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Darlington Memorial Hospital 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 safe, effective, caring, responsive and well led as good.
  • Urgent and emergency care and surgery core service ratings improved by one rating to good and end of life care improved by two ratings to outstanding.
  • At the previous inspection we found that the service did not have enough staff. At this inspection we saw that the service had enough staff to care for patients and keep them safe. 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.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
  • Operating theatres were fully established against the ‘Association for Perioperative Practice’ (AfPP staffing recommendations). This was an improvement since the last inspection.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Improvements in practice were effectively embedded with continuous development to support continued awareness and learning surrounding serious incidents and never events.
  • 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.
  • 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,

  • Whilst improvement had been made in terms of access and flow, challenges still remained which impacted on wait times in the department for patients.
  • In surgery, mandatory training for nursing and medical staff failed to meet the trust target. In surgery, the targets were met for three of the nine mandatory training modules for which qualified nursing staff were eligible and three of the eleven mandatory training modules were met for which medical staff were eligible.
  • In Surgery, medical and nursing staff failed to meet the trust target for safeguarding children training (level 2).
  • In Surgery, medical staff failed to meet the trust target for Mental Capacity Act and Deprivation of Liberty Safeguards (level 2).
  • Oxygen was not always prescribed or administered in line with national guidance.
  • 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

Good

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 stayed the same. 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.
  • Managers investigated incidents quickly, and shared lessons learned and changes in practice with staff.
  • Staff understood and followed procedures to protect vulnerable adults or children.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They supported patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Wards and directorate 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 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.
  • 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:

  • The hospital did not meet targets for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training.
  • 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.
  • Meetings with directorate managers and trust senior managers did not give assurance that they were aware of these concerns before the inspection. We were given assurance that these issues would be addressed as a matter of urgency.
  • Medical and nursing records were not stored securely in all of the areas we visited.
  • Staff satisfaction was mixed according the staff survey. Staff did not always feel actively engaged or empowered. Equality and diversity were not consistently promoted and the causes of workforce inequality were not always identified or adequately addressed.

Services for children & young people

Good

Updated 29 September 2015

Overall, services for children and young people at this hospital were good.

The children’s services actively monitored safety, risk and cleanliness. 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 the need 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 we rated the intensive care unit as good. The environment was clean and the unit complied with the trust’s infection control policy. Medical and nursing staffing levels were adequate and there was evidence of a cohesive team working approach to patient care. The senior sisters on the unit were supernumerary so staff working on a 1:1 basis with patients could rely on the sister’s individual support when needed. Staff told us this made them feel safe. Staff were aware of the systems and processes in place for reporting patient and staff incidents. Staff we spoke with told us they were encouraged to report incidents and we were given examples where staff demonstrated an open and transparent culture of doing so. Staff regularly received feedback from an incident either by email or through staff huddles.

All aspects of care delivered in the unit were audited and reviewed and could demonstrate continuous improvement. The unit had an outreach team to identify and monitor deteriorating patients, although this was not well resourced. Patients received treatment and care according to national guidelines. The unit was obtaining good-quality outcomes as evidenced by its Intensive Care National Audit and Research Centre data. We found there was good multidisciplinary team working across the unit. Staff were actively engaged in reviewing patient outcomes through research and audit activities, peer review and benchmarking.

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 that ‘went the extra mile’. For those patients who were on the unit for exceptionally long periods of time due to their illness, we observed some very special relationships which had developed over time. We observed individualised care and attention to detail given to patients and relatives, evidenced by their work with the end of life team, their visitor’s charter, care of patients with learning disabilities and implementation and consideration of the deprivation of liberty safeguards standards.

The unit was responsive to patients’ needs. Staff worked across the ITU1 and ITU2 wards to ensure the required patient-to-nurse ratio was met. They also had a bed occupancy rate of 80–85% which enabled them to plan admissions and accept emergencies. The unit occasionally experienced a delay in discharges, often due to the lack of available beds on a ward, but also because of difficulties determining who the parent team was when patients were admitted via the emergency department.

We found there was a real commitment to working as a multidisciplinary team delivering a high quality and safe service. Feedback was valued as a way of improving the service. On a number of occasions the team went over and above what would be expected in order to keep patients feeling safe and at ease. There was strong medical and nursing leadership within the unit. Staff felt well supported within an open, positive culture. However, the process for governance was still to be embedded. The trust had recently identified a designated executive director to take lead responsibility for critical care services and a critical care delivery group (CCDG) had been set up. The first meeting of the CCDG took place in January 2015.

End of life care

Outstanding

Updated 3 December 2019

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

•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.

•The end of life and palliative care team did not hold its own risk register, and risks were held on the wider Community Services Risk Register.

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.
  • 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.
  • Midwifery staff had a competency framework which evidenced their progression from preceptorship. Development of midwives continued to a senior level.
  • Guidelines and action plans were in place, regularly reviewed and ratified at formal, planned meetings.
  • 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.
  • 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.
  • All women had a named midwife and staff were available if they needed them.
  • Patient pathways and flow through departments was planned and reviewed.
  • Effective governance structures were in place.
  • Staff spoke positively about their leaders and felt respected. Plans were in place to strengthen clinical leadership.
  • Teams were working proactively with local networks to improve outcomes.

However:

  • Results from the National neonatal audit programme (NNAP) indicated some lower than average standards; for example in the percentage of mothers who were given antenatal steroids and also the percentage of premature babies who had their temperature taken within an hour of being born.

Outpatients and diagnostic imaging

Good

Updated 29 September 2015

Overall the care and treatment received by patients in the Darlington Memorial Hospital 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.

There were some areas for improvement, such as the systems in place for checking storage cupboards for expired equipment. A number of patient information leaflets across the departments were past their review date.

The departments took part in the NHS Friends and Family Test (a satisfaction survey that measures patients’ satisfaction with the healthcare they have received) 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:

  • Several areas for improvement had been identified at our previous inspection in 2017. At this inspection we found these had been addressed in full or in part.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. This was an improvement since the last inspection.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
  • Operating theatres were fully established against the ‘Association for Perioperative Practice’ (AfPP staffing recommendations). This was an improvement since the last inspection.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Improvements in practice were effectively embedded with continuous development to support continued awareness and learning surrounding serious incidents and never events.
  • The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Nurse staffing was managed using recognised tools and professional judgment. To maintain safe staffing levels, the service monitored staffing levels and reviewed these daily using nationally recognised tools alongside clinical judgment.
  • The service had enough nursing staff with the right qualifications 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 services were effective because processes were in place to ensure that guidance used by staff complied with national guidance, such as that issued by National Institute for Health and Care Excellence (NICE).
  • Staff identified patients at risk of nutritional and dehydration risk or requiring extra assistance at pre-assessment stage. Patients were offered support when required.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed kind and caring interactions on the day units between staff and patients.
  • The service had stable management structures in place, with clear lines of responsibility and accountability. We saw evidence of learning, continuous improvement and innovation within surgical services at the location.
  • Patients we spoke to felt involved in their care and had been provided with information to allow them to make informed decisions.
  • The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement of staff, patients, and key groups representing the local community.

However,

  • Mandatory training for nursing and medical staff failed to meet the trust target. In surgery, the targets were met for three of the nine mandatory training modules for which qualified nursing staff were eligible and three of the eleven mandatory training modules were met for which medical staff were eligible.
  • Medical and nursing staff failed to meet the trust target for safeguarding children training (level 2).
  • Medical staff failed to meet the trust target for Mental Capacity Act and Deprivation of Liberty Safeguards (level 2).
  • Oxygen was not prescribed or administered in line with national guidance.
  • Pain assessments were inconsistently documented for medical patients across the wards we visited. We saw documentation specific to pain assessments were used on some wards and on others we saw evidence of pain recorded within the digital platform.
  • The management of obtaining patient consent for the storage of contemporaneous records at the patient’s bedside was not robust.
  • The service had a higher than expected risk of readmission for elective admissions in general surgery and ear nose and throat and a higher than expected risk of readmission for non-elective admissions in ear nose and throat surgery compared to the England average.

Urgent and emergency services

Good

Updated 3 December 2019

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

•At the previous inspection we found that the service did not have enough staff. At this inspection we saw that the service had enough staff to care for patients and keep them safe. 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. People could access the service when they needed it and did not have to wait too long for treatment.

•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.

However

•Whilst improvement had been made in terms of access and flow, challenges still remained which impacted on wait times in the department for patients.

Other CQC inspections of services

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