The Friarage Hospital was one of two acute hospitals forming South Tees Hospitals NHS Foundation Trust. The trust provided acute hospital services to the local population as well as delivering community services in Hambleton, Redcar, Richmondshire, Middlesbrough and Cleveland. The trust also provided a range of specialist regional services to 1.5 million people in the Tees Valley and parts of Durham, North Yorkshire and Cumbria. It had a purpose-built academic centre with medical students and nursing and midwifery students undertaking their clinical placements on-site. In total, the trust had 1,351 beds across two hospitals and community, and employed around 9,000 staff. The Friarage Hospital had 170 beds.

The Friarage Hospital provided medical, surgical, critical care, maternity, children and young people’s services for people across the Hambleton and Richmondshire area. The hospital also provided urgent and emergency services (A&E) and outpatient services.

We inspected the Friarage Hospital as part of the comprehensive inspection of South Tees Hospitals NHS Foundation Trust, which includes this hospital, James Cook University Hospital and community services. We inspected the Friarage Hospital on 11 December 2014.

Overall, we rated the Friarage Hospital as ‘requires improvement’. We rated it ‘good’ for being caring and well-led, but it requires improvement in providing safe, effective and responsive care.

We rated surgical services, critical care, maternity care, services for young people, and outpatient services as ‘good’, with A&E, medical care and end of life care as ‘requiring improvement’.

Our key findings were as follows:

• Arrangements were 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 that all areas we visited were visibly clean. Infection rates of Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C. difficile) were within an expected range for the size of the trust.
• Patients were able to access suitable nutrition and hydration, including special diets. Patients reported that, on the whole, they were content with the quality and quantity of food.
• Processes were in place for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs.
• There was effective communication and collaboration between multidisciplinary teams.
• There were staff shortages, mainly due to vacancies for nursing  staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank staff overtime and locum staff were being used to fill any deficits in staff numbers.
• The composite of the Hospital Standardised Mortality Ratio (HSMR) indicators was slightly higher than the national average in this trust. The Summary Hospital-level Mortality Indicator (SHMI) was as expected.

We saw several areas of outstanding practice including:

• A team of therapeutic volunteers had been created which was led by a therapeutic nursing sister who had been in place for 18 months. The volunteers had mandatory and dementia training and were in operation 24hours a day. The role of the volunteers was to support patients who may be living with dementia or other illnesses which affected their behaviour and level of supervision required. This included engaging with patients, such as playing board games or other interests patients may have. They also supported patients who required help with eating or wanted to explore their environment. This included supporting them overnight if they were disorientated. The team had been regionally recognised for its work.
• In maternity services, the families and birth forum was involved in the design of the induction of labour suite and in championing the take-up of breastfeeding rates through the use of peer supporters, as well as improving information to raise awareness and promote the service to women when they had left the hospital.
• In maternity services, lay representatives were actively involved in the patient experience rounds and 15 Steps Challenge – a series of toolkits which are part of the productive care workstream. The toolkits help look at care in a variety of settings through the eyes of patients and service users, to help investigate what good quality care looks, sounds and feels like.

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

Importantly, the trust must:

• Ensure that there is sufficient numbers of suitably qualified and experienced staff particularly in the A&E department, medical wards, and outpatients department.
• Provide training for ward-based medical and nursing staff in the assessment of nutrition and hydration for people at the end of life and monitor how assessments are being carried out and how decisions are made.
• Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
• Ensure that, where a patient is identified as lacking the mental capacity to make a decision or be involved in a discussion around resuscitation, a mental capacity assessment is carried out and recorded in the patient’s file in accordance with national guidance.
• Review arrangements for the recording of do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions, including records of discussions with patients and their relatives to ensure that they are in accordance with national guidance.
• Ensure staff receive appropriate training and support through appraisal including the completion of mandatory training, particularly the relevant level of safeguarding and mental capacity training so that they are working to the latest up to date guidance and practices, with appropriate records maintained.
• Ensure that patients records are appropriately up dated and stored to ensure confidentially is maintain at all times in line with legislative requirements.
• Ensure that there are mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatients department.
• Ensure that resuscitation equipment and medication fridge temperatures in the diagnostic and imaging department are checked in accordance with trust policies and procedures.

In addition the trust should:

• Review College of Emergency Medicine audit data to ensure that patient outcomes are met.
• Continue to review and reduce the mortality outliers for the Hospital Standardised Mortality Ratio (HSMR) within the trust.
• The trust should ensure that patients who are medically fit are discharged in a timely manner to the appropriate setting to reduce the number of delayed discharges.
• The trust should ensure that medication omissions were monitored, investigated and reported in line with trust policy.

• Identify a formal board-level director who can promote children’s rights and views. This role should be separate from the executive safeguarding lead for children.
• Consider the commencement of a restraint-training programme for staff in A&E.
• Incorporate the use of mental capacity assessments into the trust-wide audit of DNA CPR documentation.
• Introduce patient surveys specific to the outpatients department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Over the last two years we have inspected every Trust registered hospital and community base. We have completed annual inspections of the James Cook University Hospital and The Friarage as well as completing themed inspections at the hospitals, which looked at both Accident and Emergency departments as well has the Trust’s termination of pregnancy services. We found that the Trust encouraged us to identify any ways they could improve.

Teams of CQC staff have inspected all the locations and these teams included specialist advisors and experts by experience. Throughout the two years we have held regular meetings with Trust representatives and discussed work the Trust is completing to maintain and improve their service. We have found that over the two years the Trust has remained compliant with all the regulations.

Our central analytic team have constantly reviewed the data the Trust has submitted to the various bodies overseeing their work and used this to assess the performance of the Trust. The central team have also compared this information on performance against other Trusts both in the North East, across the country and against Trusts with similar size populations and services. The last published risk rating for the Trust placed them in band 6, which is the lowest risk rating.

We found that the Trust’s quality assurance system was effective. It covered all aspects of the service and did not lose sight of the needs of the patients using the community services.

During this inspection we focused on how patients’ care was delivered within surgical departments. We also looked at how the Trust monitored the care and treatment being delivered in this environment.

We spoke with 15 patients and three relatives in the surgical admissions unit and post operative wards. People told us that they were extremely satisfied with their care. All were extremely complimentary about the surgeons: the way their operations had been complete; and care on the wards. People said, “The care is second to none”, “The staff have been absolutely fantastic", "Staff are such a friendly bunch” and “I chose to come back here because I found the care so good last time and I have not been disappointed this time either”.

People who had previously had operations at the hospital also commented that they found the recent change in practice in theatre reduced their anxiety. We were told that people now walked into theatres and placed themselves on the table. The staff told us that some operations were completed with the patient awake and so the person’s favourite music was played and a staff spent the duration of the operation chatting with them. The people we spoke with confirmed this and said, “It was a much more relaxing experience and I think it helped to lower my blood pressure”.

We found that staff within the surgical departments had access to all the equipment they needed and followed all of the guidance around how to safely complete the operations.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We inspected the trust from 8 to 10 June 2016 and undertook an unannounced inspection on 21 June 2016. We carried out this inspection as part of the Care Quality Commission’s (CQC) follow-up inspection programme to look at the specific areas where the trust was previously rated as ‘requires improvement’ when it was last comprehensively inspected on the 9-12 and 16 December 2014.

At the comprehensive inspection in 2014 the trust overall was rated as requires improvement for their acute and community services. It was requires improvement for the safe and effective key questions at both hospital locations. The remaining key questions were rated good overall. Community health services were rated good overall, with requires improvement for the urgent care centre.

During this inspection, the team looked at one key question in urgent and emergency care, medicine and outpatients at both hospital locations. One key question in children’s and young people at one of the hospitals, three key questions in end of life care at both hospitals, plus two key questions in the urgent care centre and one in community inpatients at one other location. All these services had previously been rated as requires improvement, and all came out as good following the June inspections.

We included the following locations as part of the inspection:

James Cook University Hospital

• Urgent and emergency services;
• Medical care;
• Services for children and young people;
• End of life care;
• Outpatients and diagnostic imaging.

The Friarage Hospital

• Urgent and emergency services;
• Medical care;
• End of life care;
• Outpatients and diagnostic imaging.

Redcar Primary Care Hospital

• Urgent care centre;
• Community inpatients (adults).

Our key findings were as follows:

• Patients received appropriate pain relief and were able to access suitable nutrition and hydration as required.
• There were defined and embedded systems and processes to ensure staffing levels were safe. During this inspection, we did not observe any evidence to suggest the level of nurse staffing was inadequate or caused risk to patients in the areas we visited.
• The trust had infection prevention and control procedures, which were accessible and understood by staff. Across both acute and community services patients received care in a clean, hygienic and suitably maintained environment. However, there were some issues with cleanliness in the discharge lounge at the Friarage Hospital.
• Patient outcome results had improved in areas of sepsis, senior review of patients in A&E with non-traumatic chest injury, febrile children and unscheduled return of A&E patients.
• Staff understood the basic principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and could explain how these worked in practice.

• There was consistency in the checking and servicing of equipment. However, there was one piece of equipment used in the mortuary at the Friarage Hospital, which had not been adequately maintained.

• Competent staff that followed nationally recognised pathways and guidelines treated patients. There was audit of records to make sure pathways and guidelines were followed correctly.
• Arrangements for mandatory training were good and significant improvements had been made for staff to attend.
• Medication safety was reported as a quality priority in 2016/17 and improvement targets had been set. There were improvements in the management of medicines since our last inspection particularly around effective audit and reconciliation of medicines. We found some inconsistencies in the management of medicines however, the trust nursing and pharmacy team acted promptly and these issues were addressed.
• There was an open culture around safety, including the reporting of incidents. Staff were aware of the duty of candour and there were systems to ensure that patients were informed as soon as possible if there had been an incident that required the trust to give an explanation and apology.
• The trust had developed action plans to improve performance of the 4 hour A&E target, 18 week referral to treatment times, c. difficile and 62 day cancer waiting times. These plans provided the necessary assurance that the trust had the actions and capacity to ensure compliance in 2016/2017.
• The trust had commenced a significant period of transformation and organisational re-design in 2015. There was a newly established senior executive team, and there was a clear ambition from the Board to be an outstanding organisation.
• From 1 April 2016, the trust had moved to a new clinical centre structure. There were five centres, which replaced the existing seven centres. Clinical leadership was strengthened.
• The trust had been in breach for governance and finances; however, they had made significant progress against their enforcement undertakings for both elements.
• The recent changes to the executive team were seen by staff to be very positive. There were improvements in the speed of decision-making and visibility of the senior team in clinical areas.
• The trust was strengthening the patient voice and developing strategies to enhance patient and staff engagement.

We saw several areas of outstanding practice including:

• The trust was developing a detailed programme around patient pathways/flow/out of hospital models. This included developing a detailed admission avoidance model to establish pilot schemes in acute, mental health, community and primary care services. This would ensure patients were virtually triaged earlier in their pathway rather than being admitted to A&E. This would support patients closer to home and in more appropriate facilities, and reserve acute capacity for patients who required it.
• The Lead Nurse for End of Life Care was leading on a regional piece of work for the South Tees locality looking at embedding and standardising education around the 'Deciding Right' tools  (a Northeast initiative for making care decisions in advance).

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

In addition the trust should:

• Ensure that processes are in place and understood by mortuary staff at the Friarage Hospital for the maintenance, moving and handling of equipment and transfer of deceased patients particularly out of hours.
• Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.
• Ensure that the end of life strategy is approved and implemented and move to develop a seven-day palliative care service.
• Review arrangements for the discharge lounge at the Friarage Hospital in terms of maintaining and cleaning equipment and ensuring the environment was suitable for patients and purpose.

Professor Sir Mike Richards

Chief Inspector of Hospitals