South Tees Hospitals NHS Foundation Trust

We inspected the trust from 9 to 12 December 2014 and undertook an unannounced inspection on 16 December 2014. We carried out this comprehensive inspection as part of the CQC’s comprehensive inspection programme.

We inspected the following core services:

• James Cook University Hospital – 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.
• The Friarage Hospital – urgent and emergency care, medical care, surgical care, critical care, maternity care, children’s and young people’s services, end of life care and outpatient services and diagnostic imaging.
• Community Health Services – including:
  • Community health inpatient services at Carter Bequest Primary Care Hospital, East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital, Friary Community Hospital, Lambert Memorial Community Hospital and Redcar Primary Care Hospital.
  • Community end of life care
  • Community health services for children, young people and families
  • Urgent care centres at East Cleveland Primary Care Hospital, Guisborough Primary Care Hospital and Redcar Primary Care Hospital
  • Community health services for adults

Overall, the trust was rated as requires improvement. Safety and effectiveness were rated as requires improvement. Well led, responsiveness and caring were rated as good.

The trust leadership had generally been stable over the last few years; in 2013 the director of nursing, who had previously worked in the trust for a number of years, had been appointed to the post of Chief Executive. Some further changes were expected with the retirement of the medical director and appointments to additional roles to strengthen the delivery of quality and safety within the trust. The trust was working with staff groups, local stakeholders and consulting with the general public on the development of its services and where they were best located and how to improve the effectiveness of delivery. The trust was in the process of reviewing its governance and reporting arrangements and many of the issues identified through the risk assessment of operational delivery or the impact of the transformation of services was still work in progress. The trust was facing a particularly challenging financial position with a deficit to address, entailing significant cost improvement plans. Staff were aware of the situation and had been consulted and informed of decisions about where saving should occur. Where there had been an identified risk to quality or safety, plans had been rejected or refined. It was too early to assess at the time of the inspection whether cost savings would impact on quality and safety in the next financial year. Consultation with staff was seen as a priority and work was in progress to improve on engagement with patients and the general public.

Our key findings were as follows:

• There was a transformation programme in place to reconfigure and re-structure services in order to operate more effectively, which entailed centralising and moving some services. The maternity, children’s and young people services had been re-organised so that the main service delivery was located at James Cook University Hospital. This was an ongoing programme, which included reviewing the community services and the trust was engaging with staff, the local commissioners of services and local communities as part of its development.
• There were areas of excellent practice across the trust, particularly in the maternity services, where we found the leadership to be outstanding. The service was managed by a strong, cohesive leadership team who understood the challenges of providing good quality care and had identified effective strategies and actions needed to address these. This was particularly evident with the reconfiguration of services, which were well-developed and understood throughout the department.
• Staff felt engaged and were passionate about the quality of care given to patients. Staff reported pride at working in the trust and felt encouraged and able to introduce innovative ideas to improve service development and delivery.
• Care and treatment was delivered with compassion and patients reported that they felt treated with dignity and respect.
• Across the acute hospitals and within the community services, 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 all areas we visited were visibly clean. Rates of Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. difficile) were within an expected range for the size of the trust, although the trust was aware of and was taking action to address concerns over the increasing cases of C. difficile.
• 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.
• There was effective communication and collaboration between multidisciplinary teams across the acute services and within the community.
• There were  nursing staff shortages across wards and departments, particularly at the James Cook University Hospital and Friarage Hospital in urgent and emergency care and in children’s services. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank staff were being used to fill any deficits in staff numbers, and staff were working flexibly, including undertaking overtime.
• The composite of the Hospital Standardised Mortality Ratio (HSMR) indicators was slightly higher than expected in this trust. The Summary Hospital-level Mortality Indicator (SHMI) was as expected. The trust actively reviewed mortality cases on an ongoing basis and held regular meeting with clinicians to identify issues when data was available.
• The trust was performing worse than the national average for the development of pressure sores. The prevalence rate for grade 3/4 pressure ulcers was consistently above the national average accounting for 79% of all serious incidents reported, although there had been a steady decrease throughout the year.
• There was still much more work to be done to ensure that the premises and the arrangements in place were suitable for the children’s services.
• Attendance at mandatory training and specific subject area training, particularly for safeguarding and mental capacity assessment, was low across some areas.
• Not all records were consistently completed across the acute and the community services, including the updating of care records such as assessments, fluid balance charts, risk assessments and decisions over whether to attempt to resuscitate a patient. There were also concerns over the completion of safeguarding records, particularly in the see and treat area within the accident and emergency department.

We saw several areas of outstanding practice including:

For James Cook University Hospital:

• In medical care services, a team of therapeutic volunteers had been created which was led by a therapeutic nursing sister who had been in place for 18 months. The volunteers had mandatory and dementia training and were in operation 24hours a day. The role of the volunteers was to support patients who may be living with dementia or other illnesses which affected their behaviour and level of supervision required. This included engaging with patients, such as playing board games or other interests patients may have. They also supported patients who required help with eating or wanted to explore their environment. This included supporting them overnight if they were disorientated. The volunteers predominantly worked on wards 10, 12 and 26. The team had been regionally recognised for its work.
• We found examples of outstanding leadership within Maternity services.
• In maternity services, the Families and Birth Forum was involved in the design of the induction of labour suite and championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
• In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits used as part of the productive care work stream. The toolkits helped look at care in a variety of settings through the eyes of patients and service users, to help determine what good quality care looks, sounds and feels like.
• In maternity services, a ‘baby buddy’ mobile phone app was being piloted by the community midwives to inform women of pregnancy issues, common ailments and reasons to seek advice.
• We found outstanding areas of practice in the care and involvement of young people, including a young people’s unit, participation and accreditation in the You’re Welcome toolkit in four clinical areas, the development of a young person’s advisory group, inspections of services by young people and the involvement of young people in staff interviews.

For The Friarage Hospital:

• We found examples of outstanding leadership within Maternity services
• In maternity services, the families and birth forum was involved in the design of the induction of labour suite and in championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
• In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits which are part of the productive care work stream. The toolkits help look at care in a variety of settings through the eyes of patients and service users, to help investigate what good quality care looks, sounds and feels like.

For the community services:

• Diabetes specialist nurses provided telephone support and advice and clinic sessions for patients with diabetes supported by a dietician and ran the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) programme which was accessible to patients with diabetes or the risk of developing Type 2 diabetes to provide learning and support for the patient and the health care professionals involved with them

There were several areas of good practice in the community services:

• In community end of life services a Sources of Information and Support service directory had been developed by the Hambleton and Richmondshire Palliative Care Partnership, a health and wellbeing clinic was held at Redcar Primary Care Hospital, community specialist palliative care nurses supported the National Gold Standard Framework coordination in GP practices and supported nursing and residential homes for people with cancer and other life-limiting conditions in the Middlesbrough, Redcar and Cleveland locality.

• Within community children’s, young people’s and families services a Baby Stars programme was in place to promote the social, emotional and physical development of infants, the school nursing service held weekly drop-ins for children and young people, there was a breastfeeding group with trained peer supporters and facilitators, there were good transition arrangements for young people transferring to adult services and services enabled good accessibility for children and young people by offering different clinics and opening times.
• Within the community services for adults, the community respiratory service focused proactively on preventing admissions through meeting patient’s needs and reviewing the quality and cost effectiveness of the service through audit, the falls and osteoporosis service received an award for its inpatient work in community hospitals. The tissue viability service had developed several examples of innovative practice such as a chronic oedema project and leg ulcer collaborative to support prevention of these conditions and specialist and maintenance clinics were held for patients with lymphedema.

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

Importantly, the trust must:

For James Cook University Hospital:

• Ensure that there are sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical and surgical wards, children’s wards and the paediatric intensive care unit (PICU).
• Ensure that staff have received an appraisal and appropriate supervision so that the trust can be assured they staff are competent to undertake their role.
• Ensure staff receive appropriate training, including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity Act 2005/assessment training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
• Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are carried out and decisions made.
• Ensure that all patients’ records are maintained up to date, including the recording of identification and stored confidentially in accordance with legislative requirements, particularly ensuring that paediatric care records are contemporaneous, appropriately completed and regularly audited to monitor staff compliance.
• Ensure that there are appropriate arrangements in place for the safe handling and administration of medication, including the reconciliation of patients’ medications, that all controlled drugs are appropriately checked particularly on Coronary Care Unit and that medication omissions are monitored, investigated and reported in line with trust policy.
• Ensure that ward-based nursing staff are educated in the use of syringe drivers, including best practice in the use of continuous administration of medication for the management of key symptoms at the end of life.
• Ensure the paediatric environment in A&E is reviewed so it is fit for purpose; including a process to make sure that robust risk assessments are readily accessible and available to all staff in the department.
• Ensure all toys in A&E are cleaned regularly to reduce the risk of infection.
• Ensure that there are sufficient assisted bathing facilities and moving and handling aides within the children’s and young people’s ward areas.
• Ensure the timely completion of the refurbishment of the medical block, especially wards 10 and 12, to enable people living with dementia to be cared for in a safe environment.
• Ensure that the system for nurse calls is reviewed to ensure that there is no confusion over patients calling for assistance and the emergency alert for cardiac arrest potentially causing delays in treatment.
• Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
• Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
• Ensure robust monitoring of the safe use of syringe drivers, with sharing of results and learning from safety audits.
• Ensure that an appropriate concealment trolley is in use for the transfer of the deceased, that risks have been assessed, and that all staff using the trolleys are aware of safe moving and handling practices.
• Ensure that resuscitation equipment in surgical wards and in outpatients and diagnostic imaging areas is checked in accordance with trust policies and procedures and that this is monitored.

For  The Friarage Hospital:

• Ensure that there is sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical wards, and outpatients department.
• Ensure staff receive appropriate training and support through appraisal including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
• Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are being carried out and how decisions are made.
• Ensure that patients records are appropriately up dated and stored to ensure confidentially is maintain at all times in line with legislative requirements.
• Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
• Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
• Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
• Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
• Ensure that resuscitation equipment and medication fridge temperatures in the diagnostic and imaging department are checked in accordance with trust policies and procedures.

For the Urgent Care Centres services:

• Ensure that staff have attended mandatory training in accordance with trust policy.
• Review the quality monitoring arrangements within the urgent care centres, including patient outcomes.
• Review the provision of pain relief to ensure that there are no unnecessary delays when treating patients.
• Ensure that evidence-based guidance is available for staff working in urgent care centres and that policies are appropriately reviewed and up to date.

For the Community Inpatient Services the trust must:

• Ensure that the number of staff who received safeguarding children level 2 training and safeguarding adult level 1 training meets trust targets.
• Ensure that staff have received mandatory training.
• Ensure that patient records are accurate and complete, particularly fluid balance records, venous thromboembolism (VTE or blood clot) assessments and malnutrition universal screening tool (MUST) scores.
• Ensure that staff have received an annual appraisal.
• Ensure that hazardous substances are secured, particularly at Lambert Memorial Community Hospital.
• Ensure that staff follow the escalation policy when a patient’s condition deteriorates.

In addition, the trust should consider other actions these are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Community health services for children, young people and families at this trust had well-established systems for incident reporting and analysis using the Datix healthcare software system. Staff told us, and we saw evidence in team meeting notes, that incidents were analysed at a local level and learning was discussed within teams. Staff understood their responsibilities to raise concerns, and report incidents and near misses.

There were effective arrangements in place to manage and monitor the prevention and control of infection, and safeguard people from abuse.

Outcome monitoring for children, young people and their families using the service varied. Staff assessed and delivered treatment in line with current legislation, standards and recognised evidence-based guidance. There was evidence that performance was reviewed and actions were in place to improve outcomes.

The service followed local policies and national guidance to achieve the best outcomes for young people using the service. The service was actively engaged with regional and national networks. Staff were trained and competent to give specialist advice and treatments.

Health promotion work and advice was given to young people to assist them in making safe choices and keeping themselves safe.

Children, young people and their carers said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions. Information was provided to help children and young people understand the care available to them.

Children, young people and their carers were treated with kindness and respect, ensuring that confidentiality was maintained.

Children, young people and their carers felt included in decision-making. They were listened to and able to express their opinions, which they felt were taken into account.

People were able to access care and treatment close to home in local clinics and treatment centres.

Services were flexible and worked across professional and organisational boundaries.

There were systems within all teams for learning from experiences, concerns and complaints.

Staff knew the vision, strategy and objectives for the trust. There were service and team meetings which included items on risk, safety and quality. There were systems for recording and managing risks; managers were approachable and visible.

Staff and teams worked collaboratively to deliver quality care. The services sought out and acted on feedback from patients.

The community specialist palliative care service is part of an integrated service working together with the hospital service provided at the James Cook University Hospital as part of the South Tees Hospitals NHS Foundation Trust.

We found the community specialist palliative care teams provided a safe, high-quality service for people with a life-limiting illness or at the end of life.

The service followed evidence-based guidelines which had been developed by the Specialist Palliative Care Multidisciplinary Team (SPCMDT) and the North of England Cancer Network. The guidelines incorporated the latest guidance from the National Institute for Health and Care Excellence (NICE) and other professional organisations.

There were effective arrangements in place for managing people’s pain and the service had made improvements, for example, monitoring people’s hydration and nutrition.

Staff were competent and well-qualified to meet people’s needs. All staff had completed advanced communications skills training, were able to support people’s psychological needs and provide access to services which specialised in helping people cope with the psychological aspects of their condition.

The community specialised palliative teams had developed good working relationships with GP practices, community nurses and nursing homes. In addition to caring for people, staff provided palliative care training for other healthcare professionals.

Throughout our visit we observed that the service was well-led. Staff we spoke with were clear about the development priorities for the service. They told us they felt involved in shaping the future direction of the service and were encouraged to contribute ideas for service development and innovation.

Staff reported incidents and processes were in place to ensure that lessons were learned.

Trust-wide, evidence-based guidance was available on the trust’s intranet; however, there was limited information on evidence-based care and treatment specific to urgent care. We saw hard copies of policies and standard operating procedures for the urgent care centres that had not been reviewed for several years. We were informed that guidance was being updated, but was not yet available.

There was limited audit undertaken to monitor quality and patients’ outcomes.

We were informed that 64% of staff were compliant with mandatory training. We saw that staff had been booked to attend update training.

Staff had received training in relation to urgent care and were supported to develop their skills further. The emergency care practitioners received informal supervision. There were no formal clinical supervision sessions held with staff, including those working on their own.

Appropriate systems ensured that staff were made aware of safeguarding concerns and that information was shared with other professionals. Medicines and equipment were managed appropriately.

We saw that patients and their relatives were treated with dignity and respect. Information about who was suitable to be seen at urgent care centres was displayed on site and on the trust’s website.

Patients at all centres were seen within four hours.

The management and leadership of the urgent care centres had moved to the trauma and theatres clinical centre as part of the trust’s reorganisation in April 2014. There were plans to amalgamate the three urgent care centres to one location at Redcar Primary Care Hospital from April 2015. The intention was to develop the service once on one site, however the current focus was on amalgamating the service.

The governance and risk management of the urgent care centres was managed through the trust’s trauma and theatres clinical centre. There was limited management information or quality review undertaken to enable the leadership to fully understand and develop the service.