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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

Reports


Inspection carried out on 13 to 21 Nov 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 10 August 2016
Inspection carried out on 15 –18 March 2016, 31 March, 11 May During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 15 - 18 March 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 15 - 18 March 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
See more service reports published 10 August 2016
Inspection carried out on 28 to 30 March and 12 April 2017

During an inspection looking at part of the service

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 and taken action to address the issues identified at previous inspections, particularly in critical care. However, there remained areas that required further improvement. The trust was often reactive, rather than proactive in identifying areas for development and the pace of change could be improved.
  • 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 and Haematology Oncology Day Unit required addressing to ensure they met patient need and national guidance.
  • The trust was to review the WRES work plan in line with the published 2017 guidance to ensure actions addressed the issues identified in the 2016 NHS Staff Survey and the 2017 WRES data analysis.

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.
  • The trust was meeting most national standards including national cancer standards for referrals and referral to treatment times.

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 poor 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 there is a robust, proactive approach to risk assessment and risk management which includes regular review.
  • Ensure that patient records are stored securely.

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.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 15-18, 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 and 11 May 2016. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme. We 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. Safe and well-led were rated 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.

Within the community services, we rated adult community services, community inpatients and end of life care as good. We rated well-led for adult community services as outstanding.

Our key findings were as follows:

  • The trust 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 trust requires improvement and we have seen 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 that 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 within Airedale General Hospital 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.

  • We found a culture of continual service improvement and innovation in adult community services. There were several examples of enhanced integration between health and social care within community services for adults.

  • 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 within Airedale General Hospital. 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 at the Executive Assurance Group.

  • We 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.

  • We found that patients were assessed and supported with food and drink to meet their nutritional needs.

  • A new emergency department had been opened to meet the increase in patient numbers and new models of working.

  • 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:

  • Telemedicine services provided at the digital care hub were outstanding. The telemedicine service provided remote video consultations between Airedale staff and patients in their own homes, care homes and in prisons. Clinical staff in the hub received calls from staff in care homes and could speak to residents directly whilst viewing them on the screen. They provided advice and support on the most appropriate action to take. If necessary, they could call for emergency services on the patient’s behalf whilst continuing to give advice and reassurance. This service was available 24 hours a day 365 days a year.

  • The community-based collaborative care teams were an outstanding example of a multidisciplinary team working. The teams worked across acute and community services and in collaboration with other agencies to provide a responsive service for patients 24 hours a day, 7 days a week. The teams aimed to support patients in crisis to remain in their own homes and avoid unnecessary hospital admission as well as supporting early discharge from hospital.

  • 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 round within Intensive Care must take place every day, in accordance with national guidance, to share information and carry out timely interventions.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.