St Hugh’s Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

The Care Quality Commission (CQC) undertook an announced focused inspection of St Hugh’s Hospital on 22 and 23 August 2017. Focused inspections do not usually look at all five key questions; they focus on the areas indicated by the information that triggers the focused inspection. Although they are smaller in scale, focused inspections broadly follow the same process as a comprehensive inspection. We carried out the focused follow up inspection in order to ensure the provider had taken action to comply with the regulations in the safe, effective and well-led domains in surgery and the safe and well-led domains in outpatients and diagnostic imaging services.

Following this inspection CQC served a warning notice under section 29 of the Health and Social Care Act 2008. The warning notice related to Regulation 12, (1)(2)(g) The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment. The warning notice required the provider to take action to ensure systems and processes were established to ensure the proper and safe management of medicines. We gave the provider three months to make the necessary improvements.

We undertook an unannounced inspection on 13 February 2018. The purpose of this was to follow up on the actions the provider had told us they had taken in relation to the Section 29 warning notice issued in September 2017.

CQC will not be providing a rating to St Hugh’s Hospital for this inspection. The reason for not providing a rating is because this was a very focused inspection carried out to assess whether the provider had made significant improvement to services within the required time frame. During the focussed inspection we only reviewed the management of medicines in the safe domain of the surgery core service.

At the inspection in August 2017 we found:

• Staff did not recognise or investigate medicine errors and incidents.

• Staff did not complete medicines administration charts in line with the hospital’s policy.

• Staff did not follow the hospital’s policy for the administration of controlled drugs.

• Gaps in the recording of medicine fridge temperatures.

• Only 38% of staff had completed medicines management training.

• The hospital’s own audits and the external pharmacy contractor’s audits did not provide assurance about the safe management of medicines.

At this inspection we found:

• The medicines management policy at the time of the inspection did not reflect current practice at the hospital and did not support staff to properly manage medicines.

• Although there was a governance structure and escalation process for issues involving medicines, we were concerned that senior staff’s focus was on the audit’s overall percentage compliance rather than the proper and safe management of medicines. For example, the audit from January 2018 showed 85% compliance with medicines standards, however on the day of our inspection we found 0% of the medicines administration records we reviewed were compliant with the hospital’s policy and national guidance.

• Staff did not record the temperature of the medicines fridge in line with national guidance.

• Only two out of 24 staff that worked on the ward had completed the medicines competency. The hospital’s target for completion of this was 100% by the end of February 2018.

However we also found some improvements during this inspection including:

• Medicines (including controlled drugs) were stored securely and access was restricted to authorised staff.

• Medicines to be given once-only were appropriately prescribed and staff maintained appropriate administration records.

• There was an improvement in the number of staff at the hospital that had completed medicines management training.

Although we found there had been improvements made in the proper and safe management of medicines we found there was still more work to do.

On 28 February 2018 we served a warning notice under section 29 of the Health and Social Care Act 2008. The warning notice related to Regulation 17, (1)(2) The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance. The warning notice requires the provider to take action to ensure systems and processes are established to ensure effective governance arrangements are in place in relation to the proper and safe management of medicines. We have given the provider three months to make the necessary improvements.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

St Hugh’s Hospital is operated by Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include an endoscopy suite, two operating theatres with laminar airflow; consulting rooms supported by an imaging department offering X-ray and ultrasound, and inpatient and outpatient physiotherapy services. There are 24 patient bedrooms, all with en suite bathrooms. The hospital provides surgical, outpatients and diagnostic imaging services.

We carried out an unannounced visit to the hospital on 14 November 2016 in response to information received from the public about endoscopy services. We inspected endoscopy services using our focussed inspection methodology. A focused inspection differs to a comprehensive inspection, as it is more targeted looking at specific concerns rather than gathering a holistic view across a service or provider.

In our comprehensive inspections, to get to the heart of patients’ experiences of care and treatment we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well led?

Focused inspections do not usually look at all five key questions; they focus on the areas indicated by the information that triggers the focused inspection. Although they are smaller in scale, focused inspections broadly follow the same process as a comprehensive inspection.

At this visit, we inspected the safe and well-led domains and did not inspect or rate the remaining domains: effective, caring, and responsive.

Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Services we rate

We rated the endoscopy service as requires improvement overall.

We found areas of practice in relation to endoscopy that required improvement:

• Staff in the department did not always demonstrate awareness of when to submit an incident report.
• The introduction of the surgical safety checklist was planned but not in use at the time of inspection.
• There was an inconsistent approach to managing the risk of diabetes, pacemaker implantation or anti-coagulation treatment for patients being prepared for endoscopy procedures.
• The quality of consent, procedure reporting and discharge documentation was inconsistent and in some cases illegible.
• The overall approach to clinical governance in endoscopy needed strengthening and lacked proactive management oversight.
• There was no evidence of a training needs analysis or competency framework in use for all endoscopy staff.
• There was limited evidence that development of skills and knowledge to update and increase clinical expertise was achieved.
• Endoscopy policies and procedural documents required updating.
• There was a lack of audit of the quality and clinical effectiveness of the service.
• There was no tool in place to obtain patient experience feedback from endoscopy patients.
• Staff team meetings were infrequent.

However:

We found areas of good practice in endoscopy services:

• Patients received comprehensive written information about the risks and benefits of the procedure and received clear instructions about after-care.
• We reviewed eleven sets of patient records and endoscope traceability records were complete in each.
• The endoscopy department was visibly clean and tidy in all areas visited.
• A risk register was in place for the hospital and each department within the hospital. This was under continuous review as it was still under development and staff had received training in risk management.
• The endoscopy nurse manager regularly attended the Clinical Governance Committee.
• Mandatory training compliance levels were good and all staff had received appraisals.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement notices that affected endoscopy services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (Hospitals North)

Patients spoke positively about their experience of the hospital. Comments of patients included: “The whole experience has been absolutely fine,” “They can’t do enough; they look after you,” and “This is my fourth visit; each time I have had the same level of care and treatment; the service is excellent and I have not experienced any deterioration.”

Patients spoke very positively about their mealtime experience. Nearly all patients rated the hospital food as excellent or good in the monthly inpatient quality questionnaire. One patient explained, “The food is lovely; you have a choice of three or four things and they ask each day what you want.”

Patients were happy with the way they were given their medicines. One patient who was ready to be discharged said, “I am clear about what I need to do and I have my medication already, with written instructions.” Another patient said, “They give me as required medicine for pain relief.” Another patient commented, “The medicine helped me to walk and I was able to get a good night’s sleep.”

Patients’ comments about staff included, “The staff are all very knowledgeable,” “The nursing staff are helpful and friendly and the surgeon has been particularly helpful,” and “Everybody is smiling; the nurses are lovely, and reception staff are ever so nice, so is my consultant and the physiotherapist is spot on.”

Patients we spoke with explained how they would make a complaint although they said they had no complaints to make.

Patients told us they were engaged in discussion before their treatment and gave their consent. One patient said, “We were involved in discussion when I came for my pre op. They are brilliant and they explain everything to you.” We saw a survey response which stated, “The consultant was very good; he was very informative and put my mind at ease.”

Patients and their relatives spoke positively about their experience of the service. One patient commented, “There was someone with me right up to the point they knew my blood pressure was OK, even in the recovery room. No one walked past without saying, ‘are you OK?’” We saw a survey response which stated, “I have never experienced such professional, caring and considerate care, wonderful; and means I am making a good recovery.” This was typical of other responses we reviewed.

Patients and their relatives spoke positively about their experience of the cleanliness of the hospital and about staff that worked with them. One patient told us, “The nurses and doctors have been really good; you can’t fault them.” We saw survey responses which stated, “The staff were very nice and considerate,” and “I was particularly pleased with the warm friendly feel of the place and staff.”

Patient views were regularly sought through questionnaires given to each patient on discharge. The results of the patient satisfaction survey for November 2012 showed that 92% of patients found the hospital’s service excellent overall.

During our inspection we spoke with a number of people who use the service. People we spoke with were very positive about their care and experience in hospital. They told us they received sufficient information about the hospital and the proposed treatment or procedure. The options for their treatment or procedure were explained to them in a way they could understand and they were given opportunities to ask questions. They were told about the risk and benefits of the treatment or procedure, they felt included in decisions made about their care and were given time to consider their decision about the proposed treatment or procedure.

One patient we spoke with told us: "The care was excellent, each time I saw the doctor he explained everything to me and gave me time to ask any questions." Another patient said: "I can't fault the care I've received, everything was explained very well."

As part of our inspection we talked with a number of patients. They spoke positively about the staff and care provided and told us that staff treated them with respect. Everyone we spoke with felt they were involved in their care and in making decisions about their treatment. We received comments such as “I couldn’t wish for a better service”, “The nurses come straight away when I ring my bell” and “The whole experience has been very good”.

Patients told us that they had received sufficient information about their treatment and that staff listened to them and were able to answer any questions they had. Other comments we received were “The meals are very good”, “The nurses always get you a drink when you want one”, “They (the staff) are very kind and patient”, “Nothing is too much trouble” and “I trust this hospital”.

St Hugh’s Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 05 and 06 March 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the surgery service level report.

Services we rate

Our rating of this hospital stayed the same. We rated the hospital as requires improvement overall. This was because we rated well led as inadequate, we rated safe as requires improvement and we rated effective, caring and responsive as good.

We rated the surgical services as requires improvement. This was because we rated safe as requires improvement. We rated effective, caring and responsive as good. We rated well led as inadequate.

Although the hospital had made some improvements since our previous inspection, there was still work to do in terms of safety and leadership. This was because staff did not always recognise and report concerns, incidents or near-misses. We identified some discrepancies in medicines governance and were not assured there was a consistent approach to reporting medicines incidents and escalating patient risk. Mandatory training compliance remained low in some subjects, for example, safeguarding training. Not all consultants were completing care records in line with the hospitals record keeping policy.

There was no formalised and consistent system of clinical supervision in place. We had concerns formal complaints were not always managed in accordance with hospital policy. We had concerns that the senior leadership team were not proactively managing the concerns identified in some consultants practice, behaviour and record keeping. We also found some the concerns identified at our previous inspection were not fully addressed and some controls were not fully embedded, for example, issues relating to medicines governance, which breached hospital policy. We were concerned that there was not an equitable awareness of safety and risks across all services. Staff across all services raised concerns about low morale and the culture at the hospital since our previous inspection.

However, we found the surgical care areas, equipment and facilities were well maintained and safe. We found robust infection prevention and control processes were in place, audits took place and compliance rates were high. The hospital had reported two never events following our previous inspection. These were in October and November 2017, we found following these incidents the patients were fully informed and duty of candour (DoC) applied. Root cause analysis investigations were completed, learning identified and action plans put in to place to prevent recurrence.

We saw patients were treated with care, compassion, and respect by all staff during their treatment and patients told us they were fully involved in their care.

The hospital worked with other care providers to improve services and to meet the needs of the local population. Patients could access treatment quickly. Referral to treatment performance was good with 90 to 95% of patients being treated within 18 weeks. On average patients completed their treatment within 10 weeks. There were low numbers of complaints. Staff told us the senior managers were visible and supportive. The hospital had a clear set of principles, goals and values. Despite the challenges of the previous year most staff said the hospital was a good place to work with good teamwork in their departments.

Overall, we rated the outpatient’s department as good because we rated safe, caring, responsive and well led as good. We do not rate effective for outpatients.

This was because the department was clean and tidy. All equipment had been serviced in line with requirements. Records were stored securely. Staff were aware of their safeguarding responsibilities, how to assess patients for risks and respond appropriately if any were identified. When incidents occurred, staff knew their responsibilities to report incidents and near misses. There was adequate nursing and medical staffing available in the department to meet the needs of patients.

Patients received evidence-based care delivered by competent staff from a number of different disciplines who understood their responsibilities in relation to mental capacity and consent and focused on providing good quality care and treatment. Patients could access drinks and food if their clinical condition necessitated it however, pain relief was only accessible via a prescription from the consultants working in the department.

Outpatient clinics were offered during the day, evenings and some weekends depending upon demand. Patients we spoke with were happy with the care and treatment they received. Staff were kind, courteous, patient and understanding. Patients were offered support if they needed it and provided with information about their condition presented in terms that were understandable and avoided medical jargon. Services were delivered in a way that met the needs of local people by staff who understood patients had individual needs. The hospital provided support to patients who had sensory, language, physical disability and mental health support needs.

Patients could access appointments quickly. Complaints were few however all staff took complaints seriously and aimed to provide a good quality service for patients.

The department was managed by staff who were experienced in the management of an outpatient department. There was a strategy in place to develop the services delivered by the department in line with local needs and the requirements of local services the hospital engaged with such as the local NHS trust and Clinical Commissioning Group (CCG).

The department collected information about services and had governance processes in place to monitor the quality of services delivered. Risks faced by the department were assessed, recorded and managed. Staff mostly felt well led although some had concerns about their line managers occasionally being unsupportive.

Overall, we rated the diagnostic imaging department as requires improvement. We rated well led as inadequate and safe as requires improvement. We rated caring and responsive as good. We do not rate effective in diagnostic imaging.

This was because during our time on site, the management team were unable to provide us with assurance that equipment being used had been appropriately safety checked and calibrated. This posed a potential risk to both patients and staff. Staff were not wearing appropriate safety equipment and there was no evidence of safety equipment having mandatory safety checks.

Although the hospital had received a safety assessment from their local radiation protection advisor (RPA) in November 2018 highlighting many breaches of IR(ME)R (ionising radiation medication exposure regulations), we found no evidence whilst we were on site and managers could not provide us with any evidence of how these breaches had been addressed other than with an out of date action plan showing no prioritisation and only one action completed.

Whilst on site, we were unable to find, and the hospital was unable to provide us with up to date information about safety and quality checks carried out in the department to ensure ionising radiation procedures were performed in line with national guidance and local procedures. When we arrived at the department, local rules were out of date however these were updated and replaced during the inspection.

The department did not have an established safety checklist for carrying out interventional radiology as highlighted at the hospital’s previous CQC inspection.

We were concerned about the safety of patients and staff visiting the department because the hospital could not provide us with immediate assurance that the department was safe.

The hospital was unable to provide us with evidence of how they were assured they provided evidence-based treatment. Documentation relating to evidence-based care was out of date and had not been updated to reflect the latest IR(ME)R regulations issued in 2018.

The process for quality checking the work of individuals was unclear and there was no evidence that quality assurance of images took place. We found no evidence of discrepancy meetings taking place.

We identified concerns about the senior management of the diagnostic imaging department. They were unclear about the quality assurance and safety processes involved in managing a service that uses ionising radiation. There were no robust embedded systems of governance in place and the department was reliant on one person to oversee governance and quality assurance. Staff were unclear about the governance processes in place to safeguard both them and patients.

Management and leadership was remote. Staff were unaware of any strategies or future plans for the department.

We wrote to the hospital director immediately after our inspection and told him the Care Quality Commission was considering action under section 31 of the Health and Social Care Act 2008. We told the hospital they must provide us with information which showed that patients and staff working in the diagnostic imaging department were safe from harm. The hospital voluntarily suspended diagnostic imaging services until this information was provided. CQC received this information within the required timescales and therefore the hospital was able to resume diagnostic imaging services.

However, we also found the following good practice in the diagnostic imaging department. Staff were aware of their responsibilities relating to consent and mental capacity of patients requiring x-rays or ultrasound.

Patients received care from staff who were kind and compassionate. They were given information in terms they understood and were given emotional support if it was needed. Patient feedback was positive and we were assured the hospital had carried out due diligence to ensure radiology and radiography staff were suitable qualified.

The service was planned to meet the needs of people attending the hospital and x-ray imaging was available whilst clinics were running as well as when required by inpatients. Patients did not have long waits for appointments and could be seen quickly if needed.

Services were designed to meet the needs of individuals and support was available for people living with sensory impairment, physical and learning disabilities, mental health problems and dementia.

The department had received no complaints however complaints received across the hospital were discussed with staff and lessons learned shared to improve services and prevent future complaints.

Following this inspection, we told the provider it must take some actions to comply with the regulations and it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with two requirement notices. These were related to regulation 12, safe care and treatment and regulation 17, good governance that affected surgery and the diagnostic imaging departments. Details are at the end of the report.

Name of signatory

Ellen Armistead

Deputy Chief Inspector of Hospitals North Region