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University Hospital of Hartlepool Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 February 2016

The University Hospital of Hartlepool is part of North Tees and Hartlepool NHS Foundation Trust and has 88 beds. It provides a wide range of diagnostic services, outpatient clinics, maternity services and day case and low risk surgery,

The trust gained foundation status in 2007. It has a workforce of approximately 4660 staff and serves a population of around 400,000 in Hartlepool, Stockton and parts of County Durham. The trust also provides services in a number of community facilities across the areas supported, including Peterlee Community Hospital and the One Life Centre, Hartlepool.

We inspected University Hospital Hartlepool as part of the comprehensive inspection of North Tees and Hartlepool NHS Foundation Trust and inspected University Hospital Hartlepool on 7-10 July and 29 July 2015.

Overall, we rated University Hospital Hartlepool as requires improvement. We rated it good for safe, caring and responsive, but it required improvement in providing effective and well-led care.

We rated surgical services, children’s and young people services and outpatient and diagnostic imaging services as good and medical care and maternity and gynaecology services as requires improvement.

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection. There was a dedicated infection control team to support staff and ensure policies and procedures were implemented and adhered to. We found that areas we visited were clean. On Holdforth Unit we saw that infection control procedures were not always being followed.
  • There were low rates of infection in the hospital, with no confirmed MRSA infections, two confirmed cases of Clostridium Difficile and one confirmed case of Escherichia Coli (E. Coli).
  • Patients were able to access suitable nutrition and hydration, including special diets and they reported that they were content with the quality and quantity of food.
  • There were staffing shortages with one ward unable to meet the safer staffing requirements. The trust used NHS Professionals or agency nurses to address the staffing requirements. We discussed this concern with the trust and we noted that beds had been closed on the ward to improve staffing ratios on our follow-up unannounced inspection.
  • We reviewed a significant number of policies on the intranet for medicine and maternity services that were out of date and required updating.
  • There were processes in place for the reporting of incidents and there was evidence of learning from incidents. However, governance processes were not fully developed or embedded and there were concerns in some areas regarding the maintenance and use of risk registers.
  • There were concerns regarding leadership of Holdforth Unit however the trust had addressed these concerns in part by the time of the unannounced inspection.

We saw several areas of good practice including:

  • The development of advanced nurse practitioners had enabled the hospital to respond to patients’ needs appropriately and mitigated difficulties in recruiting junior doctors.
  • The bariatric service had been developed as part of a consortium arrangement with neighbouring NHS trusts to ensure the local population had access to this service.
  • Staff had produced posters and delivered presentations at the International Society of Orthopaedic and Trauma Nursing international conference on the development of virtual fracture clinics and on the roles of speciality nurses.
  • The trust told us that a number of staff within the departments had completed modules on service improvement and that one current project was working to improve the staff engagement and sustainability in clinical supervision.
  • A project in conjunction with Hartlepool Council was initiated to improve health care for people living with learning disabilities. When a patient with learning disabilities was admitted to the hospital, an alert was generated and they were admitted to a virtual ward managed by the learning disabilities lead nurse. This ensured that the trust was able to respond to their needs in an appropriate and timely manner.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

  • Ensure there are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist.
  • Ensure staff follow trust policies and procedures for managing medicines, including controlled drugs.
  • Ensure that risk assessments are documented along with personal care and support needs and evidence that a capacity assessment has been carried out where required.
  • Ensure effective systems are in place which enable staff to assess, monitor and mitigate risks relating to the health, safety and welfare of people who use the service.
  • Ensure that all policies and procedures in the In-Hospital Care directorate are reviewed and brought up to date.
  • Ensure midwifery policies, guidelines and procedural documents are up to date and evidence based.
  • Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
  • Ensure that all annual reviews for midwives take place on a timely basis.
  • Ensure all staff attend the relevant resuscitation training.

In addition, the hospital should:

  • Ensure the processes and documentation used for appraisal of non-medical staff meets their personal development needs in children and young people services.
  • Ensure that formal drugs audits and stock checks are carried out regularly in outpatients.
  • Ensure that clinic planning, room utilisation and staffing is effectively managed and controlled for outpatient clinics including those hosted by the trust.
  • Ensure that established models of regular nursing clinical supervision are implemented for all staff involved in patient care.
  • Ensure that strategy and management plans regarding transforming the outpatients departments are communicated to all staff.
  • Have a competency based framework in place for all grades of midwives.
  • Have systems in place to achieve the nationally recommended ratio of 1:15 for supervision of midwives.
  • Indicate benchmark data on the maternity performance dashboard to measure performance.
  • Ensure the availability of a diabetes specialist midwife.
  • Provide simulation training to prevent the abduction of an infant.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 3 February 2016

Effective

Requires improvement

Updated 3 February 2016

Caring

Good

Updated 3 February 2016

Responsive

Good

Updated 3 February 2016

Well-led

Requires improvement

Updated 3 February 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 3 February 2016

Overall we rated the maternity services as requires improvement at University Hospital of Hartlepool. This was due to concerns in the areas of effective and well led. We rated safe and responsive as good and we were unable to rate services for caring as no patients were present at the time of our inspection.

We rated effective as requires improvement as there was no competency framework in place to support the development of band six midwives and this was a concern. Managers told us a competency based framework was under development and it was hoped this would be completed by September 2015. The recommended midwife to supervisor of midwives ratio was not being met. The recommendation is a ratio of 1:15 and at the time of inspection the ratio was 1:18. 27% of the trust midwifery staff had not received an annual review.

Guidelines that were out of date when we conducted the comprehensive inspection were updated by the time of the unannounced inspection; however, we were not assured that systems were in place to monitor and maintain this position. Referral times for termination of pregnancy and the full completion of the required documentation was an area for improvement. Plans had been put in place and required further audit to monitor and evidence progress.

We rated well-led as requires improvement as the maternity services risk register contained many generic risks and identifying risks specific to the services at Hartlepool was difficult. The lack of a rating system to measure performance on the maternity dashboard was also a concern. There were concerns about maternity leadership capacity as the senior operational role had a wide remit and was seen to be challenging. The midwifery management structure was flat with no additional support between the Head of Midwifery and the band seven midwives.

We found incident reporting was embedded within the service and noted examples of shared learning from incidents. Mandatory training participation rates were good and staff could articulate how they would manage safeguarding concerns.

We did find there was good local leadership and staff were engaged and committed to the service. Staff were not based in the birthing unit, but they were available when the unit needed to open and individual needs of patients were a focus. The environment was welcoming and efforts had been made to make it less clinical. Although we were unable to rate caring, the staff we spoke with were clearly dedicated and passionate about the care and services they provided.

Medical care (including older people’s care)

Requires improvement

Updated 3 February 2016

We rated the medical services provision at the University Hospital of Hartlepool as requires improvement. There was a lack of clarity around the purpose of Holdforth Unit and there were concerns about the leadership capacity, staffing levels, nursing standards and quality of care on the unit. Holdforth Unit was transferred from the In-Hospital Care directorate to the Out-of-Hospital Care directorate in May 2014. However there was confusion about where the unit sat in the hospital structure. The overarching plan for the unit was to become a nurse led community rehabilitation ward, but there was no evidence of progress towards this goal and the plans were not documented in the form of a strategy.

Incident reporting systems were embedded but there was also a lack of assurance on the effective management of the Out of Hospital care directorate risk register. Of 53 medical policies, 40 were out of date. Nursing staff were responsible for ensuring patients received their medicines in a timely and consistent way. On Holdforth Unit, we found there was a risk pain medicines might not be given at the correct intervals. Pain was well-managed on the medical rehabilitation day unit and in endoscopy.

There was no formal process for clinical supervision but 88% of staff had received an appraisal within the last 12 months. A multidisciplinary team met weekly to discuss the patients on Holdforth Unit but outcomes were not recorded in the patients’ health care record. At the time of our inspection the trust had no formal processes to audit mental capacity and best interests assessments. The trust operated a system of virtual wards. These were described as wards or groups of patients with similar characteristics. For example the dementia specialist nurse had a virtual ward of patients assigned of patients formally diagnosed with dementia and those patients who showed possible signs of dementia but with no formal diagnosis.

We spoke with 14 patients and seven relatives on Holdforth Unit who reported mixed experiences of the care they received; however the results of the NHS friends and family test for Holdforth Unit between April and June 2015 showed that 98% of patients would recommend the care they received; this is higher than the England average of 95%. The Staff and Patient Experience and Quality Standards (SPEQS) reports between April and June 2015 identified that 97% of the patients were happy with their experience. We observed an inconsistent approach to ensuring the call bells were within reach of patients.

The trust responded immediately to the concerns raised during inspection and developed an action plan to manage the identified risks. We went back to the unit unannounced to check that improvements had been made. There had been a change in ward leadership and measures were in place to improve the quality of care. For example beds had closed, staffing levels had improved and all Mental Capacity Act and Deprivation of Liberty Safeguards documentation had been audited. We were provided with assurance that the new unit leadership had introduced a system of “intentional rounding” to ensure patients’ needs were monitored effectively. The trust patient safety team planned to support the unit to audit compliance with this.

Staff on endoscopy and the medical rehabilitation day unit had a clear vision for their services and felt their managers were accessible. Staff we spoke with were aware of the corporate vision of the trust. We found the culture of care delivered by staff across all the medical services was open, dedicated, and compassionate and was strongly supported at divisional and war

Surgery

Good

Updated 3 February 2016

Overall we rated safe, effective, caring, responsive and well-led as good.

We observed patients being treated with compassion, dignity and respect throughout our inspection at this hospital. Patients commented positively on the dedication and professionalism of staff and the quality of care and treatment received. Staff were familiar with the process for reporting incidents using systems and staff confirmed themes from incidents were discussed to promote shared learning.

Care pathways were in use including enhanced recovery pathways and we saw all wards completed appropriate risk assessments. Risk assessments, care plans and test results were completed at appropriate times during a patient’s care and treatment. All wards used an early warning scoring system for the management of deteriorating patients. We looked at clinical records and observed that all patients had been consented appropriately. The development of the advanced nurse practitioner’s role had enabled patients to be consented in a timely manner.

We found that staffing levels were compliant with the required establishment and skill mix. Difficulties in the recruitment of junior doctors had been covered through the use of locum medical staffing and the development of advanced surgical care nurse practitioners and advanced trauma and emergency surgery nurse practitioners. Therapists worked closely with the nursing teams on the ward and daily handovers were carried out with members of the multidisciplinary team. The trauma and orthopaedics and surgery and urology directorates delivered consultant led seven day services.

The service was responsive to the needs of patients living with dementia and learning disabilities. A dedicated ‘Homeward’ team had been developed to ensure the arrangements for the discharge of patients was co-ordinated between all agencies and families. A pre-assessment meeting was held with the patient before the surgery date and any issues concerning discharge planning or other patient needs were discussed.

Senior managers had a clear vision and strategy for the division and staff were able to repeat this vision and discuss its meaning with us during individual interviews. Staff spoke positively about the service they provided for patients and emphasised quality and patient experience. We saw staff worked well together and there was respect between specialities and across disciplines. We saw examples of good team working on the wards between staff of different disciplines and grades.

Services for children & young people

Good

Updated 3 February 2016

Overall, we rated safe, effective, caring and responsive as good and well led as required improvement. The overall rating for the service was good.

The management team were committed to the vision and strategy for the children’s service and feedback from staff about the culture within the service, teamwork, staff support and morale was positive. However, systems and processes for risk management within the service were not effective and timely. We saw a number of high-level risks had been on the service’s joint risk register for up to nine years.

Staff received appropriate professional development, including an annual appraisal. However, the

documentation and format of the appraisal process for non-medical staff required further development

Processes and documentation relating to pain relief for children and young people required improvement; evidence showed systems and processes for pain management within the service were not well embedded. We found all clinical areas visibly clean, child-friendly and well maintained. Medicines and patient records were handled safely and there were sufficient numbers of suitably qualified staff to meet the needs of the children and young people using the service. Staff received appropriate training, which included training in safeguarding and manual handling.

There was good evidence of multidisciplinary working within and between teams and children and families using the service were provided with appropriate information. Consent procedures were in place and followed. Relatives we spoke with told us they were very happy with the care received. They said the staff were supportive and communication and involvement was good.

The children’s service was responsive to the individual needs of the children and young people who used it and there were effective systems and processes in place for dealing with complaints from people using the service.

Outpatients

Good

Updated 3 February 2016

Overall we rated the care and treatment received by patients in the University Hospital of Hartlepool outpatient and diagnostic imaging departments as good for safe, caring and responsive. We rated well-led as requires improvement. Patients were very happy with the care they received and found it to be caring and compassionate. Staff worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm because there were policies in place to make sure that any additional support needs were met. Staff were aware of these policies and how to follow them. However no nursing and midwifery registered staff or additional clinical services staff in women’s outpatients at University Hospital of Hartlepool had attended Level 2 or 3 safeguarding children training. The departments learned from complaints and incidents and put systems in place to avoid recurrences.

There were some areas that needed improvement within the outpatients department.  These included the systems in place for utilising clinic rooms effectively and communication of the departmental strategy to all levels of staff. The diagnostic imaging departments were well led, proactive and staff worked as a team across all sites towards continuous improvement for good patient care.

Other CQC inspections of services

Community & mental health inspection reports for University Hospital of Hartlepool can be found at North Tees and Hartlepool NHS Foundation Trust.