The focus for the inspection was to look at the patient journey in several clinical areas; this included children’s health, maternity care and women's health. We looked at information at a Trust level as well as at ward level. We spent time observing practice and interactions between staff and patients. We spoke with different disciplines of staff. We looked at the patient’s hospital records for sixteen people and spoke with a number of patients and a number of relatives.

We found that patients were aware of their treatment options and plans and felt that they had been fully consulted and involved. One patient said, "I have been kept well informed and have felt safe with the care provided, all the options have been fully discussed and they have kept me monitored." One child said “The nurses are happy and I like the doctors”. We saw that their care and treatment was planned and delivered in a way that ensured patients safety and welfare.

All of the wards/clinical areas visited were clean and well maintained and there were systems in place to monitor this. One patient said, "It is clean and warm and has been made as pleasant as possible for me." Others said they felt safe and comfortable.

We found good systems in place for monitoring staffing levels and skill mix. One patient spoken with said, “They have been attentive, I was in a lot of pain, I used the buzzer and they responded quickly." Patients spoken with were very satisfied with the care provided.

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 six different clinical areas at the University Hospital of North Tees. These were the accident and emergency department (A&E), the emergency assessment unit (EAU), two surgical wards and two wards providing care to older people. We spoke with a number of people who had received treatment and care within all six clinical areas. We also spoke with a number of staff during the two day inspection. This was staff of different clinical levels and grades within the organisation. We examined care records and observed care being provided to people.

Overall, we found people were treated with dignity and respect. We identified minor concerns, which were addressed immediately by the trust. People that we spoke with told us that they felt their privacy and dignity was respected and that staff had spent time discussing their care, treatment and support. We saw evidence that reflected this in the daily notes, where we could see that people had been given individual time to consider their choices in relation to pain relief and possible treatment options available.

Another person told us they had been admitted the day before via the accident and emergency (A&E) department and they felt they had been treated with dignity and respect. All staff were described as having been very professional. One person described how the doctor in A&E had discussed various treatment options with them before agreeing the appropriate care.

A person, who was on one of the surgical/orthopaedic wards, said, “I signed consent to an epidural then changed my mind. I decided to give painkillers a try. I didn’t understand the procedure, but then the nurse explained it so I have now agreed”. Another person said, “The surgeon came up and spoke to me about the procedure following surgery. He has told me about my other options. The quality of care has been consistent, not sure what time I am being discharged, just waiting for a letter for my GP”.

Another person said, "The care has been very good and I have been fully involved". This person said that no aspect of their care or treatment had been missed or forgotten.

One person said, “Staff here are excellent, they answer buzzers quickly, I am not aware of named nurses but if you shout they come and help you. The quality of care is the same day or night, there’s no prejudice there”.

Another person said, “Staff appear to be well trained, they can tell me what medicines I am on and what it’s for. The overall experience here has been excellent, no complaints at all”.

A further person said, "They always seem to be on the go but always available to give you care and support".

Our rating of services improved. We rated it them as good because;

• We rated safe, effective, caring, and responsive as good. We rated well led as requires improvement. The services we inspected in 2017 were rated good in the well led domain; however we did not inspect two services which had previously been rated as requires improvement. This made the rating for well led at core service level as requires improvement.

In urgent and emergency care;

• A system had been put in place to ensure that patients had an initial assessment on arrival to the department within 15 minutes by nurses who had undergone triage training.
• Infection control procedures were followed in relation to hand hygiene and use of personal protective equipment. Cleanliness standards were maintained
• Resuscitation and emergency equipment was checked on a daily basis in line with trust guidelines.
• Policies and procedures online were reviewed and up to date.
• There were outstanding examples of caring, compassionate care and maintaining privacy and dignity. We saw staff go the extra mile several times and their care and support exceeded good care standards. The caring relationships were highly valued by staff and promoted by the matron. There was a strong, visible person-centred culture.
• Patients and families were involved in the decision making on their care in a way that they understood.
• Services were planned in a way to meet the individual’s needs.
• Patients with a learning disability, those living with dementia, and bariatric patients could access emergency services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined up way from within the department.
• There was a sense of teamwork within the department and operational staff worked together in partnership to provide effective leadership.

In medical care;

• Incidents were investigated and managed appropriately and there was evidence of learning from incidents. Medicines were managed appropriately across medicine. The number of temporary staff used had reduced overall and bank staff were managed appropriately though the internal system.
• Medicine and elderly care participated in a wide range of local and national audits. There was clear multi-disciplinary team working across the services between different teams and wards had regular morning huddles.
• Overall, staff knowledge and understanding of the mental capacity act, deprivation of liberty standards was good. There was good access to a psychiatric liaison team across medicine.
• Staff cared for patients with compassion and treated them with dignity and respect.
• The trust’s referral to treatment time (RTT) for admitted pathways for medicine has been consistently above the England average for the entire reporting period from August 2016 to July 2017.
• Overall, morale across the service was generally good and staff described good teamwork across the wards and services. A risk register was in place and senior staff attended weekly patient safety meetings.

In Maternity;

• Women and their families were protected from avoidable harm and abuse. There were effective systems in place to report, investigate and share the learning from incidents. The content of obstetric mandatory training was continually monitored and adapted according to themes arriving from incidents. Midwifery and medical staff training compliance was better than the national recommendations despite there being a high rate of maternity leave within midwifery.
• Women had good outcomes because they received effective evidence based care and treatment, which met their needs. The service had systems in place to ensure that staff had the right skills, knowledge and experiences to provide effective care and treatment. Women and their families were supported to live healthier lives.
• Women and their families were supported and treated with dignity and respect; we found they were active partners in their care. We observed staff treat women and their families with kindness, respect and compassion.
• Services were tailored to meet the needs of individual women and their families and were delivered in such a way, which ensured flexibility, choice and continuity of care.
• The leadership, governance and culture within the service promoted the delivery of high quality person-centred care.

However:

In urgent and emergency care;

• There were risks in the emergency department to patients with mental health needs. There was no designated mental health assessment suite or facilities that met best practice guidance for a safe metal health assessment room. There were ligature points which meant the area was not fully complaint with The Psychiatric Liaison Accreditation Network (PLAN) standards.
• Mandatory training was not always completed by medical or nursing staff in a timely manner and the department needed to improve compliance with mandatory training. The department also needed to improve compliance with appraisal rates.
• The department didn’t always have sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner. The department should ensure contingency planning to accommodate future maternity leave of RSCNs
• National audit results were poor and the department was not meeting most of the standards. Further work was needed through local audit to ensure that audit compliance improved.
• The trust was worse than the England average for unplanned re-attendance.
• Complaints were not always managed in line with the trust’s policy timescales.
• Senior nursing leadership was not visible in the department during our inspection and didn’t attend the department to support their staff during our inspection.

In medical care;

• The hospital was not meeting the internal target for mandatory training across several areas. At the time of inspection, the trust was not able to accurately monitor mandatory training compliance due to administration difficulties and a delay in electronic data capture.
• Safeguarding training was not routinely available to staff who required it and was not in line with the intercollegiate document for Safeguarding children and young people (2014).
• Appraisals compliance rates were not achieving the trust target of 90% during our inspection. Clinical supervision was not embedded across all wards visited.
• Mental capacity act assessments and deprivation of liberty safeguards documentation was not always fully completed or consistent.
• The trust took an average of 46 days to investigate and close complaints; this was not with the complaints policy, which stated complaints should be completed with 25 days or 40 days for more complex complaints.

In maternity;

• We found some out of date equipment, we raised this with staff and immediate action was taken to remove them from circulation.
• Data provided by the trust showed compliance with trust mandatory training was below the required level. Medical staff met 62% of their required training; however, midwifery staff met 48% of their required training.
• Data provided by the trust showed that midwifery staff had not met the required target of safeguarding children level three and safeguarding adults level one training.