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University Hospital North Durham Requires improvement

We are carrying out a review of quality at University Hospital North Durham. We will publish a report when our review is complete. Find out more about our inspection reports.


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.

Inspection carried out on 12 Sept to 20 Oct 2017

During a routine inspection

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.


  • 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 carried out on 7-9 September 2016

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

We carried out this inspection 7 – 9 September 2016. This was a focussed unannounced inspection in response to external reviews carried out at the trust looking at serious incidents and concerns around the culture within maternity services. The external reviews were initiated by the trust following heightened scrutiny of maternity services and monitoring of the service internally. We looked at areas within the safe and well-led domains.

  • There was an ongoing review of governance structures and quality assurance processes. The Trust had identified the need to enhance governance in the service and had appointed a new leadership team who were revising current practice. Actions were agreed with external partners, some having recently been implemented, but were not yet embedded.
  • Assurance processes to ensure guidelines and practice was followed was not clear which led to confusion amongst staff and women. The assessment, compliance and approval of guidelines were included in the governance review.
  • Although weekly risk meetings were held to discuss incidents and key message bulletins were produced to inform all staff of lessons learned, some staff felt that these processes could be stronger.
  • The completion of the World Health Organisation surgical safety checklist was not meeting trust targets in all except one domain.
  • There was a newly formed senior leadership team in maternity. The team was cohesive and there was a real drive to improve the quality of the service. The team were aware of the challenges and were able to articulate the actions required to take the service forward.
  • Staff spoke positively about the leadership team and told us the head of midwifery was supportive and approachable. Plans were in place to strengthen clinical leadership.
  • Staff were aware of the process to follow to report incidents.
  • Recommended midwifery to birth ratios and consultant presence on the labour ward were met
  • Results from the NHS safety thermometer showed that women had received harm free care over the last 12 months.
  • Records relating to women’s care were detailed enough to identify individual needs and to inform staff of any risk and how they were to be managed. There were appropriate escalation procedures for women requiring an emergency response. The early warning score for assessing risks had improved.
  • The service had an action plan in response to the Morecambe Bay Investigation recommendations. The majority of these were completed with a few still partially completed due to ongoing re-organisation of the trust.

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

Importantly, the trust must:

  • Ensure that the recent improvements to the governance framework are fully embedded to support the delivery of high quality care, including assessment, approval and compliance of guidelines.
  • Improve compliance against the WHO surgical safety checklist.

In addition the trust should:

  • Continue to implement the recommendations identified in the review of midwifery staffing to ensure the appropriate deployment of staff in the correct areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3-4 and 25 February 2015

During a routine inspection

The University Hospital of North Durham was one of two acute hospitals forming County Durham and Darlington NHS Foundation Trust. This trust was one of the largest hospital and community healthcare providers in the NHS. County Durham and Darlington NHS Foundation Trust served around 600,000 people across County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside, with services including health and wellbeing services, community-based services, and acute and planned hospital services.

In total the trust had 1,331 beds across two acute hospitals and the community, and employed around 7,555 staff. The University Hospital of North Durham had 460 beds.

The University Hospital of North Durham provided medical, surgical, critical care and maternity services, and services for children and young people in County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside. The hospital also provided emergency and urgent care (A&E) and outpatient services.

We inspected the University Hospital of North Durham as part of the comprehensive inspection of County Durham and Darlington NHS Foundation Trust, which included this hospital, Darlington Memorial Hospital and the trust's community services. We inspected the University Hospital of North Durham on 3, 4 and 25 February 2015.

Overall, we rated the University Hospital of North Durham as ‘requires improvement’. We rated it ‘good’ for being caring and responsive, but it required improvement in providing safe, effective and well-led care.

We rated surgical services, critical care, services for children and young people, and outpatient and diagnostic imaging services as ‘good’, with A&E, medical care, maternity and gynaecology and end of life care as ‘requires improvement’.

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. Rates of Methicillin-resistant staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the trust.
  • Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, on the whole, they were content with the quality and quantity of food.
  • There were processes for implementing, and monitoring the use of, evidence-based guidelines and standards to meet patients’ care needs.
  • There was effective communication and collaboration between multidisciplinary teams.
  • There were staff shortages, particularly on some medical wards and in the maternity and gynaecology service, mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank, agency and locum staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.
  • Mortality rates were within acceptable limits for a hospital of this size.

There were areas of poor practice where the trust needed to make improvements.

Importantly, the trust must:

  • Review the achievements and actions taken to address national targets within A&E.
  • Review consultant levels against CEM guidance.
  • Ensure the A&E department meets cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors. Chairs and equipment that have deteriorated must be removed and replaced.
  • Ensure all toys are cleaned properly to reduce the risk of infection within the A&E department.
  • Ensure sharps bins are managed appropriately to reduce the risk of needle stick injury within the A&E department.
  • Ensure that all resuscitation drugs and equipment within the A&E department are regularly checked, cleaned and in date. This should include all grab bags and anaphylaxis kits.
  • Ensure that all relevant staff know where the difficult airway kit is kept.
  • Ensure that there are robust risk assessments in place for the paediatric environment within the A&E department. These must be readily accessible and available to all staff in the department. Risk mitigation must be outlined and an action plan to improve the area must be written.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance and taking into account patients’ dependency levels on medical wards, particularly where patients are receiving non-invasive ventilation (NIV) and require Level 2 intervention.
  • Undertake a review of current documentation relating to the care and management of patients receiving NIV to ensure that it is consistent across both the University Hospital of North Durham and Darlington Memorial Hospital.
  • Have arrangements in place for patients who are in receipt of NIV that comply with the British Thoracic Society guidelines (2008) for the use of NIV for acute exacerbation of chronic obstructive pulmonary disease.
  • Undertake a regular audit of the provision of services to patients requiring NIV to ensure that the service is safe and to the appropriate quality.
  • Ensure that patients are placed on the most appropriate ward to meet their needs, including a review of the care of patients requiring NIV to ensure that they are admitted to a suitable ward with appropriately skilled and experienced staff in line with best practice guidance.
  • Ensure that patient records are maintained up to date, are patient-centred and contain the relevant information about their treatment and care, including patients awaiting discharge to eliminate unnecessary delays.
  • Ensure that staff know the syringe driver policy and carry out/record syringe driver checks in line with this policy.
  • Add audits of syringe driver administration safety checks to the annual end of life audit programme.
  • Ensure medical staff record mental capacity assessments for patients who are unable to participate in decisions about do not attempt cardiopulmonary resuscitation (DNACPR).
  • Ensure audits of mental capacity assessments are incorporated into audits of DNACPR forms.
  • Ensure robust implementation of structural changes to the specialist palliative care team to support the development of the end of life care services.
  • Ensure data are available to identify and demonstrate the effectiveness of the end of life service.

In addition the trust should:

  • Continue to review College of Emergency Medicine (CEM) audit data to ensure patient outcomes are met.
  • Direct medical staff to check resuscitation equipment and drugs before the start of their shift even when nursing staff have completed the checks.
  • Encourage all relevant staff within the A&E department to attend violence and aggression training.
  • Ensure that patients have their medicines reconciled in accordance with trust targets.
  • Review access to patient information in languages other than English.
  • Review dedicated management time allocated to ward managers.
  • Review the patient flow of higher dependency patients throughout the hospital to ensure care was given in the most appropriate setting.
  • Have an up-to-date standard operating procedure (SOP) which clearly sets out the management of patients requiring NIV who are admitted to the University Hospital of North Durham.
  • Ensure that this guidance/SOP includes clarity on the setting/specific ward in which patients can be managed.
  • Ensure that this guidance/SOP includes staffing to patient ratios that are in line with current guidance.
  • Ensure that there is a training plan in place, which is delivered to all staff involved in the care of patients receiving NIV, and that it is competency-based and in sufficient detail to demonstrate competence in all aspects of NIV.
  • Ensure that any guidance/SOP includes an escalation plan that includes action to be taken when a bed is unavailable in an appropriate setting and when patient numbers do not match agreed staffing ratios.
  • Ensure that the intensive care unit has an outreach team to identify and monitor deteriorating patients.
  • Ensure that there is clinical pharmacist input in the intensive care unit in line with Core Standards for Intensive Care guidelines.
  • Consider ways of improving engagement between staff and managers within the care closer to home directorate with a view to achieving a joined up approach within maternity and gynaecology services. Also, consider ways of improving responsiveness and efficiency in respect to service-level decisions within this service.
  • Consider ways in which it can identify the required standards within the maternity service dashboard.
  • Consider within the maternity and gynaecology services clinical and quality strategy for 2014–16 timelines for review and achievement.
  • Consider ways of developing a coherent plan for joint working on improvements in maternity and gynaecology services.
  • Consider ways of improving timely and responsive human resource management processes, including personnel issues that impact on service delivery in maternity and gynaecology services.
  • Ensure that the paediatric high dependency unit room has specific standard operating procedures or protocols available to guide suitably trained staff.
  • Ensure that advanced paediatric nurse practitioners have a set of standard operating procedures available to guide their practice and care.
  • Formally nominate an executive or non-executive director to represent children at board level, separate from the safeguarding children executive lead role.
  • Ensure that actions against the National Care of the Dying Audit and other identified actions to develop the service are carried out in a planned and timely way with continued evaluation.
  • Ensure that systems support ways of identifying when incidents and complaints relate to end of life care so that specialist input can be provided and recorded in terms of investigation and learning.
  • Ensure that any out of date medication is removed from stock cupboards once it has expired, in line with the trust medication management policy, and have a process for monitoring this within outpatients.
  • Ensure that all fridge temperatures are checked daily and that there is a system in place to monitor that checks are taking place within the outpatient department.
  • Ensure that all resuscitation equipment is checked daily, stored securely and introduce a monitoring system to ensure that checks take place within the outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 19, 20, 21 November 2013

During a routine inspection

The inspection team consisted of one compliance manager, three compliance inspectors, two specialist professional advisors (one in Elderly Care and one in Governance) and an expert by experience who obtained patient views. The inspection focused on two main areas. Firstly, the care of elderly patients including those with dementia type illnesses. Secondly on the systems that were in place for monitoring the quality of the service and how the hospital ensured their governance processes resulted in the continuous improvement of patients' care.

We visited wards 1, 2, 3, 5, 11 and 12. We spoke with 84 patients and / or relatives during the inspection and reviewed the records of 38 patients. We spoke with matrons, ward managers, ward sisters, nurses and healthcare assistants. We also spoke at length with the trust’s lead managers and members of the board in relation to governance. In total we spoke with 48 members of staff.

All of the wards we visited were very busy during the inspection. We observed many interventions from medical and nursing staff throughout the days. Although very busy, each ward visited was noted to be very responsive to patient calls. Nurse call activations were responded to quickly; as were patients calling out to staff from their rooms.

The observed care of the patients on the wards we visited appeared to be of good quality. The staff were observed to be diligent, warm, professional and appropriate in their interactions with patients. The provider may find it useful to note that decision making in relation to DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) was found to be inconsistent. A DNACPR order means if someone’s heart or breathing stops as expected due to their medical condition, no attempt should be made to perform cardiopulmonary resuscitation (CPR).

Patient feedback on the care received was mainly positive. Patients considered the staff to be kind, courteous and considerate. They felt they were being kept fully informed by doctors, consultants and the nursing staff regarding their treatment. They felt that the staff caring for them were skilled to do so appropriately. Where people told us they had raised issues, or we spoke with staff about problems they disclosed to us, we saw these matters had already been or were resolved.

We found patients had their health care needs assessed and received appropriate treatment to meet them. Comments from patient’s and relatives included “From being admitted the care has been wonderful, the nurses never stop they are rushed off their feet”, “The doctors have been very good, discussing everything with me”, “The nurses do their job very well, I am very content with how they look after me” and “When my wife phones they give her all the information. We have no complaints, honestly.”

We found there were appropriate arrangements in place to assess and monitor the quality of service provision, including clear evidence of a governance structure and focus operating within the hospital.

We spoke at length with the trust’s lead managers and members of the board in relation to governance arrangements and assessing and monitoring the quality of service provision. The majority of the staff we interviewed were dedicated, committed and passionate and wanted to improve patient care. There was an evident culture of openness where people were prepared to admit when things had gone wrong and had acted appropriately to learn from incidents and improve patient care. We found there was a genuine willingness to engage and learn from others.

We saw examples that demonstrated good practice and improving quality. These included the development of care groups and the continuous quality improvement processes. Representatives from the care groups we spoke with said they felt they were able to drive quality and make improvements from within their own care groups and from the bottom up.

We found the majority of the assessments and plans for care we saw had been reviewed regularly and updated when required. We found some records had not been updated as regularly as required. This meant that accurate records in respect of each patient were not always being maintained. We have told the hospital to take action to address this and will return to check on this again.

Inspection carried out on 12 March 2013

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

Patients were involved in the care they received and their privacy and dignity was respected.

We spoke with ten patients in different areas of the accident and emergency department (A&E). One patient and their family in the short stay area of A&E told us the staff had treated them with privacy and dignity. They knew they were being assessed and monitored following a head injury and had been told if all was OK after 24 hours they would be discharged. They said “Everything has been explained every step of the way. They are very good.”

They also told us they had had tea and toast at breakfast time but didn’t have anything the night before because of their head injury. They said the staff always knocked on the door before entering their room. The relative said “I think communication is alright here. The staff have all been very nice.”

Inspection carried out on 17 October 2012

During a routine inspection

We visited four wards, ward 2 (acute stroke unit), ward 6 (respiratory medicine), ward 15 (plastic surgery), ward 16 (elective orthopaedics) and the accident and emergency department on this inspection. It was an early evening inspection that started at 1600.

Nearly all the patients we spoke with were satisfied with the care and treatment they had received. Comments included “Everything’s good, I’m well looked after”.

There were also many positive comments about staff. Comments included “I have nothing but admiration for them”,” Couldn’t ask for better.”

However, we did find sometimes patient’s dignity and privacy was not being respected.

Inspection carried out on 18 January 2012

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

We visited University Hospital of North Durham to check whether improvements had been made to two compliance actions. We visited ward 1 (elderly medicine), ward 3 (acute medical admissions), ward 11a (winter pressures resource), ward 12 (orthopaedic inpatients) and the orthopaedic outpatient clinic.

We spoke with patients, visitors and staff on the wards to see what improvements had been made since our last visit.

One patient told us, “I feel well looked after.” Another person said, “The staff are all very nice and helpful”.

Visitors told us that the longer visiting times were “better” because they could spend more time with older patients. Relatives were also positive about the support and information they received whilst visiting patients

One visitor told us that they had requested to stay with their relative on the ward for the last few nights. They told us that ward staff had provided them with a reclining chair during that time, and that they had been able to make hot drinks whenever they liked in the ward kitchen.

Overall, people had positive comments to make about the meals and drinks. One patient said, “It’s a marvellous place, the food is lovely.”

Another patient told us, “The meals are canny, and I’ve had a lot worse. It takes me a while to eat them because they are big portions, but I manage.”

Another person told us, “The meals have been fine, sometimes it’s a bit too much. I prefer a coloured glass because of my bad sight and they usually remember to give me one.”

Patients told us that there were “plenty of choices” of meals and drinks.

A visitor told us, “There always plenty of tea and biscuits, and she said the lunchtime mealtime was ok and she’s chosen from the menu for tonight’s meal.”

Inspection carried out on 23 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 25 August 2011

During a routine inspection

We visited the University Hospital of North Durham on 25 and 26 August 2011. During the two days we were there, we spent time on the following wards: Accident and Emergency including X.Ray, ward 3 Acute Medical Admissions and Ambulatory Care, Ward 7 Child Health, Ward 10 Post Natal, Ward 1 Elderly Medicine, Ward 12 Orthopaedics inpatients and outpatients and Ward 13 Surgery.

Generally the comments we received from patients that we spoke to were positive with many patients being satisfied with the care they received. What we saw during our visit to some of the wards at University Hospital North Durham differed from what some patients told us. Opinions about the food were varied with some people saying that they liked the food and others saying that there was not always something suitable for them to eat.