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Inspection Summary


Overall summary & rating

Good

Updated 14 March 2019

  • We inspected Surgery and rated the service outstanding. The rating for safe improved to good. The rating for well led improved to outstanding.
  • We inspected services for Children and Young People and rated the service as good. The ratings for safe and well-led improved to good.
Inspection areas

Safe

Requires improvement

Updated 14 March 2019

Effective

Good

Updated 14 March 2019

Caring

Outstanding

Updated 14 March 2019

Responsive

Good

Updated 14 March 2019

Well-led

Good

Updated 14 March 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 27 July 2016

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

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

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

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

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

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

Services for children & young people

Good

Updated 14 March 2019

Our rating of this service improved. We rated it as good because:

  • Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of flexibility and commitment.
  • Feedback from staff, parents, children and young people had resulted in changes to the service.
  • Neonatal staffing met the British Association of Perinatal Medicine Guidelines (2011)
  • The neonatal service was mostly compliant against the latest British Association of Perinatal Medicine (BAPM) Medical Staffing Guidelines (November 2018).
  • A designated adult surgeon and anaesthetist were responsible for the oversight and management of children’s surgical services.
  • The service generally controlled infection risk well. Staff kept themselves, equipment and the premises clean.
  • Service monitoring and improvement were managed through clear leadership pathways, governance, performance and risk management systems.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance; monitoring and review of clinical guidelines had taken place.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The trust planned and provided services in a way that met the needs of local people.
  • Close working with other providers, tertiary centres, commissioners, parents and young people resulted in improvements and support for the service.
  • People accessed the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
  • At our previous inspection the trust was told they must ensure the environment on the Woodlands ward was appropriate so the needs of children and young people with mental health needs were fully considered. Steps were taken but some ligature risks remained.

However:

  • The service had not fully met the Royal College of Nursing (RCN) ‘Defining staffing levels for children’s and young people’s services (2013) clinical standards’, however the trust had actions in place to mitigate this. The service had not fully met the ‘Facing the Future’ medical staffing standards, however the trust had actions in place to mitigate this.
  • Compliance against the Royal College of Surgeons (2013) Standards was not achieved. Two standards required further development; competency of theatre and recovery staff in the management of paediatric patients and the physical separation between children and adult patients in recovery.
  • Control measures to prevent the spread of infection were in place, with high compliance in infection control audits, but we observed that these control measures were not always applied.

  • Staff had not kept detailed records of patients’ care and treatment.

Critical care

Outstanding

Updated 27 July 2016

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

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

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

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

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

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

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

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

End of life care

Good

Updated 27 July 2016

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

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

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

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

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

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

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

However,

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

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

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

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

Maternity and gynaecology

Good

Updated 27 July 2016

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

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

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

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

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

Outpatients and diagnostic imaging

Outstanding

Updated 27 July 2016

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

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

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

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

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

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

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

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

Surgery

Outstanding

Updated 14 March 2019

Our rating of this service improved. We rated it as outstanding because:

  • Managers at all levels demonstrated high levels of experience and knowledge to deliver excellent quality of care. Managers were very approachable, visible and motivated staff to do their jobs well.
  • The vision and strategy for the service recognised the current risks, challenges and pressures impacting on service delivery, whilst supporting and celebrating innovation and success.
  • Seniors managers enabled engagement through collaborative working and networking. We saw an extensive number of ideas integrated into practice following engagement from staff and listening events.
  • There is a strong, visible person-centred culture. All patients we spoke with gave excellent feedback in relation to the care they received from all levels of staff, including consultants, domestic and portering staff.
  • Staff are highly motivated and extremely proud of the level of care they delivered and wanted to improve the lives of the patients they cared for. Relationships between people who use the service and staff are strong, caring and supportive.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service managed incidents well.
  • The service controlled infection risk well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it.

However:

  • Although the completion of medicines records had improved since the last inspection. Staff were not always recording minimum and maximum temperatures for medicines refrigerators.
  • Staff had limited understanding of the relevant consent and decision making requirements in relation to the Mental Capacity Act 2005 and struggled to provide examples as to when mental capacity assessments would be required.
  • The trusts referral to treatment time (RTT) for admitted pathways was consistently lower than the England average, across all specialists, however current data showed an improving picture.
  • The trust took an average of 74 days to investigate and close complaints, this was not in line with their policy.

Urgent and emergency services

Good

Updated 27 July 2016

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

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

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

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

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

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

Other CQC inspections of services

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