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Provider: South Tees Hospitals NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 15 to 17 Jan 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 28 October 2016
Inspection carried out on 8-10 June and 21 June 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 8 -10 June and 21 June 2016

During an inspection looking at part of the service

We inspected the trust from 8 to 10 June 2016 and undertook an unannounced inspection on 21 June 2016. We carried out this inspection as part of the Care Quality Commission’s (CQC) follow-up inspection programme to look at the specific areas where the trust was previously rated as ‘requires improvement’ when it was last comprehensively inspected on the 9-12 and 16 December 2014.

At the comprehensive inspection in 2014 the trust overall was rated as requires improvement for their acute and community services. It was requires improvement for the safe and effective key questions at both hospital locations. The remaining key questions were rated good overall. Community health services were rated good overall, with requires improvement for the urgent care centre.

During this inspection, the team looked at one key question in urgent and emergency care, medicine and outpatients at both hospital locations. One key question in children’s and young people at one of the hospitals, three key questions in end of life care at both hospitals, plus two key questions in the urgent care centre and one in community inpatients at one other location. All these services had previously been rated as requires improvement, and all came out as good following the June inspections.

We included the following locations as part of this inspection:

James Cook University Hospital

  • Urgent and Emergency services;
  • Medical Care;
  • Services for Children and Young People;
  • End of Life Care;
  • Outpatients and Diagnostic Imaging.

The Friarage Hospital

  • Urgent and Emergency Services;
  • Medical Care;
  • End of Life Care;
  • Outpatients and Diagnostic Imaging.

Redcar Primary Care Hospital

  • Urgent Care Centre;
  • Community Inpatients

Our key findings were as follows:

  • Patients received appropriate pain relief and were able to access suitable nutrition and hydration as required.
  • There were defined and embedded systems and processes to ensure staffing levels were safe. Nurse staffing in neonates did not fully comply with British Association of Perinatal Medicine (BAPM) standards. However, there was a period of sustained improvement in recruitment and increased staffing compliance rates since April 2016. During this inspection, we did not observe any evidence to suggest the level of nurse staffing was inadequate or caused risk to patients in the areas we visited.
  • The trust had infection prevention and control procedures, which were accessible and understood by staff. Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment. However, there were some issues with cleanliness in the discharge lounge at the Friarage Hospital.
  • Patient outcome results had improved in areas of sepsis, senior review of patients in A&E with non-traumatic chest injury, febrile children and unscheduled return of A&E patients.
  • Staff understood the basic principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and could explain how these worked in practice.
  • There was consistency in the checking and servicing of equipment. However, there was one piece of equipment used in the mortuary at the Friarage Hospital, which had not been adequately maintained.
  • Competent staff that followed nationally recognised pathways and guidelines treated patients. There was audit of records to make sure pathways and guidelines were followed correctly.
  • Arrangements for mandatory training were good and significant improvements had been made for staff to attend.
  • Medication safety was reported as a quality priority in 2016/17 and improvement targets had been set. There were improvements in the management of medicines since our last inspection particularly around effective audit and reconciliation of medicines. However, we found some inconsistencies in the storage of medicines. The trust nursing and pharmacy team acted promptly and these issues were addressed.
  • There was an open culture around safety, including the reporting of incidents. Staff were aware of the duty of candour and there were systems to ensure that patients were informed as soon as possible if there had been an incident that required the trust to give an explanation and apology.
  • The trust had developed action plans to improve performance of the 4 hour A&E target, 18 week referral to treatment times, c. difficile and 62 day cancer waiting times. These plans provided the necessary assurance that the trust had the actions and capacity to ensure compliance in 2016/2017.
  • The trust had commenced a significant period of transformation and organisational redesign in 2015. There was a newly established senior executive team, and there was a clear ambition from the Board to be an outstanding organisation.
  • From 1 April 2016, the trust had moved to a new clinical centre structure. There were five centres, which replaced the existing seven centres. Clinical leadership was strengthened.
  • The trust had been in breach for governance and finances; however, they had made significant progress against their enforcement undertakings for both elements.
  • The recent changes to the executive team were seen by staff to be very positive. There were improvements in the speed of decision-making and visibility of the senior team in clinical areas.
  • The trust was strengthening the patient voice and developing strategies to enhance patient and staff engagement.

We saw several areas of outstanding practice including:

  • The trust was developing a detailed programme around patient pathways/flow/out of hospital models. This included developing a detailed admission avoidance model to establish pilot schemes in acute, mental health, community and primary care services. This would ensure patients were virtually triaged earlier in their pathway rather than being admitted to A&E. This would support patients closer to home and in more appropriate facilities, and reserve acute capacity for patients who required it.
  • The Lead Nurse for End of Life Care was leading on a regional piece of work for the South Tees locality looking at embedding and standardising education around the 'Deciding Right' tools (a North East initiative for making care decisions in advance).

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

Importantly, the trust should:

  • Ensure that processes are in place and understood by mortuary staff at the Friarage Hospital for the maintenance, moving and handling of equipment and transfer of deceased patients particularly out of hours.
  • Ensure that the emergency nurse call bell in wards 10 and 12 is reviewed to ensure it is fit for purpose.
  • Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.
  • Ensure medication processes are followed consistently particularly ‘do not disturb’ procedures for staff completing medicine rounds.
  • Ensure that that the frequency of controlled drug balance checks are carried out in line with national guidance.
  • Ensure that the end of life strategy is approved and implemented and move to develop a seven-day palliative care service.
  • Continue to develop plans to ensure appropriate staffing levels on wards, particularly in the neonatal unit to meet the British Association of Perinatal Medicine guidelines.
  • Review arrangements for the discharge lounge at the Friarage Hospital in terms of maintaining and cleaning equipment and ensuring the environment was suitable for patients and purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 9-12 & 16 December 2014

During a routine inspection

We inspected the trust from 9 to 12 December 2014 and undertook an unannounced inspection on 16 December 2014. We carried out this comprehensive inspection as part of the CQC’s comprehensive inspection programme.

We inspected the following core services:

  • James Cook University 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.
  • The Friarage 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.
  • Community Health Services – including:

    • Community health inpatient services at Carter Bequest Primary Care Hospital, East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital, Friary Community Hospital, Lambert Memorial Community Hospital and Redcar Primary Care Hospital.
    • Community end of life care
    • Community health services for children, young people and families
    • Urgent care centres at East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital and Redcar Primary Care Hospital
    • Community health services for adults

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

The trust leadership had generally been stable over the last few years; in 2013 the director of nursing, who had previously worked in the trust for a number of years, had been appointed to the post of Chief Executive. Some further changes were expected with the retirement of the medical director and appointments to additional roles to strengthen the delivery of quality and safety within the trust. The trust was working with staff groups, local stakeholders and consulting with the general public on the development of its services and where they were best located and how to improve the effectiveness of delivery. The trust was in the process of reviewing its governance and reporting arrangements and many of the issues identified through the risk assessment of operational delivery or the impact of the transformation of services was still work in progress. The trust was facing a particularly challenging financial position with a deficit to address, entailing significant cost improvement plans. Staff were aware of the situation and had been consulted and informed of decisions about where saving should occur. Where there had been an identified risk to quality or safety, plans had been rejected or refined. It was too early to assess at the time of the inspection whether cost savings would impact on quality and safety in the next financial year. Consultation with staff was seen as a priority and work was in progress to improve on engagement with patients and the general public.

Our key findings were as follows:

  • There was a transformation programme in place to reconfigure and re-structure services in order to operate more effectively, which entailed centralising and moving some services. The maternity, children’s and young people services had been re-organised so that the main service delivery was located at James Cook University Hospital. This was an ongoing programme, which included reviewing the community services and the trust was engaging with staff, the local commissioners of services and local communities as part of its development.
  • There were areas of excellent practice across the trust, particularly in the maternity services, where we found the leadership to be outstanding. The service was managed by a strong, cohesive leadership team who understood the challenges of providing good quality care and had identified effective strategies and actions needed to address these. This was particularly evident with the reconfiguration of services, which were well-developed and understood throughout the department.
  • Staff felt engaged and were passionate about the quality of care given to patients. Staff reported pride at working in the trust and felt encouraged and able to introduce innovative ideas to improve service development and delivery.
  • Care and treatment was delivered with compassion and patients reported that they felt treated with dignity and respect.
  • Across the acute hospitals and within the community services, 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 visibly clean. Rates of Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. difficile) were within an expected range for the size of the trust, although the trust was aware of and was taking action to address concerns over the increasing cases of C. difficile.
  • 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 across the acute services and within the community.
  • There were  nursing staff shortages across wards and departments, particularly at the James Cook University Hospital and Friarage Hospital in urgent and emergency care and in children’s services. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.
  • The composite of the Hospital Standardised Mortality Ratio (HSMR) indicators was slightly higher than expected in this trust. The Summary Hospital-level Mortality Indicator (SHMI) was as expected. The trust actively reviewed mortality cases on an ongoing basis and held regular meeting with clinicians to identify issues when data was available.
  • The trust was performing worse than the national average for the development of pressure sores. The prevalence rate for grade 3/4 pressure ulcers was consistently above the national average accounting for 79% of all serious incidents reported, although there had been a steady decrease throughout the year.
  • There was still much more work to be done to ensure that the premises and the arrangements in place were suitable for the children’s services.
  • Attendance at mandatory training and specific subject area training, particularly for safeguarding and mental capacity assessment, was low across some areas.
  • Not all records were consistently completed across the acute and the community services, including the updating of care records such as assessments, fluid balance charts, risk assessments and decisions over whether to attempt to resuscitate a patient. There were also concerns over the completion of safeguarding records, particularly in the see and treat area within the accident and emergency department.

We saw several areas of outstanding practice including:

For James Cook University Hospital:

  • In medical care services, a team of therapeutic volunteers had been created which was led by a therapeutic nursing sister who had been in place for 18 months. The volunteers had mandatory and dementia training and were in operation 24hours a day. The role of the volunteers was to support patients who may be living with dementia or other illnesses which affected their behaviour and level of supervision required. This included engaging with patients, such as playing board games or other interests patients may have. They also supported patients who required help with eating or wanted to explore their environment. This included supporting them overnight if they were disorientated. The volunteers predominantly worked on wards 10, 12 and 26. The team had been regionally recognised for its work.
  • We found examples of outstanding leadership within Maternity services.
  • In maternity services, the Families and Birth Forum was involved in the design of the induction of labour suite and championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
  • In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits used as part of the productive care work stream. The toolkits helped look at care in a variety of settings through the eyes of patients and service users, to help determine what good quality care looks, sounds and feels like.
  • In maternity services, a ‘baby buddy’ mobile phone app was being piloted by the community midwives to inform women of pregnancy issues, common ailments and reasons to seek advice.
  • We found outstanding areas of practice in the care and involvement of young people, including a young people’s unit, participation and accreditation in the You’re Welcome toolkit in four clinical areas, the development of a young person’s advisory group, inspections of services by young people and the involvement of young people in staff interviews.

For The Friarage Hospital:

  • We found examples of outstanding leadership within Maternity services
  • In maternity services, the families and birth forum was involved in the design of the induction of labour suite and in championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
  • In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits which are part of the productive care work stream. The toolkits help look at care in a variety of settings through the eyes of patients and service users, to help investigate what good quality care looks, sounds and feels like.

For the community services:

  • Diabetes specialist nurses provided telephone support and advice and clinic sessions for patients with diabetes supported by a dietician and ran the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) programme which was accessible to patients with diabetes or the risk of developing Type 2 diabetes to provide learning and support for the patient and the health care professionals involved with them

There were several areas of good practice in the community services:

  • In community end of life services a Sources of Information and Support service directory had been developed by the Hambleton and Richmondshire Palliative Care Partnership, a health and wellbeing clinic was held at Redcar Primary Care Hospital, community specialist palliative care nurses supported the National Gold Standard Framework coordination in GP practices and supported nursing and residential homes for people with cancer and other life-limiting conditions in the Middlesbrough, Redcar and Cleveland locality.

  • Within community children’s, young people’s and families services a Baby Stars programme was in place to promote the social, emotional and physical development of infants, the school nursing service held weekly drop-ins for children and young people, there was a breastfeeding group with trained peer supporters and facilitators, there were good transition arrangements for young people transferring to adult services and services enabled good accessibility for children and young people by offering different clinics and opening times.
  • Within the community services for adults, the community respiratory service focused proactively on preventing admissions through meeting patient’s needs and reviewing the quality and cost effectiveness of the service through audit, the falls and osteoporosis service received an award for its inpatient work in community hospitals. The tissue viability service had developed several examples of innovative practice such as a chronic oedema project and leg ulcer collaborative to support prevention of these conditions and specialist and maintenance clinics were held for patients with lymphedema.

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

Importantly, the trust must:

For James Cook University Hospital:

  • Ensure that there are sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical and surgical wards, children’s wards and the paediatric intensive care unit (PICU).
  • Ensure that staff have received an appraisal and appropriate supervision so that the trust can be assured they staff are competent to undertake their role.
  • Ensure staff receive appropriate training, including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity Act 2005/assessment training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
  • Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are carried out and decisions made.
  • Ensure that all patients’ records are maintained up to date, including the recording of identification and stored confidentially in accordance with legislative requirements, particularly ensuring that paediatric care records are contemporaneous, appropriately completed and regularly audited to monitor staff compliance.
  • Ensure that there are appropriate arrangements in place for the safe handling and administration of medication, including the reconciliation of patients’ medications, that all controlled drugs are appropriately checked particularly on Coronary Care Unit and that medication omissions are monitored, investigated and reported in line with trust policy.
  • Ensure that ward-based nursing staff are educated in the use of syringe drivers, including best practice in the use of continuous administration of medication for the management of key symptoms at the end of life.
  • Ensure the paediatric environment in A&E is reviewed so it is fit for purpose; including a process to make sure that robust risk assessments are readily accessible and available to all staff in the department.
  • Ensure all toys in A&E are cleaned regularly to reduce the risk of infection.
  • Ensure that there are sufficient assisted bathing facilities and moving and handling aides within the children’s and young people’s ward areas.
  • Ensure the timely completion of the refurbishment of the medical block, especially wards 10 and 12, to enable people living with dementia to be cared for in a safe environment.
  • Ensure that the system for nurse calls is reviewed to ensure that there is no confusion over patients calling for assistance and the emergency alert for cardiac arrest potentially causing delays in treatment.
  • Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
  • Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
  • Ensure robust monitoring of the safe use of syringe drivers, with sharing of results and learning from safety audits.
  • Ensure that an appropriate concealment trolley is in use for the transfer of the deceased, that risks have been assessed, and that all staff using the trolleys are aware of safe moving and handling practices.
  • Ensure that resuscitation equipment in surgical wards and in outpatients and diagnostic imaging areas is checked in accordance with trust policies and procedures and that this is monitored.

For  The Friarage Hospital:

  • Ensure that there is sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical wards, and outpatients department.
  • Ensure staff receive appropriate training and support through appraisal including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
  • Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are being carried out and how decisions are made.
  • Ensure that patients records are appropriately up dated and stored to ensure confidentially is maintain at all times in line with legislative requirements.
  • Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
  • Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
  • Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
  • Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
  • Ensure that resuscitation equipment and medication fridge temperatures in the diagnostic and imaging department are checked in accordance with trust policies and procedures.

For the Urgent Care Centres services:

  • Ensure that staff have attended mandatory training in accordance with trust policy.
  • Review the quality monitoring arrangements within the urgent care centres, including patient outcomes.
  • Review the provision of pain relief to ensure that there are no unnecessary delays when treating patients.
  • Ensure that evidence-based guidance is available for staff working in urgent care centres and that policies are appropriately reviewed and up to date.

For the Community Inpatient Services the trust must:

  • Ensure that the number of staff who received safeguarding children level 2 training and safeguarding adult level 1 training meets trust targets.
  • Ensure that staff have received mandatory training.
  • Ensure that patient records are accurate and complete, particularly fluid balance records, venous thromboembolism (VTE or blood clot) assessments and malnutrition universal screening tool (MUST) scores.
  • Ensure that staff have received an annual appraisal.
  • Ensure that hazardous substances are secured, particularly at Lambert Memorial Community Hospital.
  • Ensure that staff follow the escalation policy when a patient’s condition deteriorates.

In addition, the trust should consider other actions these are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


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.