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Provider: South Tees Hospitals NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 July 2019

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated well-led at the trust level as requires improvement.
  • At trust level we rated safe, effective and well-led as requires improvement with caring and responsive as good.
  • The ratings went down for some services and domains. Both James Cook and Friarage hospitals were rated as Requires improvement overall.
  • Critical care services had deteriorated significantly since the last inspection. We found them to be inadequate in Safe at both acute hospitals and requiring improvement in effective, responsive and well led. Caring remained Good at James Cook University hospital. We did not have enough evidence to rate caring at the Friarage hospital.
  • The overall rating for urgent and emergency care at the Friarage deteriorated to requires improvement overall.
  • The well led rating in surgery at both sites went down to requires improvement.
  • The safe domain in medicine and urgent and emergency care at James Cook hospital went down one rating to requires improvement.
  • Diagnostic imaging services at both acute sites were rated as requires improvement overall.
  • Patients and carers gave positive feedback about the care they received.
  • Community services were not inspected; their previous rating was Good overall.
  • In rating the trust, we took into account the current ratings of the other 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.

Inspection areas

Safe

Requires improvement

Updated 2 July 2019

Our rating of safe went down. We rated it as requires improvement because:

  • The safety of services had deteriorated at both acute hospital sites since the previous inspections. Critical care was rated inadequate for safe at both sites. There were two serious incidents where trust and national guidance were not followed in relation to raised NEWS scores which led to adverse outcomes for the patients involved. There had also been three serious incidents resulting in patient harm as a consequence of critical care beds not being available.
  • Critical care staff were not regularly reporting incidents of staffing shortages and their impact on patient safety. We observed staffing shortages during the inspection, supernumerary coordinators were not in place in all areas and GPICS standards of 1:1 care for level three patients and 1:2 care for level two patients were not always adhered to. This posed significant risks to patients.
  • The trust did not always adhere to their own guidance on the number of elective patients taken to theatre each day who required a critical care bed post operatively. This combined with the emergency demand for beds and the James Cook University hospital being a major trauma centre, meant there was a risk that there may not be capacity in critical care.
  • Not all the critical care units were compliant with Health Building Note 04 02 best practice guidance. This was in relation to the size and design of some bed space areas and a limited number of isolation rooms. We also found storage areas were not locked or doors were propped open in each area we visited.
  • Emergency care services did not meet the current paediatric standards for children in emergency departments: paediatric patients were not fully separated from adult patients and the dedicated paediatric areas were not secure to prevent adults from entering the area or children and young people from leaving. The designated mental health room did not meet the quality standards; it contained fixings and fittings which posed ligature and harm risks to patients, visitors and staff. There were shortages of nursing staff on rotas in urgent and emergency care.
  • In medical services the medicines management surrounding reconciliation of patient medicines on admission was not robust.
  • Patient records were not secure in ward areas. Records were stored in open, unlocked trolleys; whilst the trolleys did have lids with locks they were not locked.
  • Mandatory training was below trust compliance for the services we inspected in some subjects, such as infection, prevention and control and safeguarding.
  • The lack of radiologists impacted on delivery of the diagnostic imaging services.
  • Not all diagnostic service staff were able to recognise incidents and report them appropriately. They were not effectively monitoring trends and themes from incidents. We saw incidents that had not followed the correct procedure of reporting both internally and externally.

However:

  • Medical and surgical wards had sufficient staff to keep people safe from avoidable harm and to provide the right care and treatment
  • Patients were assessed in the emergency department using the national early warning score which provided staff with early warning of deteriorating patients, enabling them to take the appropriate action and escalate any patient of concern to medical staff.
  • Within surgical services the World Health Organisation safer surgery checks were embedded.
  • Care plans and risk assessments were in place and these were completed in detail.

Effective

Requires improvement

Updated 2 July 2019

Our rating of effective went down. We rated it as requires improvement because:

  • The number of staff with the post registration award in critical care for the general HDU and ITU at the James Cook University hospital was 33%, this was below the national GPICS recommendation of 50%. The trust did not provide data for the other critical care units, so we were unable to assess compliance in these areas.
  • National Audit and Research Centre (ICNARC) data was not collected for all the critical care units at the trust. This meant they could not monitor all patients care and treatment outcomes and benchmark them against similar units.
  • There was limited critical care pharmacy provision across the units. This was not in line with GPICS recommendations, some areas had no specialist pharmacy input.
  • The number of clinical educators in critical care compared to the number of staff was not in line with GPICS recommendations.
  • Action plans we reviewed from urgent and emergency care service audits were not consistently completed, they did not have actions identified or re-audit dates included to improve performance. At the Friarage hospital the urgent and emergency care service did not participate in all the relevant national audits.
  • We did not see that patients were offered food and nutrition, if required, during their attendance in urgent and emergency care.
  • At Friarage hospital in medical care services we found that although initial nutritional risk assessments were completed, they were not always repeated weekly and some food and fluid charts were not fully completed.

However:

  • Policies and procedures in urgent and emergency care, surgery and medical care were based on national guidance such as from the Royal Colleges and the National institute for health and care excellence (NICE).
  • We saw evidence of an effective multi-disciplinary team (MDT) approach to patient care and treatment, including seeking advice and joint decision making about patients across the emergency departments and with other medical disciplines.
  • Staff assessed and monitored patients regularly to see if they were in pain and provided pain relief as required.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

  • The trust participated in national and local audits.

Caring

Good

Updated 2 July 2019

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

  • Patients told us that they received compassionate care and that staff supported their emotional needs.
  • There were examples of exceptional and excellent care provided by the Friarage surgical services staff.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Patients and relatives we spoke with told us they felt well informed by doctors and nursing staff about their condition, treatment options and plan of care.
  • Spiritual and pastoral support was available to patients from the hospital chaplaincy service.

However:

  • We observed that patients in the urgent and emergency care services were not consistently provided with buzzers to alert staff if they required assistance.
  • The critical care units that did not have curtains in place made maintaining the privacy and dignity of patients more of a challenge.

Responsive

Good

Updated 2 July 2019

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

  • The urgent and emergency care services performed better than the England average for the Department of Health’s standard for emergency departments that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. They also performed better than the England average for the Royal College of Emergency Medicine standard that patients should wait no longer than one hour from time of arrival to receiving treatment.
  • People could access the medical care and surgical services when they needed them. Waiting times from referral to treatment (RTT) and arrangements to admit, treat and discharge patients were in line with best practice and for surgery were consistently better than the England average.
  • The medical and surgical services took account of patients’ individual needs. Interpretation and translation services were available, and staff knew how to access them when needed. Staff, patients and relatives in these services were supported by an advisor for learning disability and autism. We saw initiatives in place to improve the care of those living with a learning disability or dementia.
  • Patients were pre-assessed prior to surgery, which provided the opportunity to ask questions and facilitated informed consent.

However:

  • People could not always access critical care services when they needed them. There were significant challenges with access, flow and capacity within the units. The bed occupancy had been consistently higher than the England average.
  • Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
  • The average length of stay for non-elective patients in geriatric medicine at James Cook Hospital was higher than the England average.
  • The critical care, diagnostic imaging and urgent and emergency care services did not always meet the needs of patients. There were challenges with some of the critical care environments and limited facilities for relatives to stay overnight. Follow up clinics for critical care were not well established and had no psychological input for patients. There was limited provision for patients with additional needs such as dementia and learning difficulty in the diagnostic imaging and urgent and emergency care services.

Well-led

Requires improvement

Updated 2 July 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • Incidents were not always reported, addressed in a timely manner or lessons learnt across the trust. Staff told us lessons learned were not shared with the whole team and the wider service. The diagnostic imaging service was not effectively monitoring trends and themes. We saw diagnostic incidents that had not followed the correct procedure of reporting both internally and externally.
  • Numerous staff and doctors we spoke with felt senior managers above matron level were not visible, contactable or approachable.
  • Staff morale was variable and was especially poor within critical care and surgical services.
  • Staff we spoke with said they recognised the need for changes to be implemented but considered the amount of changes and speed of change in the organisation added to existing pressures.
  • The risk registers for critical care and diagnostic imaging services in particular were not reflective of all the risks we identified including areas of concern from performance data. Regular review of risks and mitigating actions was also not always evident.
  • We could not be assured that leaders and the corporate team understood the challenges to quality and sustainability within critical care. We lacked assurance about the training and skills of staff as information and overall compliance rates for all critical care staff was not provided.

However:

  • Leadership in the urgent and emergency care services was stable and staff we spoke with felt supported by line managers and the department and centre senior management team. Staff we spoke with said that communication within the department was effective.
  • Managers at core service level in medical care promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff reported a positive culture, good team working, and various avenues in which to receive and share information and concerns.
  • The local leadership team in medical care had plans in place to address risks to the service, with access to information, such as monthly performance reports, to maintain quality.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 2 July 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

Community health inpatient services

Good

Updated 28 October 2016

At our last inspection in December 2014, we identified concerns around staff not receiving appropriate training and support through the completion of mandatory training, particularly the relevant level of safeguarding training. Additionally we found that patient records were not always accurate and complete.

During this inspection risks to patients were assessed and managed to ensure safe delivery of care.

Staff responded appropriately to safeguarding concerns. There were systems and processes for the monitoring of medicines and infection control.

Staffing levels were adequate to meet patient demands; staffing was monitored and reviewed daily.

Staff had received appropriate training and support through the completion of mandatory training, so that they were working to the latest up to date guidance and practices, with appropriate records maintained.

Staff understood their responsibilities to raise concerns and to record safety incidents. There were systems for reporting and learning from incidents.

Opportunities were available to learn from investigations and the service was aware of areas in which it needed to improve.