The York Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We assessed four quality statements.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. The service was previously in breach of the legal regulations relating to safeguarding and person centred care. Improvements were found at this assessment and the service was no longer in breach of these regulations. However, referral to treatment times were still not being met and there were times when people’s discharge did not happen in a timely way, although there had been some improvement.

We found that staff members’ understanding and awareness of assessing patient’s capacity to make decisions about their care and treatment was largely good and had improved but we did find that Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were not always fully completed and training compliance to complete these forms in line with guidance was low.

Staff did not always feel confident about the training they received in supporting people with their mental health, to protect themselves and patients.

Care in some areas required further alignment with national guidelines. For example, national guidance on completing venous thromboembolism risk assessments and the documentation and monitoring of intravenous fluids.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care was not always provided in line with national best practice guidelines. For example, national guidance on completing venous thromboembolism risk assessments and the documentation and monitoring of intravenous fluids.

However, medical services participated in most of the clinical audits where they were eligible to take part. For example, improving care of patients requiring nasogastric feeds, nutrition and hydration and the deteriorating patient. We were told that processes were being further developed as part of a wider clinical effectiveness project. National Institute for Health and Care Excellence (NICE) guidance aims to meet population needs by identifying care that is high quality, good value, and provides the best outcomes for patients.

An annual audit plan was in place which identified a programme of audits and effectiveness projects. This aligned to NICE guidance and national quality accounts for example, auditing the prevention, diagnosis and management of delirium in an acute hospital setting in accordance with NICE guidelines and auditing the quality of the management of Type 2 diabetes in accordance with NICE guidelines.

A new process was also in place to register and manage effectiveness projects to provide clear oversight and help promote continuous improvement across the services. However, this was not fully embedded across the service for us to fully assess the effectiveness.

Dashboards had been developed and were being rolled out across services. The aim of these dashboards was to improve decision making, improve resource allocation and increase real time monitoring to improve responses to mitigate the risk of impacting patient care.

Staff used information given in safety briefings and planned and delivered patients’ care and treatment with them, including what was important and mattered to them.

We saw that there were nutrition boards to communicate specific patient nutrition and hydration needs to the ward team, including any special diets and/or the identification of patients requiring assistance at mealtimes. The trust was also developing a new Food, Nutrition and Hydration Strategy for the next three years and an improvement plan. This was in line with one of the standards in the national standards for NHS healthcare food and drinks.

There had been investment in patient services operatives (PSA), a new role supporting nutrition and hydration on wards which released nursing time to care for patients. We observed these supporting patients with food and hydration. Staff told us the creation of the new PSA role had been really beneficial, and they felt more assured as a result of this that patients nutrition and hydration needs were being met.

However, a patient told us they had spent a long time in pain in the emergency department and were transferred to the ward in the early hours of the night. They told us they had not been offered breakfast or a hot drink whilst on the ward and that their family had provided food for them.

Another patient told us that they were distressed and in pain due to a suspected fracture. They told us they were hungry but had been unable to eat the food provided due to their positioning in bed, they did not feel staff considered this when providing care.

Staff had access to a range of policies which were linked to evidenced based care and national guidance and clinical effectiveness updates were escalated from the service to board subcommittees.

The service worked well across teams and services to support people.

There was work ongoing within the trust and hospital to improve the timeliness and quality of discharges to help positively improve the quality of patient care and patient experience. Examples of the initiatives included effective board rounds and criteria led discharges as well as reviewing local authority and community processes including packages of care available. The hospital was also looking at more effective integrated discharge teams.

We observed nursing handovers where staff demonstrated good patient knowledge and team working. The handovers used both verbal and written communications and a safety briefing for the whole team highlighting falls risks and infection prevention control measures in place.

Nurse team leaders completed detailed verbal handovers between shifts which included information on discharge planning.

We observed teams working together as the transfer team updated on patients that were being moved to other wards and planned additional spaces. On the respiratory ward we saw that they had a multi-disciplinary team that worked well with the palliative care team which provided support patients with lung cancer.

The service focused on initiatives around integrating the medical workforce. It promoted improving the service in a joined up way, where different staff groups could learn from one another. As part of this, staff worked across different work areas and between the trust's two sites, with the goal of broadening their understanding of the specialism and working together. We heard of many examples of staff teams working together such as specialist clinical teams and the geriatric consultants.

Staff told us they have adapted a 'no call before convey' approach into the same day emergency care service (SDEC), with the local ambulance service. The month before the assessment they accepted 52 direct referrals from the ambulance service and because of their triage process, they redirected 9 referrals who were instead taken to the emergency department due to their care needs ensuring they received care in the most appropriate way. Staff were keen to improve and evolve this process; they had been auditing the number of patients accepted via this approach and the number of patients seen in SDEC every month which we were told has doubled since 2019.

The frailty assessment unit working model had changed in October 2024. There was a multidisciplinary board round each day at 8.30am and staff told us there was good team working between pharmacists, doctors and nursing staff.

There was a named consultant 7 days a week plus additional consultant support. Patients were reviewed during a consultant-delivered ward round at least once every 24 hours, seven days a week.

There was a discharge lounge open until 8pm which accepted referrals for patients needing patient transport services until 6pm. Staff told us they had between 50-60 patients on average. It was located near the main entrance of the hospital so relatives and transport services could easily collect patients.

At the time of our assessment senior leaders told us that virtual wards were a work in progress; they were run by frailty teams and the community arm of the trust. Currently, they covered the York footprint. We were told that there were plans to expand these, but medical cover and workforce as a whole were some of the challenges the senior leaders were facing.

Discharge liaison officers were instrumental in making sure things were in place for discharge or the next step in their patient journey. One person we spoke with had had input from a liaison officer who had been coordinating social and community support for their return to the community.

The trust has a psychiatric liaison service provided by a neighbouring mental health trust. They reviewed routine referrals within 24 hours. The staff we spoke with told us that they found the team to be supportive.

The hospital also employed specialist staff to support over-65s. The mental health assessment liaison team (MHALT) had nurses, an approved mental health practitioner and a consultant. However, this team did not cover nights and weekends but worked with the psychiatric liaison team to provide cover during these times.

Whilst the service did routinely monitor people's care and treatment, it did not always ensure that patients who used the service consistently experienced positive outcomes.

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Consultant led referral to treatment times monitor the length of time from referral through to elective treatment. The national operational standard for the percentage of patients who are waiting less than 18 weeks is 92%. In October 2024, information showed that the trust had been at 55.4% with the national average (acute trusts only) of 57.9% on the 18-week pathway meaning that generally patients at the trust were waiting longer for elective treatment. However, recent national information published states that by March 2026 the intention is that the national standard will be 65% and meeting the standard of 92% by March 2029 as part of national recovery trajectories.

The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results rated the hospital overall as a grade `D' which were similar to previous audit results between October 2023 and September 2024 which were either `C' or `D'. The scores are between A and E. The trust was beginning to put actions in place to improve in response to the latest audit results. On reviewing the action plan from the previous results, whilst some actions had been achieved, others were still showing as an improvement opportunity. We reviewed incidents between October 2024 and December 2024 and found a number which showed that SSNAP standards were not always being met, for example patients being clerked within the recommended 4 hours of admission. The clerk-in procedure is an overall assessment of a patient's condition at the time of admission. We were told that there was no specific clerking cover on the stroke unit out of hours.

The service took part in trust improvement schemes, for example uptake of flu vaccinations by frontline healthcare workers and assessment and documentation of pressure ulcers. Both schemes trust wide had only been partially achieved in 2023/24.

The number of patients without criteria to reside had fluctuated between September and November 2024 across the trust but had generally been on a downward trend. On average, across the period 60% of patients without criteria to reside were not discharged on the same day. Services were taking action, for example working with their local authority partners to achieve this through a new daily second line escalation meeting.

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Between October 2023 and September 2024, the percentage of patients who were discharged on their agreed discharge date had mostly been higher than the national average. Senior leaders told us that they were aware that further work needed to be done on discharge planning from admission. We saw several innovative actions were being put in place to improve this as well as improving effective discharge plans for patients, but some of these actions were in the early stages of implementation at the time of the assessment for us to fully assess as being effective.

The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. 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 based on average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. Between June 2023 and June 2024 the hospital score was better than expected. We were told the trust was taking a proactive approach to improving its SHMI score and implementing learning and improvement where required.

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The average length of stay for patients over 7 days at the hospital was in line with the England average at 45.6 % in December 2024 with the England average at 45.7%.

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On review of information provided by the trust the rate of readmissions had been on a downward trajectory in November 2024. Readmission rates show whether patients who enter a hospital for a particular condition are readmitted to the hospital within 30 days after an initial discharge.

There was training in place on the application of the Mental Capacity Act for staff who would need to assess patients to give consent.

The service had begun to use the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. This was a new process to document the decisions for cardiopulmonary resuscitation and patients' capacity. This change in process was to be in line with other providers in the Integrated Care System.

There was a policy in place to support staff in the implementation of the ReSPECT process and form and this included guidance on signing the forms which should be by any healthcare professional who has been suitably trained; however, the senior responsible clinician should endorse it as soon as possible by adding their signature.

Senior staff told us staff were informed of the change, and training was provided during 2024 with an e-learning module available. At the time of our assessment compliance for ReSPECT training was 73% and the Mental Capacity Act at 64%. For medical care staff working on the medical care wards, this was 57% and 47%.

We observed inconsistencies in how these forms were completed on several wards. Out of the 8 reviewed none had been fully completed by being signed by a senior clinician. There was also 1 which was documented due to a change in capacity, but no capacity assessment could be evidenced as being completed in the patients notes we reviewed and staff told us this was outstanding.

The trust was currently in a transition period where both documents around decisions for cardiopulmonary resuscitation were still in use. The ReSPECT form was not available online as the trust was moving over to a new electronic patient record. However, senior staff we spoke with told us that there were currently no clear audit processes in place for the completion of these forms. Following the assessment, we were made aware the ReSPECT group worked with groups of resident doctors who were keen to be involved in quality improvement projects and were going to look at how to improve the quality of the content of the forms but this was not yet in place. This meant there was a risk that staff may be acting outside of a patient's wishes or best interests in situations that require cardiopulmonary resuscitation due to poor governance and oversight of this process.

Leaders told us that security staff should have received training in de-escalation when supporting staff in specific circumstances but were not involved in direct patient care. We were told that due to an increase in violence and aggression towards ward staff in the last 4 years, security staff was being used more to support staff where they felt their safety was at risk. We were told there should have been nursing support in place for anyone requiring enhanced support and nursing leaders were focusing on how to address the increase in violence towards staff.

We observed security staff providing enhanced supervision of a patient detained under the Mental Health Act (MHA). Security staff told us they were often called to support enhanced supervision of patients prior to Deprivation of Liberty Safeguards or sections under the MHA Act being in place. Staff told us without security support due to the staffing on wards it could be challenging to provide enhanced supervision to patients when required. We spoke with security staff providing the enhanced supervision and they told us that they had not received any training in de-escalation. However, trust leaders provided evidence of training content following the assessment but information was not provided on how many security staff had completed the training. This meant there was a risk that any incidents of harm or severity may increase.

We saw that there was conflict resolution training for staff and the compliance rate at the time of the assessment was 73% and for medical staff this was 58%. Staff told us the training provided around mental health, restraint and de-escalation did not always enable them to feel safe to protect themselves and patients. This was a risk to both patients and staff if training was not felt to be adequate to ensure any control, restraint or restrictive practices are only used when necessary, in line with current national guidance and good practice, and as a last resort.

Staff had access to the mental health team 24 hours a day to support them and patients. We were told the team were responsive and supportive but there could be significant delays getting input for patients in ward areas due to the demand in the Emergency Department.

The trust policy on use of the Mental Health Act in the Acute Hospital Setting was in the process of being updated at the time of the assessment.

Procedures were in place for gaining the consent of patients for treatment or examination. This included acting within the Mental Capacity Act 2005 and outlined Gillick competencies for children and young people and the two-stage approach were appropriate. We saw evidence of consent forms in place for patients waiting for a procedure. We saw evidence of staff being made aware of the updated consent policy in the staff bulletin.