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University Hospital North Durham Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 March 2018

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

  • We rated safe, effective and well led as requires improvement; caring and responsive were rated as good.
  • Overall, surgery had gone down one rating to requires improvement overall, urgent and emergency care stayed the same since our last inspection. Maternity services and medical care had improved.
  • Within urgent and emergency care, consultant presence in the departments did not meet the RCEM guidance of consultant presence of 16 hours a day. ST3 doctors (those in year three of speciality training) were part of the middle grade rota. This goes against the RCEM guidance that a minimum of an ST4 or equivalent is in the department at all times.
  • Within urgent and emergency care, the service did not always manage medicines well.
  • Within urgent and emergency care, the department missed key targets for caring for patients promptly. Patients did not always get a face-to-face assessment within 15 minutes of arrival or registration. Patients brought in by ambulance were not always handed over to the department within 30 minutes and this was getting worse.
  • Within urgent and emergency care, staff did not record patient care consistently.
  • Within medical care services at University Hospital North Durham, members of staff did not comply with hospital policy on the administration of covert medicines. We found evidence of staff providing medication covertly for patients without ensuring capacity assessments were in place.
  • Within medical care services, medical and nursing records were not stored securely in all areas we visited.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They did not support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • The hospital did not meet targets for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training. The knowledge and practice of staff on the wards raised concern over the effectiveness and numbers trained.
  • Eleven never events were reported over 13 months from May 2016 to May 2017. Joint working with stakeholders and a trust wide programme of learning had taken place following these never events reduce risks of harm to patients; however, despite this, two further never events occurred after September 2017. There were unacceptable numbers of never events and a strong need to further embed safer practices and learning across the trust.

However:

  • In most areas nurse staffing had improved.
  • Staff investigated incidents quickly, and shared lessons learned and changes in practice with staff.
  • Wards and department areas were clean and equipment well maintained. Staff followed infection control policies that managers monitored to improve practice.
  • Staff provided care and treatment based on national guidance and evidence and used this to develop new policies and procedures.
  • Staff cared for patients with compassion, treating them with dignity and respect.
  • Patients, families and carers gave positive feedback about their care.
  • The hospital escalation policy and procedure guidance was followed during busy times.
Inspection areas

Safe

Requires improvement

Updated 1 March 2018

Effective

Requires improvement

Updated 1 March 2018

Caring

Good

Updated 1 March 2018

Responsive

Good

Updated 1 March 2018

Well-led

Requires improvement

Updated 1 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 29 September 2015

Overall the care and treatment received by patients in the University Hospital of North Durham outpatient and imaging departments was safe, effective, caring, responsive and well led. Patients were very happy with the care they received and found it to be caring and compassionate. Staff were supported and worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm because there were policies in place to make sure that any additional support needs were met. Staff were aware of these policies and how to follow them.

The departments took part in the NHS Friends and Family Test and another satisfaction scheme called ‘I want great care’. There were comment boxes in waiting areas.

On the whole, the services offered were delivered in an innovative way to respond to patient needs and ensure that the departments worked effectively and efficiently.

Maternity and gynaecology

Good

Updated 1 March 2018

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

  • There was a newly formed senior leadership team in the maternity service covering business, midwifery and clinical leadership. We found that this team was cohesive and that there was a real drive to continue to improve the quality of the service. There were no concerns around bullying or challenging behaviour.
  • The local leadership multidisciplinary team had been restructured, was strong and effective. This was evident throughout all parts of 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.
  • There was a full and robust system to review cases at risk meetings. Completion of the World Health Organisation surgical safety checklist was closely monitored and regularly met trust targets.
  • Recommended midwifery to birth ratios were met.
  • Recruitment of medical staff had improved with good support for junior and middle grades from consultants.
  • Changes in practice were based on national guidelines and best practice, then audited to ensure they were embedded throughout the team.
  • Patient outcomes were in line with national averages.
  • 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.
  • Staff had identified opportunities to improve patient pathways and flow through departments and had introduced a new transitional care pathway.
  • The trust served a community with a wide range of needs and there were good systems in place to ensure effective communication. Teams were working proactively with local networks to improve outcomes.

Medical care (including older people’s care)

Good

Updated 1 March 2018

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

  • The hospital had enough staff with the right skill mix for the care and treatment of patients requiring non-invasive ventilation (NIV). Escalation plans, separate treatment areas and the assessment of staff competence had been developed.
  • There was a standardised and documented clinical pathway for the care and treatment of patients requiring NIV across the trust.
  • The wards and directorate areas were clean and equipment well maintained. Staff followed infection control policies that managers monitored to improve practice.
  • Staff understood and followed procedures to protect vulnerable adults or children.
  • Staff provided care and treatment based on national guidance and evidence and used this to develop new policies and procedures.
  • Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care.
  • Staff cared for patients with compassion, treating them with dignity and respect and involved patients and those close to them in decisions about their care and treatment.
  • The directorate treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The directorate had a clear vision and strategy that all staff understood and put into practice.
  • The directorate had governance, risk management and quality measures to improve patient care, safety and outcomes.
  • Staff described the culture within the service as open and transparent. Staff could raise concerns and felt listened to. They said leaders were visible and approachable.

However:

  • Members of staff did not comply with hospital policy on the administration of covert medicines.
  • We found evidence of staff providing medication covertly for patients without ensuring capacity assessments were in place. We pointed this out at the time and this was addressed immediately by the trust.
  • Staff did not understand their roles and responsibilities under the Mental Capacity Act 2005. They did not always follow legislation to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • The trust did not meet targets for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training. The knowledge and practice of staff on the wards raised concern over the effectiveness of training and numbers trained.
  • The trust policy for Mental Capacity Act and Deprivation of Liberty was brief and did not direct staff to guidance or tools for use by staff. Guidance available was incorrect and not in line with the Mental Capacity Act or the code of practice.
  • At the time of inspection we had concerns about Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training, the knowledge and practice of staff on the wards related to capacity assessments and DoLS applications and the trust policy for Mental Capacity Act and Deprivation of Liberty.
  • Medical and nursing records were not stored securely in all areas we visited.
  • Staff satisfaction was mixed according the staff survey. Staff did not always feel actively engaged or empowered.

Urgent and emergency services (A&E)

Requires improvement

Updated 1 March 2018

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

  • The service did not meet the Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival at the department.
  • The department missed key targets for caring for patients promptly. Patients did not always get a face-to-face assessment within 15 minutes of arrival or registration. Patients brought in by ambulance were not always handed over to the department within 30 minutes and this was getting worse. The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The hospital did not meet this standard for every month between September 2016 and August 2017.
  • The room used to assess patients with mental health needs, did not conform to the Psychiatric Liaison Accreditation Network (PLAN) standards.
  • The service did not always have enough staff of the right level to keep patients safe from avoidable harm.
  • The service did not always manage medicines well.
  • Managers did not update or review care pathways regularly.
  • Nursing staff looking after children were not aware competency principles when assessing capacity, decision making and obtaining consent.
  • Staff did not always record patients’ blood sugar levels when necessary.
  • Compliance with some mandatory training subjects was well below trust targets.
  • Staff satisfaction was mixed according the staff survey. Staff did not always feel actively engaged or empowered.

However:

We found some improvements since the last inspection.

  • The service had improved on many of the issues for action highlighted in the previous inspection. It had a clear vision and strategy. The department had governance, risk management and quality measures in place to improve patient care, safety and outcomes.
  • Cleanliness of the department had improved.
  • Paediatric nurse staffing had increased. Advanced nurse practitioner roles had been appointed to support the medical rota and additional alternative roles were being introduced.
  • A new escalation process was introduced to improve patient flow through the department to the rest of the hospital
  • The difficult airway trolley had been standardised throughout the trust.
  • The department had improved the care of patients requiring non-invasive ventilation (NIV).
  • Resuscitation equipment and fridge temperatures were checked daily.
  • Staff we spoke with had undertaken a two-day violence and aggression training. The lack of training was noted in the previous inspection.
  • Staff recognised incidents and knew how to report them. Lessons learnt were shared amongst staff.
  • Staff kept patients safe from harm from abuse.
  • Staff were able to identify and respond appropriately to patients at risk of deteriorating.
  • Staff provided care and treatment based on national guidance and evidence and audits took place.
  • Patients had their pain monitored effectively and re-attendance rates were better than the national standard and England average.
  • Staff cared for patients with compassion, dignity and respect. We received positive feedback from patients and carers.

Surgery

Requires improvement

Updated 1 March 2018

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

  • Seven never events occurred between May and October 2016. The trust took actions to address this. However a further four never events occurred at the trust between November 2016 and May 2017. The trust took further action but despite this two further never events occurred after September 2017
  • Operating theatres were not fully established against the ‘Association for Perioperative Practice’ (AfPP staffing recommendations). Staffing levels at night and on late shifts fell below recommended guidance.
  • Limited sepsis training was available to relevant staff.
  • Gaps in information were observed in some of the patient records we reviewed. Staff signatures were not always recognisable and signatures were not printed.
  • Theatre staff told us they had not attended regular training, as they were too busy to attend. Overall compliance with mandatory training in surgery was 51% against a trust target of 95%.
  • Task and finish groups were still in progress working on culture issues in theatres, further improvements needed to be embedded
  • There had been high rates of falls which met the serious incident criteria and amounted for around a third of all incidents.
  • Treatment delay and a failure to act on test results together accounted for 38% of all serious incidents.
  • Staff satisfaction was mixed according to the staff survey. Staff did not always feel actively engaged or empowered.

However:

  • There had been some learning from surgical never events and identified the changes in clinical practice which resulted. More recent audits of the ‘World Health Organisation (WHO) surgical safety checklist and five steps to safer surgery showed improvement.
  • Managers investigated incidents quickly, and shared lessons learned and changes in practice with staff.
  • Concerns and complaints were taken seriously, investigated, lessons learned, and outcomes shared with all staff.
  • Staff had an understanding of how to raise safeguarding concerns.
  • People gave positive feedback about the care they received. They said they were involved in decisions about their care and staff considered their emotional as well as physical needs.
  • Staff treated patients with compassion, dignity and respect.
  • Referral to treatment (RTT) times admitted performance was above the England average. Where RTT shortfalls existed, the trust had identified actions to improve performance.
  • The service was responsive to people’s needs and worked with external providers to improve people’s care and access to care pathways.
  • Over the two years, the percentage of cancelled operations at the trust showed a very minor upward trend and was generally lower than the England average.
  • Staff across both hospitals said joint working between surgical services had strengthened.
  • Staff said they felt supported by their immediate management teams and matrons were visible in clinical areas.
  • Care was provided in line with NICE clinical guideline CG50 (Acutely ill adults in hospital: recognising and responding to deterioration). Patient’s risks were assessed to determine their fitness for surgery. The service had protocols and guidelines in place to assess and monitor patient risk in real time.
  • Staff provided care and treatment based on national guidance.
  • The surgical care group had implemented governance, risk management and quality measures to improve patient care, safety and outcomes.
  • Staff described the culture within the service as open and transparent. Staff could raise concerns and felt listened to. They said leaders were visible and approachable.
  • Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care and treated patients with compassion, treating them with dignity and respect.

Intensive/critical care

Good

Updated 29 September 2015

Overall the services within critical care were good. However, some aspects of safety required improvement. The intensive care unit did not have an outreach team to identify and monitor deteriorating patients. The purpose of the service would be to assess the critically ill or deteriorating patient on wards and to stabilise them at ward level and so avoid the need to escalate to the unit. There was no clinical pharmacist input to the daily multidisciplinary ward rounds. This was not in line with the national Core Standards for Intensive Care Units 2013. The unit had just started to have its own mortality and morbidity meetings, which were still to be further embedded. Medical and nursing staffing levels were adequate, but there was no supernumerary sister or charge nurse to cover areas such as peak activity times, facilitating admissions and discharges or coordinating nurse staffing on the unit.

Patients received treatment and care according to national guidelines and the unit used an audit programme to check whether their practice was up to date and based on sound evidence. The unit was obtaining good-quality outcomes as shown by its Intensive Care National Audit and Research Centre (ICNARC) data. We found there was good multidisciplinary team working across the unit. However, the full multidisciplinary team did not attend the ward rounds.

Staff cared for patients in a compassionate manner with dignity and respect. Relatives we spoke with told us their loved ones had all their care needs met by dedicated staff. Relatives told us they were involved with their loved ones’ care and felt supported in making decisions as a family.

Bed occupancy rate within the unit was 92% which enabled it to plan admissions and accept emergencies. The unit experienced some delay in discharges, often due to the lack of available beds and due to delays in determining what the parent team was when patients were admitted via the A&E department; this also caused delays in discharges to a ward.

Staff felt well supported within an open, positive culture.  The governance processes still needed time to become embedded, with medical and nursing leadership within the unit needing further development.

Services for children & young people

Good

Updated 29 September 2015

Overall, services for children and young people were good at this hospital. Staff demonstrated awareness of how to report incidents using the trust’s reporting mechanisms and we saw these were reviewed and acted upon by the management team. We found risks were assessed and monitored, and control measures were put in place. We found all children’s clinical areas were kept clean and were regularly monitored for standards of cleanliness. Medicines were stored and administered correctly. Medical records were handled safely and protected.

Members of staff of all grades confirmed they received a range of mandatory training, although training records did not always accurately reflect training uptake. Medical staffing had some gaps but these were being managed and addressed.

The levels of nursing staff were adequate to meet the needs of children and young people.

Children’s services had made improvements to care and treatment where needs had been identified using programmes of assessment or in response to national guidelines.

Children, young people and parents told us they received compassionate care with good emotional support. Parents felt fully informed and involved in decisions relating to their child’s treatment and care.

The service was responsive to children’s and young people’s needs and was well led. The service had a clear vision and strategy. The service was led by a positive management team who worked together. The service had introduced innovative improvements with the aim of improving the delivery of care for children and families.

End of life care

Requires improvement

Updated 29 September 2015

End of life care services at this hospital required improvement. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were not always being completed accurately and comprehensively with clinical information relating to the decision, and discussions with patients and relatives not always being recorded. Mental capacity assessments were not being recorded when there was an indication that patients did not have capacity to be involved in decision making. The trust had taken part in the 2013/14 NCDAH, where it had not achieved six out of seven organisational key performance indicators. The trust performed below the England average and failed to meet all of the 10 clinical key performance indicators. The trust had an action plan in place to address areas identified as part of the National Care of the Dying Audit (NCDAH), including the implementation of training and staff surveys.

Staff were seen to be caring and compassionate and we saw that the development of pastoral and spiritual services were planned for. The specialist palliative care team provided support for patients at the end of life and for the ward staff caring for them. We observed specialist nurses and medical staff providing specialist support in a timely way, and this was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care for patients at the end of life wishing to be at home.

The specialist palliative care team had addressed issues around staff attending specialist training by attending the wards on a regular basis every day and supporting staff to develop the skills needed to care for people at the end of life through a mentoring programme. Education had been identified as a priority area by the trust and recruitment to a dedicated end of life educator post had been included in service action plans. Structural development of the services had begun in terms of the identification of workforce needs and plans being developed to address these needs, but at the time of our inspection we saw that staffing difficulties had impacted on the ability of the specialist palliative care team to take action to develop the service. Examples included taking timely action to develop the service and address issues identified, the development of out of hours consultant cover and the use of data to monitor the effectiveness of the service.

Other CQC inspections of services

Community & mental health inspection reports for University Hospital North Durham can be found at County Durham and Darlington NHS Foundation Trust.