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University Hospital of Hartlepool

Provider North Tees and Hartlepool NHS Foundation Trust Type NHS Healthcare Organisation Region North East Last inspected 16 Sep 2022

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 13 must-do 19 should-do

Must-do actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 13
Must do
Well-led
The trust must ensure effective operational oversight of risk, issues and performance.
Regulation: Regulations 17(1) and 17(2)
⚠ Senior and executive leaders did not always operate effective governance systems to manage risks and issues within the service. Governance arrangements were complex and the board did not always have sufficient oversight and focus on operational risks. The trust had a devolved leadership model and we were not assured the …
Must-do action 2 of 13
Must do
Well-led
The trust must strengthen the oversight of divisional and ‘ward to board’ governance.
Regulation: Regulations 17(1) and 17(2)
⚠ The link between governance at care group level and board was not always effective. We were not assured that there was a ‘ward to board’ thread running through the organisation’s governance systems. We were not assured that the current system enabled the flow of information from ‘ward to board’, nor …
Must-do action 3 of 13
Must do
Responsive
The trust must ensure that it operates effective systems and processes for identifying, receiving, investigating and responding to complaints.
Regulation: Regulation 16(2)
⚠ Complaints were not being handled in line with the trust’s complaints policy. We were not assured that the complaints process was robust, worked well to support patients, or led to change through learning.
Must-do action 4 of 13
Must do
Safe
The trust must ensure that its respiratory unit meets current NHS guidance in relation to washing and toilet facilities.
Regulation: Regulation 15(1)(c)
⚠ We found on inspection that the unit did not meet NHS guidance for the provision of single sex washing and toilet facilities. We were told this was because patients were not mobile so there was no need to have single sex facilities however when we visited the ward again, we …
Must-do action 5 of 13
Must do
Well-led
The trust must ensure that it complies with Duty of Candour regulations.
Regulation: Regulation 20(1)
⚠ The trust did not always discharge its responsibilities fully under Duty of Candour regulations and did not audit compliance. Only one of the six serious incident files showed evidence that Duty of Candour had been discussed with the patient or their family and there were no copies of Duty of …
Must-do action 6 of 13
Must do
Safe
The service must ensure that all care of women and their babies is undertaken in line with national guidance and best practice.
Regulation: Regulation 12(1)
⚠ Not all areas of practice followed best national guidance. Practice we observed did not follow the requirements for an hourly approach to fresheyes and this wasn’t reflected in policies, we did not see any evidence the service was updating its practice in line with requirements for frequency of monitoring. The …
Must-do action 7 of 13
Must do
Well-led
The service must ensure effective governance structures are in place to continually improve the quality and standards of care
Regulation: Regulation 17(1) and 17(2)
⚠ We found there were unclear processes of how ward to board assurances were gained about the quality and safety of services. Staff could not always articulate the governance framework for the directorate and how information flows between directorate and the board.
Must-do action 8 of 13
Must do
Safe
The service must ensure systems are put into place to ensure staffing is actively assessed, reviewed and measures put in place to improve retention.
Regulation: Regulation 18(1)
⚠ The service had a rising vacancy rate and did not monitor key safe staffing metrics. We were not assured the service was utilizing the outcome from the acuity tool effectively, no red flag reports were available and staff in some areas reported being unsure if the data they were entering …
Must-do action 9 of 13
Must do
Well-led
The service must ensure appropriate midwifery leadership is in place.
Regulation: Regulation 17(1) and 17(2)
⚠ The service lacked senior midwifery leadership and clear structures. The service lacked a midwifery leadership structure above the ward managers.
Must-do action 10 of 13
Must do
Safe
The service must ensure women who need additional care have access to appropriately trained specialist midwives.
Regulation: Regulation 12(1)
⚠ Women who needed specialist care did not have access to dedicated specialist midwives. The acute service did not have some specialist midwives in post to help care for women in need of additional support or specialist intervention. There were no acute leads in areas such as teenage pregnancy, substance misuse, …
Must-do action 11 of 13
Must do
Safe
The service must ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services in respect of restrictive practices.
Regulation: Regulation 17(2)(a)
⚠ Policies and procedures were not in place to monitor and manage restraint of children and young people in the service. We were concerned that there was no policy or guideline for staff to follow to provide physical restraint in a safe way when required, and this meant there was a …
Must-do action 12 of 13
Must do
Safe
The service must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people’s care and treatment needs.
Regulation: Regulation 18(1)
⚠ The service did not have enough medical staff with the right qualifications, skills, training and experience to match the planned numbers. There were 4.73 WTE vacancies in consultant roles out of 18.15 budgeted WTE posts, which is approximately 26%. There were not enough senior decision makers to fill the medical …
Must-do action 13 of 13
Must do
Well-led
The service must ensure that the Duty of Candour regulation is met in full for all notifiable safety incidents.
Regulation: Regulation 20(2)
⚠ Duty of candour was not always completed in line with regulation. Duty of candour was noted as "not applicable" in the incident report we reviewed, which was not in line with regulations. An appropriate apology had not been documented in the letter sent to meet the duty of candour regulation.

Should-do actions (19)

Recommended improvements to enhance service quality.

Should-do action 1 of 19
Should do
Well-led
The trust should continue to further develop its staff networks.
Should-do action 2 of 19
Should do
Well-led
The trust should consider revising its strategies to ensure that they are up to date, consistent, and complimentary.
Should-do action 3 of 19
Should do
Well-led
The trust should consider addressing its Freedom to Speak Up literature to make it clearer that the guardian can be directly contacted as a first point of contact by staff in line with national guidance.
Should-do action 4 of 19
Should do
Well-led
The trust should ensure that its board papers are up to date and publicly available on its website at all times.
Should-do action 5 of 19
Should do
Well-led
The trust should ensure that policies and procedures are correctly managed and reviewed in a timely way so that the latest and most appropriate guidance is always available to its staff.
Should-do action 6 of 19
Should do
Well-led
The trust should consider auditing its application of Duty of Candour legislation regularly to ensure compliance.
Should-do action 7 of 19
Should do
Safe
The service should work with other trust services to implement baby abduction training.
Should-do action 8 of 19
Should do
Safe
The service should ensure that incidents are reviewed and thoroughly investigated by competent staff, and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result.
Should-do action 9 of 19
Should do
Well-led
The service should create and monitor action plans with clear actions, timescales and action owners.
Should-do action 10 of 19
Should do
Safe
The service should ensure appropriate fire safety procedures and inspections are completed and records stored in line with trust policy.
Should-do action 11 of 19
Should do
Safe
The service should ensure that equipment checks are completed in line with the trust's policy.
Should-do action 12 of 19
Should do
Safe
The service should ensure that out of date medicines are disposed of in line with the trust's policy.
Should-do action 13 of 19
Should do
Safe
The service should ensure that their policy and practice for the storage of expressed breast milk is in line with national guidelines.
Should-do action 14 of 19
Should do
Responsive
The service should ensure that there are appropriate facilities and reasonable adjustments made for children and young people and their families who are being treated on adult wards to make them comfortable.
Should-do action 15 of 19
Should do
Well-led
The service should ensure that they clearly document mitigating actions taken for each risk on the risk register and evidence they monitor and manage risks appropriately.
Should-do action 16 of 19
Should do
Safe
The service should recommence simulation of child abduction to ensure their emergency preparedness.
Should-do action 17 of 19
Should do
Effective
The service should continue to improve compliance with appraisal rates in line with the trust target.
Should-do action 18 of 19
Should do
Safe
The service should improve compliance with infection prevention and control training modules to meet the target.
Should-do action 19 of 19
Should do
Responsive
The service should put plans in place to increase response rates to the NHS Friends and Family Test in the Children’s Day Unit.

Location details

CQC ID: RVWAA
Local authority: Hartlepool
Region: North East

Inspection report

Type: Location
Date: 16 September 2022
Rating: Requires Improvement
Actions: 13 must-do 19 should-do
AI-extracted 3 Jun 2026