Airedale NHS Foundation Trust

Updated 14 March 2019

The trust has approximately 324 inpatient beds located at Airedale general hospital. The trust serves a population of over 200,000 people in a large area of 700 square miles within Yorkshire and Lancashire. The area served includes areas of North Bradford and Guiseley in West Yorkshire and extends into Colne and Pendle in eastern Lancashire.

The number of whole time equivalent (WTE) staff employed by the trust as of June 2018 was 2,343 with an additional 269 WTE staff employed in a wholly owned subsidiary company (called AGH Solutions Ltd) which provides estates, facilities and procurement services.

The trust’s services are commissioned mainly by the Airedale, Wharfedale and Craven, and Bradford city, and Bradford district clinical commissioning groups.

There are three care groups;

• Integrated care (see below)
• Surgery
• Women and Children (which includes maternity).

Integrated care includes:

• Emergency department
• Acute assessment unit
• Ambulatory care
• Adult medicine
• Care of the elderly
• Palliative care
• Community services
• Therapies
• Pharmacy

The trust has a strategic clinical partnership with a neighbouring NHS foundation trust, which supports Airedale in providing sustainable services with stroke care, ENT services, ophthalmology, oral surgery, and orthodontics. There is also a strategic clinical partnership with a large teaching hospitals NHS trust, which provides support in a number of paediatric services.

The trust is a partner in a limited liability partnership (LLP- known as ‘Immedicare’) to provide telemedicine services, delivering 24 hour clinical care from specialist nurses and doctors directly into nursing and residential care homes. The trust also provides telehealth services to 37 prisons across England. (Telehealth is a term used to describe technology to support remote health monitoring, and to deliver services to patients in another location).

The trust is also a partner in another LLP with a local NHS trust providing pathology services to both trusts. The trust established a wholly owned subsidiary in March 2018 to provide estates, procurement and facilities services to the trust.

The previous chief executive retired and the new chief executive was appointed in June 2018. It is their first chief executive position. They were previously the executive director of nursing and deputy chief executive at a neighbouring trust. The new chief executive also had a system leadership role for the local heath and care partnership across Airedale, Wharfedale, and Craven; this was one of seven underpinning partnerships for the West Yorkshire and Harrogate health and care partnership.

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.

Updated 14 March 2019

Updated 14 March 2019

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.

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.

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.