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Castle Hill Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 February 2017

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. Castle Hill Hospital has cardiac and elective surgical facilities, medical research teaching and day surgery facilities (the Daisy Building), an ear, nose and throat (ENT), a breast surgery facility and outpatients as well as the Queen’s Centre for Oncology and Haematology. In total, the trust has approximately 1,300 beds and 7,400 staff. The CHH site has over 600 beds. The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected the five core services delivered from CHH which were medicine, surgery, critical care, end of life care and outpatients and diagnostics. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated CHH overall as ‘Requires improvement’; the safe, effective, responsive and well led domains were rated as ‘Requires improvement’ with caring rated as ‘Good. There had been improvements made for referral to treatment times (RTT); whilst the trust was not achieving the national standard it was meeting the local trajectories agreed with commissioners and NHS Improvement. Surgery services had improved. End of life care remained ‘Good’ across all domains. However, there was deterioration in the ratings overall for critical care from ‘Good’ to ‘Requires improvement’. Outpatients and diagnostics had improved in some areas and deteriorated in others which changed the rating from ‘Good’ in 2015 to ‘Requires improvement’ overall.

Our key findings were as follows:

  • The trust reported and investigated incidents appropriately and the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice.
  • The trust had effectively responded to a serious incident reported by Radiology in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported, of which four related to this printing issue. 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.
  • A backlog of 30,000 patient episodes/appointments had been identified by the trust prior to the inspection. There had been eight serious incidents 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. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
  • Staff were not always assessing and responding appropriately to patient risk. The trust used a National Early Warning Score (NEWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
  • Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in the patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
  • Nurse staffing shortages were evident across the majority of medical and surgical wards and Board reports indicated that safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators.
  • There were also some gaps within the medical staffing, especially within critical care.

  • The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
  • There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The trust had undertaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were then put in place.
  • Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
  • Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
  • Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved.
  • Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
  • The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited.

We saw several areas of outstanding practice including:

  • The urology service had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
  • The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
  • The responsiveness of the Specialist Palliative Care Team (SPCT) in relation to acting on referrals. For example, we saw that the SPCT was prepared to see patients without having received a referral and 98% of patients referred to the team were seen within one working day.
  • The bereavement team initiative of providing cards for relatives to write messages to their loved ones.
  • The breast care unit were using digital tomosynthesis. This method of imaging the breast in three-dimensions improves the sensitivity of detection of breast cancers by 40% and is more accurate.
  • The breast care unit carried out vacuum assisted biopsies. This one-stage procedure avoided patients needing two or three biopsies, significantly reducing the stress and anxiety for the patient and saving on resources.

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

Importantly, the trust must ensure that:

  • Planning and delivery of care meets the national standards for the referral-to-treatment time indicators and eliminates any backlog of patients waiting for follow ups with particular regard to longest waits.
  • Learning from Never events is further disseminated and lessons learnt are embedded.
  • Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National Early Warning Score (NEWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment and; that the escalation procedures are audited for effectiveness.
  • Staff have the skills, competence and experience to provide safe care and treatment especially for patients requiring critical care services.
  • Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
  • Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range.
  • Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/ taken by the patient.
  • Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
  • Effective use and auditing of best practice guidance such as the ‘Five steps to safer surgery’ checklist within theatres and standardising of procedures across specialties relating to swab counts.
  • Ensure that elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
  • Review the critical care risk register to ensure that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
  • Outpatients services have timely and effective governance processes in place to ensure they identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
  • Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient services.
  • There are at all times sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 February 2017

Effective

Requires improvement

Updated 15 February 2017

Caring

Good

Updated 15 February 2017

Responsive

Requires improvement

Updated 15 February 2017

Well-led

Requires improvement

Updated 15 February 2017

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 15 February 2017

We rated medical care services as ‘requires improvement’ overall because:

  • We found the trust had not addressed some issues raised from the comprehensive inspection in February 2014, for example: low nursing and medical staffing levels. The planned nurse and medical staffing levels were not consistently achieved and this impacted on the capacity of the medical wards.
  • Systems and processes were not completed consistently such as control checks of fridge temperatures and controlled drugs. Medication administration was not always completed and we observed gaps in medication charts that were not accounted for.
  • Audits were not always completed within the timeframe set by the trust when standards were not at acceptable levels. The trust 3G audit identified that nutrition standards were not always met and food charts were not always fully completed which would indicate if further referrals were needed. These were not highlighted as risks on the medicine risk register.
  • Some staff did not possess the specialist competencies that were required for specialist wards.
  • The trust was not achieving specific outcome targets, such as primary percutaneous coronary intervention (PPCI)
  • We observed nurse and medical leadership on the wards however ward managers were not always allowed to remain supernumerary due to nurse staffing levels.

However:

  • The trust had addressed some of the issues raised from the comprehensive inspection in February 2014, for example: the lack of available beds that led to long delays in accessing and treatment, frequent bed moves and the disconnect between the executive team and the wards. A local improvement plan was in place and, at the time of inspection, targets were being achieved to meet the 18 week referral to treatment national indicator.
  • The majority of patients and relatives felt involved in their care and thought staff were compassionate about the care they provided. Staff felt proud of the care they delivered and enjoyed working at the hospital.
  • We observed patient centred multidisciplinary team working.

Surgery

Requires improvement

Updated 15 February 2017

In 2015 we rated surgical services at CHH as ‘inadequate’. At the 2016 inspection we rated surgical services at CHH as ‘requires improvement’ overall because;

  • We had concerns over the escalation process of deteriorating patients; the systems used were not always effective.
  • We had concerns over the effectiveness of the ‘Five steps to safer surgery’ checklist, from our observations it was apparent this process was not embedded as a routine part of clinical roles.
  • From medical notes we reviewed and staff we spoke with, we did not see an effective process to ensure clinical review of orthopaedics patients by senior medical staff.
  • There were staff shortages of nursing and medical staff; these shortages were evident in all surgical areas. Within nursing, safer staffing levels were not being met. The trust recognised this was an issue and had twice-daily safety briefings to minimise the risks to patients. Nursing staff did not always complete accurately the falls and dementia risk assessments. Within medical staffing there were gaps in the junior doctor’s rota, especially overnight; this was highlighted on the risk register.
  • National audit performance was variable; the emergency laparotomy organisational audit 2015 scored red for six out of 11 outcome measures. We saw variable results in the bowel cancer audit 2015 and in the lung cancer audits.
  • Patients were not always able to access services for treatment in a timely way; the trust did not meet national performance standards for treatment and cancer standards.

However;

  • We saw improvements in the timely investigations of incidents and the sharing of lessons learned.
  • Policies for the Health Group, which we reviewed, were up to date and based on national guidance.
  • We observed good multidisciplinary working between physiotherapy teams, dietitians, and ward staff.
  • The majority of patients we spoke with provided positive feedback about their inpatient stay.
  • The Short Observational Framework for Inspection (SOFI) we carried out, showed that the majority of patient mood states were positive or neutral and interactions with patients were positive.
  • The trust had appointed substantive roles within the Surgery Health Group, this team recognised that they needed more time to develop and become fully effective in their roles.

Intensive/critical care

Requires improvement

Updated 15 February 2017

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% standard of nurses with a post registration qualification in critical care.
  • During this inspection, we identified risks to the service that were not on the risk register. We were concerned about the out of hours medical cover at CHH and the impact of the trust’s reconfiguration of services. There was a lack of recognition of this or forward planning from the Health Group management team or executive team to mitigate the risks.
  • Controls for some of the risks that had been identified were limited and unsustainable and 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 on some of the risks on the risk register.
  • We had concerns about the sustainability of the consultant rota as intensivists worked additional shifts to cover CHH. Some patients were not seen by a consultant within 12 hours of admission and twice daily ward rounds did not take place which was not in line with guidelines for the provision of intensive care services (2015).
  • Junior medical staff that worked on ICU2 out of hours did not have skills in tracheostomy and epidural management.
  • Only twenty five percent of nurses had completed a post registration critical care qualification which was lower than the minimum recommendation of 50%.
  • Planned nurse staffing levels were not consistently achieved and this impacted on the number of beds available in the critical care units.The critical care outreach team was staffed by one nurse on site 24 hours a day. The member of staff was part of the cardiac arrest and transfer team which meant they may not always be immediately available or on site.
  • 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 formal mechanisms for collecting patient or relative feedback.

However,

  • 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.
  • The service showed a good track record in safety. There had been no never events, or serious incidents.
  • There was clear nursing and medical leadership on the units and in the critical care outreach team and it was clear that staff had confidence in the units’ leadership.
  • We observed patient centred multidisciplinary team working.

End of life care

Good

Updated 15 February 2017

The last comprehensive inspection of End of life care services at the hospital was in February 2014, when we found the service to be good. During this inspection we rated this core service as ‘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 and 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 multidisciplinary 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.

Outpatients

Requires improvement

Updated 15 February 2017

We rated outpatients and diagnostic imaging services as ‘requires improvement’ overall. [KK1]

We rated the safe and responsive domains domain as ‘inadequate’, the well-led domain as ‘requires improvement’ and the caring domain as ‘good’. The effective domain was inspected but not rated. This was because we are currently not confident we are collecting sufficient evidence to rate effectiveness for outpatients and diagnostic imaging.

  • Radiology had reported a serious incident in December 2015 related to a failure to print 50,000 radiology reports. A further six serious incidents regarding specific patients had been reported, of which three related to this printing issue. 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.
  • In addition, a cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. Three of these serious incidents were at the HRI site and six at the CHH site; all eight had been reported since the last inspection. 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 and a serious incident was declared in December 2015 due to 50,000 radiology reports failing to print. This printing issue had led to a further four serious incidents related to printing errors, being declared by the time of the inspection.
  • 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 for nursing and support staff in some outpatient specialties, and in radiology there were five vacant radiologist posts and a significant proportion of radiographer vacancies in general x-ray.
  • Outpatients and radiology had increased their appointment capacity by running clinics out of hours and at the weekends, to cope with the increased demand and ensure patients had their appointments. However, there were ongoing concerns about the trust not meeting national standards for referral to treatment and urgent cancer treatment. However, a plan was in place and locally agreed trajectories, agreed with commissioners and NHSI were being met. All of the patients on the trust waiting lists were being clinically reviewed to ensure no patient came to harm. Weekly performance meetings reviewed the backlog and the individual Health Groups were taking action to review any issues.
  • Staff providing care and treatment to people in outpatients and radiology were caring. Patients gave positive feedback about the care they received and we saw 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 impairment or those who needed an interpreter.
  • The facilities and premises used to deliver services were good. The environment in all of the areas visited was in good state of repair, clean and comfortable and sufficient well-maintained equipment was available.
  • We found there were 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.
  • Outpatient services were split between the four Health Groups, meaning there were different levels of management and clinical support for each service. There was no outpatients risk register. Risks were identified on risk registers of Health Groups; however, this did not allow a cohesive oversight. There was also limited evidence of outpatient audits and quality monitoring.
  • There was inconsistency in the governance and management oversight in outpatients due to it being split across the four Health Groups. This was starting to be addressed with the setting up of a weekly Performance and Access (PandA) group, which reviewed all waiting lists by speciality. An ‘outpatient transformation project’ was also in progress, but this was running behind schedule. This project’s aims included improving clinic utilisation, bookings processes and performance against standards. We were also told that an overarching management post was to be developed.
  • 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 in which 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.
  • 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.