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Darlington Memorial Hospital 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 and well led as requires improvement; effective, caring, and responsive were rated as good.
  • Overall, urgent and emergency care, medical care and surgery stayed the same since our last inspection. Maternity services had improved.
  • Seven never events had 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.
  • The department was having difficulty meeting the four hour target. Between October 2016 and September 2017 the department had only met the monthly 95% four hour target once.
  • The hospital did not meet targets for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training.
  • There were poor levels of overall compliance with mandatory training.
  • 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.

However:

  • In most areas nurse staffing had improved.
  • Care and treatment of patients requiring non-invasive ventilation (NIV) had improved since the last inspection.
  • 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 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.

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.

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.

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 department was having difficulty meeting the four hour target. Between October 2016 and September 2017 the department had only met the monthly 95% four hour target once.
  • The room used to assess patients with mental health needs, did not fully 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.
  • Clinicians did not update or review care pathways regularly.
  • The access was blocked to the major incident store cupboard.
  • The children’s resuscitation room doors were not closed or locked allowing easy access from the main corridor, which could be a potential security risk.
  • The layout of the main reception desk did not provide privacy as patients booked in.
  • Staff did not always record patients’ blood sugar levels when necessary
  • 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.
  • 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 and abuse.
  • Staff were able to identify and respond appropriately to patients at risk of deteriorating.
  • The department met the standard for patients receiving treatment within one hour.
  • 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 staff.
  • We raised concerns with the trust that equipment servicing had not taken place. The trust said a new system was implemented and equipment service records were up to date. We did not receive documentary confirmation that the equipment whose service dates had passed were serviced.
  • 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 said they had not attended regular training, as they were too busy to attend.
  • Task and finish groups were still in progress working on culture issues in theatres, further improvements needed to be embedded.
  • 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.
  • 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.

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.
  • 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 guidance 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 trust vision and strategy was understood by staff and put into practice.
  • 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 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.

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.

End of life care

Requires improvement

Updated 29 September 2015

End of life care services at this hospital required improvement. Monitoring of the safe use of syringe drivers for end of life medication was not being recorded consistently or in line with the trust’s policy. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were generally being completed accurately and comprehensively, but mental capacity assessments were not being recorded when there was an indication that patients did not have capacity to be involved in decision making.

Staff were seen to be caring and compassionate and we saw that the development of pastoral and spiritual services were planned for as part of the end of life care steering group. We saw that 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 were being developed to address these needs, but at the time of our inspection we saw that staffing difficulties had affected the ability of the specialist palliative care team to take action to develop the service.

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 that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. 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 the preferred place of care for patients at the end of life wishing to be at home.

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.