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Scarborough Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 March 2020

We carried out an unannounced focused inspection of the emergency department at Scarborough 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 also inspected elements of the medical care core service including wards at this hospital. This included visting the admissions areas to discuss 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 for both core services and aspects of both the responsive and well led domains for the emergency department.

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.

  • Opportunities for staff to identify and quickly act upon patients at risk of deterioration on the medical wards were potentially missed or actions not always documented.

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

  • The ward environment on one ward we visited did not support staff in keeping patients safe.

However,

  • Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction

  • The emergency department had suitable equipment which was easy to access and ready for use. The department was clean and tidy despite being extremely busy during the inspection period.

  • Deteriorating patients were identified quickly in the emergency department and treatments were started in a timely manner.

  • Staff and managers in the emergency department promoted a culture that supported and valued one another.

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 was issued to the trust requiring them to make significant improvements in the quality of healthcare provided.

We also found several things that the trust should improve that did not justify regulatory action, to prevent breaching a legal requirement, or to improve service quality. These can be found under the ‘Areas for improvement’ section of the report.

Ann Ford

Deputy Chief Inspector (North)

Inspection areas

Safe

Inadequate

Updated 24 March 2020

Effective

Requires improvement

Updated 24 March 2020

Caring

Good

Updated 24 March 2020

Responsive

Requires improvement

Updated 24 March 2020

Well-led

Requires improvement

Updated 24 March 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 24 March 2020

We carried out an unannounced focused inspection of the medical care services in response to concerning information we had received in relation to care of patients in this department. We inspected using our focused inspection methodology, focusing on the concerns we had. We did not cover all key lines of enquiry. We did not change the rating of the service at this inspection.

We found breaches of regulations from previous inspections had not been effectively acted upon. The quality of health care provided by York Teaching Hospital NHS Foundation Trust required significant improvement.

Critical care

Requires improvement

Updated 28 February 2018

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

  • We rated safe and caring as good, and effective, responsive and well led as requires improvement.
  • The service had not taken action on some of the issues raised in the 2015 inspection. For example, the unit still did not have a clinical educator which was not in line with the guidelines for the provision of intensive care services (GPICS) standard and the service had not undertaken patient or relative surveys or any public engagement. At the time of this inspection, it was still not clear what critical care would look like across York and Scarborough hospitals, as the service strategy had not been finalised.
  • The risk register was not reflective of all the risks in the service. There was no record of the date the risks were added to the risk register, the date the risk should be reviewed and the controls and mitigating actions recorded were limited and did not always appear to address the cause of the risks.
  • The rehabilitation after critical illness service was limited and was not in line with GPICS or the National Institute for Health and Care Excellence (NICE) CG83 rehabilitation after critical illness. The service did not have access to patient and relative support groups.
  • Staff were not always supported to maintain and develop their professional skills. The number of nursing staff who had an up-to-date appraisal was worse than the trust’s target. The service did not meet GPICS recommendations for the number of nurses that had a post registration award in critical care nursing.
  • Senior staff acknowledged that service improvement and innovation was limited on the unit and the pace of change was slower at Scarborough than in critical care at York Hospital.

However:

  • The service had taken action on some of the issues raised in the 2015 inspection. For example, medical staffing was now in line with GPICS, mandatory training rates were better than the trust target and there had been a focus on cross-site working which had improved.
  • Systems and processes in safety, infection control, medicines management, equipment, patient records and the monitoring, assessing and responding to risk were reliable and appropriate.
  • Care and treatment was planned and delivered by a cohesive multidisciplinary team in line with current evidence based guidance.
  • All the feedback from patients and relatives was positive about the way staff treated them.

Surgery

Requires improvement

Updated 16 October 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service provided mandatory training in key skills to all staff and had systems to ensure everyone completed it but completion by medical staff at the site was poor.
  • We found gaps in records we reviewed of patients’ care and treatment. What was recorded was clear but not always dated and timed with designation and general medical council (GMC) number indicated. Records were mostly stored securely and easily available to all staff providing care.
  • The service did not always store medicines safely. Ambient room temperatures were not monitored in rooms where medicines were stored.
  • Appraisal completion figures for both nurses and medical staff were low, and clinical supervision was not conducted regularly. Medical staff appraisal rates were worse than the previous year.
  • Medical staff did not meet the trust target for completion of training on the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • The trust did not follow a two-stage consent process and most consent forms were signed on the day on the procedure.
  • The hospital showed continued, variable performance against referral to treatment times (RTT). Some admitted pathways for surgery was consistently worse than the England average.
  • Patients were cancelled at short notice due to patient flow issues and lack of available post- operative beds.
  • Some leaders were new in post following the recent operational review, completed in March 2019. Leaders, under a new care group structure, were working to understand and manage the priorities and issues the service faced.
  • Leaders operated within new governance structures and processes, which needed time to be finalised and embedded.
  • Senior management were not always visible for both patients and staff.
  • The trust was embedding the values and vision through induction and at appraisal. However, it was noted that appraisal rates, particularly for medical staff were low.
  • Staff we spoke with said morale was variable, and some expressed concerns about being moved to backfill other wards.
  • Although the papers were titled ‘clinical governance minutes’, they were very limited and focused mainly on audit, mortality and complaints. The meetings were attended by doctors only.
  • It was clear from the minutes that the structure and content of these governance meetings were still under development.

However, we also found that:

  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank, agency and locum staff a full induction. There were improved nurse and medical staffing levels since our last inspection.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The majority of staff had training on how to recognise and report abuse, and they knew how to apply it.
  • Staff completed and updated risk assessments for the majority of patients and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service controlled infection risk well. They kept equipment and the premises visibly clean.
  • The service followed best practice when prescribing, administering and recording medicines. Patients received the right medication at the right dose at the right time.
  • The service provided care and treatment based on national guidance and best practice. Staff protected the rights of patients’ subject to the Mental Health Act 1983.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Staff followed national guidelines to make sure patients fasting before surgery were not without food for long periods.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
  • Key services were available seven days a week to support timely patient care.
  • Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We saw emotional support being provided to patients, families and carers to minimise their distress.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.

Urgent and emergency services

Inadequate

Updated 24 March 2020

We carried out an unannounced focused inspection of the emergency department 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.

During this inspection we inspected using our focused inspection methodology, focusing on the concerns we had. We did not cover all key lines of enquiry.

We found breaches of regulations from previous inspections had not been effectively acted upon. The quality of health care provided by York Teaching Hospital NHS Foundation Trust required significant improvement.

Maternity

Good

Updated 16 October 2019

We rated safe, effective, caring, responsive and well-led as good.

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

  • We spoke with three women and two partners about their experiences. They said they were involved in their care and decision-making and happy with the care and treatment received.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trusts skill mix information confirmed shortfalls in middle grade doctors which was mitigated through the appointment of locum doctors. We were told that this shortfall would be resolved with the next intake of middle grade doctors as all positions were filled.
  • Community midwife caseloads met the antenatal and postnatal care provided to all resident women irrespective of place of birth: ratio of 98 cases per w.t.e midwife. (National Institute for Clinical Excellence guidance).
  • To provide a safe maternity service, the Royal College of Midwives (RCM) said there should be an average midwife to birth ratio of one midwife for every 28 births. The midwife-to-birth ratio at Scarborough hospital was 1:22. (April 2018 to July 2019).
  • 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. The trust target of 90% attendance for level 2 safeguarding adults training (which includes MCA and DOLS) was achieved for midwifery staff, but not for medical all staff.

  • The service managed patient safety incidents well and staff received feedback from incidents reported. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Joint policies, guidelines and procedures were now in use across the service.
  • Staff completed detailed records of patients’ care and treatment and updated risk assessments for each patient to remove or minimise risks. Staff identified and quickly acted upon patients at risk of deterioration. Records were up to-date and easily available to all staff providing care.

  • All staff had completed yearly practical obstetric multidisciplinary training (PROMPT) sessions. PROMPT training included deterioration of mothers and babies. Training compliance increased from 94% in June 2018 to 100% in March 2019.
  • The trust used a systematic approach to continually improve the quality of its services with effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

However:

  • The service did not make sure all staff completed mandatory training in key skills. The number of staff who completed it did not meet trust targets and managers had not appraised all staff’s work performance during 2018/19 to provide support and development.
  • The service did not always store medicines safely and we saw different practices between labour ward and hawthorn ward. Gaps in authorisation signatures against staff names were found in patient group direction paperwork. This was escalated to the senior service managers.
  • Entonox gas levels were high following a spot check on 4 December 2018 which indicated inadequate exposure control despite the use of the gas scavenging systems present. Information was given to staff regarding mitigating risks with increasing window ventilation, taking frequent breaks and ensuring women used the scavenger system to inhale and expire. Retesting was also undertaken, and background plans being made for remedial works to address air changes if the retest came back at high levels.
  • Monitoring of medicines fridges and resuscitation equipment had not taken place daily and we found out of date equipment being used in the community midwifery service. This was escalated to senior managers. Before the end of our visit the community equipment was replaced.
  • Community staff did not clean blood pressure cuffs between uses and non-packaged cotton wool balls were being used.
  • Staff were not aware of the correct procedure and products to use when cleaning the birthing pool; potentially putting women and babies at risk if not cleaned properly between use.
  • Written information was not always legible on four women’s records we reviewed.

Outpatients

Requires improvement

Updated 16 October 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • The service was not consistently assessing the clinical risk inherent in its waiting lists where patients were waiting beyond their expected appointment date for new and follow up appointments.

  • Although ophthalmology could describe the type of clinical validation (Clinical Prioritisation) for patients waiting for appointments, this was inconsistent across the trust and some specialities had not clinically validated their waiting lists. This meant there was limited oversight of clinical risk in waiting lists across the specialities. Clinical validation was not consistently documented on the risk registers for outpatients.
  • The information provided by the trust regarding overdue appointments showed this performance had deteriorated between April 2019 and June 2019. Although the trust provided information stating recovery plans and trajectories were being developed, these were not in place at the time of the inspection.
  • There had been two serious incidents relating to patient appointment delays in the ophthalmology department. The trust provided the root cause analysis for one of the incidents and this highlighted the backlog of follow up patients. This had an action plan attached.
  • People could not always access the services when they needed to receive the right care promptly. Waiting times from referral to treatment were not in line with national standards across all specialities and there were a high number of cancelled clinics for non-clinical reasons.

However:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The design, maintenance and use of facilities, premises and equipment kept people safe.
  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff kept detailed records of patients’ care and treatment.
  • The service provided care and treatment based on national guidance and evidence-based practice. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.