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Provider: North Tees and Hartlepool NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 14 March 2018

Our rating of the trust improved. We rated it as good because:

  • For acute core services we rated safe, effective, caring and responsive as good, and well-led as requires improvement. We did not inspect children and young people’s services or outpatient services. These two services had been rated as requires improvement for well led in 2016, which meant the well led rating for core services remained as requires improvement.
  • We rated three of the trust’s eight services as good. In rating the trust, we took into account the current ratings of the five acute services not inspected this time and the community services not inspected this time.
  • Community services were not inspected at this time; therefore the previous ratings remain the same at this inspection.
  • We rated well led at trust level as good.
  • Staffing numbers allowed the trust to provide safe care to patients. The trust had robust systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care.
  • Across the trust patients received care in a clean, hygienic and suitably maintained environment.
  • Medicines were managed appropriately.
  • There was evidence of good multidisciplinary working, seven day services and some health promotion such as access to drug and alcohol dependency support services.
  • Pain was reviewed effectively, mechanisms were in place to ensure that patients did not remain in pain.
  • Staff offered patients food and drinks and monitored patients’ nutrition and hydration effectively.
  • Staff were kind, caring and compassionate and had a good understanding of the needs of patients.
  • Services were planned in a way to meet the individual’s needs and the local population.
  • Access and flow across the trust had improved.
  • The urgent and emergency care department had mostly met the four hour target, only missing out in three months of the last 12.
  • The leadership, governance and culture within services promoted the delivery of high quality person-centred care.

However:

  • There was low compliance in some mandatory training modules in some of the services we inspected.
  • There were risks in the emergency department to patients with mental health needs. There was no designated mental health assessment suite or facilities that met best practice guidance for a safe metal health assessment room. There were ligature points which meant the area was not fully complaint with The Psychiatric Liaison Accreditation Network (PLAN) standards.
  • The University Hospital of North Tees performed poorly in RCEM audits including severe asthma, consultant sign off, vital signs, procedural sedation and VTE.
  • At the University Hospital of Hartlepool, maternity services were not always delivered in a way in which focused on women’s holistic needs.
Inspection areas

Safe

Good

Updated 14 March 2018

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

  • All incidents were investigated and managed appropriately and we saw evidence of learning following incidents.
  • The trust had infection prevention and control (IPC) policies, which were accessible, understood and used by staff. Across the trust patients received care in a clean, hygienic and suitably maintained environment.
  • Nursing documentation had been radically changed since our last inspection and was accurately completed and reliably recorded.
  • Staffing numbers allowed the trust to provide safe care to patients. The trust had robust systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care.
  • The midwife to birth ratio was better than that national recommendation, despite, the service experiencing a high number of staff on maternity leave the midwife to birth ration remained within guidance. The service used a nationally recognised tool to review planned and actual staffing daily and on a shift by shift basis.
  • Medical staffing on delivery suite was better than the safer childbirth (2007) recommendation. There was minimal locum staff usage
  • In urgent and emergency care, a system had been put in place to ensure that patients had an initial assessment on arrival to the department within 15 minutes by nurses who had undergone triage training.
  • There was appropriate management of medicines.

However:

  • There was low compliance in some mandatory training modules in some of the services we inspected.
  • There were risks in the emergency department to patients with mental health needs. There was no designated mental health assessment suite or facilities that met best practice guidance for a safe metal health assessment room. There were ligature points which meant the area was not fully complaint with The Psychiatric Liaison Accreditation Network (PLAN) standards.

Effective

Good

Updated 14 March 2018

Our rating of effective improved. We rated it as good because:

  • There was evidence of good multidisciplinary working, seven day services and some health promotion such as access to drug and alcohol dependency support services.
  • Pain was reviewed effectively, mechanisms were in place to ensure that patients did not remain in pain.
  • Staff offered patients food and drinks and monitored patients’ nutrition and hydration effectively.
  • We saw that staff had an understanding of consent, mental capacity and deprivation of liberty safeguards.
  • The medicine directorate participated in a number of national and local audits to assess compliance with guidelines and had a programme of audit managed by the clinical effectiveness team at the trust.
  • The trust took part in patient outcome audits such as the sentinel national stroke national audit programme and the trust has improved its overall level moving from level D in April to June 2016 to a level C in August to November 2016.
  • The maternity service based all of their policies and guidelines on current NICE guidance. We found there was an effective process of reviewing, consulting and implementing policies.
  • The maternity service had implemented the United Nations Children’s Fund (UNICEF) baby friendly initiative to support women in their feeding choices. The service had recently been reaccredited and held full accreditation.
  • We observed good multidisciplinary working between medical and midwifery staff. Staff worked closely with community services to ensure communication was as effective as possible.
  • In maternity services, women and their families had access to the service seven days a week. The maternity day assessment unit was open later in the day and over the weekend.

However:

  • Between July 2016 and June 2017, the trust’s unplanned re-attendance rate to the urgent and emergency within seven days was generally worse than the national standard of 5% and generally worse than the England average.
  • The University Hospital of North Tees performed poorly in RCEM audits including severe asthma, consultant sign off, vital signs, procedural sedation and VTE.

Caring

Good

Updated 14 March 2018

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

  • Staff were kind, caring and compassionate and had a good understanding of the needs of patients.
  • In urgent and emergency care, we saw staff go the extra mile several times and their care and support exceeded good care standards. The caring relationships were highly valued by staff and promoted by the matron. There was a strong, visible person-centred culture.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • We observed privacy and dignity being maintained for patients received care.
  • Staff recognised the importance of the emotional needs of patients. Specialist nursing staff were available to provide additional support when required.
  • Patients we spoke with were overwhelmingly positive about the service.

Responsive

Good

Updated 14 March 2018

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

  • Services were planned in a way to meet the individual’s needs and the local population.
  • Access and flow across the trust had improved.
  • The urgent and emergency care department had mostly met the four hour target, only missing out in three months of the last 12. These were the winter months when the department was under the most pressure. The department had consistently performed better than the England average.
  • The urgent and emergency care department performed better than the England average for patients leaving the department without being seen over the last 12 months.
  • The total median time patients spent in the urgent and emergency care department was consistently better than the England average.
  • There was additional support which wards and services could request if further support or advice was required. For example, there was an enhanced care team which could support wards with one to one care, a trust dementia nurse specialist and access to psychiatric liaison team services.
  • A discharge team worked closely with wards on discharge planning. Discharge was planned early across the services and the discharge team was a multi-disciplinary team.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medicine has been consistently above the England average for the entire reporting period from August 2016 to July 2017.
  • The length of stay for elective and non-elective medical patient was lower than the England average.
  • Within maternity services, women and their family’s individual needs and preferences were central to the delivery of bereavement services. Services were flexible and provided informed choice and continuity of care.
  • Within maternity services, there was a proactive approach to understanding the needs and preferences of different groups of people. Care in a way that met a woman’s individual needs. This included people with protected characteristics under the Equality Act and vulnerable women with complex needs.

However:

  • The trust had put measures in place to improve the access and flow in the department however due to bed pressures within the hospital, patients sometimes stayed in ED for an extended period of time.
  • Between July 2016 and June 2017 there were 71 complaints about medical care. The trust took an average of 46 days to investigate and close complaints; this was not in line with their complaints policy, which stated complaints should be completed with 25 days or 40 days for more complex complaints.
  • At the University Hospital of Hartlepool, maternity services were not always delivered in a way in which focused on women’s holistic needs. There was some flexibility taken regarding women’s individual needs, however, this did not meet the needs of all those who requested to book at the birth centre, as women were only able to deliver there if staff could be released from the University Hospital of North Tees site.

Well-led

Good

Updated 14 March 2018

We rated well led at both University Hospital of North Tees and University Hospital of Hartlepool as requires improvement. The services we inspected in 2017 were rated good in the well led domain; however we did not inspect two services which had previously been rated as requires improvement. This made the rating for well led at core service level as requires improvement.

However, overall our rating of well-led improved. We rated it as good because:

  • Leaders within the trust had the experience, capability and integrity to ensure that the strategy could be delivered and risks to performance addressed.
  • Leaders within the trust were knowledgeable about issues and priorities for the quality and sustainability of services, understood what the challenges were and were taking action to address them.
  • Leaders at every level were visible and approachable.
  • Overall, morale across services was generally good and staff described good teamwork across the wards and services.
  • The leadership, governance and culture within services promoted the delivery of high quality person-centred care.
  • There were processes to support staff and promote their positive wellbeing. Leaders encouraged pride and positivity in the organisation. Overwhelmingly staff were positive about and proud to work in the organisation.
Checks on specific services

End of life care

Good

Updated 3 February 2016

Overall rating for this core service Good

The Specialist Palliative Care team worked as part of a multidisciplinary team covering the acute and community based services, with specific team members dedicated to providing the community element of specialist care. Their role was to assess, support, deliver, monitor and evaluate end of life and palliative care provided by the trust. Services provided safe, co-ordinated care and we saw that staff were focused on continual learning and service development. Equipment used for patients at the end of life was easily accessible in the community and staff told us they felt they had the resources they needed to deliver quality care.

End of life care within the trust was influenced by national guidance such as the ‘Gold Standards Framework’ and we saw that good multidisciplinary working was in operation with the needs of the patient at the centre of all care activities. Patients and relatives we spoke with told us the care they received was delivered with care and compassion and that they were respected and treated with dignity. The trust was working towards a seven day specialist palliative care service and we saw that the needs of the local population were considered when reviewing the service provided. Improvements had been made to fast-track the discharge of people at the end of life and all staff were aware of and involved in, supporting patients to be cared for in their preferred place of care.

The specialist palliative care and end of life care services were well-led with both medical and nursing staff working to ensure the service meets the needs of patients. However, there was limited evidence that the end of life care strategy and service development had pro-active involvement at board level. In addition, in their support of the community inpatient service at University Hospital Hartlepool, the specialist palliative care team operated within a reactive rather than pro-active framework.

Community health services for adults

Good

Updated 3 February 2016

Overall we rated safety as good. There were systems in place to report incidents and staff told us they knew how to report incidents and received feedback from these. Staff were able to give examples on how they had learnt from incidents and how improvements were implemented. We found there were sufficient numbers of staff to make sure that care was delivered to meet patient needs and sickness rates were below the trust target of 6%. Staff had undertaken relevant mandatory training and safeguarding training and compliance rates were above 92%.

We rated effective as good. The trust monitored and identified whether they followed appropriate NICE guidance relevant to the services they provided. The service worked in conjunction with other colleagues in the trust to develop integrated care pathways in order to facilitate the delivery of care closer to home and reduce the length of time a patient needs to remain as an inpatient. Within the therapy service patient specific outcome measures were widely used to monitor and demonstrate effective care delivery and outcomes. However, within community nursing services we found there was no formalised process for clinical supervision in place. Staff told us there were differences across the trust in how this was implemented. Some staff told us they accessed clinical supervision regularly and it worked well whereas other staff told us there was no system to access supervision.

We rated the caring domain as good. We observed care being delivered and listened to staff speaking to patients and relatives on the telephone. In order to gain an understanding of people’s experiences of care, we talked to patients and their relatives who used services. During our visit we saw that patients and relatives were treated with respect, dignity and compassion and we saw caring and compassionate care being delivered. Staff were seen to be very reassuring towards patients, their relatives and other people. People we spoke with during the inspection told us they had been involved in the planning of their care.

Overall we rated the service as good as being responsive to people’s needs. The trust had a range of specialist services to meet the different needs of people which included teams for diabetes, heart failure, continence, falls and neurophysiotherapy. The dementia strategy supported the specific needs of patients; the dementia strategy covered both inpatient hospital care and patients in the community. Analysis of data showed that since April 2014 the trust achieved the referral to treatment (RTT) targets of 95% for musculoskeletal (MSK) services and podiatry services. We saw evidence the service monitored these monthly and between April and June 2015 the services continued to achieve above the 95% target. The trust had in place a concerns and complaints policy and procedure. We saw there was complaints information available within the areas we visited. Learning from complaints was shared where improvements had been identified. The outcome of the investigation was shared with the patient and an action plan was prepared that senior staff shared with their teams.

We rated the service as requires improvement for well-led. We saw the service had a risk register which identified the risk rating and what control measures the service had put in place. However, on review of the risk registers the reasons why some of the risks had been put on the risk register were unclear. Some risks were classed as generic, such as the risk of dermatitis due to allergy and exposure to skin irritants and the risk of needle stick injury. These would usually be identified on an individual basis rather than as a service risk under the relevant health and safety policy / procedure. Following the inspection, the trust told us these had been put on the risk register in response to specific incidents in the HPV (Human Papilloma Virus) immunisation team and in the GP services where unsheathed needles had been used. 

Staff told us on the whole they felt well supported by their managers and the senior management team within the directorate. Staff also reported they felt listened to and their managers were approachable. However, some staff told us whilst they felt supported by their direct line manager they felt management teams above them did not understand the pressures within the service. We found some staff were unclear about the nursing leadership for the district nursing service at the trust. We found reporting incidents was embedded across the service and we saw evidence of staff receiving feedback and learning was shared.  We found action plans were developed following serious incidents and the actions and progress had been monitored.

Community dental services

Good

Updated 3 February 2016

Overall rating for this core service Good l

Overall we found that the community dental service at North Tees and Hartlepool NHS Foundation Trust provided safe and effective care. Patients were protected from abuse and avoidable harm and there were systems in place for identifying, investigating and learning from incidents, accidents and complaints. Overall we rated the service good.

At the time of the inspection, we judged that the service was safe and people were protected from abuse and physical harm.

We judged the service was effective and that people’s care, treatment and support achieved good outcomes for them. Treatments were based on the best available evidence and the service provided good health promotion.

We judged that people were involved in their care, and were treated with compassion, kindness, dignity and respect. The service was responsive to people’s needs, specifically meeting the needs of patients who were predominantly vulnerable and had complex needs. The service was well-led in that the leadership and management of the service provided a platform on which a holistic pattern of oral health care could be provided.

In coming to these judgements we spoke with patients and carers, staff who worked in the community dental clinics and the oral health promotion team. We inspected the facilities in five clinics (100% of the trusts dental locations) at Eston Clinic, Guisborough Primary Care Hospital, the One Life Centre in Hartlepool, North Ormesby Health Village and Lawson Street Health Centre. We spoke to 5 service users, 10 relatives or carers and observed 9 patients receiving dental treatments. We examined 20 clinical patient records and spoke to 14 members of staff.

Community health services for children, young people and families

Good

Updated 3 February 2016

Overall, we rated community health services for children, young people and families as good.

Children and young people’s services were safe. Staff knew how to manage and report incidents and we saw there had been learning following a serious case review. There were good safeguarding processes in place and staff received regular formal supervision. Staffing levels and caseloads were manageable and recruitment plans were in place to ensure health visiting vacancies were filled. In addition, the clinics and children’s centres we visited were clean.

Children and young people’s services were effective. Although some performance measures were being missed, care and treatment was evidence based and staff were competent. The trust had also successfully implemented evidence based programmes, such as the family nurse partnership programme. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently. There was good evidence of multidisciplinary and multi-agency working across the services.

Children and young people’s services were very caring. Staff were passionate about delivering high quality care and were very dedicated to their patients.

Children and young people’s services were responsive. Services were planned and delivered to meet the needs of the local population in line with the commissioning framework of the trust. Staff worked hard to meet the needs of children and families in vulnerable circumstances and there were support networks in place to ensure children and young people were protected.

Children and young people’s services were well-led. The majority of staff we spoke with understood the vision and strategy for their own service and also the wider trust. There were issues with some aspects of the leadership structure due to the prolonged absence of a senior member of the team. However, plans were in place to address the shortfall. We found the culture was open and transparent and there was strong evidence of collaborative team working across all services.