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.
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 an unannounced focused inspection of the emergency department at Scarborough Hospital on the 13 and 14 January 2020, in response to concerning information we had received in relation to care of patients in this department. At the time of our inspection the department was under adverse pressure.
We also inspected elements of the medical care core service including wards at this hospital. This included visting the admissions areas to discuss patient flow from the emergency department. During this inspection we inspected using our focused inspection methodology.
We did not cover all key lines of enquiry. We looked at the safe domain for both core services and aspects of both the responsive and well led domains for the emergency department.
Our key findings were:
Patients who presented to the emergency department with mental health needs were not being cared for safely in line with national guidance (RCEM guidance and Psychiatric Liaison Accreditation Network (PLAN) Quality Standards for Liaison Psychiatry Services).
The department was not meeting the standards from The Royal College of Paediatric and Child Health Facing the future: standards for children in emergency settings.
Access and flow of patients was creating significant delays in admitting patients onto wards to enable them to receive timely and appropriate care and treatment exposing them to the risk of harm.
Systems for recording clinical information, risk assessments and care plans were not used in a consistent way to ensure safe care and treatment for patients.
We were not assured that there were sustainable, medium and longer term, plans to ensure sufficient numbers of suitably qualified, skilled, competent and experienced clinical staff to meet the needs of patients.
Opportunities for staff to identify and quickly act upon patients at risk of deterioration on the medical wards were potentially missed or actions not always documented.
Not all incidents were being reported and investigated to identify mitigating actions to prevent reoccurrence and reduce the risks to patients.
The ward environment on one ward we visited did not support staff in keeping patients safe.
However,
Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction
The emergency department had suitable equipment which was easy to access and ready for use. The department was clean and tidy despite being extremely busy during the inspection period.
Deteriorating patients were identified quickly in the emergency department and treatments were started in a timely manner.
Staff and managers in the emergency department promoted a culture that supported and valued one another.
We found areas for improvement including breaches of legal requirements that the trust must put right. These can be found in the ‘Areas for improvement’ section of this report.
Following the inspection given the concerns identified a Section 31 notice of decision and 29A warning notice of the Health and Social Care Act 2008 was issued to the trust requiring them to make significant improvements in the quality of healthcare provided.
We also found several things that the trust should improve that did not justify regulatory action, to prevent breaching a legal requirement, or to improve service quality. These can be found under the ‘Areas for improvement’ section of the report.
Ann Ford
Deputy Chief Inspector (North)
Our rating of services stayed the same. We rated it them as requires improvement because:
A summary of our findings about this location appears in the overall summary.
Scarborough Hospital was one of three main hospitals forming York Teaching Hospital NHS Foundation Trust. The trust provided acute hospital services to the local population. The trust also provided a range of other acute services from York and Bridlington hospitals to people in the wider York area, the north-eastern part of North Yorkshire and parts of the East Riding of Yorkshire. In total, the trust had approximately 1170 beds, over 8700 staff and a turnover of approximately £442,612m in 2013/14. Scarborough Hospital had approximately 300 beds.
Scarborough Hospital provided emergency and urgent care, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people in the Scarborough, Whitby and Ryedale areas of North Yorkshire.
We inspected Scarborough Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, York and Bridlington hospitals and community services. We inspected Scarborough hospital on 17 – 20, 30 – 31 March and 11 May 2015.
Overall, we rated Scarborough Hospital as ‘requires improvement’. We rated it ‘good’ for being caring but it requires improvement in providing safe, effective, responsive care and for being well-led.
We rated emergency and urgent care, medical care, surgery, critical care, maternity and gynaecological services, and outpatient and diagnostic services as ‘requires improvement’, and as ‘good’, for children & young people’s services and end of life care.
Our key findings were as follows:
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
In addition there were areas where the trust should take action and these are reported as the end of the report.
Professor Sir Mike Richards
Chief Inspector of Hospitals
We re-visited the hospital to check that the necessary improvements in these areas had been made within the A&E department.
At the end of this inspection we were satisfied that improvements had been made. Practices and procedures had been implemented to make sure that emergency situations were dealt with using an effective escalation system. Additional staff had been recruited or further appointments were planned within the department and people were being cared for in an environment that was clean and hygienic.
People visiting the A&E department for treatment on the day of inspection, and those accompanying them, made positive comments about the way they had been received into the department and about their care and treatment.
Staff told us about the changes which had been implemented since our last inspection and reported that improvements had been made, making it a better experience for people when being treated in the department.
A team of inspectors, an expert by experience and two specialist advisors visited Scarborough Hospital between 29 and 30 July 2013. We inspected Accident and Emergency (A&E), the Medical Assessment Unit (MAU ' known as Cherry Ward) and a number of maternity wards, including the delivery suite, the midwife led unit, ante-natal and post natal wards. We also spoke to people who had been admitted to Holly Ward, Willow Ward and the Intensive Care Unit
We observed some examples of good care being provided to people and a number of people told us about their positive experiences in the hospital. However, we were also told by a small number of people that their experiences, particularly whilst receiving care in A&E, had not been as good as it could have been. We also observed that some people did not always receive appropriate care and treatment in A&E because the provider's escalation procedures were not always effective in supporting basic care arrangements when demand was higher than anticipated for people attending the A&E department.
We also noted that the remedial action taken by senior managers, when staff shortages were highlighted by nursing staff and particularly when the A&E department was 'overstretched' and busy was not effective in deploying additional staff in a timely way to ameliorate the concerns raised.
Most areas of the hospital we visited were clean and hygiene and standards were good. This was not the case in the A&E department. Because of the impact of this shortfall the overall judgement was that people were not protected from the risk of infection because appropriate guidance had not been followed despite the good performance in other areas.
The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of peoples who used the service and others.
We carried out a visit on 11 October 2012. At that time we judged that there were insufficient night staff deployed to Willow ward, when people were admitted for an overnight stay. We issued a compliance action stating the Trust must increase their staffing in order to protect patients. The Trust also acknowledged that facilities on Dales ward were not ideal for overnight stays lasting more than one night. The Trust told us however, that they would be opening a newly refurbished ward in December 2012, which would be used as the escalation area, meaning the Dales ward would not be used for overnight stays.
During this follow up visit, we found that staffing levels had been increased on Willow ward during the night. We also found that the new 'Graham' ward had opened on 6 January 2013 and was being used for patient overnight stays, therefore taking pressures off the day units.
There were no outstanding issues in relation to the assessing and monitoring of service quality at this location. However, following the acquisition of this hospital by York Teaching Hospital NHS Foundation Trust in July 2012, we also looked at the governance arrangements in place across the whole of the Trust during a review of both acute hospitals.
People told us during the visit that generally they were treated well and that staff were polite and supportive. One patient said ' I have had really good care and attention, the nurses have been tremendous.' Another said ' This is my second time on this ward the care is good, the ward is clean and tidy and the food good too.'
We were told by the Trust that two day wards had been used recently to accommodate people overnight as the general wards were full. We found that one ward (the Dale Unit) was not suitable to accommodate people overnight When we raised these concerns with the Trust they told us in writing that they would no longer use the Dale unit to accommodate people overnight. We were also told that in December a new assessment ward for emergency admissions is to be opened and patients will no longer be accommodated overnight on the other surgical day ward (Willow ward).
We found only one member of staff is deployed to work on the Willow ward during the night. We consider that on some occasions patient care and safety could be compromised because of this. We have asked the trust to take action in relation to staffing levels on the unit to make sure that both patients and staff are kept safe during the night.