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Airedale General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 September 2017

We carried out a focused follow-up inspection between 28 and 30 March 2017 to confirm whether Airedale NHS Foundation Trust had made improvements to its services since our last comprehensive inspection in March 2016. We also undertook an unannounced inspection on 12 April 2017.

Focussed inspections do not look across a whole service; they focus on the areas defined by information that triggers the need for an inspection. Therefore, we did not inspect all the five key questions of safe, effective, caring, responsive and well led for each core service. We inspected core services which were rated requires improvement or where we had identified areas of concerns. We included the urgent and emergency services due to some concerns about safety in the department. We had received reports of a number of serious incidents related to missed diagnosis, therefore inspected the service to seek assurance that safety concerns were being appropriately addressed.

When we last undertook a comprehensive inspection of the trust in March 2016, we rated the trust as requires improvement. We rated safe and well-led as requires improvement. We rated effective, responsive and caring as good.

There were three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to staffing, good governance and safe care and treatment. The trust sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation.

The service was also inspected in September 2016 where there was a focus on critical care and medical care. The service was not re-rated during this unannounced inspection. During this inspection, we found the service had made some improvements.

At this inspection in March 2017, we checked whether the actions following the comprehensive inspection in March 2016 had been completed. We inspected the services at the Airedale General Hospital. We did not inspect community services provided by the trust as these were rated as good at the previous inspection.

We rated Airedale NHS Foundation Trust as requires improvement overall.

At this inspection we found:

  • The trust had made progress taken action to address the issues identified at previous inspections, particularly in critical care. However, there remained areas that required further improvement and the trust was often reactive, rather than proactive in identifying areas for development.

  • In particular, we found the governance arrangements required further strengthening. There had been changes made to the governance structure since our last inspection, but the reporting structure appeared complex and we found this was not clearly understood within the organisation. We were not assured from some of the recently reported incidents, including safeguarding incidents, that the systems and processes were fully effective.
  • There was no evidence of recent review of the critical care risk register in accordance with trust processes. Risk assessments had not been reviewed since 2013. The ward improvement plan had not been updated since September 2016 and did not include recommendations from peer and external reviews.
  • Some systems and processes required development to be fully effective. For example, the procedure for opening and closing extra capacity beds was not always followed and the systems for identifying and reporting mixed sex accommodation breaches on critical care were not effective.
  • There had been investment and improvements made to nurse staffing and the trust were actively recruiting. However, the actual number of staff on duty were often lower than the planned numbers especially on some wards in surgery and medicine. There was also a shortage of specially trained children’s nurses within ED.
  • Medicines management had improved since our previous inspection; however we identified examples of outstanding actions that had not been completed or interventions that had not been followed up following medicines reconciliation.
  • There was inconsistency in the application of systems, processes and standard operating procedures, including the WHO five steps to safer surgery, to keep people safe, particularly within theatres.
  • The environment in the Dales Unit, Haematology Oncology Day Unit and the cardiac catheter lab required addressing to ensure they met patient need and national guidance.
  • Further development of the work around Workforce Race and Equality Standards (WRES) was needed. The trust recognised this.

However:

  • Staff reported an improvement in the organisational culture since our previous inspection. There was evidence of a positive incident reporting culture.
  • Improvements had been made to the safety and communication issues identified during our previous inspection for patients being monitored by telemetry (remote cardiac monitoring).
  • We observed adherence to infection prevention and control guidance in most areas. Some areas for improvement were identified in surgery and maternity areas. Between April 2016 and February 2017, there had been reported 13 cases of C. difficile of which two were deemed avoidable. The trust reported three cases of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia in 2016/17, with no reported cases since June 2016.
  • Systems were in place and we saw evidence of implementation of the duty of candour requirements.
  • There continued to be a strong commitment to public engagement and we found creative initiatives to develop this further.
  • The hospital standardised mortality ratio (HSMR) and the summary hospital-level mortality indicator (SHMI) for the trust were within the expected range when compared to the England average.

We saw several areas of outstanding practice including:

  • The Frailty Elderly Pathway Team demonstrated a proactive approach to deal with vulnerable patients to ensure they got the right care as early as possible following hospital arrival. The team had built relationships across the internal multidisciplinary team, with social care colleagues and external care providers. The team have audited their performance and reported successes in admission avoidance, reduced length of stay, less intra-hospital moves, reduction in readmission rates, cost savings and improved patient experience. The team had been nominated for a national award.
  • Patients on the early pregnancy assessment unit (EPAU) and gynaecology acute treatment unit (GATU) were asked to provide a password, which was used to maintain confidentiality and safety when calling the unit for test results.

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

Importantly, the trust must:

Trust-wide

  • Ensure governance systems and processes are fully effective to ensure comprehensive learning from incidents.
  • Review medicines reconciliation systems and processes to ensure actions from medicines reconciliation are acted upon in a timely manner.

Urgent and emergency care services

  • Ensure that the relevant clinical pathways for children, including for sepsis, are in place.

Medical care services

  • Ensure the current capacity and demand issues faced by the Haematology Oncology Day Unit are reviewed and ensure the clinical environment where treatment is provided is fit for purpose in delivering patient care and treatment.
  • Ensure safe nurse staffing levels and safe nurse staffing skill mix is maintained across all clinical areas at all times.
  • Ensure the ‘bleep rota’ used to support nurse staffing escalation processes is revisited and ensure all escalation processes are effective in managing nurse staffing issues.
  • Ensure all staff follow the standard operating procedure covering the opening and closing of extra capacity beds/wards.
  • Ensure all patients received onto the cardiac catheter lab are handed over to a member of staff immediately on arrival and are provided with a mechanism to contact staff in the event of a care need or emergency.

Surgery services

  • Ensure that, during each shift, there are a sufficient number of suitably qualified, competent, skilled and experienced staff deployed to meet the needs of the patients.
  • Ensure that staff complete their mandatory training including safeguarding training.
  • Ensure the five steps for safer surgery including the World Health Organisation (WHO) safety checklist is consistently applied and practice audited.
  • Ensure that the environment of the Dales suite is in line with national guidelines and recommendations.
  • Ensure that patient records are stored securely.
  • Ensure there is a robust, proactive approach to risk assessment and risk management which includes regular review.

Critical care

  • Continue to implement the follow up clinic and rehabilitation after critical illness in line with Guidelines for the Provision of Intensive Care Services 2015 and NICE CG83 Rehabilitation after critical illness.
  • Review the process of identifying, recording and reporting mixed sex accommodation occurrences and breaches on ward 16.
  • Introduce a robust, proactive approach to risk assessment and risk management which includes regular review.

In addition the trust should:

Urgent and emergency services

  • Ensure that nursing staff receive APLS training to ensure that the department is meeting the intercollegiate standards.
  • Continue to recruit nurses of all disciplines, but particularly registered children’s nurses to ensure that the department meets the Royal College of Nursing guidelines relating to 24 hour cover by a registered children’s nurse in the department.
  • Continue to ensure that all non-children’s nurses attend the APES course to ensure that they have the skills to treat children in emergency situations appropriately.
  • Ensure that the department has the appropriate nursing skill mix and ensure that all applicable nurses have undergone triage training.
  • Ensure that there is assurance in place that the drugs room temperature does not exceed 25 degrees.

Medical care services

  • Ensure learning from submitted incidents is relayed to the incident reporter, relevant staff in the local clinical area and consider initiatives to share lessons learnt to the division and wider trust personnel.
  • Ensure patient risks are reassessed and documented in line with local policy and best practice guidelines.
  • Consider reviewing the number of incident reporting categories used to promote better data capture and incident analysis into themes and trends.
  • Ensure all patients self-medicating on divisional wards are fully assessed as safe to do so in line with local policy.
  • Consider a review of the divisional risk register, in particular to revisit the relevance of some historic risks listed and to ensure all current risks are rated according to actual impact on the division and the organisation.
  • Consider evaluating some of the staff engagement initiatives to ensure the aims and objectives are effective and are meeting the divisional and trust agenda.
  • Ensure clinical waste in the cardiac catheter lab is appropriately stored in a safe area whilst awaiting collection and onward disposal.

Surgery

  • Monitor and improve the attendance at governance meetings.
  • Ensure all patients self-medicating on the surgical day unit are fully assessed as safe to do so in line with local policy.

Critical care

  • Introduce a process to review and share learning from critical care morbidity and mortality.
  • Introduce a strategy to obtain and act on patient and public feedback.
  • Ensure that staff understand the deprivation of liberty safeguards (DoLs) in order to plan and deliver effective treatment and care.
  • Review the capacity and demand on the service and develop a business plan in line with the trust’s strategy.
  • Continue to deliver care in line with and address the areas where they do not meet the Guidelines for the Provision of Intensive Care Services (2015), for example, nursing staff with a postgraduate qualification and medical staffing.
  • Continue to develop the use of competency frameworks and clinical education.

Maternity and gynaecology

  • Ensure robust processes are in place to inform staff defective equipment has been reported.
  • Ensure community midwives document the named midwife on the antenatal record.
  • Work to improve the accuracy of mandatory training data.
  • Work to improve the attendance by medical staff at mandatory training.
  • Review the leadership structure on early pregnancy unit (EPAU) and gynaecology acute treatment unit (GATU), to ensure there is appropriate accountability and support.

Children and young people’s services

  • Ensure all equipment is inspected within the required time-frame  and ensure there is robust service management oversight of the equipment maintenance assurance log.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 September 2017

Effective

Good

Updated 10 August 2016

Caring

Good

Updated 10 August 2016

Responsive

Good

Updated 10 August 2016

Well-led

Requires improvement

Updated 20 September 2017

Checks on specific services

Maternity and gynaecology

Updated 20 September 2017

  • Processes had been put in place to ensure staff had checked emergency equipment. Staff also knew how to check equipment and what to do if there were any concerns.
  • Staff were aware of how to report incidents and were confident they would be investigated and findings shared throughout the service. We found a no blame culture and there were good working relationships between the medical, nursing and midwifery staff.
  • There were effective infection prevention and control practices in maternity; when we highlighted some areas of concern these were immediately rectified.
  • There were effective processes in place to ensure that risks were managed appropriately this included safeguarding and risk assessments. We found documentation was of a good standard, with monthly audits, which helped to maintain standards.
  • The service had enough staff to care for the number of patients and their level of need. Staff knew and put into practice the service’s values and they knew and had contact with managers at all levels, including the most senior.
  • The senior management team were visible within the service and had an open door policy. There were plans in place to move the service forward to support the changing needs of their commissioners and the local community. During our inspection we observed good cross directorate working between the senior management team and the surgical directorate.

However:

  • There was a discrepancy between the training data provided by the trust and the directorate data. Attendance by medical staff was significantly below the targets set by the trust.
  • The early pregnancy unit (EPAU) and gynaecology acute treatment unit (GATU) was a very specialist unit; however, we were concerned with the management of this unit as it was accountable to both the maternity and gynaecology service the surgical directorate. 

Medical care (including older people’s care)

Updated 20 September 2017

  • Learning from incidents was not fully embedded and there were missed opportunities to share lessons to improve patient safety.
  • Whilst there has been a reduction in patient harms, there continued to be a number of reported incidents classified as patient accidents, in particular, relating to falls and pressure ulcers.
  • The clinical environment in the HODU was not fit to meet current capacity and demand issues resulting in care being delivered in overcrowded facilities.
  • The clean and dirty utility facilities in the cardiac catheter lab were insufficient for the number of procedures performed. This led to waste being stored in any inappropriate area.
  • The standard operating procedure for the opening and closing of extra capacity beds/wards was not always followed.
  • Some medications requiring refrigeration were stored in a fridge, on a ward which was not constantly staffed and sometimes closed, without the required daily safety checks completed to ensure medication integrity.
  • Patients waiting in the cardiac catheter lab had no means to alert staff in the event of a care need or emergency.
  • There were periods of understaffing and inappropriate skill mix on some wards. The ‘bleep holder’ initiative to support escalation procedures in nurse staffing was not fully effective.
  • The governance framework had undergone recent review; however the new processes were not fully embedded across the division.
  • The divisional risk register provided risks back to 2012. The top three rated risks within the risk register did not mirror those reported by the leadership team. There were no group risks rated as 16 or above (high to very high category).
  • Staff morale and satisfaction was mixed.

However,

  • Staff were confident in reporting incidents and understood incident reporting procedures.
  • There had been a proactive effort to target key themes relating to patient harms, which had brought about some improvements in harm-free care. Safety thermometer data was displayed consistently on wards in a user friendly format.
  • All equipment checks met local policy standards, national guidelines and/or manufacturer recommendations.
  • Staff considered there had been a positive shift in the organisational culture in the past 12 months. Staff considered the leadership team and line managers to be more visible, approachable and receptive to concerns.

Urgent and emergency services (A&E)

Updated 20 September 2017

  • Although the department had experienced some serious incidents, these had been thoroughly investigated and action taken to implement changes and reduce the risk of further similar incidents. Audits were carried out to provide assurance that changes were being implemented.
  • Patients received care in a clean and well-appointed department with sufficient equipment to support their health needs.
  • There were effective processes in place to protect children and vulnerable adults from abuse.
  • The department was led by an effective leadership team. The department involved staff and patients in discussions about the future development of the service and had a vision and strategy to ensure that patient needs were met in the future.

However:

  • Although the department was, regularly and actively recruiting nursing staff there was a shortage of nursing staff, particularly registered children’s nurses and nurses who were trained to advanced paediatric life support standard. Not all appropriate staff had undergone additional training provided by the department to enable them to treat children in an emergency.
  • There were some consultant and middle grade medical staff vacancies that were having an impact on rota cover and not sustainable in the long term.
  • The department did not have all of the relevant pathways in place to assess and manage the risks for paediatric patients.

Surgery

Updated 20 September 2017

  • The Dales suite was not compliant with guidance from the Department of Health for specialised ventilation for healthcare premises.
  • In some clinical areas, we observed poor compliance with the trusts infection prevention and control policy and there was an inconsistent approach to the storage of single use equipment and the decontamination of laryngoscopes in theatre.
  • There was inconsistency in the application of systems, processes and standard operating procedures, including the WHO five steps to safer surgery, to keep people safe, particularly within theatres.
  • Records were not always stored securely and there was a risk that patient’s confidential information could be accessed.
  • There were occasions when actual nurse staffing levels were not in line with planned nurse staffing levels.
  • Risks that threatened the delivery of safe and effective care were not always identified promptly and adequate action taken to manage them.

However,

  • Staff were familiar with the process for reporting and investigating incidents using the trust’s electronic reporting system. We saw evidence of lessons learnt and changes in practice following incidents.
  • Patient’s observations were correctly recorded and patients who were at risk of deteriorating were escalated in a timely manner.
  • There were processes in place to ensure that medication was stored securely. Medications that required refrigeration were stored appropriately in fridges.
  • The wards and departments had systems in place for the identification and management of adults and children at risk of abuse (including domestic violence). Staff were clear about their role in reporting and escalating a safeguarding concern.
  • The service had clear governance structure and a clear responsibility and accountability framework had been established. Staff were clear about their roles and understood their level of accountability.
  • All staff spoke positively about the visibility of the senior management team and felt staff engagement and the culture within the organisation had improved.
  • Each ward had an improvement plan which was reviewed regularly by the ward leader, matron and director of nursing. Staff felt these helped drive improvement.

Intensive/critical care

Requires improvement

Updated 20 September 2017

  • Although there had been improvements, some of the issues raised at the 2016 inspection remained a concern. For example, the lack of a long term strategy, limited evidence available to show that the service had improved the arrangements for the management of risk, the unit still had some delayed discharge rates that were worse than similar units and at the time of the inspection there was no follow up or support to critical care patients following discharge from hospital.
  • The leadership team appeared to have a reactive approach to risk assessment and risk management. Some of the unit’s risk assessments had been written between 2009 and 2013. There was no evidence that senior staff had reviewed the risk assessments since these dates.
  • The arrangements for coronary care beds for level one and zero dependency patients within the same location as critical care patients of level two and three dependency was not in line with the national service specification. The trust had approved a business case for relocation of these beds; however, the senior management team were unable to confirm the date for the implementation of this.
  • Staff knew the future of the unit was for coronary care to move to another ward, but they were unable to tell us of a longer term vision or how critical care linked in to the trust’s strategy.
  • The rehabilitation after critical illness service was limited. At the time of the inspection there was no follow up or support to patients following discharge from hospital. This was not in line with Guidelines for the Provision of Intensive Care Standards 2015 (GPICS) or the National Institute of Health and Care Excellence (NICE) CG83 rehabilitation after critical illness.
  • The service did not have access to patient and relative support groups.
  • The service had not undertaken patient or relative surveys or any public engagement in service planning.
  • Staff we spoke with had a limited understanding of the deprivation of liberty safeguards (DoLs).
  • The service was still working towards some of the GPICS standards. For example, the service did not hold critical care specific morbidity and mortality meetings and out of hours medical staffing was not in line with GPICS standards.

However,

  • The service had taken action on many of the issues that related to safe and effective patient care that were raised in the 2016 inspection. For example, nurse staffing levels were now in line with GPICS and the consultant work pattern had changed to provide continuity of care. The unit now had a dedicated clinical educator and the service held records of staff’s ‘self-assessment competency’ of equipment and records of who had received training for specialist equipment.
  • There had been a significant change to the leadership team since our 2016 inspections. All staff were positive about the team and morale on the unit had improved significantly. Staff engagement had also improved.
  • Systems and processes in incident reporting, infection control, medicines management, patient records and the monitoring, assessing and responding to deteriorating patients were reliable and appropriate.
  • Staff were supported to maintain and develop their professional skills. Mandatory training and safeguarding training rates were better than the trust target.
  • Care and treatment was planned and delivered in line with current evidence based guidance and patient outcomes were in line with similar units.
  • We observed patient centred multidisciplinary team working. Staff took account of, and were able to meet people’s individual needs. All of the feedback from patients and relatives was positive about the way staff treated them.

Services for children & young people

Updated 20 September 2017

  • The leadership, governance, and culture promoted the delivery of high quality person-centred care. Staff had the skills they needed to carry out their role effectively and in line with best practice. Managers were visible and there was a real strength, passion, and resilience across medical and nursing teams to deliver high quality care to children, young people, and their families.
  • Since the previous CQC inspection, managers had taken appropriate action to mitigate and manage risk to children and young people by improving medical staffing and by implementing short-term contingency plans on the children’s ward.
  • Staff told us they were proud to work for the trust and promoted a patient-centred culture. Children, young people and parents felt medical and nursing staff communicated with them effectively, and made them feel felt safe.
  • Staff protected children and young people from avoidable harm and abuse, and they followed appropriate processes and procedures to keep them safe. The named nurse for safeguarding children was in the process of establishing a new safeguarding supervision model, to ensure staff shared best practice and lessons learnt from serious incidents and serious case reviews involving children and young people.

End of life care

Good

Updated 10 August 2016

There was seven day face to face specialist palliative care support available to patients and patients were assessed and care planned and delivered in line with evidence based guidance. There was a commitment to good quality end of life care and staff were trained and demonstrated a consistently good knowledge of end of life care issues. Pain was well managed and patients were treated with compassion, dignity and respect. We consistently heard from staff that end of life care was prioritised based on patient need. Bereaved family and friends were cared for in a sensitive and supportive way by bereavement staff.

The Gold Standards Framework was in use throughout the hospital to support the development of good quality end of life care. Two wards had been successful in achieving an independently validated quality accreditation for the Gold Standards Framework.

We saw technology had been used to enhance the delivery of effective care through the use of an electronic palliative care coordination system. Patients were identified as being in the last year of life and the information was shared with professionals. There were innovative ways to ensure care was centred around patients, for example by use of the Gold Line Service, and ‘flags’ on electronic records; when patients with additional needs were admitted at the end of life, specialist staff were alerted and could respond in a timely way.

There was positive multidisciplinary team work and a high standard of collaborative working internally in the hospital and also externally between the hospital and other services.

However, we also found that facilities for families and friends could be improved. These were not available on all wards and the route families walked to the mortuary was cluttered, shabby and unpleasant. There were several concerns about the mortuary. The viewing room used for families to see deceased patients was stark and basic. Mortuary staff did not always refer to deceased patients in a compassionate manner. There were risks to the continuity of the mortuary service; one staff member had been on call for three months with some resilience in place.

There was below the national minimum staffing requirements for hospital specialist palliative care doctors. Around 67% of patients did not have a recorded preference in 2015 for their preferred place of care.

Arrangements for monitoring standards and guidance for staff were poor. Most standards and guidance on the trust intranet were past their review date, some by several years.

Do not attempt cardiopulmonary resuscitation decisions were not always made in line with national guidance and legislation.

There had been a lack of engagement Black and Minority Ethnic (BME) communities. This was a concern to the trust as they acknowledged it was difficult to identify if the trust was meeting the needs of this group of patients at end of life.

Outpatients

Good

Updated 10 August 2016

Incidents were reported and staff knew how to report incidents. All areas visited were clean and tidy. The environment was suitable and the required equipment was available. A managed equipment service was in place for diagnostic imaging.

Medicines were found to be managed securely, however there were issues identified with refrigerator temperatures and the reporting of temperature deviations to pharmacy. Staff were aware of how to report safeguarding concerns.

Protocols were available for use in diagnostic imaging and staff were aware of national guidance from the National Institute of Health and Care Excellence (NICE). Staff understood consent and could describe examples where they document consent.

Staff treated patients with dignity and respect at the services visited. Patients were involved in their care and treatment was discussed with them. Patient feedback from the services visited was mostly positive.

Non-admitted referral to treatment targets in outpatients were being met between December 2014 and November 2015. The referral to treatment for incomplete pathway standards were met from April 2015 until November 2015. Cancer waiting time targets were met between quarter 3 2013/2014 and quarter 2 2015/2016. Staff overall were positive about working in their departments.

Other CQC inspections of services

Community & mental health inspection reports for Airedale General Hospital can be found at Airedale NHS Foundation Trust.