All inspections: Hull Royal Infirmary - Care Quality Commission

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Hull Royal Infirmary.

We inspected the maternity service at Hull University Teaching Hospitals NHS Trust as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

We reviewed the rating of the location, our rating of this hospital went down

Maternity is rated inadequate.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Hull Royal Infirmary (HRI) provides a range of acute services to the residents of Hull and the East Riding of Yorkshire, as well as specialist services to North Yorkshire, North and North East Lincolnshire. The trust has approximately 1,160 inpatient beds across the two main hospitals and employs over 7,000 whole time equivalent staff to deliver its services. Hull Royal Infirmary is a major trauma centre for the region and provides care provision for Children and Young People including paediatric emergency care, critical care facilities, acute medical and surgery services as well as the Women and Children's Hospital and the Eye Hospital.

Our rating of services stayed the same. We rated it them as requires improvement because:

We rated safe, responsive and well led as requires improvement. We rated effective and caring as good.

The trust did not always have enough medical, nursing staff and allied health professionals with the right qualifications, skills, training and experience within the services that we inspected. Staff did not identify and quickly act upon patients at risk of deterioration. Records were not always clear and up to date, stored securely and easily available to staff providing care.
People could not access the service when they needed it and received the right care promptly. Waiting time for referral to treatment and arrangements to admit and discharge were not in line with national standards in the urgent and emergency care and surgical services. The trust reported a high number of medical patients moving wards at night. We also observed that some surgical wards had a high number of medical patients and sometimes patients were moved at night.
Leaders did not always operate effective governance and risk processes, particularly in the urgent and emergency department and critical care core services. Staff were not always clear about their roles and accountabilities and did not learn from the performance of the service.

However:

The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983. Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff monitored the effectiveness of care and treatment.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients personal, cultural and religious needs. Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.

We carried out a focused desktop inspection on the Child Sexual Assault Assessment Service provided by Hull University Teaching Hospitals NHS Trust at the Hull Royal Infirmary in May 2020. Under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

We carried out this inspection to follow up on the S29a Warning Notice issued following our inspection in January 2020

We do not currently rate services provided in sexual assault referral centres.

Background

Hull University Teaching Hospitals NHS Trust (HUTHT) is commissioned by NHS England, to provide a Child Sexual Assault Assessment Service (CSAAS) for the Humberside Police area in East Yorkshire, Hull, North Lincolnshire and North East Lincolnshire, for children aged 16 and under and for 17 to 18-year old young people with vulnerabilities. The CSAAS is known as the Anlaby Suite. The CSAAS covers core hours, outside of these hours, the service is provided by other organisations.

The service provides medical and forensic assessment of children and young people who have experienced sexual abuse at the request of Humberside Police and Local Authorities’ Children’s Services. The holistic medical examination includes sexual health assessment, contraception if required, sexual health screening and treatment where clinically indicated.

The service is delivered from within a standalone building in the grounds of Hull Royal Infirmary. The building is accessible for children and young people with disabilities. The accommodation includes one forensic suite, with an adjoining shower room and waiting room. In addition, there are more comfortable interview rooms and a children’s play room.

The team includes a service manager, a clinical lead nurse, two full time registered nurses, four doctors and one administrator.

We last inspected the service in January 2020 when we judged the trust needed to make significant improvements regarding the quality of healthcare. We issued a S29a Warning Notice.

The report on the comprehensive January 2020 inspection can be found on our website at:https://www.cqc.org.uk/location/RWA01

This desk-based inspection was conducted by one CQC health and justice inspector and included a review of evidence and a teleconference with the service manager and lead nurse.

Documents we reviewed included:

The trust’s action plan in response to our Warning Notice
Temperature logs for where medicines were stored
Standard Operating Procedures for forensic cleaning and medicine stock
Photographs of the examination suite, equipment, toys and rooms following forensic cleaning
A sample of log books for monitoring the forensic cleaning
Leaflets and information available to children and young people

We did not visit the service to carry out an inspection due to the COVID -19 pandemic. However, we were able to gain sufficient assurance through the documentary evidence provided by the trust.

The inspection focused on the areas set out in the S29a Warning Notice issued to the trust on 14 February 2020.

At this inspection we found the following improvements:

A service specific self-harm and suicide risk assessment had been developed for the premises
Managers had implemented a standard operating procedure and staff guidance for forensic cleaning
There was an effective system to monitor and maintain appropriate room temperatures in areas where medicines were stored
Managers ensured staff carried out effective decontamination procedures and checked their effectiveness
Arrangements to support the communication needs of all children had improved
Staff demonstrated that children and young people could be examined by a male or female physician and that a choice was given.
A service specific competency programme enabled managers to assess staff.

We carried out this announced inspection on 29 and 30 January 2020 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a second CQC inspector and a specialist professional advisor.

To get to the heart of children and young peoples’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Background

Hull University Teaching Hospitals NHS Trust (HUTHT) is commissioned by NHS England, to provide a Child Sexual Assault Assessment Service (CSAAS) for the Humberside Police area in East Yorkshire, Hull, North Lincolnshire and North East Lincolnshire, for children under the age of 16 and for 17 to 18-year old young people with vulnerabilities. The CSAAS covers core hours, outside of these hours, the service is provided by other organisations.

The service provides medical and forensic assessment for sexual abuse at the request of Humberside Police and Local Authorities’ Children’s Services. The holistic medical examination includes sexual health assessment, contraception if required, sexual health screening and treatment where clinically indicated.

The service is delivered from within a standalone building in the grounds of Hull Royal Infirmary. The building is accessible for children and young people with disabilities. The accommodation

includes one forensic suite, with an adjoining shower room and waiting room. In addition, there are also more comfortable interview rooms and a children’s play room.

The team includes a service manager, a clinical lead nurse two full time registered nurses, four doctors and one administrator.

During the inspection we spoke with five staff members, the service manager, the Deputy Director - Quality Governance and Assurance, and the Clinical Director. We looked at policies, procedures and other records about how the service was managed. We reviewed care records for seven children and young people who had accessed the CSAAS within the last 12 months. During the period between April 2018 to March 2019, 91 children and young people had accessed services at the Anlaby Suite CSAAS. Throughout this report we have used the term children and young people to describe people who use the service to reflect our inspection of the clinical aspects of the CSAAS.

Our key findings were:

The trust had suitable safeguarding processes in place and staff understood their responsibilities for safeguarding children and young people.
The service had appropriate systems to help them identify and report incidents.
The trust had thorough staff recruitment procedures.
Systems were in place to assist staff when dealing with emergencies. Appropriate medicines and life-saving equipment were available.
The service appeared visually clean and was well maintained.
Clinical staff provided children and young people with care and treatment in line with current guidelines.
Staff asked for children and young peoples’ consent and supported children to provide consent where possible.
Staff felt well supported by managers and each other.
Staff were caring and compassionate and children and young people were treated with dignity and respect.
Children and young peoples’ privacy was respected and their personal information was protected.
There was a trust wide process in place for children, young people and their carers to complain about the service.
There was effective local leadership and support at a senior manager level.
Children, young people and staff were asked for their feedback about the service.
The culture was positive and open, which encouraged continuous improvement.

We identified regulations the provider was not meeting. The provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

There were areas where the provider should make improvements. They should:

Implement a service specific self-harm or suicide risk assessment for the premises.
Demonstrate they have offered, where possible a choice of gender of forensic examiner to all children and young people.
Consider how the communication needs of children and young people with learning disabilities are met.
Implement a service specific competency assessment for all staff.
Provide an effective system to monitor and maintain appropriate room temperatures in areas where medicines stored out of a fridge
Full details of the regulation the provider was not meeting are at the end of this report.

Our rating of services stayed the same. We rated them as requires improvement because:

We rated safe and responsive as requires improvement and effective, caring and well led as good.
We rated one of the hospital’s eight services as requires improvement and seven as good.
The rating of medical care and surgery improved from our last inspection.
There was a lack of pace in addressing some of the issues from the last inspection, for example, management of the deteriorating patient in medical care and the effective use of the five steps to safer surgery processes.
The trust had undertaken work towards improving the compliance with recording of patient’s National Early Warning Score (NEWS). However we found there were still concerns with the escalation of NEWS score in line with the trust’s policy. Nursing staff used their own clinical judgement as to when to escalate a patient’s NEWS score which was not in line with the trust’s policy.
At this inspection it was apparent the five steps to safer surgery checklist was still not embedded as a routine part of the surgical pathway. The trust had reported three never events associated with wrong site surgery or the wrong prosthesis being inserted. We could therefore not be assured that the checklist was being used correctly and consistently.
The trust did not always meet referral to treatment indicators. We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas. In addition to this the trust declared a serious incident related to a trust wide tracking issue within the electronic database. This resulted in a number of patients being lost to follow up.
Patients’ records were not always stored securely or in an organised manner. There was a risk that staff may not have access to the information they needed to deliver patient care and that the public could access patients’ confidential records.
The trust did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles to provide cover and mitigate some of the risk. However, despite the shortage of registered nurses in particular, the trust managed staffing well and had a robust escalation and review process.

However:

Staff were encouraged and knew how to report incidents. We saw evidence from actions plans and root cause analysis that serious incidents were identified and investigated appropriately.
The trust provided care based on evidence based practice and national guidance. Services reviewed the effectiveness of care through national and local reviews and implemented any findings. We saw improvements in how the trust reviewed effectiveness of the care, through monitoring and auditing compliance with nine fundamental standards.
Staff cared for patients with care and compassion and respected patient’s wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment. They provided patients with emotional support to minimise their distress.
Patient’s individual needs were met. Systems were in place for identifying patients living with dementia and learning difficulties and to support them through their hospital stay.
Staff morale was good and teams worked well together and supported each other. Managers were proud of their staff and success was celebrated through local and trust wide events.

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. HRI is the main centre for emergency services including the emergency department (ED). 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. 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 any other outpatient services which operated in other locations. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated HRI overall as ‘requires improvement’; safe, responsive and well led were rated as ‘requires improvement’ with effective and caring rated as ‘good’. Improvements had been made since our last inspection but these were not significant enough to change the rating for HRI as 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 remained ‘good’ across all domains. However, there was deterioration in the ratings overall for Critical Care, Maternity and Outpatients & Diagnostics 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%), it was still breaching the national target 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 effectively responded to a serious incident reported by Radiology 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 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 put in 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.
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 the 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 board reports indicated that 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.
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 untaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were then 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.

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 standards 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 is carried out, including safeguarding incidents relating to children, to ensure effective investigation and lessons learnt.
Staff complete risk assessments and taken 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.
It continues to work 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. They also must ensure there is enough capacity in the scanning department to implement GAP (Growth assessment protocol).
There is effective use and auditing of best practice guidance such as the “Five steps for 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 so 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.
Outpatient services have timely and effective governance processes in place to ensure they 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).
It continues to work towards the national guidelines of 1:28 midwifery staffing ratio and collect data to evidence one to one care in labour.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Hull Royal Infirmary is one of the main hospital sites for Hull and East Yorkshire Hospitals NHS Trust. The trust operates acute services from two main hospitals – Hull Royal Infirmary and Castle Hill Hospital – with a minor injuries unit at Beverley Community Hospital. Hull Royal Infirmary houses the main emergency provision for the trust, including accident and emergency services, critical care, acute medical and surgical services as well as the Women and Children’s Hospital. In total, the trust had approximately 1,300 beds and 7,400 staff. The HRI site has over 700 beds.

This was a focussed inspection of the Hull Royal Infirmary (HRI) as concerns had been identified both during a previous comprehensive inspection of Hull and East Yorkshire NHS Trust in February 2014 and concerns had also been highlighted through other information routes such as the public and staff which required following up. The follow up inspection of HRI was on 19 – 21 May 2015.

Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection. We therefore did not inspect the core services critical care or end of life services at the follow up inspection. Additionally not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At the inspection in February 2014 we found the trust was in breach of regulations relating to patient care and welfare, medicines management, staffing, premises, staff support and governance.

Overall, at the May 2015 inspection we rated the HRI as ‘requires improvement’. We rated it ‘good’ for caring, but it requires improvement in providing safe, effective and well-led care. We rated it inadequate for responsive.

We rated surgery as 'inadequate'; the urgent and emergency service, medical care, and children & young people, as ‘requires improvement’; with maternity services and outpatient and diagnostic services as ‘good’.

Our key findings were as follows:

There was continuous and persistent deterioration of the Emergency Department’s performance against the four hour target to see and treat people.
Staff within ED were unable to locate the major incident plan and they subsequently told us that the plan was unavailable as it was under review. Staff were not aware where the major incident store was located and major incident training was out of date. There was a lack of general maintenance and cleanliness issues within the theatre environment. There were also concerns about response to infection control audits within the Emergency Department.
The trust had responded to previous staffing concerns and was actively recruiting to fill posts however there were areas in medicine where nurse staffing levels were impacting on patient care and treatment particularly on the elderly care wards. There were also staffing pressures in the electrocardiography department at Castle Hill Hospital which meant staff were struggling to carry out cardiac diagnostic tests for patients. The hospital faced significant challenges in recruiting senior emergency medical staff and there was a shortage of consultant paediatric surgeons, occupational therapists and dieticians. There were also concerns about staffing levels within histopathology, emergency department, nursing and surgery.
Systems and processes on some wards for the management of medicines and the checking of resuscitation equipment did not comply with trust policy and guidance.
Most patients across the medicine health group received a good standard of care. However, on the elderly care wards patients were waiting for staff to assist them with their basic needs. Call bells were not in reach of patients in some areas. There was inconsistent use of the red top water jug system to identify patients that required assistance with nutrition and hydration. Care was not always being actively recorded in the patient’s records.
There had been changes to medical pathways of care to improve access and flow however this had not yet resulted in a significant improvement; as there continued to be delays in discharge, patient bed moves out of hours and, patients were being cared for on non-specialty or other specialty wards due to inpatient capacity issues.
There was an increase in the recruitment of consultant obstetricians and midwives. We found the birth to midwife ratio had increased from 1:35 to 1:32 since our inspection in February 2014.
The environment and facilities on the 13th Floor required improvement to protect children and young people from the risk of self-harm and/or injury. Following the inspection the Trust told us it was working with the local Child and Adolescent Mental Health Service (CAMHS) to provide staff training and introduce an accepted anti-ligature risk assessment as part of its health and safety audits.
At the time of our inspection, some procedures such as flexible hysteroscopy, were undertaken without written consent or the use of the safer steps to safer surgery. The trust was informed and action was taken.
Most staff had received safeguarding training and could demonstrate an understanding of their role and what action to take if they were concerned about a person.
There was a backlog of incidents that had not been investigated in a timely manner and therefore lessons learnt and duty of candour requirements were not being effectively applied.
There was a lack of long-term clinical strategy.

We saw several areas of outstanding practice including:

The plastics trauma team, based in outpatients, had developed a one stop service for patients to attend the department and be immediately listed for theatre when appropriate.
In relation to Radiology discrepancies we saw that the peer review process was an outstanding example of governance. The peer review meetings focussed on openness and learning and displayed a sensible application of legislation.

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

Importantly, the trust must:

address the breaches to the national targets for A & E and referral-to-treatment times to protect patients from the risks of delayed treatment and care. It must also continue to take action to address excessive waiting times for new and follow up patients with particular regard to eye services and longest waits.
ensure there is a sustainable action plan to improve the reporting performance of the histopathologist service.
ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; particularly on the elderly care wards, consultant and nursing cover within A & E; histopathologists, and surgical wards.
ensure that all incidents are investigated in a timely manner, that lessons are learnt and that duty of candour requirements are effectively acted upon and audited.
ensure that there is a policy and procedures in place to ensure that there is effective transition for young people to adult services.
ensure there is the development of a long term clinical strategy for the surgery health group which meets the clinical needs of patients and which is in line with the trust’s overarching strategy.
ensure appropriate arrangements are in place to respond to major trauma and incidents within ED.
ensure that there are robust processes in place for the checking of equipment particularly resuscitation equipment on the medical wards.
take further steps to improve the facilities for children, young people and parents on the 13th floor.
take actions to protect children and young people from the risk of self-harm and/or injury by ensuring that on the 13th floor the ligature and anchor points on the ward are addressed, and that there is an appropriate “safe room” for the use of children and young people with mental health problems. Following the inspection the Trust told us it was introducing an anti-ligature risk assessment.
ensure that patients’ nutrition and hydration is maintained in a timely manner; including the effective use of the ‘red top’ water jug system across all medical wards and the accurate recording of fluid balance and food charts for patients.
ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines on the medical wards. In addition the hospital must ensure that controlled drugs are stored appropriately and that records of the management of controlled drugs are accurately maintained and audited within A & E and children’s services.

ensure the sustainability of the work to address the concerns raised regarding the bullying culture and the outcomes from the NHS staff survey data (2014).

ensure that call bells are within reach of the patient at all times, especially on the medical wards and regular audits must be completed to monitor compliance.
review its patient pathways and patient flow through services to ensure:

the plans for the acute medical pathways from ED to discharge are effectively implemented including pro-active bed management
the seating area on the elderly assessment unit is not used for beds
plans for dealing with extra capacity are reviewed including the “reverse boarding” policy.
internal patient transfers take place in accordance with trust policy and reduce the number of patient bed moves ‘out of hours’ unless for clinical reasons
more timely discharges of patients, including working collaboratively with social care and community providers to improve the discharge system.

ensure use of best practice guidance, such as the “Safer steps to surgery” checklist and Interventional Radiological checklists for appropriate procedures in all outpatient and diagnostic imaging settings and audit their use to include completion of all sections.
ensure that appropriate procedures are in place to obtain consent for hysteroscopies within outpatients.
review the results of IPC audits across ED, all wards and theatres and identify and instigate appropriate actions including addressing the flooring and walls within theatres.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This is an updated report from the February 2014 inspection of Hull Royal Infirmary. It has been partly updated to reflect the findings from a responsive unannounced inspection of some services on the Hull Royal Infirmary site in January 2015. Details of both inspections are highlighted within the report.

Inspection February 2014:

Hull Royal Infirmary is one of the main hospital sites for Hull and East Yorkshire Hospitals NHS Trust. The trust operates acute services from two main hospitals – Hull Royal Infirmary and Castle Hill Hospital – with a minor injuries unit at Beverley Community Hospital. Hull Royal Infirmary houses the main emergency provision for the trust, including accident and emergency services, critical care, acute medical and surgical services as well as the Women and Children’s Hospital. As part of our assessment of the emergency services, we visited the minor injuries unit at Beverley Community Hospital.

We found the hospital was facing significant challenges due to the shortage of staff and insufficient capacity to deal with the increasing number of admissions, particularly patients referred to the hospital as an emergency. The shortage of nursing and medical staff, particularly junior doctors, was impacting on the care patients received, leading to delays in assessment and treatment. Staffing levels and skill mix did not always meet recommended guidance for example by Royal Colleges. There was a winter plan in operation, whereby additional beds had been opened at both hospital sites. Despite this, the high volume of admissions resulted in patients being moved around internally and across to Castle Hill Hospital, often through the night. Not all national targets, such as referral-to-treatment times in some specialties were being met. Backlogs had built up and a large number of outpatient appointments had been cancelled.

Actions had been taken to address the problems associated with staff shortages and other identified risks. Patient safety briefings and an escalation plan had been introduced to deal with issues as they arose. The trust board had agreed in November 2013 to invest £450,000 to recruit more nurses across the trust.

Staff were working hard to ensure the safety and welfare of patients, and wanted to offer a good quality of service. Some staff were proud to work at the hospital. However, others reported that they were stressed and working additional hours to cover the shortages. Doctors were covering a number of areas and did not always have the necessary competencies for the speciality. Staff reported that they were put under intense pressure to undertake additional work and meet performance targets.

Generally, patients reported that they had received good care, particularly in the critical care units and women’s service, although concerns were raised about access to treatment and the quality of care in the accident and emergency department and admissions assessment unit.

There were arrangements in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas that we visited were clean. There were systems in place for assessing, monitoring and addressing risk, with lines of reporting to the trust board. Following a recent review of incidents, these processes had been strengthened. However, many members of staff told us that they did not have the time to report incidents, and therefore this information could not be taken into account for future learning.

There had been a major refurbishment programme in the A&E department to improve facilities, and a planned development to increase capacity for dealing with major injuries and illnesses was expected to be completed by August 2014. At the present time, the department did not have the capacity in terms of facilities and staff to deal with the number of patients attending. There was a lack of appropriate senior clinicians and the children’s accident and emergency department, which had recently been refurbished, closed at midnight. The treatment of children then moved to the adult areas, with only the children’s waiting area open. The resuscitation area was kept open and appropriately qualified staff were made available when this was needed.

Despite the new consultation initiatives and strategies introduced, many staff did not feel engaged, particularly with the senior management team, although support from local managers was generally reported as good.

We found the hospitals in breach of Regulations 9 (care and welfare), 10 (governance), 13 (medicines), 15 (premises), 22 (staffing) and 23 (staff support) for the regulated activities treatment of disease, disorder or injury and diagnostic and screening procedures.

Inspection: January 2015

Following concerns raised to CQC and analysis of other evidence an unannounced focussed inspection took place on the 28 and 29 January 2015 of some services on the Hull Royal Infirmary site. The core services we inspected in January 2015 included accident and emergency, medical care and surgery. There is additional content highlighted within these specific core services of the report following this inspection. Other core services were not inspected at this time and therefore the report for those areas remains unchanged.

The focus of the inspection was the care of patients in the emergency department and the patient flow onto the wards. We found the Trust was not operating an effective system to ensure appropriate initial clinical assessment of patients therefore patients were exposed to the potential risk of harm. On the 30 March 2015 we issued a section 64 letter to the trust and requested further information about the assessment of patients in the accident and emergency department and staffing numbers.

Improvements required

Following the February 2014 and January 2015 inspection there were areas of poor practice where the trust needed to make improvements. Importantly, the trust must:

From the Inspection February 2014:

Ensure that there are sufficient numbers of suitably qualified and skilled staff and experienced people across all health groups including medical and nursing staff, particularly A&E, AAU, and medical wards.
Ensure that staff are suitably supported and receive appropriate training, including safeguarding Level 3 where appropriate, and post registration qualifications in critical care.
Ensure all staff have completed their mandatory training.
Ensure that junior doctors are appropriately supervised and not taking on roles and responsibilities for which they have yet to complete competencies in.
Ensure that there are suitable arrangements for on-call, and that junior doctors are not responsible for multiple pagers across different areas.
Review why staff feel that they are experiencing bullying and feel pressure to undertake additional hours, and put meeting targets above patient care.
Ensure that staff who are involved in caring for patients living with dementia are suitably trained, for example portering staff.
Ensure that only staff employed for caring duties, including dealing with patients exhibiting challenging behaviour due to mental health illness or dementia, support patients.
Review incident reporting to ensure that staff report incidents appropriately and in a timely manner.
Ensure that staff receive feedback from incidents reported, including never events and complaints.
Ensure lessons learned are disseminated across divisions.
Ensure that children are assessed and treated in an appropriate environment, in line with national guidance.
Ensure that patients have access to hospital appointments and cancellation of outpatient clinics is kept to a minimum.
Review the patient flow within and across hospital sites to ensure that patients are not experiencing multiple moves, including through the night.
Ensure that patients’ assessment and treatment is based on best practice guidelines and delivered in a timely manner.
Ensure patients receive appropriate fluid and nutrition to meet their needs. We found patients particularly in A&E and AAU were going without drinks and food for several hours.
Ensure that there are suitable arrangements in place for pharmacy provision across all areas to provide clinical overview and reconciliation of patient medications.
Ensure that patient records are appropriately maintained.
Provide family friendly facilities for parents on Ward 130 and the high dependency unit to enable parents to support their children.
Ensure that the environment is safe within the children’s and young people’s services by ensuring that clinical rooms have only appropriate equipment and that waste bins are appropriately stored.

From the January 2015 Inspection:

Ensure there is an effective system in place so that patients attending Accident and Emergency have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011 or such other recognised professional processes or mechanisms as the trust commits itself to.
Review the patient pathway into the hospital, particularly the A&E department, to ensure that patients are assessed and treated appropriately to meet their needs.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Hull Royal Infirmary is one of the main hospital sites for Hull and East Yorkshire Hospitals NHS Trust. The trust operates acute services from two main hospitals – Hull Royal Infirmary and Castle Hill Hospital – with a minor injuries unit at Beverley Community Hospital. The trust’s community services were not assessed as part of this review. Hull Royal Infirmary houses the main emergency provision for the trust, including accident and emergency services, critical care, acute medical and surgical services as well as the Women and Children’s Hospital. As part of our assessment of the emergency services, we visited the minor injuries unit at Beverley Community Hospital.