Harrogate District Hospital

We inspected Harrogate District Hospital as part of the comprehensive inspection of Harrogate and District NHS Foundation Trust from 2 to 5 February 2016. We carried out an unannounced inspection of the hospital on 10 February 2016. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

Overall, we rated Harrogate District Hospital as good. The majority of services were rated as good across the hospital, with some areas rated as outstanding. However, further work was needed at the 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 service had a leadership structure split between two directorates, which the trust had recognised could be more effective and was being reviewed.

We rated caring as outstanding, effective, responsive and well-led as good; and safe was rated as requires improvement.

We rated critical care and outpatients and diagnostic imaging as outstanding, urgent and emergency services, medical care, surgery, maternity and gynaecology and end of life as good. We rated services for children and young people as requires improvement.

Our key findings were as follows:

• The trust values and vision were well known across the hospital services. There was strong leadership and staff reported that the leadership team were visible and that local management was supportive. However, 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 was good morale amongst staff, they told us they were proud of their hospital and the care they delivered to patients.
• 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 were in line with the National Institute of Clinical Excellence guidance.
• There were no risks identified for in-hospital mortality, the Dr Foster Hospital Standardised Mortality Ratio Indicators or the Summary Hospital-level Mortality.
• 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.
• 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.
• Staff had a good understanding of the Mental Capacity Act 2005 and the Deprivation of Liberties Safeguards and there were well established processes in place for the obtaining of consent.
• 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.
• We rated critical care services as outstanding. People’s individual needs were central to the planning and delivery of critical care. The service engaged patients and the public to plan and improve the service. There was a proactive approach to understanding the needs of difference groups of people, and appropriate support was provided. For example for patients who had a traumatic experience in critical care. Patients were seen by the nurse and clinical psychologist in the supporting intensive therapy unit (Situp) patients’ service.
• Outpatient and diagnostic imaging services were outstanding. These services were tailored to meet the needs of individual people and were consistently exceeding performance targets
• 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 were affecting 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.
• The hospital had not undertaken a risk assessment for the admission and care of children and young people with a mental health illness. Plans were in place to obtain training from a local trust for the care of young patients with a mental health illness.
• The urgent and emergency care department was generally meeting the 95% standard for emergency departments to admit, transfer or discharge patients within four hours of arrival. However, the department was no longer large enough to suitably accommodate the number of patients, equipment and consumables needed, as these had increased over the years.
• Staffing levels and skill mix across services were generally planned in line with best practice and based on patient acuity. However, actual staffing levels did not always meet planned, for example in the urgent and emergency care department, maternity services and surgery. A recognised acuity tool was not used within children’s and young people’s services and staffing levels were not always compliant with safer staffing guidance. The trust was actively recruiting to posts and taking action to improve staffing levels through better use of the skill mix of staff.
• The standard of cleanliness throughout the hospital was to a good standard and infection control audits showed a good performance. There had been no incidence of Methicillin-resistant Staphylococcus Aureus and 16 cases of Clostridium difficile from May 2015 to August 2015. In some medical wards we found poor adherence to infection prevention and control (IPC) policies and procedures, particularly with the care of patients in isolation and the use of personal protective equipment.
• Patients received compassionate and understanding care from hospital staff at the end of their lives. All ward staff were expected to care for patients at the end of their life. There was no specialist palliative care team employed within the hospital; this support was provided by the local hospice and was only available face to face five days a week which did not meet national guidance. At weekends and out of hours advice was provided by a consultant on call service via the hospice. The trust recognised the importance of improving their approach to end of life care and had established the `Rethinking Priorities Programme’
• The facilities in the mortuary required improvement and updating. There was limited access for bereaved families at weekend and the environment was in a poor condition in places. There was a large volume of records stored; the environment was unsuitable for this purpose.

We saw several areas of outstanding practice including:

• There were innovative services that improved the care of patients on and following intensive care, such as the “Supporting intensive therapy unit patients (situp) service and the clinical psychology service to inpatients and outpatients at the follow up clinic in critical care. In addition there was 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. There was also a critical care online “virtual” journal club.
• 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.
• 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 a 30% increase in non-elective in-patient activity within general medicine, 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.

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
• 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. The trust must 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 peoples’ services.
• 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 and radiology.
• 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