The 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

Safety is a priority for everyone, and leaders embed a culture of openness and collaboration. People are always safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. Their liberty is protected where this is in their best interests and in line with legislation.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

The service was previously in breach of the legal regulations relating to safe care and treatment, premises and equipment, and staffing. While some improvements had been made, the service remained in breach of the legal regulations relating to safe care and treatment and premises and equipment. Although facilities were clean and well maintained, the environment posed various risks. Care records were not always completed, and the process for risk assessing patients with a mental health need was not fully embedded.

However, the service had a good learning culture and patients could raise concerns. Managers investigated incidents thoroughly and patients were protected and kept safe. Staff had the right skills, qualifications, and experience but also the department relied on locum and agency staff. Staff managed medicines well and involved patients in planning any changes.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People who used the service and their relatives, we spoke with, told us they knew how to raise a complaint or concern. Patients were confident about raising concerns. These were taken seriously, patients were involved in investigations if they wanted to be, and reports of the event were shared with them. Patients or those who represented them were given an apology and an explanation of the event, and patients were given a timely response.

Staff had a good understanding of how to use incident reporting systems. Staff were aware of the key themes which had arisen from recent complaints and incidents and felt confident to raise issues and concerns when they arose. Senior members of staff and leaders were involved in reviewing complaints and incidents. Safety huddles provided staff with a forum in which incidents and complaints were discussed. Reviews of incidents had led to improvements according to staff and leaders.

Safety was a top priority that involved everyone, including staff as well as patients using the service. The service had the relevant policies and procedures for incidents and complaints.

Risks were recorded and reviewed at service and trust level. Safety incidents and complaints were seen as an opportunity to put things right, learn and improve. Lessons were learned, resulting in changes that improved care for others. Staff understood the meaning of duty of candour, they were open and transparent and gave patients and families a full explanation when things went wrong.

Staff had effective systems to raise concerns both formally and informally. Reports were analysed and urgent actions taken by leaders to manage or remove risks.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when patients moved between different services. However, care records were not always completed fully.

Most patients were satisfied there was a joined up, collaborative approach to safety that involved them and their loved ones. Patients told us they understood their treatment plan and who was reviewing their care.

The local ambulance trust staff met regularly with the service in which safe systems of care were discussed.

Patients were triaged using a nationally recognised system. A direct stroke pathway could be used by ambulance crew to pre-alert a stroke nurse specialist. The patient would be immediately assessed and sent for early treatment interventions where applicable. Ambulance crew could also take patients to the ‘Frailty Same Day Emergency Care’ unit based on their illness.

The service had 24-hour access to specialist mental health support. The mental health service was managed by the local mental health trust and worked into the emergency department. Staff completed risk assessments for each patient on arrival which screened for patients who needed referring to the psychiatric liaison team.

Staff used nationally recognised tools to identify deteriorating adult and paediatric patients and escalated them appropriately. Staff followed sepsis guidelines to manage patients with sepsis. The department had a sepsis improvement group. Quarterly reports were produced which contained information on the percentage of patients appropriately screened for sepsis and the percentage of patients with sepsis who received timely antibiotics within one hour.

However, care records were not always up to date nor completed fully. We reviewed 10 care records and found gaps where documentation was incomplete, and actions not documented as taken. This was an issue noted at the last inspection and leaders were aware of this from their own documentation audits with a plan to improve in place. Some care records were paper based and others electronic which had the potential to cause confusion and duplication. The trust had plans to remedy this with the introduction of a new technical system.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Most staff had training on how to recognise and report abuse, and they knew how to apply it.

Safeguarding training completion was at 90% compliant for adult safeguarding and 94% for paediatric safeguarding levels 1 and 2 above the trust target of 87%. However, only 53% of required staff had completed level 3 training with regular performance meetings held to review and support improvement.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. We were given examples of staff contacting relevant agencies ensuring safety concerns were raised appropriately. The trust’s safeguarding policies were just out of date though remained relevant. Revised versions were due to be published in February 2025. The department had identified a safeguarding link nurse to provide additional support and advice around safeguarding concerns.

The Rapid Assessment Therapy (RAT) team provided a service in the emergency department every day from 8am to 8pm and included social workers, so there was support available to staff every day. The trust safeguarding teams were available to support staff day to day and there was daily visibility to pick up immediate concerns in the department.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

Patients understood and managed risks so that care met their needs in a way that was safe and supportive. However, staff felt that they needed more training on risk assessment screening for those presenting with a mental health.

A reliable validated and audited system was used to identify critically ill patients, whether arriving by ambulance or walking into the department.

A dedicated nurse triaged all patients brought into the department by ambulance. Patients were triaged at reception by a registered nurse and moved to an appropriate area of the department dependent on needs.

Screening tools and processes to identify deteriorating patients were used in all admission areas. An escalation policy was used for patients with potential sepsis who required immediate review. Patients with suspected or confirmed sepsis received prompt assessment when escalated. Clinicians in the department had oversight on this system of all patients on the sepsis pathway.

A referral pathway was in place with exclusion and inclusion criteria to the Same Day Emergency Care (SDEC).

A structured handover process between shift changeovers was regularly monitored and assessed for compliance.

A process for avoidable harm prevention was in place. Markers were placed on patient notes for those at risk from falls, pressure ulcers, absconding, and safeguarding. There was no delay in recognising and managing time-critical conditions, such as myocardial infarction, sepsis, stroke, or malignant arrythmias.

Leaders were accountable and acted when the emergency department was in a critical state and used technology to continuously monitor safety and performance.

Staff triaged patients at reception and undertook an initial risk assessment to identify if the patient needed to be referred to the psychiatric liaison team. However, the risk assessment process was not fully embedded. A condition had been placed on the trust’s registration in relation to this at a previous assessment, and while improvements had been made, staff did not always feel confident in using the tool. The trust acknowledged that the screening tool introduced in April 2024 had proved challenging for staff and more training in using the tool was planned. The Mental Health Care Improvement Group was leading on work to improve staff confidence using this tool and to deliver more training.

It was also difficult for clinicians to have oversight of mental health patients in the department using the digital systems. There was no way of a clinician easily seeing on the system who required support for their mental health needs in the department without clicking into each patient record.

The service did not always detect and control potential risks in the care environment. Staff did not make sure equipment, facilities and technology supported the delivery of safe care.

Patients felt the waiting area was busy and lacked space to accommodate the number of patients attending the emergency department at times. During our on-site visit, patients were sitting on the waiting room floor as seating became unavailable.

Leaders were aware the estate was not designed to accommodate the number of patients currently attending the department and had an escalation plan to support the patients and staff. There was also an estates plan for changes to improve functionality.

Patients were not always cared for in an environment that was suitably designed to meet their needs. At the time of inspection, there were ‘cohort’ areas in use. One nurse was allocated to 6 patients waiting in a cohort bay. This was a makeshift windowless area adapted to accommodate patients waiting for admission elsewhere in the hospital. Patients were triaged and risk assessed as safe to be in this bay and often stayed there for more than 24 hours. The ambulance cohort area was also a windowless room where patients waited with designated ambulance crew until they were seen in the main department.

There was only one room which had been assessed as safe for patients presenting with mental health needs. There was not a suitable room designated for children presenting with mental health needs in the paediatric department.

A process was in place for daily safety checks of specialist equipment. We reviewed the contents of the resuscitation trolleys, which contained the appropriate equipment for adult and paediatric patients. However, not all daily checks of the trolleys were completed as mandated and some pharmacy supplies within the trolleys were past their expiration date. This had been noted at the last inspection and was an issue identified in trust audits. Managers were aware of this, and a daily checklist was in place. Prior to the onsite assessment, UEC had been under extreme operational pressures due to the demands on the service and staff sickness. The trust immediately replaced all out-of-date stock in the trolleys and issued staff alerts as reminders about the requirement to check trolleys.

Equipment used to deliver care and treatment was mainly suitable for the intended purpose, stored securely and used properly. There were arrangements for the handling, storage, and disposal of clinical waste, including sharps. However, staff informed us the emergency call buzzer was inaudible in some areas and it was often unclear where the emergency was. This was a known problem on the trust risk register and several fixes had happened in an attempt to mitigate this risk.

There was poor line of sight for monitoring patients in the paediatric waiting area. This department had limited staffing, and the configuration of the rooms meant when staff were busy, they could not easily monitor children for signs of deterioration. This was also on the trust risk register as an issue but without remedy still caused worry and anxiety amongst staff.

Similarly, the RAT area housed unwell patients in cubicles, but clinical oversight of these patients was poor due the department layout and staffing numbers. A plan to change this was pending at the time of assessment.

A sluice door in the “majors” area was not locked and instead was propped open with waste bins. We found chemical substances in an unlocked sluice cupboard. These tubs of disinfectant are required to be locked according to COSHH (Control of Substances Hazardous to Health' and under the Control of Substances Hazardous to Health Regulations 2002) recommendations. The chemicals were usually stored in a locked cupboard and the trust’s own audits had identified that the sluice door was often propped open. The trust took immediate action to remedy this when we escalated the issue.

However, audits were regularly completed which reviewed equipment and the environment. Equipment needed for care and treatment was readily available and any faulty equipment was replaced promptly. Equipment used to deliver care and treatment was stored securely and used properly. Audits were completed on each shift by the nurse in charge to ensure that safety within the department was being maintained.

The service did not always ensure that there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. While the service met their staffing establishment levels, paediatric staff felt this wasn’t sufficient to ensure safe care and treatment. Staff worked together well to provide safe care that met patients’ individual needs.

Patients told us they felt there was an appropriate number of staff although they experienced lengthy waiting times. Patients using the service and their relatives told us that nurses, medical staff, and domestic staff had all been visible.

Staff told us that overall there were appropriate levels of nurse staffing apart from in the paediatric waiting area within the emergency department. Staff felt they received the support from senior members of staff to deliver safe care. They felt they had the opportunity to develop in their roles and had opportunities to learn.

Leaders covered staffing gaps with agency and bank workers and aimed to retain a key group of regular bank staff who knew the department. Clinical staff who were not formally rostered on shift were used when demand was high.

Staff had positive person-centred interactions with patients despite the demands on their time. Staff worked efficiently together. We saw senior staff supported junior staff and worked in collaboration with each other.

Mandatory training compliance for staff overall was 85% excluding life support and safeguarding training, Compliance with paediatric life support training was low. A third of nursing staff including healthcare support workers were not up to date with this training and less than 50% of medical staff were compliant. Regular performance meetings were held to review and support improvement.

Appraisals had been completed for 87% of staff against a trust target of 95%. The sister and charge nurse role had a lower rate of appraisal compared with other staff. A review was ongoing to consider how more management time could be given to improve this.

The service had enough nursing staff, advanced practitioners and support staff to keep patients safe. The service had safe recruitment practices to make sure all staff were suitably experienced, competent, and able to carry out their role. Staff underwent induction and completed competency-based training.

However, there was a lack of middle grade doctors employed in the department, which was reflected nationally, and a high percentage of shifts were covered by locum medical staff. Shifts were generally covered but recruitment and planning was hindered. Service leads considered skill mix when writing doctor rotas.

The staffing establishment level in the paediatric department was two nurses per shift, however staff reported that if one was called away to support a child elsewhere, this left the remaining paediatric nurse alone with an often busy waiting room to oversee. In response to this, the trust undertook a paediatric nursing establishment review. The Care Group Senior Leadership team deployed matrons and clinical educators to the department to add clinical support and nursing care hours. The Chief Nurse spent time listening to staff concerns and the Patient Safety Team provided additional support following concerns raised by staff identified through incident review processes. A review of the current pathway to help identify mitigations was pending a review at the time of assessment. Additional clinical staff were being made available to the department when needed in line with clinical activity.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Patients told us they found the department to be clean and tidy. They told us domestic staff were busy and visible. The department scored between 90% and 100% in a variety of cleanliness audits via the trust internal audit programme.

Staff were aware of the importance of cleanliness and hygiene and followed trust procedures when they identified concerns relating to infection, prevention, and control. Staff said they had plentiful supplies of personal protective equipment.

Staff explained the complexities of managing IPC when there was overcrowding in the department. The department had single occupancy cubicles and staff could isolate any patients who had infectious diseases. It was not feasible to do this in the waiting area and at times of high demand.

The premises and equipment were kept visibly clean and hygienic. Cleaning records were up to-date and demonstrated that all areas were cleaned regularly, and equipment was cleaned after any patient contact. We observed staff following infection control principles, including the use of personal protective equipment, effective handwashing and being bare below the elbow. Hand hygiene signage was displayed throughout the department.

The department monitored key metrics in relation to infection rates, including MRSA, MSSA and E. Coli. All patients were screened for infectious diseases at presentation which was then followed up by the hospital’s infectious diseases.

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

Medicines were stored securely, and access was restricted to authorised staff. The pharmacy team had oversight of medicines management, and the automated cabinets facilitated audit of stocks. Policies and procedures were in place to support the use and security of the automated medicines cabinets used within the department. However, during the inspection, we saw that some processes such as adding and removing staff from the system were not being followed and work was needed to improve timing of access.

The pharmacy team provided a weekday service. The team comprised of a pharmacist who was also the lead for medical care and a pharmacy technician. At the last inspection the team were concerned that they were not able to see everyone due to minimal staffing and the situation had not changed at this inspection. The team prioritised seeing patients with high-risk medicines or time critical medicines. The electronic prescribing system facilitated the team’s ability to identify these patients so they could be seen first. Trust wide data provided showed that 87% of patients on critical medicines were seen by the pharmacy team within 24 hours of admission. For the remaining patients 53% were seen within 24 hours and 65% were seen within 48 hours. It was not possible to break this data down to see how many of these reviews were completed in the emergency department.

At the last inspection concerns were raised regarding wrist bands, allergies and medicines administration. At this assessment, patients who attended the department were given wrist bands during triage which ensured that when medicines were administered, checks could be made for allergies for example. All patients we saw had wrist bands.

Where patients required medicines to take home, FP10s were provided. We checked supplies of FP10s and found that records did not match the number of prescriptions. The trust took immediate action to improve the recording and staff awareness of how to manage the safe use of FP10s. Some pre-labelled take home medicines were available to help facilitate faster discharges.

Patient Group Directions were available to facilitate quick access to medicines, these were reviewed regularly and staff who had access to them were signed off once competent.

Work had been completed and policy developed to support the safe use of rapid tranquilisation within the medical and emergency department. This was regularly reviewed by clinical staff, however, no audit had been undertaken.

The lead pharmacist provided updates to the care group regarding medicines, this included oversight of key risks, learning from incidents, training and costings. It had been identified that some risks could be mitigated by medicines training being provided to new staff during induction to the department however this had not been implemented yet due to capacity in the pharmacy team.

The trust had a medicines safety strategy which detailed their strategic priorities and how they intended to reach them. Staff told us how they would report medicines incidents and for issues identified during the inspection incident forms were completed and actions provided to CQC. We saw examples of how learning from medicines incidents was shared with staff across the trust. The trust had a process for reviewing patient safety alerts and documenting actions completed.