Our rating of services stayed the same. We rated them as requires improvement because:

• We rated safe and responsive as requires improvement and effective, caring and well led as good.
• We rated one of the hospital’s eight services as requires improvement and seven as good.
• The rating of medical care and surgery improved from our last inspection.
• There was a lack of pace in addressing some of the issues from the last inspection, for example, management of the deteriorating patient in medical care and the effective use of the five steps to safer surgery processes.
• The trust had undertaken work towards improving the compliance with recording of patient’s National Early Warning Score (NEWS). However we found there were still concerns with the escalation of NEWS score in line with the trust’s policy. Nursing staff used their own clinical judgement as to when to escalate a patient’s NEWS score which was not in line with the trust’s policy.
• At this inspection it was apparent the five steps to safer surgery checklist was still not embedded as a routine part of the surgical pathway. The trust had reported three never events associated with wrong site surgery or the wrong prosthesis being inserted. We could therefore not be assured that the checklist was being used correctly and consistently.
• The trust did not always meet referral to treatment indicators. We saw high numbers of patients waiting for first and follow up appointments across several outpatient areas. In addition to this the trust declared a serious incident related to a trust wide tracking issue within the electronic database. This resulted in a number of patients being lost to follow up.
• Patients’ records were not always stored securely or in an organised manner. There was a risk that staff may not have access to the information they needed to deliver patient care and that the public could access patients’ confidential records.
• The trust did not always have appropriate numbers of staff to ensure patients received safe care and treatment. The trust had introduced some additional staff and roles to provide cover and mitigate some of the risk. However, despite the shortage of registered nurses in particular, the trust managed staffing well and had a robust escalation and review process.

However:

• Staff were encouraged and knew how to report incidents. We saw evidence from actions plans and root cause analysis that serious incidents were identified and investigated appropriately.
• The trust provided care based on evidence based practice and national guidance. Services reviewed the effectiveness of care through national and local reviews and implemented any findings. We saw improvements in how the trust reviewed effectiveness of the care, through monitoring and auditing compliance with nine fundamental standards.
• Staff cared for patients with care and compassion and respected patient’s wishes. Staff provided individualised care and involved patients and those close to them in decisions about their care and treatment. They provided patients with emotional support to minimise their distress.
• Patient’s individual needs were met. Systems were in place for identifying patients living with dementia and learning difficulties and to support them through their hospital stay.
• Staff morale was good and teams worked well together and supported each other. Managers were proud of their staff and success was celebrated through local and trust wide events.

People told us what it was like to be a patient in Hull Royal Infirmary. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an additional two CQC inspectors, a practising professional and an expert by experience, who has had personal experience of using or caring for someone who uses this type of service.

Most patients spoken with were happy with the care they had received and said they were involved in decisions about their treatment. They said staff were pleasant and discreet and not rushed. Comments included, “Yes the staff are nice when they speak to me”, “The staff are very caring and very good, they explain what is happening and what they are going to do” and “My treatment and care has only been discussed between me and the staff.”

Patients stated they felt the staff treated them kindly, their money and belongings were safe and they felt safe. Comments included, “I talk to a nurse” and “I just ring my buzzer if I am worried about anything.”

Patients spoken with told us they enjoyed their meals and they had the opportunity to choose from a menu. Comments included, “Food is hot and meals are enjoyable” and “We have regular drinks throughout the day.”

Patients also told us that some wards were very busy but staff had time to talk to them and provide care and treatment. Most patients said that staff responded to call bells quickly and they were complimentary about the staff team.

Patients were aware that records were held about their care and treatment but some said they had not seen their care plan.

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.

People who use the service told us that they were satisfied with the quality of services and were complimentary about the direct care received from all of the care staff. They felt that they could talk to the staff and were confident that staff listened to their worries or concerns, treated them with respect and involved them in their care. However, some people did comment that staff always appeared busy. Two people shared concerns with us regarding individual aspects of their care but both stressed that those particular concerns did not detract from the overall satisfaction of the ward staff.

People told us that they had been given information and choices about the birth they wanted. They told us that they were happy with the care provided and felt they could raise any concerns. They said that the father or birthing partner was fully involved.

One person felt that communication could be improved upon.

Hull and East Yorkshire Hospitals NHS Trust operates from two main hospital sites – Hull Royal Infirmary (HRI) and Castle Hill Hospital (CHH) in Cottingham. HRI is the main centre for emergency services including the emergency department (ED). The trust provides services for a population of approximately 602,700 people. This is made up of approximately 260,500 people in the city of Kingston Upon Hull, and 342,200 in the East Riding of Yorkshire.

We completed a comprehensive inspection of the trust from the 28 June to the 1 July 2016 which included a review of progress made on the previous inspections in May 2015 and February 2014. We inspected all eight core services at HRI. We also inspected the minor injuries service operated by the trust at East Riding Community Hospital and outpatient services at the Westbourne NHS centre. We did not visit any other outpatient services which operated in other locations. In addition, we carried out unannounced inspections on 9 June and the 11 July 2016.

We rated HRI overall as ‘requires improvement’; safe, responsive and well led were rated as ‘requires improvement’ with effective and caring rated as ‘good’. Improvements had been made since our last inspection but these were not significant enough to change the rating for HRI as whole. Some areas had made considerable improvements, especially the emergency department (ED) which was now rated as ‘good’. Medical Care, Surgery and Children’s Services had improved. End of Life Care remained ‘good’ across all domains. However, there was deterioration in the ratings overall for Critical Care, Maternity and Outpatients & Diagnostics from ‘good’ to ‘requires improvement’.

Our key findings were as follows:

• The care of patients within the emergency department had significantly improved since the last inspection. The trust was meeting the locally agreed trajectories for the number of patients seen within four hours (in June 2016, 85.9% of patients were seen within four hours, which was in line with the agreed trajectory of 85.1%), it was still breaching the national target of 95%.
• The trust reported and investigated incidents appropriately, the previous backlog had reduced. However, staff in some areas could not tell us about lessons learned or changes to practice, including within maternity where a never event had occurred.
• The trust had effectively responded to a serious incident reported by Radiology in December 2015 related to a failure to print 50,000 radiology reports. A further seven serious incidents regarding specific patients had been reported four of which related to this printing issue. These incidents had been identified by the trust, action had been taken to change the system and additional safety alerts had been added which if breached were reported to the medical director.
• A backlog of 30,000 patient episodes had been identified by the trust prior to the inspection. A cluster of eight serious incidents had been declared in outpatients, relating to patients that had not had their appointments when they should. This had led to delays in diagnosis and incidents of varying harm to patients. The trust had put in a clinical validation procedure in June 2016 to reduce the likelihood of this happening again.
• We had concerns within the children’s services about: the competency of staff to care for patients with mental health needs; that not all incidents, including ‘near misses’ and some safeguarding incidents had been classified correctly and therefore not fully investigated or possible lessons learnt and; four safeguarding children guidelines were out of date.
• Staff were not always assessing and responding appropriately to patient risk. The trust used a National early warning score (NEWS) and the Modified Early Obstetric Warning Score (MEOWS) to identify deterioration in a patient’s condition. We saw some examples of when escalation of a deteriorating patient had not happened in a timely way and some staff were unclear about what to do if a patient’s score increased (indicating deterioration). The trust was aware of this and was putting actions in place to improve this.
• Falls risk assessments were often not completed or not fully completed. Nutritional assessments were partly completed in the patient records, which may have resulted in a failure to identify patients at risk of malnutrition. We also found poor compliance with the completion of fluid balance charts.
• Nurse staffing shortages were evident across the majority of medical and surgical wards and board reports indicated that safer staffing levels were not always met. The trust recognised this was an issue and had put in place twice daily safety briefings and associated actions to minimise risk to patients as well as new ward support roles, such as discharge facilitators. The maternity service did not collect the relevant data and therefore could not provide assurance that women received one to one care in labour.
• There were also some gaps within the medical staffing, especially within critical care.
• The Summary Hospital-level Mortality Indicator (SHMI) for the Trust had deteriorated and was 112.2 which was higher than the England average (100) in March 2016. 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 based on average England figures, given the characteristics of the patients treated there. The Hospital Standardised Mortality Ratio (HSMR) was 98.6 in May 2016 which was similar to the England ratio (100) of observed deaths and expected deaths.
• There were three active outlier mortality alerts at the time of the inspection. These were for septicaemia (except in labour), coronary artery bypass graft (CABG) and reduction of fracture of bone (upper and lower limb). This meant that deaths within these areas had been outside of the expected range. The Trust had untaken a case note review to determine if any of the deaths were avoidable, what lessons could be learnt and actions were then put in place.
• Although medicines were stored and administered appropriately, we found gaps and errors in the recording of medicines administration and in the monitoring of checks of controlled drugs which had been a concern at our 2015 inspection.
• Leadership had improved. There was a clear vision and strategy for the trust with an operational plan on how this would be delivered. We found an improved staff culture, staff were engaged and there was good teamwork.
• Feedback from patients and relatives was positive. We saw good interactions between staff and patients. Staff maintained patients’ privacy and dignity when providing care. Caring within medicine had improved although there were some instances on the acute medical unit at HRI where not all call bells were within reach of patients.
• Patients told us they were offered a choice of food and regularly offered drinks. Patients were offered alternatives on the food menu and were provided with snacks, if required, during the day.
• The areas we visited were clean and ward cleanliness scores were displayed in public areas. We observed good infection prevention and control practice on all wards we visited. There had been a significant improvement in the operating theatre environment at HRI.

We saw several areas of outstanding practice including:

• The urology services had introduced robotic surgery for prostate cancers in May 2015; this had since been extended to cover colorectal surgery.
• The critical care teacher trainers had been shortlisted for a national nursing award for their training courses and had been asked to write an article for a national nursing journal.
• The perinatal mental health team/midwifery team had been shortlisted for the Royal College of Midwives Annual Midwifery Awards 2016 for effective partnership working in supporting women with perinatal mental health.
• Recreational co-ordinators had been introduced in medical elderly wards. Their role was to provide patients with activities and stimulation whilst in hospital.
• The responsiveness of the Specialist Palliative Care team (SPCT) in relation to acting on referrals.
• The bereavement initiative of providing cards for relatives to write messages to their loved ones
• The International Glaucoma Association had awarded the ophthalmology department an innovation award for their glaucoma monitoring work.
• Radiology at the trust was an exemplar site for the BSIR (British Society of Interventional Radiology) IQ programme for interventional radiology.
• The ultrasound department was the UK reference site for Toshiba in the fields of elastography and fusion guided imaging.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must ensure that:

• Planning and delivering care meets the national standards for A&E; meets the referral-to-treatment time indicators and; eliminates any backlog of patients waiting for follow ups with particular regard to eye services and longest waits.
• A review of the process for categorising incidents is carried out, including safeguarding incidents relating to children, to ensure effective investigation and lessons learnt.
• Staff complete risk assessments and taken action to mitigate any such risks for patients; in particular, risk assessments for falls and for children with mental health concerns.
• Learning from never events is further disseminated and lessons learnt are embedded.
• Staff are knowledgeable about when to escalate a deteriorating patient using the trust’s National early warning score (NEWS) and Modified Early Obstetric Warning Score (MEOWS) escalation procedures; that patients requiring escalation receive timely and appropriate treatment and; that the escalation procedures are audited for effectiveness.
• Staff have the skills, competence and experience to provide safe care and treatment for children with mental health needs and patients requiring critical care services.
• It continues to work actively with other professionals, internally and externally, to make sure that care and treatment remains safe for children with mental health needs using the services.
• Staff follow the established procedures for checking resuscitation equipment in accordance with trust policy.
• Staff record medicine refrigerator temperatures daily and respond appropriately when these fall outside of the recommended range, especially within A&E.
• Staff sign drug charts after the medication has been dispensed and not before (or before and after if required) to provide assurance that medications have been given to/ taken by the patient.
• Records of the management of controlled drugs are accurately maintained and audited within A&E.
• Patients’ food and fluid charts are fully completed and audited to ensure appropriate actions are taken for patients.
• Staff who work with children and young people are knowledgeable about Gillick competence and that a process is in place for gaining consent from children under 16.
• Antenatal consultant clinics have the capacity to meet the needs of women. They also must ensure there is enough capacity in the scanning department to implement GAP (Growth assessment protocol).
• There is effective use and auditing of best practice guidance such as the “Five steps for safer surgery” checklist within theatres and standardising of procedures across specialties relating to swab counts.
• Elective orthopaedic patients are regularly assessed and monitored by senior medical staff.
• The critical care risk register is reviewed so that all risks to the service are included and timely action is taken in relation to the controls in place and escalation to the board.
• Outpatient services have timely and effective governance processes in place to ensure they identify and actively manage risks and audit processes to monitor and improve the quality of the service provided.
• Medical records are stored securely and are accessible for authorised people in order to deliver safe care and treatment, especially within outpatient and maternity services.
• At all times there are sufficient numbers of suitability skilled, qualified and experienced staff (including junior doctors) in line with best practice and national guidance taking into account patients’ dependency levels on surgical and medical wards. And specifically to ensure critical care services have sufficient numbers of staff to sustain the requirements of national guidelines (Guidelines for the Provision of Intensive Care Services 2015 and Operational Standards and Competencies for Critical Care Outreach Services 2012).
• It continues to work towards the national guidelines of 1:28 midwifery staffing ratio and collect data to evidence one to one care in labour.

In addition there were areas where the trust should take action and these are reported at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals