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The James Cook University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 July 2019

We rated James Cook University Hospital as requires improvement because:

  • The ratings went down for some services and domains. We rated the hospital as requires improvement for safe and well-led with effective, caring and responsive as good.
  • Critical care services had deteriorated significantly since the last inspection. We found them to be inadequate in Safe and requiring improvement in effective, responsive and well led. Caring remained Good. We were not assured that nurse staffing levels were always appropriate and in line with national GPICS recommendations.
  • There were significant challenges with access, flow and capacity within the critical care units. The bed occupancy had been consistently higher than the England average.
  • The critical care risk register not was reflective of all the risks we saw and areas of concern identified from performance data.
  • Diagnostic imaging services were rated as requires improvement overall. We were not assured staff were able to recognise incidents and report them appropriately. Staff told us lessons learned were not always shared with the whole team and the wider service. There was a shortage of radiologists which was impacting on the service.
  • Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
  • There was a lack of evidence to demonstrate engagement with patients who used the diagnostic and radiology services.
  • The well led rating in surgery at both sites went down to requires improvement because numerous staff and doctors we spoke with felt senior managers above matron level were not visible, contactable or approachable.
  • The safe domain in medicine and urgent and emergency care at James Cook hospital went down one rating to requires improvement. Paediatric patients attending the urgent and emergency care service were not fully separated from adult patients. Dedicated paediatric areas were not secure to prevent adults from entering the area or children and young people from leaving. The designated mental health room did not meet the quality standards for liaison psychiatry services, it contained fixings and fittings which posed ligature and harm risks to patients, visitors and staff. There were shortages of nursing staff within the department; these shortages were evident on the majority of shifts and consultant cover did not meet the major trauma standard requirements.
  • Nursing and Medical staff training compliance for mandatory training failed to meet the trust target of 90%.
  • We lacked assurance of shared learning and actions taken surrounding a serious patient safety incident in the catheter laboratory including whether staff were adhering to hospital policy surrounding swab and needle checks.
  • Medicines management surrounding reconciliation of patient medicines on admission was not robust. At this inspection we found the 24-hour medicines reconciliation compliance rate had deteriorated to 58.5% in (December 2018) against a trust target of 80%.

However:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions between staff and patients.
  • On the majority of occasions, the urgent and emergency care service was meeting and performing better than the national performance standards. Patient flow within the department was effective.
  • Policies and procedures were based on relevant national guidance.
  • Within medical care and surgery services nurse staffing was managed using recognised tools and professional judgment.
  • Staff identified patients in medical care at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.
  • Managers at all levels in the emergency and medical care services had the right skills and abilities to run a service providing high-quality sustainable care.
  • In surgery the World Health Organisation safer surgery checks were embedded.
  • Pain was well controlled for patients and we observed good multidisciplinary working.
Inspection areas

Safe

Requires improvement

Updated 2 July 2019

Effective

Good

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:

  • The service had taken action to address the following concerns since our last inspection:
  • A planned 19 week refurbishment was underway on wards 9, 10 and 12. Ward 3 had been refurbished and the nurse and emergency call systems issue had been resolved as part of this programme.
  • Action had been taken to recruit additional pharmacy staff and pharmacy technicians to ensure consistency across wards.
  • Priority was given to staff when dispensing medication to promote safe effective practice.
  • We saw evidence on wards we visited that nurses checked controlled drugs in line with policy and audit practice confirmed consistent practice.

In addition;

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • To maintain safe nurse staffing levels, the service monitored staffing levels and reviewed these daily using nationally recognised tools alongside clinical judgment.
  • The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • 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.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff identified patients at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support to eat and drink when required.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed positive, kind and caring interactions on the day units and between staff and patients.
  • Patients we spoke to felt involved in their care and had been provided with information to allow them to make informed decisions.
  • The core service had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
  • The medical service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • The clinical centre had stable management structures in place, with clear lines of responsibility and accountability. We saw evidence of learning, continuous improvement and innovation within medical services at the location.

However:

  • Nursing and Medical staff training compliance for mandatory training failed to meet the trust target of 90%. Nursing staff achieved 10 out of 24 of their core standards whilst medical staff met two of their 20 core standards.
  • Medical staff failed to meet the trust target of 90% compliance with three of the five core standards in relation to safeguarding vulnerable adults training.
  • Nursing and medical staff training failed to meet the trust target of 90% for Mental Capacity and Deprivation of Liberty Safeguards training.
  • Medicines management surrounding reconciliation of patient medicines on admission was not robust.
  • Patient records were not securely stored on ward areas.
  • We lacked assurance of shared learning and actions taken surrounding a serious patient safety incident in the cardiac catheter laboratory including whether staff were adhering to hospital policy surrounding swab and needle checks.
  • The James Cook University Hospital had a higher than expected risk of readmission for elective admissions against the England average.
  • The service failed to meet the minimum standard in the 2017 Lung Cancer Audit for the proportion of patients seen by a Cancer Nurse Specialist.
  • The average length of stay for non-elective patients in geriatric medicine at James Cook University Hospital was longer than the England average.
  • One specialty was worse than the England average for RTT rates (percentage within 18 weeks) for admitted pathways within medicine.

Services for children & young people

Good

Updated 28 October 2016

We rated safe for children and young people as good because:

Staff ensured the ward environment and clinical areas were ‘child-friendly’, secure, clean and well maintained. Equipment was checked, labelled and safely stored.

Medicines and clinical records were stored securely. Documentation was good with each child and young person having an individualised plan of care.

The service had good local procedures to monitor changes in a child’s condition and arrangements with network colleagues to escalate care when a child deteriorated.

Staff followed trust mandatory training requirements. Managers were working to ensure all staff completed necessary training and to meet trust targets.

There had been an improvement in staffing levels in all paediatric areas since the inspection in December 2014. Additional recruitment was planned to re-enforce staffing in the neonatal unit to ensure compliance with national staffing guidelines. Staffing levels were managed appropriately to ensure they were safe.

Staff reported concerns and incidents where they felt this compromised a child’s safety and wellbeing. Outcomes and lessons learnt from investigations were shared with all staff.

Critical care

Requires improvement

Updated 2 July 2019

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

  • We were not assured that nurse staffing levels were always appropriate and in line with GPICS recommendations.
  • We had concerns over the number of infections and incidents related to patients not being able to be isolated.
  • We had concerns over the number of pressure ulcers reported in the service.
  • We had concerns over the management of patients needed critical care when capacity was a challenge.
  • Nursing and Medical staff training compliance for mandatory training failed to meet the trust target of 90%.
  • Medicines management surrounding the stock check and recording of controlled drugs did not follow trust policy in all areas.
  • We were concerned about the training and competence of nursing staff as we could not be provided with information on training for all areas.
  • The provision of specialist pharmacists and clinical educators was not in line with GPICS recommendations.
  • Policies and guidelines could not be seen on site as staff could not locate them.
  • There were significant challenges with access, flow and capacity within the units. The bed occupancy had been consistently higher than the England average.
  • The ICNARC data showed the number of out of hours discharges was higher when compared to similar units.
  • The risk register not was reflective of all the risks we saw and areas of concern identified from performance data.
  • We lacked assurance that the strategic aims had processes to monitor their implementation, and what progress was being made to deliver these.
  • We could not be assured that the corporate team understood the challenges to quality and sustainability.

However:

  • We saw good standards of record keeping in all areas visited.
  • Daily checks of emergency equipment were undertaken in all areas.
  • Patient outcomes, for the units that contributed to ICNARC, were in line with or better when compared to similar units.
  • We saw evidence of screening for delirium and the nutritional and hydration needs of patients were met.
  • Pain was well controlled for patients and we observed good multidisciplinary working.
  • Staff cared for patients with compassion. Feedback from the patients and relatives we were able to speak with was positive. We observed care and interactions which were kind and compassionate.
  • The service took account of patients’ individual needs and received a low number of complaints.
  • There was a clear focus of patient centred care and teamwork with systems in place to engage with patients and their relatives.
  • The number of non-clinical transfers were lower and/or comparable with similar units.

End of life care

Good

Updated 28 October 2016

We rated safe, effective and well-led for end of life care as good because:

The service had made significant improvements in audit and completion of DNACPR forms. Nutrition and hydration assessments were included in an individualised patient assessment tool for patients at the end of life.

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.

We saw clear, well-documented and individualised care of the dying documents. The referral process was clear and responsive and staff ensured that patient’s wishes were central to the care planning process.

However, although there was a clear vision for the service, which specialist palliative care staff had developed, the trust specific strategy for end of life care was in draft and under review and it was not clear when Board approval would be finalised.

The trust did not have an overall strategic lead for palliative care but this was identified as a future development. There was no action date to implement this role but the Board were keen to ensure that this happened.

Maternity and gynaecology

Good

Updated 10 June 2015

Overall, maternity services were good in all areas reviewed, with services rated as ‘outstanding' for being well-led. We observed exemplary practice in the care and treatment of women.

The service provided safe and effective care in accordance with recommended practices. Outcomes for women using the service were continuously monitored and, where improvements were required, action was taken.

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

Women’s individual needs 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 implemented action to improve the quality of care.

The maternity and gynaecology services were led by a highly committed, enthusiastic team, each 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 very strong engagement with patients and staff. There was evidence of innovation and a proactive approach to performance improvement.

Outpatients and diagnostic imaging

Good

Updated 28 October 2016

We rated safe for outpatients and diagnostic services as good because:

There had been improvements in all areas identified during the 2014 inspection. There were processes to ensure that resuscitation equipment was checked each day. Staff had enough personal protective equipment in all the areas and staff knew how to dispose of items safely and within guidelines.

There were sufficient staff of all specialties and grades to provide a good standard of care in the departments we visited.

There were processes to ensure medicines were managed safely. Practices were monitored and improvements made where required. Staff identified and responded appropriately to changing risks to patients, including deteriorating health and medical emergencies.

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 and well-led as requires improvement.
  • There were sufficient numbers of skilled medical and nursing staff to care for patients.
  • 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.
  • There was a positive incident reporting culture and staff received feedback following incident investigations.
  • Medicines were stored, prescribed and administered safely.
  • Trust policies were available for staff to access on the trust intranet. These reflected national evidence-based best practice and guidelines. The surgery service participated in numerous national audits to improve quality.
  • 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. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients with mental health conditions and those who lacked the capacity to make decisions about their care.
  • Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. We saw staff care for patients with compassion.
  • 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.
  • Staff, patients and relatives were supported by an advisor for learning disability and autism. We saw initiatives in place to improve the care of those living with a learning disability or dementia.
  • Governance metrics were presented as dashboards each month and displayed on model-ward boards, for all 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 services 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:

  • Numerous staff and doctors we spoke with felt senior managers above matron level were not visible, contactable or approachable. Staff 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 raised concerns that there were too many different surgical specialties located on ward 8 and this made it a stressful environment to work in. They told us they never felt ‘on top of the work’.
  • Some staff and doctors we spoke with told us there was a lack of anaesthetists, which meant they felt ‘stretched but not unsafe’. They explained this was because of a national shortage of anaesthetists.
  • The 90.0% mandatory training compliance target was not met for any of the mandatory training modules for which medical staff were eligible.
  • Although staff said they had enough equipment to carry out their role, some raised concerns that equipment nearing end of its life was unreliable and not always replaced promptly.
  • The quality of record keeping was not consistently high which meant we were not assured that staff always maintained accurate and contemporaneous records for all patients.
  • We were not assured that patient records on the wards were always stored securely and there was a risk of access to records by unauthorised persons, when unattended.

  • Consent was not routinely obtained in accordance with best practise, as a two-stage process.

Urgent and emergency services

Good

Updated 2 July 2019

Our overall rating of this service was good because:

  • Patients we spoke with were consistently positive about the care and experience they had received. Medical and nursing staff treated patients with dignity and respect; they supported patients and relatives who became distressed and understood the emotional impact an attendance in the emergency department had on the health and wellbeing of patients and relatives.
  • On the majority of occasions, the trust was meeting and performing better than the national performance standards.
  • Our observations of the emergency department showed patient flow was effective. Improved “front door” assessments including navigation had been implemented which supported timely, decision making.
  • 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 provided cover within the department 24 hours a day, seven days a week.
  • Staff applied safeguarding procedures for adults and children so that vulnerable people were protected from abuse.
  • Leadership in the department was stable and staff we spoke with felt supported by line managers and the senior management team.
  • The service had clear governance structures. Within the department we saw robust escalation systems in place and governance procedures to avoid overcrowding.
  • Policies and procedures were based on guidance from the Royal College of Emergency Medicine and the National Institute for health and care Excellence (NICE).
  • The service had systems in place for reporting, monitoring and learning from incidents. Staff we spoke with knew how to report incidents.

However:

  • We did not receive assurance that the current paediatric environment met the standards for children in emergency departments.
  • The designated mental health room did not meet the quality standards for liaison psychiatry services, it contained fixings and fittings which posed ligature and harm risks to patients, visitors and staff.
  • There were shortages of nursing staff within the department; these shortages were evident on the majority of shifts we reviewed.
  • We observed that patients were not routinely offered food and nutrition if required during their admission.
  • We did not receive assurance that the provision for major trauma within the centre was able to meet all requirements of the major trauma standards on a consistent basis; specifically, consultant cover on site.
  • Audit action plans we reviewed were not consistently completed, they did not all have actions identified or re-audit dates included to improve performance.
  • Mandatory training rates did not consistently meet the trust target of 90%.

Diagnostic imaging

Requires improvement

Updated 2 July 2019

We rated it this service as requires improvement because:

  • The service did not have enough radiologists which impacted on the service provision.
  • The service was below the trust’s compliance rate of 90% for mandatory training.
  • Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
  • Incidents were not always being reported or when incidents were reported the correct process was not always being followed. We saw a lack of evidence of the service monitoring trends and themes. There was limited learning from incidents.
  • There were limited provisions/support for patients who had additional/complex 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.
  • We saw no evidence to demonstrate engagement with patients who used the diagnostic and radiology services.

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.