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University Hospital North Durham Good

Inspection Summary


Overall summary & rating

Good

Updated 3 December 2019

Our rating of services improved. We rated it them as good because:

  • We rated effective, caring, responsive and well led as good and safe as requires improvement.
  • Urgent and emergency care services remained the same at requires improvement. Surgery improved by one rating to good and end of life care improved by two ratings to outstanding.
  • 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 had suitable premises and equipment and looked after them well. Staff kept themselves, equipment and premises clean. They used control measures to prevent the spread of infection.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness such as that issued by National Institute for Health and Care Excellence (NICE). Managers checked to make sure staff followed guidance.
  • End of life care had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • End of life care had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
  • End of life care managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

However,

  • There were challenges in meeting the Royal College of Emergency Medicine (RCEM) workforce recommendations in relation to consultant staffing in the emergency department.
  • There were challenges in meeting guidelines relating to the care of children in the department in terms of appropriately trained staff being available in the emergency department.
  • Medical training compliance in Mental Capacity were below trust targets.
  • There were some concerns over the general environment in terms of staff safety as areas had unrestricted access in the emergency department.
  • Syringe driver safety checks were not completed in accordance with trust policy (‘Policy for the administration of subcutaneous medication’). We were not assured training in the specific syringe devices used throughout the trust was followed up or monitored at ward level.
Inspection areas

Safe

Requires improvement

Updated 3 December 2019

Effective

Good

Updated 3 December 2019

Caring

Good

Updated 3 December 2019

Responsive

Good

Updated 3 December 2019

Well-led

Good

Updated 3 December 2019

Checks on specific services

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.

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.

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.

End of life care

Outstanding

Updated 3 December 2019

•The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

•The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

•The service provided care and treatment based on national guidance and evidence of its effectiveness.

•The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

•The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

•Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

•The service had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.

•Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

•The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

However:

•Syringe driver safety checks were not completed in accordance with trust policy (‘Policy for the administration of subcutaneous medication’). We were not assured training in the specific syringe devices used throughout the trust was followed up or monitored at ward level.

•The service did not consistently use systems and processes to safely prescribe, administer, record and store medicines. Pain care plans were not completed in all patient records.

•The results of the first round of the ‘National Audit of Care at the End of Life’ (2019) showed the trust scored lower when compared nationally for documented assessments of nutrition between recognition and time of death and hydration.

•Pain assessments were inconsistently documented for palliative and end of life care patients across wards visited. We saw documentation specific to pain assessments were used on some wards and on others we saw no evidence of pain assessment.

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.

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.

Surgery

Good

Updated 3 December 2019

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

•The service provided mandatory training for staff and managers ensured staff completed this training. This ensured that the service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

•Staff maintained appropriate records of care and treatment both electronically and on paper.

•The service had suitable premises and equipment and looked after them well. Staff kept themselves, equipment and premises clean. They used control measures to prevent the spread of infection.

•The service provided care and treatment based on national guidance and evidence of its effectiveness such as that issued by National Institute for Health and Care Excellence (NICE). Managers checked to make sure staff followed guidance.

•Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed staff interacting with patients in a professional manner during the inspection.

•Staff involved patients and those close to them in decisions about their care and treatment. This ensured that patients were able to make informed decisions about their care. The trust planned and provided services in a way that met the needs of local people.

•Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. They were visible and approachable for patients and staff.

•The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

•The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However,

•For nursing staff eligible for infection prevention and control training, only 52% had completed this training against the trust’s completion target rate of 85%.

•Medical staff had not met the trust’s target completion rates for six of the mandatory training courses.

•Nursing and medical staff had not met the trust’s target completion rate for safeguarding children level 2.

•The management of obtaining patient consent for the storage of patient records at the patients’ bedside was not robust.

Urgent and emergency services

Requires improvement

Updated 3 December 2019

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

•There were challenges in meeting the Royal College of Emergency Medicine (RCEM) workforce recommendations in relation to consultant staffing.

•There were challenges in meeting guidelines relating to the care of children in the department in terms of appropriately trained staff being available.

•Medical training compliance in Mental Capacity were below trust targets.

•There were some concerns over the general environment in terms of staff safety as areas had unrestricted access.

•Concerns identified at the previous inspection regarding access and flow through the department remained a challenge.

•Whilst improvements had been seen there were still large number of patients staying in the department for longer than the recommended standard.

However;

•Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

•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, took account of patients’ individual needs, and made it easy for people to give feedback.

•Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. 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 continually.

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.