Huddersfield Royal Infirmary

Updated 20 June 2018

Calderdale and Huddersfield NHS Foundation Trust is an integrated trust. It 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. The trust also provides community services in the Calderdale area. The trust has approximately 800 beds and 6,000 staff.

Huddersfield Royal Infirmary provides a full range of acute services. The accident and emergency department provides a 24 hour, seven day a week service. Huddersfield Royal Infirmary is a designated trauma unit and also has a clinical decisions unit with five inpatient beds. The hospital has a six-bed midwifery-led birth centre for women considered low risk. The hospital provides acute surgery for children and initial triage and assessment for medical patients presenting to the emergency department is available. The critical care unit at the hospital provides combined intensive care and high dependency care.

Huddersfield Royal Infirmary saw over 48,600 inpatient admissions between February 2017 and January 2018. There were also over 134,600 outpatient attendances in the same period at Huddersfield Royal Infirmary as well as 144,293 outpatient attendances at the Acre Mill outpatient service; of which 97,205 were attendances.

We inspected Huddersfield Royal Infirmary in March 2016 and rated the hospital as requires improvement. We rated safe, effective, responsive and well led as requires improvement and caring was rated as good. We found the hospital was in breach of regulations and issued four requirement notices in regard to Regulation 12: Safe care and treatment; Regulation 17: Good governance and Regulation 18: Staffing.

Our recent inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity, and we re-inspected all domains and key questions.

As part of this inspection, we visited the urgent and emergency care, critical care, maternity and children and young people’s services. We visited the wards and clinical areas. We spoke with 62 members of staff from all levels and reviewed over 20 patient and prescription records. We also spoke with over 36 patients or carers. We observed daily practice and before and after our inspection, we reviewed performance information about the trust and reviewed information provided to us by the trust.

Updated 20 June 2018

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.

Updated 15 August 2016

We rated medical care (including older people’s care) as good overall because:

Staff understood their responsibilities to raise concerns and report incidents. Senior staff managed staffing shortfalls proactively.

Staff delivered evidence based care and overall patient outcomes recorded in local and national audit were good. There was good evidence of collaborative and effective multi-disciplinary team working.

Staff cared for their patients. Patients had individual care plans and felt safe. Staff considered physical, emotional and social aspects of wellbeing. Patients were positive about the care received and would recommend the service as a place to receive care.

The division was responding to the internal and external demands placed upon it. Staff made reasonable adjustments in response to individual patient needs and to accommodate vulnerable patient groups.

Managers led the division well with an open and honest culture. Governance arrangements were set up to effectively identify, manage and plan service improvements, efficiencies and to implement actions to mitigate risks affecting upon service provision.

However:

We found the divisional management of patient safety incidents to require improvement, in particular, around incident grading and investigation. The division were consistently below national target for harm free care.

There were noted delays in transferring patient care into non-hospital settings leading to bed occupancy pressures. The bed pressures lead to a number of patients moving after 10pm at night and occasioned a mixed sex breach.

While staff were passionate about working in the division, a number felt as though there could be better communication from senior management and more attention to their well-being.

Updated 20 June 2018

Our rating of this service improved. We rated it as good because:

• Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of flexibility and commitment.
• Feedback from staff, parents, children and young people had resulted in changes to aspects within the service.
• The service was well led with a clear leadership structure in place.
• The advanced paediatric nurse practitioner (APNP) role was introduced to the service. Seven APNP worked on both hospital sites. Predominantly, the APNP role supported the Huddersfield hospital site by supporting the children’s workforce from a medical and nursing perspective.
• Service monitoring and improvement was managed through governance, performance and risk management systems.
• Clinical risks were identified with ongoing monitoring in place. The service had identified guidelines and protocols to assess and monitor patient risk and react to changes in risk level.
• Staff knowledge of the incident reporting process was good and incident-reporting processes were robust.
• We checked equipment throughout the service and maintenance checks were confirmed. Monitoring records of resuscitation equipment showed regular monitoring took place.
• There was good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).
• The trust mandatory training target was 95%; Mandatory training completion was 100% in children’s services. The majority of staff (96%) had received an annual appraisal.
• Advanced paediatric life support (APLS) trained nurses were rostered on every shift. The trust confirmed that 22 staff had completed the APLS course.

However:

• Aspects of best practice staffing guidance as identified by the Royal College of Nursing (2013) were not fully implemented. However, staffing levels were considered safe by senior management and the staff we spoke with and senior support could be accessed when needed.
• The service was not compliant against the ‘Facing the Future’ standards because of a lack of permanent consultant cover between 5pm – 10pm. However, the risk had been mitigated as Paediatric Consultant staff were contactable after 5pm and at weekends. Consultant staff told us that they would attend and oversee the child’s care and treatment when needed.
• Trust training statistics identified a shortfall in nursing attendance at paediatric life support training.

Updated 20 June 2018

Our rating of this service improved. We rated it as good because:

• We rated safe, effective, responsive, caring and well led as good.
• Mandatory training compliance was high for medical and nursing staff and the number of staff with a post registration certificate in critical care had significant improved.
• Nurse staffing levels were delivered in line with Guidelines for the Provision of Intensive Care Services 2015 (GPICS) standards and patient outcomes were in line with those of similar units.
• The systems and processes in place for management of patient records and the assessment of patient risks were reliable and followed national guidance.
• Care was evidence based and feedback from patient and relatives was positive. The privacy and dignity of patients was maintained and care was compassionate.
• There was consideration given to the individual needs of patients and there had been no complaints about the service.
• Access and flow through the unit had improved. The number of surgical patients cancelled on the day of surgery due to a critical care bed not being available had reduced. The number of patients cared for in theatre recovery when a critical care bed was unavailable had also reduced.
• There was a vision and strategy for the service. There was clear medical and nursing leadership with an understanding of the risks and challenges to the service.

However;

• There were some groups of staff with low levels of morale and a lack of designated leadership within the critical care outreach team.

Updated 15 August 2016

We rated end of life care services as good overall because:

Patients were provided with an end of life care service that was safe and caring. The mortuary was clean and well maintained.

Staff delivering end of life care understood their responsibilities with regard to reporting incidents and ensured information and lessons learnt were shared proactively with other colleagues within the hospital.

We saw clear, well documented and individualised care of the dying documents and appropriately completed DNACPR forms.

The referral process was clear and responsive and staff ensured that patient’s wishes were central to the care planning process.

Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care.

However:

The end of Life Strategy / Vision was in draft form. It did not contain business objectives for the team and lacked robust definition of what the vision and outcomes would be for the team in the future.

There was a limited approach to obtaining the views of people who used the service and other stakeholders. There was no mechanism to ensure feedback was captured and actioned in a timely way.

Updated 20 June 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

• Audit and report data showed risk assessments and records were completed appropriately and in a timely manner. We saw systems were in place for reviewing, monitoring, and sharing lessons learned from incidents.
• Clinical outcomes for mothers and their babies at the trust had improved since our last inspection.
• There were good completion rates for maternity specific training across the trust, and all maternity staff at Huddersfield Royal Infirmary had received an appraisal.
• Procedures were in place to refer and safeguard adults and children from abuse; and staff we spoke with felt confident making referrals and escalating difficult or complex cases.
• Areas we inspected were visibly clean, and audit data showed good hygiene standards.
• The emergency equipment we reviewed was appropriately sealed, in date, and daily and weekly checklists had been completed.
• There were policies in place to manage admittance criteria, emergencies and pathways for transfer from Huddersfield Birth centre to the Calderdale site. The overall transfer time from the birth centre to the Calderdale site was in line with the national average for free-standing birth centres.
• Considerable work had been undertaken since our last inspection to collect and act on the views of people who used maternity services. The women and their relatives we spoke with gave positive feedback about staff, and felt they had been included in decision making.
• Since our last inspection, methods had been introduced to better understand and improve the culture within maternity services; these included anonymous staff surveys, workshops, and human factors masterclasses.
• We saw participation in and learning from external reviews. For example, those undertaken by the Royal College of Obstetricians and Gynaecologists (RCOG) and local Healthwatch groups.

However:

• Mandatory training and safeguarding training completion rates for midwifery and nursing staff at Huddersfield Royal Infirmary did not meet compliance targets set by the trust.
• Complaints were not completed in a timely way and in line with the trust policy timescales.
• The transfer rates of women from Huddersfield birth centre to the Calderdale site were higher than average compared to other free-standing birth centres, and only 12% of critical calls met the eight minute target for attendance at the birth centre in 2017.
• There were occasions when women gave birth with too few midwifes present in Huddersfield birth centre; this went against trust protocol.

Updated 15 August 2016

We rated the service as good overall. We rated the responsive domain as requires improvement and the safe, caring and well-led domains as good. The effective domain was inspected but not rated. This was because we are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients & diagnostic imaging.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed.

The environment we inspected was visibly clean and staff followed robust infection control procedures. Records were stored electronically for X-ray images and OPD had a mixture of electronic and paper records. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Outpatients and radiology nurse staffing levels were appropriate with a low number of vacancies. Radiographer vacancies were higher; a recruitment plan was in place and fifteen staff had been recruited, due to start in the summer of 2016. There were also recruitment issues with ultra-sonographers and breast radiologists. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the agreement for purchase of a third MRI scanner. Diagnostic imaging waits were within targets for the national waiting times.

Staff had good access to evidence based protocols and pathways. The OP and radiology departments were very busy during the inspection but patients received good communication and support during their time there. Staff followed consent procedures and had a good understanding of the Mental Capacity Act (2005).

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients living with a learning disability or dementia. Staff clearly demonstrated that they put the patient first.

The diagnostic imaging department had a local development plan in place to improve services and the environment. The plan gave a comprehensive review of the demand and capacity on the department to deliver a sustainable and high quality clinical service, taking account of seven-day working plans.

Governance processes were embedded across diagnostics and the pathology and radiology teams felt supported in the new directorate structure however governance processes in OP were less well developed.

However:

People were not always able to access OP services when they needed to. There were issues with appointment backlogs, waiting lists and appointment bookings. Patients experienced long waiting times within the departments, appointment delays and cancellations. Outpatient clinics were often overbooked and we found issues with capacity and demand in all OP clinics. Actions taken to address these issues had not always been effective.

Staff we spoke with were aware of the complaints policy and told us most complaints and concerns were resolved locally. A high proportion of the total complaints received by the outpatients department (22%) related to appointment problems.

We did not see any evidence to show current trends and themes from incidents and complaints were monitored.

Updated 15 August 2016

We rated surgical services as good because:

The service had good systems and processes in place to protect patients and maintain safety. Staff understood the process for reporting and investigating incidents and there were good reporting and feedback processes at Huddersfield Royal Infirmary. Each ward recorded and displayed individual incidences of insignificant, minor and moderate falls, catheterized urinary tract infections (C.UTIs) and pressure ulcers. Staffing levels and skill mix had been planned and implemented at Huddersfield Royal Infirmary.

All patients reported pain management needs had been met in a timely manner. Care of patients’ nutrition and hydration were being met as part of the surgical care pathway. We observed patients being cared for with dignity, compassion and respect in all the surgical wards and departments we inspected. Feedback from patients through the NHS Friends and Family Test consistently showed patients would recommend the hospital to friends and family.

The breast surgical divisional management team had developed an action plan from the National Cancer Patient Experience Survey which included an enhanced role for the breast cancer nurse to explain to patients the potential care and treatment options available.

The ‘Five Steps to Safer Surgery’ and completion of the World Health Organisation (WHO) checklist was consistently good at the hospital. Mandatory training was well attended and meeting overall training targets was in progress with action plans in place to meet year end targets.

Wards and departments were spacious, visibly clean and well organised. We saw evidence of regular audit with regard to infection control and cleanliness.

The service had introduced a seven day acute rota for general surgery resulting in significant improvement to consultant presence in theatre and improved treatment and a post-operative survival rates.

Patient care was personalised in line with patient preferences, individual and cultural needs and ensured flexibility, choice and continuity of care. Clear strategies were in place and implemented to improve the care of patients. For example, the appointment of link nurses, associate care practitioners and engagement support workers.

Senior managers had a clear vision and strategy for the division and identified actions for addressing issues, the strategy clearly identified objectives for improving patient care and safety. There was good staff morale and staff felt supported at ward level.

We observed care that was coordinated and discharge and transfer planning took account of patient’s individual needs.

However:

There was no rota for the management of patients with gastrointestinal bleeds by an endoscopy consultant. This had not been resolved at the time of our inspection and staff identified this as a risk to the safety of patients.

Daily temperatures for the storage of medications were not all within the correct limits on all wards and were recorded outside the margins for the safe storage of medicines. No action had been taken to check whether records were accurate or whether there was a fault with equipment.

Trust data showed only 45% of complaints were closed within target in the surgical division.

Updated 20 June 2018

Our rating of this service stayed the same. We rated it as good because:

• Staff knew how to report incidents and there was an investigation process in place. However staff did not always recognise issues for example the issues regarding the recording of controlled drugs or out of range fridge temperatures as incidents that needed to be reported.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. There were a range of pathways that complied with the National Institute for Health and Care Excellence guidelines and the Royal College of Emergency Medicine’s clinical standards for emergency departments.
• The department had a website called EM Beds which was used as a repository for the standard operating processes (SOPs), patient pathways, policies and guidelines in use across both hospital sites.
• The service supported staff so they were competent for their roles. Nursing appraisal numbers had improved since the last inspection.
• Staff cared for patients with compassion, treating them with dignity and respect. Feedback from patients confirmed that staff treated them well and with kindness.
• There were still issues with meeting national targets and standards in relation to patients waiting for treatment and admission to hospital; however the performance was generally better than the England average.
• Learning from complaints and incidents was cascaded to staff and there was a clear focus on quality and continuous improvement.
• Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff told us they were proud to work in the department.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a clear management structure at directorate and departmental levels. The managers knew about the quality issues, priorities and challenges in the department.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action. The department had an education strategy for emergency nursing with a focus on educating, developing and growing a strong and competent nursing workforce.

However:

• There was consultant presence five days per week on a rota and weekends on a voluntary rota basis. Work was continuing to meet national guidelines of consultant presence for 16 hours per day.
• At the time of our inspection the service was not recording or storing medicines appropriately. We found out of range fridge temperatures and gaps in recording of controlled drugs.
• There was no suitable room to accommodate patients presenting with mental ill-health.
• The service did not have registered paediatric nurses on shift. However, paediatric advanced nurse practitioners could be utilised from the paediatric ward and staff undertook two days paediatric training on induction, including basic paediatric life support.
• The service did not always meet environmental audit targets for cleanliness or infection control. We found some areas on inspection that required deep cleaning.
• Consumables in some areas of the department did not appear to be checked regularly and were expired. However, this was rectified immediately on site.
• The trust had only met its target of 95% in one out of six areas of mandatory training; however three of the six areas were very close at 94% at the end of March 2018.