Harrogate and District NHS Foundation Trust

Harrogate and District NHS Foundation Trust is an integrated trust providing acute hospital and community services to Harrogate district, North East and West Leeds. The trust also provides children’s healthcare services in North Yorkshire. The trust was authorised as a Foundation Trust in January 2005 and serves a population of approximately 900,000 people.

We inspected Harrogate and District NHS Foundation Trust (the trust) as part of our comprehensive inspection programme. We inspected all eight core services at Harrogate District Hospital, the in-patient services at Ripon Community Hospital, the minor injuries units at Selby and Ripon as well as community dental services, community healthcare services for adults, and children’s community services across various areas served by the trust. In addition, we carried out an unannounced inspection on 10 February 2016. Harrogate District Hospital had been previously inspected in January 2014, but not rated at that time.

We have rated Harrogate and District Foundation Trust as overall good. On the whole service provision was good across the trust, with some areas rated as outstanding. However, there were some services that required more attention, particularly children’s and young people’s and end of life services within the acute hospital and the community in-patient services and minor injuries units. Plans were in place regarding the development of the community in-patient services with the introduction of new models of care.

There had been changes made to the arrangements within the trust since the Chief Executive was appointed in August 2014, including a refresh of the trust values and a strengthening of the governance arrangements across all sites. There was confidence in the executive team across all areas of the trust and staff were proud to work for the organisation. Much work had been done to bring together the acute and community services to operate as one organisation and on the whole this had been successful. However, there was still some areas where further work was needed to integrate the services, particularly the community in-patient services and minor injuries unit. Further work was needed at the acute hospital to develop the children’s and young people’s services, the trust were aware of this and new leadership had been introduced. There was no strategic plan in place for end of life care, although in its absence the trust had developed a care of the dying adult and bereavement policy. The responsiveness of this service also required improvement.

We found some outstanding practices, particularly aspects of caring and also within service delivery for critical care, outpatient and diagnostic services, community health services for adults and community dental services. This was a values driven organisation, staff at all levels were aware of the values and these were embedded in practice, for example as part of the recruitment process. There was an open and honest reporting culture and staff support was strong across the trust.

Our key findings were as follows:

• There were clear values that had been developed with staff. Staff had confidence with the leadership team, who were reported to be visible and accessible.
• There was a clear trust vision and strategy across the trust and for each of the services. Staff were aware of their role in this strategy and understood the ambition for ‘Excellence every time’.
• There was good morale amongst staff, they told us they were proud of their trust and the care they delivered to patients.
• There was strong leadership and staff reported that there was a supportive culture. Despite the large geographically dispersal of services, with challenges associated with this, staff reported that they felt connected to the trust as a whole, although more work was needed to promote this within the minor injuries units and the community inpatient services. Further work was needed to ensure that the practices and delivery of services within the minor injuries unit and the community in-patient services were consistent with the rest of the trust.
• There was a strong governance framework, which ensured that responsibilities were clear and that quality, performance and risks were understood and managed effectively.
• Overall the community dental services were outstanding. Services were patient focused and highly responsive to needs ensuring that the right care was delivered at the right time. Patients were given time and space to relax in the dental environment. Staff were accommodating to patients’ needs and constantly looking for new ways to make the service more accessible to people with anxieties and phobias as well as special needs.
• Community health services for adults were outstanding overall and specifically in relation to caring and being well-led. Feedback we received from patients was consistently positive and they told us that staff go the extra mile which we witnessed during our inspection.
• Services within critical care were outstanding as people’s individual needs were central to the planning and delivery of the service. There was a proactive approach to understanding the individual needs of patients and designing the delivery of care around these.
• Outpatient and diagnostic imaging services were outstanding. These services were tailored to meet the needs of individual people and were consistently exceeding performance targets.
• The senior leadership within the children and young people’s services had only been in post for a relatively short time. Therefore, the service had yet to fully develop a comprehensive vision, strategy and further work was needed to embed the governance structures.
• There were governance, risk management and quality measurements in place to promote positive patient outcomes. Care was delivered in accordance with national and best practice guidance. Policies, procedures and local guidelines were based on evidence based practice and in line with the National Institute of Clinical Excellence guidance.
• There were no risks identified in the measures for mortality, including in-house mortality, the Hospitals Standardised Mortality Ratio (HMSR) and Summary Hospital-level Mortality (SHMI).
• There was openness and transparency about incident reporting and learning lessons. The hospital had a strong safety culture and staff were confident in the reporting of incidents.
• Cleanliness was to a good standard throughout the services and there were systems in place to prevent and control infection. On the whole staff adhered to trust policies and procedures, although we observed lapses in some areas. Some services lacked a robust audit programme, which could support the identification of inconsistent infection and prevention and control practices so these could be addressed.
• At the Harrogate District Hospital site, a redesign project was underway which aimed to improve patient flow and enhance the patient experience for acute medical admissions. To aid with patient flow, discharge liaison nurses facilitated the timely discharge of complex patients.
• Patients were treated with dignity and respect. There was consistently high scores in the Friends and Family Test for patients who would recommend the service. Some medical wards regularly achieved 100%. Staff were alerted when a patient with specific needs was admitted or attended clinic and reasonable adjustments were made for patients living with dementia or had a learning disability.
• The safe use of innovative approaches to care was encouraged; collaborative team working was positively promoted. Patients’ access to pain relief and nutrition was good.
• Staff told us there were good training opportunities available to them and nurses were well supported with completing their nurse revalidation. However, in some areas, for example medical care junior doctors told us that work pressures was effecting their training as they did not have enough opportunities to learn and were not having regular supervision. Not all staff, particularly in the children’s and young people’s service had completed the relevant children’s safeguarding training.
• Staffing levels and skill mix across services were generally planned in line with best practice, patient acuity and national guidance. However, actual staffing levels did not always meet planned, for example in the urgent and emergency care department, children’s services and surgery. The trust was actively recruiting to posts and taking action to improve staffing levels through better use of the skill mix of staff.

We saw several areas of outstanding practice including:

Harrogate District Hospital

• The supporting intensive therapy unit patients (situp) service.
• Clinical psychology service to inpatients and outpatients at the follow up clinic in critical care.
• The use of patient diaries on critical care by the multidisciplinary team.
• The critical care outreach team’s leadership, advanced clinical skills and commitment to education.

• The critical care online “virtual” journal club.
• We spoke with the diabetes specialist nurses who demonstrated how they used information from the Electronic Prescribing and Medicines Administration (EPMA) system to monitor patients’ blood sugar readings and insulin doses. If a patient had a blood sugar reading of less than 4 or more than 15, a specialist nurse would proactively visit them. This enabled the team to target those patients early who required a review and allowed interventions to be made before referrals were received. This also helped to streamline the team’s workflow. We thought this was innovative practice.
• The redesign of the acute admissions and assessment pathway, known as the ‘FLIP’ project was outstanding. The project was initiated and driven by staff. It involved the redesign and integration of the CATT Ward and the CAT team. Although the project started in October 2015, the benefits of the project were already being seen. Despite up to a 13% increase in non-elective in-patient activity within medical specialities, the percentage bed occupancy had decreased from October 2015 to January 2016 compared to the previous year. Managers attributed the fact that the hospital had not needed to open up the 12 bedded winter pressures escalation ward to the success of the project.
• The main outpatient department was an accredited centre for the treatment of faecal incontinence using percutaneous tibial nerve stimulation. Staff told us they were the first NHS centre to be awarded this accreditation.
• A review of the glaucoma pathway had led to; the redesign of the layout and content of the clinic rooms, the introduction of a virtual clinic for lower risk glaucoma patients and the ongoing development of nurse practitioners.

Community Dental Services

• The individual care offered to patients was specific to the patient’s needs. Where conventional care would not meet the needs of the patient, the service was willing to adapt to meet their needs. This included carrying out assessments in non-clinical spaces to enable patients to relax and providing calming reassurance to distressed patients. Staff had a high level of skill in creating a relaxing and professional environment. Meeting the needs of a patient was seen as a challenge to be met and patients were not turned away for being too complex.
• The service responded effectively to the needs of the community and staff were actively seeking out groups of people who were at risk from poor dental hygiene or who were normally excluded from routine dental treatment. The work the service was doing with prisoners, the homeless and people with a history of substance misuse was reflective of this inclusive approach to ensuring all people can receive the best dental support.

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

• Take steps to ensure that the environment on the Woodlands ward is appropriate to allow the needs of children and young people with mental health needs to be fully taken into account
• Ensure that accurate nursing records are kept in line with professional standards particularly in urgent and emergency services and that medical records are stored securely in services for children and young people and within the mortuary area.
• Ensure that good infection protection and control practices are adhered to particularly on all medical wards and that an effective infection prevention and control audit programme for the environment and hand hygiene in services for community adults and the Selby MIU is in operation.
• Ensure that all medicines are stored safely and are disposed of when out of date. This particularly applies to oxygen cylinders and drugs on the emergency trolleys in the hospital and the checking of controlled drug stocks in the MIU.
• Ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels particularly in medicine, end of life care and children and young people.
• Ensure all staff have completed mandatory training, role specific training and had an annual appraisal particularly: appraisal rates within maternity and gynaecology; mental health training for paediatric staff and; safeguarding training in both community and acute services for children and young people.
• Ensure guidelines and protocols are up to date and there is an effective system in place to review these in a timely manner particularly in maternity and gynaecology; radiology and PGDs (patient group directives), treating children under one years old and joint working arrangements with GP OOHs and the local EDs in the minor injury units.
• Ensure medical devices are subject to servicing in line with recommended guidelines especially in services for community adults.
• Improve the facilities in and access to the mortuary.

Additionally there were other areas of action identified where the trust should take action and these are listed at the end of the reports.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

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

We rated community inpatient services as requires improvement. This is because:

• We saw that community inpatient services were caring and responsive. However we found the service required improvement for safe and effective care and also required improvement for well led. The care provided did not always focus on patient rehabilitation and reablement.

• Feedback from patients and relatives was very positive and we observed staff to be compassionate and caring in their approach. Patients were not empowered to take control of their rehabilitation.

• We saw evidence of good multi-disciplinary working across nursing, therapy and medical teams but there was a lack of leadership within the multi-disciplinary team which meant that plans of care for individual patients were not clear or focussed or holistic.

• The service did not provide an effective rehabilitation service. It was not performance managed or monitored and lacked leadership.

• There was a lack of consistent therapy input as the therapy staff working in a community team that responded to crisis intervention in the community.

• Medicines management was generally good but patients were not offered the chance to manage their own medication as a means to prepare for leaving the hospital environment.

• Patient records were well managed and national guidelines were followed for falls prevention and pressure ulcers. However there were some gaps in the management of patients’ nutritional needs and a lack of documentation to support what actions had been taken to meet these needs. Patients’ notes and records were not securely stored.

• Staff felt involved in patient care, mandatory training was managed well and some staff had received appraisals.

• Most staff followed infection control procedures and all areas we inspected were clean. There was not a comprehensive or robust system in place for the maintenance, servicing and safety checking of electrical equipment on the ward.

• Food and fluids were within patients’ reach and most patients told us they enjoyed the food provided and were supported if necessary. Patients felt safe and cared for during their stay and staff were sensitive, compassionate and maintained dignity and respect for their patients.

• Patients and their relatives were not given adequate information about their environment, the purpose of the ward and what to expect during their admission or on discharge from hospital.

• The ward environment was challenging due to the age of the building and the layout in terms of space and visibility of patients. There had been no reasonable adjustments made to the environment for those patients living with dementia.

• Admissions and discharges were well managed although the ward team sometimes felt under pressure to accept patients who did not meet the full admission criteria, particularly those with dementia or confusion. Delayed discharges were mainly due to family choice, lack of nursing home places and waiting for packages of care to be put in place.

• 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 have raised many thousands of pounds to support the care and comfort of patients using the service.

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.

The service prioritised patient protection from avoidable harm and abuse. Patients were seen and treated quickly; in an appropriate environment with good facilities. The departments met the national standard for seeing, treating and discharging patients within four hours.

Patients’ complaints were taken seriously and responded to in a timely way. Feedback from patients was positive and patients were treated with compassion, dignity and respect.

Staff had the appropriate qualifications however; there were no competency packages for new or non-qualified staff. Structures, processes and systems of accountability including governance and management partnerships, and joint working arrangements were not clearly set out. The minor injuries units and ED worked in isolation of each other.

There were lack of clinical audits of patient outcomes at the MIU’s and a lack of presence of senior leaders.