11 October 2022 to 17 March 2023
During a routine inspection
York and Scarborough Teaching Hospital NHS Foundation Trust provides a comprehensive range of acute hospital and specialist healthcare for approximately 800,000 people living in York, North Yorkshire, Northeast Yorkshire, and Ryedale.
The trust manages three acute hospital sites and five community hospitals. There are type 1 ED at York and Scarborough.
There is a workforce of over 10,000 staff working across the hospitals and in the community.
The York Hospital is the Trust’s largest hospital. It has over 700 beds and offers a range of inpatient and outpatient services. It provides acute medical and surgical services, including trauma, intensive care, and cardiothoracic services.
Scarborough Hospital is the Trust’s second largest hospital. It provides acute medical and surgical services, including trauma and intensive care services.
We carried out this unannounced inspection of York and Scarborough Teaching Hospitals NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services.
We inspected Emergency and Urgent Care, Medical care, and Maternity services. We also inspected the well-led key question for the trust overall. We did not inspect surgery, critical care, services for young people and children, end of life care, out-patients, or diagnostics at this inspection.
In March 2022 we carried out an unannounced focused inspection of Medical care of the York Hospital following significant safety concerns we had received. Following this inspection, we issued a warning notice Section 29A under the Health and Social Care Act 2008 in regard to the standards of care provided on the medical wards. We suspended the rating of good for this service.
At this inspection the trust rating of requires improvement stayed the same. We did see improvements made as a result of our warning notice on the medical wards.
Following our core service inspections we sent the trust a letter of intent to take urgent enforcement action of serious concerns we found in maternity services and the emergency department at York.
Risks included identification and management of deteriorating patients, management of patients waiting within the departments and medicines management, including controlled drugs in both core services. We also found that the mental health room in the emergency department was unsuitable, and the service did not control infection and prevention well. We also raised concerns regarding assessing and responding to risk within the maternity services, for example the lack of available CTG machines to monitor fetal well-being.
We returned to reinspect these core services during the well led inspection. We found some improvement in the emergency department. However, we did not find similar improvements in maternity services and therefore imposed urgent conditions upon the service. These included:
- implementing an effective system for managing and responding to patient risk to ensure all mothers and babies were cared for in a safe and effective manner and in line with national guidance
- Operating an effective clinical escalation system to ensure every woman attending the hospital is triaged, assessed, and streamlined by appropriately skilled and qualified staff.
- Implementing an effective risk and governance system which ensures that:
- There was oversight at service, division, and board level in the management of the maternity services.
- There were effective quality assurance systems in place to support the delivery of safe and quality care.
- Risk and occurrence of incidents were properly identified and managed, to include an effective system of recording actions taken and ensuring learning from any incidents.
- Serious incidents were reflected and reported correctly in line with national guidance and adequately investigated.
- Ensuring learning was shared from the investigation.
- Incident grading was reviewed to ensure it was accurate and in line with national guidance.
Following our inspection in November, CQC received concerns in relation to staff behaviours, bullying, harassment, and discrimination. As such we extended our well-led inspection to include further staff interviews including board level managers, staff focus groups for staff who belonged to an equality network or staff who felt they had a protected characteristic and a trust wide CQC staff survey. We received a total of 1028 responses to our staff survey.
Our rating of services stayed the same. We rated them as requires improvement because:
- We rated safe, effective, and responsive as requires improvement, caring as good and well-led as inadequate.
- We rated 3 of the trust’s 9 services as inadequate and 3 as requires improvement. In rating the trust, we took into account the current ratings of the 19 services not inspected this time.
- Staff did not always meet the trust target for mandatory, role specific and safeguarding training. Services did not control infection risk well. The maintenance, use of facilities, premises and equipment did not always keep people safe. Staff did not always manage clinical waste well. Staff did not complete risk assessments for each patient promptly. Staff did not identify and quickly act upon patients at risk of deterioration. Services did not always have enough nursing and medical staff with the right qualifications, skills, training, and experience to keep patients safe. Staff did not keep detailed records of patients’ care and treatment. Records were not always clear, up-to-date, or stored securely. Services did not manage medicines well. Managers did not always investigate incidents and share lessons learnt promptly.
- The trust did not always provide good care and treatment, use the findings to make improvements and achieve good outcomes for women. Policies were not always updated with national guidance and evidence-based practice in a timely manner. The trust did not always make sure staff were competent for their roles. Senior leaders did not always appraise staff’s work performance and did not always hold supervision meetings with them to provide support and development.
- Staff did not always treat patients with compassion and kindness in the emergency department at York. They could not always respect their privacy and dignity and take account of their individual needs.
- The maternity service did not always plan and provide care in a way that met the needs of local people. It was not inclusive and did not always take account of patients’ individual needs and preferences. People could not access the service when they needed it to receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
- Senior leaders were not always visible and did not always support staff to develop their skills. The vision and strategy had not yet been embedded. They did not always use systems to manage performance effectively or make decisions and improvements. They did not have clear oversight of the key risks and had not always mitigated immediate risks. Staff did not always feel respected, valued, and supported. They were not always clear about their roles, responsibilities, and accountabilities. The trust did not have a culture where staff could raise concerns without fear as they were not always managed appropriately. Leaders and staff did not always engage with patients, staff, equality groups, the public and local organisations to plan and manage services.
However:
- Staff provided good care and treatment and gave patients enough to eat and drink. They advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week and staff worked well together.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
How we carried out the inspection
The team that carried out the well led inspection included two inspection managers, 10 inspectors, one assistant inspector and an inspection planner. In addition, there was an executive reviewer plus three specialist advisors experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Deputy Director of Operations.
During the core service inspection we spoke with 72 members of staff including nursing, medical, healthcare assistants, porters, and domestics.We received feedback from 72 patients who had accessed treatment in maternity, medicine, and urgent and emergency service. We reviewed 84 patient records and a range of policies, procedures and other documents relating to the running of the service. We observed various handovers and MDT safety huddle meetings. We also looked at a range of performance data and documents including meeting minutes, audits, and action plans.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.