You are here

Hull Royal Infirmary Requires improvement

We are carrying out checks at Hull Royal Infirmary using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 June 2018

Our rating of services stayed the same. We rated them as requires improvement because:

  • We rated safe and responsive as requires improvement and effective, caring and well led as good.
  • We rated one of the hospital’s eight services as requires improvement and seven as good.
  • The rating of medical care and surgery improved from our last inspection.
  • There was a lack of pace in addressing some of the issues from the last inspection, for example, management of the deteriorating patient in medical care and the effective use of the five steps to safer surgery processes.
  • The trust had undertaken work towards improving the compliance with recording of patient’s National Early Warning Score (NEWS). However we found there were still concerns with the escalation of NEWS score in line with the trust’s policy. Nursing staff used their own clinical judgement as to when to escalate a patient’s NEWS score which was not in line with the trust’s policy.
  • At this inspection it was apparent the five steps to safer surgery checklist was still not embedded as a routine part of the surgical pathway. The trust had reported three never events associated with wrong site surgery or the wrong prosthesis being inserted. We could therefore not be assured that the checklist was being used correctly and consistently.
  • The trust did not always meet referral to treatment indicators. We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas. In addition to this the trust declared a serious incident related to a trust wide tracking issue within the electronic database. This resulted in a number of patients being lost to follow up.
  • Patients’ records were not always stored securely or in an organised manner. There was a risk that staff may not have access to the information they needed to deliver patient care and that the public could access patients’ confidential records.
  • The trust did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles to provide cover and mitigate some of the risk. However, despite the shortage of registered nurses in particular, the trust managed staffing well and had a robust escalation and review process.

However:

  • Staff were encouraged and knew how to report incidents. We saw evidence from actions plans and root cause analysis that serious incidents were identified and investigated appropriately.
  • The trust provided care based on evidence based practice and national guidance. Services reviewed the effectiveness of care through national and local reviews and implemented any findings. We saw improvements in how the trust reviewed effectiveness of the care, through monitoring and auditing compliance with nine fundamental standards.
  • Staff cared for patients with care and compassion and respected patient’s wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment. They provided patients with emotional support to minimise their distress.
  • Patient’s individual needs were met. Systems were in place for identifying patients living with dementia and learning difficulties and to support them through their hospital stay.
  • Staff morale was good and teams worked well together and supported each other. Managers were proud of their staff and success was celebrated through local and trust wide events.
Inspection areas

Safe

Requires improvement

Updated 1 June 2018

Effective

Good

Updated 1 June 2018

Caring

Good

Updated 1 June 2018

Responsive

Requires improvement

Updated 1 June 2018

Well-led

Good

Updated 1 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 15 February 2017

At the inspection in 2015 we rated outpatients and diagnostic imaging services as ‘Good’ overall. The effective domain was inspected but not rated. This was because we are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging. In 2016 we rated the services overall as ‘Requires improvement’ because.

  • The trust was not meeting the national referral to treatment (RTT) standards for incomplete pathways. This meant patients were not always able to access outpatient services when they needed to. There were appointment backlogs and waiting lists in the majority of outpatient specialties, which totalled over 30,000 patient episodes at the time of the inspection.
  • A cluster of eight serious incidents had been declared in Outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients, including deaths. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
  • In radiology, there had been two never events involving wrong site/side surgery since the 2015 inspection and a previous never event in March 2015.
  • One of the issues identified at the last inspection was the inconsistent use of safety checklists when carrying out day surgery in outpatients and interventional radiology procedures. We found there was still inconsistency in the use of safety checklists across different specialties, and this was not being audited.
  • The numbers of suitably qualified and experienced staff were insufficient in some areas at the last inspection, notably histopathology consultants and echo cardiographers. At this inspection, we found staffing for these two groups had improved, although there were still vacancies. However, we found high levels of vacancies in some outpatient specialties, and in radiology, there were five vacant radiologist posts and a significant proportion of radiographer vacancies in general x-ray.
  • The facilities and premises used to deliver services were of variable quality. Some outpatient clinics were short of space, and some clinical areas located in the main building were in need of refurbishment and repair.
  • We found there was a high number (166) of complaints about outpatients; 26% of the complaints received by the trust in the previous financial year related to outpatients. Patient care was the main category of complaint received. Radiology had received eight complaints in the same period and pathology none.
  • There was inconsistency in the governance and management oversight in outpatients due to the clinics being split across the four Health Groups. The trust had recognised this and it was being addressed with a weekly Performance and Access (PandA) group, which reviewed all waiting lists, by speciality and an ‘outpatient transformation project’, which was running behind schedule. This project was to improve clinic utilisation, booking processes and performance against national standards. We were also told that an overarching management post was to be developed.

However,

  • The trust was working with local commissioners on capacity and demand planning and had agreed local trajectories in order to move towards achieving the national target of 92% for the 18-week incomplete pathway. Standard operating procedures and clinical validation had been agreed in early June 2016 and was ongoing at the time of the inspection. Weekly performance meetings reviewed the backlog and the individual Health Groups were taking action.
  • At the last inspection, patients undergoing hysteroscopy within gynaecology outpatients were not completing consent forms. We found these patients were now completing consent forms as required.
  • Outpatients and radiology had increased their capacity by running clinics out of hours and at the weekends, to cope with the increased demand and to make sure patients had their appointments in a timely manner.
  • Staff providing care and treatment to people in outpatients and radiology were very caring. Patients gave positive feedback about the care they received, and staff treated patients with dignity and respect.
  • Service planning and delivery accommodated the individual needs of people with additional needs or disabilities in the majority of the areas we visited. For example, there was additional support for patients with learning needs, dementia, hearing deficiencies or those who needed an interpreter.
  • Risks recorded within the Health Groups’ risk registers reflected the main concerns. There was no overarching risk register for outpatients which meant there was a lack of cohesive oversight, and limited evidence of outpatient audits and quality monitoring.
  • Leadership, governance and continuous quality improvement in radiology and pathology was well established. There were robust processes for risk management and quality monitoring and both departments were accredited. Radiology was partway through a five-year equipment replacement programme, all of the computerised radiology (CR) equipment was being replaced with digital radiology (DR) equipment. The department had enough CR equipment to maintain the service while refurbishments (retrofits) were being carried out.
  • The trust had effectively managed a serious incident that had been declared by Radiology in December 2015 regarding 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents being declared by the time of the inspection. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
  • Staff and managers in radiology had a clear vision and strategy for future developments within the department and were aware of the risks and challenges they faced. The trust had effectively managed a serious incident that had been declared by Radiology in December 2015 regarding 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents being declared by the time of the inspection. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
  • Staff and managers in Radiology had a clear vision and strategy for future developments within the department and were aware of the risks and challenges they faced.

Maternity

Good

Updated 1 June 2018

  • There was a senior leadership team in the maternity service covering business, midwifery and clinical leadership. We found that this team was cohesive and promoted a positive culture in the service.
  • Staff were encouraged and knew how to report incidents. We saw evidence from actions plans and root cause analysis that serious incidents were identified and investigated appropriately.
  • Completion of the World Health Organisation surgical safety checklist was monitored and regularly met trust targets.
  • Recruitment of midwifery and medical staff had improved with a good number of applications for posts.
  • Changes in practice were based on national guidelines and best practice and audited to ensure they were embedded throughout the team.
  • Patient outcomes were mostly in line with national averages when compared to similar services.
  • A full seven day service was provided.
  • Women we spoke to all felt involved in their care and had been provided with information to allow them to make informed decisions.
  • Staff were compassionate and caring and there were counselling and bereavement services available in the unit when required.
  • The trust served a community with a wide range of needs and there were good systems in place to ensure effective communication.

However:

  • The number of elective caesarean sections carried out was worse than the England average and the trust had been identified as an outlier for this data.
  • Staff had identified opportunities to improve patient pathways and flow through departments, although these were not yet implemented.

Outpatients

Good

Updated 1 June 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated the service as good because:

  • The previous inspection identified a lack of effective governance processes within outpatients. At this inspection we saw the trust had strengthened these processes by introducing performance reports, performance and access meetings and a trustwide outpatients governance committee.
  • The majority of staff we spoke with knew how to report incidents and about learning lessons from incidents within the individual health groups.
  • All staff we spoke with felt positive about the new management changes and the future of outpatients.
  • Some work had been undertaken to look at staff skills and develop training specific to the needs of individual staff.
  • Most patients we spoke with told us that staff were caring and friendly.
  • Complaints were investigated thoroughly and in a timely manner.
  • Mandatory training compliance figures were high.

However:

  • The previous inspection identified that the trust must ensure the effective use and auditing of best practice. We saw inconsistent completion of safety checklists when carrying out surgery in outpatients and no audit activity to review this or drive improvement.
  • Some problems with the storage of patient records remained. Patient records were not always stored securely in some clinics visited.
  • The trust was not meetings its internal appraisal standard.
  • The previous inspection found issues with waiting times for patients and referral to treatment indicators not always being met. During this inspection, we found that referral to treatment indicators were still not always met.
  • We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas, resulting in backlogs. This issue was also identified within the previous inspection report.

Maternity and gynaecology

Requires improvement

Updated 15 February 2017

At the comprehensive inspection in 2014 we rated Maternity and gynaecology services as ‘Good’. In 2016 the services were rated as ‘Requires improvement’ overall because:

  • We found process for recognising deteriorating patients were not always reliable. It was not clear from observation charts how frequently observations should be repeated if a patient was unwell.
  • The service did not meet the national benchmarking for midwifery staffing. Data was not collected on the number of women who received 1:1 care in labour to provide assurance about midwifery staffing levels.
  • We found that some governance arrangements did not always allow for identification of risk.
  • Lessons learnt following a recent never event were not embedded.
  • We found that in some areas the approach to service delivery was reactive especially in relation to how the service had implemented the Growth Assessment Protocol (GAP).

However:

  • Clinical areas were clean and tidy with sufficient equipment to meet the needs of patients.
  • Patient outcomes were in line with national averages when compared to similar services.
  • Women spoke positively about their experience and said they felt well supported and cared for.
  • The trust had engaged with the public and sought their views over the development of the midwifery lead birthing unit.
  • We saw strong leadership at a local level. Staff felt supported and felt their concerns would be listened to.

Medical care (including older people’s care)

Good

Updated 1 June 2018

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

  • We saw improvements with medicine compliance previously raised as a concern with the trust. Medicine reconciliation, recording of fridge temperatures and recording of controlled drugs had all seen improvement since our last inspection in June 2016.
  • Patients received adequate food and drink during their admissions. Pain relief was provided. Patient outcomes were audited and reviewed in line with national audits. Multidisciplinary team working was in place and staff had the relevant training to be competent in their roles.
  • Staff provided care with compassion and treated patients with kindness. Emotional support was provided to patients to minimise their distress. Patients felt involved in their care and were well informed by staff.
  • We saw improvements with the access and flow within the hospital. Various projects were in place to reduce the length of stay and provide care within a home environment. The number of bed moves had reduced since our last inspection in June 2016. The way medical outliers were managed had changed and no outlying patients were sent to Castle Hill Hospital. Patients were cohorted on specific wards at Hull Royal Infirmary site however the trust required to develop a more consistent approach across the site in monitoring patients.
  • We saw that services were well-led and staff were provided with leadership and a clear vision for their health group. Governance and risk management systems were in place to provide assurances across the services.

However:

  • We were not assured that patient’s documentation was fully completed. Some records did not always contain the relevant information and staff had not completed certain risk assessments such as falls, nutrition and mental capacity. Nursing and medical staffing levels were not always at the required level and staff fill rates were reduced as a result.
  • We raised concerns to the trust regarding the escalation of deteriorating patients. We were not assured that patients received medical reviews for raised observations in line with their trust policy.
  • We were not assured that nursing staff followed the trust policy or nursing and midwifery (NMC) standards in administering medicines to patients.
  • Knowledge of mental capacity and deprivation of liberty safeguards (DoLS) varied between staff. We were not assured that patient’s mental capacity was recorded to reflect the patient’s current mental capacity.

Urgent and emergency services (A&E)

Good

Updated 15 February 2017

 At our previous inspection in May 2015, the service was rated as ‘Requires improvement’ overall. In June 2016 we rated this core service as ‘Good’ because:

  • The service was meeting a locally agreed trajectory to see and treat patients within four hours of arrival, and had done so for three consecutive months.
  • The trust had invested substantially in the environment of the emergency department and in new equipment including its major trauma facilities.
  • Staff were encouraged to report incidents and lessons were learned from the investigation of incidents.
  • Nursing staffing was close to meeting planned establishment levels and medical staffing had significantly improved.
  • Patients care and treatment followed evidence based guidance and recognised best practice standards that were monitored for consistency. Care was delivered with compassion and staff treated patients with dignity and respect.
  • Risks to the delivery of care and treatment for patients were appropriately managed. The governance of the department had become more embedded
  • A positive culture in the emergency department reflected the improved culture in the trust and staff commented to us favourably about this. The executive team and senior staff in the emergency department were recognised and respected.

However:

  • For an extended period, the trust has failed to meet the target to see and treat 95% of emergency patients within four hours of arrival.
  • We found gaps in the recording of medicines administration and in the monitoring of checks of controlled drugs.
  • No formal arrangements or protocols were in place for liaison with other specialties.

Surgery

Good

Updated 1 June 2018

  • We saw improvements in some of the areas that were a concern at the previous inspection. For example, the processes staff used to identify and escalate patients who were deteriorating and in the recording of medicine refrigerator and resuscitation equipment checks.
  • Patients we spoke with were consistently positive about the care and experience they had received.
  • Policies and procedures were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE).
  • We observed effective multidisciplinary working and staff we spoke with had a good understanding in relation to mental capacity and deprivation of liberty safeguards. Staff understood the need to gain consent and understood the relevant consent and decision making requirements.
  • We observed evidence of care which took into account the individual needs of patients. Patients described the care they received in positive terms. Patients we spoke with reported staff were caring and compassionate.
  • The service had systems in place for reporting, monitoring and learning from incidents. Staff we spoke with knew how to report incidents.
  • We found wards and departments we visited visibly clean and tidy, and we saw ward cleanliness scores displayed in public corridors.
  • The health group had a stable management structure in place and staff we spoke with felt supported by the senior management team.

However:

  • From our observations it was apparent the five steps to safer surgery checklist, was not embedded as a routine part of the surgical pathway.
  • There were shortages of nursing and medical staff: these shortages were evident in the majority of surgical areas.
  • We saw variable performance in all national audits with some criterion performing worse than the national rate, some within the expected range and some performing better than expected. Action plans we reviewed did not capture all the issues of concern within the audit and did not clearly demonstrate all the areas of action that the trust had taken.
  • The trust was not meeting the national performance standards for treatment or cancer standards. The trust referral to treatment times were consistently worse than the England average, fluctuating around 60%. Seven out of nine surgical specialities were worse than the England average performance.

Intensive/critical care

Requires improvement

Updated 15 February 2017

We had not inspected critical care services at HRI since February 2014 when they were rated as ‘Good’. During this inspection we rated critical care as ‘Requires improvement’ because:

  • The trust had not addressed some of the issues raised from the comprehensive inspection in February 2014, for example, staffing in the critical care outreach team, the frequency of the consultant on call rota and less than the 50% national standard of nurses with a post registration qualification in critical care.
  • During this inspection, we identified that controls for some of the risks on the risk register were limited and unsustainable. There was not clear evidence or assurance of escalation of the risks beyond the Health Group. Staff gave us examples of a lack of action of some of the risks on the risk register.
  • There was no documented evidence that some patients were seen by a consultant within 12 hours of admission or that twice daily ward rounds took place. The medical staff to patient ratio, during out of hours, exceeded recommendations. This was not in line with guidelines for the provision of intensive care services (2015)
  • We identified risks to the service that were not on the risk register. For example, non-compliance with guidelines for provision of intensive care services (2015), particularly a rehabilitation after critical illness service, critical care outreach staffing and service suspension and lack of escalation of NEWS scores.
  • We had concerns about the sustainability of the consultant rota as intensivists worked additional shifts. Some patients were not seen by a consultant within 12 hours of admission; twice daily ward rounds did not take place and medical staff to patient ratio, during out of hours, exceeded recommendations. This was not in line with guidelines for the provision of intensive care services (2015).
  • Planned nurse staffing levels were not consistently achieved and this impacted on the number of beds available in the critical care units Only twenty five percent of nurses had completed a post registration critical care qualification which was lower than the minimum recommendation of 50%.
  • The critical care outreach team was staffed by one nurse on site 24 hours a day. This member of staff was part of the trauma and transfer teams which meant they may not always be immediately available or on site. They were also part of the cardiac arrest team. We saw evidence of two incidents that had been reported due to the lack of a critical care outreach service.
  • We saw evidence during our inspection of patients who were referred to critical care requiring level three care that had not been escalated in line with trust policy.
  • The rehabilitation after critical illness service was limited and not in line with the guidelines for the provision of intensive care services (2015).
  • Patients did not have access to formal psychology input following critical care. The service had limited mechanisms of collecting patient or relative feedback.

However, we also found:

  • Patient outcomes were the same as or better than similar units and care and treatment was planned and delivered in line with evidence-based guidance, standards, best practice and legislation.
  • There was clear nursing and medical leadership on the units and in the critical care outreach team and staff had confidence in the units’ leadership.
  • Senior staff acknowledged the psychological needs of their staff. Staff had the opportunity to have post traumatic incident debriefing sessions.
  • We observed patient centred multidisciplinary team working.
  • The service showed a good track record in safety. There had been no never events, or serious incidents.

Services for children & young people

Good

Updated 15 February 2017

At the 2015 inspection, we rated the services for children and young people as ‘Requires improvement’.

At the 2016 inspection we saw improvements had been made and rated the services overall as ‘Good’ because:

  • Nurse staffing was appropriate and was planned using an acuity tool. Multidisciplinary working took place and staff worked well as a cohesive team. Staff were passionate about their roles and were dedicated to making sure their patients had the best care possible.
  • Requirements around the duty of candour were being met.
  • The service performed positively in infection prevention and control audits.
  • Policies were based on national and local guidelines. Consent to care and treatment was obtained in line with legislation and guidance.
  • Staff treated children, young people and their relatives/carers with kindness, compassion, dignity and respect. Families felt informed about the care of their child, and involved in the decisions about care.
  • Wherever possible mothers were not separated from their new-born baby and facilities were available for parents to be resident at the hospital with their child.
  • We saw children and young people being assessed and treated in a timely way. A discharge liaison team was available to ensure babies were discharged from the neonatal unit in a timely way.
  • Playrooms and a schoolroom were available to meet the learning needs of patients.
  • Following our inspection, the trust informed us they had decided to commission an out of area review by an independent mental health provider trust. This was to make sure the service was meeting people’s needs.
  • Staff spoke positively about their managers and the culture of the trust and were able to articulate the trust’s vision and values.

However,

  • Not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and four safeguarding children guidelines were out of date.
  • The care documentation did not clearly reflect the mental health needs of the patients and how those needs would be met.
  • We were not assured that staff had the knowledge and competencies to meet the needs of children and young people with mental health needs in their care.
  • There were several unfilled junior doctors posts, which had resulted in the inability to meet the demands of the service.
  • Records concerning the administration of medications were not appropriately completed.

End of life care

Good

Updated 15 February 2017

At the comprehensive inspection of end of life care services in February 2014 we found the service to be ‘Good’ overall. In 2016 the rating remained ‘Good’ overall because:

  • Patients were protected from avoidable harm and abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and managers shared the learning from incidents.
  • Mandatory training across most services was above the trust targets and medicines were prescribed and administered safely in line with policy. Staffing levels were appropriate for the services provided.
  • People’s care and treatment was planned and delivered in line with current evidence-based guidance. Information about people’s care and treatment, and their outcomes, were routinely collected and monitored. Staff providing care at the end of life were highly skilled and competent. There was evidence of multi-disciplinary working across all teams. The trust had recently employed more resources to provide seven-day specialist palliative care nursing availability. Consent to care and treatment was obtained in line with legislation and guidance.
  • Feedback we received from patients was consistently positive about the way staff treated them. We observed a number of staff and patient interactions during our inspection. We observed consistently caring and compassionate staff. Patients and their families were supported emotionally. We saw an initiative that had been implemented by the bereavement team that we thought was outstanding.
  • Services were planned and delivered in a way that meets the needs of the local population. All teams involved in caring for patients at the end of life were highly responsive to the needs of the patients in their care and those close to them. Care and treatment was coordinated with other services and other providers to ensure that specialist teams saw patients in a timely manner and patients’ choice in relation to where their care was delivered was achieved. We saw evidence that staff were responsive to meeting the needs of vulnerable patients including those living with dementia.
  • All teams were aware of the trust vision and values. Whilst there was no trust end of life strategy at the time of our inspection, the Specialist Palliative Care Team (SPCT) were working collaboratively with other providers and using the national End of Life Care strategy to benchmark and influence the care and treatment they provided to patients. Robust governance, risk management and quality measurement processes were embedded. Staff told us that senior staff were visible and supportive. There was a lead consultant for end of life care and a director who provided representation at the trust board. We found that staff in all teams were consistently positive, friendly, helpful and approachable in all areas we visited. All staff were team focused and we saw examples of innovation, improvement and sustainability.