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Goole & District Hospital Requires improvement

We are carrying out checks at Goole & District Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 September 2018

Our rating of services went down. We rated them as requires improvement because:

  • We rated safe, effective, responsive and well led as requires improvement and caring as good.
  • At this inspection we saw improvements in some of the hospital’s services but some services had deteriorated since our previous inspection
  • We rated three of the hospital’s five services as good, one as requires improvement and one as inadequate.
  • There was limited evidence that staff had the skills, training and experience to provide the right care and treatment. For example, appraisal rates for a number of staff groups were worse than the trust target and mandatory training rates in four of the five services at the hospital were below the trust target of 85%.
  • We found examples in medical care and outpatients where there had not been sufficient effective senior clinical oversight to manage risk and respond to urgent or changing patient needs.
  • The total number of patients on outpatient waiting lists had increased since the previous inspection.
  • Services at the hospital did not have a vision, strategy or business plan. We saw examples where service delivery did not seem to have been addressed, for example, the delayed discharges in medical care and utilisation of the birthing suite.
  • The hospital did not engage effectively with patients, staff, and the public to plan and manage services.

However:

  • Staff cared for patients with care and compassion and respected patients’ wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff felt well-supported by their local leaders and the culture of the hospital was patient-centred.
Inspection areas

Safe

Requires improvement

Updated 12 September 2018

Effective

Requires improvement

Updated 12 September 2018

Caring

Good

Updated 12 September 2018

Responsive

Requires improvement

Updated 12 September 2018

Well-led

Requires improvement

Updated 12 September 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 15 April 2016

We rated the safe, caring, responsive and well-led domains as good; the effective domain for diagnostic imaging was inspected but not rated.

When we inspected outpatients at this location in April 2014, the service overall was rated as good and the responsive domain was rated as requires improvement. This was because the hospital had a relatively high did not attend (DNA) rate (10%) and levels of cancellations of outpatient appointments (6.6%).

We did not inspect diagnostic imaging at the last inspection; therefore, all five domains were included at this inspection visit.

Following the last inspection, we asked the provider to make improvements. We went back on this inspection to check whether the provider had made these improvements.

We found the DNA rates in outpatients had improved overall but clinic cancellation rates were worse, apart from in ophthalmology.

Patients received harm-free care and treatment in a clean and well-equipped hospital from staff who had received appropriate training. Although radiology was short of medical staff across the trust, this did not affect patient care.

We found patients in ophthalmology outpatients and radiology were happy with the care and treatment they received. They told us staff were kind, caring and compassionate.

Staff were competent and worked to national guidance, which made sure patients received the best care and treatment. Patients were protected from the risk of harm, because policies and procedures were in place to ensure this was managed appropriately.

Patients received follow-up appointments when they should receive them and there were no issues identified with backlogs at the GDH site. Staff told us they liked working at GDH, their managers were supportive and there was good teamwork.

Outpatient, phlebotomy and radiology services offered at GDH met patients’ needs and ensured the departments worked effectively and efficiently.

Maternity

Good

Updated 12 September 2018

We previously inspected maternity jointly with gynaecology so we could not compare our new ratings directly with previous ratings. We rated it as good because:

  • The management structure in place had clear lines of responsibility and accountability, and we saw evidence of frequent maternity services meetings and panels, which were appropriately attended.
  • Some policies were past their date of review and the trust was aware of this. However, each out of date policy was allocated to a member of staff to review and update within a specific timeframe. A policy review group was also in place. We were assured by the management team that the out-of-date policies would be updated quickly.
  • There were protocols in place for the midwifery-led unit and homebirths, which detailed admittance criteria, escalation protocols, pathways for transfer, and actions in the event of emergencies.
  • The completion rate for resuscitation training surpassed the trust target, and staff undertook emergency skills and drills training. Staff had recently completed additional ‘baby lifeline’ training focussed on childbirth emergencies in the community.
  • We saw systems were in place for reviewing, monitoring, and sharing lessons learned from incidents. We saw evidence of learning from concerns and complaints.
  • Safeguarding procedures were in place to refer and safeguard adults and children from abuse, and there was a safeguarding midwife based on site. Safeguarding training completion rates were above or very close to meeting trust targets.
  • Equipment, facilities and specialist midwifes were available to meet the needs of patients. A consultant-led obstetric clinic was held in the midwifery-led unit. We observed good team working, with midwives working collaboratively and with respect for each other’s roles.
  • Outcomes for women were largely positive. The proportion of women who experienced a third or fourth degree tear and large postpartum haemorrhage were within trust targets. The stillbirth rate was also within trust target.
  • The women and their relatives we spoke with gave positive feedback about staff and felt they had been supported and included in decision making. Staff were positive about providing good quality and compassionate care to women.

However:

  • Nursing and midwifery staff were not up-to-date with their appraisals. They were not meeting the trust compliance target of 95%.
  • Nursing and midwifery staff were non-compliant for mandatory training. Completion rates were below the trust target of 85%.
  • The community midwife caseloads were non-compliant against national guidance. The level was 143 against the national guidance of 96 cases per WTE midwife.
  • There were relatively high proportions of babies born before 37 weeks gestation, and babies born with a low birth weight at term compared to regional averages. The proportion of women smoking at time of booking and at time of delivery was high. At time of inspection, we were not shown any actions in place to address this.
  • We saw a decline in the number of women utilising the birthing suite. Only three women had birthed at the unit in the 12 months prior to our inspection. Plans to publicise the service had been ongoing since our last inspection.

Outpatients

Inadequate

Updated 12 September 2018

  • There were 31,295 patients overdue their follow up appointment as at March 2018. This was worse than the previous inspection.
  • The trust had started to clinically validate and administratively validate some waiting lists; however, this was not complete for all patients across all waiting lists.
  • Referral to treatment indicators were not met across all specialities. This had not improved since the previous inspection.
  • There were 320 patients waiting over 52 weeks at the trust as at March 2018. This was worse than the previous inspection.
  • The trust was performing worse than the 85% operational standard for cancer patients receiving their first treatment within 62 days of an urgent GP referral.
  • The ‘did not attend’ rate for Goole & District Hospital (Acute) was higher than the England average.
  • There was no formal strategy for outpatients at the trust and staff were not always aware of the trust vision and values.

However:

  • Nurse staffing levels were generally as planned in outpatients.
  • Staff had access to trust policies and audits that were relevant to outpatients were completed within specialities.
  • Staff were friendly and provided compassionate care to patients and ensured privacy and dignity was maintained.
  • Patient feedback regarding services was generally positive.
  • Staff told us morale was generally good across the services.

Maternity and gynaecology

Good

Updated 15 April 2016

Overall we rated the service as good. Staff were encouraged to report incidents and systems were in place following investigation to help rapidly disseminate learning. Women during labour received two midwives to one woman care and escalation procedures were in place to ensure there were sufficient staff. The unit provided individualised care and patients were treated with privacy, dignity and respect. Women received care according to professional best practice clinical guidelines. Pain relief of choice was available for women in labour.

Services were planned and delivered to enable women to have the flexibility, choice and continuity of care wherever possible. A supervisor of midwives was available for all women who had chosen to have a home birth and this included a home visit to discuss their birth plan.

Staff were clear about the vision of the service they provided and were committed to providing midwife led, holistic care. Staff told us their manager was approachable, supportive; teamwork was good and they felt listened to.

The trust’s gap analysis based on the findings of the Kirkup Report, identified the need for a clinical risk midwife and a practice development midwife; the management team were working to address these shortfalls. We found in the midwife led unit the refrigerator temperature had not always been maintained at the desired temperature of between 2 to 8°C.

Medical care (including older people’s care)

Requires improvement

Updated 12 September 2018

  • We had some concerns about whether there was sufficient effective senior clinical oversight to manage risk and take appropriate action to respond to urgent or changing patient needs. For example, there had been a serious incident where a patient’s anti-seizure medicines had been missed over several days due to difficulties with a naso-gastric tube, the patient had suffered a seizure and needed to be transferred to Scunthorpe hospital.
  • Daily checks of resuscitation equipment were not routinely completed and risk assessments and observations were not always reviewed in line with policy.
  • We had some concerns about medicines management and pharmacy support. There were no arrangements for pharmacy support on the NRC, which meant there was infrequent medicines reconciliation, medicines were not always available when needed, and we were not assured that nursing staff always recognised and reported medicine incidents. Fridge temperatures were not always checked daily on the NRC and the date of opening of liquid medicines was not always recorded.
  • Nursing audits, such as recording of food and fluid intake, omitted medicines and completion of risk assessments had not been carried out on the GDH medical ward or the NRC.
  • Staff were not routinely using trust policy and guidance to support patients with on-going need for enteral nutrition (naso-gastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding). For example, we found gaps in monitoring of nutritional and fluid intake for these patients. A recent serious incident had highlighted a need for training for staff in caring for patients with a nasogastric feeding tube.
  • From February 2017 to January 2018 there were 101 reported delayed discharges for GDH. Staff told us these were usually due to waiting for packages of care to be put in place or because of delays with ambulances.
  • There was no overarching, fully developed strategy or business plan for the medical service or for community adult services for 2018/2019, although there was a local strategy for the NRC which was part of the community services division. We were not assured that risks on the medical risk register were being actively managed or effectively overseen.
  • Although audits had been undertaken for infection prevention and control and timeliness of observations, there was no evidence of audits regarding recording of food and fluid intake and omitted medicines. The observations audit showed very poor compliance. Risk assessments had not been carried out on the GDH medical wards.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so and mandatory training compliance for nursing staff was just below the trust target.
  • We observed good infection, prevention and control practice (IPC) in most instances. Environmental and infection prevention and control audits were carried out on both wards and ward 3 took part in quality matron observational audits.
  • Incidents were reported; staff were open and honest with patients when things went wrong and managers gave feedback to staff and shared learning from serious incidents.
  • Most staff within medicine at GDH had received an appraisal. There was evidence of good multidisciplinary working on both wards to benefit patients and staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion and patient and families’ comments were very positive about the calm atmosphere, speed of response and caring approach of staff. Staff worked hard to meet patients’ individual needs and supported patients to take part in a variety of activities appropriate to their ability and goals.
  • There had been changes to the medical service senior management team and they had clear ideas and early plans for how the services needed to be developed. Staff on both wards told us local leaders were approachable and supportive.

Diagnostic imaging

Good

Updated 12 September 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as good at this inspection because:

  • Patients were safe and there were processes in place to ensure they were not overexposed to radiation.
  • The service had sufficient staff, who had completed mandatory training to support patients’ needs.
  • The department was clean and tidy. Equipment was maintained and in working order. Breakdowns were repaired quickly.
  • The department at GDH was effective. Patients were seen quickly on arrival and there were facilities to meet their individual needs.
  • Staff had access to policies and procedures based on best practice.
  • Staff were aware of their responsibilities relating to consent, mental capacity and safeguarding of vulnerable people.
  • Performance against national and local standards, targets and performance indicators was closely monitored. Waiting times for urgent patient pathways were being met at GDH.
  • Staff felt well supported locally by their manager and colleagues and the culture of the department was patient centred. The wider trust had started to engage with staff although this was a work in progress.

However:

  • Medical staffing was low across the trust with significant vacancies and those medical staff in place were not up-to-date with mandatory training.
  • At the time of the inspection we did not see evidence that the department was participating in local clinical audit, therefore we were not assured policies and procedures were being adhered to. However, after the initial report was written, the trust sent us evidence to show some clinical audit was being carried out by radiologists.
  • Once treated, patients had long waits to receive the results of their tests. This was a trust-wide problem compounded by low medical staffing numbers.

Minor injuries unit

Good

Updated 15 April 2016

We found the minor injuries unit at Goole and District Hospital to be good for the effective domain. We did not rate the service in relation to the other four domains.

Evidence-based care and treatment was provided although some of the guidelines were past their review dates; work was taking place to action this.

We found the unit fully supported all grades of staff in their development. There was good multidisciplinary working. However, there was no service level agreement with the local mental health trust as to how long it would take them to come and assess a patient.

Given that this was a small unit in a small hospital there was good access to services seven days a week. Staff we spoke with showed a good knowledge of consent procedures, the Mental Capacity Act, and the associated Deprivation of Liberty Safeguards.

We were told of a recently conducted mental health audit. Apart from this, there was no further evidence presented to us regarding the measurement of patient outcomes.

Surgery

Good

Updated 12 September 2018

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

  • There were multidisciplinary team (MDT) meetings held to discuss patients on specific pathways. These meetings included attendance from specialist nurses, surgeons, anaesthetists and radiologists.
  • The hospital provided timely elective surgical treatments for patients. The service was in the process of increasing the utilisation of Goole and District Hospital for orthopaedic patients.
  • Staff felt supported by their managers and colleagues at ward level. Staff enjoyed working for the trust and the directorate.
  • From our observations it was apparent that the five steps to safer surgery checklist was embedded as a routine part of the surgical pathway. This was an improvement from our previous inspection.
  • The majority of patients we spoke with were complimentary about the care and experience they had received.
  • The service had an electronic system in place for reporting, monitoring and learning from incidents. Staff we spoke with could confidently describe how to report incidents.
  • We found wards and departments we visited clean and tidy and free from clutter. We saw ward cleanliness scores displayed in public corridors.

However:

  • The trust must ensure that mandatory training compliance for nursing staff meets their own target.
  • We saw variable performance in national audits in the service. The trust was not meeting the national performance standards for treatment or cancer standards.
  • Appraisal rates for staff at Goole and District Hospital were worse than the trust target.