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Scarborough Hospital Requires improvement

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

We are carrying out a review of quality at Scarborough Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 October 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We inspected Urgent and Emergency Care and rated the service as requires improvement which was the same rating as previous. The ratings for safe went down to inadequate. The ratings for effective and responsive stayed the same as requires improvement. The ratings for Well led went down to requires improvement.
  • We inspected Medical Care and rated the service as requires improvement which was the same rating as previous. The ratings for safe went down to inadequate. The rating for effective, responsive and well led stayed the same as requires improvement.
  • We inspected Surgical services and rated the service as requires improvement which was the same as the previous rating. The ratings for safe improved to good. The ratings for effective and caring stayed the same as good. The ratings for responsive and well led stayed the same as requires improvement.
  • We inspected Maternity services and rated the service as good which was an improvement. The ratings for safe and effective improved to good. The ratings for caring, responsive and well led stayed the same as good.
  • We inspected Outpatient services and rated the service as requires improvement. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. The ratings for safe, responsive and well led was requires improvement. The ratings for caring was good. The effective domain is not rated.

Checks on specific services

Reference: safe not found

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. 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.

Reference: effective not found

Good

Updated 16 October 2019

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

We do not rate effective in outpatients, however during the inspection we found:

  • The service provided care and treatment based on national guidance and evidence-based practice.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff monitored the effectiveness of care and treatment.
  • The service made sure staff were competent for their roles.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.

Reference: caring not found

Good

Updated 16 October 2019

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Reference: responsive not found

Requires improvement

Updated 16 October 2019

  • People could not always access the services when they needed to receive the right care promptly. Waiting times from referral to treatment were not always in line with national standards.

  • There were patients waiting past their appointment dates for follow up patients. For example, the trust provided information on the follow up waiting list stating as at April 2019 there were 10,972 patients who were overdue their appointment.
  • Referral to treatment indicators were not always met across all the specialties. For example, in thoracic medicine and ophthalmology for incomplete pathways. For cancer waiting times, the trust performed worse than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.
  • At the time of the inspection, there were no recovery plans or trajectories for improvement for the various specialities. However, the trust provided information highlighting the recovery plans and trajectories were being developed and that this work would be complete by the middle of July 2019.
  • The service had cancelled 209 clinics within fourteen days in March 2019 and 180 clinics were cancelled within fourteen days in April 2019. The target was less than 180 clinics cancelled within fourteen days.
  • The lack of clinical validation of waiting lists meant that there was the risk of patients being re-appointed unnecessarily and patients not being seen on time or in line with their clinical need.

However:

  • The service was inclusive and took account of patients’ individual needs and preferences.
  • 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.

Reference: wellled not found

Requires improvement

Updated 16 October 2019

  • Clinical Validation (Clinical Prioritisation) and assessment of risk within outpatients waiting lists had not been implemented across all specialties. The trust had started to clinical validate some waiting lists, for example ophthalmology, however this was inconsistent and not complete across all specialties.
  • Although leaders and teams used systems to manage performance, they did not always identify relevant risks and issues. Clinical validation (Clinical Prioritisation) 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 were being developed, these were not in place at the time of the inspection.

However:

  • Leaders were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear.

Medical care (including older people’s 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, effective and responsive as requires improvement. We rated caring and well-led as good.
  • There continued to be insufficient numbers of suitably skilled, qualified and experienced registered nurses, in line with best practice and national guidance, taking into account patients’ dependency levels.
  • There was a reliance on staff goodwill, bank and agency workers and ward managers relinquishing managerial shifts to support clinical work.
  • A number of registered nurse shifts remained unfilled despite escalation processes and wards worked below assessed levels based on acuity.
  • Medical staffing was reliant upon short term and long term locum support at all grades.
  • Staff did not always follow trust policy and recognised guidelines for the prescribing of antimicrobials and checking controlled drugs.
  • Staff awareness and understanding of the principles underpinning the Mental Capacity Act was variable. There was not a robust approach to the assessment of capacity and staff could not confirm who was responsible for completing such an assessment or how and where this was captured within the patient record.
  • The clinical guidance for sepsis management required updating.
  • The process for the management and completion of staff appraisals required review as there was significant variation in compliance across the wards.
  • The initiatives to support the care for patients living with dementia were not fully embedded however staff made some reasonable adjustments to support vulnerable patient groups on the wards.
  • There were a number of patient bed moves between 10pm and 6am.
  • There were a number of medical patients being cared for on non-medical wards (outliers). These patients occasionally moved between consultants and this interrupted continuity of care.
  • Staff morale and well-being was being compromised due to workforce limitations.
  • Service risk registers lacked detail regarding review and updates.

However:

  • There had been a marked improvement in mandatory training completion.
  • Infection prevention and control audits covering hand hygiene and environmental cleanliness were better than the trust target.
  • Staff ensured patients were comfortable and received pain relief in a timely manner.
  • Patients commented positively about food choice, quality and service. There were a number of made available to patients to meet individual needs.
  • Patients commented positively about the care they received and we observed genuinely kind, compassionate and warm care interactions.
  • Staff made changes to care delivery following patient feedback and concerns raised.
  • There was evidence of actions taken to account for variable outcomes in local and national audit.
  • Local leadership was good and staff reported senior managers were present in clinical areas.
  • Staff were aware of the trust vision, strategy and objectives. Staff were also aware of directorate strategies specific to their area of practice. Wards at Scarborough Hospital had developed their own ward based mission statements to reflect their patient cohort.
  • Staff reported an improved cultural shift in the previous 12 months.
  • There was evidence of service improvements and local innovations to support patient care.

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 28 February 2018

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

  • We rated effective, caring and responsive as good and safe and well led as requires improvement.
  • Registered nurse and care staff were not always at optimum levels and we saw that there were a significant number of registered nursing shifts which could not be filled despite active recruitment. This was mitigated by the use of agency staff and those redeployed from other wards.
  • Medical staff vacancies were higher than the York Hospital despite active recruitment. This was mitigated by the use of locums.
  • Referral to treatment times (RTT) improved following our last inspection, however this had fallen back to below the national average during 2017 in most surgical directorates.
  • There was a significant amount of medical staff who had not received safeguarding adults and children’s training, and some mandatory training modules which included ‘do not attempt cardiopulmonary resuscitation’.
  • We saw gaps in record books of checking emergency trolleys and anaesthetic machine log books in theatre areas.
  • Staff did not always have access to clinical supervision as part of their learning and development. This was linked to professional revalidation.
  • None of the staff groups at Scarborough Hospital met the trust target for appraisals

However:

  • We saw that wards and theatre areas were visibly clean and staff observed infection prevention and control measures.
  • Nursing staff we spoke with said that there was good teamwork.
  • The trust had set up a urology ‘one stop shop’ at Malton Community Hospital where patients were seen and had appropriate tests carried out and discharged with a clear plan of care prior to going home. This prevented the patient having to attend several appointments.
  • Staff we spoke with told us that they felt well supported by local leadership who tried to address the short and long term staffing problems.
  • We observed good compassionate care and emotional support.
  • Scarborough Hospital had better than the national average for readmissions in all surgical directorates.

Urgent and emergency services

Requires improvement

Updated 28 February 2018

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

  • We rated caring and well led as good, and safe, effective and responsive as requires improvement.
  • The department was failing to meet the majority of national standards relating to Accident and Emergency performance including: four hour waits, re-attendance rates, time from decision to admit to admission, median time to treatment and ambulance handover times (however, recent information showed that this was improving).
  • Staff were not meeting the trust’s mandatory training targets, therefore staff were not up to date with mandatory training. We also identified this at our last inspection.
  • Nursing and medical staffing in the department was not always meeting planned staffing levels. There was a heavy reliance on bank and agency nursing staff. There was a reliance on locum doctors to fill gaps in the medical rota and there were concerns about the long term sustainability of consultant cover. Consultant cover was not 16 hours per day as per Royal College of Emergency Medicine (RCEM) guidance.
  • Not all staff received annual appraisals.
  • Information in clinical records was not consistent or robust and was not subject to regular clinical audit.
  • Patients had long waits in the department once a decision to admit them had been made. This was predominantly due to the lack of beds available to admit patients in to the trust, although mental health patients were also affected.
  • Information for patients in alternative formats such as large print or braille and other languages was not available.
  • Staff in the department reported very low morale and we had concerns about the culture as some staff told us they felt undervalued.

However:

  • The department was aware of its problems and risks and had changed practice and processes in an attempt to tackle them, such as by the introduction of new nursing roles to support ambulance handovers and manage the flow of patients through the department.
  • Patients experiencing long waits were provided with hospital beds and the department were trialling new ways of working that could improve the experience of patients or improve the efficiency of the department.
  • Patients received care and treatment that was caring and compassionate from staff who were working hard to make sure that patient experience was positive and supportive.
  • The department was able to meet the physical and emotional needs of patients. Specialist equipment was available for patients with physical disability. There was access to pastoral support for patients of any or no religion.

Reference: improvement not found

Updated 16 October 2019

We found areas for improvement in this service. See the Areas for Improvement section above.

Reference: keyfacts not found

Updated 16 October 2019

Scarborough hospital is the second largest hospital in the York Teaching Hospital NHS Foundation Trust. The hospital provides a range of outpatient services and is based in Scarborough.

The trust had 976,357 first and follow up outpatient appointments from February 2018 to January 2019. From February 2018 to January 2019 there were 246,658 outpatient appointments at Scarborough Hospital.

During the inspection we visited the main outpatients’ departments. During the inspection we visited the ophthalmology, general medicine clinics, general surgery clinics, ear, nose and throat and phlebotomy.

We spoke with 21 staff, 23 patients and relatives and reviewed eight records during the inspection.

Reference: outstandingpractice not found

Updated 16 October 2019

We found examples of outstanding practice in this service. See the Outstanding practice section above.