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Inspection Summary


Overall summary & rating

Good

Updated 28 February 2018

Inspection areas

Safe

Requires improvement

Updated 28 February 2018

Effective

Good

Updated 28 February 2018

Caring

Good

Updated 28 February 2018

Responsive

Good

Updated 28 February 2018

Well-led

Good

Updated 28 February 2018

Checks on specific services

Medical care (including older people’s care)

Good

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • We rated safe, caring, responsive and well led as good. We rated effective as requires improvement.
  • Staff were aware of how and when to report incidents, they received feedback and lessons learned were shared. Systems and processes in infection control, medicines management, equipment, patient records and the monitoring, assessing and responding to risk were reliable and appropriate.
  • Nurse staffing levels appeared to have improved since the last inspection. When the registered nurse average fill rate was below 100% we saw that on many wards the trust increased the care staff average fill rate to over 100%. Senior managers closed beds when they considered staffing levels were unsafe and translated to a potential risk to patients.
  • We observed good multidisciplinary team (MDT) working at the hospital. The trust monitored compliance with the NHS services, seven days a week forum, seven day services priority standards and reported some key achievements in medicine. The service had developed a number of care pathways and guidelines underpinned by national guidance.
  • Patients gave us positive feedback about the care they received. Patients told us that the staff caring and compassionate. Staff completed a holistic assessment of each individual and understood the importance of emotional support for each patient and their family. We heard of examples from staff where they were able to meet the needs of vulnerable patients.
  • Services were provided and adapted to meet the needs of the local population across the wide geographical area covered. On the whole average lengths of stay at the hospital were similar to or better than the national averages for elective and emergency admissions.
  • Wards had implemented the SAFER (senior review, all patients, flow, early discharge and review) patient flow bundle and discharge liaison officers to improve patient care and flow in the service.
  • Staff we spoke with talked positively about local clinical ward based leadership at York Hospital. The leadership teams had an understanding of the current challenges and pressures impacting on service delivery and patient care.
  • Directorates had individual visions and strategies that linked to the trust’s five year strategy. Staff were aware of the trusts values and we saw these displayed. In addition, some wards had their own pledges displayed.
  • Staff emphasised a real strength in local ward based teams. They were proud of the morale on their wards and how staff had risen to challenges. Staff were aware of the risks to their service. These risks were recorded and broadly correlated with our findings during inspection.
  • We saw numerous examples of improvements and innovation.

However:

  • Staff we spoke with did not have an understanding of when a mental capacity assessment should take place and were unable to articulate when assessments would be required to allow for nursing interventions to take place. This meant that there was a risk that the mental capacity of patients was not being appropriately considered.
  • Staff were not always supported to maintain and develop their professional skills. The mandatory training and safeguarding training rates in the service were worse than the trust target and the number of nursing staff in the service who had an up-to- date appraisal was worse than the trust’s target.
  • The sepsis clinical guideline used in the service at the time of the inspection was past its review date and required updating.
  • The initiatives to support the care for patients living with dementia were not fully embedded on the wards and in departments.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medicine was variable. The latest period, showed 85% of this group of patients were treated within18 weeks. This was worse than the England average of 90%.
  • At the time of the inspection the service had limited mechanisms to gather patient or relative feedback and there was limited clear public engagement.

Urgent and emergency services (A&E)

Good

Updated 28 February 2018

Surgery

Good

Updated 28 February 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well led as good.
  • There had been an improvement in nurse staffing levels since our last inspection and evidence of continuing recruitment and the development of nurse associates.
  • We saw that wards and theatre areas were visibly clean and staff observed infection prevention and control measures.
  • There had been an improvement in the discharge process with the recruitment of three discharge co-ordinators for the surgical unit. Patients did not have to wait so long for their discharge medications.
  • There was direct pharmacy support to the wards to support staff in prescribing and review prescription charts. Staff were aware that oxygen should be prescribed except in an emergency.
  • Nursing staff said that there was good teamwork and morale had improved.
  • Nursing and care staff achieved the trusts target for mandatory and safeguarding training.
  • We observed good compassionate care and emotional support.
  • We observed good local leadership.

However:

  • There was difficulty in recruiting medical staff. This was mitigated by the use of locum staff. This had an impact on mandatory and safeguarding training.
  • Referral to treatment times had initially improved since our last inspection but then deteriorated in most directorates.
  • Staff did not always have access to clinical supervision as part of their learning and development.

Intensive/critical care

Good

Updated 28 February 2018

Our overall rating of this service improved. We rated it as good because:

  • We rated safe, effective, caring, responsive and well led as good.
  • We found that all staff had received mandatory training and most had undergone a recent appraisal. The appointment of a clinical practice educator had further supported the learning and development of staff. This fostered an environment focused on improvement, with involvement in research and projects evident from different members of the multidisciplinary team.
  • The systems and processes in place for management of medicines, infection prevention and control, patient records and the assessment of patient risks were reliable and followed national guidance.
  • Nurse staffing levels and medical care was delivered in line with Guidelines for the Provision of Intensive Care Services 2015 (GPICS) standards and patient outcomes were in line with those of similar units.
  • Care was patient focused and individual needs were considered when planning and delivering care. The feedback from patients and relatives we were able to speak with was consistently positive and we were given examples of staff ‘going the extra mile’ with regards to patient care. Patient diaries and a follow up clinic helped support patients and families following discharge from the unit.
  • Access to care was based on patients’ needs and beds within the unit were flexed between level two and level three as required. The number of delayed discharges and non-clinical transfers were in line with those of similar units.
  • There was strong nursing and medical leadership evident on the unit and within the critical care outreach team. Staff felt supported and valued and morale was high. We observed an open culture within the multidisciplinary team.

However:

  • The service did not meet all GPICS standards, for example pharmacy provision and the number of nursing staff with a post registration certificate in critical care nursing. However mitigation and actions to address this had been put in place.
  • Safety thermometer data was variable. The results of this were not publically displayed. We also found patient feedback was not displayed on the unit.
  • Access and flow had been affected by patients requiring non-invasive ventilation who would normally be cared for on the ward, requiring to be cared for on the unit.
  • Whilst the risk register was reflective of the risks we identified, it was felt mitigating actions did not always address the cause of the issue. There were no review dates on the register.
  • The service strategy had not been finalised and this had been identified as an issue at the previous inspection.