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Scarborough Hospital Requires improvement

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

We are carrying out checks at Scarborough Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 October 2015

Scarborough 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 York 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. Scarborough Hospital had approximately 300 beds.

Scarborough Hospital provided emergency and urgent care, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people in the Scarborough, Whitby and Ryedale areas of North Yorkshire.

We inspected Scarborough Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, York and Bridlington hospitals and community services. We inspected Scarborough hospital on 17 – 20, 30 – 31 March and 11 May 2015.

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

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

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.
  • The trust had no mortality outliers. However, the Summary Hospital-level Mortality Indicator (SHMI) for Scarborough hospital of 107 was higher 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.
  • 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.
  • Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; and radiologists. The trust was actively trying to recruiting to the majority of these roles.
  • There were policies and guidelines on the intranet. However, there were some guidelines in maternity services relating separately to Scarborough Hospital and York Hospital, which were out of date and did not adhere to national guidance.
  • 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.
  • Staff we spoke with had varying views about their engagement and involvement with the process of integration. A number of staff were concerns that Scarborough was seen as the “Poor relation”.
  • Pathways, policies and protocols were not always reviewed and some still had to be harmonised across the trust to avoid confusion among staff.
  • Four of the eight core services we inspected had good local leadership within the service.

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

Importantly, the trust must:

  • ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance, taking into account patients’ dependency levels, especially in A & E, on the medical and surgical wards, operating department practitioner (ODP) cover within theatres, radiology and senior medical cover in relation to cross-site working. Additionally within critical care the provider must ensure staffing levels are adequate to ensure clinical education, unit management, clinical coordination, continuity of care, and effective outreach.
  • ensure that there is adequate access for patients to pain management and dietetic services within critical care
  • ensure improvements are made in the 18 week referral to treatment time target and cancer waiting times so that patients have access to timely care and treatment.
  • ensure that staff, especially within medicine, outpatients & diagnostics and critical care, complete their mandatory training, and have access to necessary training, especially basic life support, mental capacity and consent (Outpatients and diagnostic staff), safeguarding vulnerable adults and safeguarding children.
  • ensure that pathways, policies and protocols are reviewed and harmonised across the trust, to avoid confusion among staff, and address any gaps identified.
  • ensure that patient flow into and out of critical care is specifically in relation to delayed discharges, delayed admissions, running at high capacity and non-clinical transfers out of the unit.
  • ensure that all equipment is tested in a timely manner and in line with the Trust’s policy, especially checks on fridges and resuscitation equipment.
  • ensure that there is a clear clinical strategy for both critical care and outpatients and diagnostics and that staff are engaged in agreeing the future direction and involved in the decision-making processes about the future of the service.

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 8 October 2015

Effective

Requires improvement

Updated 8 October 2015

Caring

Good

Updated 8 October 2015

Responsive

Requires improvement

Updated 8 October 2015

Well-led

Requires improvement

Updated 8 October 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 8 October 2015

Overall the maternity service at York hospital required improvement. The staff did not always receive feedback / lessons learnt from incidents and there were concerns about staffing of theatres out of hours. There were policies and guidelines on the intranet. However, there were guidelines relating separately to Scarborough Hospital or York Hospital in place, which were out of date and did not adhere to national guidance. There were policies and guidelines on the intranet. However, these were different for each hospital, some were out of date and did not adhere to national guidance. Monitoring of performance was difficult to review.

Staff were caring and treated women with respect. The services were responsive and delivered in a way that met the needs of the women accessing them.

Medical care (including older people’s care)

Requires improvement

Updated 8 October 2015

Overall, we judged this service as requires improvement. In the main, patients were protected from avoidable harm and abuse. However, the provider was unable to consistently provide safe staffing levels. Mandatory training compliance needed to improve across medical services at both hospitals.

Following the acquisition of Scarborough hospital staff told us they were confused about which protocols and the lack of availability of some protocols. Results from the Sentinel Stroke National Audit Programme (SSNAP) showed no recent improvement, and there were a number of indicators from other national audits that were below the national average.

Patients were happy with the care they received, and found the service to be caring and compassionate.

There were concerns about the management of patient flow through the hospital including access to senior medical staff to make timely decisions, and delayed discharges.

Staff told us that they were well supported by their immediate line manager, but the executive and senior divisional leadership was reported to be lacking in visibility and effectiveness. Staff shortages impacted upon ward manager’s ability to effectively lead their teams. Some staff did not feel that they were always actively engaged or consulted regarding service changes.

Urgent and emergency services (A&E)

Requires improvement

Updated 8 October 2015

Overall we rated the safe domain as requiring improvement. The majority of patients were not clinically assessed when they first arrived in the department. Some patients waited up to two hours for a clinical assessment. The department was visibly clean and infection control precautions were adhered to. The emergency department had a separate children’s treatment room which was spacious and well-equipped. However, it was not sufficient for all the children who attended and so some children had to be treated in adult areas. We found there were shortages in medical and nursing staff and not all staff had received up to date mandatory or safeguarding training.

Overall we rated the effective domain as requiring improvement. Patients’ care and treatment were planned and delivered in line with current evidence-based guidance, standards and best practice. There was participation in national clinical audits. Information about effectiveness was shared with, and understood by, staff working in the department.

Overall we rated the caring domain as good. We spoke with patients and relatives who told us on the whole they were happy with the care they received. The majority of patients that we spoke with said that they had been involved in the planning of their care and had understood what had been said to them.

Patients and relatives told us that they had been consulted about their treatment and felt involved in their care.

Overall we rated the department as requiring improvement for being responsive. We found less than 50% of nurses had received training about the needs of people with dementia and only a third had received training about learning difficulties. The department had been unable to meet the national target of admitting or discharging 95% of patients within four hours and between 1 October 2014 and 31 December 2014 there had been 349 recorded black breaches. Staff responded well to any complaints or concerns and used learning from these to improve future care and treatment.

Overall we rated the service as requiring improvement for being well-led. Although there was not a written strategy all staff that we spoke with understood the vision for the department. They wanted to rapidly assess and treat all patients presenting to the department in a safe and effective manner. Senior staff told us that there was a strategy for achieving the vision. However, it had proved difficult to implement. Monthly governance meetings were held and all staff were encouraged to attend, including junior members of staff. Nursing and medical staff told us that the senior clinical and managerial staff had the knowledge, skills and personal integrity to effectively lead their department. Staff told us that they felt respected and valued by their colleagues and the leadership team within the ED.

Surgery

Requires improvement

Updated 8 October 2015

Nurse staffing levels were not always maintained as planned. Services were responsive to patients’ individual needs, but there were breaches of waiting times, such as the 18-week referral-to-treatment time (RTT) target and the achievement of cancer waiting times. There had been one ‘never event’ in surgery in the last 12 months relating to wrong site surgery. Never events are serious, largely preventable patient safety incidents that should not occur if proper preventative measures are taken.

The service provided effective and evidence-based care and treatment. Patients received compassionate care and their privacy and dignity were maintained.

Senior leaders understood their roles and responsibilities to oversee the standards of service provision in surgical areas. However, work was continuing to integrate surgical services and to deliver common standards of care across the three hospital sites. There was innovative practice, including a new surgical ward and assessment unit.

Intensive/critical care

Requires improvement

Updated 8 October 2015

Staff were caring and professional. Patients, their relatives and friends spoke highly of the care provided on the unit. There were positive comments from staff in relation to culture and teamwork. Some aspects of staffing did not meet national best practice guidance, particularly the medical on-call rota. Nurse staffing presented a mixed picture, with shortfalls particularly in relation to clinical education, unit management, clinical coordination, continuity of care and outreach. Staff could not be released for training frequently enough. Support from specialist teams was limited as there was no hospital-wide pain team and input from the dietetics service did not meet best practice recommendations.

There were suitable processes in place in relation to incident management, safeguarding and assessing and responding to patient risk. The environment and layout of the unit did not meet national best practice guidance. Space around the beds on the unit was limited and storage space was a problem. The environment was visibly clean and patient safety outcome data did not raise any concerns.

The high number of patients who were non-clinical transfers out of the unit had a negative impact on patient safety, which was a concern. The services were part of the Case Mix Programme managed by ICNARC was positive, but there was limited evidence of other measures being taken to assess effectiveness. Service and strategic planning was at an early stage and there was a lack of certainty about the future design of the service and any immediate actions to mitigate delayed discharge, delayed admissions and high capacity. Ideas were in place for developing the service and improving safety but were not formalised or clearly mapped out.

Services for children & young people

Good

Updated 8 October 2015

There were enough nursing staff to meet the needs of children and families because some beds were closed. Children’s services did not have all the necessary individual risk assessment tools in place so staff were not able to conduct a robust, individualised risk assessment when required. Training records submitted by the trust prior to the inspection showed varying levels of training uptake by members of staff, but not all were achieving the 75% compliance set by the Trust.

Children, young people and parents told us that they received compassionate care with good emotional support. Parents felt informed and involved in decisions relating to their child’s treatment and care. Staff of all grades told us that children’s services were offered very limited CAMHS (Child and Adolescent Mental Health Services) support for children with mental health needs by other providers; the children’s directorate risk register also noted this.

The service was responsive to children’s and young people’s needs and was well led. The service had a clear vision and strategy.

End of life care

Good

Updated 8 October 2015

We saw that end of life care services were safe, effective, caring and responsive, with elements of outstanding practice in terms of being well led. We observed specialist nurses and medical staff provided specialist support in a timely way that aimed to develop the skills of non-specialist staff and ensure the quality of end of life care. Staff were caring and compassionate and we saw the service was responsive to patients’ needs. There was good use of auditing to identify and improve patient outcomes.

The trust had a clear vision and strategy for end of life care services. There was consistent leadership including the development of a number of initiatives, such as non-cancer end of life care and the development of training to improve advance care planning discussions, including those relating to DNA CPR.

Outpatients

Requires improvement

Updated 8 October 2015

Overall the care and treatment received by patients in Scarborough General Hospital outpatients and diagnostic imaging departments required improvement. Some policies and procedures were not being followed and staff were not attending mandatory training. There were also a significant number of a 27% vacancy rate for nurses in outpatients; a 12% vacancy rate for additional clinical services staff and a 43% vacancy rate for radiologists in some departments.

The managers told us that they reported any radiation incidents to the Care Quality Commission under Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). We requested information about IR(ME)R reportable incidents, but this was not provided to us. This meant we were unable to judge the outcomes for the incidents and whether corrective action had been taken by the unit to promote safety. We were unable to ascertain whether the trust was consulting and receiving regular advice and reporting from its radiation protection adviser to comply with the Ionising Radiations Regulations 1999 (IRR99).The morale of staff was low, especially within radiology, and staff felt that they only ever received negative feedback from managers. Many staff we spoke with felt the acquisition had not been handled sensitively and they felt excluded. Staff survey results had deteriorated from the previous year’s results.

Patients were very happy with the care they received and found it to be caring and compassionate. Services were on the whole responsive to patient needs and the care patients received was effective.