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

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Patient’s we spoke with were mostly very positive about their experiences of care and treatment. Patients stated that they were kept informed and were involved in making decisions about their care and treatment options. Most patients told us that all of the staff were pleasant and respectful; they felt staff listened and responded to their needs in a timely manner. Example comments included ‘I have observed good responses from staff to other more dependent patient’s’. One person said ‘everything fine, things are explained’ when asked do staff explain and ask if it’s alright before they help you. Another person commented staff are ‘very reassuring, explain what is going to happen, they answer questions when asked’.

Patients were very complimentary about the quality and service of food, they commented that the quality of food overall was good and staff were always at hand to assist them if required. They told us that they had been asked about their food likes and dislikes and that staff always checked if they have had enough to eat and often second helpings were offered.

Our rating of services stayed the same. We rated it them 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 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 theatre areas was not compliant with national standards related to airflow.
• 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.
• 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.
• 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. This transcription introduced an additional risk of errors, 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 secure and compliance with information governance training was poor.
• 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 aging buildings.

However;

• We found all staff to be caring and responsive to patient’s 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, tidy, and free from clutter.