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Airedale General Hospital Requires improvement

Reports


Other CQC inspections of services

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

Inspection carried out on 28 to 30 March and 17 April 2017

During an inspection to make sure that the improvements required had been made

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

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

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

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

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

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

We rated Airedale NHS Foundation Trust as requires improvement overall.

At this inspection we found:

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

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

However:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

Trust-wide

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

Urgent and emergency care services

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

Medical care services

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

Surgery services

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

Critical care

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

In addition the trust should:

Urgent and emergency services

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

Medical care services

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

Surgery

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

Critical care

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

Maternity and gynaecology

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

Children and young people’s services

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

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 5 Sept 2016

During an inspection to make sure that the improvements required had been made

The Care Quality Commission (CQC) carried out an unannounced inspection of Airedale General Hospital on the 5 September 2016. The purpose was to look at specific areas in relation to the safe and well-led domains on the Critical Care Unit (CCU) and on some of the medical wards.

The areas inspected in September 2016 included a selection of wards/departments that were identified as a concern during the March 2016 comprehensive inspection, as well as areas where concerns were not identified during the previous inspection but where local intelligence suggested that risks may have increased in those areas. This included concerns regarding risks of patients deteriorating without appropriate monitoring or escalation, and nurse staffing levels.

CQC will not be providing a rating to Airedale General Hospital for this inspection. The reason for not providing a rating was because this was a very focused inspection carried out to assess whether the trust had made significant improvement to services within the prescribed time frame.

In Medical care our key findings were:

  • Daily checks of emergency equipment on ward 15 had not been completed daily when patients had been cared for on the ward. The resuscitation trolley had not been checked for the previous six days and there was no oxygen on the trolley. This had been recently replaced and was stored elsewhere on the unit, which meant in an emergency situation staff may not have all the appropriate equipment available for them to use.
  • On the ward there was a signposted male toilet area and a disabled toilet and shower cubicle. There was no dedicated female bathroom on the ward on the day of inspection.
  • Ward 15 did not store controlled drugs; these were provided by ward 14. Therefore if a patient on ward 15 required controlled drugs the nurse would be given assistance of a registered nurse from ward 14 to check and administer the drug. If ward 14 was busy, the nurse would bleep for the assistance of a matron.
  • On the day of inspection we found records were not stored securely on ward 15. Medical and nursing notes were stored in cardboard boxes on the nurses’ station, and were left unattended whilst staff cared for patients.
  • Monitoring of patients on the ward with telemetry varied dependent on clinical need and the patients National Early Warning Score (NEWS). The ward would undertake their own observations of a patient and record on a NEWS chart; however, staff told us there was no guidance as to how often this would be done other than the nurses clinical judgement. We found there was no set guidance from the trust on what ward monitoring should be undertaken for these patients.
  • Staff described NEWS and clinical judgement as factors when escalating concerning patients. All staff we spoke with were able to describe the process they would follow. However we found in six patient records that clinical observations had not always been completed in the specified time-frame.
  • Following the inspection the trust informed CQC that ward 10 had opened on one occasion on 29 September 2016. The opening of the additional 4 beds was in response to a surge in acute activity. To ensure the area was staffed safely, the decision was made to open the doors between the wards 9 and 10. Ward 9 staff had cared for the four patients located on ward 10 in addition to the patients on ward 9. This meant there were two registered nurses with support from Health care assistants for a total of 33 patients for the night shift.

In Critical Care our key findings were:

  • Staff told us that sharing information and learning from incidents had improved on the unit.
  • The unit had closed beds since our inspection in March 2016 to support safer nurse staffing levels. We reviewed staffing data for three months and saw there was a general improvement in nurse staffing levels however there still remained shortfalls on some shifts and the unit did not have a supernumerary co-ordinator.
  • There had been a process of two person equipment checks introduced in critical care following a serious incident in April 2016. Staff were required to check ‘high risk’ equipment with another nurse at the beginning of each shift or for each new admission. However we observed three care charts and one chart did not have a countersign for one shift out of three opportunities to do so.

  • Since our inspection in March 2016 the trust had introduced a new process for the monitoring of telemetry patients and the nurse co-ordinator on the critical care unit had oversight of telemetry patients.

  • The unit had developed a process for monitoring staff compliance with medical device training. The ward educator was managing the training and the lead nurse had oversight of this. We saw there was a good level of compliance with the training.

  • Changes had been made at a senior leadership level and support had been put into place on the unit. There was now a dedicated lead nurse, matron and nurse consultant working on the unit.
  • Staff we spoke with felt that safety had been given greater priority and that incidents and lessons learnt had been shared in an open and transparent way at staff meetings. Staff spoke positively about the new management team.
  • There was an improved process and system for appraisal of staff across the unit. The new lead nurse and nurse consultant had achieved 81% of all staff appraisals over three months, with planned dates in place for the remaining team.
  • The clinical nurse educator had been given more time to fulfil the expectations of the role and worked alongside staff or released staff to attend training. There was co-ordination of all staff commencing and completing the critical care STEPS training programme in order to evidence competence and knowledge of the team.
  • Following our inspection in March 2016 the trust had put in place a critical care action plan. We reviewed the action plan and found that of a total of 23 recommendations, 19 had been delivered, three were on track to be delivered and one was partially delivered.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 15-18 March 2016, 31 March and 11 May 2016

During a routine inspection

We inspected Airedale NHS Foundation Trust from 15 -18 March 2016 and undertook an unannounced inspection on 31 March 2016. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme. We had previously inspected Airedale General Hospital in September 2013. This was part of our pilot for the comprehensive programme. The hospital was not rated at that time.

We included the following locations as part of this inspection:

  • Airedale General Hospital
  • Community services including adult community services, community inpatients and end of life care.

Following our inspection in March 2016, the Trust informed us of a serious incident that had occurred on the critical care unit at Airedale General Hospital. On further analysis of other evidence, we undertook a further unannounced focussed inspection on 11 May 2016. The focus of the inspection was staffing levels, training and competency of staff, equipment checks and patient care within the critical care unit.

We rated Airedale General Hospital as requires improvement. We rated caring, effective and responsive as good. We rated safe and well-led as requires improvement.

We rated emergency and urgent care, maternity and gynaecology, services for children and young people, end of life care and outpatients and diagnostics as good. We rated critical care, medical care and surgery as requires improvement.

Our key findings were as follows:

  • The hospital was inspected in September 2013 and our inspection report at the time demonstrated good quality of services generally with some concerns relating to critical care in particular. Our inspection of March 2016 showed that whilst the majority of services were good, the hospital requires improvement and we have seen a deterioration in some services namely critical care, surgery and medicine.
  • Most staff reported a positive culture and we found that staff were caring and treated patients and their families with dignity. However, we saw evidence there were areas of the trust that, whilst staff reported feeling proud to work at Airedale, some staff described a less open and positive culture. We had some concern over leadership and the relationship with and management of staff, particularly in critical care.
  • Nurse staffing levels in many clinical areas were regularly below the planned number. This was a particular concern in critical care, medical care, surgery and children’s services. Planned nurse staffing levels in critical care were below the levels recommended in national guidance.
  • Medical staffing numbers did not meet national guidance in the emergency department and there were insufficient intensivists in critical care. We saw the trust were committed to further recruitment of ED consultants and had five intensivists employed.
  • The management of medicines required improvement in several areas across the hospital.
  • We had concerns about the escalation process of deteriorating patients particularly with medical care and surgery; systems used were not always effective.
  • We found governance systems and processes were not always effective and, in some areas, staff’s understanding and application was inconsistent. Risks were not always identified and where these were, there was not always sufficient assurance in place.
  • Mandatory training compliance did not meet the trust’s target of 80% in several areas including medical care and surgery. This was monitored within business groups, at the Mandatory Training Group and the Executive Assurance Group.
  • However, we also found the hospital was clean and observed that most staff adhered to infection control principles. Between March 2015 and March 2016 there were three incidents of MRSA at the trust. Incidents of MSSA and Clostridium difficile had been mainly in line with the England average.
  • Mortality indicators showed no evidence of risk.
  • Outcomes for patients were mostly the same as or better than the England average.
  • We found that patients were assessed and supported with food and drink to meet their nutritional needs.
  • A new emergency department had been built to meet the increase in patient numbers and new models of working. In eight of the last 12 months, the trust had exceeded the standard of 95% standard for emergency departments to admit, transfer or discharge patients within four hours of arrival which was higher than the England average.
  • The trust had a ‘Right Care’ vision. The majority of staff understood the vision. Directorate plans were in place which supported the trust’s vision and strategy.

  • Following our inspection in March 2016, the Trust informed us of a serious incident that had occurred on the critical care unit. A further unannounced inspection showed insufficient action had been taken to prevent recurrence. Consequently, we spoke with the Chief Executive to gain assurance that additional actions were taken to ensure safety.

We saw several areas of outstanding practice including:

  • Within end of life care, there were innovative ways to ensure care was patient centred for example 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.
  • Through the use of an electronic record and an integration system, a shared record could be accessed securely by partners across all the care settings to obtain a tailored view of an individual’s information.

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

Importantly, the trust must:

  • The trust must ensure that, during each shift, there are a sufficient number of suitably qualified, competent, skilled and experienced staff deployed to meet the needs of the patients.
  • The trust must ensure that the remote telemetry monitoring of patients is safe and effective.
  • The trust must review the governance arrangements and management of risks within critical care to ensure that arrangements for assessing, monitoring and improving the quality and safety of the service are effective.
  • The trust must review the effectiveness of controls and actions on the local and corporate risk register, particularly in medical care and children and young people’s services.
  • The trust must continue to improve engagement with staff and respond appropriately to concerns raised by staff.
  • The trust must ensure that staff complete their mandatory training including safeguarding training.
  • The trust must ensure that guidelines are up to date and meet national recommendations within NICE guidance or guidance from similar bodies.
  • The trust must ensure that physiological observations and NEWS are calculated, monitored and that all patients at risk of deterioration are escalated in line with trust guidance.
  • The trust must ensure the safe storage and administrations of medicines.
  • The trust must improve compliance in medicines reconciliation.
  • The trust must ensure records are stored and completed in line with professional standards, including an individualised care plan.
  • The trust must ensure an effective system is in place to ensure that community paediatric letters are produced and communicated in a timely manner.
  • The trust must ensure that resuscitation and emergency equipment including neonatal resuscitaires, is checked on a daily basis in line with trust guidelines.
  • The trust must ensure the five steps for safer surgery including the World Health Organisation (WHO) safety checklist is consistently applied and practice audited.
  • The trust must ensure that were the responsibility for surgical patients is transferred to another person, the care of these patients is effectively communicated.
  • The trust must ensure there are sufficient numbers of intensivists deployed in accordance with national guidance.
  • The unit must ensure a minimum of 50% of nursing staff have a post registration qualifications in critical care.
  • A multi-disciplinary clinical ward rounds within Critical Care must take place every day, in accordance with national guidance, to share information and carry out timely interventions.

In addition the trust should:

Urgent and emergency care

  • The trust should review why the number of patients leaving without being seen is higher than national average, and take action to reduce this number.
  • The trust should improve ambulance turnaround times.
  • The trust should ensure all MAJAX equipment is checked regularly and is in date.
  • The trust should review compliance with the infection prevention guidelines when administrating intravenous drugs.
  • The trust should review the recording of the cleaning of the children’s area including the toys.

Medical care

  • The trust should consider performing a regular service specific mortality review and ensure actions are taken as a result of the review.
  • The trust should display the full safety thermometer information to patients, visitors and staff.
  • The trust should review the environment and capacity in the haematology and oncology day unit.

Surgery

  • The trust should ensure patients receive timely pain relief.
  • The trust should ensure staff have access to up to date policies and guidelines based on best practice.
  • The trust should review ward rounds on the surgical areas to ensure patients are appropriately reviewed by senior doctors.

Critical care

  • The trust should review implementation of the Guidelines for the Provision of Intensive Care Services (PICS) 2015 guidance.

Maternity and gynaecology

  • The trust should consider developing a maternity and gynaecology strategy to give direction and achievable objectives to the department.
  • The trust should consider safety briefings as part of daily communication with staff in maternity services.
  • The trust should review the use of the ‘scrub’ midwife on the labour ward and staffing establishment in maternity using a standardised acuity tool.
  • The trust should consider submitting and displaying data to the maternity safety thermometer.
  • The trust should audit the compliance of MEOWS charts on the labour ward.
  • The trust should have systems in place to ensure investigations, including root cause analyses, are completed in a timely manner and in line with national guidance.

Children and young people

  • The trust should review the environment in the child development centre.
  • The trust should review the provision of food to children so each person’s nutritional needs are met.

End of life care

  • The trust should ensure that ‘do not attempt cardiopulmonary resuscitation’ decisions are always made in line with national guidance and legislation.
  • The trust should review the route families take to the mortuary and work to improve the environment in the viewing room.
  • The trust should review the mode of transport used for transferring deceased babies and small infants to mortuary.
  • The trust should review infection prevention and control measures within the mortuary.
  • The trust should review the staffing levels for specialist palliative care team doctors.
  • The trust should review resilience around staffing in the mortuary.
  • The trust should work to improve recorded preferred place of death.
  • The trust should consider auditing the responsiveness of referrals to SPCT.
  • The trust should improve engagement with Black and Minority Ethnic (BME) communities, to identify if the trust is meeting the needs of this group of patients at end of life.

Outpatients and diagnostics

  • The trust should review shared learning from incidents and complaints regularly and to all groups of staff.
  • The trust should review the use of clinical supervision in the outpatient department
  • The trust should continue to address cancer waiting time targets.
  • Outpatient services should consider regular team meetings.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 19-20 and 27 September 2013

During a routine inspection

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

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

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

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

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

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

We rated Airedale NHS Foundation Trust as requires improvement overall.

At this inspection we found:

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

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

However:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

Trust-wide

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

Urgent and emergency care services

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

Medical care services

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

Surgery services

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

Critical care

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

In addition the trust should:

Urgent and emergency services

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

Medical care services

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

Surgery

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

Critical care

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

Maternity and gynaecology

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

Children and young people’s services

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

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 13, 14 November 2012

During a routine inspection

We visited ward five a stroke unit, ward six a older persons medical ward, ward 14 a surgical assessment unit and ward 15 a medical assessment unit.

Most of the patients we spoke with were positive about their care and about their experience at the hospital. They said “when I ask for help staff responds quickly, and “no problems with the care and support provided”.

Patients were admitted onto ward 14 and 15, to have their medical needs assessed. We spoke with 22 patients most told us they were either dealt with promptly or if they had to wait; they had understood the reasons why. Most told us they were satisfied with the care and treatment they had received. All praised the staff and said how helpful but busy they were. One person said they had received “good care by the nurses”. Others told us “I received the help I needed, I have no complaints at all”,” it is good they are doing all they can for me”.

Staff told us patients received good care and their needs were met. However, some of the staff we spoke with on ward 15 said they were very busy sometimes and found it difficult to meet people’s needs when the trolley bay was open. (The trolley bay was an extra assessment area on Ward 15, which was opened when the accident and emergency department was busy, it could take up to nine extra patients.) We raised this with the Trusts management team who told us they had identified the risks and were in the process of making improvements to the ward.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 13 April 2011

During a themed inspection looking at Dignity and Nutrition

Patient’s we spoke with were mostly very positive about their experiences of care and treatment. Patients stated that they were kept informed and were involved in making decisions about their care and treatment options. Most patients told us that all of the staff were pleasant and respectful; they felt staff listened and responded to their needs in a timely manner. Example comments included ‘I have observed good responses from staff to other more dependent patient’s’. One person said ‘everything fine, things are explained’ when asked do staff explain and ask if it’s alright before they help you. Another person commented staff are ‘very reassuring, explain what is going to happen, they answer questions when asked’.

Patients were very complimentary about the quality and service of food, they commented that the quality of food overall was good and staff were always at hand to assist them if required. They told us that they had been asked about their food likes and dislikes and that staff always checked if they have had enough to eat and often second helpings were offered.