Hull University Teaching Hospitals NHS Trust

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull, and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected all eight core services at HRI and five at CHH. We also inspected the minor injuries service operated by the trust at East Riding Community Hospital and outpatient services at the Westbourne NHS Centre. We did not visit outpatient services which operated in other locations. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated the trust overall as ‘requires improvement’. We rated safe, effective, responsive and well led as ‘requires improvement’ and caring as ‘good’. The trust had made improvements since our last inspection but these were not significant enough to change the rating for the trust as a whole. Some areas had made considerable improvements, especially the emergency department (ED) which was now rated as ‘good’. Medical care, surgery, and children’s services had improved. End of life care which was inspected in 2014 remained ‘good’ across all domains. However, there was deterioration in the ratings overall for critical care (last inspected 2014) maternity and outpatients & diagnostic services from ‘good’ to ‘requires improvement’.

Our key findings were as follows:

• The care of patients within the emergency department had significantly improved since the last inspection. The trust was meeting the locally agreed trajectories for the number of patients seen within four hours (in June 2016, 85.9% of patients were seen within four hours, which was in line with the agreed trajectory of 85.1%), but was still breaching the national standard of 95%.
• The trust reported and investigated incidents appropriately, the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice including within maternity where a never event had occurred.
• The trust had taken effective action when Radiology had reported a serious incident in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported four of which related to this printing issue. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which, if breached, were reported to the medical director.
• A backlog of 30,000 patient episodes/appointments had been identified by the trust prior to the inspection. A cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients. The trust had implemented a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
• We had concerns within the children’s services about: the competency of staff to care for patients with mental health needs; that not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and; four safeguarding children guidelines were out of date. However, the parents’ sitting room facilities on the 13th floor had been improved following receipt of charitable funds.
• Staff were not always assessing and responding appropriately to patient risk. The trust used a National Early Warning Score (NEWS) and the Modified Early Obstetric Warning Score (MEOWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
• Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in some patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
• Nurse staffing shortages were evident across the majority of medical and surgical wards and the trust’s safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators. The maternity service did not collect the relevant data and therefore could not provide assurance that women received one to one care in labour.
• There were also some gaps within the medical staffing, especially within critical care and paediatrics.

• The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
• There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The trust had undertaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were put in place.
• Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
• Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
• Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved although there were some instances on the acute medical unit at HRI where not all call bells were within reach of patients.
• Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
• The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited.
• There had been a significant improvement in the operating theatre environment at HRI.

We saw several areas of outstanding practice including:

• The urology services had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
• The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
• The perinatal mental health team/midwifery team had been shortlisted for the Royal College of Midwives Annual Midwifery Awards 2016 for effective partnership working in supporting women with perinatal mental health.
• Recreational co-ordinators had been introduced in medical elderly wards. Their role was to provide patients with activities and stimulation whilst in hospital.
• The responsiveness of the Specialist Palliative Care team (SPCT) in relation to acting on referrals.
• The bereavement initiative of providing cards for relatives to write messages to their loved ones.
• The International Glaucoma Association had awarded the ophthalmology department an innovation award for their glaucoma monitoring work.
• Radiology at the trust was an exemplar site for the BSIR (British Society of Interventional Radiology) IQ programme for interventional radiology.
• The ultrasound department was the UK reference site for Toshiba in the fields of elastography and fusion guided imaging.
• The breast care unit were using digital tomosynthesis. This method of imaging the breast in three-dimensions improves the sensitivity of detection of breast cancers by 40% and is more accurate.
• The breast care unit carried out vacuum assisted biopsies. This one-stage procedure avoided patients needing two or three biopsies, significantly reducing the stress and anxiety for the patient and saving on resources.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must ensure that:

• Planning and delivering care meets the national standard for A&E; meets the referral-to-treatment time indicators and; eliminates any backlog of patients waiting for follow ups with particular regard to eye services and longest waits.
• A review of the process for categorising incidents occurs, including safeguarding incidents, relating to children, to ensure effective investigations and that lessons are learnt.
• Staff complete risk assessments and take action to mitigate any such risks for patients; in particular, risk assessments for falls and for children with mental health concerns.
• Learning from never events is further disseminated and lessons learnt are embedded.
• Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National early warning score (NEWS) and Modified Early Obstetric Warning Score (MEOWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment, and; that the escalation procedures are audited for effectiveness.
• Staff have the skills, competence and experience to provide safe care and treatment for children with mental health needs and patients requiring critical care services.
• Work continues actively with other professionals internally and externally to make sure that care and treatment remains safe for children with mental health needs using the services.
• Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
• Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range, especially within A&E.
• Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/taken by the patient.
• Records of the management of controlled drugs are accurately maintained and audited within A&E.
• Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
• Staff who work with children and young people are knowledgeable about Gillick competence and that a process is in place for gaining consent from children under 16.
• Antenatal consultant clinics have the capacity to meet the needs of women and that there is enough capacity in the scanning department to implement the Growth Assessment Protocol (GAP).
• There is effective use and auditing of best practice guidance such as the “Five steps to safer surgery” checklist within theatres and standardising of procedures across specialties relating to swab counts.
• Elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
• The critical care risk register is reviewed to ensure that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
• Ensure outpatient services have timely and effective governance processes in place which identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
• Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient and maternity services.
• At all times there are sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance, taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).
• Continues to work towards the national guidelines of 1:28 midwifery staffing ratio and collect data to evidence one to one care in labour.
• It takes further steps to improve the facilities for young people on the 13th floor of HRI.

In addition there were areas where the trust should take action and these are reported at the end of the two individual hospital reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals