Airedale General Hospital

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

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

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

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

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

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

We rated Airedale NHS Foundation Trust as requires improvement overall.

At this inspection we found:

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

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

However:

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

We saw several areas of outstanding practice including:

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

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

Importantly, the trust must:

Trust-wide

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

Urgent and emergency care services

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

Medical care services

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

Surgery services

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

Critical care

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

In addition the trust should:

Urgent and emergency services

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

Medical care services

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

Surgery

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

Critical care

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

Maternity and gynaecology

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

Children and young people’s services

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

Professor Edward Baker

Chief Inspector of Hospitals

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

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

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

In Medical care our key findings were:

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

In Critical Care our key findings were:

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

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

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

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

Professor Sir Mike Richards

Chief Inspector of Hospitals