Friarage Hospital

Updated 19 January 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Friarage Maternity Centre (FMC).

We inspected the maternity service as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The FMC provides maternity services to the South Tees population.

The midwifery led unit at the Friarage included a birth centre and day assessment unit. Between 1 January 2023 and 30 June 2023, 51 babies were born at this service.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

This location was last inspected under the maternity and gynaecology framework in 2015. Following a consultation process CQC split the assessment of maternity and gynaecology in 2018. As such the historical maternity and gynaecology rating is not comparable to the current maternity inspection and is therefore retired. This means that the resulting rating for Safe and Well-led from this inspection will be the first rating of maternity services for the location. We rated safe as good and well led as requires improvement. This does not affect the overall hospital level rating.

We also inspected 1 other maternity service run by South Tees NHS Foundation Trust. Our reports are here:

The James Cook University Hospital - Care Quality Commission (cqc.org.uk)

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the Friarage Maternity Centre (FMC), based within the Friarage Hospital in Northallerton, North Yorkshire. This is 1 of 2 acute hospitals forming South Tees Hospitals NHS Foundation Trust. FMC became a standalone midwifery-led unit in 2014 and was run by a team of midwives who provided care to women and birthing people with straightforward pregnancies. Women and birthing people were advised to transfer to James Cook University Hospital Obstetric- Led Unit when any complications occurred.

We spoke with the chief nurse, outpatient matron, 2 midwives and 1 maternity support worker. We were unable to speak with any women, birthing people or families. We did not receive any responses to our give feedback on care posters which were in place during the inspection.

We reviewed 6 care records of women and birthing people and 3 observation and escalation charts.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 24 May 2023

Updated 10 June 2015

We rated services for children and young people as ‘good’. The children’s services actively monitored safety, risk and cleanliness. We did not identify any concerns regarding nursing and medical staffing at the Friarage Hospital.

At Friarage Hospital there was only one young person available to talk with during our inspection visit and they were very happy with the care they received. We reviewed 63 questionnaires submitted since 1 November 2014 and these showed that parents provided positive feedback with no negative responses.

We found that a recent service reconfiguration was being closely monitored and managed in partnership with commissioners and other healthcare providers. We found access and flow was good within the hospital and its link to the main children’s services at James Cook University Hospital.

The service had a clear vision and strategy based on the National Service Framework for Children. The service was led by a positive management team who worked well together. The service regularly introduced innovative improvements with the aim of constantly improving the delivery of care for children and families.

Updated 2 July 2019

We rated it as requires improvement because:

• The service did not have enough radiologists which impacted on delivery of the service.
• We found infection control procedures were not always followed.
• We were not assured staff were able to recognise incidents and report them appropriately. Staff told us lessons learned were not shared with the whole team and the wider service. The service was not effectively monitoring trends and themes. We saw incidents that had not followed the correct procedure of reporting both internally and externally.
• Performance for achieving the timescales for provision of diagnostic radiology for cancer patients were not achieved.
• There were limited provisions/support for individuals with additional needs such as dementia or learning difficulties.
• Not all risks which managers told us about were documented on the risk register although the service had procedures in place to report and manage risks.

However:

• The service provided care and treatment based on national guidance.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff cared for patients with compassion.

Updated 28 October 2016

Overall end of life care was rated as good because:

Staff delivering end of life care understood their responsibilities with regard to reporting incidents and ensured information and lessons learnt were shared proactively with other colleagues within the hospital.

There were improvements made since the last inspection in documentation of individualised care of the dying documents and appropriately completed Do Not Attempt Resuscitation forms.

However:

Some equipment in the mortuary was not safe for its intended use. Risk assessments for porters and security staff were found to be out of date.

There was no regular audit programme for infection prevention and control in the mortuary.

Updated 19 January 2024

Updated 28 October 2016

Outpatient and diagnostic imaging was rated for safe as good because:

Departments were clean and hygiene standards were good. Staff ensured equipment was clean and well maintained, so patients received the treatment they needed safely.

Incidents were reported using an electronic reporting system and staff knew how to report incidents. Incidents were investigated and ‘lessons learned’ were shared with staff.

Staff had received appropriate training and support through the completion of mandatory training, so that they were working to the latest up to date guidance and practices, with appropriate records maintained.

Updated 24 May 2023