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University Hospital of North Tees Good

Inspection Summary


Overall summary & rating

Good

Updated 14 March 2018

Our rating of services improved. We rated it them as good because;

  • We rated safe, effective, caring, and responsive as good. We rated well led as requires improvement. The services we inspected in 2017 were rated good in the well led domain; however we did not inspect two services which had previously been rated as requires improvement. This made the rating for well led at core service level as requires improvement.

In urgent and emergency care;

  • A system had been put in place to ensure that patients had an initial assessment on arrival to the department within 15 minutes by nurses who had undergone triage training.
  • Infection control procedures were followed in relation to hand hygiene and use of personal protective equipment. Cleanliness standards were maintained
  • Resuscitation and emergency equipment was checked on a daily basis in line with trust guidelines.
  • Policies and procedures online were reviewed and up to date.
  • There were outstanding examples of caring, compassionate care and maintaining privacy and dignity. We saw staff go the extra mile several times and their care and support exceeded good care standards. The caring relationships were highly valued by staff and promoted by the matron. There was a strong, visible person-centred culture.
  • Patients and families were involved in the decision making on their care in a way that they understood.
  • Services were planned in a way to meet the individual’s needs.
  • Patients with a learning disability, those living with dementia, and bariatric patients could access emergency services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined up way from within the department.
  • There was a sense of teamwork within the department and operational staff worked together in partnership to provide effective leadership.

In medical care;

  • Incidents were investigated and managed appropriately and there was evidence of learning from incidents. Medicines were managed appropriately across medicine. The number of temporary staff used had reduced overall and bank staff were managed appropriately though the internal system.
  • Medicine and elderly care participated in a wide range of local and national audits. There was clear multi-disciplinary team working across the services between different teams and wards had regular morning huddles.
  • Overall, staff knowledge and understanding of the mental capacity act, deprivation of liberty standards was good. There was good access to a psychiatric liaison team across medicine.
  • Staff cared for patients with compassion and treated them with dignity and respect.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medicine has been consistently above the England average for the entire reporting period from August 2016 to July 2017.
  • Overall, morale across the service was generally good and staff described good teamwork across the wards and services. A risk register was in place and senior staff attended weekly patient safety meetings.

In Maternity;

  • Women and their families were protected from avoidable harm and abuse. There were effective systems in place to report, investigate and share the learning from incidents. The content of obstetric mandatory training was continually monitored and adapted according to themes arriving from incidents. Midwifery and medical staff training compliance was better than the national recommendations despite there being a high rate of maternity leave within midwifery.
  • Women had good outcomes because they received effective evidence based care and treatment, which met their needs. The service had systems in place to ensure that staff had the right skills, knowledge and experiences to provide effective care and treatment. Women and their families were supported to live healthier lives.
  • Women and their families were supported and treated with dignity and respect; we found they were active partners in their care. We observed staff treat women and their families with kindness, respect and compassion.
  • Services were tailored to meet the needs of individual women and their families and were delivered in such a way, which ensured flexibility, choice and continuity of care.
  • The leadership, governance and culture within the service promoted the delivery of high quality person-centred care.

However:

In urgent and emergency care;

  • There were risks in the emergency department to patients with mental health needs. There was no designated mental health assessment suite or facilities that met best practice guidance for a safe metal health assessment room. There were ligature points which meant the area was not fully complaint with The Psychiatric Liaison Accreditation Network (PLAN) standards.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and the department needed to improve compliance with mandatory training. The department also needed to improve compliance with appraisal rates.
  • The department didn’t always have sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner. The department should ensure contingency planning to accommodate future maternity leave of RSCNs
  • National audit results were poor and the department was not meeting most of the standards. Further work was needed through local audit to ensure that audit compliance improved.
  • The trust was worse than the England average for unplanned re-attendance.
  • Complaints were not always managed in line with the trust’s policy timescales.
  • Senior nursing leadership was not visible in the department during our inspection and didn’t attend the department to support their staff during our inspection.

In medical care;

  • The hospital was not meeting the internal target for mandatory training across several areas. At the time of inspection, the trust was not able to accurately monitor mandatory training compliance due to administration difficulties and a delay in electronic data capture.
  • Safeguarding training was not routinely available to staff who required it and was not in line with the intercollegiate document for Safeguarding children and young people (2014).
  • Appraisals compliance rates were not achieving the trust target of 90% during our inspection. Clinical supervision was not embedded across all wards visited.
  • Mental capacity act assessments and deprivation of liberty safeguards documentation was not always fully completed or consistent.
  • The trust took an average of 46 days to investigate and close complaints; this was not with the complaints policy, which stated complaints should be completed with 25 days or 40 days for more complex complaints.

In maternity;

  • We found some out of date equipment, we raised this with staff and immediate action was taken to remove them from circulation.
  • Data provided by the trust showed compliance with trust mandatory training was below the required level. Medical staff met 62% of their required training; however, midwifery staff met 48% of their required training.
  • Data provided by the trust showed that midwifery staff had not met the required target of safeguarding children level three and safeguarding adults level one training.
Inspection areas

Safe

Good

Updated 14 March 2018

Effective

Good

Updated 14 March 2018

Caring

Good

Updated 14 March 2018

Responsive

Good

Updated 14 March 2018

Well-led

Requires improvement

Updated 14 March 2018

Checks on specific services

Critical care

Good

Updated 3 February 2016

We found critical care services to be good for safe, effective, caring, responsive and well-led.

There was a real commitment to work as a multidisciplinary team delivering a patient centred and high quality service. Patients were at the centre of the service and high quality care was a priority for staff. There was a good track record on safety with lessons learned and improvements made when things went wrong. Staff knew how to report incidents. The environment was clean but there was a lack of space due to the position of the unit within the hospital. The service had recently put in place a Critical Care Outreach Team (CCOT) to identify and monitor the deteriorating patient. The purpose of this service was to assess the critically ill or deteriorating patient on wards and to stabilise the patient at ward level and so avoid the need to escalate to the unit.

Medical and nursing staffing levels were adequate and there was evidence of a cohesive team working approach to patient care. The unit was staffed according to the Core Standards for Intensive Care Units and nursing and support staff provided flexibility within the department to provide the level of care that met patients’ care needs.

Patients received treatment and care according to national guidelines and the service used an audit programme to check whether their practice was up to date and based on sound evidence. The service was obtaining good-quality outcomes as evidenced by its Intensive Care National Audit and Research Centre (ICNARC) data. We found there was good multidisciplinary team working across the service.

There was a clear open, transparent culture which had been established with the new leadership team. Staff felt valued and supported by their managers and received the appropriate training and supervision to enable them to meet patients’ individual needs. Both medical and nursing staff we spoke with were passionate about providing a holistic and multidisciplinary approach to assessing, planning and treating patients. This was demonstrated by regular multidisciplinary meetings and excellent communication with the patients and relatives.

We observed individualised care and attention to detail given to patients and relatives evidenced by their work with the end of life team, care of patients with learning disabilities and implementation and consideration of the Deprivation of Liberty Standards (DoLS)

Outpatients and diagnostic imaging

Good

Updated 3 February 2016

Overall the care and treatment received by patients in the University Hospital of North Tees outpatient and diagnostic imaging departments was safe, caring and responsive. 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. The departments learned from complaints and incidents and put systems in place to avoid recurrences.

Senior managers were familiar with the trust’s vision for the future of the outpatients department and were aware of the risks and challenges. However staff told us they felt the service was fragmented and changes to meet current and future departmental needs could not be considered because there was no clear departmental strategy following a pause in plans for a new hospital at Stockton. It was not always possible to see from the risk register which risks had been managed and which were still waiting to be actioned. The diagnostic imaging department had good leadership and management and staff told us they were kept informed and involved in strategic working and plans for the future.

Urgent and emergency services

Good

Updated 14 March 2018

Our rating of this service improved. We rated it as good because:

  • We rated caring as outstanding. We rated safe, responsive and well led as good. We rated effective as requires improvement.
  • A system had been put in place to ensure that patients had an initial assessment on arrival to the department within 15 minutes by nurses who had undergone triage training.
  • Infection control procedures were followed in relation to hand hygiene and use of personal protective equipment. Cleanliness standards were maintained
  • Resuscitation and emergency equipment was checked on a daily basis in line with trust guidelines.
  • Policies and procedures online were reviewed and up to date.
  • There were outstanding examples of caring, compassionate care and maintaining privacy and dignity. We saw staff go the extra mile several times and their care and support exceeded good care standards. The caring relationships were highly valued by staff and promoted by the matron. There was a strong, visible person-centred culture.
  • Patients and families were involved in the decision making on their care in a way that they understood.
  • Services were planned in a way to meet the individual’s needs.
  • Patients with a learning disability, those living with dementia, and bariatric patients could access emergency services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined up way from within the department.
  • There was a sense of teamwork within the department and operational staff worked together in partnership to provide effective leadership.

However:

  • The emergency department did not have a designated mental health assessment suite or facilities that met best practice guidance for a safe metal health assessment room. Staff assessed patients who presented at the accident and emergency department in rooms that had ligature points. The accident and emergency department did not have environmental risk assessments that included ligature risks. Staff did not routinely carry personal alarms and the quiet area did not have an alarm system.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and the department needed to improve compliance with mandatory training. The department also needed to improve compliance with appraisal rates in the department.
  • The department didn’t always have sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
  • National audit results were poor and the department was not meeting most of the standards. Further work was needed through local audit to ensure that audit compliance improved.
  • The trust was worse than the England average for unplanned re-attendance.
  • Complaints were not always managed in line with the trust’s policy timescales.
  • Senior nursing leadership was not visible in the department during our inspection and didn’t attend the department to support staff during our inspection.

Maternity

Good

Updated 14 March 2018

Our overall rating of this service improved. We rated it as good because:

  • Women and their families were protected from avoidable harm and abuse. There were effective systems in place to report, investigate and share the learning from incidents. The content of obstetric mandatory training was continually monitored and adapted according to themes arriving from incidents. Midwifery and medical staff training compliance was better than the national recommendations despite there being a high rate of maternity leave within midwifery.
  • Women had good outcomes because they received effective evidence based care and treatment, which met their needs. The service has systems in place to ensure that staff had the right skills, knowledge and experiences to provide effective care and treatment. Women and their families were supported to live healthier lives.
  • Women and their families were supported and treated with dignity and respect; we found they were active partners in their care. We observed staff treat women and their families with kindness, respect and compassion.
  • Services were tailored to meet the needs of individual women and their families and were delivered in such a way, which ensured flexibility, choice and continuity of care.
  • The leadership, governance and culture within the service promoted the delivery of high quality person-centred care.

However:

  • We found out of date equipment available for use additionally we found some concerns with cleanliness in some areas of the service, once this was highlighted with staff immediate action was taken.
  • Data provided suggested that attendance at Trust mandatory training for both midwifery and medical staff, attendance of midwifery staff at safeguarding level three was below the target.
  • The appraisal rate for both medical and midwifery staff was below the trust target.
  • A new leadership structure had been implemented just prior to our inspection; we were concerned with the capacity of the deputy head of midwifery to undertake a dual role.

Maternity and gynaecology

Requires improvement

Updated 3 February 2016

Overall the maternity and gynaecology services at University Hospital North Tees were rated as requires improvement; this was due to concerns in the areas of safe, effective and well-led. We found the service to be caring and responsive and rated these as good.

We lacked assurance around the consistent checking of emergency equipment and full completion and management of patient records in maternity services. We observed a staff handover on the delivery suite that was not comprehensive or inclusive of matters relating potential safety issues. We also had concerns about staffing and skills mix on the maternity unit.

The lack of a competency framework for midwives, out of date guidelines and the failure to achieve the recommended midwife to supervisor ratio led us to a rating of requires improvement for effective. Although we were informed the out of date guidelines had been updated on our return visit, we lacked assurance that the guidelines and learning from serious incidents were embedded with all staff.

Although some areas were well-led overall, the current risk register did not give assurance that risk within the department was being managed appropriately. The staff we spoke with and observed in practice were compassionate and patient focused and patients were very happy with the care they received.

Medical care (including older people’s care)

Good

Updated 14 March 2018

Our overall rating of this service improved. We rated it as good because:

  • Incidents were investigated and managed appropriately and there was evidence of learning from incidents. There were no Never Events reported between the period of September 2016 and August 2017. Medicines were managed appropriately across medicine and the directorate was working towards the corporate infection control strategy. The number of temporary staff used within the medical directorate had reduced overall and bank staff were managed appropriately though the internal system.
  • Medicine and elderly care participated in different local and national audits. Pain assessments scores were in use on wards visited and nutrition and hydration tools were used such as the malnutrition screening tool. There was clear multi-disciplinary team working across the services between different teams and wards had regular morning huddles.
  • Overall, staff knowledge and understanding of the mental capacity act, deprivation of liberty standards was good. There was access to a psychiatric liaison team across medicine.
  • Staff cared for patients with compassion and treated them with dignity and respect. Patient feedback about services was generally positive and patients told us they felt involved in their care and treatment.
  • Senior managers we spoke with were able to describe how they planned for services. The trust’s referral to treatment time (RTT) for admitted pathways for medicine has been consistently above the England average for the entire reporting period from August 2016 to July 2017.
  • Overall, morale across the service was generally good and staff described good teamwork across the wards and services. A risk register was in place and senior staff attended weekly patient safety meetings. Matrons held regular drop in sessions to enable families and carers to provide feedback to senior staff about the services.

However:

  • The hospital was not meeting the internal target for mandatory training across several areas. At the time of inspection, the trust was not able to accurately monitor mandatory training compliance due to administration difficulties and a delay in electronic data capture.
  • Staff in the endoscopy unit who required level 3 children’s safeguarding training had not completed the training. this was not in line with the Intercollegiate Safeguarding Children and Young People guidance (2014)
  • Appraisals compliance rates were not achieving the trust target of 95% during our inspection. Clinical supervision was not embedded across all wards visited.
  • Mental capacity act assessments and deprivation of liberty safeguards documentation was not always fully completed or consistent.
  • The trust took an average of 46 days to investigate and close complaints, this is not with their complaints policy, which states complaints should be completed with 25 days or 40 days for more complex complaints.

Surgery

Good

Updated 3 February 2016

We rated surgery services to be good for safe, effective, caring, responsive and well-led.

Staff were aware and familiar with the process for reporting and investigating incidents using the trust’s reporting system. Staff told us feedback on reported incidents was given and felt they were appropriately supported. A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment. Care records showed risk assessments were being appropriately completed for all patients on admission to the hospital. Infection control information was visible in all ward and patient areas. Monthly cleanliness audits were undertaken and results were displayed through the Nursing Dashboard in ward areas.

Staffing levels for wards were calculated using a recognised tool and trust ‘template’. We reviewed the nurse staffing levels on all wards visited and within theatres and found that levels were compliant with the required establishment and skill mix. We reviewed patient records and saw medical patients had been placed on surgical wards (‘boarders’) when beds were not available on medical wards. Although medical ‘boarders’ were under the care of medical clinicians, surgical staff told us they did not feel able to provide the same level of care to medical patients.

We observed patients being treated with compassion, dignity and respect throughout our inspection at this hospital. We saw ward managers and matrons were available on the wards so that relatives and patients could speak with them. We saw information leaflets and posters available for patients explaining their procedure and after care arrangements. Patients were able to access counselling services and the mental health team. Therapists worked closely with the nursing teams on the wards and staff told us they had good access to physiotherapists, occupational therapists and speech and language therapists.

The service was responsive to the needs of patients living with dementia and learning disabilities. All wards had dementia champions as well as a learning disability liaison nurse. There was access to an independent mental capacity advocate (IMCA) for when best interest decision meetings were required. Complaints were handled in line with the trust policy and were discussed at monthly staff meetings where training needs and learning was identified as appropriate.

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. Joint clinical governance and directorate meetings were held each month. The directorate risk register was updated following these meetings and we saw that action plans were monitored across the division. Records for 2014 showed that staff across all wards in surgery and theatres had received an appraisal or had an appraisal planned. Staff said speciality managers were available, visible within the division and approachable; leadership of the service was good.

Services for children & young people

Good

Updated 3 February 2016

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

Staff knew how to report incidents and these were followed up appropriately. Lessons learned were shared and preventive measures put in place. Staff of all grades confirmed they received appropriate mandatory training to enable them to carry out their roles effectively and safely; training included awareness of safeguarding procedures. There were sufficient well-trained and competent nursing and medical staff to ensure children and young people were treated safely. There were some gaps in the medical staffing establishment; however, several new doctors were due to start in post. Children and young people did not always have access to appropriate pain relief as and when required, there was no evidence of the use of pain assessment tools in the care records reviewed.

Children, young people, and their families told us they received supportive care. They said the staff were kind and provided them with compassionate care and emotional support. They also felt well informed and involved. Staff and families both told us they would recommend the service to their families and friends and feedback from surveys carried out by the children’s service was all positive.

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. 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. The need to improve risk register management was known by the trust board and a plan was in place but not yet implemented. The risk register was not regularly reviewed at the patient safety and risk management meetings and risks were not actively managed by using the risk register. There was no resuscitation trolley in the children’s outpatient department. Staff were able to describe the procedure they would follow but the trust response to mitigate this risk was not clearly documented in the risk assessment or on the risk register and both documents required updating.

End of life care

Good

Updated 3 February 2016

We rated End of Life Care services as good. Patients were provided with an end of life care service that was safe and caring. We found the specialist palliative care team, mortuary and chaplaincy team were effective, responsive and well led and delivered safe and caring services. The local teams were very responsive to patient requests with evidence of end of life patients able to be discharged under the trust’s Fast Track Rapid Discharge process. We saw good links with the community services, General Practitioners and care and nursing homes within the trust’s geographical area.

The service provided good and effective person-centred care to patients through support of patients and their families, for example, the introduction of the Family Voice project. The Family’s Voice is a diary given to relatives or friends of dying patients inviting them to be a part of care planning. By use of the diary relatives are invited to assess if the care provided by the ward achieves the expected standard. The Family Voice project and its outcomes were now being disseminated to trusts nationwide.

The staff throughout the hospital knew how to make referrals and people were appropriately referred to and assessed by the specialist palliative care team in a timely fashion, therefore individual needs were met. The hospital’s new integrated technology system had improved efficiency within the specialist palliative care team and given staff better access to patient information.

The mortuary was clean and well-maintained; infection control risks were managed with clear reporting procedures in place. Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care. An out-of-hours system was in place for hospital staff community colleagues to access appropriate equipment, for example, syringe drivers. The chaplaincy and bereavement service supported families’ emotional needs when patients were at the end of life and continued to provide support to families afterwards.

Other CQC inspections of services

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