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Pontefract Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 October 2017

The Mid Yorkshire Hospitals NHS Trust is an integrated trust, which provides acute and community health services. The trust serves two local populations; Wakefield which has a population of 355,000 people and North Kirklees with a population of 185,000 people. The trust operates acute services from three main hospitals – Pinderfields Hospital, Dewsbury and District Hospital and Pontefract Hospital. At Pontefract, the trust had approximately 61 general and acute beds and four beds in Maternity. The trust also employed 7,948 staff, of which 536 were based at Pontefract. This included 28 medical staff and 261 nursing staff.

We carried out a comprehensive inspection of the trust between 16 and 19 May 2017. This included unannounced visit to the trust 11 and 22 May and 5 June 2017. The inspection took place as part of our comprehensive inspection programme of The Mid Yorkshire Hospitals NHS Trust and to follow up on progress from our previous comprehensive inspection in July 2014, a focused inspections in June 2015, and unannounced focused inspection in August and September 2015. Focused inspections do not look across a whole service; they focus on the areas defined by the information that triggers the need for the focused inspection.

At the inspection in July 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment, consent to care and treatment and staffing. We issued two warning notices in relation to safeguarding people who use services from abuse and management of medicines.

At the inspection in July 2015 and our follow up unannounced inspections, we found that the trust was in breach of regulations relating to safe care and treatment of patients, addressing patients nutritional needs, safe staffing, and governance. We issued requirement notices to the trust in respect of these breaches.

Our key findings from our inspection in May 2017 are as follows.

We rated Pontefract Hospital as requires improvement because:

  • Nursing and medical staffing in some areas was a concern. In the emergency department nurse staffing was not always meeting planned staffing levels or national guidance. Nursing staff were frequently being moved to wards to cover staffing shortages. Midwifery staffing was below nationally recommended levels and community midwifery caseloads were above the national recommendations.

  • Access and flow was a challenge at this hospital. We saw that the hospital was failing to meet the majority of national standards relating to Accident and Emergency performance, including: four hour waits, re-attendance rates, time from decision to admit to admission, median time to treatment and ambulance handover times. However, recent information showed that performance was improving.

  • Patients had long waits in the emergency department once a decision to admit them had been made. This was predominantly due to the lack of beds available to admit patients in to the trust, although mental health patients were also affected. Women experienced long waits at the antenatal clinic, and some were required to stand, as there was not enough seating.

  • There were issues regarding referral to treatment (RTT) indicators and waiting lists for appointments. There was an appointment backlog which had deteriorated since the last inspection and was at 19,647 patients waiting more than three months for a follow up appointment. Staff told us clinical validation had occurred on some waiting lists, for example in ophthalmology. However, this had not occurred on all backlogs across the trust. Between February 2016 and January 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance.

  • Staff across most specialties were not meeting the trust’s mandatory training and appraisal targets. We were not assured of the competence of midwifery staff with regard to basic skills such as cannulation and perineal suturing.

  • Recording of pain scores and National Early Warning Scores (NEWS) was not consistent and some audits identified a deterioration in compliance with recording NEWS scores.

  • We were not assured that all staff were competent to use medical devices. There was also limited assurance that electronic equipment had annual safety checks.

  • Although there was a newly implemented governance process, this was yet to be embedded in practice. The emergency department did not take part in RCEM or clinical audits and therefore there was no assurance that standards of care were being met. The maternity risk register contained a large number of risks, and many had a review date in the past. This led to concern that the risk register was not being appropriately scrutinised. Duty of candour was not well understood across all staff groups; however senior managers could describe the duty of candour.

However,

  • Patients received care and treatment that was caring and compassionate from staff who were working hard to make sure that patient experience was positive and supportive. Staff were able to meet the physical and emotional needs of patients. There was access to pastoral support for patients of any or no religion.

  • A trust incident reporting system was used to report incidents and staff we spoke with were aware of how to report incidents. Staff were aware of how to report safeguarding concerns. We saw evidence that Root Cause Analysis (RCA) and investigations of serious incidents were comprehensive .

  • Patients had good outcomes from surgery and they received effective care and treatment to meet their needs. The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care.

  • There were clear governance processes in place. Management could describe the risks to the service and the ways they were mitigating these risks. Services were engaged in reviewing staffing levels and considering how staffing concerns could be addressed via recruitment and the introduction of new staff roles.

  • Staff praised the executive management team of the trust and told us that since our last inspection the atmosphere of the trust felt different. Staff were positive about the future and felt that problems were now more open and being addressed by leaders.

Importantly, the trust must:

  • Ensure that mandatory training levels are meeting the trust standard.

  • Ensure that there are suitably skilled staff available taking into account best practice, national guidelines and patients’ dependency levels.

In addition the trust should:

  • Ensure that there are suitably skilled staff available taking into account best practice, national guidelines and patients’ dependency levels.

  • Ensure that all staff have annual appraisals.

  • Continue to focus on achieving A&E standards and ensure that improved performance against standard is maintained.

  • Ensure that records are completed fully and that records are stored securely.

  • Ensure that staff triage training is robust and that staff carrying out triage are experienced ED clinicians.

  • Continue to address issues of non-compliance with referral to treatment indicators and the backlog of patients waiting for appointments.

  • Ensure work to improve the completion of consent forms in line with trust expectations.

  • Review the risk registers and remove or archive any risks that no longer apply.

  • Increase local audit activity to encourage continuous improvement.

  • Ensure it continues to address capacity and demand across all outpatient services.

  • Consider ways of ensuring team meetings in main outpatients are regular and consistent.

  • Consider ways of ensuring environmental compliance issues with carpets in departments.

  • Improve the assessment and recording of patient pain scores.

  • Ensure there are appropriately qualified or experienced children’s nurses in ED.

  • Undertake clinical audit in ED to ensure that national and local standards of care are being met.

  • Improve the reliability of the blood diagnostic service.

  • Ensure that robust recruitment and retention policies continue, to improve staff and skill shortages; with particular emphasis on theatre recruitment.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 13 October 2017

Effective

Good

Updated 13 October 2017

Caring

Good

Updated 13 October 2017

Responsive

Requires improvement

Updated 13 October 2017

Well-led

Good

Updated 13 October 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 13 October 2017

There were robust practices in place to check emergency equipment. The service had bid successfully for Department of Health Safety training and had allocated the funding appropriately.

Following our previous inspection the service reviewed staffing using a recognised acuity tool and this recommended a shortfall of 18 whole time equivalents. The service had an agreed plan to fill these posts over three years.

The rates of normal birth were better than the England average. We found good multidisciplinary working between midwifery and medical staff. We observed good and friendly interactions between staff, women and relatives. There was sympathetic engagement with staff and patients around the reconfiguration of maternity services.

The service had a comprehensive business plan, which included plans to increase staffing levels including specialist midwifery posts.

However:

We were not assured that staff were competent to use medical devices. There was also little assurance that electronic equipment had an annual safety checks. We were not assured of the competence of staff with regard to basic skills such as cannulation and perineal suturing. Attendance of hospital midwives at Obstetric emergency training was below the trust target of 95% at 86%. We found a lack of skills and drills scenarios on the Friarwood Birth Centre.

Midwifery staffing was below nationally recommended levels at 1:31. The community midwifery caseloads were above the national recommendations. Women experienced long waits at the antenatal clinic, and some were required to stand, as there was not enough seating.

The risk register contained a large number of risks, and many had a review date in the past. This led to concern that the risk register was not being appropriately scrutinised.

Medical care (including older people’s care)

Requires improvement

Updated 3 December 2015

We had concerns regarding the registered nurse staffing levels on the unit. Mandatory and statutory training compliance was variable on the unit. There was 100% compliance in manual handling (practical training) however there was low compliance in patient safety training, resuscitation, infection prevention and control. There were systems in place to report incidents and staff told us they knew how to report incidents and received feedback from these.

We reviewed information that showed that the service participated in national audits, which monitored patient outcomes and monitored service performance. There were formal processes in place to ensure that staff had received training, supervision and an annual appraisal. However appraisal rates for nursing staff was 60%. We found malnutrition universal screening tool (MUST) was completed fully. We observed that there were jugs of water on patients’ side tables. Red jugs were used to help indicate to staff which people required support and encouragement with drinking.

Staff were able to demonstrate their knowledge of mental capacity assessments and deprivation of liberty safeguards and we saw examples in practice on the unit.

Although patients were concerned that nurses had too much to do they were generally happy with their care and the way they were treated by staff on the unit. In May 2015 we saw the results of the friends and family test which indicated 100% of patients who would recommend the service they had received to friends and family who need similar treatment or care. Patients we spoke to felt that they were listened to by staff. Patients were aware of what treatment they were having and said that this had been explained to them properly.

We found the number of medical outliers had reduced on surgical wards since our last inspection in July 2014. We found the service had specialist roles to support people’s individual needs which included a learning disability nurse. There was a ward based action group which aimed to enhance the environment for patients. This had resulted in upgrading the day room and sourcing higher chairs for tall patients. Visiting times have also been extended to allow relatives to be involved in supporting patients at mealtimes.

There were systems to record concerns and complaints raised within the department, review these and take action to improve patients’ experience.

There had been a history of change at ward manager, matron and senior leadership within the division of medicine and we found at this inspection a number of ward managers and senior nurses had been in post less than six months. Some of the matrons continued to cover more than on hospital site which meant they were not always visible at the hospital site. Throughout the inspections we found nurse staffing levels on wards continued to be a problem. Therapy staff told us that although they do not have much contact with more senior managers they feel confident that their line managers take their concerns and messages further up the organisational chain. We were told that there was no specific nurse or medical lead for Pontefract Hospital.

Within the division there was a monthly governance meeting at which all incidents were discussed with consultants and specialist nurses. We saw information in the meeting minutes which showed incidents, training and complaints were discussed. In addition to the governance meeting we saw the division of medicine produced a governance, patient harm and patient experience report.

Urgent and emergency services (A&E)

Requires improvement

Updated 13 October 2017

The department was failing to meet the majority of national standards relating to Accident and Emergency performance, including: four hour waits, re-attendance rates, time from decision to admit to admission, median time to treatment and ambulance handover times. However, recent information showed that performance was improving.

Staff were not meeting the trust’s mandatory training targets and we had concerns about the robustness of the triage training process because inexperienced nurses were being trained to carry out triage. Additionally nursing staff were not receiving annual appraisals.

Nursing and medical staffing in the department was not always meeting planned staffing levels and nursing staff were frequently being moved to wards to cover staffing shortages. Recording of pain scores and National Early Warning Scores (NEWS) was not consistent. Additionally, the Pontefract department did not take part in RCEM or clinical audits and therefore there was no assurance that standards of care were being met.

Patients had long waits in the department once a decision to admit them had been made. This was predominantly due to the lack of beds available to admit patients in to the trust, although mental health patients were also affected. Although there was a newly implemented governance process, this was yet to be embedded in practice.

However:

The department was aware of its problems and risks and had changed practice and processes in an attempt to tackle them, such as the introduction of new nursing roles.

Patients received care and treatment that was caring and compassionate from staff who were working hard to make sure that patient experience of the department was positive and supportive. The department was able to meet the physical and emotional needs of patients. Specialist equipment was available for bariatric patients and patients with physical disability. There was access to pastoral support for patients of any or no religion.

Staff praised the executive management team of the trust and the department and told us since our last inspection the atmosphere of the trust felt different. Staff were positive about the future and felt that problems were now more open and being addressed.

Surgery

Good

Updated 13 October 2017

Senior nursing staff had daily responsibility for safe and effective nurse staffing levels and staffing guidelines with clear escalation procedures were in place. Appropriate risk assessments were completed accurately for falls, pressure ulcers, National Early Warning Scores (NEWS), sepsis screening and malnutrition. Staff were aware of escalation procedures.

We saw evidence that Root Cause Analysis (RCA) and investigations of serious incidents were comprehensive and highlighted immediate actions taken, chronology of events, findings, care and delivery problems, root causes, recommendations, lessons learned and action plans. We observed the ‘Five Steps to Safer Surgery’ checklist being used appropriately in theatre and saw completed preoperative checklists and consent documentation in patient’s notes.

Patients had good outcomes as they received effective care and treatment to meet their needs. The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care. A trauma dashboard had been developed to monitor overnight admissions across the division and highlight the need for extra bed capacity.

There were clear governance processes in place to monitor the service provided. A clear responsibility and accountability framework had been established. The division handled 97% of complaints within trust timescales (95% target). Leadership at each level was visible, staff had confidence in the leadership and staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

However:

Medical staff did not meet the trust target for mandatory core training completion, this included safeguarding. Across the division, NEWS audits (March 2017) showed that 59% of observations were recorded which were worse than the 67% compliance rate in the previous audit.

There were 108 medication incidents recorded between March 2016 and February 2017 across the surgical division.

Between February 2016 and January 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance.

Outpatients

Requires improvement

Updated 13 October 2017

There were issues regarding referral to treatment (RTT) indicators and waiting lists for appointments. There was an appointment backlog which had deteriorated since the last inspection and was at 19,647 patients waiting more than three months for a follow up appointment. Staff told us clinical validation had occurred on some waiting lists, for example in ophthalmology. However this had not occurred on all backlogs across the trust.

No specialties were above the England average for non-admitted referral to treatment (RTT) (percentage within 18 weeks), however the trust were progressing work on addressing this with a trajectory to be achieving the indicators by March 2018. The trust did not measure how many patients waited over 30 minutes for imaging within departments. The trust measured turnaround times in a different way from Keogh standards. They measured time taken from referral to report rather than referral to image and a separate measurement of image to report. Although measured differently, trust and national targets were not consistently met.

Duty of candour was not well understood across all staff groups; however senior managers could describe the duty of candour. Mandatory training completion rates and targets were not always met. Appraisals completion rates did not always achieve the trust target.

In main outpatients, team meetings did not always happen monthly. Managers were aware of this and told us they were addressing consistency of team meetings in main outpatients.

However:

A trust incident reporting system was used to report incidents and staff we spoke with were aware of how to report incidents. Staff were aware of how to report safeguarding concerns.

Areas we visited were visibly clean and tidy. Medicines checked were found to be stored securely and were in date. Staff told us records were available for clinics when required.

Actual staffing levels were in line with the planned staffing levels in most areas. Staff provided compassionate care to patients visiting the service and ensured privacy and dignity was maintained. Diagnostic services were delivered by caring, committed and compassionate staff.

Managers were able to describe their focus around addressing issues with the referral to treatment indicators and addressing waiting times. There were referral to treatment recovery plans in place for various specialties. The Did Not Attend (DNA) rate was lower than the England average.

Risk registers were in place and managers took risks to the divisional governance meetings. Management could describe the risks to the service and the ways they were mitigating these risks. Most staff we spoke with told us managers and team leaders were available, supportive and visible. Staff we spoke with told us there was good teamwork within teams and there was a culture of openness and honesty. Diagnostic imaging leaders encouraged and enabled staff to develop their own skills and knowledge, share good practice nationally, and improve the service.