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Provider: Harrogate and District NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 27 July 2016

Harrogate and District NHS Foundation Trust is an integrated trust providing acute hospital and community services to Harrogate district, North East and West Leeds. The trust also provides children’s healthcare services in North Yorkshire. The trust was authorised as a Foundation Trust in January 2005 and serves a population of approximately 900,000 people.

We inspected Harrogate and District NHS Foundation Trust (the trust) as part of our comprehensive inspection programme. We inspected all eight core services at Harrogate District Hospital, the in-patient services at Ripon Community Hospital, the minor injuries units at Selby and Ripon as well as community dental services, community healthcare services for adults, and children’s community services across various areas served by the trust. In addition, we carried out an unannounced inspection on 10 February 2016. Harrogate District Hospital had been previously inspected in January 2014, but not rated at that time.

We have rated Harrogate and District Foundation Trust as overall good. On the whole service provision was good across the trust, with some areas rated as outstanding. However, there were some services that required more attention, particularly children’s and young people’s and end of life services within the acute hospital and the community in-patient services and minor injuries units. Plans were in place regarding the development of the community in-patient services with the introduction of new models of care.

There had been changes made to the arrangements within the trust since the Chief Executive was appointed in August 2014, including a refresh of the trust values and a strengthening of the governance arrangements across all sites. There was confidence in the executive team across all areas of the trust and staff were proud to work for the organisation. Much work had been done to bring together the acute and community services to operate as one organisation and on the whole this had been successful. However, there was still some areas where further work was needed to integrate the services, particularly the community in-patient services and minor injuries unit. Further work was needed at the acute 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 responsiveness of this service also required improvement.

We found some outstanding practices, particularly aspects of caring and also within service delivery for critical care, outpatient and diagnostic services, community health services for adults and community dental services. This was a values driven organisation, staff at all levels were aware of the values and these were embedded in practice, for example as part of the recruitment process. There was an open and honest reporting culture and staff support was strong across the trust.

Our key findings were as follows:

  • There were clear values that had been developed with staff. Staff had confidence with the leadership team, who were reported to be visible and accessible.
  • There was a clear trust vision and strategy across the trust and for each of the services. Staff were aware of their role in this strategy and understood the ambition for ‘Excellence every time’.
  • There was good morale amongst staff, they told us they were proud of their trust and the care they delivered to patients.
  • There was strong leadership and staff reported that there was a supportive culture. Despite the large geographically dispersal of services, with challenges associated with this, staff reported that they felt connected to the trust as a whole, although more work was needed to promote this within the minor injuries units and the community inpatient services. Further work was needed to ensure that the practices and delivery of services within the minor injuries unit and the community in-patient services were consistent with the rest of the trust.
  • There was a strong governance framework, which ensured that responsibilities were clear and that quality, performance and risks were understood and managed effectively.
  • Overall the community dental services were outstanding. Services were patient focused and highly responsive to needs ensuring that the right care was delivered at the right time. Patients were given time and space to relax in the dental environment. Staff were accommodating to patients’ needs and constantly looking for new ways to make the service more accessible to people with anxieties and phobias as well as special needs.
  • Community health services for adults were outstanding overall and specifically in relation to caring and being well-led. Feedback we received from patients was consistently positive and they told us that staff go the extra mile which we witnessed during our inspection.
  • Services within critical care were outstanding as people’s individual needs were central to the planning and delivery of the service. There was a proactive approach to understanding the individual needs of patients and designing the delivery of care around these.
  • Outpatient and diagnostic imaging services were outstanding. These services were tailored to meet the needs of individual people and were consistently exceeding performance targets.
  • 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 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 in line with the National Institute of Clinical Excellence guidance.
  • There were no risks identified in the measures for mortality, including in-house mortality, the Hospitals Standardised Mortality Ratio (HMSR) and Summary Hospital-level Mortality (SHMI).
  • 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.
  • Cleanliness was to a good standard throughout the services and there were systems in place to prevent and control infection. On the whole staff adhered to trust policies and procedures, although we observed lapses in some areas. Some services lacked a robust audit programme, which could support the identification of inconsistent infection and prevention and control practices so these could be addressed.
  • At the Harrogate District Hospital site, 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.
  • 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.
  • 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 was effecting 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.
  • Staffing levels and skill mix across services were generally planned in line with best practice, patient acuity and national guidance. However, actual staffing levels did not always meet planned, for example in the urgent and emergency care department, children’s services and surgery. The trust was actively recruiting to posts and taking action to improve staffing levels through better use of the skill mix of staff.

We saw several areas of outstanding practice including:

Harrogate District Hospital

  • The supporting intensive therapy unit patients (situp) service.
  • Clinical psychology service to inpatients and outpatients at the follow up clinic in critical care.
  • 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.

  • The critical care online “virtual” journal club.
  • 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 up to a 13% increase in non-elective in-patient activity within medical specialities, 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.
  • 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.

Community Dental Services

  • The individual care offered to patients was specific to the patient’s needs. Where conventional care would not meet the needs of the patient, the service was willing to adapt to meet their needs. This included carrying out assessments in non-clinical spaces to enable patients to relax and providing calming reassurance to distressed patients. Staff had a high level of skill in creating a relaxing and professional environment. Meeting the needs of a patient was seen as a challenge to be met and patients were not turned away for being too complex.
  • The service responded effectively to the needs of the community and staff were actively seeking out groups of people who were at risk from poor dental hygiene or who were normally excluded from routine dental treatment. The work the service was doing with prisoners, the homeless and people with a history of substance misuse was reflective of this inclusive approach to ensuring all people can receive the best dental support.

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 and that an effective infection prevention and control audit programme for the environment and hand hygiene in services for community adults and the Selby MIU is in operation.
  • 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 and the checking of controlled drug stocks in the MIU.
  • 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 people.
  • 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; radiology and PGDs (patient group directives), treating children under one years old and joint working arrangements with GP OOHs and the local EDs in the minor injury units.
  • Ensure medical devices are subject to servicing in line with recommended guidelines especially in services for community adults.
  • 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

There was a good incident reporting culture within the trust, with feedback and lessons learnt shared across different services areas. Staff confirmed that openness and honesty was promoted and they would discuss with patients any incidents that they had been involved in and offer an apology. However, we found that staffing was an issue across some areas, such as medicine and children’s services, although steps were taken to reduce risk and the impact on patient care. There was limited resource for adult safeguarding as there was only a lead and one nurse across the trust, which meant this service was stretched. There were safeguarding processes in place in maternity services, but these required further embedding.

Duty of Candour

  • The duty of candour requires health organisations, as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, to notify the relevant person that the incident has occurred and provide reasonable support to the relevant person in relation to the incident and offer an apology. There was a trigger on the electronic incident reporting system to alert staff that the duty of candour was relevant to the case.
  • Duty of candour was covered by two trust policies: the `Being Open’ policy’ and the `Identification, reporting and management of incidents including SIRIs (Serious Incidents Requiring Investigation) policy’. The policy had been communicated to staff through news bulletins and was on an intranet screen saver. In addition, the trust had produced a staff information leaflet.
  • Staff across the trust were aware of the new regulation and the key principals, including a general duty on the organisation to act in an open and transparent way in relation to care provided to patients. Systems were in place to ensure patients were given an apology when something went wrong and informed of any actions resulting from any investigation of incidents. Staff were able to give examples of when this had taken place and we saw this recorded in the incident and complaint report documents sampled.

Safeguarding

  • The trust safeguarding arrangements consisted of an executive lead; the chief nurse and a team whose role was to ensure safeguarding practices met current regulations. The team comprised of a lead for vulnerable adults, with a name doctor and senior nurse. For children’s there was a named doctor, two named nurses, two specialist nurses and a named midwife. The team were responsible for providing safeguarding training, provide advice, monitoring and supporting supervision. The named nurses took responsibility for attending multi-disciplinary meetings with the local safeguarding children’s board.
  • The adults safeguarding nurse also led on learning disability issues, although was not trained in learning disabilities. At the time of the inspection the trust was recruiting to a specialist learning disabilities nurse.
  • For matters involving adults safeguarding reports and issues were examined at the safeguarding adults steering group, which reported to the supporting vulnerable people group, which reported to the senior management team meeting. For children’s safeguarding issues there was a safeguarding children’s governance group, which also followed the same route as adults, up to the supporting vulnerable people steering group to the senior management team.
  • Annual reports were produced about adult and children’s safeguarding matters within the trust. Policies and procedures were in place to cover safeguarding across adult and children’s services. However, there was no safeguarding strategy for children and although there were guidelines for staff to follow, these did not include cases where a non- independently mobile child presented with a bruise nor was there a policy to provide guidance to staff on this issue.
  • There was a robust framework for safeguarding supervision across all the services, which provided care to children in the community. However, we saw examples where best practice in safeguarding was not always implemented.
  • The trust target for safeguarding training was 75-95%. Staff completion across the trust was variable for the different levels of training. Data provided showed training rates for children’s Level 3 at 62% across the trust. However, health visitors and school nurses had achieved 86% compliance. The safeguarding children annual report published in July 2015, acknowledged that improving participation in Level 3 training was an action point. During the inspection, the safeguarding team told us they had made changes to the training programme to improve the uptake of training. It was envisaged that the development of an e-learning package would improve access.
  • There was a mixed system for flagging safeguarding concerns, particularly those related to child protection cases. For example, in some maternity services, where there were no flags used, and the emergency care department. However, staff maintained records for these cases and in the emergency department the staff could access the locally held records.
  • The team also supported a paediatric liaison nurse. Their role was to provide communication between acute services, such as the emergency department, and the community staff working with children and families. This was to enable staff to share and act on safeguarding information. This work was recognised locally with an award from the trust. In adult services staff were aware of the safeguarding process and were able to give examples of when they had raised safeguarding concerns.

Incidents

  • There was an electronic incident reporting system, which enabled management overview of incidents reported and the identification of emerging themes and trends.
  • Generally, staff received feedback from incident reporting and lessons were shared across services. Staff reported that improvements in governance arrangements had positively impacted on information shared about incidents. However, this was variable across some community services, for example, across community services for children and the community in-patient services.
  • There had been one never event reported from October 2014 to September 2015, which was a wrong tooth extraction. We saw that lessons had been learnt and shared across the trust for this incident. There had been 102 serious incidents reported for this period, 71 of which were pressure ulcers. There had been a programme of measures put in place to raise the profile of pressure ulcer prevention, awareness and steps taken to reduce the number and severity. The numbers of pressure ulcers were closely monitored by the Board and reported on regularly. There had been 21 slips/trips and falls incidents, three maternity/obstetric incidents and two surgical/invasive procedure incidents.
  • We reviewed a range of serious incidents and the associated root cause analyses (RCAs). We found that the general quality of the investigations, subsequent RCA and report rigorous and of good quality. Each RCA was led by a consultant and had a non-executive director associated with it to add further scrutiny. We were told the governance team did not close an incident until they received the evidence of completion of any required actions.
  • Staff received mandatory training and they also had the opportunities to access additional training to support their work with children.

Equipment

  • In 2010/11 a review was commissioned by the trust from an external party of the management of its estate. Following this review a full management restructure within estates was completed including the appointment to a new role, deputy director of estates.
  • The situation at the time of the inspection was that the deputy director of estates had developed a full workplan to resolve the two main issues that had been identified in the review: maintenance staffing challenges and a £14million backlog in maintenance. The trust invested £7million on the site and on clearing the backlog. This had improved over the last few months and it was anticipated that the backlog would be cleared by August/September 2016. The trust had additionally invested a further £200,000 in recruiting staff. The risk due to the backlog and staffing was entered on the corporate risk register.
  • Equipment was identified and prioritised for repair and servicing. It was acknowledged that this was work in progress and plans were in place to ensure compliance with the necessary servicing requirements. Staff were able to obtain support with equipment should there be concerns about the safe use of a device.
  • Data provided by the trust showed that 865 medical devices were in date for service; however 188 (22%) were out of date. This included twenty-six high-risk items, one of which was a defibrillator in a remote clinic which was last serviced in March 2014. We were told that all maintenance of high risk devices had been addressed. The asset register was RAG rated (red, amber and green) to identify the risk level and plans were in place to prioritise equipment checks and servicing. Not all areas had a system in place for checking electrical equipment for example on the community in-patients unit.
  • We found that there were systems in place for checking resuscitation trolleys and equipment and that these were consistently adhered to.

Infection Prevention and Control

  • There was an infection prevention and control (IPC) team, which consisted of a lead doctor, three microbiologists and specialist nurses. There were appropriate arrangements in place, including policies and procedures, audit programmes, incident investigation and performance data presented to the Board, although it was unclear as to how the Board was assured that all the criteria of the Hygiene Code were met. For example, we found no evidence of infection prevention or cleanliness audits carried out at Selby minor injuries unit.
  • Staff completed infection prevention and control training as part of their statutory mandatory training. The trust target for infection prevention and control training was 75-95% and staff were achieving an 85% training rate.
  • There had been no Methicillin-resistant Aureus (MRSA) reported from August 2014 to August 2015, and 16 cases of Clostridium difficile. MRSA screening was undertaken for elective cases, although there were no set standards over when this should be done apart from at admission. Root cause analysis was undertaken on all incidents, and the results of these investigations were shared to drive improvement.
  • Generally, IPC policies, procedures and best practice were well established within the trust. However, there were some areas where staff were not always adhering to trust policy, for example in the community children’s and young people’s services and in-patients unit.

Staffing

  • There were staff shortages in some services, particularly in nursing staff. The nursing and midwifery strategy was in development, and included reviewing the opportunities to provide a more structured pathway of development from band 2 staff to band four and the use of advanced clinical practioners (ACPs) to support the medical roles.
  • The national safer nursing care staffing tool was used three times a year to review staffing levels across the trust.
  • There was no trust-wide live electronic nursing dashboard to monitor fill rates, red flag incidents, or the acuity and dependency levels. There was, however a staffing review twice a day where the levels of staffing and any gaps were identified and actions taken to address these.
  • The chief nurse reported the nursing position to the Board using a dashboard by ward which included staffing levels, falls, pressure ulcers and complaints.
  • The trust had increased the nurse staffing establishment in 2014 on the care of the elderly wards, Byland and Jervaulx, and then again increased staffing levels in 2015 in Woodlands ward, the ED, CATT, AMU and Nidderdale ward. However, the highest vacancies were on Byland and Jervaulx wards, where about 60% of the qualified nurse roles were filled at the time of the inspection. The gaps in staffing on the medical wards were mainly mitigated by moving staff from other wards, using agency staff and incentivised payments for existing staff.
  • A senior nurse rota had recently been introduced in January 2016 for patient safety and to support the site out of hours. This was in operation 5-8pm on week days and part of the day on a weekend.
  • There were revalidation workshops in place and all registrants who were due in the first four weeks of operation had been identified, written to and given support to help them through the process. Health visitor caseloads in February 2015 averaged at 316 families across the county. Lord Laming (2009) recommended that caseloads should not exceed 300 families. The caseloads were corporate, meaning teams worked together to ensure there was equity in workloads.
  • Health visiting staff reported a positive impact of the ‘Health Visitor – Call to Action’ in that they had seen staff increases in their teams across the county. However, there were ten whole time equivalent vacancies reported for health visiting in the data provided.
  • The school nurse vacancy rate was 4.4 whole time equivalent and specialist children’s services vacancy rate was 4.13 whole time equivalent.
  • The community paediatric service was staffed by paediatricians from the acute service, in the Harrogate area. Community paediatric services across other areas of the county were supported by other NHS trusts. We were told by the LAC team that this had a negative impact on meeting targets for assessments.
  • The learning disabilities team had a caseload of 40 children, with 33 children on the waiting list.
  • Community children’s nurses had a caseload of 56 children, and specialist school nurses working in special schools provided care to 229 children.
  • In the medical staffing skill mix the percentage of junior doctors when compared to the England average was higher and for consultants it was similar to the England average. Some junior doctors reported that staffing was an issue, particularly in the medical services, including for out of hours and at weekends.
  • Medical cover for the community in-patients’ service was provided by general practitioners (GP) from three practices. A GP would visit the ward daily Monday to Friday and a consultant geriatrician visited the ward once a week and attended multi-disciplinary team meetings.
  • At the minor injury units there were periods at the beginning and end of the day were there was a lone nurse practitioner on duty. Lack of security arrangements and one lone worker could be a potential risk. However, there were no reported incidents in the last six months.

Mandatory training

  • There was a programme of mandatory and statutory training available for all staff, which covered areas such as moving and handling, safeguarding, information governance and infection control.
  • Generally completion of mandatory training was good, for example the trust target for mandatory training was 75-95%. Staff working in children’s services were achieving a training rate of 83%. However, not all courses were completed to the expected levels, in safeguarding for example. Due to staff shortages access to training could be problematic. Some junior doctors told us that in some areas, particularly medicine access to training could be difficult as they were too busy to take time out to attend.
  • There was competency assessment taking place, but this was not consistent across all services. For example although staff at the minor injuries unit were appropriately qualified, there were no competency packages for new or non-qualified staff.

Medicines

  • There were appropriate policies and procedures in place for the management of medicines. We saw that staff were trained and adhering to trust policies, although the use of controlled drugs was rare at the minor injuries units, there were some inconsistencies over checking controlled drugs in line with trust policy.
  • There was an electronic prescribing and administration system in place. The pharmacy service had trained and supported staff with its use. A pharmacist and pharmacy technicians visited the wards to check on medicines and were involved in the medicines optimisation processes, including medicines reconciliation, discharge planning and stock control.
  • The trust had a system and standard operating procedure to manage the cold chain to ensure the safe storage and transportation of vaccines to schools. The trust had recently introduced the use of thermometers for the medical bags used for transporting vaccines, to ensure the vaccines remained within the correct temperature range. Patient group directives (PGD) were used by health care staff to enable them to give medication and immunisations without a prescription. We were provided with a sample of electronic copies, which were up to date and signed by staff.

Effective

Good

Updated 27 July 2016

People’s care and treatment was generally planned and delivered in line with current evidence-based guidance, standards, best practice and legislation, although this was not embedded in some services across the trust.

Evidence based care and treatment

  • Protocols and policies based on current evidence were available for staff on the ward and on the intranet.
  • For example, the local guidelines for treatment of patients with Chronic Obstructive Pulmonary Disease (COPD) were based on the National Institute of Clinical Excellence (NICE) guideline CG101.
  • Ward managers undertook local audits such as hand hygiene and documentation audits. The results were shared with staff at team meetings and were displayed on ward notice boards and in staff areas.
  • The trust had a sepsis screening tool, which identified if a patient needed urgent intravenous antibiotics. We saw that on one occasion this had not been implemented correctly which led to a three hour delay in the patient receiving antibiotic therapy.
  • Medicines management was routinely audited across the trust and included medicines reconciliation, safe and secure storage of medicines, controlled drugs, and pharmacy intervention monitoring. Audit results were disseminated through the appropriate groups and action plans were prepared and acted on.
  • Trust policies were regularly reviewed and covered all aspects of medicines management. These were accessible via the hospital intranet to all staff.
  • Care and treatment was in line with best practice and national guidelines, such as the National Institute of Clinical Excellence.
  • Staff were aware of best practice guidance and they told us policies were easily accessible on the trust intranet.
  • National guidelines were followed for fall and pressure ulcers, with specific efforts being made to reduce the incidence of both. However, in the community in-patient service there were no specific care pathways or care plans in use for particular conditions, which meant a reliance on the nursing hand over sheets for communication. The trust’s fundamental nursing care plan was used for all patients.
  • There was a centrally hosted clinical computer system, which allowed most staff to access and share records.
  • The trust was involved in audits to ensure that patients’ nutrition and hydration needs were met across the trust.
  • There was participation in relevant local and national audits, including clinical audits and other monitoring activities, such as reviews of services and benchmarking.
  • Staff could access pathways of care required to deliver the health child programmes 0-5 and 5-19 year olds. The 0-5 years’ service was using research tools for development of assessments.

Patient outcomes

  • The trust had developed new policies and care plans for the prevention and early identification of pressure ulcers with the support of the tissue viability service. However, we did see in some patient’s notes that actions taken were not always recorded.
  • The trust had participated in a range of clinical audits including the first National Chronic Obstructive Pulmonary Disease Audit Programme in 2015. The results, learning and areas for improvement were shared with staff.
  • The endoscopy unit at Harrogate District Hospital had achieved Joint Advisory Group on Gastro-Intestinal Endoscopy (JAG) accreditation.
  • In the Stroke Sentinel National Audit Programme, Harrogate District Hospital achieved an overall score of D (on scale of A – E, with E being the worst) for July – September 2015 admissions. For both team and patient centred indicators, standards by discharge were rated highest and speech and language therapy was rated as worst.
  • The Myocardial Ischaemia National Audit Project (MINAP) audit for this trust was better than the England average for two out of the three indicators for 2013-2014.
  • Performance in the National Diabetes Inpatient Audit (2013) was mixed with the hospital performing better than the England average ten areas and worse in ten.
  • There was a lower risk of readmission for both elective and non-elective patients at Harrogate District Hospital compared to the England average with the exception of cardiology for non-elective, which was slightly higher than the England average.
  • Within the community children’s service patient needs were assessed before care and treatment started and there was evidence of care planning. Health visitor key performance indicators were based on commissioners’ requirements and related to waiting times and patient contacts
  • The trust’s HSMR increased in July 2015 to 104.52, which was above the national average but within expected levels. At specialty level, there were three specialties (Geriatric Medicine, Respiratory Medicine and Gastroenterology) with a standardised mortality rate above expected levels
  • The SHMI reduced in May 2015 to 96.11. This was below the national average and within expected levels. At specialty level, there were two specialties (Geriatric Medicine and Respiratory Medicine) with a standardised mortality rate above expected levels. Looking at the data by site, Ripon hospital had a higher than expected mortality rate. The Clinical Director for UCC Directorate had commissioned a retrospective clinical case note review of all deaths within 30 days of discharge from Ripon Hospital.
  • There were systems in place to effectively monitor if a patient was deteriorating over time. Observations were recorded on an electronic system which automatically calculated the national early warning score (NEWS) and automatically escalated an alert to the relevant staff. If there was no response from the first tier then there were two further alerts up to consultant level to ensure that a patient’s condition was reviewed. However, some junior doctors said they were experiencing difficulties with the patient tracking system and the impact on bleeps. It was stated that it could be difficult at times to identify whether a patient is flagging as deteriorating with this system, which meant the doctors could not work as effectively as they wanted.

Multidisciplinary working

  • Staff across the trust reported good working relationships within the multidisciplinary teams.
  • Multi-disciplinary team meetings took place on Trinity ward once a week and involved the visiting consultant geriatrician. We saw examples where staff from different disciplines positively impacted the care of patients. For example, in the community in-patients’ service, we observed therapist and nurses working together with patients to support and encourage them to carry out their activities with confidence.
  • There was a culture of good multi-disciplinary working across the community children’s services. The Looked After Children’s team had developed good working relationships with social services, community paediatricians, therapy services health visitors and school nurses to ensure that looked after children were prioritised. There was established collaborative working with other agencies such as children’s centres and schools.

Consent, Mental Capacity Act & Deprivation of Liberty safeguards

  • Staff generally had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS), including how this worked in practice to support and protect patients who were unable to make decisions themselves.
  • Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005.
  • Staff received training on capacity through e-leaning as part of the mandatory training schedule.
  • Mental capacity was assessed when appropriate and the capacity to consent was recorded. We saw evidence that patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. However, in a sample of records, not all the information expected was recorded, for example evidence for the decision and family/carer or independent mental capacity advocate involvement.
  • For community services, the patient’s agreement for rehabilitation was part of the admission criteria, although not always recorded in the documentation.
  • A corporate business case was being developed though the chief nurse for a full time post to lead the work on MCA and DOLS. It was expected that this would go the director’s team for approval later in February 2016.
  • DOLS applications were seen and tracked by the governance team; therefore the trust could identify the patient numbers. There had been an increase in DOLS applications following two master classes delivered to staff.

Caring

Outstanding

Updated 27 July 2016

Across the trust we found staff kind, caring and taking extra steps to improve their patients’ experience of the services. This was particularly true in the critical care unit and with the community dental services, where staff consistently sought out opportunities to understand their patients’ needs, and that of their families/carers, to improve and enrich the experience. Feedback from patients was highly positive, with staff’s efforts commended.

Compassionate care

  • Throughout the inspection across the trust, we observed staff treating patients with dignity and respect. Staff spoke with patients and their carers in a friendly and compassionate manner. Patients’ privacy was protected.
  • In the children and young people’s service staff were passionate about their roles and were dedicated to making sure children had the best care possible.
  • We observed staff delivering care to children and their families in clinic settings and in their own homes. We saw staff treat children and families with dignity and respect at all times. They were sensitive to the children’s needs, demonstrating kindness and compassion. We observed good relationships between the staff, children and their carers.
  • Feedback from parents was consistently positive. They told us staff were caring, accessible and knowledgeable. Friends and Family Test data for the therapy services between October 2015 and December 2015 showed that 100%, of the 20 patients who responded, would recommend children’s services. We saw evidence of ‘you said, we did’ feedback to families using therapy services.
  • Of the 77 CQC comment cards completed by children and families, all had positive comments about the service they used.

  • Within the dental services we found that staff understood the special demands that children may have and were supportive and respectful of these.
  • Social, cultural, religious and personal needs were respected by staff. Staff told us that they liked to be honest and open with children, explaining procedures and treatment fully, so that they were involved in their care. Appointments were not rushed as staff were understanding that their patients may require more support.

  • Feedback through CQC comment cards demonstrated that a large number of patients were appreciative and positive about care provided within the dental services. Several cards specifically mentioned the positive treatment of children, some whom presented with behaviours that were challenging.
  • In critical care all staff communicated in a kind and compassionate way with both conscious and unconscious patients.
  • Staff sensitively managed conversations regarding a patient’s condition, prognosis, care and treatment options. A member of the nursing staff had been nominated for multiple awards for their compassionate care. A member of the medical staff had won the trust doctor or dentist of the year awarded for their patient advocate approach and exceptional bedside manner with patients and their family.

Understanding and involvement of patients and those close to them

  • Patients reported that they were kept informed and were involved in their treatment. Staff communicated in a way that the patient could understand.
  • For patients with a learning disability, they were involved in the decision as to whether they had a flag against their name to alert staff to their presence in the ward/department.
  • Staff involved relatives and carers of patients living with dementia and discussed their care, treatment and how best to alert staff to their needs.
  • We saw in records where patients and their relatives had been involved in making decisions about their care and treatment.

Emotional support

  • We saw evidence of changes being made to services to meet the emotional needs of patients. For example in the outpatient services, in the Robert Ogden Centre, a second exit had been made available for patients and their families who were upset and would rather not walk out through the main waiting area.
  • In the dental service patients were given time and space to relax and feel comfortable in the dental environment. Staff were accommodating to patients and constantly looking for new ways to make the service more accessible to people with anxieties and phobias.
  • In the community services for adults, feedback from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us staff go the extra mile and we witnessed this during the inspection.
  • Relationships between patients, those close to them and staff were strong, caring and supportive. These relationships were highly valued by staff and promoted by leaders. Patients were supported emotionally. All staff were responsive to the psychological needs of patients. We saw psychological assessment and depression scoring tools being used for patients when appropriate.

Responsive

Good

Updated 27 July 2016

People’s individual needs and preferences were for most services central to the planning and delivery of services. There was excellent continuity of care for dental patients and they had choice about treatments. Within critical care 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.

However, support for people with dementia or learning disabilities could be improved, especially if the planned staff appointments took place. The trust did not achieve the standard for seven day access to face to face specialist support for end of life care. 

It was not possible for staff to identify everyone who might benefit from palliative care team support because of work pressures in the hospital and the limited palliative care cover available. There was no locally agreed service plan in place for end of life care with commissioners.

Service planning and delivery to meet the needs of local people

  • Services were planned to meet people’s needs. There were examples of this throughout the trust.
  • A rapid improvement workshop had been undertaken to look for ways to reduce the ophthalmic waiting list and a new process had been trialled with 40 patients who had glaucoma. The process involved rating patients as red, amber or green and streaming them to consultant led other medical grade or virtual clinics as appropriate. Following a successful trial, this process was to be rolled out in March 2016.
  • The department had submitted a business case to recruit and train three advanced nurse practitioners for medical retina care. These nurses would support the consultant ophthalmologists with clinical assessment and follow up of these patients.
  • The trust did not achieve the standard for seven day access to face to face specialist support for end of life care.
  • It was not possible for staff to identify everyone who might benefit from palliative care team support because of work pressures in the hospital and the limited palliative care cover available.
  • There was no locally agreed service plan in place for end of life care with commissioners.

Meeting people's individual needs

  • We found some good examples of individual patients needs being met. Reasonable adjustments could be made for patients with a learning disability and patients with dementia had an "all about me form completed".
  • Within critical care 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.
  • 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 did face challenges in relation to children being seen on adult surgery lists, but plans were being put together to increase paediatric day surgery provision.
  • The dental service worked closely with other agencies to improve access for complex patient groups. This included working closely with primary dental care providers, homeless people, prisoners and people who are resident in nursing or care homes. Stakeholder involvement was high and the service values the thoughts and opinions of the people it cared for and those who care for them. Adjustments had been made to improve access to dental clinics, and where problems were identified, patient’s opinions were sought in how to improve facilities to greater meet their needs.
  • Community services for children were provided in a range of venues to promote accessibility. Staff responded to the needs of young people and families who were vulnerable, by providing tailored services and gaining specialist knowledge.
  • There was an equality and diversity strategy group in place to help identify and meet the needs of harder to reach groups. The trust was also working with a local advocacy organisation and a national carers’ charity.
  • Board members we spoke with were aware of the developments in place, and those required, to meet the needs of people with learning disabilities and dementia. Worksteams had recently been strengthened for learning disability, MCA and DOLS.
  • Care plan templates had been developed for end of life care patients that were based on national guidance which provided each patient with an individualised plan based on their needs.

Learning disability

  • There was a learning disability steering group which was accountable to the Supporting Vulnerable People Steering Group The purpose of the group was to: support work to enhance the care of patients with a learning disability at the trust; provide a steer for the trust in relation to caring for people with a learning disability and their carers and; provide a forum for discussion in relation to the learning disabilities agenda. The terms of reference had been agreed in January 2016.
  • There was a lead nurse for learning disability who was a nurse with a special interest; they did not have a learning disability registration. This role was approximately for one day per week as part of their role as senior nurse for adult safeguarding.
  • The nurse had surveyed staff to ask about how competent they felt they were in caring for patients with LD. This had resulted in a paper to the Board and a request for additional staffing was approved: a band 6 qualified learning disability nurse for four days a week to case manage patients but also to educate staff.
  • There was an electronic system in place to identify people with learning disabilities within the acute hospital. At the time of the inspection there were approximately 200 patients identified with five receiving care in the hospital. Staff indicated that the flag was only added to a patient’s electronic record with their consent or as a best interest decision by their family/carer.
  • The trust had set up web pages on its intranet to provide guidance and resources for staff. There was also a working group, which had been set up with matrons from each directorate and a dental nurse to oversee the development of learning disability services within the trust. There was an action plan in place which was monitored by this group.
  • The lead nurse and matrons were notified of any admissions via an email when each patient with an LD flag was admitted or attended the emergency department to help ensure the right care plan was in place for each patient.
  • Where possible reasonable adjustments were made to enhance the care of patients with LD which included open visiting; free TV, fast track PAT testing on items from home; being able to bring other familiar items from home.
  • There was a learning disability team from another NHS trust which supported community staff to care for patients in the community.
  • MIU staff told us they did not have any specific guidance to assist them on how to support patients with a learning disability. They told us they would encourage their carer to stay with the patient to help alleviate any anxieties the patient may have. A ‘VIP’ card had been introduced which contained medical and personal information and used for patients with a learning disability.
  • The trust was not effectively measuring or monitoring its performance in relation to meeting the needs of those with LD.
  • Training of staff was not currently recorded or monitored within the trust. Following a survey of 208 staff 34% said they had training and 17% said they had watched the video which was available.

Dementia

  • At the time of the inspection, there was not a specialist nurse for dementia. However, the trust had recently appointed a matron who was also an older persons’ champion who commenced in the Trust on the 28 September 2015. This role incorporated dementia and had responsibility to lead and improve dementia care within the trust. There was also a medical consultant who had 0.5Pas per week to support the dementia work.
  • The head of nursing in Integrated care was the deputy chair of the dementia working group and was leading work on dementia across the organisation with the clinical lead.
  • There were three dementia CQuIns (Commissioning for Quality and Innovation) in place for staff training, supporting carers and effective discharge.
  • As on the 1 February 80% of all substantive staff who had a training requirement for dementia awareness training had completed this (1283 trained out of 1602). 87% of all substantive staff who had a training requirement for dementia tier 1 training had completed this training (1535 trained out of 1760). 256 staff had attended the full day dementia training for clinical staff (tier 2).Two advanced clinical practioners were being trained.
  • The consultant reviewed discharge summaries on a monthly basis to identify patients who may need a referral for an assessment of possible dementia.
  • The ‘Butterfly scheme’ to help staff identify patients who may need additional support had been relaunched in November 2015 with 35 nurse champions attending a workshop. For patients who required additional observation and support the trust increased the staffing of band 2 health care assistants. The trust had also applied for funding to develop therapeutic support workers
  • There was a specific work plan in place to enhance the care environment for patients on Byland and Jervaulx wards. This included the use of murals, large clock faces, specific books, signage and re-decorating toilet areas. Tea parties were held on Byland ward. The elderly care clinics were on the ground floor, separate from the rest of outpatients with a quieter calming environment. Consultation with a carers group had identified concerns about the size of ED and that it was not conducive to wait in.
  • In A&E a box was available which contained reminiscent objects such as a ration book and old pictures. This was used to reduce patients' anxieties of being in an unfamiliar place. A staff member told us it was a helpful tool and many patients enjoyed looking through the items. ’Twiddlemuffs’ were available, which are knitted woollen muffs with items such as ribbons, large buttons or textured fabrics attached that patients with dementia can twiddle in their hands. Patients with dementia often have restless hands and like something to keep them occupied. The Twiddlemuffs provide a source of visual, tactile and sensory stimulation at the same time as keeping hands snug and warm.
  • There was not anything specific in place to care for patients with dementia who attended MIU. Staff told us if patients were distressed they would see them as quickly as possible, and encourage their carers to stay with them.
  • Patients with a diagnosis of dementia had an ‘all about me’ form completed. This allowed staff to get to know the person’s likes, dislikes and interests in order to provide patient centred care.

Access and flow

  • Access to services was good. Cancer waiting times data showed good performance and a redesign project was underway, which aimed to improve patient flow and enhance the patient experience within acute medical admissions. Waiting times, delays and cancellations were minimal and managed appropriately.
  • Thirty one percent of appointments were new patients and 62% were follow up appointments with 7% unattended and cancelled appointments. The national averages were 25% new and 55% follow up appointments with 20% cancelled or unattended appointments. The trust's ‘new to review’ rate (the ratio of new appointments to follow-up) was consistently better than the England average between July 2014 and June 2015. The trust actively managed new to follow up ratios and outliers from the expected range were highlighted and investigated to ascertain the reasons for this and identify whether any improvements could be made.
  • The trust had a ‘did not attend’ (DNA) rate of 5%, which was better than the national DNA rate of 7%.
  • The percentage of patients (with all cancers) waiting less than 31 days and 62 days from urgent GP referral to first definitive treatment was consistently better than both the standard and the England averages. Between Quarter (Q) 1 2013/2014 and Q 2 2014/2015, the percentage of people waiting less than 31 days ranged between 99% and 100%. The percentage of people waiting less than 62 days ranged between 90% and 91%, during the same time period.
  • The percentage of people seen by a specialist within 2 weeks following an urgent GP referral was consistently better than both the standard and the England average. Between Q1 2013/2014 and Q2 2014/2015, the percentage ranged between 95% and 99%.
  • The bed occupancy for this trust since quarter one 2014/15 had been below the England average which helped ensure effective access and flow of patients.
  • Discharge liaison nurses facilitated the timely discharge of complex patients. This included patients with delayed discharges. The nurses liaised closely with social services, care managers and family/carers regarding support on discharge and attended best interest meetings for patients who lacked mental capacity.
  • Delayed transfer of care were mainly due to two factors ‘patient or family choice’ (35.2%) and waiting further NHS non-acute care’ (33.1%). These proportions were significantly higher than the England averages of 13.4% and 20.2% respectively. The percentage of disputes (8.8%) regarding discharges was also higher than the England average (1.2%) The trust was significantly better at ensuring patients were assessed promptly with only 1.2% of discharges being delayed waiting for an assessment compared with 18.5% nationally.
  • Clear pathways were in place for children and young people to attend the trust. Guidance was also in place for staff to aide in identifying children and young people that required more specialist care and arrangements were in place with local trust’s and transport agencies to ensure that children and young people could access the right care at the right time.
  • In the ED, the trust achieved the national 4 hour standard during Quarter 1, 2 & 3 in 2015/16. The diagnostic waiting times for this trust were consistently delivered between October 2013 and October 2015, which is better than the England average.
  • Performance on MIU waiting times and compliance to national targets such as seeing, treating and discharging patients within four hours of referral was met by the MIU’s consistently.
  • Waiting times for children to receive specialist developmental assessments was within national targets.

Learning from complaints and concerns

  • We saw evidence that the trust was open and transparent in responding to complaints
  • The chief executive was responsible for ensuring that all complaints were dealt with effectively and signed all final responses to complaints and compliments.
  • The Medical Director and Chief Nurse were the designated Board of Directors members responsible for compliance with the Making Experiences Count (MEC) Policy (which included complaints). This was being revised and was due to go to the Board’s quality committee in March 2016 for review and approval.
  • Day to day responsibility was held by the Department of Patient Experience and Risk Management which included the Head of Risk Management who was the trust’s designated Complaints Manager and was accountable to the Medical Director.
  • The complaints and PALS service had been amalgamated into a patient experience team (PET) following feedback from the public with the intention of proving a more seamless service for those using it. There were 3.4 wte staff in the PET dealing with complaints.
  • The operational directors were responsible for the implementation of the MEC process in their own directorate and ensuring that appropriate quality assurance of each response was provided when a directorate investigation was undertaken. They identified Investigating Officers for the investigation of complaints and designated complaint leads for the implementation of the MEC procedure.
  • The clinical Director is accountable for ensuring that there is a robust system within their Directorate for receiving and responding to feedback including how learning is shared both within and across the Directorates.
  • Complainants were contacted in the first three days following receipt of the response and we corroborated this through a review of a sample of complaints. Complainants were offered meetings from the first point of contact. The overall response time was dependent on the severity of the complaint however, there was a proposal being considered for a 25 day target for completion of complaints in the revised policy.
  • There were specific metrics in place to monitor the effectiveness of the complaints process. These included that 95% of cases should have met the target timescale set at the initial agreement with the complainant; the number of complaints per year; the number of cases re-opened, the number of cases sent/upheld by the ombudsman; the percentage of action plans completed with the deadline and the satisfaction of the complainants.
  • Timescales for completion of complaints were not always met. However, over 90% of complaints were responded to within 25 working days from July to September 2015 following improvements in the process.
  • Complaints were reviewed at a number of levels: the Complaints and Risk Management group which was chaired by the chief nurse or medical director; at the patient experience committee; as part of the monthly integrated quality dashboard; at Quality of Care Team meetings and were also reported to commissioners..
  • The trust reviewed monthly complaints and feedback dashboard reports at the Patient Experience Committee.
  • The main themes were communication, ophthalmology, outpatients and pain management in relation to end of life care.
  • Any lessons learnt were shared at directorate meetings and put on the Trust’s intranet.
  • There were patient experience volunteers at the ‘front of house’ to meet and greet people entering the hospital. They feedback issues identified to the team.
  • Staff were aware of the policy for managing concerns and complaints and how to find it on the intranet. Staff said they tried to resolve minor complaints at source to prevent them escalating to formal complaints.
  • Staff used the lessons learned from patient complaints to improve clinical practice.
  • We reviewed six complaints in detail and found that they had been investigated appropriately and responses provided to the complainants which included  apologies. They had been appropriately risk assessed and the investigations were thorough. 

Well-led

Good

Updated 27 July 2016

There had been changes made to the arrangements within the trust since the Chief Executive was appointed in August 2014, including a refresh of the trust values and a strengthening of the governance arrangements across all sites. There was confidence in the executive team across all areas of the trust and staff were proud to work for the organisation.

The governance arrangements had been strengthened and there were good reporting systems in place. This was a values driven organisation, staff at all levels were aware of the values and these were embedded in practices, for example as part of the recruitment process. There was an open and honest reporting culture and staff support was strong across the trust.

Generally much progress had been made in integrating the community and the acute services, but there were some areas that required further attention such as the minor injuries units and the community in-patient service. In these areas the leadership was less effective and in the community in-patient services there was a lack of central purpose. We found that in some areas expected practices such as training on dealing with major incidents at the minor injury units and auditing of infection prevention and control procedures were not consistently taking place.

Vision and strategy

  • The trust had a clear vision, ‘Excellence every time’, with three accompanying values – Respectful, Passionate and Responsible, with the first principal, ‘You matter most’.
  • There was a credible strategy – evidenced in Board papers, and documentation throughout the services. Board members actively participated in the development of the trust’s strategy. Non-executive members told us there were Board business development days and there had been a full day session looking at strategic priorities for the trust.
  • The trust strategy, which was embedded across the trust, had strategic objectives, to deliver high quality care, to work with partners to deliver integrated care and to ensure clinical and financial sustainability.
  • The trust’s longer term strategy focussed on integrating primary, secondary and social care services. This ambition had been key to the trust being selected as one of the ‘Vanguard’ schemes in March 2015 and the trust was working with partners to develop this approach.
  • The vision and values were developed with the staff using a process known as ‘word map’. These were rolled out to the trust and could be found embedded on the lanyards worn by staff, on screen savers and within trust documentation. The values were central to practices throughout the trust for example, within recruitment processes where prospective employees were not recruited unless they could demonstrate the value set. We were given examples where people were not appointed as they did not demonstrate the value set to fit to the organisation.
  • Each service had its own vision and staff were able to describe these. For example, in the dental service the vision and the strategy had been used as a basis for the development of goals with the aims of achieving excellent dental care for all patients in a sustainable and effective way. The service was forward thinking with a proactive leadership team. However, not all staff in some services were clear about their local vision and purpose, for example in the community in-patient services.
  • There was a children’s strategy and there were staff representatives at Trust Board level to promote the voice of children in the service they provide. However, there was not a designated non-executive director for children and young people on the Board. There was new leadership within the children’s and young people’s services and this had yet had the opportunity to develop and embed a vision and strategy at local level.
  • There was an IT strategy in place for 2014-2019, which clearly highlighted the developments required by the trust. The Board had been engaged with the development of the strategy and it was due for review in July 2016. There was an acknowledgement of the challenges in place to provide effective IT across a wide geographical and rural area. There were clear plans in place to address this going forward, although there continued to be risk associated with the lack of an integrated IT system especially in community services.

Governance, risk management and quality measurement

  • There were three directorates for the delivery of services, these were overseen by the senior management team and consisted of the elective care services, the integrated care directorate and the urgent, community and cancer care directorate. To support the delivery of services there were regular professional team, specialist team and multi-disciplinary team meetings. Generally meetings were well attended, although representation from some of the community services such as the minor injuries units and community in-patient services were not always evident. Indeed the minor injuries units and the urgent and emergency care services appeared to work in isolation from each other, with no joint staff meetings or limited liaison between sites.
  • The governance arrangements had been strengthened and a range of committees sat underneath the executive and senior management team level. There were five Board committees, audit, quality, finance, remuneration and nomination. Within the structure were sub-committees including a corporate risk review group, supporting vulnerable people group and improving patient safety group.
  • The Board regularly received updates in relation to the board assurance framework and corporate risk register through the Chief Executive report at each Board meeting. The board assurance framework and corporate risk register were received at the Board on a quarterly basis. The board assurance framework was aligned to the trust’s strategic objectives. There were 16 strategic risks identified that could adversely impact the trust’s strategic priorities and these were reviewed monthly.
  • The Board focussed on developing solutions for the strategic risks, for example as seen with the new models of care for the frail elderly, the introduction of an overarching IT platform and the programme to improve patient flow through urgent and emergency care.
  • There was a robust cost improvement programme (CIP) in place and the process included a clear assessment of risk to quality at the development stage. The Board and the finance committee received assurance reports on the delivery of the CIP programme.
  • There was effective Board level challenge from the non-executive directors (NEDs), although further development was underway to support this. The NEDs chaired the committees and challenged on quality related matters. The quality committee had the ability to undertake deeper dives into issues of concern as these evolved.
  • There were service level risk registers, which were reviewed monthly; any risk scoring above 12 was escalated to the corporate risk register. The directorates reviewed service level risk registers quarterly. The directorates held monthly quality governance meetings, which reported to the directorate Boards. Risks, incidents and complaints were reported at these meetings for consideration as to whether they needed escalating to more senior levels in the trust. However, we found that in some areas that there was a lack of robust auditing, particularly with infection prevention and control in the minor injuries unit at Selby.
  • Serious incidents were reported appropriately via the trust electronic incident reporting system. There was a strong culture of incident reporting. There were appropriate investigations into the root cause of the incident so that learning could take place across the trust. There were particularly strong links between associated specialties such as the dental services and the maxillo-facial surgery service due to similarities in their working practices in general anaesthesia. However, some staff reported that they did not always receive feedback or had access to shared learning, from incident investigations for example in the community in-patient services.
  • The governance framework and processes had been reviewed by the new Chief Executive. There had been a well led review in December 2015, which found the trust was self-aware of its strengths and areas for improvement, with no material concerns regarding the leadership and governance arrangements within the trust and a positive level of awareness
  • An integrated performance dashboard was in place and working well. There was ongoing review and development to ensure it remained fit for purpose. In addition, there was internal reflection on the performance of the Board committees. For example, the Chair would discuss how effective meetings were at the end of each session so as to inform and improve the next meeting.
  • Further work was required to bring the end of life services in line with national guidance. The services were split across two directorates, which did not aide in consistent practice and oversight. In addition, the trust did not monitor if patients achieved their wish for preferred place of care or death. As this was not routinely identified, this information could not be used to improve or develop services. There was a risk register for end of life care, which identified the risk to patient care of not providing the required level of direct specialist palliative care and ability to support improvement projects due to under resourced consultant provision. It stated that there was a lack of clarity regarding level of service commissioned. However, the trust was developing a strategy for end of life services in line with national guidance and this would include the recruitment of specialist staff.

Leadership of the trust

  • Staff across the trust reported that the Chief Executive and the executive team were visible and visited areas across the hospital and community.
  • A clinical lead and their deputy were responsible for the implementation of policies and procedures, including in relation to infection prevention and control, managing medical emergencies and incident reporting. However, we found some policies were out of date in maternity and there were some areas where implementation of infection prevention and control could be improved."
  • Across the trust staff regularly reported that services were ‘like a family’. The leadership team were approachable, visible and supportive. Staff reported that team leaders and clinical leads were very much part of the team and that staff worked well together.
  • The whole Board participated in director inspections across the services within the trust, where an executive director, a non-executive and infection prevention and control staff visited specific services, including those in the community. In addition, the executive and non-executive members of the Board and governors participated in safety visits to acute and community services. This increased visibility of the Board and enabled a stronger board to ward view of the organisation.

Culture within the trust

  • In the 2015 NHS National Staff Survey, 69% of staff would recommend their organisation as a place to work. This is better than the national average of 58%. In the same survey, 78% of staff would be happy with the standard of care provided by the trust if a friend or relative needed treatment. This is better than the national average of 67%.
  • Staff told us they were proud to work at the trust and that achieving high levels of patient care was important to them. In the NHS National Staff Survey the trust scored 3.92 for staff who would recommend the organisation as a place to work or receive treatment. This is better than the national average of 3.71.
  • Staff spoke of a strong culture of continuous learning and development and many had undergone extra training and had plans in place for further development.
  • Staff reported that the working environment was respectful of all staff, regardless of role and that they felt valued at work.
  • In the 2015 NHS National Staff Survey, the percentage of staff experiencing physical violence from patients, relatives or the public in the last 12 months was 16%. This was worse than the national average of 14%.
  • Staff were encouraged to speak up with ideas or concerns and they were involved in changes that affected them, one example given was when the rota system was changed.
  • Staff working in the children’s community service told us they felt the trust had invested in community services and they felt valued as a service.
  • In the 2015 NHS National Staff Survey, the percentage of staff who had experienced harassment, bullying or abuse from patients, relatives or the public in the last 12 months was 23%, which is better than the national average of 26%.
  • In the same staff survey, the percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months was 21%, which is better than the national average of 29%.
  • Staff were aware of their responsibilities under the Duty of Candour, which was introduced as a statutory requirement for NHS trusts in November 2014.

Fit and Proper Persons

  • The trust was undertaking the appropriate checks on executives and non-executives in compliance with the Fit and Proper Persons Requirement (FPPR) (Regulation five of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensured that directors of NHS providers are fit and proper to carry out their role.
  • Actions taken included undertaking pre-employment checks, a search of insolvency and bankruptcy register, a search of disqualified director register and a self-declaration of fitness which included explanation of past conduct/character issues where appropriate.
  • We reviewed a sample of files of the executive and non-executive directors and found the appropriate checks had been completed.

Public engagement

  • There was no patient experience strategy in place at the time of the inspection however we were told that one was being developed and would be presented to the senior management team and Board in April 2016. It would also cover equality and diversity.
  • There was an improving patient experience group, which included trust governors and Clinical Commissioning Group lay members. The group met and reviewed compliments, friends and family test, complaints and PALS information, patient feedback and, serious incidents.
  • The trust engaged with services users across the services. This was especially demonstrated with the way the staff in the trust engaged with patients with complex and specialist needs.
  • There was a patient story at the beginning of each Board meeting, which was usually a patient and/or family members attending in person. As a result of one of these the way the senior nurse on call operates was changes to be available seven days a week and visits the wards.
  • There was good engagement between the trust and its council of governors. The governors we spoke with commented that the trust was open and that they always get a good response if they have queries or concerns at a council meeting. The governors participate in patient safety visits and sit on many of the Trust’s committees, for example, they are invited to attend the quality, fiancé and audit committees in an observational role.
  • The trust had approximately 17,500 members which it communicated with regularly and had events three times a year to encourage discussion and feedback.

Staff engagement

  • In the 2015 NHS National NHS Staff Survey, the overall score for staff engagement was 3.92, which is better than the national average of 3.79.
  • Consultation took place with staff, including specific events such as community dental service visionary event, to look at service improvements and innovations.
  • Information was shared with staff through the trust’s intranet and emails were sent out with the latest update on changes and developments in the services. Bulletins were issued via email to keep staff up to date at remote sites.
  • Staff at all levels attended staff meetings and these were held regularly. There was a staff side committee/partnership forum in place which was chaired by a retired member of staff which met monthly. The forum had representatives on the HR policy advisory group and the Pay, terms and conditions group. We were told by the forum that there was good dialogue with the management team. The CEO has been attending for part of the meeting since September 2016.
  • Staff reported that they felt informed and consulted about service development and changes in policies and procedures.
  • Staff were able to report concerns and felt included in lessons learnt from incidents across the trust.

Innovation, improvement and sustainability

Harrogate District Hospital

  • 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.
  • 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. 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.
  • 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.
  • The trust was part of a national vanguard programme. This was a nationally sponsored service improvement programme. As part of that programme the trust was developing new models of care for end of life care provision.
  • The trust had developed end of life plans used by patients for recording information about their wishes at the end of life. The leaflet allowed patients to record their thoughts about the care they wanted to receive and the things they did not want to happen. Patients could also record information about what was important to them for example pets or possessions.
  • The trust had completed the ‘Rethinking Priorities Programme’. This was a development programme which involved consultant medical staff evaluating the care provided to patients approaching the end of life. The programme addressed some of the most difficult issues medical staff faced for example identifying of patients in the last year of life was not always easy and the challenges varied between specialties. The programme also covered difficulties in starting a conversation about aims of treatment and planning future care, how to improve communication between primary and secondary care when each may defer to the other and how senior clinicians could learn from their peers. The programme had successfully raised awareness of advanced care planning in stroke services and neurology, ceilings of care and recognising the last 12 months of life in urology.

Adult Community Health Services

  • The matron and senior managers told us about the vanguard project (transforming community services) for the intermediate care teams. The aim for this would be to coordinate and deliver the care to patients with complex needs. The team included district nurses, therapists, care support workers, pharmacists, long-term conditions practitioners, continence nurses, mental health staff and social care staff.
  • The trust IPC team had developed and launched their own website. Staff told us that the website had a number of resources and was divided in to categories including policies, education, leaflets and articles.
  • The speech and language team had piloted two Parkinson’s groups. The patients attending this group had been asked for feedback and had suggested longer sessions, with a social element and that more were held. After evaluation, the group was due to recommence in April 2016 and would involve speech and language final year students supported by a speech and language therapist.
  • The podiatry team won an innovation award in 2011 for the evidence based care package developed for plantar fasciitis. The team were also currently involved in a research programme. Two members of staff had been allocated non clinical time to complete this research which involved identifying patients who were at high risk of amputation in later life for example any patients who were over forty years old, obese, had deformities, were smokers or who were non-compliant with treatment. The initiative involved staff working with these patients to identify and try to address the risk factors to prevent them becoming high-risk patients. The aim was early recognition, identification and pre-treating to reduce the risk to the patient and also prevent the potential resource drain due to more complex care and treatment being needed in future years.
  • In addition, the podiatry service were involving undergraduates in innovation. They referred this as undergraduate skills building (USB). Students were involved in collating FTT data; this was seen as a positive step due to the students being neutral to the patient and the service. In return, the service allowed students the opportunity to identify if there were any areas of practice that they would like to observe. One example of this was that the podiatry team had been able to arrange for a student to observe foot surgery with the surgeon and patients consent.

Community Children’s and Young People’s Service

  • An autism diagnostic service had been introduced in line with NICE guidelines. This supported a multi-disciplinary approach to ADOS assessment (Autism Diagnostic Observation Schedule).
  • The service worked in collaboration another trust which provided CAMHS telephone support for staff. This allowed staff to receive timely advice and information to support children with mental health needs.
  • The service had developed ”No wrong door” dedicated to young people with multiple vulnerabilities. Young people could access the right care through one key worker.

Community Dental Services

  • The service had recently recruited two specialists in paediatric dentistry and a consultant in special care dentistry to develop the skill mix within the dental team. As patients’ dental and medical requirements became more complex so did the range of clinical expertise the service needed to offer to meet the needs of patients seen. Specialist posts would advance the range of skills to achieve this. The new clinical commission guides and patient pathways that had been developed also detailed the need for specialist and consultant led treatments along with consultant led managed clinical networks.
  • A digital X-ray system business case had been started. This would allow the service to move to totally digital record keeping, improving the ability to share news and information with staff and improve communication between sites and localities.
  • A dental team newsletter had been developed to improve the sharing of news and information with staff; this improved communication between sites and localities.
  • However, senior staff told us that financial constraints had limited the level of care the service could provide. Staffing levels meant that the service had longer waiting times than they would like.
Checks on specific services

Community dental services

Outstanding

Updated 27 July 2016

Overall we rated community dental services at this trust as outstanding. Services were effective and focussed on the needs of the patients treated and the wider community through oral healthcare education services. We observed that the service was able to meet the needs of patients who visited the clinics for care and treatment due in part to the open minded and flexible approach the staff had towards delivering care and treatment.

There were systems for identifying, investigating and learning from incidents and the service had a strong culture of reporting incidents. The service protected patients from abuse, and where harm had been caused, thorough investigations had occurred and changes to the service implemented to prevent further harm occurring. Infection prevention and control procedures were in place and audits were carried out regularly. The environment was clean and tidy. In some clinics, site maintenance was poor, this had been identified in the risk register and staff had made changes in practice to ensure patients were not put at risk.

Patients and carers reported positive experiences of care. We observed examples of staff providing care in a compassionate and supportive way. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke passionately about their work and the treatment they provided. This was reflected in the comments from patients on Care Quality Commission share your experience cards which were all positive.

At each clinic we visited, staff responded to patient needs. Effective multidisciplinary team working ensured patients received care that was at the right time and right for their needs. Delays to treatment were kept to a minimum through effective time management and escalation strategies, however managers had identified staffing issues as being a concern.

The service was well led and both the operational and the trust wide management team were visible. Staff told us that the culture was open, transparent and that managers were approachable. Staff said they felt well supported and valued, with many having worked for the service for many years. The service had a strategy with aims and objectives for promoting dental health with patients and the wider community.

Community health inpatient services

Requires improvement

Updated 27 July 2016

We rated community inpatient services as requires improvement. This is because:

  • We saw that community inpatient services were caring and responsive. However we found the service required improvement for safe and effective care and also required improvement for well led. The care provided did not always focus on patient rehabilitation and reablement.

  • Feedback from patients and relatives was very positive and we observed staff to be compassionate and caring in their approach. Patients were not empowered to take control of their rehabilitation.

  • We saw evidence of good multi-disciplinary working across nursing, therapy and medical teams but there was a lack of leadership within the multi-disciplinary team which meant that plans of care for individual patients were not clear or focussed or holistic.

  • The service did not provide an effective rehabilitation service. It was not performance managed or monitored and lacked leadership.

  • There was a lack of consistent therapy input as the therapy staff working in a community team that responded to crisis intervention in the community.

  • Medicines management was generally good but patients were not offered the chance to manage their own medication as a means to prepare for leaving the hospital environment.

  • Patient records were well managed and national guidelines were followed for falls prevention and pressure ulcers. However there were some gaps in the management of patients’ nutritional needs and a lack of documentation to support what actions had been taken to meet these needs. Patients’ notes and records were not securely stored.

  • Staff felt involved in patient care, mandatory training was managed well and some staff had received appraisals.

  • Most staff followed infection control procedures and all areas we inspected were clean. There was not a comprehensive or robust system in place for the maintenance, servicing and safety checking of electrical equipment on the ward.

  • Food and fluids were within patients’ reach and most patients told us they enjoyed the food provided and were supported if necessary. Patients felt safe and cared for during their stay and staff were sensitive, compassionate and maintained dignity and respect for their patients.

  • Patients and their relatives were not given adequate information about their environment, the purpose of the ward and what to expect during their admission or on discharge from hospital.

  • The ward environment was challenging due to the age of the building and the layout in terms of space and visibility of patients. There had been no reasonable adjustments made to the environment for those patients living with dementia.

  • Admissions and discharges were well managed although the ward team sometimes felt under pressure to accept patients who did not meet the full admission criteria, particularly those with dementia or confusion. Delayed discharges were mainly due to family choice, lack of nursing home places and waiting for packages of care to be put in place.

  • The service received very few written complaints and was very much appreciated by the local community. The hospital was extremely well supported by the local Friends of Ripon Hospital committee who have raised many thousands of pounds to support the care and comfort of patients using the service.

Community health services for adults

Outstanding

Updated 27 July 2016

Overall, we rated adult community health services as good for safe, effective and responsive and outstanding for caring and well led.

We rated safe as good because the teams were collating safety performance data and most of the time this was better than the national average. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Managers shared the learning from incidents across teams. All staff took a proactive approach to safeguarding. Mandatory training across all services was above the trust targets. Medicines were stored securely in and staff administered these in line with the trusts policies. Staff handovers were effective and patient care records were completed to a high standard. We found that people were protected from avoidable harm and abuse. The trust had robust systems in place for managing risks including major incident planning. Access to equipment in people’s homes was good and the trust had robust systems in place for the delivery and collection of equipment. However, we also found that some medical devices were out of date for servicing and maintenance. There was limited evidence of environmental and hand hygiene compliance audit. Managers and staff members in community nursing and therapies teams told us that staffing was an issue. Staff told us that they often work more than their contracted hours due to demands on the service. Gaps in staffing were filled but this was mainly by substantive members of staff working bank shifts that might not be sustainable in the long term.

We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. A centrally hosted clinical computer system allowed most staff to access and share records. Patients were receiving advice about pain relief. There was participation in relevant local and national audits. Staff received timely appraisals and were supported with professional development. There was evidence of multi-disciplinary working across all teams and evidence of collaborative working with the local authority. Referral processes were straightforward and staff did not raise any concerns about these. Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that patients were supported to make decisions. However, we also found that although most staff had access to information via the trust intranet, staff at remote sites told us, at times, they felt isolated, experienced difficulties and frustrations in relation to the IT systems. Staff told us that not having mobile working devices caused them duplication in work and created a significant amount of non-effective work time. We also found that not all care pathways reflected references to nationally recognised best practice.

We rated caring as outstanding because feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff go the extra mile and we witnessed this during our inspection. We observed a number of staff and patient or carer interactions during our inspection. This included fifteen home visits and six observations during clinic appointments. We observed consistently caring and compassionate staff. We received 174 comment cards during our inspection, these also consistently contained positive comments about the community adult services, in particular about the podiatry services. Staff were highly motivated and inspired to offer care that is kind, promotes people’s dignity, and involved them in planning their care. Patients said that staff were ‘wonderful’ and ‘amazing’. We saw staff providing detailed explanations of procedures, thorough assessment of all needs and reassurance. Relationships between patients, those close to them and staff were strong, caring and supportive. Patients were supported emotionally. All staff were responsive to the psychological needs of patients.

We rated responsive as good because services were planned and delivered in a way that meets the needs of the local population. The needs of different people were taken into account when planning and delivering services. Staff respected the equality and diversity of patients and their families. The facilities and premises were appropriate for the services being delivered. We saw evidence that staff were responsive to meeting the needs of vulnerable patients including those living with dementia, a cancer diagnosis and learning disabilities. The community nursing and therapies team provided a seven day, twenty-four hour service. The community equipment store had moved from a five to a six-day service and staff we spoke to told us that they would be keen to extend this further. Podiatry services were provided across the region. There were low numbers of complaints. We spoke with senior staff and found that there was an openness and transparency in how complaints were dealt with. Complaints and concerns were taken seriously and responded to in a timely way. We saw evidence of improvements made to the quality of care as a result of complaints and concerns.

We rated well led as outstanding because the trust had a clear statement of vision and values which was integrated within the teams. Staff we spoke to were aware of and based their care around the trusts values. Senior staff shared details of the board and governance meetings with staff. Staff within the community service teams were aware of their risks and could explain these including any work that was being undertaken or that had been completed in order to mitigate their risks. Senior staff were visible and supportive to staff and patients. The majority of staff in the service told us that senior staff for the trust were also engaged with the services provided in the community. All staff we spoke with said that senior staff were very approachable. One said they had a ‘fantastic supportive team, I love my job. I feel very well led and have never been happier’. We witnessed the culture within teams as being team focused and positive. All staff we spoke with told us that they worked as part of a team and felt supported within their service. We saw good examples of public engagement within most teams. Staff were proud of the teams they worked in and told us about innovation they had been involved in. There was a strong focus on continuous learning and improvement at all staff levels. Staff shared innovations and improvement work that they were involved in.

Community health services for children, young people and families

Good

Updated 27 July 2016

Overall, we rated the service as good.

The service reported incidents and there were examples in some areas of community children’s services where feedback from reporting was provided. There were changes in practice as a result of lessons learnt from incidents, for example in information governance. However, this was not consistent across all community services for children.

There was a robust framework for safeguarding supervision across all the services which provided care to children in the community. However, not all staff disciplines were meeting the trust target for safeguarding level three training.

There were areas of infection control and prevention where the service was not adhering to trust policy.

Staff received mandatory training and they also had the opportunities to access additional training to support their work with children.

The service was rolling out a programme of electronic record keeping. This provided staff with up to date information about children, including safeguarding concerns. It allowed staff to share information with other practitioners in a timely way. The electronic system for patient records allowed the service to monitor targets and for teams to report issues when commissioned targets and patient outcomes were not being met.

There was a children’s strategy and there were staff representatives at Trust Board level to promote the voice of children in the service they provide, but there was not a designated non-executive director for children and young people on the board. Children at the centre of care was seen throughout the service.

There were clear lines of reporting from frontline practitioners to the trust Board, through governance meetings and structures.

Staff told us they felt the trust had invested in community services and they felt valued as a service

Urgent care services

Requires improvement

Updated 27 July 2016

The service prioritised patient protection from avoidable harm and abuse. Patients were seen and treated quickly; in an appropriate environment with good facilities. The departments met the national standard for seeing, treating and discharging patients within four hours.

Patients’ complaints were taken seriously and responded to in a timely way. Feedback from patients was positive and patients were treated with compassion, dignity and respect.

Staff had the appropriate qualifications however; there were no competency packages for new or non-qualified staff. Structures, processes and systems of accountability including governance and management partnerships, and joint working arrangements were not clearly set out. The minor injuries units and ED worked in isolation of each other.

There were lack of clinical audits of patient outcomes at the MIU’s and a lack of presence of senior leaders.