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Hull Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 June 2020

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

  • We rated safe, responsive and well led as requires improvement. We rated effective and caring as good.

  • The trust did not always have enough medical, nursing staff and allied health professionals with the right qualifications, skills, training and experience within the services that we inspected. Staff did not identify and quickly act upon patients at risk of deterioration. Records were not always clear and up to date, stored securely and easily available to staff providing care.
  • People could not access the service when they needed it and received the right care promptly. Waiting time for referral to treatment and arrangements to admit and discharge were not in line with national standards in the urgent and emergency care and surgical services. The trust reported a high number of medical patients moving wards at night. We also observed that some surgical wards had a high number of medical patients and sometimes patients were moved at night.
  • Leaders did not always operate effective governance and risk processes, particularly in the urgent and emergency department and critical care core services. Staff were not always clear about their roles and accountabilities and did not learn from the performance of the service.

However:

  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983. Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff monitored the effectiveness of care and treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients personal, cultural and religious needs. Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.

Inspection areas

Safe

Requires improvement

Updated 24 June 2020

Effective

Good

Updated 24 June 2020

Caring

Good

Updated 24 June 2020

Responsive

Requires improvement

Updated 24 June 2020

Well-led

Requires improvement

Updated 24 June 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 24 June 2020

Our rating of this service stayed the same. We rated it as good because:

  • We rated effective, caring, responsive and well led as good. We rated safe as requires improvement.
  • The service provided mandatory training in key skills to all staff and made sure everyone completed it and staff understood how to protect patients from abuse. The service used systems and processes to safely prescribe, administer, record and store medicines and the service managed patient safety incidents well.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it and received the right care promptly. The service made it easy for people to give feedback and raise concerns about care received.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Leaders were sighted on their risks and had plans in place to manage them. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services.

However:

  • Staff did not always identify and quickly act upon patients at risk of deterioration and the service did not always have enough nursing staff with the right qualifications, skills, training and experience. Medical and nursing records were not always stored securely and items which were classed as under the control of substances hazardous to health (COSHH) were not always stored safely and securely to protect vulnerable patients.
  • The endoscopy unit had failed to achieve the Joint Advisory Group on Endoscopy (JAG) accreditation. The process for assessing and recording a patient’s mental capacity and best interest decisions was not fully embedded and the service was not meeting their target of 85% for staff in medical care receiving their appraisal.
  • On one ward we visited, staff did not always respond to patients in a timely way and did not ensure patients dignity was maintained.
  • The trust reported a high number of medical patients moving wards at night.

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.

Critical care

Good

Updated 24 June 2020

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

  • We rated safe, effective, caring and responsive as good. We rated well led as requires improvement.
  • The service provided mandatory training in key skills to all staff and made sure most staff completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. They kept equipment and the premises visibly clean. Staff managed clinical waste well. Staff completed and updated risk assessments for each patient and took action to remove or minimise risks. On the whole, the service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe. Staff kept detailed records of patients’ care and treatment. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.
  • Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff monitored the effectiveness of care and treatment. The service made sure most staff were competent for their roles. Most key services were available seven days a week. Staff supported patients to make informed decisions about their care and treatment. They used measures that limit patients' liberty appropriately. Staff protected the rights of patients subject to the Mental Health Act 1983.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients personal, cultural and religious needs. Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.
  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. The service was inclusive and took account of patients’ individual needs and preferences. Bedside diaries were used to support patients and their families during critical illness. People could access the service when they needed it and received the right care promptly.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff felt respected, supported and valued. The service had an open culture.

However:

  • Whilst there had been some improvement to the numbers of staff in the critical care outreach team, this was still not adequately staffed out of hours and at weekends.
  • The overnight stay facilities for families were not adequate. The service did not have enough allied health professionals with the right qualifications, skills, training and experience. Records were not always clear and organised.
  • We were concerned that care and treatment might not always be based on national guidance and best practice. Not all staff had an up to date appraisal and less than the 50% of nurses had a post registration qualification in critical care.
  • The service was still not providing a formal follow up clinic in line with GPICS standards and the National Institute of Health and Care Excellence (NICE) CG83 best practice guidance.
  • Leaders did not always operate effective governance processes. We were concerned about the lack of oversight in relation to the review of policies and procedures relevant to the units. There had been a lack of pace to address risks on the risk register. For example, we were told a business case to address the isolation facilities had been submitted for consideration but this had not been approved consistently.

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.

Surgery

Good

Updated 24 June 2020

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well led as good.
  • The service provided mandatory training in key skills to all staff. Staff understood how to protect patients from abuse. The service controlled infection risk well and kept the environment and equipment clean. Staff completed and updated risk assessments for each patient which removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The service planned enough nursing and support staff to keep patients safe from avoidable harm and to provide the right care and treatment. Records were stored securely and easily available to all staff providing care. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence-based practice. Staff protected the rights of patient’s subject to the Mental Health Act 1983. Staff followed national guidelines to make sure patients fasting before surgery were not without food for long periods. Staff assessed and monitored patients regularly to see if they were in pain, and gave pain relief in a timely way. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service made sure staff were competent for their roles. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Key services were available seven days a week to support timely patient care. Staff gave patients practical support and advice to lead healthier lives. Staff supported patients to make informed decisions about their care and treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. The service was inclusive and took account of patients’ individual needs and preferences. Staff coordinated care with other services and providers. It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. The service had a vision for what it wanted to achieve and a strategy to turn it into action. Leaders and staff understood and knew how to apply them and monitor progress. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear. Leaders operated effective governance processes. Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. The service collected reliable data and analysed it. Leaders collaborated with partner organisations to help improve services for patients. All staff were committed to continually learning and improving services and leaders encouraged innovation and participation in research.

However:

  • Planned staffing numbers were not always maintained. The service did not consistently have enough medical staff; but had taken steps to help mitigate against this by recruiting advanced clinical practitioners, employing physician assistants, and extending locum contracts.
  • Patient records were not always stored in a logical, chronological order. Staff did not consistently document that they gave patients enough food and drink to meet their needs and improve their health.
  • Some waiting times from referral to treatment were not always in line with national standards. We observed some surgical wards had medical patients (outliers) located on them. Patients were sometimes moved between wards at night, and data showed 38.5% of all moves at night were confined to two surgical wards at the location.
  • Leaders and staff did not always actively engage with patients, staff, equality groups, the public and local organisations to plan and manage services. The senior leadership team were aware of engagement ‘gaps’ and were developing plans to better engage service user and representation groups.

Urgent and emergency services

Requires improvement

Updated 24 June 2020

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

  • We rated safe, responsive and well led as requires improvement. We rated effective and caring as good.
  • The service did not have enough medical and paediatric nursing staff to care for patients and keep them safe. There were insufficient senior medical staff to cover the paediatric emergency department 24 hours a day, seven days a week. Nursing staff who provided paediatric cover may not always have the appropriate paediatric competencies. Staff did not complete the initial risk assessments for paediatric patients including the paediatric early warning score. There was a delay to risk assessing adult patients and mental health patients. The service did not keep fully completed care records.
  • People could not access the service when they needed it and had to wait for treatment. The trust had a higher percentage of patients waiting more than four hours, compared to the England average. Performance against the national standard for patients to be admitted, transferred or discharged within four hours of arrival in the emergency department was deteriorating. The flow of patients in the hospital presented a major challenge to the responsiveness of the department. Although medical and nursing staff were proactive in moving patients through the department, the flow of patients was often hindered by the lack of bed provision in the hospital.
  • Managers did not make sure staff were competent. We were not assured there was always suitably skilled nursing cover deployed to ensure paediatric staff would be able to support the paediatric emergency department.
  • Although the service had a vision for what it wanted to achieve the strategy did not mitigate fully some of the safety and quality issues the department faced, particularly related to patient flow, staffing and paediatrics. Leaders did not have effective governance processes. Staff were not clear about their roles and accountabilities and did not learn from the performance of the service.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. It also managed medicines well. The service managed safety incidents well and learned lessons from them. The environment was appropriate to care for patients with mental health needs.
  • Staff provided appropriate and effective care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to effective information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Leaders supported staff to develop their skills. Staff felt respected, supported and valued.

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.