Our rating of the hospital improved since the last inspection. We rated it as good because:

• We rated the hospital as good overall. This improved from the rating of requires improvement following our previous inspection.
• We rated caring at this hospital as good. This stayed the same as our previous rating. Across all the services we inspected, we found staff treated patients with kindness, compassion, and respect. Patients and their relatives commented positively about the care they received.
• We rated effective, responsive and well-led at this hospital as good. This improved from the rating of requires improvement following our previous inspection. The services we inspected had visible leadership and a positive staff culture. There were effective systems in place for governance, risk management and quality monitoring. Services were planned and delivered to meet patient needs and most patients were admitted and discharged from the hospital in a timely manner.
• Our rating for safe at this hospital stayed the same as our previous rating. We rated safe at this hospital as requires improvement. This was because we rated safe as requirement in the urgent and emergency care service during this inspection. There was also one service (medical care) that was not inspected on this visit that was rated as requires improvement for safe.
• We rated urgent an emergency care as good overall. Our rating stayed the same since the last inspection. We rated effective, caring, responsive and well led as good. We rated safe as requires improvement because we identified areas for improvement in relation to medicines management, we found consumable items were not regularly checked and the environment was not suitable for patients with ill mental health because of ligature risks. The service did not meet national guidelines for consultant presence for 16 hours per day.
• We rated critical care, maternity and services for children and young people as good overall. All five domains were rated as good for these services. Our ratings for these services had improved since the last inspection.

Huddersfield Royal Infirmary is part of Calderdale and Huddersfield NHS Foundation Trust (CHFT). When we carried out an inspection of the Huddersfield Royal Infirmary in August 2013 we found improvements were needed relating to the safety and suitability of premises.

We made this visit to see what actions had been taken.

Since our last visit we found that improvements had been made in relation to the safety and suitability of premises.

We spoke with the Trusts Director of Planning Performance Estates & Facilities and they told us since our last visit attempts to recruit a permanent Chartered Engineer to support them had not been successful. However as an interim measure a Consultant Chartered Engineer had been employed full time until a permanent replacement is recruited. We saw from the information provided the trust had re-advertised for an Assistant Director of Estates & Facilities of a Chartered Engineering status on 17th January 2014.

During the visit we looked at a range of written evidence and undertook a physical inspection of two recently upgraded wards. We also gathered evidence using a combination of, interviews and meetings with a number of managers and staff from estates and nursing. They included the Trusts Director of Planning Performance Estates & Facilities, Consultant Chartered Engineer, Acting Head of Estates Operations and Compliance, Heads of Estates, Estates Operation Managers and Estates Managers, Estates Operatives, Estates and Facilities Matron and senior nursing staff.

Overall the meetings with the managers and staff were positive and everyone we spoke with was open honest and frank about the actions the trust had taken to improve the safety and suitability of the premises. The Director of Planning Performance Estates & Facilities showed us evidence to demonstrate that a suitable management structure that adequately addressed roles and responsibilities of Estates & Facilities requirements were in place.

We visited a number of areas within the hospital they included; ward one medical and ambulatory assessment, ward six short stay, ward seven acute complex care, ward 19 orthopaedic trauma and ward 21 rehabilitation. We reviewed the care and treatment records of nine people using the services spoke with 11 people using the service, eight relatives and 15 members of staff

The majority of people using the service and relatives were positive about their experiences of care and treatment at the hospital. Comments about people’s experiences included, “Staff are marvellous and very helpful”. “Staff they treat me with dignity and respect and if I press the bell they come even though they’re very busy”. “Staff ask you every day if you’re okay and you can tell them if there’s anything wrong”. “Staff are now keeping me informed after my family spoke to the matron”.

Comments received from visitors; “I was allowed to stay overnight with my relative and I feel privileged to have stayed”. “Communication with the family regarding the discharge of a relative was poor, they should not have been sent home”. Two family members told us that "Once they had complained the communications between the staff and the family improved".

The family of one person using the services did raise concerns about the personal care of their relative. We provided the CEO with direct feedback on these concerns.

We spoke with four people who use the service and they told us that they did not have to wait long to be seen by staff. Two of the people we spoke with were admitted via ambulance and told us they had waited less than 30 minutes before they were diagnosed and treated by staff.

We spoke with ambulance staff who told us the traffic outside the A & E department is chaotic and they are sometimes blocked from leaving to attend another call because of other vehicles. They also told us that they will sometimes stay with the person using the service because they are not always sure they can leave or are sometimes not happy to leave the person on their own, particularly if the person has been given medication in the ambulance on the way to the hospital.

The people we spoke with told us that staff were very friendly and helpful.

The patients we spoke to told us that they were happy with the treatment they receive. The also told us that staff had explained why they were here and staff listen to them.

The patients we spoke to told us that they did not have any concerns with the meals they were offered. They also told us that were given a choice of food of drink and staff asked them if they needed support.

Calderdale and Huddersfield NHS Foundation Trust is an integrated trust, which provides acute and community health services. The trust serves two populations; Greater Huddersfield which has a population of 248,000 people and Calderdale with a population of 205,300 people. The Trust operates acute services from two main hospitals - Calderdale Royal Hospital and Huddersfield Royal Infirmary In total; the trust had approximately 824 beds and 5,831 staff.

We carried out an inspection of the trust between 8-11 March 2016 as part of our comprehensive inspection programme. In addition, unannounced inspections were carried out on 16 and 22 March 2016.

We included the following locations as part of the inspection:

• Huddersfield Royal Infirmary

• Calderdale Royal Hospital

• Community services including adult community services, community services for children, young people and families and community end of life care

We inspected the following core services:

• Emergency & Urgent Care
• Medical Care
• Surgery
• Critical Care
• Maternity & Gynaecology
• Services for Children and Young People
• End of Life Care
• Outpatients & Diagnostic Imaging

Overall, we rated the trust as requires improvement. We rated safe, effective and well led as requires improvement and caring and responsive was rated as good. We rated the Huddersfield Royal Infirmary and Calderdale Royal Hospital as requires improvement and community services as good.

Our key findings were as follows:

• The trust had infection prevention and control policies, which were accessible, and used by staff. Across both acute and community services patients received care in a clean and hygienic environment.

• Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, overall, they were content with the quality and quantity of food.

• The trust promoted a positive incident reporting culture. Processes were in place for being open and honest when things went wrong and patients given an apology and explanation when incidents occurred.

• Staffing levels throughout the trust were planned and monitored. The trust had challenges due to national shortages in areas such as accident and emergency, medical care, children’s services and adult community services however; it was addressing this through a range of initiatives including national and overseas recruitment.

• Medical staffing numbers did not meet national guidance in the emergency departments across both sites.

• The accident and emergency departments’ provision for paediatric patients was limited with only one paediatric qualified staff member on duty during our inspection across both sites and limited facilities available for children and young people.

• Not all staff within children’s services had received safeguarding training at the appropriate level for their role in line with the requirements of the Safeguarding children and young people: roles and competences for healthcare staff Intercollegiate document (RCPCH March 2014).

• Patient outcome measures showed the trust had mixed performances against the national averages when compared with other hospitals with some outcomes performing better and some performing worse.

• The trust had consistently achieved the national standard for percentage of patients discharged, admitted or transferred within four hours of arrival to A&E in eight of the last 12 months. Between April 2015 and March 2016 the year to date percentage of patients achieving this target was 93.88% which was just below the target of 95%.

• The trust had consistently achieved the national indicators for patients on the admitted, non-admitted and incomplete referral to treatment pathways.

• The trust had a nurse consultant for older people and a learning disabilities matron. Across the trust 200 Matrons and Sisters had received training and were vulnerable adult’s leaders to ensure the vulnerable adult care principles and process were embedded into practice. This included care of patients living with dementia.

• The estates and facilities team throughout the trust were focussed on improving the quality of patient care and experience and considered this when undertaking work to improve the environment.

• Across the services we found a variable understanding from staff regarding consent and mental capacity.

• The trust performance for responding to complaints within the relevant timescale was 48% against a target of 100%.

• The trust had an overall vision which was underpinned by behaviours, goals and responses to support the delivery of the vision. The trust vision was “Together we will deliver outstanding compassionate care to the communities we serve.” The trust vision was supported by four ‘pillars’ of behaviours that were expected of all employees.

• There were a number of concerns within maternity services which included feedback from patients during the inspection, the numbers of large volume postpartum haemorrhages (PPH), third and fourth degree tears, the antenatal assessment of mums to ensure they delivered in the appropriate setting and the ability to open a second obstetric theatre.

• We found during the inspection that there were a number of patients on the clinical decision units (CDU) in the accident and emergency departments who had an extended length of stay on the units whilst waiting for a general inpatient bed.

• It was difficult to determine how the service had planned services to meet the needs of local children and young people at Huddersfield Royal infirmary. There was no clear rationale or model of care for the services provided on the paediatric assessment unit.

We saw areas of outstanding practice including:

• The development and growth of the ambulatory care service to support the hospital sites and meet local need. The trust had vulnerable adult’s leaders to ensure the vulnerable adult care principles and process was embedded into practice.
• Engagement support workers had been appointed to provide engagement, socialisation and companionship, cognitive and physical support for patients with dementia and/or delirium. The team supported patients during the day with either group or one-to-one activities which promoted sleep at night. Through providing suitable engaging activities during the day, less 1:1 care was required during the day and night. This also helped other patients experience by reducing sleep disruption on the wards.
• The trust had worked closely with local higher education facilities and offered an enrichment programme to ‘A’ level students to experience working in a hospital environment but particularly with patients living with dementia or experiencing delirium.
• The development of NEWS and ‘Nerve centre’ technology to identify deteriorating patients for prompt care escalation and intervention.
• The use by critical care outreach of the NEWS and Nerve Centre technology to drive effective identification of the deteriorating patient in ward areas. This supported early admission to critical care, and in turn better patient outcomes. The team could use the system to prevent readmission of critical care discharges.
• A proactive, positive and energised discharge coordination team together with an integrated MDT working to provide care to the patient in the most appropriate environment.
• Within community services multidisciplinary and multiagency working was completely integrated in some teams with staff having a good understanding of each other roles. This led to a seamless service for patients and there was a collective responsibility to meet patients’ needs in the community.
• The diagnostic imaging department worked hard to reduce the patient radiation doses, and had presented this work at national and international conferences.
• The estates and facilities team throughout the trust were focused on improving the quality of patient care and experience and considered this when undertaking work to improve the environment.

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

Importantly, the trust must:

• The trust must continue to 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.

• The trust must continue to embed and strengthen governance processes within the clinical divisions and at ward level.

• The trust must ensure all staff have completed mandatory training, role specific training and had an annual appraisal.

• The trust must continue to strengthen staff knowledge and training in relation to mental capacity act and deprivation of liberty safeguards.

• The service must ensure staff have an understanding of Gillick competence.

• The trust must continue to identify and learn from avoidable deaths and disseminate information throughout the divisions and the trust.

• The trust must ensure staff have undertaken safeguarding training at the appropriate levels for their role. The service must also ensure all relevant staff are aware of Female genital mutilation (FGM) and the reporting processes for this.

• The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.

• The trust must ensure that interpreting services are used appropriately and written information is available in other languages across all its community services.

• The trust must ensure that appropriate risk assessments are carried out in relation to mobility and pressure risk and ensure that suitable equipment is available and utilised to mitigate these risks.

• Within maternity services the service must focus on patient experience and ensure women feel supported and involved in their care.

• The trust must review the provision of a second emergency obstetric theatre to ensure patients receive appropriate care.

• The trust must continue work to reduce the numbers of third and fourth degree tears following an assisted birth and the incidence of PPH greater than 1500mls following delivery.

• The trust must review the admission of critical care patients to theatre recovery when critical care beds are not available to ensure staff suitably skilled, qualified and experienced to care for these patients.

• The trust must continue to review arrangements for capacity and demand in critical care.

• The trust must ensure that patients on clinical decision unit meet the specifications for patients to be nursed on the unit and standard operating procedures are followed.

• The trust must ensure there are improvements to the timeliness of complaint responses.

• The trust must ensure there is formal rota for the management of patients with gastrointestinal bleeds by an endoscopy consultant

• The trust must review the model of care for the services provided on the paediatric assessment unit at Huddersfield Royal Infirmary.

In addition the trust should:

• The trust should review the availability or referral processes for formal patient psychological and emotional support following a critical illness.

• The trust should review the handover arrangements from the hospital at night team to the critical care team to ensure continuity of patient care across the hospital.

• The trust should ensure that relevant staff have received training in root cause analysis to enable them to provide comprehensive investigations into incidents.

• The trust should provide consultation opportunities and team collaboration in the development and completion of its business strategy and vision for end of life care.

• The trust should ensure that children are seen in an appropriate environment by staff that are suitably skilled, qualified and experienced.

• The trust should ensure signage throughout the HRI main building and Acre Mills reflect the current configuration of clinics and services.

• The trust should ensure there is access to seven-day week working for radiology services.

Professor Sir Mike Richards

Chief Inspector of Hospitals