Inspectors mark down two key services at major Teesside hospital
EMBARGOED UNTIL 00.01, Wednesday, May 25.
Two key services at a Teesside hospital have seen their ratings downgraded – with staff shortages and troubles feeding patients properly flagged by inspectors.
Surgery and medical care at James Cook University Hospital were both found wanting after inspections by the Care Quality Commission (CQC) in February. Both saw their ratings drop from good to requiring improvement – with the wider South Tees Hospitals Trust seeing its overall rating still remain below good after a below-par inspection in 2019.
The visits also triggered a warning notice telling the trust to make immediate improvements after worries about risk assessments, food and drink for patients and unsafe discharges were raised by the watchdog. Trust bosses say they were already taking action – and are making a raft of additional changes in response to the visits.
They also pointed to how the Omicron covid variant had made it one of the most challenging winters the trust had ever experienced – with 500 covid related staff absences at the winter peak. A lengthy 50 page report honed in on surgery and medical care at the Marton Road site after concerns were flagged up by other health partners.
The watchdog spoke to more than 70 staff, managers and 35 patients. While there were some bright spots in teamwork, kindness and compassion shown by teams, there were shortcomings in the number of workers available, maintaining patient dignity and privacy, and making sure patients had enough to eat or drink.
Rating of medical care at James Cook went down from good to requiring improvement. The watchdog put this down to the service not always having enough staff – with workers not consistently assessing risks to patients.
The report also found patients were not always safely discharged – and staff didn’t always make sure they had enough to eat or drink. It stated: “Staff did not always respect patient’s privacy and dignity or have the time to interact meaningfully with patients.
“Staff were not always discreet, and we saw examples of patient’s privacy and dignity not being maintained. Patients’ families were not always involved in their care.”
However, inspectors did find staff knew how to protect patients from abuse, they gave pain relief when it was needed, and treated them with compassion and kindness. The safety of the service was still judged as requiring improvement – with some targets narrowly missed on safeguarding training.
The CQC also found staff didn’t always complete risk assessments for each patient. When it came to meal services, hospital staff did not always adjust patient beds to be fully upright to improve their comfort and swallowing at mealtimes.
Workers spoken to by the CQC told inspectors about “inappropriate patient moves” including one “out of hours”. The report also detailed how the CQC reviewed discharges – finding 162 patients over six wards who were “discharge ready” but not sent away in January.
However, this figure had improved from 204 in November, and 176 in December. Nevertheless, the timings of the discharges did prompt some concern – with only half of them happening before 5pm over a two week period in February, meaning time became tight and there weren’t smooth flows of patients in and out of the site.
Another concern flagged was the number of nursing and support staff available – with the CQC finding there weren’t always enough to keep patients safe. A review of medical wards in December found seven out of 10 had struggled to fill registered nursing shifts, particularly on night shifts.
Sickness rates were also high – and there were also some shortcomings flagged when it came to administering medication. The report added: “We saw one patient example whose notes stated clearly that their Parkinson’s medication must be delivered on time.
“On admission to the ward, their oral medication had not been prescribed for several days as they were nil-by-mouth, and an alternative had not been provided. This had been raised as a concern by the patient’s family – the patient’s pain assessment chart was not fully completed on two consecutive days in their admission.”
The report also found the service did not always manage safety incidents well – and managers did not always investigate them thoroughly. While staff did report incidents and near misses, the reporting system showed a rise in serious events and other lower grade problems where patients had come to harm.
The report added: “We could see similar themes emerging around nutrition and hydration – for example, patients losing a lot of weight unexpectedly while in hospital, or reporting not being fed for several days – and inappropriate discharge. For example, patients going home without important medicines, or a care package in place that would support their needs.
“Other organisations also voiced their concerns about the types and numbers of incidents the trust had reported. We saw that the frequency of this type of incident had increased over recent months, and this was an important factor in our decision to inspect the trust when we did.”
The CQC was not assured the trust was learning from incidents but workers they spoke to did know how to report them. Doubts were also flagged about ensuring patients had enough to eat and drink.
The report added: “We observed patients whose meals were left at the end of their bed, out of reach and they were not made available to them in a timely way. We observed patients at mealtimes during the inspection across all wards we visited and did not see consistent support from staff when it was required.
“Staff did not always adjust patient beds to be fully upright to help with their swallowing.”
The watchdog also noted a patient they saw receiving food one lunchtime whose notes showed they were concerned about eating. Inspectors watched a care support worker returning the food to housekeeping staff “because they couldn’t swallow” – but they were told to return it to the patients as there was “nothing else”.
The support worker mashed up the food and left the patient but 20 minutes later no staff had returned and the patient hadn’t eaten any. And the food was later removed.
The report added: “We checked the patient’s food chart, which said they had received and eaten a teaspoon of soup. They had not been served soup and had not eaten anything.
“Their evening meal was also observed, and was wrongly recorded, both what the patient had been served, and what they had eaten.”
Despite some shortcomings, the CQC did note good things at the hospital including helping with pain relief, the service making sure staff were competent and how doctors, nurses and staff worked well as a team. Staff also treated patients with compassion and kindness.
However, the CQC judged they didn’t always respect their privacy and dignity. There were examples seen where patients were not encouraged to sit in their chair for mealtimes – or to get out of bed to wash or dress.
The report added: “We saw that staff did not always have time to provide individualised care or support to patients and this sometimes meant their privacy and dignity was not maintained on medical wards.” They found one patient called out for help 13 times in 20 minutes but staff “did not routinely respond” to his call for assistance.
But the CQC also saw staff maintaining patient’s privacy and dignity by closing curtains when undertaking care. Patients needing extra help due to agitation or increased confusion could also be supported by a specialist team of staff.
Surgery at James Cook saw its rating drop and was also judged to need improvement. The CQC found the service did not consistently have enough staff with the right qualifications, skills, training, and experience to keep patients safe from “avoidable harm”.
Not all records were clear and up to date. And, again, staff did not always provide patients with enough food and drink to meet their needs and improve their health.
However, the trust did make sure surgery staff were competent for their roles, teamwork was good and staff treated patients with compassion and kindness. There were one or two issues with maintaining privacy and dignity.
On one ward, a patient had died but the door was open to a side room where the body could be seen covered in a sheet. The report added: “There was no notice on the door stating do not enter to respect the patient’s privacy and dignity at end of life.
“We noted there was a patient on an end-of-life pathway in the next side room where a family was visiting. There was potential for additional distress had the family walked past the room.
“On the same ward we observed a female patient being assisted to walk to the toilet with a zimmer frame. The patient’s privacy and dignity were not respected as the patient’s hospital gown was open at the back.
“When a nurse noted an inspector had observed, assistance and support was given.”
The watchdog ruled South Tees still needs to improve overall. Sarah Dronsfield, from the CQC, said that while staff had worked hard and treated people with kindness, there were areas where improvements were needed.
She added: “We observed issues around nutrition and hydration, for example some patients were losing a lot of weight unexpectedly while in hospital, or not being fed properly. There had also been an increase in inappropriate discharge, for example, some patients going home without important medicines or social care packages in place which could put them at risk of harm.
“We also saw patients who required additional support with their meals not being given the help they need. Sometimes meals were left at the end of the bed, and people were unable to reach.
“Staff didn’t always adjust the beds to a comfortable position so people could eat comfortably and safely.” Ms Dronsfield said they’d noted the number of cases where patients had come to harm had risen – with other organisations voicing concerns.
She added: “Despite asking the trust for evidence of learning and changes they had made as a result of these incidents, we saw the same type of incidents reoccurring. We were therefore not assured that the trust was learning from its incidents and had strong systems in place to ensure that this happened.”
However, the CQC says the trust’s leadership responded quickly and had looked at what it would do to improve.
In response to the findings, the trust pointed to how it had cared for almost 7,000 covid patients since the pandemic struck – and how 500 covid-related staff absences hit at the peak of winter’s surge. Officials said it had already taken action – with £8m spent on new digital systems to get rid of ageing IT and bulky paper records.
This included a new way of recording food and drink assessments for patients. A care hub has also been created to help people get home safely – and mealtime menus have been reviewed alongside patients.
Trust officials also say the existing rating dates back to 2019 – with the latest inspection not covering many other areas. They pointed to the permanent recruitment of more than 200 extra nurses and midwives, and above average patient experience survey scores for medical care and the experience of youngsters at the trust.
Chief nurse Dr Hilary Lloyd said the trust fully accepted the findings and its staff had “acted immediately” on the CQC’s feedback. She added: “As just one example, we have strengthened our approach to protected mealtimes to make sure ward-based colleagues have the time and space to ensure patients receive the right meal at the right time with the right amount of support, and that food and drink is properly recorded.
“I am pleased that inspectors also found that doctors and nurses worked well together for the benefit of patients across multidisciplinary teams, and treated patients with compassion and kindness. The CQC also praised the responsiveness of colleagues at all levels of the organisation, and we are determined to continue making the necessary changes and learning and improving as part of our recovery from the pandemic.”
Trust leaders said omicron had “played a big part” despite the vaccination programme and treatment options. Chief medical officer Dr Mike Stewart said their covid response had helped mean the trust had some of the lowest hospital infection rates in the region.
He added: “However, the measures required to maintain strong covid infection prevention for patients and service users – combined with the impact this winter’s record-breaking community infection rates had on our colleagues, with more than 500 covid-related absences at the Omicron wave’s peak – meant that not every patient always had the experience we would want. It’s also the case that while Omicron caused particular challenges this winter, this pressure has been continuous since July of last year due to the Delta variant.”
Dr Stewart said they would continue to take action in response to the CQC.
Andy McDonald, MP for Middlesbrough, said: “I cannot say enough just how much in awe I am of all the staff who have worked at James Cook University Hospital during the most deeply challenging Covid crisis. Their dedication and commitment can never be underestimated.
“It is hardly surprising that given the past few difficult years, the Hospital has not been able to make the progress everyone would like to have seen. As demand on services is reduced I would hope to see the measures already put in place continue and more improvements made. No-one wants to see standards fall.
“I will be meeting with the Trust’s Chief Executive shortly and will be discussing the CQC report in detail as we move forward from the inspection.”