You are here

Provider: County Durham and Darlington NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 March 2018

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

  • We rated safe, effective and well led as requires improvement; caring and responsive were rated as good at service level.
  • We rated both the University Hospital North Durham and Darlington Memorial Hospital as requires improvement.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • We rated well led at the trust level as good.
Inspection areas

Safe

Requires improvement

Updated 1 March 2018

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

  • Although staffing levels had improved, the trust still did not have enough staff with the right qualifications, skills and training. Staff numbers were lower than planned in urgent and emergency care.
  • Within urgent and emergency care, consultant presence in the departments did not meet the RCEM guidance of consultant presence of 16 hours a day. ST3 doctors (those in year three of speciality training) were part of the middle grade rota. This goes against the RCEM guidance that a minimum of an ST4 or equivalent is in the department at all times.
  • Within urgent and emergency care, the service did not always manage medicines well.
  • Within urgent and emergency care, the department missed key targets for caring for patients promptly. Patients did not always get a face-to-face assessment within 15 minutes of arrival or registration. Patients brought in by ambulance were not always handed over to the department within 30 minutes and this was getting worse.
  • Within urgent and emergency care, staff did not record patient care consistently.
  • Within urgent and emergency care, although the service had a separate room to assess patients with mental health needs, it did not conform to the Psychiatric Liaison Accreditation Network (PLAN) standards.
  • Within medical care services at University Hospital North Durham, members of staff did not comply with hospital policy on the administration of covert medicines. We found evidence of staff providing medication covertly for patients without ensuring capacity assessments were in place.
  • Within medical care services, medical and nursing records were not stored securely in all areas we visited.
  • Eleven never events were reported over 13 months from May 2016 to May 2017. Three of the never events reported in the second half of 2016/17 related to 2014 or before. This meant there had been a large ‘batch’ of never events in the first half of 2016/17; and two clusters of two never events, which occurred in February and April 2017, and October and November 2017. Joint working with stakeholders and a trust wide programme of learning had taken place following these never events reduce risks of harm to patients; however, despite this, two further never events occurred after September 2017. There was a strong need to further embed safer practices and learning across the trust.

However:

  • Managers investigated incidents quickly, and shared lessons learned and changes in practice with staff.
  • Staff understood and followed procedures to protect vulnerable adults or children.
  • The trust had plans for dealing with major incidents and staff understood their roles. The plans had been tested and reviewed.
  • The wards and department areas were clean and equipment well maintained. Staff followed infection control policies that managers monitored to improve practice. Cleanliness within the urgent and emergency care departments had improved since the last inspection.
  • Care and treatment of patients requiring non-invasive ventilation (NIV) had improved since the last inspection.

Effective

Requires improvement

Updated 1 March 2018

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

  • Staff did not understand their roles and responsibilities under the Mental Capacity Act 2005. They did not always follow legislation and best practice for those who lacked the capacity to make decisions about their care.
  • The trust did not meet targets for Mental Capacity Act and Deprivation of Liberty Safeguards training. The knowledge and practice of staff on the wards raised concern over the effectiveness and numbers trained.
  • The trust policies ‘Policy and guidance notes for staff on the Mental Capacity Act 2005’ (reviewed January 2017) and ‘Deprivation of Liberty Safeguards’ (reviewed December 2016) did not direct staff to guidance or tools for use by staff.
  • Clinicians did not update or review care pathways regularly in emergency department.
  • Nursing staff in the emergency department looking after children were not aware of the Fraser guidelines and Gillick competency principles when assessing capacity, decision making and obtaining consent from children.
  • Results from the national neonatal audit programme (NNAP) indicated some lower than average standards; for example in the percentage of mothers who were given antenatal steroids and also the percentage of premature babies who had their temperature taken within an hour of being born.

However:

  • Staff provided care and treatment based on national guidance and evidence and used this to develop new policies and procedures.
  • Managers monitored the effectiveness of care and treatment through continuous local and national audits.
  • The electronic patient record system provided up to date patient clinical information available to all members of staff.
  • There was effective multi-disciplinary (MDT) working to secure good outcomes and seamless care for patients across the trust.

Caring

Good

Updated 1 March 2018

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

  • Staff cared for patients with compassion, treating them with dignity and respect.
  • Patients, families and carers gave positive feedback about their care.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.

Responsive

Good

Updated 1 March 2018

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

  • Referral to treatment (RTT) times for admitted performance was above the England average. Where RTT shortfalls existed, the trust had identified actions to improve performance.
  • The escalation policy and procedure guidance was followed during busy times. The director of nursing, matrons and service managers attended capacity bed meetings to monitor bed availability, discuss concerns and identify flow issues.
  • Services were planned and delivered in a way that met the needs of local people. They worked with commissioners, external providers and local authorities.
  • Systems were in place for the management of complaints, and there was evidence of improvements following complaints.

However:

  • The service did not meet the Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival at the emergency department. It breached this target 11 times between October 2016 and September 2017.
  • Over the 12 months from August 2016 and July 2017, four patients trust wide waited more than 12 hours in the emergency department from the ‘decision to admit’ until being admitted.
  • Between September 2016 and August 2017 the percentage of patients leaving this hospital before being seen for treatment in the emergency department was consistently worse compared to the England average.
  • Between September 2016 and August 2017, the time spent in the emergency department was consistently worse than the England average.

Well-led

Good

Updated 1 March 2018

Our rating of well-led at core service level stayed the same. We rated it as requires improvement because:

  • There was a need to strongly embed learning from never events in order to minimise risk to patients. Seven never events occurred between May and October 2016. The trust took actions to address this. However a further four never events occurred at the trust between November 2016 and May 2017. The trust took further action but despite this two further never events occurred after September 2017.
  • At the time of inspection, in medical care services, we had concerns about Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training, the knowledge and practice of staff on the wards related to capacity assessments and DoLS applications and the trust policy for Mental Capacity Act and Deprivation of Liberty.
  • Meetings with directorate managers and trust senior managers did not give assurance that they were aware of these concerns before the inspection. We were given assurance that these issues would be addressed as a matter of urgency.
  • Not all risks were identified by the urgent and emergency care department and risk assessments were not carried out for patients with mental health needs.

However:

  • Most services had a clear vision and strategy, which was understood by staff.
  • Services had governance, risk management and quality measures to improve patient care, safety and outcomes.
  • Services had a clear management structure at both directorate and care group level. The managers knew about the quality issues, priorities and challenges.
  • The culture within services was open and transparent. Staff could raise concerns and felt listened to. They said leaders were visible and approachable.
  • There was a newly formed senior leadership team in the maternity service covering business, midwifery and clinical leadership. We found that this team was cohesive and that there was a real drive to continue improve the quality of the service.
Checks on specific services

Community dental services

Good

Updated 29 September 2015

Overall, we rated community dental services as good. We found dental services provided safe and effective care. Patients were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were effective and focused on the needs of patients and their oral healthcare. We observed good examples of effective, collaborative working practices within the service. It can be difficult for the service to recruit dentists essentially because of the rural nature of County Durham and the current financial climate of the NHS. However, the service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

The patients we spoke with, and their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were through what they did.

At each of the clinics we visited the staff responded to patient needs. We found the service had begun actively seeking the views of patients using a variety of means. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs at the right time. Through effective management of resources, delays to treatment were kept within reasonable limits.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said that they generally felt well supported and that they could raise any concerns.

Community health inpatient services

Good

Updated 29 September 2015

Overall, community in patient services were good. Medical cover was provided in different ways at each location. Advanced nurse practitioners held responsibility for inpatient services at night, but in some locations the most senior member of staff on duty was a band 5 staff nurse. Services did not use a nursing dependency tool to calculate numbers of nursing staff required. On most wards there were two qualified nurses on duty for all shifts. When the ward was full this meant that there was a qualified nurse ratio of 1:11 or 1:12 (1 qualified nurse for 11 or 12 patients). This falls outside the recommended Royal College of Nursing (RCN) ratio of 1:8.However, managers supported staff to access additional nursing and healthcare assistant staff when clinical needs or new complex admissions required extra staff. Staff told us that their managers were supportive and trusted them to make clinical decisions regarding staffing.

Most patient records were appropriately completed, care plans were individualised and we found evidence of goal setting and discharge planning. However, medical nursing documentation received from the acute site with patient transfers was not always complete and all pages were not always sent to the community ward. We found that nursing assessments and risk assessments were in place and where risks were identified relevant to scores and patient status, appropriate action plans were in place and regularly reviewed during inpatient stays.

Incidents were reported, managed and investigated. There was evidence that learning and subsequent changes had taken place as a result of incidents. Staff understood their personal and professional responsibilities and applied the principles of the Duty of Candour legislation as part of their working roles.

Staff followed infection control principles and were seen to wash their hands and use hand sanitising gel appropriately. All staff were ‘bare below the elbow’. Staff felt involved and were encouraged to give feedback on patient care both informally and at ward handovers.

Peer review was carried out across the care closer to home directorate using an observational site visit tool. This gave a rating against each quality assurance target and recommendations for actions where appropriate. Staff told us that this activity was valued by all senior staff as an opportunity to share good practice. There was little evidence that community hospitals benchmarked their outcomes or quality of care against national guidelines or standards.

Admission criteria and pathways were in place and patients were mostly admitted appropriately for nursing care and/or therapy input, although there were some inappropriate admissions to the community wards from the acute services, especially A&E. Access to therapy was inconsistent between services. Some had access to part-time therapy support on weekdays while others carried out assessments prior to admission but on-going maintenance therapy was not available. Discharge planning was integral to the care of patients and home visits were incorporated into the plans to help assess the patients’ moods, wellbeing, safety and mobility needs. This allowed sufficient time to identify any equipment required and to allow efficient ordering prior to a formal discharge. Delayed transfers of care throughout the trust were due to a range of causes, most of which scored equally or considerably less (better) than national averages.

Patients and visitors told us that the care they received from staff was excellent and that patients felt safe and cared for during their stay. We observed staff speaking to patients in a sensitive and compassionate manner. There was a good range of quality information leaflets for patients and families to read and keep. Staff ensured they were as involved as possible about making decisions about their care and feeling empowered to care for themselves as soon as they were able.

Staff understood the trust’s overall vision, but there was no clear vision or strategy for the future regarding community services. There had been recent changes within community inpatients and staff expected further change in future. Risk management meetings were held monthly, but staff awareness and the engagement of risk management was inconsistent. Staff we spoke to were very positive and proud of the service, the team and provision of care to patients. Ward staff encouraged patients to complete a questionnaire prior to discharge. Although low numbers of patients completed the questionnaires the results were good overall and all patients commented that the staff had been kind, considerate and caring. Staff felt they provided a good link between acute services and the community and had good connections with therapy teams who followed up patients’ progress at home.

Community urgent care services

Good

Updated 29 September 2015

Overall, we rated this service as good, although safety was rated as requires improvement. Although staff told us that there were usually sufficient staff to meet the need of the patients, there were high levels of staff sickness at the urgent care centre at Peterlee Community Hospital. Long-term sickness was being managed and agency staff were occasionally used to cover at Peterlee, with cover at other sites being provided by staff working longer hours or staff from other centres covering vacant shifts. Several staff from Bishop Auckland urgent care centre had recently left the service due to the uncertain future of the service. Staff teams usually consisted of GPs, urgent care practitioners and healthcare assistants. Staffing levels in centres were much higher during the day than at night and often, at Shotley Bridge urgent care centre, a single member of staff could be left to work in the department if a GP was called away. In one centre, the urgent care practitioner also held the second crash pager for the whole community hospital, to support the Advanced Nurse Practitioner within the hospital. Incidents of violence and aggression towards staff had been reported by staff and a security alert had been raised at Peterlee urgent care centre when a member of staff had felt threatened at night. A risk assessment had subsequently been carried out.

Staff were confident in reporting incidents and safeguarding concerns and we saw from staff meeting minutes that incidents and learning from incidents were discussed regularly. There was a child protection lead practitioner in the team. Documentation was correctly and consistently completed. Staff knew the procedure to follow if a patient’s condition deteriorated and transfer to the emergency department or admission to the acute site was required.

We saw some evidence of assessment tools in use. There was audit undertaken to monitor quality and people’s outcomes Multidisciplinary team meetings were held quarterly in each centre and included a range of staff (e.g. GP/Reception/Practitioner/HCA). Cross Centre Clinical Governance meetings were held monthly. Across all centres there were good relationships with local GP practices. Information was available via the electronic records system and discharge information was available electronically to other users of the system, such as local GPs.

Staff were competent in their roles and attended regular quarterly team meetings. They discussed best practice and changes in guidelines. Staff competency documents and supervision notes were unavailable during our visit. There were a number of care pathways in use, which demonstrated good patient outcomes. Staff told us that trust guidelines and National Institute for Health and Care Excellence (NICE) guidance were followed across all centres. They also explained that they frequently used their own clinical judgement and relied on professional integrity and responsibility.

Patients and their relatives or carers were treated in all interactions with dignity, respect and care was provided in a compassionate way. They were provided with relevant verbal information, emotional support and explanations about their care and staff checked patients’ understanding of the care planned and provided.

Radiology was available during the day at Shotley Bridge, Bishop Auckland and Peterlee centres. Patients attending Seaham urgent care centre would need to be transferred to Peterlee urgent care centre for radiology services. Premises were accessible for patients with limited mobility and peoples’ individual needs were well met by the delivery of patient-centred care. All services worked well together and coordinated within and across sites to ensure the best possible care was given. There was good access for staff to refer to the mental health team, who would attend the unit if called. There were clear criteria for ensuring all babies and pregnant women were seen by a GP, as well as patients returning to the centre on two or more occasions.

Governance structures were clear to both staff and managers. Learning from incidents was shared via the urgent care clinical governance group, which also discussed peer support and reviews. The management and leadership of urgent care had changed and a relatively new postholder was managing services across the stand-alone urgent care centres (Bishop Auckland, Shotley Bridge, Peterlee and Seaham). The culture within the service was mostly positive and confident and was actively looking at ways to improve. All the staff we spoke with were positive about the contribution they made to patient care and were very positive about the teams they worked in. Staff felt supported by managers, despite experiencing a prolonged period of transition and change, and reported effective team working. The changes were aimed at improving the services for local communities and ensuring sustainability.

Community health services for children, young people and families

Good

Updated 29 September 2015

There were systems in place for reporting and investigating incidents involving children and families. Systems were in place, through the integrated governance reporting system, to identify themes and to learn and share the learning from incidents. Incident reporting was increasing and support was available for practitioners who reported incidents. There was a good understanding of infection control procedures and we saw that staff used hand hygiene gels during two immunisation sessions we attended. Similarly, there was good knowledge of how to keep medicines safe in schools and children centres. Health visitor caseloads were within an acceptable range and met Lord Laming (2009) recommendations. There was one risk identified in relation to raising the level of safeguarding training required to Level two for clinicians. There was an action plan that set out the timescale for this change and a targeted approach.

The Healthy Child Programme was delivered to children and young people and initiatives such as UNICEF baby friendly were in operation. Children and young people’s needs were assessed and treatment was delivered in line with current legislation, standards and recognised evidence-based guidance. For example, the trust had a Family Nurse Partnership team. Staff worked to deliver assessment and treatment in accordance with standards and evidence-based guidance. There was some monitoring of outcomes for patients and plans were in hand to redesign and restructure the services to make better use of resources and improve effectiveness. Multidisciplinary team working was effective. Staff were competent and working well as an integrated team in the interests of patients. Staff development, supervision and performance appraisal were in place and compliance was good.

Overall we rated children’s and young people’s services good for the quality of care. In all the services we visited we staff were providing compassionate and sensitive care. Children and families were encouraged to be involved in their care. Patients we spoke with, and their families, felt that they were treated with dignity and respect.

We found that the services were planned and delivered to meet the needs of children and their families. Structures had been redesigned in response to the people’s changing needs and the need to manage resources between ‘universal’ and ‘targeted’ services. We found that there was good access to translation services and an understanding of the need to respond to cultural differences in the area. There was an open and transparent approach to complaints and they were treated as an opportunity for shared learning and service improvement.

There was a clear vision and strategy where the priorities of the trust were understood locally. Staff working in community children’s services were committed to their work and understood the priorities of the service and their individual teams. The integration of community services into the trust was ongoing. There was strong support for the local leadership and staff appreciated the high levels of honest communication and new drive for quality.

Community health services for adults

Good

Updated 29 September 2015

Overall, we rated community health services for adults as good. We found there was a robust reporting system in place and staff felt able to report incidents and raise concerns in a ‘no blame’ culture. Equipment was well maintained and fit for purpose. Staff adhered to good infection control practices and we saw that medicines were stored and administered safely.

Electronic records were complete but we found patient-held paper records to be incomplete. We saw that staff used care planning and care pathways to effectively manage patients’ health needs. There was positive multidisciplinary working across and between services and different professionals, which provided good, effective outcomes for patients.

We did not identify any long standing staff vacancies and we were confident that staff were trained in safeguarding, the Mental Capacity Act and deprivation of liberty safeguards.

We saw numerous examples of compassionate care and patients’ dignity and privacy being respected. All the patients and carers we spoke to told us they valued the service and found the staff excellent. Patients and their carers received emotional support from staff during visits.

Patients were treated in their own homes or clinics and services were provided to prevent hospital admissions. We saw that patients were supported when they were moving between services and we observed positive inter-professional relationships. We found that complaints were addressed at the lowest possible level, but, when identified, lessons were learnt and disseminated effectively throughout the service.

All staff were aware of the vision and strategy for the trust and their service and could relate their roles in achieving this. Governance and quality measures were embedded in the service. Audits were widely used to monitor quality and receive patient feedback. Leadership within the service was strong and visible and staff demonstrated a clear respect for local leaders. The culture within the service was positive and all the staff we spoke with spoke highly of their teams and line managers.

End of life care

Good

Updated 29 September 2015

Overall community end of life services were good, although there were some aspects of well-led that required improvement. The community specialist palliative care service (CSPCS) provided a safe service. Staff were clear about their responsibilities for clinical safety, operated within clear national clinical guidelines and reported and analysed clinical safety issues and incidents. The service had arrangements in place for reporting and analysing incidents. Staff were aware of current infection prevention and control guidelines and we observed good infection prevention and control practice. Medical support for the CSPCS was provided by one full-time consultant in palliative care medicine. The consultant in post had been absent for several months. The post had been covered by a recently retired consultant who provided cover six sessions per week. A second consultant post was vacant.

CSPCS had been developed in line with national guidance. The service used the palliative and end of life guidelines developed by the North of England Cancer Network. These provided staff with guidance on palliative and end of life care planning, pain management, symptom management and emotional and psychological support. CSPCS staff were appropriately qualified and experienced to give specialist advice and we saw evidence of good multidisciplinary team working as part of the approach to supporting patients in the community. The service had arrangements in place for managing patient’s pain, managing symptoms and supporting their nutrition and hydration needs. The Liverpool Care Pathway had been replaced by guidance developed by the Northern England Strategic Clinical Networks, ‘Guidance for care of patients who are ill enough to die’, June 2014. There was no access to specialist palliative care advice out of hours. There was no specialist or general training programme in place for palliative and end of life care. Some community nursing staff who were coordinating people’s care had not received training in palliative and end of life care.

Patients were treated with dignity, respect and compassion.

The service worked well with other services and had developed services in partnership with the local clinical commissioning group to ensure patients needs were met. Specialist community palliative care staff reviewed the needs of newly referred patients and adjusted their priorities to ensure they provided a responsive service. Any complaints were reviewed and investigated, and any learning from complaints was cascaded to staff.

The service had been without senior leadership for some time. The consultant in palliative care medicine in post had been absent for several months. The post had been covered by a recently retired consultant who provided cover six sessions per week. A second consultant post was vacant. Team leaders had been identified for each of the localities. These were senior nurses who took on operational management responsibilities over and above their clinical caseloads. Staff understood the strategic aims of the organisation and felt involved in the clinical quality improvement framework.