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Goole & District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 February 2020

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

  • There had been little progress identified in this inspection and in some services a deterioration.
  • Within outpatients continued backlogs were identified and within diagnostic imaging there was also an increased backlog of patient awaiting diagnostic image services and the subsequent reporting of x-rays. There were unknown risks due to these backlogs.
  • There had been incidents where patients had come to harm due to delays in receiving appointments in both outpatients and diagnostic imaging. We had significant concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • In maternity we were not assured leaders had oversight of clear and reliable midwifery and nurse staffing data; and we saw sickness rates were high. Community caseloads exceeded the recommended ratio of 96 to 98 cases per WTE midwife. A high proportion of community clinics had been cancelled in the 12 months prior to inspection.
  • The service provided mandatory training in key skills to staff but had not ensured everyone had complete it. Across most services there were continued low levels of mandatory training.
  • Investigations of complaints were not managed in a timely way and in line with trust policy.
  • Across most services there continued to be a lack of clear strategies at this level.
  • Systems to manage performance were not consistently used to improve performance.
  • There continued to be changes in the governance structures and processes which had not become embedded and therefore there was limited oversight.
  • There was limited evidence of continuous improvement and innovation across most core services.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Overall staff felt respected, supported and valued.
  • Most services had an open culture where patients, their families and staff could raise concerns without fear.
Inspection areas

Safe

Inadequate

Updated 7 February 2020

Effective

Good

Updated 7 February 2020

Caring

Good

Updated 7 February 2020

Responsive

Inadequate

Updated 7 February 2020

Well-led

Requires improvement

Updated 7 February 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 7 February 2020

We previously inspected medical care services at this site under this trust and overall rated it as requires improvement with requires improvement in safe, effective and well-led, and good in caring and responsive.

At this inspection we rated the services as good because:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix and gave bank and agency staff a full induction.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patient’s consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • 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. The service included patients in the investigation of their complaint.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

However:

  • Compliance rates for mandatory training for medical staff were poor. The 85% target was not met for any of the ten modules. We saw the trust had an action plan to improve compliance. The plan was medical staff would be compliant by November 2019.

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 7 February 2020

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix and gave bank and agency staff a full induction.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patient’s consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limit patients' liberty.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • 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. The service included patients in the investigation of their complaint.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

However:

  • In theatres some equipment had gaps in its checking regime. While staff explained this was due to theatres being closed on those days, the system for recording this needed to be improved.
  • In theatre recovery and prior to transfer back to a ward, staff were not totalling their observation scores to create a national early warning score (NEWS) score, for use by ward staff. This did not appear to comply with the trust’s policy. We raised this with staff and were told the issue would be addressed.
  • Even though it was clear the trust was going through a further period of change, it was noted that a clearly defined plan, with approved budgets and milestones, to realise the ambition for surgery at the Goole site, was still in progress.
  • While the overall governance system functioned, we did find instances in the evidence we reviewed that suggested governance needed tightening up. For example, in theatres at Goole, the new form used in theatres recovery was released for use by staff even though key information was missing from the form. In theatres, NEWS totals were not being calculated for sharing on handover to ward staff. This was arguably in non-compliance with the trust’s own policy in this area. In ward areas, for instance, one surgical healthcare team were not completing the space provided on the consent form for re-consenting the patient on the day of the procedure.
  • While staff did have access to information to manage their service, various sources of information we reviewed suggested that data management and reliability were an issue for the trust.
  • For the surgery division at the Goole site, we saw little evidence of learning, continuous improvement and innovation.

Diagnostic imaging

Inadequate

Updated 7 February 2020

Our rating of this service went down. We rated it as inadequate because:

  • Patients could not always access the service when they needed it. Waiting and result reporting times were not in line with national standards.
  • There had been incidents where patients had come to harm due to delays in reporting results. We had significant concerns regarding this and after the inspection, the Care Quality Commission completed a section 31 letter of intent to seek further clarification from the trust.
  • Safety was not a sufficient priority. Although there was measurement and monitoring of safety performance, there was a limited response leading to unacceptable levels of incidents and potential harm.
  • There had been a lack of pace to address the backlogs and therefore there were concerns that incidents and near misses were not recognised which had caused harm and put patients at risk of harm or potential harm.

  • From May 2018 to April 2019, the percentage of patients waiting more than six weeks to see a clinician (12%) was higher than the England average (3%).
  • Substantial, ongoing and frequent staff shortages increased risks to people who used services.
  • Although, the trust had systems for identifying risks in place, opportunities to prevent and minimise harm were missed.
  • Since our last inspection in 2018, the backlog in unreported results had increased from 5,364 examinations (3,686 patients) to 10,701 examinations (7,045 patients) in July 2019.
  • The contract with the external reporting company to address the backlog had been put in place in August 2019. This delay increased the potential risk of harm to patients.
  • At the time of inspection, the overall backlog in unreported results across all modalities was 7,942 delays (4,719 patients).
  • Following inspection, the initial trajectory for clearing the backlog in unreported results had changed and extended, increasing the risk of potential and actual harm to patients still within the backlog of unreported and delayed results.
  • There were trust wide shortages of radiologists. This impacted on reporting rates across the trust.
  • Although there was some resistance from existing radiologists to supporting the long-term development of radiographers’ capacity to report on results, the expansion of plain film reporting to chest and abdomen was supported and the Trust had also put in place other initiatives to improve their reporting capacity.
  • Local rules were not clear as to which procedures could be requested by individual clinicians.
  • Local dosage reference levels (DRLs) were not in place or displayed in all appropriate rooms.
  • A finalised divisional strategy was not in place and had been developed to draft stage only.

However:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment.
  • Staff we spoke with were aware of their responsibilities in relation to duty of candour.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • In August 2019, 86% of people who completed the Friends and Family Test (FFT) were extremely likely or likely to recommend this service to their family and friends.
  • The service planned and provided care in a way that met the needs of local people and the communities served.

Maternity

Good

Updated 7 February 2020

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

  • The service provided care and treatment based on national guidance and best practice. Staff completed and updated risk assessments for each woman and took action to remove or minimise risks. Staff were competent for their roles.
  • Staff understood how to protect women and children 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. Staff carried out daily and weekly safety checks of specialist and emergency equipment, and the service controlled infection risk well.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • Staff treated women with compassion and kindness, provided emotional support, respected their privacy and dignity, and took account of their individual needs. Staff supported women to make informed decisions about their care and treatment and followed national guidance to gain patients’ consent.
  • The service had an open culture where patients, their families and staff could raise concerns without fear. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • The service provided mandatory training in key skills to all staff; however, they did not make sure all staff completed it. Completion rates for safeguarding adults’ training and Mental Capacity training were low among community midwifery staff.

However:

  • We were not assured leaders had oversight of clear and reliable midwifery and nurse staffing data; and we saw sickness rates were high. Community caseloads, allowing for some changes in allowances and changes in NICE Guidance since 2009, exceeded the recommended ratio of 96 to 98 cases per WTE midwife. A high proportion of community clinics had been cancelled in the 12 months prior to inspection.
  • Leaders and senior staff had the necessary experience and knowledge to lead effectively. However, there had been some instability in the leadership team. Staff expressed concerns about leadership stability and the implementation of new models of care; and described morale within the service had wavered.

  • We saw a continued pattern of decline in use of the midwife-led birth suite at the hospital. No decisive action had been taken to ensure the sustainability of the unit, and there was no local vision for the maternity service and a strategy to turn it into action.

Outpatients

Inadequate

Updated 7 February 2020

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

  • The trust had identified incidents in 2018 and 2019 where patients had come to harm due to delays in receiving appointments in out-patients.  We had significant concerns regarding this and requested further information from the trust on what it was doing to limit risk in a section 31 “letter of intent to seek further clarification from the trust”. The trust provided a response to this. CQC continue to have concerns about the risks of harm and potential harm to patients when waiting times remain lengthy. However, we were assured that the trust had put in place oversight mechanisms and processes to limit the risks.
  • After the inspection, the trust told us they had revised the inclusion criteria for patients to be added to the clinical harm review in ophthalmology to include any delay that exceeded the speciality/department risk stratification criteria. For example, in September 2019, this new risk stratification criteria had identified 83 patients to be added to the clinical harm review. Of these 83 patients, 37 patients had been seen and assessed for harm and the trust highlighted there was no harm in 24 of these patients, there was low harm in ten patients and one moderate harm and two severe harm. Out of the 83 patients identified, the remaining 46 patients were due to have a clinical harm review in November 2019.
  • Whilst the trust had implemented clinical validation to help ensure patients were seen in order of clinical need, there remained significant risk in some waiting lists due to the volume of patients on the waiting list and the service not meeting the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral for a suspected cancer diagnosis. This was an ongoing concern since our previous inspection. The trust provided information after the inspection stating they were taking steps to address the challenges with cancer performance in accordance with the trust’s performance management framework.
  • We did not see evidence of safety checklists being used in any areas other than in ophthalmology.
  • Although records were now stored securely, which was an improvement since our last inspection, records were not always timed or signed by staff, and staff did not always provide their role or designation. Written notes were not consistently legible. These concerns were ongoing since our previous inspection.
  • Although the oversight of waiting lists and backlogs had improved, the July 2019 board papers showed there remained 33,673 overdue outpatient review appointments in May 2019. Overall there had been improvements with the referral to treatment indicators, however there remained specialties which did not always achieve the referral to treatment indicators.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for non-admitted pathways has been worse than the England overall performance. The latest figures for May 2019, showed 78.7% of this group of patients were treated within 18 weeks versus the England average of 87.6%.
  • From June 2018 to May 2019 the trust’s referral to treatment time (RTT) for incomplete pathways has been worse the England overall performance, although there has been an improving trend from January to May 2019. The latest figures for May 2019 showed 77.8% of patients still waiting for treatment had been waiting for less than 18 weeks, versus the England average of 86.4%.
  • From June 2018 to June 2019, the trust received 134 complaints in relation to outpatients at the trust (27.6% of total complaints received by the trust). 66 complaints were still open and under investigation or partially upheld with no closed date. Of the 68 complaints that were closed, the trust took an average of 82.2 working days to investigate and close complaints. This was not in line with their complaints policy, which states complaints should be closed within 60 working days.
  • From March 2018 to February 2019, the did not attend rate for Diana, Princess of Wales Hospital was higher (worse) than the England average. At the previous inspection, there was no strategy in place and although the trust had developed a strategy and provided the draft strategy for outpatients, this was still a draft version.

However, we also found:

  • 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. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. Staff managed clinical waste well.
  • 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. Managers regularly reviewed staffing levels and skill mix and gave bank staff a full induction. The service used systems and processes to safely prescribe, administer, record and store medicines.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff gave patients practical support and advice to lead healthier lives. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • 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. Patients were given contact details for specialist nurses to contact with any worries or questions.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Patients we spoke with gave positive feedback about their care and treatment in outpatients at this hospital.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and teams used systems to manage performance.
  • There had been improvement in some areas and improved oversight and governance regarding the challenges across outpatient services. The services had implemented procedures to support the work regarding the challenges in outpatients, for example outpatient leaders monitored performance through performance reports and regular meetings.
  • The service collected data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Leaders and staff actively and openly engaged with patients.