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 carried out this responsive inspection because we had received some information that alleged that people using the service in Ward 23 were at risk because:

- the ward was closed due to an outbreak of diarrhoea

- they were not receiving sufficient fluids and food and fluid charts were not being completed

- dying patients were not being placed on end of life pathways

- patients were missing vital medication

A high proportion of people using the service were unable to express their views to us due to their general medical conditions. In order to determine how care and treatment was provided we spoke with staff, observed their practices and looked at some people's care records.

Patients told us they were 'more than happy' with their care in the hospital. They said they can 'voice their views' about their treatment and care and that staff included them in whatever decisions were being made. Nurses were described as ‘lovely, really nice.’ One patient told us that staff ‘go the extra mile to make sure we are looked after properly.’ One patient told us, "Nurses are lovely, especially in intensive care. They don’t get enough credit." One patient told us about the discussion she had had with the doctors and they had taken her views into account and changed the treatment being given. The patient said she had felt ‘listened to and treated with respect.’ Another patient told us about the way nurses had been supportive when the patient had been 'frightened' about the future and the treatment they were having. The patient also said [the staff had] 'been very clear about their condition and treatment and the prognosis.' They said staff have been 'clear and understanding.'

Some people were not able to share their views with us about their experiences of care on the ward. However, during our observations we judged that peoples’ needs were being well met. Those who did comment said, "Don't worry, we are well looked after in here." Another patient said, "They are very very good" when referring to the staff on the ward.

We visited York Hospital on three separate days. Five inspectors were involved on each visit during the day and two inspectors returned to the hospital during one evening visit to speak to relatives and visitors.

We spoke to over thirty patients across eight wards. Patients told us that the care was good and staff were helpful. Everyone we spoke to about consent to treatment told us they had been consulted, given full explanations about what to expect and that doctors and nurses ‘went out of their way’ to make sure patients understood what was going to happen. One patient told us, “I have always been provided with a good explanation about the treatment” and said that if they did not understand anything they raised it and ‘always received an answer.’ Patients also commented positively about the care they received from staff. They told us that where the staff member was of a different gender to them they always made sure that the patient was comfortable with this and they were given opportunities to refuse.

One patient commented that their emergency treatment, prior to moving to a ward, had been carried out ”very calmly” and that they had been well looked after. They along with other patients also said that they had been treated with respect.

Two patients did make comments about having to wait too long for staff to answer their buzzers when they needed assistance to use the toilet. One said “sometimes I have to wait a long time when I buzz. I try my best to do what I can but yesterday I wet myself twice because it took them ages to come”.

Patients told us that they had no complaints to make but that the staff had told them about the complaints procedure and that they could talk to the ward sister first if they were unhappy about anything relating to their stay in hospital.

Relatives also reported positively about the quality of care provided by the hospital. One relative told us they thought the care was ‘excellent and first class.’ And another commented that “I feel my relative has been in safe hands”.

Patients who commented on the food generally made positive comments about the choice and variety of food available, however a few patients did not think the food was very good.

The York Hospital was one of three main hospitals forming York Teaching Hospital NHS Foundation Trust. The trust provided acute hospital services to the local population. The trust also provided a range of other acute services from Scarborough and Bridlington hospitals to people in the wider York area, the north-eastern part of North Yorkshire and parts of the East Riding of Yorkshire. In total, the trust had approximately 1170 beds, over 8700 staff and a turnover of approximately £442,612m in 2013/14. The York Hospital had over 700 beds.

The York Hospital provided urgent and emergency services, medical care, surgery, maternity and gynaecology services, paediatrics services, outpatients and diagnostics and end of life care for people primarily to the York and surrounding area, but also served the people in the Scarborough, Whitby and Ryedale areas of North Yorkshire for some services.

We inspected the York Hospital as part of the comprehensive inspection of York Teaching Hospital NHS Foundation Trust, which includes this hospital, Scarborough and Bridlington hospitals and community services. We inspected York hospital on 17 – 20, 30 – 31 March 2015.

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

We rated urgent and emergency service and critical care as ‘requires improvement’, with medical care, surgery, maternity and gynaecological service, children & young people, outpatient and diagnostic services and, end of life care as ‘good’.

Our key findings were as follows:

• Care and treatment was delivered with compassion and patients reported that they felt they were treated with dignity and respect.
• Patients were able to access suitable nutrition and hydration, including special diets. Patients were satisfied with their meals and said that they had a good choice of food and sufficient drinks throughout the day.
• We found the hospital was visibly clean, hand-washing facilities and hand cleaning gels were available throughout the department and we saw good examples of hand hygiene by all staff. The last episode of MRSA septicaemia was more than 500 days prior to the inspection.
• There were concerns that patients arriving in the A & E department did not receive a timely clinical assessment of their condition.
• At the time of the inspection, in the majority of services the Trust was below its own target of 75% for mandatory training including safeguarding training. The Trust’s target was to achieve 75% minimum compliance for the year ending August 2015. We have since been informed by the Trust that the figures provided to the CQC only included the training provided for the period of six months prior to the inspection as this was the time the Trust implemented a new system to capture and record training carried out. We were told the compliance levels did not include any training staff may have had prior to the 1 September 2014 and we were not provided with evidence to reflect this in the overall training levels.
• There were processes for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. However, we found that some maternity services policies and guidelines were out of date.
• The trust had no mortality outliers and mortality rates were as expected when compared with other trusts. The Summary Hospital-level Mortality Indicator (SHMI) of 98 was lower than both the Trust overall (102) the England average (100) in June 2014. 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 on the basis of average England figures, given the characteristics of the patients treated there.
• Some areas had staff shortages: nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical areas; and radiologists. The trust was actively recruiting to the majority of these roles.
• Patients were not always protected from the risks of delayed treatment and care as the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets were not being achieved.
• The trust was half way through its five year plan to integrate services following the acquisition of Scarborough & North East Yorkshire NHS Trust in 2013.Services within all three of the acute hospitals were at differing stages of integration.
• Seven of the eight core services we inspected had good local leadership within the service.

We saw several areas of outstanding practice including:

• The appointment of a senior paediatric specialty trainee ‘quality improvement fellow’ for one year has led to improvements such as the use of technology in handover sessions, with further plans for development of electronic recording of clinical observations and the PAWS assessment.
• We saw positive partnership working with and support from CAMHS in York, which ensured that the acute inpatient wards had seven-day support. The community nursing team also had a CAMHS nurse specialist allocated to the team who provided psychological support for families and staff.
• The innovative way in which central lines were monitored, which included a central line clinical pathway. The critical care unit were finalists for an Institute for Healthcare Improvement (IHI) safety award.
• The medical service had an innovative facilitating rapid elderly discharge again (FREDA) team, which provided multidisciplinary support and rehabilitation to elderly outlying patients.
• Ward 25, an integrated orthopaedic and geriatric ward, worked closely with the A&E department, and actively identified elderly patients with a fractured neck of femur, to speed up flow to the ward and on to theatre, had demonstrated positive outcomes of speedier rehabilitation and reduced length of stay, with the majority of patients returning to their usual place of residence.
• Phlebotomy outreach clinics in the local community, which have led to improved access to the service.
• Availability of pathology services in the oncology outpatient department, meaning that up-to-date blood results are available for patients when they see the consultant in clinic. Treatment changes are based on up-to-date information.

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

Importantly, the trust must:

• Ensure all patients have an initial assessment of their condition carried out by appropriately qualified clinical staff within 15 minutes of the arrival of the patient at the Accident and Emergency Department in such a manner as to comply with the Guidance issued by the College of Emergency Medicine and others in their “Triage Position Statement” dated April 2011.
• Ensure that there are at all times sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels; nursing staff on medical and surgical wards; consultant cover within A & E; registered children’s nurses on ward 17 and other appropriate clinical area; and radiologists.
• Ensure there are suitable arrangements in place for staff within the medicine and surgery, outpatient and diagnostic services to receive appropriate training and appraisals in line with Trust policy, including the completion of mandatory training, particularly the relevant level of children and adult safeguarding training and basic life support so that they are working to the up to date requirements and good practice.

• The provider must address the breaches to the national targets for A & E, referral-to-treatment time targets, and achievement of cancer waiting time targets to protect patients from the risks of delayed treatment and care.

• The provider must ensure that patients’ privacy and dignity is maintained when being cared for in the bays in the nursing enhanced unit based on ward 16.
• The provider must ensure effective plans are in place and implemented to eliminate the non-clinical delayed discharges and delayed admissions on the critical care unit.

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