Calderdale and Huddersfield NHS Foundation Trust

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 ensure that the equipment inventory is updated in community adult services and that all equipment in use is properly maintained and checked.

• The trust should ensure there are systems to measure effectiveness and responsiveness of the services within community adult services.

• 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

Overall we rated this service as good because:

• We found this was a service where the patient was put first and holistic care was delivered.

• The service had a system in place to report incidents and staff were able to use this.

• Staff were able to give examples of where they had learned from incidents and how improvements had been implemented.

• Staff sickness levels were lower than the trust target and staff morale was high.

• Staff delivered evidence based care and treatment and followed appropriate national guidance.

• We observed kind and compassionate care being delivered by knowledgeable staff and patients told us they were happy with the service they received.

• There were fully integrated multidisciplinary teams that worked effectively in a variety of settings. A seamless service was provided with a combination of health and social care input.

• There was a range of services offered and patients did not have to wait long for care and treatment.

• There were a low number of complaints received by the service.

• There was a well-managed risk register with action plans and control measures in place.

• Despite a recent significant change in the trust structure and management arrangements staff told us they felt well supported and that managers were approachable.

However:

• Mandatory training levels were below the trust target.

• We found there had been some staff shortages but the service had managed this well.

• Some documentation required updating and standardising across the service.

• There was a lack of comprehensive performance data within the community services. This was impacting on their ability to properly measure effectiveness and responsiveness of the services within the division.

• Complaint responses and lessons learned were not always shared with staff in an effective or meaningful way but plans were in place to improve this.

• Community equipment was not well managed therefore staff were not aware of what equipment was available or if it was safe to use.

• Staff felt that senior managers in the trust did not fully understand the pressures on staff who worked in the community.

• The trust had established risk reporting structures in place. Incidents were investigated and reported in line with policy. We saw evidence of the service sharing learning with staff. Staff were knowledgable and experienced in safeguarding children and recognising risk. There were safeguarding systems in place to protect children and young people from harm.

• Staffing levels were appropriate for services provided and were in line with commissioned levels. There had been problems of recruitment in childrens therapy services. The risks had been mitigated by temporary actions.

• Staff had received mandatory training at trust level of expectation. There was a broad understanding of the duty of candour and some staff had received training.

• Staff practiced evidence based care and treatment. There was good evidence of multi- disciplinary working within the trust and with external agencies. Staff were aware of the principles of consent and we observed them practising it in their work. There were clear and accessible routes into other services. Some staff reported that the transition between health visiting services and school nursing was not as smooth now that this service was under the umbrella of a social enterprise company.

• The trust was meeting recognised targets set by NHS England for this year and it’s Commissioning for Quality and Innovation (CQUIN) target for breastfeeding post delivery. However this figure decreased significantly on discharge from maternity care. The service had identified this issue and mitigating actions were being taken to address them.

• There were good appraisal rates throughout the service and systems in place to identify dates of reappraisal.

• We spoke with children and their families, and observed care taking place. We found evidence that staff practiced compassionate care and provided emotional support. People who used the service told us that they felt involved with their care. They had understood the care and advice offered to them.

• The trust planned and delivered services that met peoples needs and were responsive to the changing needs of the population. We saw evidence of innovation in care to meet the needs of the local population and hard to reach groups. This included one health visitor who services for parents who misused substances. This service took into account equality and diversity needs and that of vulnerable groups.

• There was access to translation and interpreting services and staff said that they had knowledge of the trust’s interpreting policy. Staff were aware of local links into services for new migrants and lesbian, gay, bisexual and transgender (LGBT) community.

• Services were easily accessible for children and their families. There was flexibility in how these were provided to suit individual need. There were minimal complaints about the service and these had been dealt with in a timely manner.

• There was a clear vision for the service that was child and family focussed and demonstrated innovation. There were systems in place linking governance, risk management and quality measurement at service and board level. Staff said that they were aware of these and that all levels of management, including the chief executive were visible and accessible.

• Although the community management level was currently interim pending re-configuration, this had not affected staff morale. Staff told us that they worked in an open culture and were given the opportunity to develop individually and as teams. There was evidence of engagement with both the public and staff members. We saw evidence of staff and public feedback. This was used to drive and improve services.

• There were many examples of innovative practice aimed at increased access to services for children and their families. These were evaluated to ensure that staff understood and could learn from both successes and failures.

Overall we rated the service as good. We rated the end of life service in the trust as good for safe, effective, caring responsive and well-led. The service understood how to identify safety concerns and risks to patient safety. Incident reporting was embedded in the service and learning from incidents was shared across the service to ensure improvements were made.

Medicines were effectively managed and improvements from incidents were used to improve care and treatment of patients.

Patients could access services out of hours staff worked well with GP practices to ensure patients who were receiving end of life care and their relatives were cared for and supported in the last days of life.

Staff worked within multi-disciplinary teams to allow co-ordination of care and there were meetings held with every GP practice in the area where the team provided end of life care.

There was a 24 hour telephone service and referrals to the service were acknowledged within 10 minutes of referral and contacted by telephone within one hour of the referral. Patients and their relatives were contacted by the service within 3 hours.

There was a clinical educator post within the service to co-ordinate and provide training and staff had access to specialist training. Staff had one to ones with their manager and yearly appraisals. Staff understood their roles and responsibilities for providing end of life care.

Care was provided based on national guidance such as The National Institute for Health and Care Excellence (NICE). The trust had developed and was implementing an Individual care of the dying document (ICODD) which was based on the five priorities of care document in the community.

The service had developed an end of life dashboard and they monitored patient outcomes. Information about patient care and outcomes were shared with the trust and commissioners of the service to continue to improve patient care.

The service had a vision for the service which was understood by all staff and staff felt the service was well managed and patient care was a priority for all staff.