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Provider: Harrogate and District NHS Foundation Trust Good

Reports


Inspection carried out on 2-5 Feb 2016 with an unannounced inspection 10 February 2016

During a routine inspection

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


CQC inspections of services

Service reports published 27 July 2016
Inspection carried out on 2-5 February 2016 During an inspection of Community health services for children, young people and families Download report PDF | 280.38 KB (opens in a new tab)
Inspection carried out on 2-5 February 2016 During an inspection of Community health inpatient services Download report PDF | 390.68 KB (opens in a new tab)
Inspection carried out on 2-5 February 2016 During an inspection of Community dental services Download report PDF | 334.67 KB (opens in a new tab)
Inspection carried out on 2-5 February 2016 During an inspection of Community health services for adults Download report PDF | 397.61 KB (opens in a new tab)
Inspection carried out on 2-5 February 2016 During an inspection of Urgent care services Download report PDF | 271.22 KB (opens in a new tab)
See more service reports published 27 July 2016

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