Scarborough 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question requires improvement. At this assessment the rating remained requires improvement. We found continued breaches of legal regulations in relation to medical staff training, access to services and consent. We also identified new breaches of regulation in relation to infection prevention and control, and assessing patient needs. This meant some aspects of the service were not always safe and there was limited assurance about safety.

The service did not always manage medicines well nor did they adhere to the principles of infection prevention and control. We did not see a consistent approach to the completion of patient risk assessments, or to the recognition and escalation of the deteriorating patient. The training provided was comprehensive, but the service did not ensure that all medical staff completed it.

People were able to raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff involved people in planning any changes.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents as the department promoted a no blame culture and told us incidents were essential for learning.

Incidents would be shared in staff meetings, and any themes or trends would be shared in the daily huddles that were held throughout each day.

We reviewed 5 incidents from samples of incidents and saw that all 5 had been managed appropriately.

We saw examples of learning from incidents. Work had been undertaken to ensure that the new department layout worked effectively for both patients and staff. This gave staff the opportunity to trial new ideas and different ways of working.

All staff we spoke with were able to articulate the complaints process and how they would facilitate patients making a complaint. We noted that staff would proactively request feedback and that equal importance was given to both positive and negative issues. We noted multiple examples of information regarding the complaints process distributed across the department.

We reviewed the most recent complaint received by the department prior to inspection and found that it had been managed appropriately and investigated, actions were identified and responded to within the appropriate timescale.

All staff were aware of their responsibilities under duty of candour and were able to give examples of when they had applied these principles. There was an up-to-date policy covering duty of candour.

Risks were managed by senior leaders within the department, and all senior leaders could articulate the highest risks in the department. The highest risk at time of the inspection was overcrowding in the department and a limit on the temporary escalation spaces. We saw that staff were working to ensure that the new department footprint was utilised in the most appropriate manner.

We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff learnt from incidents and complaints as all information was shared by senior leaders. We saw examples of service users being listened to and their views being considered.

The service did not consistently work well to ensure all patients experienced safe systems, pathways and transitions.

On arrival to the emergency department, patients who self-attended were first seen by a senior nurse for initial assessment and then allocated patients to the most appropriate clinical area. Once the patient was in the allocated clinical area they would receive a full triage of their symptoms.

During periods of high acuity and reduced patient flow, patients in the waiting area were at increased risk of not receiving effective monitoring of their condition nor an appropriate response if they became more unwell. At one stage on 7 October we saw 16 patients within the waiting room who had not received additional observations whilst waiting to be moved into a clinical area. We saw 2 patients who had become more unwell whilst in the waiting room who needed immediate escalation and treatment. Following review of their patient record we saw that both had only received 1 set of observations. Limited space and volume of patients sometimes resulted in extended waits for full triage or repeated observations. Examples were provided by staff of patients deteriorating while waiting.

There was 1 healthcare assistant allocated to the waiting room to provide oversight. We saw that they could be asked to undertake other tasks within the department, such as transferring patients to other areas within the hospital, which reduced oversight of the waiting room.

We identified a significant safety concern where the department relied on local ambulance trust guidance that allowed ambulance crews to leave patients after 45 minutes without completing a formal handover to hospital staff. This resulted in patients being left unmonitored and unknown to staff, creating a serious risk that deterioration would not be recognised or acted upon promptly. We observed a patient presenting with chest pain who had not been handed over to staff and whose condition deteriorated while waiting. Inspectors intervened to escalate the situation, after which the patient received urgent assessment and treatment.

Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff, including those awaiting admission under medical or surgical specialities. We noted the emergency department staff retained medical oversight and nursing care for those patients. This caused increased demand on the staff and space available for patients.

We raised significant concerns with senior leaders regarding the level of patient risk. Additional staff were allocated immediately to the waiting room to provide increased oversight and to mitigate the risk associated with long waits.

Patients streamed to the emergency department were triaged by trained staff using the Manchester Triage System (MTS). There were pathways to stream patients directly to speciality assessment.

Senior staff were allocated to all clinical areas to maintain oversight. There were board rounds and safety huddles undertaken throughout the day. All board rounds and huddles were led by senior clinicians and recorded as being completed in documentation held within the department. We did not see any errors or omissions when we reviewed records for the current and previous month. We observed that all huddles and board rounds contained all pertinent information to enable effective oversight.

The service had 24-hour access to specialist mental health support. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions.

We saw examples of electronic discharge summaries being completed which contained all relevant information about the patients stay in the department if they were discharged home.

Bed management meetings were held throughout the day. The purpose of these meetings was to maintain oversight of patient flow across the hospital and to escalate any issues within the emergency department.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s 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.

We saw that all staff had received the correct level of safeguarding training as recommended in the Safeguarding children and young people & children and young people in care: Competencies for health care staff.

All staff we spoke with knew how to make a safeguarding referral and would do so when appropriate. We also noted that feedback from safeguarding was included in staff meetings and daily staff huddles. Feedback was also shared by email to ensure all staff received it.

All 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. We saw multiple examples of patient notes being updated regarding their status and that the electronic record included any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw that the hospital safeguarding team provided a visible presence within the department. This allowed for greater levels of support and guidance for department staff.

Audits were undertaken to ensure all safeguarding were completed as appropriate, we reviewed the most recent audit and saw no errors.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. We did note that Mental Capacity Act training had only been completed by 53% of all medical staff.

We did not observe any interactions that required restraint or restrictive practice, but we observed junior medical staff requesting advice and support from senior colleagues.

The evidence did not show a consistently good standard. The service did not demonstrate how they work with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs but could not consistently demonstrate that it was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients about their care and treatment; however, they failed to provide reliable or effective methods to support patients with communication difficulties. Staff referred to a tablet device with built-in interpretation but were unable to explain how it should be used in practice, raising concerns about the service’s ability to meet communication needs.

Staff were expected to use a nationally recognised tool to identify deteriorating patients and escalate concerns appropriately. While vital signs were recorded and National Early Warning Scores (NEWS2) calculated, we identified poor and inconsistent use of the system, including 10 instances of incomplete or missing observations during the inspection. Although an escalation policy was in place, the lack of consistent implementation placed patients at risk. Following inspection, we requested copies of completed audits concerning NEWS2, but none were provided.

Staff did not always complete risk assessments for each patient on admission / arrival. We reviewed patient notes and saw repeated omissions, we also noted in audits provided after inspection that risk assessments were not always completed in a timely manner.

We did note that all patients presenting with symptoms of sepsis were being managed in line with guidance. We saw that the department had recently introduced measures to improve previous issues with the recognition and treatment of sepsis. We saw new pathways that had been developed and by the introduction of a sepsis trolley which contained all the necessary information, documentation and treatment required for prompt treatment.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being used within the emergency department to enable awareness to staff of specific patient need.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

We saw multiple patients being managed in temporary escalation spaces in non-clinical areas. This meant patients were waiting in areas close to external doors or with high footfall. We also noted these areas did not have adequate facilities for personal care.

We noted that the paediatric waiting area did not follow national recommendations, it did not have audio-visual or secure physical separation from the main waiting room. We also noted that the paediatric assessment room and resuscitation space were not separate from the main department. Staff were aware that this was not recommended under current guidance and mitigations were in place to manage and maintain oversight of this issue.

The emergency department was visibly clean with cleaning being regularly undertaken. The service participated in clinical environmental audits. We requested the previous months audits which showed cleanliness was maintained consistently within the department.

The designated mental health assessment room was fully Psychiatric Liaison Accreditation Network (PLAN) compliant. There were 2 allocated cubicles that could be made ligature free if required. We reviewed the risk assessments and found them complete and without omission.

All clinical and non-clinical waste was managed appropriately.

At the previous inspection we found issues with the overall environment, at this inspection we saw that the new Urgent and Emergency Care Centre had been opened since then bringing together emergency, same-day emergency, and acute medical services - along with diagnostics such as CT scanning. This was a noted improvement.

The evidence showed significant shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not consistently make sure staff received effective support, supervision and development. The service was previously in breach of the legal regulation in relation to medical staff mandatory training compliance. Improvements were not found at this assessment, and the service remained in breach of this regulation.

Most nursing staff kept up to date with their mandatory training. At the time of our assessment, mandatory training compliance for nursing staff was 83%. This was below the trust target of 85%. The mandatory training compliance for medical staff was 60% and below the trust target.

Resuscitation training for all staff was inconsistently completed. Nursing staff completion for adult resuscitation training was 87% with paediatric resuscitation at 81% against a trust target of 85%. We did note that advanced adult resuscitation was below target at 67%.

Medical staff resuscitation training was beneath trust target in all areas. Adult Resuscitation compliance was 65%, adult advanced resuscitation was at 70% compliance. Paediatric resuscitation showed 0% compliance and paediatric advanced resuscitation 38% compliance.

The department could not meet the standard for registered nurses (children) and as mitigation would use adult trained nurses at band 6 and 7 who had completed paediatric competencies, information provided following inspection showed that only 72% of applicable staff had completed the paediatric competency training.

We were told that all new staff within the department would receive a full induction, but we noted that a local induction had only been completed for 60% of nurses and 36% for medical staffing in the 12 months prior to inspection. This meant we were not assured that all staff had received a full induction.

We saw that both nursing and medical staffing was at the required level for the department.

All non-permanent staff we spoke with told us that they had a full orientation on their first shift in the emergency department.

Managers supported all staff to develop through yearly, constructive appraisals of their work. The data provided showed that medical staff appraisal completion was 90%. The nursing staff appraisal completion rate was 87% in the last 12 months.

All nursing staff we spoke with had undertaken core competencies when first employed within the emergency department. All newly appointed staff were able to describe a period of being supernumerary when first in the emergency department.

The mandatory training for staff was comprehensive and when completed met the needs of patients and staff. The training covered topics, such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety, and information governance.

Senior leaders calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift using a safer staffing tool. We noted that staffing needs were assessed twice a day which allowed for escalation and for extra staff to be provided if required.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We noted an inconsistent use of ‘I am clean’ stickers which showed when a piece of equipment was last cleaned. The stickers were either missing or incomplete.

We did not observe any staff cleaning equipment between use which meant there was an increased possibility of cross contamination.

We saw staff failing to use protective equipment (PPE). correctly and saw staff coming out of cubicles and not removing their PPE before commencing additional tasks. We also noted a lack of handwashing from all grades of staff within the department.

We reviewed audit results following inspection and found that all audits provided had highlighted incorrect use of PPE and issues with low hand hygiene compliance.

We noted that 100% of staff had completed level 1 training and 92% had completed level 2.

We did see that there were designated areas for the safe management of patients with infectious diseases but at the time of our assessment there were no patients who required this level of input.

The service did not consistently follow safe systems and processes for prescribing and administering medicines.

Patient records reviewed during the inspection did not always contain full medicines histories, and medicines were not consistently prescribed in a timely manner. Of the 4 records we reviewed, 3 did not include a comprehensive medicines history. One patient had not been prescribed their insulin, and another did not receive pain relief for approximately 10 hours. This increased the risk of patients not receiving the correct medicines when required.

We found 2 cases where the expiry date of liquid medicines had lapsed and 1 where the date of opening had not been recorded. This meant it was unclear whether the medicine remained suitable for use. These issues had not been identified during the medicine expiry checking process and posed a risk of expired medicines being administered.

An out-of-date controlled drug had been identified and logged, and the expiry date had been marked on the packaging. However, it had not been fully segregated from usable stock or returned to pharmacy, creating a risk of it being used in error.

Patient Group Directions were available and in date; however, not all had been signed by the Authorising Manager. We were told that competency assessments were undertaken every 3 years, but evidence of these was not provided during the inspection.

Completion of Medicines Management training was 64% in Same Day Emergency Care/Emergency Assessment Unit and 65% in the Emergency Department and Minor Injury Unit. The trust recognised that further improvement was required to ensure all staff received appropriate training.

Medicines reconciliation was undertaken by the pharmacy team using a manual process to identify and prioritise patients. The trust recognised that this process required strengthening and planned to implement a new digital system to improve accuracy and efficiency. When reconciliation was undertaken, multiple information sources were used to confirm accuracy. However, there was no designated pharmacist supporting the emergency department, which was not in line with current guidance from the Royal College of Emergency Medicine.

Medicines were stored safely and securely in most areas visited. Temperature monitoring was completed to ensure medicines remained safe for use. Controlled drugs were stored securely, and records were accurate. Any discrepancies were identified and reported promptly.

There were systems in place to replenish medicines when needed, and the pharmacy provided regular support to supply and manage stock. Pre-labelled packs were available for commonly used discharge medicines, with other medicines supplied by pharmacy or prescribed on FP10 prescriptions, which were stored securely.

We also saw evidence of good practice. A patient identified as being at high risk of sepsis was promptly recognised, and appropriate treatment was initiated within 1 hour of identification.