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University Hospital of North Tees Good

Reports


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.

Inspection carried out on 21 Nov to 21 Dec 2017

During a routine inspection

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 carried out on 7-10 and 29 July 2015

During a routine inspection

University Hospital North Tees provides acute care services for North Tees and Hartlepool NHS Foundation Trust. The hospital has 563 beds and provides urgent and emergency care services, critical care services, medical services, surgical services, maternity services, outpatient services and children and young people’s services.

The trust gained foundation status in 2007. It has a workforce of approximately 5500 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 North Tees as part of the comprehensive inspection of North Tees and Hartlepool NHS Foundation Trust, which included this hospital and community services. We inspected University Hospital North Tees on 7-10 July and 29 July 2015.

Overall, we rated University Hospital North Tees as requires improvement. We rated it as requires improvement for safe, effective and well-led services and good for caring and responsive services.

We rated emergency and urgent care, medical services and maternity and gynaecology services as requires improvement and surgery, end of life care, children and young people’s services and critical care as good.

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection. A dedicated infection control team to supported staff and ensured policies and procedures were implemented and adhered to. We found that areas we visited were clean. In the A&E department we saw that infection control procedures were not always being followed.
  • At the time of inspection, infection rates for methicillin resistant Staphylococcus aureus (MRSA) and Clostridium Difficile (C Difficile) were within an acceptable range for this size of hospital.
  • The trust had not met the A&E four hour target between January 2015 to March 2015 however performance had started to improve
  • Patients were able to access suitable nutrition and hydration, including special diets. We observed the use of red trays for at risk patients who required support with feeding and coloured plates and bowls for patients living with dementia. Patients reported the food provided during their stay was satisfactory and valued the opportunity to choose the size of their meal.
  • There were staffing shortages in some areas across both nursing and medical professions with some wards unable to meet the safer staffing requirements. The trust used agency nurses and locum doctors to address the staffing requirements.
  • There were processes for implementing and monitoring the use of evidence based guidelines and standards to meet the needs of differing patient groups across the hospital.
  • There were a significant number of policies on the intranet for medicine and maternity services that were out of date and required reviewing and revising.
  • There were processes in place for the reporting of incidents and there was learning from incidents; however the root cause analyses and related action plans lacked detail. Governance processes were not fully developed or embedded across the divisions and there were concerns in some areas regarding the maintenance and use of risk registers.
  • The trust was reported in July 2015 (Health and Social Care Information Centre) as among the 11 worst performing trusts in England for mortality performance. The trust had implemented actions to improve the trust position for both mortality indicators and been open to external scrutiny.
  • There was concern regarding leadership capacity within midwifery services and the impact that had on professional development and clinical standards.

We saw several areas of good practice including:

  • The development of advanced nurse practitioners had enabled the hospital to respond to patient needs appropriately and mitigated difficulties 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.
  • A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment.
  • The critical care team achieved a network award, which recognised excellent work in relation to “target” training. The team had also achieved recognition for their work related to critical care competencies, difficult airway and skills drills.
  • The critical care team achieved 58% for its consideration of patients for tissue donation. The team were the second highest achiever for corneal donations. Overall the team’s approach to tissue and organ donation was impressive, demonstrating a compassionate and sensitive approach to patients and relatives.
  • The paediatric and neonatal departments participated in a number of national and local research studies and were involved in a large number of clinical trials. The management team and several other staff told us the department had recently obtained a £3.5 million grant for an ‘OSCAR study.’ This study is for high frequency Oscillation in Acute Respiratory distress syndrome, comparing conventional positive pressure ventilation with high frequency oscillatory ventilation.
  • The neonatal unit had implemented the ‘Small Wonders’ initiative for premature babies; this was designed by the charity Best Beginnings. Small Wonders supports parents in their baby’s care in ways shown to improve health outcomes for their babies.
  • Staff in the maternity day assessment unit attended training on Gestation Related Optimal Weight (GROW) software which aims to reduce the number of stillbirths by using customised growth charts.
  • ‘NIPE Smart’ had recently been implemented within the maternity directorate. This is an information technology screening management system which has a robust system of capturing data on newborn and infant screening examinations with the aim of reducing the number of babies diagnosed with a medical congenital condition at a late stage.

  • Outpatient department staff produced posters and delivered presentations at the International Society of Orthopaedic and Trauma nurses on the development of virtual fracture clinics and on the roles of speciality nurses.
  • A number of staff within the outpatients department completed modules on service improvement including one current project to improve the staff engagement and sustainability in clinical supervision.
  • Staff worked on the development of health promotion packs within main outpatients to be rolled out within the orthopaedic department as a pilot to explore how this can be sustained.

  • The lead consultant radiologist for the specialist procedure known as CTPA (CT pulmonary angiography) presented the experiences of staff and patient outcomes to a panel at a major CT equipment manufacturer.

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

Importantly, the trust 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 medicines are stored according to storage requirements to maintain their efficacy in maternity services.
  • 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 pain in children and young people is assessed and managed effectively.
  • Ensure that the competency criteria for staff who are triaging patients are clearly documented and include recognised competency–based triage training.
  • Ensure that infection control procedures are followed in relation to hand hygiene and use of personal protective equipment.
  • Ensure that resuscitation and emergency equipment is checked on a daily basis in line with trust guidelines.
  • Ensure cleanliness standards are maintained.
  • 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.
  • Midwifery policies, guidelines and procedural documents must be 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 trust should:

  • Consider strengthening the senior nurse capacity in the A&E department.
  • Consider reviewing the system for documenting the follow-up of admitted head injury patients by the A&E department
  • Consider a system in A&E to enable patients with allergies to be recognised quickly and easily without the presence of medical records
  • Ensure that staff are following the correct procedure when dispensing medication using the Omnicell including checking the prescription at the time of dispensing.
  • Consider a continuous audit of all MCA and DoLs assessments and referrals and share lessons learned.
  • Consider assessing the access to the emergency resuscitation trolley on the haematology day unit.
  • Consider putting engaged notices on toilet doors to protect dignity if the door is kept unlocked for staff to gain access to vulnerable patients.
  • Send electronic communication to the patient’s GP on discharge from the critical care unit.
  • Ensure handover meetings are held in a private and confidential area in children’s services.
  • Ensure that all patient documentation remains confidential during patient visits to the outpatients department.
  • Ensure that all outpatient treatment rooms are cleaned before use.
  • Ensure that formal drugs audits and stock checks carried out regularly in outpatients.
  • Ensure that medicines are stored appropriately to ensure their quality is maintained.
  • Ensure that overall communication, outpatient clinic planning, room utilisation and staffing is formally managed and controlled, including clinics involving staff from other trusts.
  • Ensure that patients in the children’s outpatient department are afforded privacy when speaking with reception staff.
  • Update the risk assessment related to paediatric resuscitation in the children’s outpatient department.
  • Ensure that some clean and safe methods for entertaining or distracting children are provided within the diagnostic imaging department.
  • Ensure that staff adhere to the coding system for recording on medication charts
  • Ensure that staff fully adhere to infection control policies and close doors on side rooms where patients are being barrier nursed.
  • Ensure the processes and documentation used for appraisal of non-medical staff monitors their performance and meets their personal development needs.
  • Review the process for storage of post-transfusion blood bags while retained on ward areas.
  • Review whether documentation for patients living with dementia are completed and comprehensive.
  • Ensure that within outpatient services, action plans from audits, risk registers and meetings are maintained, regularly revisited and amended to show where actions have been completed or remain outstanding.
  • Ensure that established models of regular nursing clinical supervision are implemented for all staff involved in patient care in outpatient services.
  • Ensure that patients and staff are informed if clinics are cancelled, including those involving clinicians and staff from other trusts.
  • Ensure that strategy and management plans regarding transforming the outpatients departments are communicated to all staff.
  • Consider recording decision made at the evening medical ward rounds on the critical care unit.
  • Consider how the critical outreach service will be maintained.
  • Review the recruitment of medical staff, particularly junior doctors in the surgical unit.
  • File maternity healthcare documentation according to the trust records management policy to avoid loss or misplacement of information
  • Indicate benchmark data on the maternity performance dashboard to measure performance.
  • Ensure that ‘fresh eyes’ checks are recorded when undertaken.
  • Review the senior midwifery structure and experience resource to ensure that all the midwifery roles needed for coordination and oversight of each service are appropriately covered.
  • Monitor and internally report the level of provision of 1:1 maternity care
  • Hold staff handovers in maternity services in an environment that reduces the possibility of distraction and interruption.
  • 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.
  • Consider safety briefings as part of daily communication with staff in maternity services.
  • Include describing the reporting arrangements for Supervisors of Midwives following investigations, audits or reviews in the maternity services risk management strategy.
  • Provide simulation training exercises to prevent the abduction of an infant

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 12 February 2013

During a routine inspection

The focus for the inspection was to look at the patient journey in several clinical areas; this included children’s health, maternity care and women's health. We looked at information at a Trust level as well as at ward level. We spent time observing practice and interactions between staff and patients. We spoke with different disciplines of staff. We looked at the patient’s hospital records for sixteen people and spoke with a number of patients and a number of relatives.

We found that patients were aware of their treatment options and plans and felt that they had been fully consulted and involved. One patient said, "I have been kept well informed and have felt safe with the care provided, all the options have been fully discussed and they have kept me monitored." One child said “The nurses are happy and I like the doctors”. We saw that their care and treatment was planned and delivered in a way that ensured patients safety and welfare.

All of the wards/clinical areas visited were clean and well maintained and there were systems in place to monitor this. One patient said, "It is clean and warm and has been made as pleasant as possible for me." Others said they felt safe and comfortable.

We found good systems in place for monitoring staffing levels and skill mix. One patient spoken with said, “They have been attentive, I was in a lot of pain, I used the buzzer and they responded quickly." Patients spoken with were very satisfied with the care provided.

Inspection carried out on 23 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 17 November 2011

During an inspection in response to concerns

We visited six different clinical areas at the University Hospital of North Tees. These were the accident and emergency department (A&E), the emergency assessment unit (EAU), two surgical wards and two wards providing care to older people. We spoke with a number of people who had received treatment and care within all six clinical areas. We also spoke with a number of staff during the two day inspection. This was staff of different clinical levels and grades within the organisation. We examined care records and observed care being provided to people.

Overall, we found people were treated with dignity and respect. We identified minor concerns, which were addressed immediately by the trust. People that we spoke with told us that they felt their privacy and dignity was respected and that staff had spent time discussing their care, treatment and support. We saw evidence that reflected this in the daily notes, where we could see that people had been given individual time to consider their choices in relation to pain relief and possible treatment options available.

Another person told us they had been admitted the day before via the accident and emergency (A&E) department and they felt they had been treated with dignity and respect. All staff were described as having been very professional. One person described how the doctor in A&E had discussed various treatment options with them before agreeing the appropriate care.

A person, who was on one of the surgical/orthopaedic wards, said, “I signed consent to an epidural then changed my mind. I decided to give painkillers a try. I didn’t understand the procedure, but then the nurse explained it so I have now agreed”. Another person said, “The surgeon came up and spoke to me about the procedure following surgery. He has told me about my other options. The quality of care has been consistent, not sure what time I am being discharged, just waiting for a letter for my GP”.

Another person said, "The care has been very good and I have been fully involved". This person said that no aspect of their care or treatment had been missed or forgotten.

One person said, “Staff here are excellent, they answer buzzers quickly, I am not aware of named nurses but if you shout they come and help you. The quality of care is the same day or night, there’s no prejudice there”.

Another person said, “Staff appear to be well trained, they can tell me what medicines I am on and what it’s for. The overall experience here has been excellent, no complaints at all”.

A further person said, "They always seem to be on the go but always available to give you care and support".