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 mental health and physical health needs were met and focused on clinical areas that were more likely to be providing medical and nursing care to patients with these needs. We went to the Accident and Emergency department, the Emergency Admission's Units, ward 24 and 33 and the neurosciences outpatients department. We also looked at how the Trust dealt with complaints.

We spoke with 18 patients and nine relatives from across these departments. Some of the patients were not able to discuss their experiences so we observed how these people’s needs were met. Patients and relatives told us that they found the staff always treated them with respect and thought the care they received was of a very high standard. All said both doctors and nurses ensured they understood their plan of care.

We observed that staff across the departments ensured people’s dignity was maintained. We found that staff and the Trust understood the process for obtaining patients’ consent; what to do when people lacked capacity; or were placing themselves at risk. We also found that complaint procedures were used effectively.

People said, “I went to the outpatients department where everything was explained to me in great detail”, “The staff were brilliant when looking after me. When I needed help with washing they made sure that they kept me covered with sheets and towels” and “They encouraged me to do what I could and helped me when needed. “

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 visited four different clinical areas at the James Cook University hospital. These were the accident and emergency department (A&E), the male and female assessment units (AAU and ward 1) and ward 2. We also followed the patient pathway through the radiography department which was linked to the A&E department. We spoke with a number of people who had received treatment and care within all four clinical areas.

People spoken with said that their privacy and dignity was respected and that staff had spent time discussing their care, treatment and support. One person said “The doctor explained everything, she was very nice and patient.” People said that they were not afraid to ask questions. One person had been in accident and emergency then spent time in an assessment unit before being transferred to the ward. They said that the nurse stayed with them after the doctor’s round to make sure they understood what had been said about their admission.

People spoken with were very satisfied with the care and attention they had received in the hospital. When asked how well they had been cared for people said; “Very well indeed. It’s as good as it could be, the staff are lovely, everything you want you have” and “Very well, I can’t complain, it’s good here.”

People on the assessment units and ward 2 told us that they had been involved in planning for their discharge and that, where appropriate, information had been given to their relatives.

People on the female assessment ward and ward 2 said that there seemed to be enough staff on duty to meet their needs. They said “I’ve noticed that if you press the bell you don’t hear any alarm ringing, but it must be ringing somewhere because they come straight away.”

When we asked if the care was the same over the 24 hour period one person said “There seem to be less staff at night, but it is quieter so they come just the same, I’ve not had a problem”. Another person said “yes I think so. There’s not any particular shift where you think, oh maybe I won’t get looked after. They are all good.”

One of the patients we spoke with said, “The care has improved since I was last here.”

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. Nurse staffing in neonates did not fully comply with British Association of Perinatal Medicine (BAPM) standards. However, there was a period of sustained improvement in recruitment and increased staffing compliance rates since April 2016. 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.
• 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.
• 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. However, we found some inconsistencies in the storage of medicines. 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 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 North East 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 the emergency nurse call system in wards 10 and 12 is reviewed to ensure it is fit for purpose.
• Continue to review the level and frequency of support provided by pharmacists and pharmacy technicians to ensure consistency across wards.
• Ensure medication processes are followed consistently particularly ‘do not disturb’ procedures for staff completing medicine rounds.
• Ensure that that the frequency of controlled drug balance checks is carried out in line with national guidance.
• Ensure that the end of life strategy is approved and implemented and move to develop a seven-day palliative care service.
• Continue to develop plans to ensure that staffing levels particularly in the neonatal unit meet the British Association of Perinatal Medicine guidelines.

Professor Sir Mike Richards

​Chief Inspector of Hospitals