In July 2013 we inspected the hospital and found that they needed to make improvements in three different areas, all within the A&E department. At that inspection we found that although there were procedures in place to deal with emergencies which are reasonably expected to arise from time to time and which would, if they arose, affect, or be likely to affect, the provision of services. These were not always effective in ensuring care needs were met within A&E. In addition to this, we found that the levels of staffing available could also impact on the amount of time staff had to deliver basic care. We also found that the department was not clean and staff were not adhering to infection control procedures.

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.

In October 2012 we received information of concern about the care and support some people had received when they had been admitted to day surgery units (Willow ward and Dales ward) for an overnight stay, when the general hospital wards were full.

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.

We carried out this inspection because we had received some information of concern about the care and support some people had received when they had been admitted to a day surgery unit for an overnight stay when the general hospital wards were full.

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.

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:

• Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
• Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
• We found the hospital was visibly clean, Hand-washing facilities and hand cleaning gels were available throughout the department and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
• The trust had no mortality outliers. However, the Summary Hospital-level Mortality Indicator (SHMI) for Scarborough hospital of 107 was higher than both the Trust overall (102) the England average (100) in June 2014. 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 on the basis of average England figures, given the characteristics of the patients treated there.
• There were concerns that patients arriving in the A & E department did not receive a timely clinical assessment of their condition.
• At the time of the inspection, in the majority of services the Trust was below its own target of 75% for mandatory training including safeguarding training. The Trust’s target was to achieve 75% minimum compliance for the year ending August 2015. We have since been informed by the Trust that the figures provided to the CQC only included the training provided for the period of six months prior to the inspection as this was the time the Trust implemented a new system to capture and record training carried out. We were told the compliance levels did not include any training staff may have had prior to the 1 September 2014 and we were not provided with evidence to reflect this in the overall training levels.
• Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; and radiologists. The trust was actively trying to recruiting to the majority of these roles.
• There were policies and guidelines on the intranet. However, there were some guidelines in maternity services relating separately to Scarborough Hospital and York Hospital, which were out of date and did not adhere to national guidance.
• Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
• The trust was half way through its five year plan to integrate services following the acquisition of Scarborough & North East Yorkshire NHS Trust in 2013.Services within all three of the acute hospitals were at differing stages of integration.
• Staff we spoke with had varying views about their engagement and involvement with the process of integration. A number of staff were concerns that Scarborough was seen as the “Poor relation”.
• Pathways, policies and protocols were not always reviewed and some still had to be harmonised across the trust to avoid confusion among staff.
• Four of the eight core services we inspected had good local leadership within the service.

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

Importantly, the trust must:

• ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff, in line with best practice and national guidance, taking into account patients’ dependency levels, especially in A & E, on the medical and surgical wards, operating department practitioner (ODP) cover within theatres, radiology and senior medical cover in relation to cross-site working. Additionally within critical care the provider must ensure staffing levels are adequate to ensure clinical education, unit management, clinical coordination, continuity of care, and effective outreach.
• ensure that there is adequate access for patients to pain management and dietetic services within critical care
• ensure improvements are made in the 18 week referral to treatment time target and cancer waiting times so that patients have access to timely care and treatment.
• ensure that staff, especially within medicine, outpatients & diagnostics and critical care, complete their mandatory training, and have access to necessary training, especially basic life support, mental capacity and consent (Outpatients and diagnostic staff), safeguarding vulnerable adults and safeguarding children.
• ensure that pathways, policies and protocols are reviewed and harmonised across the trust, to avoid confusion among staff, and address any gaps identified.
• ensure that patient flow into and out of critical care is specifically in relation to delayed discharges, delayed admissions, running at high capacity and non-clinical transfers out of the unit.
• ensure that all equipment is tested in a timely manner and in line with the Trust’s policy, especially checks on fridges and resuscitation equipment.
• ensure that there is a clear clinical strategy for both critical care and outpatients and diagnostics and that staff are engaged in agreeing the future direction and involved in the decision-making processes about the future of the service.

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