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Friarage Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 July 2019

We rated the Friarage hospital as requires improvement because:

  • The ratings went down for some services and domains. We rated the hospital as requires improvement for safe, effective and well led with caring and responsive as good.
  • In critical care GPICS recommendations for nurse staffing, pharmacy provision and MDT ward rounds were not met. We found recorded evidence of patient harm relating to staff shortages. We were not assured of staff competence, skills and knowledge to deliver effective care and treatment.
  • Theatre department team meetings no longer took place.
  • We did not receive assurance that the current or planned paediatric pathways, staff competence, or trained staff out of hours was sufficient to meet the current standards for children receiving care in urgent and emergency care services.
  • Medical staffing was insufficient in the emergency department, critical care and radiology. There was a heavy reliance on locum staff to fill rotas and this impacted on services provided.
  • Medical staff mandatory training compliance, including safeguarding children and adults, did not meet trust targets.
  • Specialist environments did not meet safety standards. Privacy and dignity of critical care patients could not be maintained. Infection control procedures were not always followed in diagnostic imaging departments. In some areas fridge temperature records did not show actions taken when temperatures were out of range.
  • We were not assured diagnostic imaging staff were always able to recognise, report or learn from incidents. There was no effective monitoring of incident trends and themes. There were procedures in place to identify and manage risks but some risks identified were not documented according to procedure. Risks were not regularly reviewed in all areas.
  • There was a higher than expected risk of readmission for elective admissions when compared to the England average. Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
  • It was not clear that leaders understood the challenges staff faced. Staff morale was variable, because of staffing issues and their impact on patient care and staff well-being. Staff in most areas inspected raised concerns that senior managers above matron level were not visible and not accessible. Staff below manager level were not aware of the trust strategy going forward. Staff considered the amount of changes and speed of change in the organisation added to existing pressures.

However:

  • Records and documentation were clear, legible, dated, timed and signed in accordance with local policy and professional registering bodies. We observed robust medicines management processes in place. Staff used a national early warning score (NEWS 2) to assess and escalate if patients’ health deteriorated. World Health Organisation safer surgery checks were embedded.
  • Most staff were aware of how and when to report incidents. Staff understood how to protect patients from abuse and worked well with other agencies to do so.
  • In most areas there were sufficient competent staff to care for patients. Compliance levels for mandatory training for nursing staff in most areas was good and staff were supported to attend training.
  • Departments were visibly clean and tidy, and most areas had cleaning schedules and records in place.
  • Staff cared for patients with compassion. Medical and nursing staff at all levels advocated for a positive patient experience. Patients we spoke with were consistently positive about the care and experience they had received. Relatives said they were kept fully informed and involved.
  • A mental health liaison team was available 24 hours a day, seven days a week. There were specialist staff and initiatives for those living with a learning disability or living with dementia, although this was not the case in all departments and some areas such as diagnostic imaging had very limited provision. Staff had access to a dedicated pain management team and a palliative care team, to support patients with complex pain needs.
  • On the majority of occasions, the trust was meeting and performing better than the national performance standards for emergency care and referral to treatment targets (RTT). Staff participated in national audits; performance against these was mainly the same as or better than other hospitals.
  • Governance metrics were presented as dashboards each month and displayed on model-ward boards, for staff to see.

Inspection areas

Safe

Requires improvement

Updated 2 July 2019

Effective

Requires improvement

Updated 2 July 2019

Caring

Good

Updated 2 July 2019

Responsive

Good

Updated 2 July 2019

Well-led

Requires improvement

Updated 2 July 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 2 July 2019

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

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service had a strong patient focus and staff at all levels advocated for a positive patient experience.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with during the inspection told us there was good teamwork and morale was generally high.
  • Staff spoke positively about their local leaders and said they were supportive and accessible.
  • The governance structure was clear and the local leadership team had plans in place to address risks to the service, with access to information, such as monthly performance reports, to maintain quality.
  • The service had mechanisms in place to manage access and flow throughout the hospital, including daily flow meetings, discharge pathways and facilitators, flow leads and daily board rounds.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The service had enough staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • 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 monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

However:

  • Medical staff were not all up to date with the required mandatory training. Training compliance failed to meet the trust target of 90% in all 11 core standards and compliance with safeguarding children (Level 2) and safeguarding vulnerable adults training was low.

Services for children & young people

Good

Updated 10 June 2015

We rated services for children and young people as ‘good’. The children’s services actively monitored safety, risk and cleanliness. We did not identify any concerns regarding nursing and medical staffing at the Friarage Hospital.

At Friarage Hospital there was only one young person available to talk with during our inspection visit and they were very happy with the care they received. We reviewed 63 questionnaires submitted since 1 November 2014 and these showed that parents provided positive feedback with no negative responses.

We found that a recent service reconfiguration was being closely monitored and managed in partnership with commissioners and other healthcare providers. We found access and flow was good within the hospital and its link to the main children’s services at James Cook University Hospital.

The service had a clear vision and strategy based on the National Service Framework for Children. The service was led by a positive management team who worked well together. The service regularly introduced innovative improvements with the aim of constantly improving the delivery of care for children and families.

Critical care

Requires improvement

Updated 2 July 2019

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

  • There were medical and nurse staffing shortages. The unit was heavily reliant on locum staff and continuity of care was not provided. GPICS standards for nursing care were often not adhered to. We found recorded evidence of patient harm relating to staff shortages.
  • There was a lack of assurance over training compliance. Basic life support and manual handling figures for medical staff were below 50%. We were not assured of nursing staff competence, skills and knowledge to deliver effective care and treatment.
  • GPICS recommendations for pharmacy provision and MDT ward rounds were not met.
  • There was insufficient space around bed areas, a lack of hand wash basins and the design of isolation rooms did not meet Department of Health standards. Privacy and dignity of patients could not be maintained as the unit did not have curtains in place.
  • Access, flow and capacity within the units did not always meet patient needs and bed occupancy rates had been consistently higher than the England average.
  • The critical care outreach team did not provide a 24/7service. Follow up clinics were not well established and there was no psychological input for patients.
  • The risk register not was reflective of all the risks identified. Risks were not regularly reviewed or acted upon in a timely manner.
  • It was not clear that leaders understood the challenges staff faced. Staff morale was low, because of staffing issues and their impact on patient care and staff well-being.

However:

  • Staff demonstrated a good knowledge for safeguarding with good training compliance rates.
  • Records and prescription charts were fully completed and in line with trust and professional standards. We saw evidence of screening for delirium, monitoring of pain, nutrition and hydration with support from specialist staff. There was MDT input into decision making and care planning. There were individualised care plans and good used of patient diaries.
  • National ICNARC data for Friarage hospital showed that patient outcomes: mortality and readmission rates and bed delays, were in line with or better than when compared to similar units.
  • Staff cared for patients with compassion and provided emotional support to patients and their relatives. There were few complaints and a clear focus on patient centred care.

End of life care

Good

Updated 28 October 2016

Overall end of life care was rated as good because:

Staff delivering end of life care understood their responsibilities with regard to reporting incidents and ensured information and lessons learnt were shared proactively with other colleagues within the hospital.

There were improvements made since the last inspection in documentation of individualised care of the dying documents and appropriately completed Do Not Attempt Resuscitation forms.

However:

Some equipment in the mortuary was not safe for its intended use.

Risk assessments for porters and security staff were found to be out of date.

There was no regular audit programme for infection prevention and control in the mortuary.

Maternity and gynaecology

Good

Updated 10 June 2015

Overall maternity services were good in all areas, with an ‘outstanding’ rating for being well-led. The service provided safe and effective care in accordance with recommended practices.

Resources, including equipment and staffing, were sufficient to meet the needs of women. Staff had the correct skills, knowledge and experience to do their jobs.

The individual needs of women were taken into account in planning the level of support throughout pregnancy. Women were treated with kindness, dignity and respect while they received care and treatment.

The maternity services were led by a highly committed, enthusiastic team, with each member sharing a passion and responsibility for delivering a high-quality service. Governance arrangements were embedded at all levels and enabled the effective identification and monitoring of risks and the review of progress on action plans. There was strong engagement with patients and a focus on gaining greater involvement from patients’ groups who represented the local population using the service.

Outpatients and diagnostic imaging

Good

Updated 28 October 2016

Outpatient and diagnostic imaging was rated for safe as good because:

Departments were clean and hygiene standards were good. Staff ensured equipment was clean and well maintained, so patients received the treatment they needed safely.

Incidents were reported using an electronic reporting system and staff knew how to report incidents. Incidents were investigated and ‘lessons learned’ were shared with staff.

Staff had received appropriate training and support through the completion of mandatory training, so that they were working to the latest up to date guidance and practices, with appropriate records maintained.

Surgery

Good

Updated 2 July 2019

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

  • We rated safe, effective, caring and responsive as good, with well-led as requires improvement.
  • There were sufficient numbers of skilled medical and nursing staff to care for patients although coverage of the anaesthetic rota was challenging.
  • We observed the World Health Organisation safer surgery checks were embedded and that staff used the national early warning score (NEWS 2) to identify if the clinical condition of a patient was deteriorating and required early intervention and or escalation to keep the patient safe.
  • All areas we visited were clean and tidy and most had cleaning schedules and records in place.
  • Staff were aware of how and when to report incidents, including safeguarding concerns.
  • The surgery service participated in national audits to monitor and improve quality.
  • All patients we spoke with who identified they had experienced pain, said this had been managed well.
  • Patients we spoke with told us they felt safe and well cared for. Relatives we spoke with said they could speak with doctors and senior nursing staff when they wanted to. Patients had access to clinical nurse specialists for support and advice, when needed.
  • From September 2017 to August 2018 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently better than or similar to the England average.
  • There was an advisor for learning disability and autism, to support staff, patients and families. There were dementia friendly initiatives available and staff used patient passports for those living with a learning disability or living with dementia.
  • Governance metrics were presented as dashboards each month and displayed on model-ward boards, for staff to see. Managers explained it was their responsibility to ensure all staff were aware and did this through staff huddles around the model-ward board, staff meetings and written bulletins.
  • We saw that the surgical centre had an active risk register in place which identified risk, controls, gaps in control and action plans. All risks had review dates in place with evidence of updates.

However:

  • Staff and doctors that we spoke with raised concerns to us that senior managers above matron level were not visible and not accessible. Staff we spoke with said morale was variable.
  • Staff we spoke with said they recognised the need for changes to be implemented but considered the amount of changes and speed of change in the organisation added to existing pressures.
  • Staff we spoke with in theatres said they no longer held department meetings as these had been stopped by trust managers.
  • The 90.0% mandatory training compliance target was not met for any of the mandatory training modules for which medical staff were eligible.
  • Fridge temperature records did not indicate actions taken to safeguard medicines, when the fridge temperature was not within the required range.
  • All patients at the trust had a higher expected risk of readmission for elective admissions when compared to the England average.
  • Consent was not routinely obtained in accordance with best practise, as a two-stage process.
  • Call bells were not always answered promptly while patient safety huddles were in progress. We observed a huddle that was held in an open area which meant there was a risk patients and relatives could hear what was being discussed.

Urgent and emergency services

Requires improvement

Updated 2 July 2019

  • We did not receive assurance that the current or planned paediatric pathways met the national standards for children receiving care in emergency departments.
  • Staff receiving children in the department did not have the appropriate paediatric competence to provide immediate assessment. Data provided by the trust, showed that this was been carried out by reception staff.
  • There was a lack of appropriate paediatric trained staff out of hours.
  • Overnight pathways did not provide assurance of a responsive emergency department, staff we spoke with highlighted confusion about processes and provided information which showed inconsistent decision making.
  • The designated mental health room did not meet the quality standards for liaison psychiatry services, it contained fixings and fittings which posed potential ligature and other risks to patients.
  • Training compliance rates for resuscitation training was not supplied in a consistent way to provide assurance that the current resuscitation provision in the department met the required standards.
  • We observed that patients had no access to water during their admission
  • Consultant presence was not available onsite seven days a week; they were not onsite over the weekend. During 2018, there had been four occasions when the department had to close to admissions due to no middle grade doctor being available.
  • Mandatory training rates did not consistently meet the trust target of 90%.
  • Audit action plans we reviewed were not consistently completed, they did not have actions identified or re-audit dates included to improve performance.

However:

  • The service had recognised the need for improvements in the emergency pathways; these required a change to service and a preferred clinical model had been developed. At the time of the inspection in January 2019, the senior management team anticipated agreement and formal consultation later in the year. Following the inspection at the trust’s board meeting on the 5 February it was agreed that this would be urgently implemented on a temporary basis to maintain patient safety.
  • Patients we spoke with were consistently positive about the care and experience they had received.
  • On the majority of occasions, the trust was meeting and performing better than the national performance standards.
  • The department was visibly clean and tidy, and staff protected themselves and patients from infections by cleaning their hands and equipment.
  • A mental health liaison team was available 24 hours a day, seven days a week.
  • Leadership in the department was stable and staff we spoke with felt supported by line managers and the senior management team.

Diagnostic imaging

Requires improvement

Updated 2 July 2019

We rated it as requires improvement because:

  • The service did not have enough radiologists which impacted on delivery of the service.
  • We found infection control procedures were not always followed.
  • We were not assured staff were able to recognise incidents and report them appropriately. Staff told us lessons learned were not shared with the whole team and the wider service. The service was not effectively monitoring trends and themes. We saw incidents that had not followed the correct procedure of reporting both internally and externally.
  • Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
  • There were limited provisions/support for individuals with additional needs such as dementia or learning difficulties.
  • Not all risks which managers told us about were documented on the risk register although the service had procedures in place to report and manage risks.

However:

  • The service provided care and treatment based on national guidance.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion.