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Airedale General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 March 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

We rated urgent and emergency care, and surgery as requires improvement. We rated medicine, critical care and diagnostic imaging as good.

  • We found that some concerns highlighted following our last inspections in 2016 and 2017 had not been addressed despite us telling the trust they must make improvements. Use of the World Health Organisation (WHO) checklist was not embedded and the environment in theatre areas was not compliant with national standards related to airflow.
  • We had concerns about nurse and medical staffing. There were high numbers of unfilled shifts for registered nurses in some clinical areas. Staff told us they gave medications late and completed poor or infrequent documentation as a result of poor staffing. Completion of paediatric sepsis pathway documentation was poor.
  • There were gaps in medical cover in the emergency department and the trust was not compliant with national standards for the out of hours medical cover in the critical care unit. We had raised concerns about out of hours medical cover in 2016 and 2017.
  • Risk assessments were not always completed or reviewed. Patients were not always assessed for delirium in line with best practice. Risks that threatened the delivery of safe and effective care were not always identified promptly. For example, ward staff did not consistently report the impact of suboptimal staffing levels on patient care. This had been a concern at our previous inspection.
  • Staff did not always recognise, report or record incidents and not all incidents were effectively investigated. This meant opportunity for learning from incidents was missed. We were not assured systems to communicate lessons learned from serious incidents and never events to all staff were always effective.
  • We had concerns about the assessment and management of patients with mental health needs. Patients waited several hours in the emergency department to be assessed, and the gaps in out of hours mental health liaison meant patients who had arrived during the night were often still waiting the next morning.
  • In some areas, there was poor compliance with the trust’s infection prevention and control policy; this included staff not adhering to the uniform policy and there was an inconsistent approach to labelling of clean equipment. Some environments, particularly the walls and fixtures on two surgical wards were in poor order; they required repair and could not be cleaned effectively. Equipment cleaning schedules on wards were not comprehensively completed and visibly dirty equipment was stored with visibly clean equipment and consumables.
  • There were both paper and electronic records in use. This meant in some areas, staff recorded information on paper forms then had to transcribe that to electronic records. This transcription introduced an additional risk of errors, and it took staff extra time to do this.
  • We were not assured that storage of patient records on the wards was compliant with data protection regulations; there was a risk that patient’s confidential information could be accessed inappropriately. Paper patient records were not secure and compliance with information governance training was poor.
  • Complaint investigation and response times did not consistently meet the trust target of 40 days; on average it took 56 days to investigate and close complaints.
  • Governance over policies, procedures, other documents such as patient pathways was not robust; several were past the date for review and there was limited evidence of document control.
  • Several clinical and non-clinical areas were in a poor state of repair and reflected the aging buildings.

However;

  • We found all staff to be caring and responsive to patient’s needs. Staff cared for patients with compassion. There was a strong focus in all the areas we visited to put patient need first. Staff at all levels worked to do their best for patients and treat them with dignity and respect. We saw staff calmly putting patients and their families at ease during difficult situations.
  • Without exception, the staff we spoke with were friendly, warm and welcoming. We saw good examples of teamwork where clinical and non-clinical staff worked together for the benefit of patients. Therapy teams and other health and social care professionals worked well alongside nursing and medical staff for the benefit of patients.
  • Feedback from patients we spoke with confirmed that staff treated them well and with kindness. Patients and their relatives told us that they were involved in planning their care and that communication with staff was good. Patients told us they felt safe and well looked after.
  • Staff we spoke with had a good understanding of safeguarding processes and understood their roles and responsibilities under the Mental Health Act, and the Mental Capacity Act. Most staff knew how to support patients who lacked capacity to make decisions about their care; staff knew what action they needed to take in such situations.
  • Staff worked hard to provide for the needs of vulnerable groups of patients such as those living with dementia or those with learning disabilities.
  • Leaders of the core services were approachable, supportive and promoted a positive culture. Most staff told us the leaders were supportive, inclusive, visible and approachable. They told us the trust felt like a better place to work in the last five or six months prior to our inspection.
  • Management of medicines had improved since our last inspection. We saw areas where pharmacy staff were present on wards to provide support to ward teams.
  • When something went wrong, staff were open and honest. They had good awareness of duty of candour.
  • The environments had been improved in some of the areas we visited. Most of the areas we visited were visibly clean, tidy, and free from clutter.
Inspection areas

Safe

Requires improvement

Updated 14 March 2019

Effective

Good

Updated 14 March 2019

Caring

Good

Updated 14 March 2019

Responsive

Good

Updated 14 March 2019

Well-led

Requires improvement

Updated 14 March 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 14 March 2019

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

The service had taken action to address the following concerns from our last inspection.

  • The service was managing incidents well, staff were reporting incidents that were investigated and were receiving feedback. Learning was shared across departments through newsletters and emails and was discussed at staff meetings and safety huddles.
  • Action had been taken to improve the environment in the haematology and oncology day unit, within the limits of the department.
  • An escalation process for opening extra capacity beds had been introduced and staff felt this had improved the situation.
  • The service leadership was embedded and staff reported service managers as inclusive, visible, approachable and supportive.

In addition;

  • Staff we spoke with had a good understanding of safeguarding and understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care and what action they need to take when they had concerns.
  • The service took part in several national and local audits and there was a monthly programme of nursing audits which were used to inform ward development plans. National Falls and Lung cancer audits showed good results.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. The relative risk of readmission and length of stay was generally better than the England average.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service had a strong patient focus and staff at all levels advocated for a positive patient experience.
  • The service took account of patients’ individual needs and worked hard to provide for the needs of vulnerable groups of patients such as those with dementia and learning disabilities
  • The service had a vision for what it wanted to achieve and was working towards this by engaging with clinical networks, other providers, staff, patients, commissioners and local community groups. There were a number of examples service improvements and innovation where staff and stakeholders were involved.

However;

  • Nursing and medical staffing remained a concern for medical services. While staff the main felt patients were safe, they did give; late medicine administration, poor or infrequent documentation, stressed staff and very limited management time as examples of the impact of low numbers of staff. Ward managers were part of the registered staff to patient numbers and did not have any protected time for management duties and we were concerned that staffing risk was not fully understood or mitigated due to the process of short-notice requests for agency staff and need for executive approval, which was likely to contribute to the high number of unfilled nursing shifts.
  • We found that risk assessments were not always completed or reviewed when they should be, food and fluid charts were not always fully completed and fluid balance was not calculated.
  • The appraisal rates for nursing staff and additional clinical staff were; 63.7% and 77% respectively which were below the trust target of 85%. Mandatory training compliance was below the trust target of 80% at the time of our inspection.
  • Paper patient records were not secure as these were stored in unlockable trolleys in public areas of the wards.
  • There was no seven-day therapy service for patients recovering from stroke or requiring ongoing rehabilitation for other conditions.
  • Despite the work the service was undertaking to reduce delayed transfers of care, from April 2018 to November 2018 benchmarked in the upper quartile (highest) in the NHS Improvement daily dashboard. In November the trust had managed to reduce the delays to 1.7%.
  • Length of stay and relative risk of readmission for respiratory patients was worse than the England average.

Services for children & young people

Updated 20 September 2017

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

Critical care

Good

Updated 14 March 2019

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

  • We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement.
  • Compliance levels for mandatory training were positive and staff told us they were supported to attend training. All areas we visited were clean and well maintained.
  • Staff assessed patients and escalated their care when necessary. Medical and nursing staffs’ documentation was clear, legible, dated, timed and signed in line with the guidelines for the provision of intensive care services and their registering bodies.
  • Staff were aware of how and when to report incidents, including safeguarding concerns. The unit displayed patient safety information, this showed 98% of incidents resulted in low or no harm to patients.
  • There had been one never event on the unit however, we saw that staff received feedback and lessons learned were shared and duty of candour was applied.
  • The unit had introduced mortality and morbidity meetings and staff told us these were beneficial in supporting learning from deaths.
  • Guidelines, pathways and policies were produced in line with national best practice guidelines and recommendations.
  • Patients were assessed and supported effectively with their individual needs including nutrition, hydration and pain relief.
  • We saw effective working between all staff involved in the care of patients on the unit during our inspection and staff reported positive working relationships with all members of the multidisciplinary team.
  • The service participated in national audit and undertook local audits. We saw evidence of action plans to address any improvements that were identified.
  • The service had a dedicated clinical educator which was in line with GPICS standards.
  • There were sufficient numbers of skilled nursing staff to safely care for patients. All staff had an up to date appraisal and staff were supported to professionally develop.
  • We saw staff seeking patient consent before providing care and treatment. Staff had a good understanding of restraint, the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Patients and their relatives gave positive feedback: patients told us they felt safe on the wards and that staff were caring and compassionate.
  • The unit displayed Friends and Family Test (FFT) feedback. This showed 100% of patients and their families recommending the unit, in September 2018
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff provided emotional support to patients and their loved ones. The unit also had access to a psychologist to provide emotional support.
  • The unit had initiatives in place to support children visiting loved ones in the unit and also those who suffered a bereavement.
  • Services were planned to meet the needs of local people. The unit was part of the local and regional critical care network.
  • The unit had introduced a follow up clinic and rehabilitation after critical illness in line with GPICS and National Institute for Health and Care Excellence (NICE) CG83.
  • The unit had 11 bed spaces. The trust declared three level three beds and four level two beds to the critical care network. However, the bed use could be flexed to meet the needs of patients.
  • The service had an outreach team available 24 hour per day, seven days a week to provide support for patients discharged from the unit or those who were acutely unwell on other wards or departments across the hospital.
  • We saw positive examples of how the staff provided care based on individualised needs. The unit had open visiting however visiting could be varied depending on the activity within the unit and individual patient and family needs.
  • Information was displayed on the unit about translation and interpreter services.
  • The trust participated in the Intensive Care National Audit Research Centre (ICNARC). Hospital mortality and non-clinical transfers were within the expected range.
  • There were low numbers of complaints and high numbers of compliments. We saw compliment cards and information displayed on the unit about how to raise a concern.
  • There was a clear leadership structure. Staff told us that their line manager and the senior team were visible, approachable and supportive.
  • We found the culture of the unit was open and inclusive for staff and patients. The staff we spoke with were friendly, warm and welcoming, without exception.
  • Local governance arrangements were robust, and the team was aware of the risks to their service. We saw a detailed report which included the developments, risks and strategic aims for the unit.
  • All staff had access to ‘Aireshare’, the trusts intranet, each area had their own section on the site which allowed staff to access policies and procedures most relevant to their area of work and also access to meetings minutes.
  • The unit had developed a written patient engagement strategy and had purchased a memory tree, to allow relatives to leave feedback.
  • We saw positive examples of innovation and improvement.

However, we also found:

  • There had been limited progress on some of the actions required to ensure the unit fully met GPICS standards. The unit was not meeting the GPICS standards for medical care cover.
  • Some staff reported concerns about out of hours admissions. We were told that these sometimes happened without discussion with or assessment by the on call medical team.
  • Some staff did not always adhere to the trusts uniform policy.
  • We found poor stock rotation processes and out of date items of equipment.
  • Not all medical devices showed when they were last checked and serviced.
  • Waste disposal containers for sharp instruments and medicines were not always stored safely. However, these concerns were addressed immediately during our inspection.
  • Patients were not assessed for delirium in line with best practice guidance.
  • ICNARC data showed the proportion of non-delayed, out-of-hours discharges to a ward was ‘worse than expected’.
  • We were also told that delayed discharges, for medically fit patients, sometimes happened because the speciality team, the patient was being cared for, had requested admission to a specific ward where a bed was unavailable.

End of life care

Good

Updated 10 August 2016

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

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

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

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

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

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

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

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

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

Maternity and gynaecology

Updated 20 September 2017

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

However:

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

Outpatients and diagnostic imaging

Good

Updated 10 August 2016

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

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

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

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

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

Surgery

Requires improvement

Updated 14 March 2019

Our rating of this service stayed the same. We rated effective, caring and responsive as good and safe and well-led as requires improvement.

We rated surgery overall as requires improvement because:

  • There were actions we told the provider they must address at our last inspection, which were not fully addressed at this inspection.
  • The environment in the Dales Suite, specifically, provision of a specialist ventilation system was not in place and did not comply with national guidance. This was a concern at our previous inspection.
  • In some ward areas, we observed poor compliance with the trust’s infection prevention and control policy and there was an inconsistent approach to labelling of clean equipment.
  • Some environmental areas, particularly the walls and fixtures in clean utility rooms on two surgical wards were in poor order and required repair and could not be cleaned effectively.
  • Equipment cleaning schedules on wards were not comprehensively completed and we saw dirty phlebotomy trays stored with visibly clean equipment and consumables. There was no consistent system of labelling to indicate that equipment had been cleaned and was fit for use.
  • We had concerns in theatres that compliance with the WHO safer surgery process was not fully embedded and this was a concern at our previous inspection.
  • We had concerns that surgical wards were not always staffed safely, particularly at night. Nurse staffing was a concern at our previous inspection.
  • Risks that threatened the delivery of safe and effective care were not always identified promptly. For example, ward staff did not consistently report the impact of suboptimal staffing levels on patient care. This was a concern at our previous inspection.
  • Staff did not always recognise, report or record incidents and not all incidents were effectively investigated. This meant opportunities for learning from incidents were missed.
  • We were not assured that storage of patient records on the wards was compliant with General Data Protection Regulations and there was a risk that patient’s confidential information could be accessed.
  • We were not assured systems in place to communicate lessons learned from serious incidents and never events to all staff were effective.
  • Complaint investigation and response times did not consistently meet the trust target of forty days; for fifteen complaints that had been closed at the time of data submission, the trust took an average of 53.1 working days (mean) to investigate and close these complaints.

However:

  • There was good compliance with recording of safety checks for emergency equipment on the wards and in theatres.
  • Management of medicines had improved since our last inspection.
  • Staff had good awareness of duty of candour and we were assured this was imbedded.

Urgent and emergency services

Requires improvement

Updated 14 March 2019

Our rating of this service went down. We rated it it as requires improvement because:

  • We found that concerns highlighted following our last inspection had not been addressed at this inspection.
  • We had concerns about nurse staffing levels and consultant cover in the department.
  • Time from arrival to initial assessment was consistently worse than the England median, meaning patients did not always receive timely clinical triage.
  • We had concerns about the assessment of patients with mental health needs.
  • Mandatory training compliance for medical staff did not meet the trust’s target.
  • Completion of paediatric sepsis pathway documentation was poor.
  • The department failed to achieve the Royal College of Emergency Medicine (RCEM) audit standards.
  • The median time to treatment was higher than the England average.
  • The trust consistently failed to meet the four-hour emergency care standard, although performed better than the England average.

However:

  • We saw improvements in staff training management and compliance, including provision of training for staff caring for sick children.
  • The department was clean and tidy, with well-maintained equipment.
  • Medicines were managed safely.
  • Senior staff had a focus on improving department security.
  • Incidents were reported and learning from incidents was shared with staff.
  • Staff had a comprehensive induction, regular appraisals and were supported to develop their knowledge and skills.
  • We saw good examples of teamwork within the department, and with the wider multi-disciplinary team.
  • We found all staff to be caring and responsive to patients’ needs.
  • Patients were kept up to date with information regarding their care, and were given opportunities to provide feedback.
  • Leaders were approachable, supportive and promoted a positive culture.
  • Managers had oversight of issues relating to performance.
  • Staff and patient engagement was encouraged and valued.

Diagnostic imaging

Good

Updated 14 March 2019

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • We rated safe as requires improvement, effective was not rated, caring, responsive and well led as good.
  • Staff had access to incident reporting systems and were aware of how to report incidents. Areas visited we visibly clean and tidy. Medicines checked were stored securely.
  • Staff could describe the audits the service completed and had access to radiation protection advisors and there were radiation protection supervisors in the department.
  • Staff could offer patients food and drink as required in the department. Most staff told us they had appraisals and there were reporting radiographers in the department. Mental capacity act training compliance achieved the trust target between April 2017 and March 2018.
  • Staff provided compassionate care and provided reassurance to patients as required. Chaperones were available as required in the service. Patient feedback during the inspection was positive.
  • There were local diagnostic imaging business meetings to manage capacity and demand and managers could describe how the service planned services. The service had a weekly metric meeting to manage and monitor waiting times and reporting times.
  • There was a department bookings team for diagnostic imaging and staff told us interpreters were available as required.
  • Managers could describe the vision for the service and there was a management structure in place in the department. The service had introduced a governance lead in each modality.
  • Managers could describe the risks to the service and there was a risk register in place.
  • Staff told us the department culture had improved and there was good teamwork in the teams.
  • Staff had access to the required information systems and managers had access to weekly metric reports to monitor performance and key performance indicators across the service.

However, we also found:

  • There were various policies, procedures and documents which had not been reviewed and there was limited evidence of document control in the department.
  • Mandatory training compliance was not always achieved. The trust target for safeguarding children mandatory training was not achieved for nursing staff. WHO safety checklist audits had recently been implemented, however the audit results did not highlight overall compliance. There had been two never events in the previous 12 months.
  • There were issues with patient group directions (PGD) with the authorising manager section of the PGD not being signed, incorrect expiry and review dates and one PGD had an incorrect route of administration as the document name. The refrigerator temperature checklist had missing checked dates in September 2018 and oxygen and suction checklist had missing dates between July 2018 and November 2018.
  • There were paper copies of the pathways seen during the inspection past their review date.
  • From April 2017 to March 2018, 77.1% of staff in diagnostic imaging at the trust received an appraisal compared to a trust target of 85%.
  • The service had not always met the six week waiting targets in the previous 12 months, although this had improved in the previous two months prior to the inspection and data provided by the trust showed areas where there were reporting backlogs and waiting times breaching targets.
  • The service did not investigate and close complaints in line with the trust policy.
  • The governance structure had recently been reviewed and was not fully embedded.
Other CQC inspections of services

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