York and Scarborough Teaching Hospitals NHS Foundation Trust

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.

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.

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.

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.