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Inspection carried out on 18 and 19 February 2020

During a routine inspection

We carried out this announced inspection over two days on 18 and 19 February 2020 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. Two CQC inspectors, supported by a specialist professional advisor carried out this inspection.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

          Is it safe?

          Is it effective?

          Is it caring?

          Is it responsive to people’s needs?

          Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Background

The North Yorkshire Child Sexual Assault Assessment Service (CSAAS) is situated in The York Hospital. The service operates from a discrete set of rooms accessed via a paediatric ward. The CSAAS is accessible for people who use wheelchairs.

The service is jointly commissioned by NHS England and the Police and Crime Commissioner for North Yorkshire and is provided by York Teaching Hospital Foundation Trust. The CSAAS offers health services and forensic medical examinations to children and young people, aged 15 and under, who have been sexually assaulted or abused. The service can also see older young people aged 16 to 18 who have additional vulnerabilities, this is decided on a case by case basis in conjunction with the local adult sexual assault referral centre. The service does not accept self-referrals. All referrals must be made by police or social care staff. The North Yorkshire CSAAS is available Monday to Friday from 9am to 5pm excluding bank holidays. Children and young people requiring care outside of these times are referred to other services in the region.

The unit is accessed via an intercom and consists of a waiting room, a forensic examination room, a bathroom and an office which is used by CSAAS staff as well as the hospital safeguarding team. The CSAAS is staffed by a full-time lead nurse, a part time nurse and a part time administrator. Four paediatric consultants cover the service on a rota basis. Play therapists, who are employed on the neighbouring paediatric ward, can offer support to children and young people who are attending the unit. The service does not employ Independent Sexual Violence Advisors (ISVAs) or counsellors directly and refers children and young people into these services. The ISVA and counselling services, therefore, were not part of this inspection.

During our inspection we spoke with staff members including the lead nurse, the lead play therapist and a Forensic Medical Examiner (FME). We looked at 14 patient records and three staff recruitment files. We looked at policies and procedures and other records about how the service is managed.

Our key findings were:

  • The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The clinical staff provided children and young people's care and treatment in line with current guidelines.
  • Staff treated children and young people with dignity and respect and took care to protect their privacy and personal information.
  • The service asked children and young people and their families and carers for feedback about the services they provided.
  • The service had a culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The service staff dealt with feedback positively and efficiently.
  • The staff had suitable information governance arrangements.
  • The service appeared clean and well maintained

During our inspection, we found concerns that children and young people were at risk of having their forensic DNA samples compromised by cross-contamination. When we identified these issues, the provider took immediate action and decided it would no longer see children and young people in the North Yorkshire Child Sexual Assault Assessment Service (CSAAS) who required a forensic medical examination. We were satisfied that the actions the provider took removed this risk to children and young people.

We identified regulations the provider was not meeting. They must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care .

Full details of the regulations the provider was not meeting are at the end of this report.

There were areas where the provider could make improvements. They should:

  • Offer, whenever possible a choice of gender of medical examiner.
  • Complete the planned programme of mandatory training and level three children’s safeguarding training, so that all staff have received the required amount of training in line with trust policy.
  • Consider how the communication needs of children and young people of different ages and with learning needs are met.
  • Improve multi-disciplinary documentation of care.

Inspection carried out on 13 January to 14 January 2020

During an inspection to make sure that the improvements required had been made

We carried out an unannounced focused inspection of the emergency department at York Hospital on the 13 and 14 January 2020, in response to concerning information we had received in relation to care of patients in this department. At the time of our inspection the department was under adverse pressure.

We did not inspect any other core service or wards at this hospital, however we discussed patient flow from the emergency department. During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry. We looked at the safe domain and aspects of both the responsive and well led domains.

Our key findings were:

  • Patients who presented to the emergency department with mental health needs were not being cared for safely in line with national guidance (RCEM guidance and Psychiatric Liaison Accreditation Network (PLAN) Quality Standards for Liaison Psychiatry Services).

  • The department was not meeting the standards from The Royal College of Paediatric and Child Health Facing the future: standards for children in emergency settings.

  • Access and flow of patients was creating significant delays in admitting patients onto wards to enable them to receive timely and appropriate care and treatment exposing them to the risk of harm.

  • Systems for recording clinical information, risk assessments and care plans were not used in a consistent way to ensure safe care and treatment for patients.

  • We were not assured that there were sustainable, medium and longer term, plans to ensure sufficient numbers of suitably qualified, skilled, competent and experienced clinical staff to meet the needs of patients.

  • Not all incidents were being reported and investigated to identify mitigating actions to prevent reoccurrence and reduce the risks to patients.

We found areas for improvement including breaches of legal requirements that the trust must put right. These can be found in the ‘Areas for improvement’ section of this report.

Following the inspection given the concerns identified a Section 31 notice of decision and 29A warning notice of the Health and Social Care Act 2008 were issued to the trust requiring them to make significant improvements in the quality of healthcare provided.

Ann Ford

Deputy Chief Inspector (North)

Inspection carried out on 19 September 2017

During a routine inspection

Inspection carried out on 17 – 20 and 30 – 31 March 2015

During an inspection to make sure that the improvements required had been made

The York Hospital was one of three main hospitals forming York Teaching Hospital NHS Foundation Trust. The trust provided acute hospital services to the local population. The trust also provided a range of other acute services from Scarborough and Bridlington hospitals to people in the wider York area, the north-eastern part of North Yorkshire and parts of the East Riding of Yorkshire. In total, the trust had approximately 1170 beds, over 8700 staff and a turnover of approximately £442,612m in 2013/14. The York Hospital had over 700 beds.

The York Hospital provided urgent and emergency services, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people primarily to the York and surrounding area, but also served the people in the Scarborough, Whitby and Ryedale areas of North Yorkshire for some services.

We inspected the York Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, Scarborough and Bridlington hospitals and community services. We inspected York hospital on 17 – 20, 30 – 31 March 2015.

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

We rated urgent and emergency service and critical care as ‘requires improvement’, with medical care, surgery, maternity and gynaecological service, children & young people, outpatient and diagnostic services and, end of life care as ‘good’.

Our key findings were as follows:

  • Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
  • Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
  • We found the hospital was visibly clean, hand-washing facilities and hand cleaning gels were available throughout the department and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
  • There were concerns that patients arriving in the A & E department did not receive a timely clinical assessment of their condition.
  • At the time of the inspection, in the majority of services the Trust was below its own target of 75% for mandatory training including safeguarding training. The Trust’s target was to achieve 75% minimum compliance for the year ending August 2015. We have since been informed by the Trust that the figures provided to the CQC only included the training provided for the period of six months prior to the inspection as this was the time the Trust implemented a new system to capture and record training carried out. We were told the compliance levels did not include any training staff may have had prior to the 1 September 2014 and we were not provided with evidence to reflect this in the overall training levels.
  • There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. However, we found that some maternity services policies and guidelines were out of date.
  • The trust had no mortality outliers and mortality rates were as expected when compared with other trusts. The Summary Hospital-level Mortality Indicator (SHMI) of 98 was lower than both the Trust overall (102) the England average (100) in June 2014. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  • Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical areas; and radiologists. The trust was actively recruiting to the majority of these roles.
  • Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
  • The trust was half way through its five year plan to integrate services following the acquisition of Scarborough & North East Yorkshire NHS Trust in 2013.Services within all three of the acute hospitals were at differing stages of integration.
  • Seven of the eight core services we inspected had good local leadership within the service.

We saw several areas of outstanding practice including:

  • The appointment of a senior paediatric specialty trainee ‘quality improvement fellow’ for one year has led to improvements such as the use of technology in handover sessions, with further plans for development of electronic recording of clinical observations and the PAWS assessment.
  • We saw positive partnership working with and support from CAMHS in York, which ensured that the acute inpatient wards had seven-day support. The community nursing team also had a CAMHS nurse specialist allocated to the team who provided psychological support for families and staff.
  • The innovative way in which central lines were monitored, which included a central line clinical pathway. The critical care unit were finalists for an Institute for Healthcare Improvement (IHI) safety award.
  • The medical service had an innovative facilitating rapid elderly discharge again (FREDA) team, which provided multidisciplinary support and rehabilitation to elderly outlying patients.
  • Ward 25, an integrated orthopaedic and geriatric ward, worked closely with the A&E department, and actively identified elderly patients with a fractured neck of femur, to speed up flow to the ward and on to theatre, had demonstrated positive outcomes of speedier rehabilitation and reduced length of stay, with the majority of patients returning to their usual place of residence.
  • Phlebotomy outreach clinics in the local community, which have led to improved access to the service.
  • Availability of pathology services in the oncology outpatient department, meaning that up-to-date blood results are available for patients when they see the consultant in clinic. Treatment changes are based on up-to-date information.

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

Importantly, the trust must:

  • Ensure all patients have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011.
  • Ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical area; and radiologists.
  • Ensure there are suitable arrangements in place for staff within the medicine and surgery, outpatient and diagnostic services to receive appropriate training and appraisals in line with Trust policy, including the completion of mandatory training, particularly the relevant level of children and adult safeguarding training and basic life support so that they are working to the up to date requirements and good practice.

  • The provider must address the breaches to the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets to protect patients from the risks of delayed treatment and care.

  • The provider must ensure that patients’ privacy and dignity is maintained when being cared for in the bays in the nursing enhanced unit based on ward 16.
  • The provider must ensure effective plans are in place and implemented to eliminate the non-clinical delayed discharges and delayed admissions on the critical care unit.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 17, 18, 30, 31 March 2015

During Reference: R6 not found

Inspection carried out on 31 July and 1 August 2013

During a routine inspection

York Hospital is part of the York Teaching Hospital NHS Foundation Trust. A team of inspectors and a specialist advisor visited the site between 31 July and 1 August 2013.

The focus for the inspection was to look at the patient journey through accident and emergency (A&E) and admission to the hospital. We spent time observing practice and interactions between staff and people visiting the department. We spoke with a range of staff, including doctors and nurses, and with people who had been admitted to a ward following assessment and treatment in A&E. We visited Ward 14, the rapid assessment unit (RAU) and the medical assessment unit (MAU).

We found that people were treated with respect by the staff. People were aware of their treatment options and plans and they felt that they had been fully consulted and involved. One patient told us, �The staff are wonderful, they have explained everything to me.� We saw that care and treatment was planned and delivered in a way that ensured people�s safety and welfare.

We found the clinical areas in the departments we visited were clean and well maintained and there were systems in place to monitor this.

At the time of our visit we found there were sufficient staff in all of the areas and wards we visited and that systems were in place for monitoring staffing levels and the skills mix. However, several nursing and medical staff we spoke with told us that they felt there were insufficient staff available at times to deal with the workload, particularly if A&E was busy. To put this into context it is worth stating that during our inspection we were told the department was �unusually quiet� so we were unable to assess what �busy� would look and feel like.

We saw that there were systems in place to record and monitor comments and complaints.

We found that risks and untoward incidents were recorded and audited by staff at both departmental and board level. The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of peoples who used the service and others.

Inspection carried out on 8, 9 January 2013

During a routine inspection

We visited all of the paediatric and maternity wards during our two day inspection. This included two children�s wards, antenatal, postnatal, labour, maternity triage and the special care baby unit. Comments from patients included: �The nurses explain what is happening, and get my consent for all the treatments.� Another person told us, �The doctors and the nurses take time to explain everything. Nothing is too much trouble.� We observed staff treating people with respect, being polite and courteous.

We spoke with over 18 members of staff, ward sisters, two registrars and members of the executive board. Staff told us patients received good, safe care and that they were committed to providing an excellent service. All the people we spoke with were positive about their care and experiences at the hospital. We looked at medical records and found that, overall, records were well kept.

Overall the premises were found to be fit for purpose; however the children�s ward areas were found to be showing signs of wear and tear and might benefit from some modernisation. At no point during our visit to the wards were mixed gender bays found. The staffing levels on the wards we visited were adequate.

We looked at medical records and found that overall records were well kept. We also looked at the governance arrangements in place across the whole of the Trust and found that systems were in place for monitoring and assessing the quality of the service provided.