsis six bundle. There were hand sanitiser dispensers in clinical areas. We saw aseptic non-touch technique (ANTT) and hand hygiene displays on a noticeboard. Hospital staff had achieved 100% hand hygiene compliance in quarter 2 2024. The hospital implemented a new operating theatre cleaning schedule program from January 2024. This meant leads could monitor and audit cleaning easier. This was not fully embedded until March; theatre staff had completed this monthly up to the end of June 2024. The staff canteen did not accept cash payments to help improve infection prevention, and reduce waiting times. Food poisoning bacteria and micro-organism information with hygiene rules and useful advice was displayed outside the canteen.

Staff ensured young patients had no bacterial infections before treatment. For example, they covered MRSA as part of risk assessments. Staff swabbed patients pre-surgery for MRSA based on a defined criteria and in line with policy. MRSA is a type of bacteria which can cause a serious infection and needs immediate treatment if it gets in the body. If patients tested positive, their surgery was delayed until they had received two clear or negative swabs. Staff also routinely undertook a CPE respiratory assessment for patients on their day of surgery. Patients with significantly high temperatures were flagged, as staff told us some young patients with infections still attended surgery. The hospital reported no infections in their PHIN data refreshed to March 2023 and PROMs data. All surgical equipment was clean and suitable for use. Theatre equipment was sterilised offsite at the provider’s regional northern hub. This meant the service completed timely procedures such as occasional endoscopies or cystoscopies on young people. The hospital’s infection prevention coordinator carried out a diagnostic imaging cleanliness audit on 9 May 2024. This scored 97% compliance, maintaining the department’s 5-star clean rating. 172 of 193 staff (89%) had completed infection prevention and control (IPC) training as of June 2024. Staff completion of the infection prevention practical module was 138 of 192 (72%).

The service managed very few and limited medicines for young patients. This mostly comprised acne medication which the hospital pharmacy prepared as tablets to take home (TTO). The service’s protocol had changed to mitigate any medicines administration errors whereby two staff members had to sign off any acne medicines, as these could have severe side effects. Prescribing staff sent all other medicines back to the patients’ GP.

Staff gave patients wristbands to help confirm their details and keep them safe. These were a different colour if they had any allergies; wristbands were red if the patient had allergies, and white if patients had no allergies. Staff recorded any allergies and related information for young patients in all the patient records we reviewed. They confirmed this information at the booking and preassessment stages where we saw allergies documented in patient’s risk assessments. Any common allergies such as penicillin flagged as alerts on the electronic patient record (EPR). Staff used and updated an allergies screen on their EPR system for all child patients. Non-prescribing pharmacists could not alter any prescriptions for patients; however, they could flag an incorrect prescription when completing their drug reviews. The resident doctor or consultant would have to amend this. The hospital had no prescribing pharmacists at the time of our inspection. The pharmacist checked young patient’s prescription charts and liaised with nursing and medical staff about care plans. Young patients were given pain relief before and during their operation in accordance with their amount of pain. CQC observed a tonsillectomy patient being administered diclofenac and fentanyl. This was carried out appropriately and in line with guidance. CQC reviewed an adverse incident which showed the service had reported a documentation error or omission involving a young person in outpatients in January 2024. Staff had not recorded the patient’s allergy status when they attended for a postoperative wound review. As a result, staff were reminded to ensure allergy status was updated on all patient records.

The provider had rolled out an electronic prescribing system for easier medicines management. This system flagged any patient allergies to stop certain drugs being prescribed. The system also considered crossover antibiotics such as penicillin and flucloxacillin; these would flag up as not prescribable. However, one clinician bemoaned the E-prescribing as clunky; it took them five minutes per prescription instead of 30 seconds with a pad.