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Provider: Hull University Teaching Hospitals NHS Trust Requires improvement

Reports


Inspection carried out on 7 February 2018

During a routine inspection

We rated effective, caring and well-led as good, and safe and responsive as requires improvement.

Our rating of Hull Royal Infirmary stayed the same. We rated it as requires improvement. We rated seven of the hospital’s eight services as good and one as requires improvement.

Our rating of Castle Hill Hospital improved. We rated it as good. We rated three of the hospital’s five services as good and two as requires improvement.

In rating the trust, we took into account the current ratings of the four services not inspected this time.

  • We rated well-led for the trust overall as good. This was not an aggregation of the core service ratings.


CQC inspections of services

Inspection carried out on 9 June, 28 June – 1 July and 11 July 2016

During a routine inspection

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull, and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected all eight core services at HRI and five at CHH. We also inspected the minor injuries service operated by the trust at East Riding Community Hospital and outpatient services at the Westbourne NHS Centre. We did not visit outpatient services which operated in other locations. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated the trust overall as ‘requires improvement’. We rated safe, effective, responsive and well led as ‘requires improvement’ and caring as ‘good’. The trust had made improvements since our last inspection but these were not significant enough to change the rating for the trust as a whole. Some areas had made considerable improvements, especially the emergency department (ED) which was now rated as ‘good’. Medical care, surgery, and children’s services had improved. End of life care which was inspected in 2014 remained ‘good’ across all domains. However, there was deterioration in the ratings overall for critical care (last inspected 2014) maternity and outpatients & diagnostic services from ‘good’ to ‘requires improvement’.

Our key findings were as follows:

  • The care of patients within the emergency department had significantly improved since the last inspection. The trust was meeting the locally agreed trajectories for the number of patients seen within four hours (in June 2016, 85.9% of patients were seen within four hours, which was in line with the agreed trajectory of 85.1%), but was still breaching the national standard of 95%.
  • The trust reported and investigated incidents appropriately, the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice including within maternity where a never event had occurred.
  • The trust had taken effective action when Radiology had reported a serious incident in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported four of which related to this printing issue. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which, if breached, were reported to the medical director.
  • A backlog of 30,000 patient episodes/appointments had been identified by the trust prior to the inspection. A cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients. The trust had implemented a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
  • We had concerns within the children’s services about: the competency of staff to care for patients with mental health needs; that not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and; four safeguarding children guidelines were out of date. However, the parents’ sitting room facilities on the 13th floor had been improved following receipt of charitable funds.
  • Staff were not always assessing and responding appropriately to patient risk. The trust used a National Early Warning Score (NEWS) and the Modified Early Obstetric Warning Score (MEOWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
  • Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in some patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
  • Nurse staffing shortages were evident across the majority of medical and surgical wards and the trust’s safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators. The maternity service did not collect the relevant data and therefore could not provide assurance that women received one to one care in labour.
  • There were also some gaps within the medical staffing, especially within critical care and paediatrics.

  • The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. 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 based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
  • There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The trust had undertaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were put in place.
  • Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
  • Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
  • Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved although there were some instances on the acute medical unit at HRI where not all call bells were within reach of patients.
  • Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
  • The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited.
  • There had been a significant improvement in the operating theatre environment at HRI.

We saw several areas of outstanding practice including:

  • The urology services had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
  • The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
  • The perinatal mental health team/midwifery team had been shortlisted for the Royal College of Midwives Annual Midwifery Awards 2016 for effective partnership working in supporting women with perinatal mental health.
  • Recreational co-ordinators had been introduced in medical elderly wards. Their role was to provide patients with activities and stimulation whilst in hospital.
  • The responsiveness of the Specialist Palliative Care team (SPCT) in relation to acting on referrals.
  • The bereavement initiative of providing cards for relatives to write messages to their loved ones.
  • The International Glaucoma Association had awarded the ophthalmology department an innovation award for their glaucoma monitoring work.
  • Radiology at the trust was an exemplar site for the BSIR (British Society of Interventional Radiology) IQ programme for interventional radiology.
  • The ultrasound department was the UK reference site for Toshiba in the fields of elastography and fusion guided imaging.
  • The breast care unit were using digital tomosynthesis. This method of imaging the breast in three-dimensions improves the sensitivity of detection of breast cancers by 40% and is more accurate.
  • The breast care unit carried out vacuum assisted biopsies. This one-stage procedure avoided patients needing two or three biopsies, significantly reducing the stress and anxiety for the patient and saving on resources.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must ensure that:

  • Planning and delivering care meets the national standard for A&E; meets the referral-to-treatment time indicators and; eliminates any backlog of patients waiting for follow ups with particular regard to eye services and longest waits.
  • A review of the process for categorising incidents occurs, including safeguarding incidents, relating to children, to ensure effective investigations and that lessons are learnt.
  • Staff complete risk assessments and take action to mitigate any such risks for patients; in particular, risk assessments for falls and for children with mental health concerns.
  • Learning from never events is further disseminated and lessons learnt are embedded.
  • Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National early warning score (NEWS) and Modified Early Obstetric Warning Score (MEOWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment, and; that the escalation procedures are audited for effectiveness.
  • Staff have the skills, competence and experience to provide safe care and treatment for children with mental health needs and patients requiring critical care services.
  • Work continues actively with other professionals internally and externally to make sure that care and treatment remains safe for children with mental health needs using the services.
  • Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
  • Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range, especially within A&E.
  • Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/taken by the patient.
  • Records of the management of controlled drugs are accurately maintained and audited within A&E.
  • Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
  • Staff who work with children and young people are knowledgeable about Gillick competence and that a process is in place for gaining consent from children under 16.
  • Antenatal consultant clinics have the capacity to meet the needs of women and that there is enough capacity in the scanning department to implement the Growth Assessment Protocol (GAP).
  • There is effective use and auditing of best practice guidance such as the “Five steps to safer surgery” checklist within theatres and standardising of procedures across specialties relating to swab counts.
  • Elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
  • The critical care risk register is reviewed to ensure that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
  • Ensure outpatient services have timely and effective governance processes in place which identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
  • Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient and maternity services.
  • At all times there are sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance, taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).
  • Continues to work towards the national guidelines of 1:28 midwifery staffing ratio and collect data to evidence one to one care in labour.
  • It takes further steps to improve the facilities for young people on the 13th floor of HRI.

In addition there were areas where the trust should take action and these are reported at the end of the two individual hospital reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 19 – 21 May 2015

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

The Hull and East Yorkshire Hospitals NHS trust operates acute services from two main hospitals – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) – with a minor injuries unit at Beverley Community Hospital and some outpatient services within other community locations. In total, the trust had approximately 1,300 beds and 7,400 staff.

Hull Royal Infirmary houses the main emergency provision for the trust, including accident and emergency services, critical care, acute medical and surgical services as well as the Women and Children’s Hospital. The HRI site has over 700 beds. Castle Hill hospital has cardiac and elective surgical facilities, medical research teaching and day surgery facilities (the Daisy Building), ear, nose and throat (ENT) services and breast surgery facilities and outpatients. The CHH site has over 600 beds.

We carried out a follow up inspection of the trust between 19 – 21 May 2015 in response to concerns that had been identified both during a previous comprehensive inspection of Hull and East Yorkshire NHS Trust in February 2014 and highlighted through other information routes.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We therefore did not inspect critical care services or end of life services at the follow up inspection. Additionally not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At the inspection in February 2014 we found the trust was in breach of regulations relating to patient care and welfare, medicines management, staffing, premises, staff support and governance.

Overall we rated the trust as ‘requires improvement’. We rated it ‘good’ for being effective and caring. The trust ‘required improvement’ in the domains of safe, responsive and well led.

Our key findings were as follows:

  • The trust had responded to previous staffing concerns and was actively recruiting to fill posts however there were areas in medicine where nurse staffing levels were impacting on patient care and treatment particularly on the elderly care wards. There were also staffing pressures in the electrocardiography department at Castle Hill Hospital which meant staff were struggling to carry out cardiac diagnostic tests for patients.
  • Systems and processes on some wards for the management of medicines and the checking of resuscitation equipment did not comply with trust policy and guidance.
  • Most patients across the medicine health group received a good standard of care. However, on the elderly care wards patients were waiting for staff to assist them with their basic needs. Call bells were not in reach of patients in some areas. There was inconsistent use of the red top water jug system to identify patients that required assistance with nutrition and hydration. Care was not always being actively recorded in the patient’s records.
  • There had been changes to medical pathways of care to improve access and flow however this had not yet resulted in a significant improvement as there continued to be delays in discharge, patient bed moves out of hours and, patients were being cared for on non-specialty or other specialty wards due to inpatient capacity issues.
  • There was an increase in the recruitment of consultant obstetricians and midwives. We found the birth to midwife ratio had increased from 1:35 to 1:32 since our inspection in February 2014.
  • Most staff had received safeguarding training and could demonstrate an understanding of their role and what action to take if they were concerned about a person.
  • At the time of the inspection the trust was a mortality outlier for deaths from septicaemia (except in labour). This had been persistently raised. Actions plans had been put in place however the number of deaths remained raised.
  • The Summary Hospital-level Mortality Indicator (SHMI) for the Trust was 108.3 which was higher than 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 numbers 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. The Hospital Standardised Mortality Ratio (HSMR) was 99.2 which was similar to the England ratio (100) of observed deaths and expected deaths.

We saw several areas of good practice including:

  • The appointment of an internal anti-bullying Tsar (a doctor) to lead the anti-bullying work. We received many positive comments about the tsar and their approach to the role.
  • The opening of the new emergency department represented a substantial improvement in the facilities for the hospital so that emergency care and treatment was provided in a suitable environment.

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

  • Address the breaches to the national targets for A & E and referral-to-treatment times to protect patients from the risks of delayed treatment and care. It must also continue to take action to address excessive waiting times for new and follow up patients with particular regard to eye services and longest waits.
  • Ensure there is a sustainable action plan to improve the reporting performance of histopathologist service.
  • 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; particularly on the elderly care wards, consultant and nursing cover within A &E; histopathologists, echocardiography team and surgical wards.
  • Ensure the sustainability of the work to address the concerns raised regarding the bullying culture and the outcomes from the NHS staff survey data (2014)
  • Ensure that all incidents are investigated in a timely manner, that lessons are learnt and that duty of candour requirements are effectively acted upon and audited.
  • Ensure that there is a policy and procedures in place to ensure that there is effective transition for young people to adult services
  • Ensure there is the development of a long term clinical strategy for the surgery health group which meets the clinical needs of patients and which is in line with the trust’s overarching strategy.
  • Ensure appropriate arrangements are in place to respond to major trauma and incidents within ED.
  • Ensure that there is an effective and timely system in place, which operates to respond to, and act on, complaints.
  • Ensure that there are robust processes in place for the checking of equipment particularly resuscitation equipment on the medical wards.
  • Take further steps to improve the facilities for children, young people and parents on the 13th floor.
  • Take actions to protect children and young people from the risk of self-harm and/or injury by ensuring that on the 13th floor the ligature and anchor points on the ward are addressed, and that there is an appropriate “safe bed space” for the use of children and young people with mental health needs. Following the inspection the Trust told us it was implementing an accepted anti-ligature risk assessment.
  • Ensure that patients’ nutrition and hydration is maintained in a timely manner; including the effective use of the ‘red top’ water jug system across all medical wards and the accurate recording of fluid balance and food charts for patients.
  • Ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines on the medical wards. In addition the Trust must ensure that controlled drugs are stored appropriately and that records of the management of controlled drugs are accurately maintained and audited within A & E and children’s services.
  • Ensure that call bells are within reach of the patient at all times, especially on the medical wards and regular audits must be completed to monitor compliance
  • Review its patient pathways and patient flow through services to ensure:

  1. Plans for the acute medical pathways from ED to discharge are effectively implemented including pro-active bed management
  2. The seating area on the elderly assessment unit is not used for beds
  3. Plans for dealing with extra capacity are reviewed including the “reverse boarding” policy.
  4. Internal patient transfers take place in accordance with trust policy and reduce the number of patient bed moves ‘out of hours’ unless for clinical reasons
  5. More timely discharges of patients, including working collaboratively with social care and community providers to improve the discharge system.

  • Ensure use of best practice guidance, such as the “Safer steps to surgery” checklist and Interventional Radiological checklists for appropriate procedures in all outpatient and diagnostic imaging settings and audit their use to include completion of all sections.
  • Ensure that appropriate procedures are in place to obtain consent for hysteroscopies within outpatients.
  • Review the results of IPC audits across ED, all wards and theatres and identify and instigate appropriate actions including addressing the flooring and walls within theatres
  • Ensure there are timely and effective governance processes in place to identify and actively manage risks throughout the organisation

In addition there were areas where the trust should take action and these are reported at the end of the two individual hospital reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3, 4, 5, 10 and 11 February 2014

During a routine inspection

Hull and East Yorkshire Hospitals NHS Trust serves a population of 660,000 and provides a range of acute and elective services to the residents of Hull and East Riding of Yorkshire. It is designated as a Major Trauma Centre. The trust employs approximately 8,000 staff. The trust operates acute services from two main hospitals – Hull Royal Infirmary and Castle Hill – with a minor injury unit based at Beverley Community Hospital. Accident and emergency services, women’s and children’s services are located at Hull Royal Infirmary with mainly elective services, including cardiology, ear, nose and throat and oncology provided at Castle Hill Hospital.

We found that the trust had a clear vision and organisational development was taking place, involving a range of stakeholders, including patients and staff. New initiatives to engage and empower staff to drive improvement within the trust had been introduced. There were systems and procedures in place to identify and monitor risk. The incident reporting system had recently been strengthened. However, we found that not all incidents were being reported and learning from these was not consistently shared across the trust.

The trust was facing significant challenges due to the shortage of staff and insufficient capacity to deal with the increasing numbers of admissions, particularly patients referred to the hospital as an emergency. The shortage of nursing and medical staff, particularly junior doctors, was impacting on the care patients received, leading to delays in assessment and treatment. Staffing levels and skill mix did not always meet professional body recommendations. The trust board was taking action and had agreed to invest in recruiting more nursing staff, and was in the process of recruiting into medical posts.

The accident and emergency department did not have the capacity in terms of facilities and staffing to deal with the numbers of patients attending. There was a lack of appropriate senior clinicians and the children’s accident and emergency department could not provide a dedicated 24-hour service. A refurbishment programme was due to be completed by October 2014, which will increase the size and capacity of the department. However, in the meantime patients faced long waits, including on trolleys in corridors.

There were systems to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. All the areas we visited were clean.

The minor injuries unit at Beverley Community Hospital provided a good service and patients were satisfied with their care and treatment.

The trust scored above the national average for the friends and family test. In the Care Quality Commission’s 2012 Adult Inpatient Survey the trust performed about the same overall as other trusts, although it was worse than other trusts for questions on accident and emergency services. Local surveys and patient feedback showed that, generally, patients received good care, particularly in the critical care units. However, patients reported poor experiences of delays in diagnosis, access to treatment, poor communication and difficulties in obtaining outpatient department appointments.

The trust was improving the way it engaged with people, and was in the process of changing the culture within the trust to be more outward-facing. However, despite the new initiatives and strategies, many staff did not feel engaged, particularly with the senior management team. Learning was not routinely shared between health groups and divisions. Some staff across the trust with whom we spoke reported that they felt pressure to meet performance targets and spoke of a bullying culture in some areas.

We found the trust in breach of Regulations 9 (care and welfare), 10 (governance), 13 (medicines), 15 (premises), 22 (staffing) and 23 (staff support) for the regulated activities of ‘treatment of disease, disorder or injury’ and ‘diagnostic and screening procedures’.

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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.