15 and 16 November 2016
During a routine inspection
We rated this hospital as “Good overall.”
This was because
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There were adequate systems in place to protect people from avoidable harm and learn from incidents.
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The hospital was visibly clean and well maintained. There were systems in place to prevent the spread of infection.
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There were effective systems in place to ensure the safe storage, use and administration of medicines.
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Mandatory training levels for staff were good.
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There were adequate numbers of suitably qualified, skilled and experienced staff to meet patients’ needs.There were effective arrangements in place to ensure staff had, and maintained the skills required to do their jobs.
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People received nutrition and hydration that met their preferences and needs.
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Care was delivered in line with national guidance and outcomes for patients were good.
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The individual needs of patients were met including those in vulnerable circumstances such as those living with a learning disability or dementia.
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Patients could access care when they needed it and were treated with compassion. Their privacy and dignity was maintained at all times.
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Staff were aware of the vision and strategy of the hospital.
We found areas of practice that required improvement across the hospital.
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Duty of candour processes were not always being followed as outlined in the hospital policy.
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Root cause analysis methodology was not always applied in the investigation of incidents.
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There was no process in place to risk assess or check areas of non-compliance with National Institute of Health and Care Excellence (NICE) guidance.
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The hospital risk register was not a live document and risks did not appear to be actively managed.
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Complaints were not always managed in a timely manner.
In out-patients and diagnostic imaging:
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Not all patient records included discharge summaries.
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Records did not always show if there was a safe-guarding concern for the patient.
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Records did not always show if a patient had additional needs for example, communication issues or a learning disability.
Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.
Ellen Armistead
Deputy Chief Inspector of Hospitals (North)