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Provider: Airedale NHS Foundation Trust Requires improvement

On 14 March 2019, we published a report on how well Airedale 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

Requires improvement

Updated 14 March 2019

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

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

  • We had concerns about nurse and medical staffing. There were high numbers of unfilled shifts for registered nurses in some clinical areas. Staff told us they gave medications late and completed poor or infrequent documentation as a result of poor staffing. Completion of paediatric sepsis pathway documentation was poor.
  • We found that some concerns highlighted following our last inspections in 2016 and 2017 had not been addressed despite us telling the trust they must make improvements. Use of the World Health Organisation (WHO) checklist was not embedded and the environment in a theatres area was not compliant with national standards related to airflow.
  • There were gaps in medical cover in the emergency department and the trust was not compliant with national standards for the out of hours medical cover in the critical care unit. We had raised concerns about out of hours medical cover in 2016 and 2017.
  • Risk assessments were not always completed or reviewed. Patients were not always assessed for delirium in line with best practice. Risks that threatened the delivery of safe and effective care were not always identified promptly. For example, ward staff did not consistently report the impact of suboptimal staffing levels on patient care. This had been a concern at our previous inspection.
  • Staff did not always recognise, report or record incidents and not all incidents were effectively investigated. This meant opportunity for learning from incidents was missed. We were not assured systems to communicate lessons learned from serious incidents and never events to all staff were always effective
  • We had concerns about the assessment and management of patients with mental health needs. Patients waited several hours in the emergency department to be assessed, and the gaps in out of hours mental health liaison meant patients who had arrived during the night were often still waiting the next morning.
  • In some areas, there was poor compliance with the trust’s infection prevention and control policy; this included staff not adhering to the uniform policy and there was an inconsistent approach to labelling of clean equipment. Some environments, particularly the walls and fixtures on two surgical wards were in poor order; they required repair and could not be cleaned effectively. Equipment cleaning schedules on wards were not comprehensively completed and visibly dirty equipment was stored with visibly clean equipment and consumables.
  • Processes intended to keep staff safe had not always been followed. For example, there was no evidence checks on the lead aprons in the x ray department had taken place since 2012.
  • There were both paper and electronic records in use. This meant in some areas, staff recorded information on paper forms then had to transcribe that to electronic records. There were potentials for error, and it took staff extra time to do this.
  • We were not assured that storage of patient records on the wards was compliant with data protection regulations; there was a risk that patient’s confidential information could be accessed inappropriately. Paper patient records were not stored securely.
  • Complaint investigation and response times did not consistently meet the trust target of 40 days; on average it took 56 days to investigate and close complaints.
  • Governance over policies, procedures, other documents such as patient pathways was not robust; several were past the date for review and there was limited evidence of document control.
  • Several clinical and non-clinical areas were in a poor state of repair and reflected the ageing buildings.

However;

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

Safe

Requires improvement

Updated 14 March 2019

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

  • We had concerns there was not always enough suitably qualified, competent, skilled and experienced staff to meet the needs of patients. Nurse staffing was not always at safe levels. Staffing levels and staff skill mix had been identified as an issue at our last inspection. Short notice agency requests contributed to the number of unfilled shifts. Some acutely ill or dependent patients received less than two hours of care from a registered nurse each day and around four hours of care from support workers.
  • Staff told us they did not always report sub-optimal staffing levels and how this impacted on patient care. Managers were aware of instances where there was one registered nurse on duty which had not been reported on the electronic incident reporting system. This had been identified at our last inspection.
  • At our last inspection we found the national guidance for registered children’s nurse provision was not being met. At this inspection there was still a shortage of children’s nurses, although mitigations were in place.
  • Medical staffing remained a concern. There had been increased on-call commitments for doctors over recent months. Consultant cover was not always in line with national guidance in emergency department, critical care or obstetrics. If an emergency surgical or obstetric patient needed to go to theatre, there were insufficient numbers of appropriately trained medical staff available to safely care for patients. Not all patients were assessed by medical staff before being admitted to critical care.
  • Only half of all patients in emergency department received an initial assessment within 15 minutes of arrival. It was unclear from the nursing records we looked at on the wards, whether there was a standard set of risk assessments for all patients as not all patients had all risk assessments. We found that risk assessments such as falls and manual handling were not always reviewed when they should be.
  • There was inconsistent compliance with world health organisation (WHO) safer surgery checks. During 2018 there had been never events related to poor compliance with the checklist.
  • Patient safety incidents were not consistently well managed. Although staff recognised incidents, they did not always appropriately report them and there was not a robust lessons- learned process.
  • Both paper and electronic records were in use in some areas. Staff told us they found this confusing, and we saw it lead to some inconsistencies and incomplete documentation. Sepsis audits found incomplete documentation.
  • We were not assured that patient records on the wards were always stored securely and there was a risk of access to records by unauthorised persons.
  • Although we saw improvements in mandatory training overall, there were gaps in compliance with essential training (including safeguarding training) for registered nurses and doctors.
  • There were inconsistencies in infection prevention and control measures. Staff did not ensure all ward areas and equipment were clean and cleaned equipment was not always labelled. Some walls and fixtures on the wards were damaged significantly and could not be cleaned effectively. Some staff did not always adhere to the trusts uniform policy.
  • There were theatre areas which were not compliant with national guidance around airflow.
  • Risk assessments and treatment plans for patients with mental health problems were inconsistent; records we checked indicated no documented risk assessment for nine patients who waited up to two hours before they were reviewed. Some patients waited over five hours for an assessment. The mental health assessment room in emergency department did not meet the required standards.

However;

  • There was improved oversight of mandatory training in some areas where there was a clinical educator in post. Compliance levels for mandatory training were increasing and staff told us they had better access to complete some training online and through other means such as workbooks.
  • Most staff we spoke with had a good understanding of safeguarding, what action they need to take when they had concerns and knew who to go to if they needed advice or support.
  • Medicines reconciliation practices had improved since our last inspection. Medicines were stored, prescribed, and administered safely.
  • There were appropriate measures to prevent the spread of infection. Patient movement was appropriately restricted to prevent spread of infection during outbreaks.
  • When things went wrong, staff apologised and gave patient’s honest information and suitable support.
  • Most areas we visited were clean and tidy.
  • Handwritten records were legible, dated, timed, and signed.

Effective

Good

Updated 14 March 2019

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

  • Trust policies were available for staff to access on the trust intranet. These included a range of pathways and guidance which reflected national evidence based best practice and guidelines. Care and treatment was mostly based on national guidance.
  • Services monitored the effectiveness of care and treatment, and used the findings to improve care. There had been reduction in some patient harms, for example, falls, by using national guidance.
  • Staff assessed and monitored patients regularly using suitable assessment tools, to see if they were in pain. They supported those who found it difficult to communicate. We saw overall improvements in documentation of pain assessments.
  • Staff of different kinds worked together to benefit patients. Registered staff, non-registered support workers, allied health and social care professionals and support services worked well together. We saw positive examples of good teamwork.
  • Patients were supported with their nutrition and hydration needs. Overall, staff referred to dieticians when specialist advice or support was needed. Support was provided at mealtimes to make sure patients received food and drink on time. Services took account of patients’ religious, cultural, and other preferences.
  • Staff received training in consent, the Mental Capacity Act and Deprivation of Liberty Safeguards, and overall, demonstrated good knowledge of these; they knew how to support patients who lacked the capacity to make decisions about their care.
  • Overall, staff received annual appraisals, and were supported to learn and develop. Some areas exceed the trust target for staff receiving an appraisal.
  • There were some pre-operative education sessions to enhance patient recovery of some patients undergoing planned surgery.

However;

  • Performance in some audits was mixed; standards were not always achieved.
  • Consent was not routinely obtained in accordance with best practise, as a two- stage process.
  • There were higher unplanned re-attendance rates in emergency department, and higher than expected risk of readmission for non-elective and elective admissions.
  • Information provided to us by the trust before our inspection showed some appraisal rates of staff were well below the trust target; however by December 2018 the appraisal rate was 96% on average.
  • There was no seven-day therapy service for patients recovering from stroke or requiring ongoing rehabilitation for other conditions. Physiotherapy rehabilitation outcome measures were not audited; therefore services could not measure if desired outcomes were met for patients.
  • We saw evidence that some pathways and processes had not been reviewed which meant staff were not always able to follow the most recent guidance.

Caring

Good

Updated 14 March 2019

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

  • We saw all staff cared for patients with compassion. Feedback from patients during the inspection was positive. We found staff of all grades to be polite, respectful, professional, and non-judgmental in their approach.
  • We observed staff responding to patients’ needs in a compassionate and timely manner. Staff involved patients and those close to them in decisions about their care and treatment. We saw that patients were provided with regular updates regarding their treatment, and patients told us they felt well informed.
  • We saw discreet and confidential communication, and curtains were used between bed spaces, or side ward doors were closed before treatment commenced to maintain privacy and dignity.
  • Staff supported patients with their emotional needs. Some patients also had access to specialist nurses for further information and support.
  • We saw staff introduce themselves by name and sometimes ask patients what they preferred to be called.
  • The response rate for the friends and family test was better than the England average. There were consistently high recommendation rates of over 90%.
  • We observed staff responded promptly to call bells or requests for assistance from patients.
  • There was a multi-faith chaplaincy service which supported staff, patients, and families with religious, spiritual, and pastoral support.

Responsive

Good

Updated 14 March 2019

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

  • Services were generally planned and provided to meet the needs of local people. The services worked in partnership with clinical commissioning groups (CCGs) and other providers across clinical networks to deliver the services people needed.
  • Some planned operations were carried out on a Saturday morning for the benefit of patients and to reduce waiting lists.
  • There were integrated pathways and positive examples of services working together with other care providers to improve service delivery to the local population.
  • Some clinical areas had been designed and improved to be more responsive to patient needs, for example the emergency department and acute assessment unit.
  • There had been some adaptations to other areas to make the environment more suitable for patients living with dementia or those with learning disabilities.
  • Services worked hard to reduce length of stay where appropriate, and work had been done to reduce delays in discharge or transfer of care from hospital.
  • Interpretation services were available and staff knew how to access them when needed.
  • There were more compliments then complaints received into the core services, and we saw lots of thank you cards. Information about how to raise a concern was clearly displayed.
  • Learning from complaints was generally shared within teams.

However;

  • Overall, complaints were not responded to and closed within the trust target of 40 days. The average response time was 56 days; we saw delays over 64 days.
  • Responsiveness to the needs of patients with mental health needs was not always timely. There were gaps in the out of hours service.
  • Some performance times in the emergency department were worse than the national average, for example the time from arrival to treatment.
  • From October 2017 to September 2018 the trust consistently failed to meet the four hour emergency care standard. However, apart from one month (August 2018) the trust consistently performed better than the England average.
  • There were longer lengths of stay for some patients, for example those with some respiratory conditions.
  • There were backlogs in waiting times which were not in line with national standards.

Well-led

Requires improvement

Updated 14 March 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • We found that concerns highlighted following our last inspection had not been addressed; these related to nurse staffing, initial assessment of patients, mandatory training compliance for medical staff, compliance with the safer surgery checklist and record keeping. We were not assured services had adequate oversight of these issues. We saw the pace of improvement since our last inspection was too slow. Following our previous inspection, we told the trust they must take action in respect of these issues.
  • We were not assured that managers fully understood the staffing situation in terms of nurse to patient ratios and we were concerned that staffing risk was not fully mitigated. For example some managers were unclear how suboptimal staffing levels impacted on patient care; that risks associated with staffing threatened the delivery of safe and high quality care.
  • There had been limited progress on some actions to ensure the critical care unit fully met national standards. In particular we were concerned about the out of hours medical cover which meant patients’ safety could be at risk due to their being insufficient numbers of appropriately trained medical staff available. This could also result in a perceived lack of support available for more junior staff.
  • There was limited or no evidence of action plans after some audits, for example the royal college of emergency medicine audits.
  • Ward managers had limited time to carry out their management duties as they were part of the’ numbers’ on their wards.
  • We had concerns about the security of patient records in ward areas as these were stored in unlockable trolleys in public areas of the wards.
  • A limited number of staff told us they did not always feel supported. They felt pressured and told us morale was low.
  • Some consultants told us services were more target driven than patient focussed. Although they said the recent appointment of the two deputy medical directors was supportive and was helping.

However;

  • Service leaders were approachable, visible, supportive, and well respected. Front line staff and leaders were appreciative of each other’s roles and of how they contributed to delivering a high standard of patient care and positive patient experience.
  • Front line staff were enthusiastic, open, welcoming and friendly without exception. They told us about the ‘right care’ vision and values, and what they wanted to achieve for patients. Leaders told us of collaboration with clinical networks, other providers, staff, patients, and local community groups.
  • .All staff we spoke with told us Airedale hospital was a good place to work. They told us the culture was positive and that there was a sense of purpose for the benefit of patients.
  • We saw improved governance structures in most areas; there was oversight of performance targets and patient safety measures. Some wards and clinical areas had development plans which identified actions and named people responsible to make improvements where needed.
  • There was positive engagement with patients, staff, the public and local organisations to seek feedback as a way to improve services. Staff we spoke with told us they felt listened to and we heard examples from staff and service managers who had been, or were involved in quality improvement work.
  • Generally, there was commitment to learn from things going well, or when something went wrong. Some services had been proactive to improve since the last inspection.
  • Staff were supported to learn and develop through in-house courses and university based learning.
  • There were some approaches to address recruitment difficulties and work with local universities to train nursing associates. Support workers were engaged in a programme of up-skilling to undertake extended roles.
Assessment of the use of resources

Use of resources summary

Good

Updated 14 March 2019

Combined rating
Checks on specific services

Community health inpatient services

Good

Updated 10 August 2016

Overall rating for this core service

Good

We rated the service as good overall.

Staff understood and fulfilled their responsibilities to raise concerns, report incidents and near misses. They were involved in taking action to prevent further occurrences.

Patient risks were assessed, monitored and managed on a day-to-day basis. The assessments were person-centred and reviewed regularly and staff responded appropriately to changes in risks.

Staffing levels were consistently at the planned level and where patients had been risk assessed as needing additional support this was provided.

Safeguarding vulnerable adults and children were given sufficient priority and all staff had completed the relevant training.

Patients had comprehensive assessments of their needs completed, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. Expected outcomes were agreed with the patient, reviewed and updated.

Staff were competent and were supported to acquire and develop further skills to carry out their roles effectively and in line with best practice. The learning needs of staff were identified and training was put in place to meet these. Staff were supported to deliver effective care and treatment and undertake clinical supervision to enhance their role.

Multi-disciplinary team working was effective and well coordinated and staff worked collaboratively to meet the range and complexity of patient’s needs.

Staff were caring, they respected patients’ privacy and dignity. Patients felt supported and involved in their care to make informed decisions.

They were encouraged to manage their own health and care when they could and to maintain independence.

Staff were proud of the care they delivered to patients on their ward and enjoyed working there.

The services were planned and delivered in a way that met the needs of the local community. People knew how to raise concerns and complaints and these were responded to and improvements made.

Governance in the service was effective. Risks were identified and appropriately raised onto the risk register. The leadership, governance and culture of the service promoted the delivery of person centred care. Candour, transparency and challenges to practice were managed and addressed.

Th

e hospital was an old historic building not owned by the trust. A number of risks relating to the building had been identified and escalated to landlords for action. The risks were on the trust’s risk register for monitoring purposes.

  • Limited pharmacy cover and support was in place on the ward. There were no

    dedicated activities for patients to encourage their personal wellbeing and rehabilitation.

Community health services for adults

Good

Updated 10 August 2016

Overall, we found services for community adults to be good.

There was a good culture of incident reporting. Staff received feedback and there was evidence of shared learning and responding to incidents to prevent reoccurrence. Staff understood their role with regard to keeping patients safe. They knew about the different types of abuse to look for and how to raise a safeguarding concern. There was excellent compliance with adult safeguarding training. We observed good infection control practices and compliance with mandatory training was high, exceeding the trust target in all areas but one. Staff were aware of the key risks to patients and how to detect if there was deterioration in a patient’s condition. Risk assessments were completed thoroughly with actions clearly documented to reduce risks. Staffing levels were good and staff said their workload was manageable. Community staff received excellent clinical support from advanced nurse practitioners.

Community services for adults worked with pathways based on National Institute of Clinical Excellence (NICE) guidelines and took part in local and national audit. We saw effective use of telemedicine. The digital care hub housed the intermediate care hub, the gold line service which provided care for patients in the last 12 months of their life, and the telemedicine service. Patient outcomes were measured at both local and service level. We saw examples of positive patient outcomes following intervention from community services. Staff appraisal rates were high at 89% and staff received regular supervision. Advanced Nurse Practitioners (ANPs) provided advice and support for staff caring for patients with complex conditions. We saw many examples of multidisciplinary and multi-agency working in order to provide effective care for patients. The Craven collaborative care team were a multi-professional team, which included mental health nurses and social care workers. Access to information was good. Patient records were held on the same electronic system used by the hospital and by most GP practices in the area. This allowed for sharing of information and good communication between health care staff. There was a plan to improve this further with agile working.

Caring was good. Patients we spoke with were happy with the care they received and told us staff were kind and supportive. We observed staff treating patients with dignity and respect. Teams had dignity champions whose role was to challenge poor care and promote dignity. Staff provided holistic care. There was a focus on promoting independence and enabling patients to manage their long term conditions. There was emotional support available for patients and carers. Mental health nurses worked in the collaborative care teams and could offer assessment and treatment to patients with mental health conditions. Specialist nurses were able to give emotional support to patients and their families. They also referred patients to other organisations able to offer support.

Friends and Family Test data for community services showed consistently high scores of between 95% and 100% for patients who would recommend the service to their friends and family.

Community services for adults were responsive. There was close working with commissioners to provide services to meet the needs of the local population. Services were planned in conjunction with the acute hospital, and other agencies to provide integrated care to patients. We found some good examples of services responding to the needs of a diverse population. An interpreter was present at the cardiac rehabilitation exercise classes and there were women only hydrotherapy sessions available. Community services for adults were extremely accessible and timely. The telehealth service provided immediate access to expert opinion and diagnosis and was available 24 hours a day, seven days a week. Staffing at the hub was increased in the evenings, on weekends and bank holidays when demand was highest. The needs of vulnerable people were met. Mental health nurses were based in the collaborative care teams and could provide mental health support for patients. Teams had a dementia link person who attended the dementia focus group and shared information with the teams. The service received a low level of complaints and a high level of compliments. Staff told us they tried to deal with informal complaints as early as possible before they escalated.

We found community services were extremely well led. Senior managers shaped their services to meet the overall trust vision of ‘Right Care’. Services were being developed and transformed to ensure that patients received care closer to home. Clear governance arrangements were in place with risks assessed, documented and control measures implemented. Community services produced a monthly quality account dashboard, which showed performance against patient safety, clinical effectiveness and patient experience indicators. We found strong leadership at local and senior level. Staff spoke highly of their managers and told us they often saw them and they were approachable. Managers told us they were extremely proud of their staff. There was patient involvement in focus groups to develop new pathways of care and the service participated in the Friends and Family Test. Staff were highly engaged. They enjoyed their work and were patient centred in their approach. They told us they felt valued, supported and well managed. We found a culture of continual service improvement and innovation with a willingness to embrace new ways of working.

End of life care

Good

Updated 10 August 2016

We rated the service as good overall.

Staff felt fully supported and fulfilled their responsibilities to raise concerns and report incidents and near misses. Transparency and openness about safety was encouraged. Plans were in place to respond to emergencies and major situations.

Staff used recognised documentation to ensure that patient’s wishes were assessed in relation to their end of life care needs. We saw good examples of evidence based practice. Systems were in place for patients to receive anticipatory medications.

Staff were trained and competent within their role. Training had been provided to increase knowledge where staff felt they required specialist skills in relation to end of life care.

Effective MDT working and co-ordinated care pathways allowed for continuity of patient care. Gold Line allowed people to contact the service for support and advice to meet the patient’s end of life care needs 24 hours a day. Services worked together to ensure that 24 hour end of life patient care was provided in the community.

Patients and relatives were treated with dignity, respect and felt supported and cared for. Staff communicated well and worked together to plan the care and treatment. They encouraged patients to be involved in the decision-making about their end of life care needs. We observed staff responded compassionately when patients and families required support and helped them to cope emotionally.

Responsive times were good when patients were required to access services. Complaints and concerns were responded and listened to and improvements were made as a result.

We saw evidence of good leadership in the community teams and Harden ward and teams met regularly to discuss their roles and service. The leadership, governance and culture of the service promoted the delivery of person centred care. An open and honest culture was adopted where managers met with staff regularly to discuss their service.

However we also found:

Limited participation in national audits and the community teams and in patient ward were not always involved in trust wide audits. We observed delays in the timescales of re-evaluating audits.

We found some DNACPR forms did not meet the required standard.