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Provider: Harrogate and District NHS Foundation Trust Good

On 14 March 2019, we published a report on how well Harrogate and District NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 14 March 2019

Our rating of the trust stayed the same. We rated it as good because:

  • We rated effective, responsive and well led as good, safe as requires improvement and caring as outstanding.
  • We took into account the current ratings of the six core services across one acute location and three community services not inspected at this time. Hence, five acute services across the trust are rated overall as good and three are rated as outstanding; and three community services are rated good and two are rated as outstanding.
  • The overall rating for the trust’s acute location remained the same. We rated Harrogate District Hospital as good. Community services improved. We rated community services as outstanding.

Harrogate District Hospital

  • 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 rating for safe and well-led improved to good.

Community health inpatient services

  • We rated this service as good. Safe, effective and well led improved to good.

Community health urgent care services (MIU)

  • We rated this service as good. Safe, effective and well led improved to good.

Inspection areas

Safe

Requires improvement

Updated 14 March 2019

Our rating of safe stayed the same. We took into account the current ratings of services not inspected this time.

We rated it as requires improvement because:

  • We cannot rate safe within this service higher than requires improvement because we did not inspect two core services, urgent and emergency care and medical care, which were rated as requires improvement at our previous inspection. This is in line with our published inspection methodology. Although improvements have been made in surgery and children and young people services this was not enough to improve the overall rating in this domain.
  • In children and young people services, some staff we asked were not aware of an environmental risk assessment or formal ligature risk assessment for the ward.
  • In children and young people services, 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.
  • In children and young people services, staff had not kept detailed records of patients’ care and treatment.
  • Within community inpatient services, there were issues with the environment in terms of space and security.

However:

  • Services managed patient safety incidents well.
  • Services used safety monitoring results well.
  • Services controlled infection risk well.
  • Robust escalation processes were in place to treat deteriorating patients in a timely manner.
  • In most areas, there was enough staff with the right qualifications, skills and experience to keep people safe from avoidable harm and to provide the right care and treatment.

Effective

Good

Updated 14 March 2019

  • The trust provided care and treatment based on national guidance. Staff monitored the effectiveness of care and treatment and used findings to improve them.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used specific feeding and hydration techniques when necessary.
  • Overall, staff assessed and monitored patients regularly to see if they were in pain.
  • Staff were competent to complete their roles.
  • Staff from different roles worked together as a team to benefit patients.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They understood how and when to assess whether a patient had the capacity to make decisions.

However:

  • Staff on Woodlands ward had not assessed and monitored patients regularly to see if they were in pain. Pain assessment tools were in place but were not used for every child that required monitoring of their pain. The evidenced based pain tools had not been audited since implementation.

Caring

Outstanding

Updated 14 March 2019

  • Staff cared for people with compassion and dignity at all times. Staff at all levels went the extra mile to ensure that people received the appropriate care, treatment and support. We observed many examples of this during our inspection.
  • Consideration of people’s privacy and dignity was consistently applied. We observed many examples of this during our inspection.
  • Feedback from people who used services was continually positive about the way staff treat patients.
  • There was a strong, visible person-centred culture. People felt really cared for and that they mattered.

Responsive

Good

Updated 14 March 2019

  • The trust planned and provided services in a way that met the needs of the local people.
  • Services took into account patients’ individual needs.
  • People could access services when they needed them.
  • The trust treated concerns and complaints seriously, investigated them and learned lessons which was shared with staff.

However:

  • Across the services we inspected, the average time taken to close complaints was not in line with the trust’s complaints policy.

Well-led

Good

Updated 14 March 2019

  • Managers at all levels in the trust had the right skills, knowledge and abilities to run a service. Managers were visible and approachable.
  • The trust had a clear vision and strategy. Most staff knew, understood and supported the vision.
  • Managers across the trust promoted a positive culture that supported and valued staff. Staff felt respected, valued and supported.
  • Governance processes were clear and easily understood at both the strategic and operational levels.
  • The trust had effective processes to identify, understand, monitor and address current and future risks.
  • The trust collected, analysed, managed and used information well; it had clear service performance measures in place which were effectively monitored and reported.

  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • There were robust systems and processes for learning and continuous improvement. There was a strong focus on quality improvement throughout the trust which was well embedded. There were examples of innovation in care.
Assessment of the use of resources

Use of resources summary

Good

Updated 14 March 2019

Combined rating
Checks on specific services

Community urgent care services

Good

Updated 14 March 2019

  • The provision of community based urgent and emergency services at both Ripon and Selby was of a consistently high standard. The service provided was safe, in that it protects service users from avoidable harm and abuse. Staff provided care in environments that were suitable and well maintained.
  • The care and treatment of those patients using the service had good outcomes, it was based on the best available evidence and promoted good quality of life. Staff were highly qualified, experienced and worked in specialist roles effectively and efficiently.
  • The services available were carried out by staff in a caring, compassionate and respectful way, with dignity underpinning the treatment offered
  • The urgent and emergency care services available are not a 24 hour a day service but were available every day of the year. When open, the services provided met the needs of the community served, and alternative services were available when the units were shut.
  • The service allowed for differing levels of need including those patients whose needs would be described as complex. It strived to remove barriers and offer timely, effective care to all.
  • The community based urgent and emergency services were run effectively, by dedicated leaders with a clear vision and strategy. Since our last inspection changes have been made to the senior leadership and close links have been developed with the main emergency department.

Community health inpatient services

Good

Updated 14 March 2019

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

  • We found the service had made improvements in the focus on patient rehabilitation, holistic care and therapy planning, maintenance of equipment, information provided to patients and their families, compliance with the ward admission criteria, and ward leadership.
  • The ward team had strengthened the admission criteria to ensure staff referring patients had sufficient information on the aims of the ward and its nurse-led provision.
  • We observed staff to be compassionate and caring in their approach and feedback from patients and relatives confirmed this.
  • There were sufficient nursing and therapy staff to provide a good service to patients and ward staff worked as a multidisciplinary team to provide holistic rehabilitation care. We found records included written patient consent to rehabilitation and full risk assessments with regular updates. Patients’ nutritional needs were well managed.
  • Management and storage of medicines and patient records had improved.
  • Mandatory training was managed well and most staff had received appraisals. There was an audit cycle to ensure safety performance, infection control and the environment were monitored and managed appropriately and all areas we inspected were clean.
  • Admissions and discharges were well managed. A discharge liaison nurse ensured patients from acute wards were assessed prior to admission and ensured safe and effective discharges. The multidisciplinary team met weekly to discuss every patient’s care needs.
  • Food and fluids were within patients’ reach and all patients told us they enjoyed the food provided and were supported if necessary.
  • A large rehabilitation area was used in a neighbouring area of the hospital with physiotherapy equipment and access to the occupational therapy kitchen. There was appropriate furniture for dining and social activities. Patient bed areas were arranged to mirror patients’ own home environments to encourage and motivate them to improve their mobility and confidence prior to discharge.
  • Although the ward environment remained challenging due to the age of the building and the layout in terms of space and visibility of patients, staff had provided improved signage to better suit the needs of people with dementia.
  • The service received very few written complaints and was very much appreciated by the local community. The hospital was extremely well supported by the local Friends of Ripon Hospital committee who continued to raise many thousands of pounds to support the care and comfort of patients using the service.

However:

  • The ward environment and bathroom facilities were old and some patient showers had been decommissioned although there were sufficient bathrooms for patient needs.
  • There was a shortage of storage space and trolleys were parked in corridors, causing bottlenecks, particularly at the entrance to the ward. These were easily moved but caused extra work for staff and presented risks to access.
  • Patients had previously not been offered the chance to manage their own medication to prepare for leaving the hospital environment. Staff had attempted to improve this by using individual bedside lockers to store each patient’s medicines. However, staff held only one key for all lockers so medicines were only available to patients at drug round times.

Community health services for children, young people and families

Good

Updated 27 July 2016

Overall, we rated the service as good.

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

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

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

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

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

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

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

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

Community health services for adults

Outstanding

Updated 27 July 2016

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

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

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

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

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

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

Community dental services

Outstanding

Updated 27 July 2016

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

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

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

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

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