University Hospital of North Tees

University Hospital North Tees provides acute care services for North Tees and Hartlepool NHS Foundation Trust. The hospital has 563 beds and provides urgent and emergency care services, critical care services, medical services, surgical services, maternity services, outpatient services and children and young people’s services.

The trust gained foundation status in 2007. It has a workforce of approximately 5500 staff and serves a population of around 400,000 in Hartlepool, Stockton and parts of County Durham. The trust also provides services in a number of community facilities across the areas supported, including Peterlee Community Hospital and the One Life Centre, Hartlepool.

We inspected University Hospital North Tees as part of the comprehensive inspection of North Tees and Hartlepool NHS Foundation Trust, which included this hospital and community services. We inspected University Hospital North Tees on 7-10 July and 29 July 2015.

Overall, we rated University Hospital North Tees as requires improvement. We rated it as requires improvement for safe, effective and well-led services and good for caring and responsive services.

We rated emergency and urgent care, medical services and maternity and gynaecology services as requires improvement and surgery, end of life care, children and young people’s services and critical care as good.

Our key findings were as follows:

• Arrangements were in place to manage and monitor the prevention and control of infection. A dedicated infection control team to supported staff and ensured policies and procedures were implemented and adhered to. We found that areas we visited were clean. In the A&E department we saw that infection control procedures were not always being followed.
• At the time of inspection, infection rates for methicillin resistant Staphylococcus aureus (MRSA) and Clostridium Difficile (C Difficile) were within an acceptable range for this size of hospital.
• The trust had not met the A&E four hour target between January 2015 to March 2015 however performance had started to improve
• Patients were able to access suitable nutrition and hydration, including special diets. We observed the use of red trays for at risk patients who required support with feeding and coloured plates and bowls for patients living with dementia. Patients reported the food provided during their stay was satisfactory and valued the opportunity to choose the size of their meal.
• There were staffing shortages in some areas across both nursing and medical professions with some wards unable to meet the safer staffing requirements. The trust used agency nurses and locum doctors to address the staffing requirements.
• There were processes for implementing and monitoring the use of evidence based guidelines and standards to meet the needs of differing patient groups across the hospital.
• There were a significant number of policies on the intranet for medicine and maternity services that were out of date and required reviewing and revising.
• There were processes in place for the reporting of incidents and there was learning from incidents; however the root cause analyses and related action plans lacked detail. Governance processes were not fully developed or embedded across the divisions and there were concerns in some areas regarding the maintenance and use of risk registers.
• The trust was reported in July 2015 (Health and Social Care Information Centre) as among the 11 worst performing trusts in England for mortality performance. The trust had implemented actions to improve the trust position for both mortality indicators and been open to external scrutiny.
• There was concern regarding leadership capacity within midwifery services and the impact that had on professional development and clinical standards.

We saw several areas of good practice including:

• The development of advanced nurse practitioners had enabled the hospital to respond to patient needs appropriately and mitigated difficulties recruiting junior doctors.
• The bariatric service had been developed as part of a consortium arrangement with neighbouring NHS trusts to ensure the local population had access to this service.
• A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment.
• The critical care team achieved a network award, which recognised excellent work in relation to “target” training. The team had also achieved recognition for their work related to critical care competencies, difficult airway and skills drills.
• The critical care team achieved 58% for its consideration of patients for tissue donation. The team were the second highest achiever for corneal donations. Overall the team’s approach to tissue and organ donation was impressive, demonstrating a compassionate and sensitive approach to patients and relatives.
• The paediatric and neonatal departments participated in a number of national and local research studies and were involved in a large number of clinical trials. The management team and several other staff told us the department had recently obtained a £3.5 million grant for an ‘OSCAR study.’ This study is for high frequency Oscillation in Acute Respiratory distress syndrome, comparing conventional positive pressure ventilation with high frequency oscillatory ventilation.
• The neonatal unit had implemented the ‘Small Wonders’ initiative for premature babies; this was designed by the charity Best Beginnings. Small Wonders supports parents in their baby’s care in ways shown to improve health outcomes for their babies.
• Staff in the maternity day assessment unit attended training on Gestation Related Optimal Weight (GROW) software which aims to reduce the number of stillbirths by using customised growth charts.
• ‘NIPE Smart’ had recently been implemented within the maternity directorate. This is an information technology screening management system which has a robust system of capturing data on newborn and infant screening examinations with the aim of reducing the number of babies diagnosed with a medical congenital condition at a late stage.

• Outpatient department staff produced posters and delivered presentations at the International Society of Orthopaedic and Trauma nurses on the development of virtual fracture clinics and on the roles of speciality nurses.
• A number of staff within the outpatients department completed modules on service improvement including one current project to improve the staff engagement and sustainability in clinical supervision.
• Staff worked on the development of health promotion packs within main outpatients to be rolled out within the orthopaedic department as a pilot to explore how this can be sustained.

• The lead consultant radiologist for the specialist procedure known as CTPA (CT pulmonary angiography) presented the experiences of staff and patient outcomes to a panel at a major CT equipment manufacturer.

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

Importantly, the trust must:

• Ensure there are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist.

• Ensure staff follow trust policies and procedures for managing medicines, including controlled drugs. Ensure that medicines are stored according to storage requirements to maintain their efficacy in maternity services.
• Ensure that risk assessments are documented along with personal care and support needs and evidence that a capacity assessment has been carried out where required.
• Ensure pain in children and young people is assessed and managed effectively.
• Ensure that the competency criteria for staff who are triaging patients are clearly documented and include recognised competency–based triage training.
• Ensure that infection control procedures are followed in relation to hand hygiene and use of personal protective equipment.
• Ensure that resuscitation and emergency equipment is checked on a daily basis in line with trust guidelines.
• Ensure cleanliness standards are maintained.
• Ensure effective systems are in place which enable staff to assess, monitor and mitigate risks relating to the health, safety and welfare of people who use the service.
• Ensure that all policies and procedures in the In-Hospital care directorate are reviewed and brought up to date.
• Midwifery policies, guidelines and procedural documents must be up to date and evidence based.
• Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
• Ensure that all annual reviews for midwives take place on a timely basis.
• Ensure all staff attend the relevant resuscitation training.

In addition the trust should:

• Consider strengthening the senior nurse capacity in the A&E department.
• Consider reviewing the system for documenting the follow-up of admitted head injury patients by the A&E department
• Consider a system in A&E to enable patients with allergies to be recognised quickly and easily without the presence of medical records
• Ensure that staff are following the correct procedure when dispensing medication using the Omnicell including checking the prescription at the time of dispensing.
• Consider a continuous audit of all MCA and DoLs assessments and referrals and share lessons learned.
• Consider assessing the access to the emergency resuscitation trolley on the haematology day unit.
• Consider putting engaged notices on toilet doors to protect dignity if the door is kept unlocked for staff to gain access to vulnerable patients.
• Send electronic communication to the patient’s GP on discharge from the critical care unit.
• Ensure handover meetings are held in a private and confidential area in children’s services.
• Ensure that all patient documentation remains confidential during patient visits to the outpatients department.
• Ensure that all outpatient treatment rooms are cleaned before use.
• Ensure that formal drugs audits and stock checks carried out regularly in outpatients.
• Ensure that medicines are stored appropriately to ensure their quality is maintained.
• Ensure that overall communication, outpatient clinic planning, room utilisation and staffing is formally managed and controlled, including clinics involving staff from other trusts.
• Ensure that patients in the children’s outpatient department are afforded privacy when speaking with reception staff.
• Update the risk assessment related to paediatric resuscitation in the children’s outpatient department.
• Ensure that some clean and safe methods for entertaining or distracting children are provided within the diagnostic imaging department.
• Ensure that staff adhere to the coding system for recording on medication charts
• Ensure that staff fully adhere to infection control policies and close doors on side rooms where patients are being barrier nursed.
• Ensure the processes and documentation used for appraisal of non-medical staff monitors their performance and meets their personal development needs.
• Review the process for storage of post-transfusion blood bags while retained on ward areas.
• Review whether documentation for patients living with dementia are completed and comprehensive.
• Ensure that within outpatient services, action plans from audits, risk registers and meetings are maintained, regularly revisited and amended to show where actions have been completed or remain outstanding.
• Ensure that established models of regular nursing clinical supervision are implemented for all staff involved in patient care in outpatient services.
• Ensure that patients and staff are informed if clinics are cancelled, including those involving clinicians and staff from other trusts.
• Ensure that strategy and management plans regarding transforming the outpatients departments are communicated to all staff.
• Consider recording decision made at the evening medical ward rounds on the critical care unit.
• Consider how the critical outreach service will be maintained.
• Review the recruitment of medical staff, particularly junior doctors in the surgical unit.
• File maternity healthcare documentation according to the trust records management policy to avoid loss or misplacement of information
• Indicate benchmark data on the maternity performance dashboard to measure performance.
• Ensure that ‘fresh eyes’ checks are recorded when undertaken.
• Review the senior midwifery structure and experience resource to ensure that all the midwifery roles needed for coordination and oversight of each service are appropriately covered.
• Monitor and internally report the level of provision of 1:1 maternity care
• Hold staff handovers in maternity services in an environment that reduces the possibility of distraction and interruption.
• Have a competency based framework in place for all grades of midwives.
• Have systems in place to achieve the nationally recommended ratio of 1:15 for supervision of midwives.
• Consider safety briefings as part of daily communication with staff in maternity services.
• Include describing the reporting arrangements for Supervisors of Midwives following investigations, audits or reviews in the maternity services risk management strategy.
• Provide simulation training exercises to prevent the abduction of an infant

Professor Sir Mike Richards

Chief Inspector of Hospitals