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South Tyneside District Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 March 2018

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

  • Although staff were aware of incident reporting procedures, they did not always report all incidents. Some staff expressed concerns about lack of reporting because of lack of feedback or perceived action.
  • Compliance with the World Health Organisation (WHO) surgical safety checklist was variable. We also found some concerns in relation to medicine fridges in surgical services.
  • There was low compliance in some mandatory training modules in all the services we inspected.
  • Some appraisal completion rates were below the trust’s target of 90%. In surgery completion rates were worse than the previous year and particularly low in theatres at 44%. We were not aware of any plans to address this.
  • We found that some patient pathways in the medicine core service were out-of-date and did not have any references to nationally-recognised, evidence-based, best-practice guidance.
  • The critical care unit lacked ITU-specific clinical guidelines and staff did not consistently monitor the effectiveness of care and treatment through continuous local and national audits.
  • We found low compliance in the completion of the risk of malnutrition screening tools.
  • We did not see individualised, patient-centred plans of care, and in some areas we raised concern about the security of care records, although, following our inspection we gained assurance that the trust was taking action to address record security.
  • There was a lack of seven-day consultant cover on most medical and elderly-care wards.
  • We saw limited information about how to make a complaint displayed throughout the hospital. Patient information leaflets were not readily available.
  • We saw that some risks in the medicine core service had remained on the risk register as moderate or high for more than three years. Some risks in relation to patient records had not been recognised prior to our inspection
  • There had been some improvement with regards to the culture in theatre. Processes and trust guidance was being followed more consistently to manage issues. However we were still provided with examples of inappropriate behaviour and not all staff felt able to report this.
  • Although the surgical services directorate had a governance structure, there were no local governance arrangements within critical care and communication was informal.
  • The ward manager of the surgical centre inpatient unit did not have dedicated non-clinical time to fulfil leadership and management responsibilities. This was evidenced with gaps in monthly audit data collection.
  • The critical care ward manager did not have dedicated non-clinical time to fulfil leadership and management responsibilities. This affected their ability to maintain a robust oversight of incidents and the overall effectiveness of the unit.

However:

  • All areas we visited were predominantly clean and well-maintained.
  • Staff provided compassionate care to patients and respected patient privacy and dignity. Patients we spoke with were positive about the service, their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Services were planned to meet the needs of local people and referral-to-treatment times were better than the England average. The number of bed moves at night and the numbers of medical patients cared for on surgical wards showed an improving picture.
  • Issues from the previous inspection in surgery had been significantly improved with regards to patients being cared for in recovery and the impact of medical boarders on surgical wards. Referral to treatment times and cancelled operations were better than England averages. We found patient care to be individualised.
  • Performance indicators for the emergency department were mostly positive, and the trust had achieved the 95% four hour standard for the previous seven months.
  • Staff were aware of the trust’s vision and values, their morale was generally good and they told us they were proud to work at the trust.
Inspection areas

Safe

Requires improvement

Updated 2 March 2018

Effective

Requires improvement

Updated 2 March 2018

Caring

Good

Updated 2 March 2018

Responsive

Good

Updated 2 March 2018

Well-led

Requires improvement

Updated 2 March 2018

Checks on specific services

Critical care

Requires improvement

Updated 2 March 2018

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

  • Although the surgical services directorate had a governance structure, there were no local governance arrangements within critical care and communication was informal.
  • The unit did not adhere to all national standards such as NICE clinical guidelines 83 which meant patients did not receive rehabilitation care after critical illness.
  • The service did not provide a follow-up clinic for patients discharged from critical care.
  • Mandatory training compliance was low in some modules and only 19% of nurses had completed safeguarding adults training.
  • Although the ward manager had budgeted managerial time they had not always been able to take this due to clinical demand.
  • The unit lacked ITU-specific clinical guidelines and staff did not consistently monitor the effectiveness of care and treatment through continuous local and national audits.

However:

  • The trust had taken appropriate action to in response to all of the concerns we raised at the previous inspection.
  • There was a new storage cupboard and a dedicated room for relatives. The trust had also improved the patient shower facilities.
  • The trust had appointed a dedicated ITU pharmacist. Medical and nursing staff spoke positively about the improvements they had introduced in the unit to improve the management of medicines.
  • The trust had recently appointed a clinical nurse educator who worked at the unit two days a week.
  • The trust had implemented a new escalation plan and standard operating procedure to ensure critical care patients were nursed appropriately in theatre recovery.
  • Staff told us they were proud to work for the trust and promoted a patient-centred culture.
  • Patients received effective care and treatment, planned and delivered in line with evidence-based practice.
  • Patients and families felt medical staff communicated with them effectively, kept them involved and informed about care and treatment, promoted the values of dignity and respect, and were kind and compassionate.
  • On a day-to-day basis, nursing and medical staff assessed, monitored, and managed risks to patients. Practitioners completed comprehensive risk assessments and services were available 24 hour a day, seven days a week.

Outpatients and diagnostic imaging

Good

Updated 1 December 2015

Overall, we rated outpatient and diagnostic services as good for being safe, caring, responsive and well-led.

The level of care and treatment delivered by the outpatient and imaging services was good. Arrangements were in place for managing radiation risks and incidents within the comprehensive local rules. Staffing levels were based on the knowledge and expertise of department managers and were flexible to meet the varied demands of clinics and patients.

Referral to treatment times met national targets but the rate for patients not attending appointments was slightly higher than the national average. Outpatient clinics ran every day, including some evenings and occasionally at weekends. Imaging services for inpatients were available seven days a week and service availability was increasing and continuously improving.

During the inspection, we saw and were told by patients that the staff working in the outpatient and diagnostic imaging departments were kind, caring and compassionate at every stage of their journey and patients were given sufficient time for explanations about their care and were encouraged to ask questions

The Trust vision and strategy were well embedded and discussed at staff meetings. There were strong governance arrangements of which staff were aware and we observed good, positive and friendly interactions between staff and managers.

Urgent and emergency services

Requires improvement

Updated 2 March 2018

  • During this inspection we found that caring, responsive and well-led were good.
  • There were systems to report incidents. Staff had received mandatory training and records seen were clear and legible. Staffing numbers allowed the department to provide safe care to patients.
  • Staff had access to and used national guidance and protocols. Snack packs were available for patients, and pain assessments were carried out during the initial assessments. Staff received regular appraisals, which were an opportunity to discuss development and learning. Staff described effective joint-working arrangements to meet the needs of patients.
  • Staff provided compassionate care to patients and respected patient privacy and dignity. Patients we spoke with were positive about the service.
  • We found during this inspection that performance times and indicators for the department had improved and the department was documenting time of arrival and time of discharge correctly. This had been raised as a concern at the previous inspection. Services were planned with the emergency department delivery boards and the strategic group.
  • There was a clear leadership structure in the department, and the senior managers of the service told us of their vision and focus on achieving the performance standards for the department. Risk registers were in place, and senior staff could describe the governance arrangements. Morale was generally good across the department.

Maternity and gynaecology

Good

Updated 1 December 2015

Overall, we rated maternity and gynaecology services as good for being safe, caring, responsive and effective and requiring improvement for well-led.

The service provided safe and effective care in accordance with recommended practices. Outcomes for women using the service were monitored and where improvements were required action was taken. Care and treatment was planned and delivered in a way to ensure women’s safety and welfare. Resources, including equipment and staffing, were sufficient to meet the needs of women. Staff had the correct skills, knowledge and experience to do their job.

The individual needs of women were taken into account in planning the level of support throughout their pregnancy. Women were treated with kindness, dignity and respect. The service took account of complaints and concerns and took action to improve the quality of care. A positive culture of openness and candour was evident and senior managers were visible and approachable. Although the senior management team were aware of the challenges to the service and had a vision for the future there was no formal strategy for maternity or gynaecology services, which set out how the service was to achieve its priorities or to ensure that staff understood their role in achieving the services objectives.

Medical care (including older people’s care)

Good

Updated 2 March 2018

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

  • We rated safe, caring, responsive and well-led as good. We rated effective as requires improvement.
  • Staff were aware of how and when to report incidents including safeguarding concerns. We saw that staff received feedback and lessons learned were shared. All areas we visited were predominantly clean and well-maintained. Staff practised safe infection-control techniques, and audit results were positive. There were low numbers of hospital-acquired infections. Equipment was available, and this was serviced in line with manufacturer’s recommendations. Staff assessed patients for risk of deterioration and escalated their care when necessary. Nurse staffing levels had improved and staffing reviews had been completed, resulting in an uplift of registered nurses.
  • We saw good examples of multidisciplinary working. The majority of staff had a yearly appraisal. Staff told us they were encouraged and supported to professionally develop. We saw staff seeking patient consent before providing care and treatment. We saw that capacity assessments were completed for all patients where appropriate. Most staff we spoke with had a clear understanding about what would constitute a deprivation of liberty and were aware of when they would apply for an urgent authorisation.
  • Patients, relatives and carers gave predominantly positive feedback. Patients told us they felt safe on the wards. Patients told us that the staff were caring and compassionate. One person described the staff as outstanding. We observed staff treating patients compassionately and with dignity and respect. Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Services were planned to meet the needs of local people and referral-to-treatment times were better than the England average. The endoscopy unit was providing evening appointments for people who worked to reduce absence from work. In addition, the service was trialling a pre-assessment service to reduce the number of patients failing to attend, and to ensure patients were fully informed about their procedure. The number of bed moves at night and the numbers of medical patients cared for on surgical wards showed an improving picture. We saw some positive examples of staff supporting vulnerable patients such as those living with dementia.
  • Staff told us that their line managers were visible, approachable and supportive. We saw positive leadership at ward and team level. Staff were aware of the trust’s vision and values, and we saw these displayed. In addition, some wards had their own mission statements displayed. The senior leadership team had a clear future strategy for the services. Staff of all disciplines, on all wards we visited, were friendly and positive. Staff told us that they prioritised patient safety, were team focused and were ‘like a family’. Local governance arrangements were robust. Ward managers attended divisional governance meetings. Ward managers were aware of the risks to their service. We saw numerous examples of improvements and innovation.

However:

  • There was low compliance in some mandatory training modules.
  • We did not see individualised, patient-centred plans of care, and in some areas we raised concern about the security of care records, although, following our inspection we gained assurance that the trust was taking action to address record security.
  • We had concerns that the planned staffing on some wards did not meet the recommended one registered nurse to eight patients. Medicine reconciliation was mostly below the trust target of 80%.
  • We found that some patient pathways were out-of-date and did not have any references to nationally-recognised, evidence-based, best-practice guidance.
  • Patients told us they received pain relief in a timely manner however pain relief was not evaluated, and there had been no pain audits completed by the trust in the twelve months prior to our inspection.
  • We found low compliance in the completion of the risk of malnutrition screening tools.
  • We did not see evidence of goal setting or patient outcome measures being used.
  • We saw variable performance in national audit outcomes, with the trust performing worse than the England average in a number of key audits.
  • There was a lack of seven-day consultant cover on most medical and elderly-care wards.
  • The trust was failing to meet performance targets for complaints responses, and we saw limited information about how to make a complaint displayed throughout the hospital.
  • We raised concern in some areas about the security of patients’ care records.
  • Some staff we spoke with told us they felt uncertain about the future due to the trust’s alliance with a neighbouring trust.

Surgery

Requires improvement

Updated 2 March 2018

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

  • Our rating for safe stayed the same; the trust had addressed some of the areas of concern highlighted at the last inspection. For example there was an escalation plan for when critical care patients needed to be cared for in recovery. However mandatory training rates and compliance with the World Health Organisation (WHO) surgical safety checklist was variable. We also found some concerns in relation to medicine fridges.
  • Our rating for effective stayed the same. Care and treatment was evidence based and patient outcome measured were recorded via national audits.
  • Our rating for caring stayed the same. Care was patient centred and compassionate; we received positive feedback from the patients and relatives we spoke with.
  • Our rating for responsive improved. Issues from the previous inspection had been significantly improved with regards to patients being cared for in recovery and the impact of medical boarders on surgical wards. Referral to treatment times and cancelled operations were better than England averages. We found patient care to be individualised.
  • Our rating for well-led improved. The concerns around the difficult working environment in theatre had improved. Changes in leadership had had a positive impact. However we were concerned that there were a number of areas highlighted at the previous inspection that had not improved.

Services for children & young people

Requires improvement

Updated 28 October 2016

End of life care

Good

Updated 1 December 2015

We rated end of life services as good for safe, effective,  responsive and well-led. Caring was rated as  outstanding.

The trust came top of the league for best performing hospitals in England in The Cancer Patient Experience Survey: Insight Report and League Table 2014 and was in the top three in the same survey in 2013. The survey covers all 153 acute and specialist NHS Trusts in England that provide adult acute cancer services. Areas of excellent performance in the survey included emotional support from nursing and medical staff, clear explanations of what was wrong and what to expect, involvement of family members and easy contact with the cancer specialist nurse. Staff treated patients with dignity and respect and patients told us they felt well cared for. Staff supported patients and their families in a timely and appropriate way and involved patients and their families in planning care and treatment. Patients and their families were supported to cope emotionally with their care and treatment and there were systems in place to provide emotional support to staff when required.

Incident reporting was effective and embedded across the service. When things went wrong incidents were investigated, and lessons learned were shared. Staff responded appropriately to safeguarding concerns.

There were systems and processes for the monitoring of medication, infection control and they were regularly reviewed and improvements made. Staffing levels were monitored and reviewed to keep patients safe and meet their needs. Documentation and care records were completed appropriately. Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were completed consistently. Equipment was available for patients and appropriate safety checks were in place.

End of life care was evidence based and followed national guidance. There was a multi-disciplinary approach to care and treatment. Palliative care staff were appropriately qualified and competent to carry out their role.

Patients’ needs and preferences were important in the planning and delivery of services. An end of life strategy was not in place but a steering group was established to develop a trust-wide strategy across acute and community services. Patients could access services in a way that suited them. Any complaints were dealt with appropriately and any lessons learnt were shared with staff. There were governance arrangements in place and the service monitored and audited the quality of the service. Clinical governance arrangements provided assurance that end of life care was being well managed and information about patient experience was collected, reviewed and acted upon.

Other CQC inspections of services

Community & mental health inspection reports for South Tyneside District Hospital can be found at South Tyneside NHS Foundation Trust.