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Castle Hill Hospital Requires improvement

We are carrying out checks at Castle Hill Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 9 June, 28 June – 1 July and 11 July 2016

During a routine inspection

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 carried out on 19 – 21 May 2015

During an inspection to make sure that the improvements required had been made

Castle Hill hospital (CHH) is one of the main hospital sites for Hull and East Yorkshire Hospitals NHS Trust. The trust operates services from two main hospitals – Hull Royal Infirmary and Castle Hill Hospital – with a minor injuries unit at Beverley Community Hospital. Castle Hill hospital has cardiac and elective surgical facilities, new medical research teaching and day surgery facilities (the Daisy Building), an ear, nose and throat (ENT) and breast surgery facility and outpatients as well as the Queen`s Centre for oncology and Haematology. In total, the trust had approximately 1,300 beds and 7,400 staff. The CHH site has over 600 beds.

This was a focussed inspection of the CHH as concerns had been identified both during a previous comprehensive inspection of Hull and East Yorkshire NHS Trust in February 2014 and concerns had also been highlighted through other information routes such as the public and staff which required following up. The follow up inspection of CHH was on 19 – 21 May 2015.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We inspected surgery and outpatients and diagnostics but did not inspect the other core services at CHH which were critical care and end of life services. Additionally not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected. Almost all medical care had transferred to Hull Royal Infirmary since the February 2014 therefore these services are covered in HRI report

At the inspection in February 2014 we found the trust was in breach of regulations relating to patient care and welfare, medicines management, staffing, staff support and governance.

Overall, at the May 2015 inspection we rated the CHH as ‘requires improvement’. We rated it ‘good’ for being caring, but it requires improvement in providing safe and responsive care and in being well led. We inspected effective in out-patients & diagnostic imaging but we are currently not confident that we are collecting sufficient evidence to rate effectiveness.

We rated surgery as ‘inadequate’ and outpatient and diagnostic services as ‘good’.

Our key findings were as follows:

  • The trust had responded to previous staffing concerns and was actively recruiting to fill posts however there were areas where nurse staffing levels were impacting on patient care and treatment on the surgical wards. There were also staffing pressures in the electrocardiography department.
  • Most staff had received safeguarding training and could demonstrate an understanding of their role and what action to take if they were concerned about a person.
  • There were a number of areas of concerns in relation to infection prevention and control. These included breaches of national guidance for orthopaedic patients who were not ‘ring-fenced’ to prevent cross infections; patients who had undergone joint replacements had been placed in a bay with other surgical patients. The pack room for day theatres, which stored the stock used in theatres, had inadequate ventilation to maintain infection prevention and control standards.
  • The trust was not meeting the overall referral to treatment targets (RTTs) of 90% of patients admitted for treatment from a waiting list within 18 weeks of referral.

In relation to Radiology discrepancies we saw that the peer review process was an outstanding example of governance. The peer review meetings focussed on openness and learning and displayed a sensible application of legislation.

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

Importantly, the hospital must:

  • ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; particularly the histopathologists, the echocardiography team and surgical staff.
  • ensure there is a sustainable action plan to improve the reporting performance of histopathologist service.
  • address the breaches to the national targets for referral-to-treatment times to protect patients from the risks of delayed treatment and care. It must also continue to take action to address excessive waiting times for new and follow up patients with particular regard those waiting the longest.
  • ensure use of best practice guidance, such as national guidance to “ring-fence” orthopaedic patients to prevent cross infections; the safer steps to surgery checklist and Interventional Radiological checklists for appropriate procedures in all outpatient and diagnostic imaging settings and audit their use to include completion of all sections.
  • ensure the sustainability of the work to address the concerns raised regarding the bullying culture and the outcomes from the NHS staff survey data (2014).
  • ensure there is the development of a long term clinical strategy for the surgery health group in line with the Trust’s overarching strategy which meets the clinical needs of patients.
  • ensure there are timely and effective governance processes in place to identify and actively manage risks throughout the organisation.
  • ensure compliance with theatre engineering performance measures and annual servicing of ventilation systems for all theatres.
  • review the results of IPC audits across all wards and theatres and identify and instigate appropriate actions including addressing the flooring and walls within theatres.

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3, 4 and 11 February 2014

During a routine inspection

Castle Hill Hospital is one of the main hospital sites for Hull and East Yorkshire Hospitals NHS Trust. The trust operates acute services from two main hospitals: Castle Hill and the Hull Royal Infirmary. The community services operated by the trust were not assessed as part of this review. The trust serves a population of 660,000 and provides a range of acute services to the residents of Hull and East Riding of Yorkshire as well as a number of specialist services to North Yorkshire, North and North East Lincolnshire.

Castle Hill Hospital has 610 beds and provides acute medical and elective surgical services, including cardio-thoracic, breast, ear, nose and throat (ENT) and oncology services. Critical care is provided in two units, which support the cardiology and cardio-thoracic services. There are no accident and emergency services at this hospital: these are provided at Hull Royal Infirmary.

We found that the hospital was facing significant challenges due to the shortage of staff and insufficient capacity to deal with the increasing number of admissions. The shortage of nursing and medical staff, particularly junior doctors was impacting on the care patients received, leading to delays in assessment and treatment. There was a winter plan in operation, whereby additional beds had been opened on one ward, to alleviate pressure on bed space across the trust. Despite this, the high volume of admissions resulted in patients being moved around the hospital and across to Hull Royal Infirmary, often through the night. The hospital was not meeting all nationally set targets such as referral-to-treatment times in some specialties and backlogs had built up. A large number of outpatient appointments had been cancelled.

Staff were working hard to ensure the safety and welfare of patients, including working additional hours. We found that doctors were covering a number of areas in addition to their normal allocation and did not always have the necessary competencies for the speciality. Some staff reported that they were put under pressure to undertake additional workload and meet performance targets.

Patient feedback about care was generally positive and staff were reported to be caring and compassionate.

There were systems to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. All areas visited were clean.

There were systems in place for assessing, monitoring and addressing risk, with lines of reporting to the trust board. However, many staff told us that they did not have the time to report incidents, and there was little shared learning across divisions.

The trust was aware of the challenges over staff shortages and the high volume of admissions and had taken steps to address these. However, recruitment had proved difficult and had led to a high usage of locum staff. We saw some good examples of local leadership and highly motivated staff, but this was not consistent across the hospital. Staff felt generally supported by local leaders but not engaged with the executive management team.

We found the hospitals in breach of Regulations 9 (care and welfare), 10 (governance), 13 (medicines,) 22 (staffing) and 23 (staff support) for the regulated activities of treatment of disease, disorder or injury and diagnostic and screening procedures.

Inspection carried out on 21, 22, 23 October 2013

During an inspection in response to concerns

We visited the hospital in response to concerning information we had received. We visited wards and reviewed information that was referred to us by the local authority following concerns being raised.

Patients confirmed that their care and treatment options were discussed with them and they were asked for their consent to their care and treatment. A patient told us that they were always consulted about treatment. Another patient we spoke with said, “Everything that happens is my choice, the doctors and nurses give you advice about what is best but I decide what happens to me.”

Patients and visitors were mainly positive about the ward staff and the treatment they were receiving. A patient described how they were kept informed about what was happening at all stages of their care. A patient told us they were, “Very happy with the care indeed.” This reflected other positive comments we received.

We found that whilst some staff demonstrated a clear understanding of what constituted abuse, this did not include all staff. We also found that operational differences between the safeguarding procedures for the two local authorities caused complications for staff in actioning safeguarding alerts. Staff were unclear as to what they needed to do to progress incidents or allegations of abuse. We found that not all safeguarding incidents were reported or investigated.

Inspection carried out on 12, 13, 14 June 2013

During a routine inspection

Patients we spoke with were satisfied with the standard of care they had received. They described care as “Excellent” and said staff were kind and respected their privacy and dignity. One patient told us, “I felt valued as an individual.” Another patient said the staff were “kindness itself.”

We spoke with patients who were ready for discharge. Most of them told us they were aware of and had been involved in their discharge arrangements. They also confirmed they had received information to take away with them.

The patients we spoke with told us they did not have any concerns about how staff handled their medicines and the care they received. They all said that they were asked about what medicines they were taking when they were first admitted to hospital. However, some patients had little idea about changes to their medication that had been made during their stay and what, if any, additional side effects may occur. One patient was given a painkiller after a fall and experienced an adverse reaction that they had not been warned about. They described the experience as “frightening.”

The hospital arranged for patients to be consulted and to discuss matters which affected the running of the service.

Patients’ care and treatment records were completed in a consistent way, so information could be located easily. Records were kept in a way that ensured confidential information about patients could be safeguarded, to prevent unauthorised people gaining access to them.

Inspection carried out on 9 January 2013

During a routine inspection

We spoke with people at the hospital's outpatient reception area. People were complimentary about most aspects of their care, although the waiting time from the appointment on their letter to the actual time seen in a clinic or receiving treatment was an issue with two people. Once person told us that when they attended for their operation, they had to wait four hours for a bed and although staff appeared sympathetic, the person told us that speaking to others, four hours was "lucky" and this person had been sat with another person who had their operation cancelled twice through what were related to them as "winter pressures." Everybody we spoke with felt the staff were trying to help. One person told us that "nurses are pushed off their feet but they get to you and always manage in the end." Another person observed that "if they got their appointment times sorted more accurately, people would feel more comfortable, staff would have to apologise less and be able to get on with their jobs more."

We saw that the areas inspected were clean and tidy with evidence of infection control measures in place. Completion of record keeping was timely and assessments led to planned care. Coping with winter pressures did put one ward inspected under strain which led to some care being not as optimal as the trust had planned.

Inspection carried out on 10 February 2012

During an inspection to make sure that the improvements required had been made

We spoke with patients on three wards, both regarding their specific care and their general impression of the hospital. Most were satisfied with their care, felt they had been informed over their condition and the course of treatment, felt the wards were clean and tidy and gave positive comments regarding the attention staff were giving them. Some were complimentary about the food whilst anothers felt the quality could be improved.

Comments included “Everybody’s been great,” “friendly and outgoing staff,” “It is nice to be able to walk to theatre rather than be on a trolley, it helps reduce my anxiety.” Can’t really complain.” “All staff happy and really polite.”

Inspection carried out on 23 June 2011

During an inspection in response to concerns

The people we spoke to were happy with the level of care and support they had been offered at the birthing centre. They told us that they were impressed with the calm atmosphere and that they trusted the staff and felt safe. They talked to us about the support they had received prior to attending the centre and how they could regularly see their community midwife. People felt that they had been given choices about the care that they wanted and were supported to raise concerns. They spoke highly of the staff and told us that their husband or birthing partner were fully involved.

One person was disappointed that they had been sent home early due to staff shortages.

Inspection carried out on 6 December 2010 and 20 September 2011

During a routine inspection

Overall, people were happy with the treatment that they have received at Castle Hill Hospital. They spoke positively about the staff and how their privacy and dignity was maintained. The majority told us that they received clear explanations regarding their treatment, the risks and the options available.

Comments included: ‘ They always knock on the door’, ‘ I am very impressed’, ‘ Very well looked after, staff are very nice’ and ‘ Doctors come round and tell you what is going on’.