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Provider: County Durham and Darlington NHS Foundation Trust Requires improvement

Reports


Inspection carried out on 12 Sept to 20 Oct 2017

During a routine inspection

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.


CQC inspections of services

Service reports published 29 September 2015
Inspection carried out on 3-6 February 2015 During an inspection of Community health inpatient services Download report PDF | 379.93 KB (opens in a new tab)
Inspection carried out on 4 – 6 February 2015 During an inspection of Community urgent care services Download report PDF | 290.86 KB (opens in a new tab)
Inspection carried out on 4-6 February 2015 During an inspection of Community health services for children, young people and families Download report PDF | 313.09 KB (opens in a new tab)
Inspection carried out on 3-6 February 2015 During an inspection of Community health services for adults Download report PDF | 279.38 KB (opens in a new tab)
Inspection carried out on 4-6 February 2015 During an inspection of End of life care Download report PDF | 293.08 KB (opens in a new tab)
Inspection carried out on 4-6 February 2015 During an inspection of Community dental services Download report PDF | 280.79 KB (opens in a new tab)
See more service reports published 29 September 2015
Inspection carried out on 3 February – 6 February 2015

During a routine inspection

We inspected County Durham and Darlington NHS Foundation Trust from 3–6 February 2015 and 27 February and undertook an unannounced inspection on 25 February 2015. We carried out this comprehensive inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

The trust had an evolving executive team. The Chief Executive was previously the Finance Director and Chief Operating Officer, and was appointed in 2012. The Chief Nurse was leaving the trust in April 2015. The Chair had been in post since 2007 and was stepping down in February 2015 with a newly appointed Chair taking up post shortly after. There was a Chief Operating Officer starting in post in February 2015 and this role was a new development.

We inspected the following core services:

  • The University Hospital of North Durham – 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.
  • Darlington Memorial Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, outpatient services and diagnostic imaging.
  • Community health services, including:

    • Community health inpatient services
    • Community adult and long-term conditions
    • Community end of life care
    • Community health services for children, young people and families
    • Urgent care centres
    • Dental Services.

Overall, the trust was rated as ‘Requires Improvement’. Safety, effectiveness and well-led were rated as required improvement; caring and responsive were rated as good.

Our key findings were as follows:

  • Across both the acute hospitals and in the community, 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 most areas we visited were clean. Rates of Methicillin-resistant staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the trust.
  • 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, both in hospitals and across community services.
  • There was effective communication and collaboration between multidisciplinary teams.
  • There were staff shortages, particularly on some medical wards and in maternity and gynaecology , mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank, agency and locum staff were being used to make up for any deficits in staff numbers and staff were working flexibly, including undertaking overtime.
  • The emergency department at Durham did not have a paediatric trained nurse on all shifts
  • Mortality rates were within acceptable limits for a trust of this size, and processes for reviewing morbidity and mortality had been established and were evolving to include the core service teams. There was a weekly review of morbidity and mortality by a senior group of Clinicians and this informed the Mortality Committee.
  • Equipment was well maintained, both in the hospitals and in community services.
  • Incidents were reported and lessons were learnt and disseminated.
  • A small proportion of community staff reported that there was no clear vision or strategy for community services, although there was a clinical strategy that was still being developed at the time of inspection.
  • Care and treatment was delivered with compassion, and patients reported that they felt they were treated with dignity and respect.
  • Staff did not always feel engaged with the development of their services. The contract for a number of community services was due to be re-tendered, but staff reported not being engaged with this process.
  • There was evidence to demonstrate that there were differences between the acute hospital sites with regard to clinical practice and leadership; these differences were seen in areas including the provision of non-invasive ventilation services and maternity services.
  • There were inconsistencies in the provision of pharmacy support in hospitals and community services.
  • There was inconsistent access to therapy services in the community.
  • Governance processes were not fully embedded across all parts of the organisation.

We saw several areas of good practice including:

  • An exceptionally caring critical care service in Darlington, where inspectors observed individualised care and attention to detail given to patients and relatives. This was shown by the trust's work with the end of life team, its visitor’s charter, care of patients with learning disabilities, and implementation and consideration of the deprivation of liberty safeguards (DoLs). In addition, memory bands were used for patients and their relatives.
  • Safety huddles had been implemented on the wards at the University Hospital of North Durham.
  • There was consistently positive feedback from patients and relatives about community nursing teams, with care being described as 'excellent'.
  • The dietetics team was committed to improving nutrition, with the work it had undertaken being published and shared nationally.
  • The County Durham Rapid Early Specialist Team (CREST) service provided early senior and multidisciplinary assessment for frail older people, which facilitated safe, early, supported discharge, and managed patients with an anticipated short length of stay.
  • There was a family nurse partnership established to provide intensive support for teenage mothers.
  • Staff in the CT department had received ‘Making a difference’ award in February 2014.
  • Staff on ward 52 had recently been awarded the ‘Quality mark for elder-friendly hospital wards’.

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

Importantly the trust must:

  • Review current governance processes to ensure they are embedded to ensure consistency across acute and community services.
  • Review and ensure that all members of the board are fully aware of their lead responsibilities within the Board Assurance Framework.
  • Review the achievements and actions taken to address national targets within the accident and emergency departments (A&E).
  • Review consultant levels against CEM guidance.
  • Ensure the A&E departments meet cleanliness, infection control and hygiene standards, particularly relating to high and low level dust, blood stains, equipment and floors. Chairs and equipment that have deteriorated must be removed and replaced.
  • Ensure all toys are cleaned properly to reduce the risk of infection within the A&E department.
  • Ensure sharps bins are managed appropriately to reduce the risk of needle stick injury within the A&E department.
  • Ensure that all resuscitation drugs and equipment within the A&E department are regularly checked, cleaned and in date. This should include all grab bags and anaphylaxis kits.
  • Ensure that all relevant staff know where the Difficult Airway Kit is kept.
  • Ensure there are robust risk assessments in place for the paediatric environment within the A&E department. These must be readily accessible and available to all staff in the department. Risk mitigation must be outlined and an action plan to improve the area must be written.
  • Ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance and taking into account patients’ dependency levels on medical wards, particularly where patients are receiving non-invasive ventilation (NIV) and require level 2 intervention.
  • Undertake a review of current documentation relating to the care and management of patients receiving NIV to ensure that it is consistent across both the University Hospital of North Durham and Darlington Memorial Hospital.
  • Have arrangements in place for patients receiving NIV that comply with the British Thoracic Society guidelines (2008) for the use of NIV for acute exacerbation of chronic obstructive pulmonary disease.
  • Undertake a regular audit of the provision of services to patients requiring NIV to ensure that the service is safe and of appropriate quality.
  • Ensure that patients are placed on the most appropriate ward to meet their needs, including a review of the care of patients requiring NIV to ensure that they are admitted to a suitable ward with appropriately skilled and experienced staff in line with best practice guidance.
  • Ensure that patient records, including those for patients awaiting discharge, are kept up to date, are patient-centred and contain relevant information about their treatment and care, in order to eliminate unnecessary delays.
  • Ensure that the trust undertakes a review of the skills, knowledge and capabilities of nurses to complete accurate and timely care plans that meet the needs of the patients.
  • Establish a consistent approach to critical care outreach services across the organisation.
  • Ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced medical staff within maternity and gynaecology services.
  • Ensure that there are processes in place by which to identify, acknowledge and address risks through robust management processes within maternity and gynaecology services.
  • Ensure the paediatric high dependency unit room has specific standard operating procedures or protocols available to guide suitably trained staff.
  • Ensure advanced paediatric nurse practitioners have a set of standard operating procedures available to guide their practice and care.
  • Review paediatric nurse cover in the A&E department at Durham to ensure all shifts are covered with a paediatric nurse either through service level agreement with the paediatric department or through the appointment of paediatric nurses to the department, to ensure a consistent approach across the organisation.
  • Ensure that staff know the syringe driver policy and carry out/record syringe driver checks in line with this policy.
  • Add audits of syringe driver administration safety checks to the annual end of life audit programme.
  • Ensure medical staff record mental capacity assessments for patients who are unable to participate in decisions about ‘do not attempt cardiopulmonary resuscitation’ (DNACPR).
  • Ensure audits of mental capacity assessments are incorporated into audits of DNACPR forms.
  • Ensure robust implementation of structural changes to the specialist palliative care team to support the development of the end of life care services.
  • Ensure data are available to identify and demonstrate the effectiveness of the end of life service.
  • Ensure that all resuscitation equipment is checked daily and stored securely, and introduce a monitoring system to ensure that checks take place within the outpatient departments.
  • Address the lack of consultant medical staff cover in end of life community services.
  • Develop access to out-of-hours advice for healthcare professionals caring for palliative and end of life patients within community.
  • Ensure there is effective leadership and management in place to maintain and develop the community end of life service.

In addition the trust should:

  • Continue to review College of Emergency Medicine (CEM) audit data to ensure patient outcomes are met.
  • Review the complaint process in terms of board oversight, CEO involvement and clinical direction.
  • Direct medical staff to check resuscitation equipment and drugs before the start of their shift even when nursing staff have completed the checks.
  • Encourage all relevant staff within the A&E department to attend violence and aggression training.
  • Ensure patients have their medicines reconciled in accordance with trust targets.
  • Review access to patient information in languages other than English.
  • Review dedicated management time allocated to ward managers.
  • Review the patient flow of higher dependency patients throughout the hospital to ensure care is given in the most appropriate setting.
  • Have an up-to-date standard operating procedure (SOP) for both acute hospitals which clearly sets out the management of admitted patients who require NIV.
  • Ensure that this guidance/SOP includes clarity on the setting/specific ward in which patients can be managed.
  • Ensure that this guidance/SOP includes staffing-to-patient ratios that are in line with current guidance.
  • Ensure that there is a training plan in place, which is delivered to all staff involved in the care of patients receiving NIV, and that it is competency based and in sufficient detail to demonstrate competence in all aspects of NIV.
  • Ensure that any guidance/SOP includes an escalation plan that includes action to be taken when a bed is unavailable in an appropriate setting and when patient numbers do not match agreed staffing ratios.
  • Ensure that the intensive care unit has an outreach team to identify and monitor deteriorating patients.
  • Ensure that there is clinical pharmacist input in the intensive care units on both sites in line with ‘Core standards for intensive care’ guidelines.
  • Consider ways of improving engagement between staff and managers within the care closer to home directorate with a view to achieving a joined up approach within maternity and gynaecology services. Also, consider ways of improving responsiveness and efficiency in respect to service-level decisions within this service.
  • Consider ways in which it can identify the required standards within the maternity service dashboard.
  • Consider, within the maternity and gynaecology services clinical and quality strategy for 2014–16, timelines for review and achievement.
  • Consider ways of developing a coherent plan for joint working on improvements in maternity and gynaecology services.
  • Consider ways for improving timely and responsive human resource management processes, including personnel issues that impact on service delivery in maternity and gynaecology services.
  • Formally nominate an executive or non-executive director to represent children at board level, separate from the safeguarding children executive lead role.
  • Ensure actions in response to the National Care of the Dying Audit (NCDAH), and other identified actions to develop the service, are carried out in a planned and timely way with continued evaluation.
  • Ensure systems support ways of identifying when incidents and complaints relate to end of life care so that specialist input can be provided and recorded in terms of investigation and learning.
  • Ensure that any out of date medication is removed from stock cupboards once it has expired, in line with the trust medication management policy, and have a process for monitoring this within the outpatient departments.
  • Ensure that all fridge temperatures are checked daily and that there is a system in place to monitor checks taking place within the outpatient departments. The trust should ensure that the cold chain is robust.
  • Ensure that all clinicians within children and young people’s community services have the appropriate level of children's safeguarding training.
  • Improve audit activity to monitor quality and patient outcomes within the urgent care centres.
  • Review staffing at night within the urgent care centres.
  • Review the need for paediatric-trained nurses in the urgent care centres.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.