You are here

Provider: York Teaching Hospital NHS Foundation Trust Requires improvement

On 16 October 2019, we published a report on how well York Teaching Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 October 2019

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

  • We rated, effective, caring and responsive as good, and safe and well led as requires improvement. In rating the trust, we took into account the current ratings of the services not inspected this time.
  • York Hospital was not inspected at this time; therefore, its ratings remained the same. In 2017 the hospital was rated as good overall. We rated effective, caring, responsive and well-led as good, and safe as requires improvement.
  • Scarborough Hospital was rated as requires improvement overall. We rated safe as inadequate, effective, responsive and well-led as requires improvement and caring as good.
  • Bridlington Hospital was rated as good overall. We rated safe, effective, caring, and responsive as good, and well-led as requires improvement.
  • Community services were not inspected at this time; therefore, ratings remained the same. In 2017 we rated effective, caring, responsive and well-led as good, and safe as requires improvement.
  • We rated well-led for the trust overall as requires improvement.

Inspection areas

Safe

Requires improvement

Updated 16 October 2019

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

  • Within medicine services at Scarborough Hospital there was a risk that the service did not have sufficient staff with the right qualifications, skills, training and experience. This meant there was a risk the service could not keep patients safe from avoidable harm and provide the right care and treatment in a timely way.
  • The urgent and emergency care department did not have any paediatric trained nursing or medical staff and compliance with paediatric life support training was poor. However paediatric pathways were in place to support staff to safely care for children in the department.
  • Within medicine services, across a number of wards at Scarborough Hospital we found gaps in records of patients’ care and treatment. What was recorded was clear but not always up-to-date. This included food and fluid charts not being completed properly. This was an issue at the last inspection.
  • For a number of the core services, we found low levels of mandatory training compliance for medical staff. We were particularly concerned about the low levels of compliance in advanced life support training and safeguarding training for both children and adults in urgent and emergency care.
  • In outpatients, the service was not consistently assessing the clinical risk inherent in its waiting lists where patients were waiting beyond their expected appointment date for new and follow up appointments. Although ophthalmology had a system of clinical validation (Clinical Prioritisation) for patients waiting for appointments, this was inconsistent across the trust and some specialities had not clinically validated their waiting lists. This meant there was limited oversight of clinical risk in waiting lists across the specialities. Clinical validation was not consistently documented on the risk registers for outpatients and trust performance regarding overdue appointments was deteriorating.

  • We had concerns, in some services, about the systems and processes to safely prescribe, administer, record and store medicines.
  • In some services, resuscitation equipment and fridge temperatures were not checked daily.

However:

  • The midwife-to-birth ratio at Scarborough hospital was 1:22. (April 2018 to July 2019) which was better than the Royal College of Midwives (RCM) recommendation of an average of one midwife for every 28 births.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service managed patient safety incidents well and staff received feedback from incidents reported.

Effective

Good

Updated 16 October 2019

Our rating of effective stayed the same. We rated it as good because:

  • Services provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patient’s subject to the Mental Health Act 1983.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patient’s consent.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Staff followed national guidelines to make sure patients fasting before surgery were not without food for long periods.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
  • The maternity service had achieved UNICEF Baby Friendly Accreditation’ level three. The UNICEF UK Baby Friendly Initiative supports breastfeeding and parent infant relationships by working with public services to improve standards of care.

However:

  • Staff appraisals in some services did not meet the trust target rate so there was a risk the service could not make sure staff were competent for their roles.
  • While staff monitored the effectiveness of care and treatment, results in some national audits showed poor outcomes.

Caring

Good

Updated 16 October 2019

Our rating of caring stayed the same. We rated it as good because:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We found that patients received compassionate care from staff which supported their privacy and dignity.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. Most patients we spoke with felt staff were attentive and took time to explain things. Patients had access to chaplaincy services for those with a faith or none.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff understood the needs of their patients and involved carers. For instance, wards supported flexible visiting times for family and carers.

Responsive

Good

Updated 16 October 2019

Our rating of responsive stayed the same. We rated it as good because:

  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. However more work was needed to improve flow through the hospital to reduce waiting times in the urgent and emergency care department and reduce delayed transfers of care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • From April 2018 to March 2019 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was better than the England average in every month except for January 2019 when it was similar.
  • People could access the maternity service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were mostly in line with national standards.

However:

  • Waiting times across some specialities from referral to treatment were not always in line with national standards and there were patients waiting past their appointment dates for follow up. For cancer waiting times, the trust performed worse than the 85% operational standard for patients receiving their first treatment within 62 days of an urgent GP referral.
  • There were high numbers of cancelled clinics and increasing numbers of operations cancelled at short- notice.
  • The trust did not meet all of the urgent and emergency care standards.
  • Only 36% of complainants had received a completed response within the trust standard of 30 days.

Well-led

Requires improvement

Updated 16 October 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Although leaders had the skills and abilities to run the service, there was ongoing instability and change. Some leaders were new in post following the recent operational review, completed in March 2019 and were working to understand and manage the priorities and issues the service faced. Some services were failing to improve national performance targets.
  • Although the trust had an overarching vision and strategy the vision for services at Scarborough and Bridlington lacked coherence and details on how to turn existing directorate strategies into action.
  • While most staff felt respected and valued, some staff at Scarborough hospital did not feel supported and felt that not all senior managers took seriously the work pressure they were under or the impact of staff shortages on staff and patient safety.
  • There was a lack of governance oversight at department level. Staff were not always clear about the governance processes. Leaders operated within new governance processes and not all staff were clear about staff were not clear about their roles and accountabilities.
  • Not all the risks we identified risks were included on risk registers. For example, medical staff compliance with mandatory training and low compliance in children’s safeguarding and paediatric life support training; and lack of clinical validation (Clinical Prioritisation) and assessment of risk within outpatients waiting lists were not documented on risk registers.
  • The services had not addressed all of the issues identified at our last inspection in 2017.
  • The records management system within the trust was currently a hybrid system of electronic and paper, this meant that staff could not always find the data they needed, easily, to understand performance, make decisions and plan improvements.

However:

  • Leaders understood issues the service faced and staff at all levels were focused on the needs of patients receiving care. Staff reported an improving culture and felt that patients, their families and staff could raise concerns without fear.
  • Staff identified and escalated relevant risks and issues and identified actions to reduce their impact.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • Staff were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. There were examples of learning, improvement and innovation.

Checks on specific services

Community health services for children, young people and families

Good

Updated 8 October 2015

Overall rating for this core service Good

We found that services were effective and that staff were caring and responsive. In particular, we found in the ‘responsive’ domain that there were very good systems in place to provide translation services for people whose first language was not English, and sign language interpretation services for people who were profoundly deaf.

The ‘safe’ domain has been rated as requiring improvement. There were concerns raised with us that the design and environment of the contraceptive and sexual health service clinic at Monkgate in York did not allow for full confidentiality. We also found that 10,000 records were not completely secure at one of the trust’s locations. Staff told us that they were concerned that there was a backlog of paper documents resulting from a lack of scanners in some locations.

There was concern among school nursing staff that there was not enough flexibility built into staffing numbers and arrangements.

Overall, we found that the service was well led, although there was some concern from staff about a lack of support from senior managers within the school nursing and health visiting service.

End of life care

Good

Updated 8 October 2015

York Teaching Hospital forms part of the York Teaching Hospital NHS Foundation Trust and provides end of life care services on site and in partnership with Scarborough Hospital and Bridlington Hospital as well as community and hospice services. The community hospitals we inspected did not have any wards that specifically provided end of life care. Patients requiring end of life care were identified and cared for in ward areas throughout the community hospitals and in their own homes with support from the specialist palliative care team and district nurses.

The community wards we inspected were at New Selby War Memorial Hospital and Malton Community Hospital. We also saw people in their own homes and spoke to staff at the Scott Road Medical Centre and to community district nurses and nurses from the community palliative care team. Specialist palliative care was provided as part of an integrated service across both hospital and community teams.

During our inspection we spoke with a palliative care consultant, the lead end of life care nurse, the medical director, director of nursing, specialist palliative care nurses, chaplaincy staff, medical staff, nursing staff and allied healthcare professionals. In total, we spoke with 16 patients, 14 relatives and 15 members of staff.

We visited both of the community wards and people in their own homes as well as district nursing clinics. We reviewed the records of 16 patients who were receiving end of life care and 10 who were in receipt of palliative care.

We viewed seven DNA CPR forms (‘do not resuscitate in the event of a cardiac arrest’). Of these, five were appropriately signed and dated and there was a clearly documented decision, with reasoning and relevant clinical information. We reviewed audits, surveys and feedback reports specific to end of life care.

Staff were aware of and had access to the trust’s online incident reporting system. We saw evidence of learning from incidents to improve practice. Overall, the standards of cleanliness and hygiene were good and staff demonstrated a good knowledge of procedures for the management, storage and disposal of clinical waste, environmental cleanliness and prevention of healthcare acquired infections. Procedures were in place to ensure that equipment was maintained regularly and fit for purpose.

Community nursing staff reviewed their caseloads according to patient need; end of life patients took priority. Relatives and patients we spoke with talked positively about access to staff. We did not find evidence to suggest that community nurse staffing levels were adversely affecting the quality of patient care.

The trust had removed the use of the Liverpool Care Pathway and replaced it with an ‘individualised care plan for the last days of life’. Training in the replacement approach was still being undertaken by the trust. Patients receiving end of life services had their pain control reviewed daily. We saw that care followed the National Institute for Health and Care Excellence (NICE) Quality Standard CG140. The care records we reviewed showed that staff supported and advised patients who were identified as being at nutritional risk.

We saw that the trust had an action plan in place to address areas identified as part of the National Care of the Dying Audit for Hospitals (NCDAH), and that a number of areas had been addressed at the time of our inspection. The care and treatment provided achieved positive outcomes for people who used the service. Patients receiving end of life care were supported by a multidisciplinary end of life care team, which included a specialist palliative care team, consultants, GPs and district nurses.

Community end of life services were caring. Throughout our inspection, staff spoke with compassion, dignity and respect regarding the patients they cared for. All of the patients and relatives we spoke with told us that care was good. They were treated with respect and dignity and felt involved in their care and treatment.

We found that the service had a good understanding of the different needs of the people it served. Services were planned, designed and delivered to meet those needs. We saw that patients were able to dictate both their preferred place of care and preferred place of death through advance care planning. The trust monitored the performance of its end of life treatment and care service.

The end of life service had a clear local vision to improve and develop high-quality end of life care across the service. Most staff were aware of the trust’s vision and strategy; however, this was not fully embedded among all staff. There was good leadership and support from local managers, and most staff felt engaged. However, there was a lack of engagement with senior management. Risk management and quality assurance processes were in place at a local level. There was visible, motivated and committed leadership in terms of end of life care at board and service levels and a number of initiatives were in place to develop services.

Community health services for adults

Good

Updated 8 October 2015

Overall, we judged that community health services for adults were good, although some aspects of safety required improvement.

Incidents were reported across teams and serious incidents were investigated using root cause analysis, although staff received little feedback to share learning from incidents. There was a policy in place relating to the Duty of Candour requirement. The safeguarding adults policy was applied as part of practice, although safeguarding adults training was not up to date for a significant number of community services staff. The service had robust systems in place for the management and use of controlled drugs. Correct infection control techniques were followed. Staff demonstrated a sound awareness of key risks to patients and were proactive in responding to identified risks, although some local risk management arrangements lacked robustness.

The service faced some challenges with workforce planning and recruitment. Mandatory training participation rates for all modules across community services (except fire safety) fell below the trust minimum compliance target of 75%. Staff working alone were supported using informal procedures that were applied quite loosely in some teams; this meant that staff had some concerns regarding their own safety, particularly in the evening and at weekends. Some locations provided cramped facilities for staff and, outside the city of York, delays were encountered in the supply and maintenance of equipment, which potentially affected patient safety.

Policies and best practice guidelines were used to support care and treatment and staff understood their roles and responsibilities in the delivery of evidence-based care. A recognised assessment tool supported by national guidance was used to support the review of patients with pain symptoms. Nutrition and hydration assessments were usually completed, and patients were referred appropriately to specialist services. The NHS Safety Thermometer was completed. The service had an audit programme for 2014/15, but audits in community services were limited and there was no clinical audit plan in place.

Staff received annual appraisals and staff development and training were supported through a learning hub. Mentoring arrangements were used and a competency framework for therapy staff was being implemented from April 2015. Not all services were aware of clinical supervision arrangements. Multidisciplinary team meetings were held for complex patients and good relationships existed with primary care. Poor communication about the patient pathway was being addressed by working collaboratively. Most staff had an understanding of the Mental Capacity Act.

Patients and relatives were treated with respect, dignity, and compassion. Staff respected patient confidentiality in discussions with patients and their relatives and in written records or other communications. Staff provided emotional support to patients and their relatives.

Patients were assessed promptly for care and treatment and referrals were triaged. Any patient who was deemed to be an urgent priority was seen very promptly, usually within five working days. The single point of access did not currently include therapy services and there was no overnight or weekend community nursing service in Scarborough or Ryedale. Communication with hard-to-reach groups in the Scarborough area included good examples of involving homeless people and those who used substances. The service received few complaints but learning from the investigation of any complaints was shared.

The dementia strategy needed development for community-based services. We found evidence of poor access to services for some patients with a learning disability and some communication issues with mental health services. The timely supply of equipment for bariatric patients needed to be addressed. Discharge liaison arrangements between the acute hospital and community settings required some refinement.

The management arrangements for community services were being reviewed. An assistant director of nursing had recently commenced in post with specific responsibility for community services. The governance structure of the trust included an operational community services group. A central risk register was in place for community services but we identified some concerns regarding the escalation of risk. Senior staff met monthly to review clinical and managerial issues, to develop action plans resulting from audits, and to share learning. Learning was also shared at regular team meetings with nursing staff.

Recent changes to the structure of community services were viewed positively by staff. Staff mainly identified with the trust’s mission statement and followed its values, although no specific vision or strategy had been developed for community services. Senior community nursing staff were supported by senior nurse management. Clinical leadership required development. We found a mainly positive culture in community services although several teams told us that there was a hospital-focused, acute culture in the organisation with York seen as the centre. The service was a national pilot site for the development of community hubs to support the delivery of care nearer to home.

Community health inpatient services

Good

Updated 8 October 2015

Overall rating for this core service Good

Overall we rated effective, caring, responsive and well-led as good. We rated safety as requiring improvement.

Medical cover was provided in different ways in each location, but no service had dedicated or immediately accessible medical support in the evenings, at night or over the weekend. On most wards, there were two qualified nurses on duty for day shifts and the numbers of healthcare assistants met the staffing needs for the time of day. However, wards were full, this meant that at night there was a qualified nurse-to-patient ratio of up to 1:24 and during the day up to 1:12 (one qualified nurse for 24 or 12 patients). Following the inspection, the trust told us they had approved a case for increasing nurse staffing at night from 1 to 2 RNs in all its community units and recruitment was underway at the time of inspection. The controlled drug registers were generally found to be accurate. We found that pharmacy support was inconsistent and that a pharmacy technician was available once a week or less in the units. Resuscitation trolleys were kept in good order, and all equipment and materials were found to be in good condition and in date.

There was little evidence that community hospitals benchmarked their outcomes or quality of care against national guidelines or standards for patient care. However, staff were encouraged to give feedback on patient care both informally and formally at handovers. Clinical audits were carried out regularly and generally good levels of compliance were recorded. Staff told us at times audits were suspended for up to six months due to staff shortages. Following the inspection, the trust commented that they were not aware of any occasions where audits were suspended for this reason. There were some inappropriate admissions to the community wards from acute services, especially A&E, but these were risk managed and redirected to acute care if patients were not medically stable. The level of involvement of patients in care-planning varied. There was good planning and communication with therapy staff, however patients repeatedly told us they had not been told about their nursing care and treatment plans.

We spoke to 44 patients and 13 visitors who all told us that the care they received from all staff was excellent and that patients felt safe and cared for during their stay. We observed staff speaking to patients in a sensitive and compassionate manner. Staff knocked on doors before entering private areas and used privacy screens where available. Staff were kind and compassionate but had little time for patients to discuss their feelings and anxieties or to support them to talk about problems.

Facilities and equipment were available to meet the needs of patients. For example, rehabilitation equipment was available at most locations and hoists were provided. Admission criteria and pathways were in place and patients were usually admitted appropriately for nursing care and/or therapy input. Staff felt that they provided a good link between acute services and the community and had good connections with the therapy teams that followed up patients’ progress at home. Therapy staff supported patients from Monday to Friday. There was no therapy input at weekends and this often resulted in a break in the continuity of treatment and progress.

Staff understood the trust’s overall vision but there was no clear vision or strategy for the future regarding community services. There had been several recent changes within community services and staff expected further changes in the future, especially in Ryedale district and Whitby Community Hospital. Nurses told us they were taking on increasingly complex responsibilities involved in prescribing and night-time cover. Concerns about staffing levels were expressed by both staff and managers.  Managers supported staff to access additional nursing and healthcare assistant staff when clinical needs or new complex admissions required it. Staff told us that their managers were supportive.