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Inspection Summary


Overall summary & rating

Good

Updated 27 July 2016

We inspected Harrogate District Hospital as part of the comprehensive inspection of Harrogate and District NHS Foundation Trust from 2 to 5 February 2016. We carried out an unannounced inspection of the hospital on 10 February 2016. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

Overall, we rated Harrogate District Hospital as good. The majority of services were rated as good across the hospital, with some areas rated as outstanding. However, further work was needed at the hospital to develop the children’s and young people’s services, the trust were aware of this and new leadership had been introduced. There was no strategic plan in place for end of life care, although in its absence the trust had developed a care of the dying adult and bereavement policy. The service had a leadership structure split between two directorates, which the trust had recognised could be more effective and was being reviewed.

We rated caring as outstanding, effective, responsive and well-led as good; and safe was rated as requires improvement.

We rated critical care and outpatients and diagnostic imaging as outstanding, urgent and emergency services, medical care, surgery, maternity and gynaecology and end of life as good. We rated services for children and young people as requires improvement.

Our key findings were as follows:

  • The trust values and vision were well known across the hospital services. There was strong leadership and staff reported that the leadership team were visible and that local management was supportive. However, the senior leadership within the children and young people’s services had only been in post for a relatively short time. Therefore, the service had yet to fully develop a comprehensive vision, strategy and further work was needed to embed the governance structures.
  • There was good morale amongst staff, they told us they were proud of their hospital and the care they delivered to patients.
  • There were governance, risk management and quality measurements in place to promote positive patient outcomes. Care was delivered in accordance with national and best practice guidance. Policies, procedures and local guidelines were based on evidence based practice and were in line with the National Institute of Clinical Excellence guidance.
  • There were no risks identified for in-hospital mortality, the Dr Foster Hospital Standardised Mortality Ratio Indicators or the Summary Hospital-level Mortality.
  • There was openness and transparency about incident reporting and learning lessons. The hospital had a strong safety culture and staff were confident in the reporting of incidents.
  • A redesign project was underway which aimed to improve patient flow and enhance the patient experience for acute medical admissions. To aid with patient flow, discharge liaison nurses facilitated the timely discharge of complex patients.
  • Patients were treated with dignity and respect. There was consistently high scores in the Friends and Family Test for patients who would recommend the service. Some medical wards regularly achieved 100%. Staff were alerted when a patient with specific needs was admitted or attended clinic and reasonable adjustments were made for patients living with dementia or had a learning disability.
  • Staff had a good understanding of the Mental Capacity Act 2005 and the Deprivation of Liberties Safeguards and there were well established processes in place for the obtaining of consent.
  • The safe use of innovative approaches to care was encouraged; collaborative team working was positively promoted. Patients’ access to pain relief and nutrition was good.
  • We rated critical care services as outstanding. People’s individual needs were central to the planning and delivery of critical care. The service engaged patients and the public to plan and improve the service. There was a proactive approach to understanding the needs of difference groups of people, and appropriate support was provided. For example for patients who had a traumatic experience in critical care. Patients were seen by the nurse and clinical psychologist in the supporting intensive therapy unit (Situp) patients’ service.
  • Outpatient and diagnostic imaging services were outstanding. These services were tailored to meet the needs of individual people and were consistently exceeding performance targets
  • Staff told us there were good training opportunities available to them and nurses were well supported with completing their nurse revalidation. However, in some areas, for example medical care junior doctors told us that work pressures were affecting their training as they did not have enough opportunities to learn and were not having regular supervision. Not all staff, particularly in the children’s and young people’s service had completed the relevant children’s safeguarding training.
  • The hospital had not undertaken a risk assessment for the admission and care of children and young people with a mental health illness. Plans were in place to obtain training from a local trust for the care of young patients with a mental health illness.
  • The urgent and emergency care department was generally meeting the 95% standard for emergency departments to admit, transfer or discharge patients within four hours of arrival. However, the department was no longer large enough to suitably accommodate the number of patients, equipment and consumables needed, as these had increased over the years.
  • Staffing levels and skill mix across services were generally planned in line with best practice and based on patient acuity. However, actual staffing levels did not always meet planned, for example in the urgent and emergency care department, maternity services and surgery. A recognised acuity tool was not used within children’s and young people’s services and staffing levels were not always compliant with safer staffing guidance. The trust was actively recruiting to posts and taking action to improve staffing levels through better use of the skill mix of staff.
  • The standard of cleanliness throughout the hospital was to a good standard and infection control audits showed a good performance. There had been no incidence of Methicillin-resistant Staphylococcus Aureus and 16 cases of Clostridium difficile from May 2015 to August 2015. In some medical wards we found poor adherence to infection prevention and control (IPC) policies and procedures, particularly with the care of patients in isolation and the use of personal protective equipment.
  • Patients received compassionate and understanding care from hospital staff at the end of their lives. All ward staff were expected to care for patients at the end of their life. There was no specialist palliative care team employed within the hospital; this support was provided by the local hospice and was only available face to face five days a week which did not meet national guidance. At weekends and out of hours advice was provided by a consultant on call service via the hospice. The trust recognised the importance of improving their approach to end of life care and had established the `Rethinking Priorities Programme’
  • The facilities in the mortuary required improvement and updating. There was limited access for bereaved families at weekend and the environment was in a poor condition in places. There was a large volume of records stored; the environment was unsuitable for this purpose.

We saw several areas of outstanding practice including:

  • There were innovative services that improved the care of patients on and following intensive care, such as the “Supporting intensive therapy unit patients (situp) service and the clinical psychology service to inpatients and outpatients at the follow up clinic in critical care. In addition there was the use of patient diaries on critical care by the multidisciplinary team. The critical care outreach team’s leadership, advanced clinical skills and commitment to education. There was also a critical care online “virtual” journal club.
  • The main outpatient department was an accredited centre for the treatment of faecal incontinence using percutaneous tibial nerve stimulation. Staff told us they were the first NHS centre to be awarded this accreditation.
  • A review of the glaucoma pathway had led to; the redesign of the layout and content of the clinic rooms, the introduction of a virtual clinic for lower risk glaucoma patients and the ongoing development of nurse practitioners.
  • We spoke with the diabetes specialist nurses who demonstrated how they used information from the Electronic Prescribing and Medicines Administration (EPMA) system to monitor patients’ blood sugar readings and insulin doses. If a patient had a blood sugar reading of less than 4 or more than 15, a specialist nurse would proactively visit them. This enabled the team to target those patients early who required a review and allowed interventions to be made before referrals were received. This also helped to streamline the team’s workflow. We thought this was innovative practice.
  • The redesign of the acute admissions and assessment pathway, known as the ‘FLIP’ project was outstanding. The project was initiated and driven by staff. It involved the redesign and integration of the CATT Ward and the CAT team. Although the project started in October 2015, the benefits of the project were already being seen. Despite a 30% increase in non-elective in-patient activity within general medicine, the percentage bed occupancy had decreased from October 2015 to January 2016 compared to the previous year. Managers attributed the fact that the hospital had not needed to open up the 12 bedded winter pressures escalation ward to the success of the project.

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

Importantly, the trust must:

  • take steps to ensure that the environment on the Woodlands ward is appropriate to allow the needs of children and young people with mental health needs to be fully taken into account.
  • ensure that accurate nursing records are kept in line with professional standards particularly in urgent and emergency services and that medical records are stored securely in services for children and young people and within the mortuary area.
  • ensure that good infection protection and control practices are adhered to particularly on all medical wards
  • ensure that all medicines are stored safely and are disposed of when out of date. This particularly applies to oxygen cylinders and drugs on the emergency trolleys in the hospital. The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels particularly in medicine, end of life care and children and young peoples’ services.
  • ensure all staff have completed mandatory training, role specific training and had an annual appraisal particularly: appraisal rates within maternity and gynaecology; mental health training for paediatric staff and; safeguarding training in both community and acute services for children and young people.
  • ensure guidelines and protocols are up to date and there is an effective system in place to review these in a timely manner particularly in maternity and gynaecology and radiology.
  • improve the facilities in and access to the mortuary.

Additionally there were other areas of action identified where the trust should take action and these are listed at the end of the reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 July 2016

Effective

Good

Updated 27 July 2016

Caring

Outstanding

Updated 27 July 2016

Responsive

Good

Updated 27 July 2016

Well-led

Good

Updated 27 July 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 27 July 2016

Staff were encouraged to report incidents and systems were in place following investigation to disseminate learning to staff. Systems were in place to protect patients from abuse and staff were aware of the procedures to follow.

Records relating to women’s care were of a good standard. Risks to women were identified, monitored and managed to keep them safe. Records were kept secure in line with the data protection procedures.

The unit was meeting the nationally recommended birth to midwife ratio of 1:28. However, there had been some recent vacancies, which the trust was actively recruiting to. In the interim, any increased demand on the service was met by moving staff, between departments and the community. Managers informed us that all new staff would be in post and operational by April 2016.

However, medication training for community midwives was 29%. All staff must receive appropriate training necessary to carry out their duties.

We found worn wooden storage units were being used in delivery suite. The units could not be effectively cleaned and therefore a risk to infection control. There was not always an appropriate sized cuff available for use with the blood pressure machine. Although there were alternative methods available to obtain a blood pressure recording, the trust should ensure variable sizes of blood pressure cuffs are available.

Medical care (including older people’s care)

Good

Updated 27 July 2016

Patients were treated with dignity and respect. We saw some individual examples of staff demonstrating great empathy and kindness. There were consistently high scores in the Friends and Family Test Scores for patients who would recommend the service. Some medical wards regularly achieved 100%. Patients told us they felt well informed and included in decisions about their care. There was good emotional support particularly within the Robert Ogden Centre.

Services were effective. Protocols and policies based on current evidence were available for staff on the ward and on the intranet. We found local guidelines based on the National Institute for Health and Care Excellence (NICE) guidelines. There were good examples of multidisciplinary working.

Nursing and therapy staff told us that there were good training opportunities available to them and nurses were well supported in completing their revalidation. However, junior doctors told us that work pressure was affecting their training as they were did not having have enough opportunities to learn and were not having regular supervision. Staff we spoke to had a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

Access to services was good with cancer waiting times data showing good performance. A redesign project was underway which aimed to improve patient flow and enhance the patient experience within acute medical admissions. Discharge liaison nurses facilitated the timely discharge of complex patients. Reasonable adjustments were made for patients with a learning disability and staff completed ‘all about me’ forms for patients living with dementia.

The senior management team for medicine were clear on their greatest risks and we saw this clearly documented on the directorate risk register. Control measures were in place to reduce the level of risk. Staff often saw senior managers, especially the chief nurse who was on the wards regularly and staff said was approachable. Staff spoke highly of their managers and told us they felt well supported and listened to. The trust vision and values were well known. We found good morale amongst staff and they told us they were proud of their hospital and the care they delivered to patients.

However, we found medical care services to required improvement for safe. Although wards appeared clean, we observed some poor infection control practices on several wards we visited. Doors to isolation rooms were often left open and staff did not always observe good hand hygiene and correct use of personal protective equipment. We found several issues with medicines. Hypo-boxes were not always checked according to the policy and the contents of the box were not always complete. One injection was found to be out of date on the resuscitation trolley on one ward and we found three cylinders of oxygen which were out of date and not stored safely on one ward. We also discovered medicines left unattended on the nurse’s station on Fountains AMU. Nurse staffing was an issue however, the trust had recognised this and had taken measures to minimise the risk to patients.

Urgent and emergency services (A&E)

Good

Updated 27 July 2016

Openness and transparency about safety was encouraged and there was a strong culture of reporting incidents. Staff followed infection prevention and control guidelines and managed medicines effectively.

Care delivered reflected national guidelines. There were policies and procedures in place that were developed in conjunction with national guidance and best practice evidence from professional bodies. Multidisciplinary working was established with a 24-hour seven-day service provided. However; some services were available out of hours as an on call service. The trust was working towards the delivery of sustaining seven-day services.

Patients and relatives were treated with dignity, respect and compassion. We heard staff use language that was appropriate for patients to understand their treatment and to be involved in decisions about their care.

The service had systems and processes in place to facilitate the flow of patients through the department and the department was generally achieving the 95% standard for emergency departments to admit, transfer or discharge patients within four hours of arrival.

There were governance, risk management and quality measurements and processes in place to enhance patient outcomes. There was strong leadership and management, and a strong supportive culture of openness, transparency and honesty. Staff were proud to work in the department.

However, the service had ‘out grown’, the current size of the department as the number of patients, equipment and consumables had increased over the years. Although, staffing levels and skill mix was planned in line with busy periods; the planned nurse staffing numbers were not always met. Documentation was not always completed appropriately.

Surgery

Good

Updated 27 July 2016

Staff protected patients from avoidable harm and abuse, openness and transparency was encouraged. There was a holistic approach to assessing, planning and delivering care and treatment to patients who use the services. All wards used an early warning scoring system for the management of deteriorating patients.

The safe use of innovative approaches to care was encouraged; teams were encouraged to work collaboratively. Staff were able to meet the needs of patients’ through the way services were organised and delivered. Patient’s access to pain relief and nutrition was good and performance outcomes post-surgery were mainly better than the England average.

Patients were respected and valued as individuals, feedback from patients was positive. We observed positive interactions between staff and patients during the inspection. Staff were proud of the level of care they delivered and wanted to improve the lives of the patients they cared for.

Senior managers had a clear statement of vision for the service. The directorate and wards had quality priorities identified. Staff on the wards worked well together with respect for other specialities.

At times staffing levels did fall below established levels, but the trust were actively recruiting to posts and taking action to improve staffing levels through improvements in the skill mix of staff.

However, we did have concerns over the effectiveness of the five steps for safer surgery; the trust had recognised the issue and had actions in place to improve the process. Access for staff to appraisals required improvement as only 52.3% of staff had received an appraisal.

Intensive/critical care

Outstanding

Updated 27 July 2016

People’s individual needs were central to the planning and delivery of critical care services and the management team worked with leads in the trust to plan service delivery. The service engaged patients and the public to plan and improve critical care services.

Access to care was managed to take account of peoples need. The unit’s bed occupancy was mainly lower than the England average and the delayed discharge and out of hours discharge rates were much better than similar units and the national average.

There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met these needs. For example, patients who staff knew had a traumatic experience in critical care were seen by the nurse and clinical psychologist in the supporting intensive therapy unit patients (situp) service. Patient diaries and a follow up clinic formed part of the rehabilitation after critical illness service.

There was clear nursing and medical leadership on the unit and in the critical care outreach team with the integrity, capacity and capability to lead the service effectively. It was clear that staff had confidence in the leadership and there were high levels of staff engagement and satisfaction. We observed a supportive and open culture, where nursing, multi-disciplinary and medical staff were approachable and valued each other’s opinions.

Staff considered patients individual preferences and were motivated and inspired by leaders to deliver person centred, holistic care. Patients received psychological support from specialist staff during and following their critical care stay to help them cope emotionally with their care and treatment. Feedback from patients and relatives was continually positive about all aspects of their care. Staff had been nominated for awards for their patient care.

The service had a good track record in safety and had provided 100% harm free care between September 2014 and September 2015. Systems and processes in infection control, medicines management, patient records and the monitoring, assessing and responding to risk were reliable and appropriate to keep patients safe. Staffing levels and skill mix were planned and reviewed to keep people safe at all times.

Patient outcomes were the same as or better than similar units and care and treatment was planned and delivered in line with evidence based guidance, standards, best practice and legislation.

However, the service did not meet all the recommendations in the Guidelines for the Provision of Intensive Care Services (2015), for example, a lack of a supernumerary nurse, aspects of the medical staffing arrangements and the percentage of post registration qualification for critical care nurses on the unit.

Services for children & young people

Requires improvement

Updated 27 July 2016

The senior leadership group had only been in post for a relatively short period. This meant that there had not yet been time for the service to develop a comprehensive vision and strategy for children’s services within the trust. Governance structures required further embedding, including ward meetings to establish engagement with staff groups and with the public.

Nurse staffing was not planned in accordance with recognised acuity tools or compliant with safe staffing guidance. Staff felt that incidents were under reported due to staffing pressures. Children and young people attending for surgery or via A&E were not always cared for in a suitable environment and were placed on adult surgery lists, which was not in accordance with national guidance. The trust understood this issue and plans were being developed to increase paediatric day surgery provision.

No formal risk assessment had been carried out to consider the needs of children and young people who attended the ward with mental health needs. Staff had identified that there were shortfalls in training for this and had arranged training with a local NHS trust. The trust had not met its target for staff receiving appropriate levels of safeguarding training in accordance with national standards, although staff were achieving targets for mandatory training overall.

Cleanliness and infection control audits showed good performance. Pain was managed effectively and nutritional needs of patients were met. Care was appropriately recorded in the medical records, although the child’s voice did not appear reflected in records. Records were also not always stored securely.

Staff adhered to evidenced based practice and the service was accredited by external schemes, such as the UNICEF baby friendly initiative. Children and young people could access inpatient services at any time. Clinical staffing was appropriate with medical cover on site at all times and consultant support available via a consultant of the week system. Pharmacy advice and support was also available seven days a week.

Appropriate policies and procedures were in place to consider consent and we noted good consent practices in place. The trust faced a challenge in staff receiving up to date appraisals and ensuring all staff received clinical supervision and had appropriate training to care for children and young people. The trust was aware of these challenges and this was due to be addressed by the new leadership team.

Services were planned to identify the needs of the local population. Children and young people attending services were routinely seen in dedicated ward and outpatient areas for the majority of the care they received. The trust had identified the needs of the local population and planned to create a paediatric assessment unit.

Staff told us that they previously felt that there was a lack of senior leadership within the service. However, they were positive about the new service and trust level leadership and felt that this would lead to improvements in services for children and young people.

End of life care

Good

Updated 27 July 2016

The end of life care services were rated good overall. We rated the service as good for safe, effective, caring and well-led. We rated responsiveness as requires improvement.

We found patients received compassionate and understanding care on all the wards at the hospital and from the hospital chaplaincy service.

There was a strong culture of incident reporting. Staff knew how to report incidents and there was feedback and learning from incidents. Staff had a good understanding of the duty of candour and apologised when things went wrong.

The trust participated in the National Care of the Dying Audit of hospitals. The 2015 results showed that staff recognised that the patient would probably die in the coming hours or days in 96% of cases. The care of the patient was discussed with a nominated person important to the patient in 87% of cases and 69% of patients received a holistic assessment and care plan in the last 24 hours of life. The audit results for 2014 indicated that the trust scored better than the England average for eight out of 10 clinical indicators and three out of seven of the organisational indicators.

The trust had produced new guidance for staff that was based on up to date evidence and national guidelines. There were multi-disciplinary team (MDT) meetings in place. A care planning process had been developed and was being used based on current national guidance. Staff could access evidence based guidelines for symptom management. Equipment was available promptly from the equipment library when requested.

There were senior Board level executive and non-executive leads in place and an end of life steering group. The trust recognised the importance of improving their approach to end of life care by establishing the ‘Rethinking Priorities Programme’. This was a development programme which involved consultant medical staff evaluating some of the most challenging aspects of providing a high quality service to patients approaching the end of life.

The trust was working with their local clinical commissioning group (CCG) and community teams to develop a five year strategic plan for end of life care. Progress developing the strategy was slower than planned and was not completed in February 2016, when we inspected. However, in the absence of an agreed local strategy the trust had developed a care of the dying adult and bereavement policy.

However,

The service level agreement with the local hospice to provide specialist palliative care clinical nurse specialists (CNS), the supportive care CNS had expired. Specialist face to face palliative care was only available Monday-Friday which was not meeting the national guidance of a seven day service. There was 24 hour specialist palliative care telephone advice available from an on call palliative medicine consultant in the region, who could be contacted via the local hospice. Care for people at the end of their life was not part of the trust’s mandatory training.

The trust were unable to fully measure the quality of the service provided or measure improvements because they did not collect quality information such as recording the preferred place of care for patients. The trust recognised this and planned to develop quality measures.

Facilities in the mortuary required improvement and updating; the drainage and floor covering in the mortuary was old and appeared dirty with poor facilities for viewing and arrangements for transferring patients from the ward. The mortuary’s facilities for accommodating bariatric patients were limited as they could only accommodate patients up to a certain size. There was limited access to the mortuary at weekends for relatives. Porters were trained to transfer bodies to the mortuary but were not mortuary technicians so were not able to prepare the body for viewing. This relied on the trained mortuary staff being available and they only worked Monday to Friday although there were some on call facilities.

We found a large number of historical autopsy post mortem reports stored in the mortuary, some of which dated back to 1970. This breached the NHS Code of Practice, which states that these records should have been destroyed once they are 30 years old.

Outpatients

Outstanding

Updated 27 July 2016

Patients received safe care and staff were aware of the actions they should take in case of a major incident. Incidents were reported, investigated appropriately and lessons learned were shared with all staff. The cleanliness and hygiene in the departments was within acceptable standards.

Staff were aware of the various policies designed to protect vulnerable adults and children. Patients were protected from receiving unsafe treatment as medical records were available 99% of the time and electronic records of diagnostic results, x-ray images and reports and correspondence were also available. There were sufficient staff to deliver services safely.

However, The WHO surgical safety checklist was not yet fully implemented in imaging areas, the phlebotomy room was not ideal for patients from infection prevention, and control perspective as it contained stores and staff coats. The environment at Ripon hospital outpatients and imaging departments needed some updating and repair.

Care and treatment in outpatients and diagnostic imaging was evidence-based and performance targets consistently met. Staff were competent, received an annual appraisal and there was multidisciplinary working established. Staff undertook regular audits in imaging and pathology departments regarding quality assurance to check practice against national standards.

However, there were a number of pieces of equipment, which were ageing, and in need of replacement, this was particularly in the imaging services.

Staff in all areas treated patients with kindness and respect. Privacy and dignity was maintained at all times. Staff were able to signpost patients to support groups and counselling services when necessary.

Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. Initiatives including virtual clinics, and nurse led services meant patients could easily access specialist advice and support. The trust was consistently exceeding its performance targets and England averages for referral to treatment times (RTT) and for diagnostic waits. The trust consistently exceeded cancer waiting time targets. The Trust was actively managing its waiting lists for both new and follow-up patients and there was a clear plan to reduce the numbers of ophthalmology patients awaiting review appointments. The trust had developed a number of one-stop services for patients and had well-embedded outreach services. The clinical assessment team, fast track systems and the rapid access clinics meant patients could access specialist assessment and diagnostics very quickly.

The services were visionary and innovative and there was a well-embedded culture of service improvement. Staff and members of the public were engaged in service improvements.

Other CQC inspections of services

Community & mental health inspection reports for Harrogate District Hospital can be found at Harrogate and District NHS Foundation Trust.