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Darlington Memorial Hospital Requires improvement

Reports


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.

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 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 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.

Our key findings were as follows:

  • 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.
  • Following work the trust had undertaken with the support of occupational psychologists and the more recent external reviews, there was some improvement in clinical behaviours but there continued to be issues relating to the cohesiveness of certain groups of medical staff. Certain elements of the obstetrics team remained dysfunctional with a lack of clinical engagement and support. The trust was continuing to work with the relevant members of staff and external partners to resolve current issues.
  • 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.
  • The antenatal clinic relied upon a paper-based logbook to record blood test results. This was a potential risk to patient confidentiality and loss of data.
  • There was a lack of space for handover on the delivery suite to take place.
  • 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 action continues to be taken to address poor behaviours and performance that is inconsistent with vision and values.
  • 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.
  • Review the process for recording of blood test results in the antenatal clinic.
  • Improve the environment for handover on delivery suite to ensure it is fit for purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5 and 6 February 2015

During a routine inspection

Darlington Memorial 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. It served around 600,000 people across County Durham, Darlington, North Yorkshire, the Tees Valley and South Tyneside 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 7555 staff. Darlington Memorial Hospital had 410 beds.

Darlington Memorial Hospital provided medical, surgical, critical care and maternity services, and services for children and young people, for 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 Darlington Memorial Hospital as part of the comprehensive inspection of County Durham and Darlington NHS Foundation Trust, which included this hospital, University Hospital of North Durham and the trust's community services. We inspected Darlington Memorial Hospital on 5 and 6 February 2015.

Overall, we rated Darlington Memorial as ‘requires improvement’. We rated it ‘good’ for being caring, effective and responsive, but it required improvement in providing safe and well-led care.

We rated medical care, surgical services, critical care, services for children and young people, maternity and gynaecology, and outpatient and diagnostic imaging services as ‘good’, with A&E, 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, 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 working overtime.
  • Mortality rates were within acceptable limits for a hospital of this size.

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

Importantly, the trust must:

  • Review the achievements and actions taken to address the targets set nationally within A&E.
  • Review consultant levels against CEM guidance.
  • Ensure that the A&E department meets cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors.
  • Ensure that the area outside the accident and emergency decontamination facility is free from dirt, litter and debris.
  • Be able to demonstrate that all toys are cleaned properly to reduce the risk of infection within the A&E department.
  • Ensure that staff regularly check all resuscitation drugs and equipment within the A&E department.
  • Ensure medicine fridges are locked and temperatures are checked regularly within the A&E department; this will include recording maximum and minimum fridge temperatures.
  • Ensure that medical gases are stored in a secure facility within the A&E department.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff on medical wards, in line with best practice and national guidance; taking into account patients’ dependency levels, particularly where patients are receiving non-invasive ventilation (NIV) and require Level 2 intervention. Also, ensure that actual staffing levels meet planned staffing levels.
  • 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, including those for patients awaiting discharge, are maintained and up to date, are patient-centred, contain the relevant information about their treatment and care, and serve to eliminate unnecessary delays.
  • Ensure that staff are conversant with the syringe driver policy and carrying out/recording 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 that medical staff record mental capacity assessments for patients who are unable to participate in decisions about do not attempt cardiopulmonary resuscitation (DNACPR).
  • Ensure that 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 that data is 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 within the A&E department.
  • Extend its safeguarding assessment processes and consider child sexual exploitation for all age appropriate children.
  • 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 through the hospital to ensure care is given in the most appropriate setting.
  • 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 timelines for review and achievement within the maternity and gynaecology services clinical and quality strategy for 2014–16 .
  • Consider ways of developing a coherent plan for joint working on improvements to maternity and gynaecology services.
  • Consider ways for improving timely and responsive human resource management processes, including personnel issues that affect service delivery in maternity and gynaecology services.
  • Ensure that the paediatric high dependency room has specific standard operating procedures or protocols available to guide the suitably trained staff required to deliver high dependency care.
  • 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. This should be separate from the safeguarding children executive lead role.
  • Review access and security arrangements to theatres and recovery areas.
  • Review the servicing of all equipment within the theatre and recovery areas to ensure maintenance and service arrangements are within required timescales.
  • Improve the systems in place to remove out of date stock or stock no longer used from store cupboards in the outpatient department.
  • 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 22, 23, 24 October 2013

During a routine inspection

The inspection team consisted of one compliance manager, three compliance inspectors, two specialist professional advisors (one in Accident and Emergency (A&E) and one in Infection Prevention and Control) and an expert by experience who obtained patient views. The inspection focused on two main areas. Firstly, how people experienced care and treatment from the moment they attended A&E, to inpatient care and through to the point of discharge to their home. Secondly on the management and organisational processes the hospital and its staff had in place with regards to infection prevention and control.

We visited A&E and wards 14, 21, 31, 33, 34, 44, 51 and 52. We spoke with 50 patients and / or relatives during the inspection; 30 in A&E and 20 on the hospital wards and reviewed the records of more than 20 patients. We spoke with ward sisters, nurses, healthcare assistants, catering and domestic cleaning staff. We spoke at length with the trust’s lead managers involved in infection prevention and control. This included the Director of Infection Prevention and Control (DIPC) and the infection prevention and control lead nurse. We also spoke with senior staff within facilities, estates, endoscopy, sterile services, theatres, catering, microbiology and pharmacy.

We found the A&E department appeared calm and well-ordered on the days we were there. Overall we observed patients were treated with dignity and respect by the nursing and medical staff on the days of inspection. This was reflected in the comments we received from patients, both within A&E and from patients who had been admitted onto the wards.

Comments from the patients we spoke with in A&E about how well they’d been kept informed were mixed. Some patients within the minor injuries streams said they’d been kept well informed about how their treatment was progressing, whereas others said they weren’t aware of the different systems operating within the department. Comments included “We have had triage sorted out, been seen and just been discharged….We have had plenty of information and understand what is wrong. We have been treated with respect; the whole experience has been very good” and “Not been informed by anyone from the department as to what is happening.” Comments from patients within the major injuries stream were largely positive and included “They (the staff) are polite and very pleasant” and “My experience here has been marvellous.”

We found patients had their health care needs assessed and received appropriate treatment to meet them; both within A&E and on the hospital wards. Patients told us staff were friendly and helpful. Comments included “I rang the buzzer during the night as the man opposite was confused and trying to get out of bed. They (the staff) came directly no problem”, “I think the staff are well trained to do their job” and “I am happy with the care I have received.”

The overall structure and governance in relation to infection prevention and control was judged to be positive. We found there were effective systems in place to reduce the risk and spread of infection. We saw clinical and patient areas were kept clean. We saw domestic staff were cleaning across all areas during our inspection. We saw staff regularly washed their hands and used disinfecting hand cleaner. We saw dispensers of hand cleaner at the entrance to the wards and at the entrances to bays and side rooms. We saw people who entered the wards for treatment or to visit people were encouraged to use these cleaners to help prevent the spread of germs.

Inspection carried out on 7 November 2012

During a routine inspection

Patients told us they were treated with dignity and respect. They said they were able to make informed choices and their privacy was maintained. One patient told us “The staff nurses and doctors explained to me what was going on.”

Patients care records were written in a clear and easy to understand way. The assessments and care plans contained within each person’s record detailed how staff should support each individual in the person’s preferred way.

The provider had sufficient numbers of staff with the right competencies, knowledge, skills and experience to meet the needs of patients.

The provider had clear procedures in place, which were followed in practice, for receiving, handling and responding to complaints.

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 5 July 2011

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

The patients that we spoke to said that they were happy with the food they got. We did not get any comments from patients about any of the other outcomes that we reviewed during this visit.

Inspection carried out on 9, 10 March 2011

During a routine inspection

When we visited the hospital we did not receive any comments from people who used the service or their relatives that gave us cause for concern. People told us that they were treated well and that staff were polite and kept them informed. They told us that the food was good and that there was enough staff on duty to meet their needs. One person told us that they had seen a big improvement in the hospital from when they were last in several years ago.