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Provider: York Teaching Hospital NHS Foundation Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 19 September 2017

During a routine inspection

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

  • We rated safe and effective as requires improvement, caring and responsive as good.
  • Our ratings of two of the three hospitals stayed the same; we rated Scarborough and Bridlington hospitals as requires improvement. Our rating of York Hospital improved, we rated it as good.
  • In rating the trust we took into account the current ratings of the seven services not inspected this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • We rated well-led at the trust level as requires improvement.


CQC inspections of services

Service reports published 8 October 2015
Inspection carried out on 17–20 March 2015 During an inspection of End of life care Download report PDF | 320.05 KB (opens in a new tab)
Inspection carried out on 17–20 March 2015 During an inspection of Community health services for children, young people and families Download report PDF | 295.23 KB (opens in a new tab)
Inspection carried out on 17–20 March 2015 During an inspection of Community health inpatient services Download report PDF | 310.77 KB (opens in a new tab)
Inspection carried out on 17–20 March 2015 During an inspection of Community health services for adults Download report PDF | 475.37 KB (opens in a new tab)
See more service reports published 8 October 2015
Inspection carried out on 17 – 20, 30 - 31 March and 11 May 2015

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

We inspected the trust from 17 to 20 March 2015 and undertook unannounced inspections on the 30 and 31 March 2015 and the 11 May 2015. We carried out this comprehensive inspection as part of the CQC’s comprehensive inspection programme.

We inspected the following core services:

  • The York Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care, outpatient services and diagnostic imaging.
  • Scarborough Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care and outpatient services and diagnostic imaging.
  • Bridlington Hospital - medical care, surgical care, end of life care and outpatient services and diagnostic imaging.
  • Community Health Services – including:

  • Community health inpatient services at White Cross Court Rehabilitation Unit, Archways Intermediate Care Unit, St Monica’s Community Hospital, New Selby War Memorial Hospital, Malton Community Hospital and Whitby Community Hospital Community end of life care
  • Community health services for children, young people and families
  • Community health services for adults
  • Community end of life services

Overall, the trust was rated as requires improvement. Safety, responsiveness and well led were rated as requires improvement. Effective and caring were rated as good.

The trust leadership had generally been stable over the last few years but had recently seen some changes: two appointments had been made, a chief operating officer in 2015 and in the latter part of 2014 a new director of nursing. A new chairman was to start in April 2015. The trust was half way through a five year integration plan following the acquisition of Scarborough and North East Yorkshire NHS Trust and had also acquired community services in 2011. These acquisitions had considerably increased the size and complexity of the Trust. At the time of inspection, as part of its programme of continued improvement, the trust was in the process of reviewing its governance and reporting arrangements.

Our key findings were as follows:

  • Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
  • Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
  • We found the hospitals were visibly clean, hand-washing facilities and hand cleaning gels were available throughout the services and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
  • The provider was unable to consistently provide safe staffing levels across the trust. There were shortages of: nursing staff on some medical and surgical wards; consultant cover within A & E; and community inpatient staff. The trust was actively trying to recruit to the majority of these roles.
  • There was additional concerns regarding the operation of ward 24, the winter pressures ward at York district hospital, which was often reliant on a majority of hospital bank and agency workers to staff it.
  • Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
  • There were concerns that patients arriving in both A & E departments did not receive a timely clinical assessment of their condition.
  • The trust was not achieving its own target of 75% compliance with mandatory training which included safeguarding training.
  • The trust had no mortality outliers. However, the Summary Hospital-level Mortality Indicator (SHMI) for Scarborough hospital of 107 was higher than both the Trust overall (102) the England average (100) in June 2014. At York hospital for the same period the indicator was 98. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
  • There was no hospital-wide pain team at Scarborough; the critical care unit staff supported patients requiring pain management in-house. We were told that staff, including the consultant intensivists, were experienced and able to competently manage work relating to pain management.
  • Protocols, guidelines and pathways of care in all three hospital sites were variable and not yet fully established.
  • There had been significant work to develop services to support the needs of people living with dementia.
  • The design and environment of the contraceptive and sexual health service clinic at Monkgate in York did not allow for full confidentiality.
  • There were 10,000 records not completely secured at one of the trust’s community locations.
  • Governance arrangements and assurance that issues had been identified and acted upon in a timely manner required improvement.
  • The culture within the trust was, in the main, positive and open. Staff wanted to work more collaboratively across the three acute hospitals and community and felt that this area was improving. There were however, some frustrations voiced by staff especially at the Scarborough and Bridlington hospitals regarding the acquisition and lack of senior leadership and presence on site.

We saw several areas of outstanding practice including:

  • The appointment of a senior paediatric specialty trainee ‘quality improvement fellow’ for one year has led to improvements such as the use of technology in handover sessions, with further plans for development of electronic recording of clinical observations and the PAWS assessment.
  • We saw positive partnership working with and support from CAMHS in York, which ensured that the acute inpatient wards had seven-day support. The community nursing team also had a CAMHS nurse specialist allocated to the team who provided psychological support for families and staff.
  • The trust had developed non-cancer pathways to support quality care for patients who were at the end of life. Specific innovations included pathways for patients with COPD and heart failure and included working on advance care planning initiatives to ensure patients’ preferences and choices were clear.
  • The innovative way in which central venous lines were monitored, which included a central line clinical pathway. The critical care unit were finalists for an Institute for Healthcare Improvement (IHI) safety award for this pathway.
  • The medical service had an innovative facilitating rapid elderly discharge again (FREDA) team, which provided multidisciplinary support and rehabilitation to elderly outlying patients.
  • Ward 25, an integrated orthopaedic and geriatric ward, worked closely with the A&E department, and actively identified elderly patients with a fractured neck of femur, to speed up flow to the ward and on to theatre, had demonstrated positive outcomes of speedier rehabilitation and reduced length of stay, with the majority of patients returning to their usual place of residence.
  • Phlebotomy outreach clinics in the local community, have led to improved access to the service.
  • Availability of pathology services in the oncology outpatient department, meant that up-to-date blood results were available for patients when they saw the consultant in clinic. Treatment changes were based on up-to-date information.

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

Importantly, the trust must:

For York hospital:

  • ensure all patients have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011.
  • ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels including; nursing staff on medical and surgical wards; consultant cover within A & E; and registered children’s nurses on ward 17 and other clinical areas where children were treated..
  • ensure there are suitable arrangements in place for staff to receive appropriate training and appraisals in line with Trust policy, including the completion of mandatory training, particularly the relevant level of children and adult safeguarding training and basic life support so that they are working to the up to date requirements and good practice.
  • address the breaches to the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets to protect patients from the risks of delayed treatment and care.
  • ensure that patients’ privacy and dignity is maintained when being cared for in the bays in the nursing enhanced unit based on ward 16.

For Scarborough hospital:

  • ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance, taking into account patients’ dependency levels, especially in A & E, on the medical and surgical wards, operating department practitioner (ODP) cover within theatres, radiology and senior medical cover in relation to cross-site working. Additionally within critical care the provider must ensure staffing levels are adequate to ensure clinical education, unit management, clinical coordination, continuity of care, and effective outreach.
  • ensure that there is adequate access for patients to pain management and dietetic services within critical care.
  • ensure improvements are made in the 18 week referral to treatment time target and cancer waiting times so that patients have access to timely care and treatment.
  • ensure that staff, especially within medicine, outpatients & diagnostics and critical care, complete their mandatory training, and have access to necessary training, especially basic life support, mental capacity and consent (Outpatients and diagnostic staff), safeguarding vulnerable adults and safeguarding children.
  • ensure that pathways, policies and protocols are reviewed and harmonised across the trust, to avoid confusion among staff, and address any gaps identified.
  • ensure that patient flow into and out of critical care is improved, specifically in relation to delayed discharges, delayed admissions, running at high capacity and non-clinical transfers out of the unit.
  • ensure that all equipment is tested in a timely manner and in line with the Trust’s policy, especially checks on fridges and resuscitation equipment.
  • ensure that there is a clear clinical strategy for both critical care and outpatients and diagnostics and that staff are engaged in agreeing the future direction and involved in the decision-making processes about the future of the service.

For Bridlington hospital:

  • ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance, taking into account patients’ dependency levels; especially in relation to staffing of the medical and surgical areas.
  • review the uptake and monitoring of training, and ensure that staff are compliant with mandatory training requirements, especially in the areas of moving and handling, fire safety, safeguarding vulnerable adults, and safeguarding children.

For community services:

  • ensure there are sufficient numbers of suitably skilled, qualified and experienced staff, in
  • line with best practice and national guidance, taking into account patients’ dependency levels for community inpatient services.
  • review the uptake and monitoring of training, and ensure that staff in community services are compliant with mandatory training requirements.
  • ensure that patient records are fully secured when stored.
  • review arrangements to support community staff working alone to ensure their safety.

In addition there were actions the trust should take and these are listed at the end of each of the individual location and community service reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.