York and Scarborough Teaching Hospitals NHS Foundation Trust

Updated 30 June 2023

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.

Updated 8 October 2015

Overall, we judged that community health services for adults were good, although some aspects of safety required improvement.

Incidents were reported across teams and serious incidents were investigated using root cause analysis, although staff received little feedback to share learning from incidents. There was a policy in place relating to the Duty of Candour requirement. The safeguarding adults policy was applied as part of practice, although safeguarding adults training was not up to date for a significant number of community services staff. The service had robust systems in place for the management and use of controlled drugs. Correct infection control techniques were followed. Staff demonstrated a sound awareness of key risks to patients and were proactive in responding to identified risks, although some local risk management arrangements lacked robustness.

The service faced some challenges with workforce planning and recruitment. Mandatory training participation rates for all modules across community services (except fire safety) fell below the trust minimum compliance target of 75%. Staff working alone were supported using informal procedures that were applied quite loosely in some teams; this meant that staff had some concerns regarding their own safety, particularly in the evening and at weekends. Some locations provided cramped facilities for staff and, outside the city of York, delays were encountered in the supply and maintenance of equipment, which potentially affected patient safety.

Policies and best practice guidelines were used to support care and treatment and staff understood their roles and responsibilities in the delivery of evidence-based care. A recognised assessment tool supported by national guidance was used to support the review of patients with pain symptoms. Nutrition and hydration assessments were usually completed, and patients were referred appropriately to specialist services. The NHS Safety Thermometer was completed. The service had an audit programme for 2014/15, but audits in community services were limited and there was no clinical audit plan in place.

Staff received annual appraisals and staff development and training were supported through a learning hub. Mentoring arrangements were used and a competency framework for therapy staff was being implemented from April 2015. Not all services were aware of clinical supervision arrangements. Multidisciplinary team meetings were held for complex patients and good relationships existed with primary care. Poor communication about the patient pathway was being addressed by working collaboratively. Most staff had an understanding of the Mental Capacity Act.

Patients and relatives were treated with respect, dignity, and compassion. Staff respected patient confidentiality in discussions with patients and their relatives and in written records or other communications. Staff provided emotional support to patients and their relatives.

Patients were assessed promptly for care and treatment and referrals were triaged. Any patient who was deemed to be an urgent priority was seen very promptly, usually within five working days. The single point of access did not currently include therapy services and there was no overnight or weekend community nursing service in Scarborough or Ryedale. Communication with hard-to-reach groups in the Scarborough area included good examples of involving homeless people and those who used substances. The service received few complaints but learning from the investigation of any complaints was shared.

The dementia strategy needed development for community-based services. We found evidence of poor access to services for some patients with a learning disability and some communication issues with mental health services. The timely supply of equipment for bariatric patients needed to be addressed. Discharge liaison arrangements between the acute hospital and community settings required some refinement.

The management arrangements for community services were being reviewed. An assistant director of nursing had recently commenced in post with specific responsibility for community services. The governance structure of the trust included an operational community services group. A central risk register was in place for community services but we identified some concerns regarding the escalation of risk. Senior staff met monthly to review clinical and managerial issues, to develop action plans resulting from audits, and to share learning. Learning was also shared at regular team meetings with nursing staff.

Recent changes to the structure of community services were viewed positively by staff. Staff mainly identified with the trust’s mission statement and followed its values, although no specific vision or strategy had been developed for community services. Senior community nursing staff were supported by senior nurse management. Clinical leadership required development. We found a mainly positive culture in community services although several teams told us that there was a hospital-focused, acute culture in the organisation with York seen as the centre. The service was a national pilot site for the development of community hubs to support the delivery of care nearer to home.

Updated 8 October 2015

Overall rating for this core service Good

We found that services were effective and that staff were caring and responsive. In particular, we found in the ‘responsive’ domain that there were very good systems in place to provide translation services for people whose first language was not English, and sign language interpretation services for people who were profoundly deaf.

The ‘safe’ domain has been rated as requiring improvement. There were concerns raised with us that the design and environment of the contraceptive and sexual health service clinic at Monkgate in York did not allow for full confidentiality. We also found that 10,000 records were not completely secure at one of the trust’s locations. Staff told us that they were concerned that there was a backlog of paper documents resulting from a lack of scanners in some locations.

There was concern among school nursing staff that there was not enough flexibility built into staffing numbers and arrangements.

Overall, we found that the service was well led, although there was some concern from staff about a lack of support from senior managers within the school nursing and health visiting service.

Updated 8 October 2015

Overall rating for this core service Good

Overall we rated effective, caring, responsive and well-led as good. We rated safety as requiring improvement.

Medical cover was provided in different ways in each location, but no service had dedicated or immediately accessible medical support in the evenings, at night or over the weekend. On most wards, there were two qualified nurses on duty for day shifts and the numbers of healthcare assistants met the staffing needs for the time of day. However, wards were full, this meant that at night there was a qualified nurse-to-patient ratio of up to 1:24 and during the day up to 1:12 (one qualified nurse for 24 or 12 patients). Following the inspection, the trust told us they had approved a case for increasing nurse staffing at night from 1 to 2 RNs in all its community units and recruitment was underway at the time of inspection. The controlled drug registers were generally found to be accurate. We found that pharmacy support was inconsistent and that a pharmacy technician was available once a week or less in the units. Resuscitation trolleys were kept in good order, and all equipment and materials were found to be in good condition and in date.

There was little evidence that community hospitals benchmarked their outcomes or quality of care against national guidelines or standards for patient care. However, staff were encouraged to give feedback on patient care both informally and formally at handovers. Clinical audits were carried out regularly and generally good levels of compliance were recorded. Staff told us at times audits were suspended for up to six months due to staff shortages. Following the inspection, the trust commented that they were not aware of any occasions where audits were suspended for this reason. There were some inappropriate admissions to the community wards from acute services, especially A&E, but these were risk managed and redirected to acute care if patients were not medically stable. The level of involvement of patients in care-planning varied. There was good planning and communication with therapy staff, however patients repeatedly told us they had not been told about their nursing care and treatment plans.

We spoke to 44 patients and 13 visitors who all told us that the care they received from all staff was excellent and that patients felt safe and cared for during their stay. We observed staff speaking to patients in a sensitive and compassionate manner. Staff knocked on doors before entering private areas and used privacy screens where available. Staff were kind and compassionate but had little time for patients to discuss their feelings and anxieties or to support them to talk about problems.

Facilities and equipment were available to meet the needs of patients. For example, rehabilitation equipment was available at most locations and hoists were provided. Admission criteria and pathways were in place and patients were usually admitted appropriately for nursing care and/or therapy input. Staff felt that they provided a good link between acute services and the community and had good connections with the therapy teams that followed up patients’ progress at home. Therapy staff supported patients from Monday to Friday. There was no therapy input at weekends and this often resulted in a break in the continuity of treatment and progress.

Staff understood the trust’s overall vision but there was no clear vision or strategy for the future regarding community services. There had been several recent changes within community services and staff expected further changes in the future, especially in Ryedale district and Whitby Community Hospital. Nurses told us they were taking on increasingly complex responsibilities involved in prescribing and night-time cover. Concerns about staffing levels were expressed by both staff and managers.  Managers supported staff to access additional nursing and healthcare assistant staff when clinical needs or new complex admissions required it. Staff told us that their managers were supportive.

Updated 8 October 2015

York Teaching Hospital forms part of the York Teaching Hospital NHS Foundation Trust and provides end of life care services on site and in partnership with Scarborough Hospital and Bridlington Hospital as well as community and hospice services. The community hospitals we inspected did not have any wards that specifically provided end of life care. Patients requiring end of life care were identified and cared for in ward areas throughout the community hospitals and in their own homes with support from the specialist palliative care team and district nurses.

The community wards we inspected were at New Selby War Memorial Hospital and Malton Community Hospital. We also saw people in their own homes and spoke to staff at the Scott Road Medical Centre and to community district nurses and nurses from the community palliative care team. Specialist palliative care was provided as part of an integrated service across both hospital and community teams.

During our inspection we spoke with a palliative care consultant, the lead end of life care nurse, the medical director, director of nursing, specialist palliative care nurses, chaplaincy staff, medical staff, nursing staff and allied healthcare professionals. In total, we spoke with 16 patients, 14 relatives and 15 members of staff.

We visited both of the community wards and people in their own homes as well as district nursing clinics. We reviewed the records of 16 patients who were receiving end of life care and 10 who were in receipt of palliative care.

We viewed seven DNA CPR forms (‘do not resuscitate in the event of a cardiac arrest’). Of these, five were appropriately signed and dated and there was a clearly documented decision, with reasoning and relevant clinical information. We reviewed audits, surveys and feedback reports specific to end of life care.

Staff were aware of and had access to the trust’s online incident reporting system. We saw evidence of learning from incidents to improve practice. Overall, the standards of cleanliness and hygiene were good and staff demonstrated a good knowledge of procedures for the management, storage and disposal of clinical waste, environmental cleanliness and prevention of healthcare acquired infections. Procedures were in place to ensure that equipment was maintained regularly and fit for purpose.

Community nursing staff reviewed their caseloads according to patient need; end of life patients took priority. Relatives and patients we spoke with talked positively about access to staff. We did not find evidence to suggest that community nurse staffing levels were adversely affecting the quality of patient care.

The trust had removed the use of the Liverpool Care Pathway and replaced it with an ‘individualised care plan for the last days of life’. Training in the replacement approach was still being undertaken by the trust. Patients receiving end of life services had their pain control reviewed daily. We saw that care followed the National Institute for Health and Care Excellence (NICE) Quality Standard CG140. The care records we reviewed showed that staff supported and advised patients who were identified as being at nutritional risk.

We saw that the trust had an action plan in place to address areas identified as part of the National Care of the Dying Audit for Hospitals (NCDAH), and that a number of areas had been addressed at the time of our inspection. The care and treatment provided achieved positive outcomes for people who used the service. Patients receiving end of life care were supported by a multidisciplinary end of life care team, which included a specialist palliative care team, consultants, GPs and district nurses.

Community end of life services were caring. Throughout our inspection, staff spoke with compassion, dignity and respect regarding the patients they cared for. All of the patients and relatives we spoke with told us that care was good. They were treated with respect and dignity and felt involved in their care and treatment.

We found that the service had a good understanding of the different needs of the people it served. Services were planned, designed and delivered to meet those needs. We saw that patients were able to dictate both their preferred place of care and preferred place of death through advance care planning. The trust monitored the performance of its end of life treatment and care service.

The end of life service had a clear local vision to improve and develop high-quality end of life care across the service. Most staff were aware of the trust’s vision and strategy; however, this was not fully embedded among all staff. There was good leadership and support from local managers, and most staff felt engaged. However, there was a lack of engagement with senior management. Risk management and quality assurance processes were in place at a local level. There was visible, motivated and committed leadership in terms of end of life care at board and service levels and a number of initiatives were in place to develop services.