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Pontefract Hospital Requires improvement

We are carrying out checks at Pontefract Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 December 2018

  • We found that the Pontefract Medical Stroke Rehabilitation Unit (PMSRU) and the Urgent Treatment Centre (UTC) did not always have enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Managers could not always match staffing levels to patient need and could not increase staffing when care demands rose.
  • We were concerned about patient risk assessment and patient records on the PMSRU. We did not see evidence that patient risk assessments for falls, pressure damage and nutrition were updated weekly or following transfer to the unit. We found that staff kept poor records of patients’ care and treatment. Records were not completed to a good standard and we found incomplete and misfiled notes.
  • We saw that staff on the PMSRU did not have always time to give compassionate care to patients because nurse staff levels were low. We noted call bells ringing for more than five minutes and patients were calling out for help. There were not always enough staff to ensure those patients who needed assistance with their meals received it. Some of the housekeeping staff worked additional hours to help with meals when nurse staffing levels were low.
  • We had some concerns about clinical audit at the hospital. There was limited evidence of clinical audits taking place in the UTC, so we were unable to gain assurance of positive patient outcomes in the service. In maternity services, we noted significant delays with the local maternity audit programme overall.
  • Across the hospital we found that paper copies of patient group directions used for various medicines including ibuprofen and paracetamol and co-codamol had not been reviewed since 2014 and had not been signed by relevant staff.
  • In the outpatients service there was a backlog of 18,374 patients waiting for follow up appointments. Although the backlog of patients waiting for follow up appointments had improved slightly since our last inspection we were concerned about the slow pace of clearing the backlog and it was not clear what the trajectories were for clearing the backlog. In addition, the trust could not provide evidence that clinical validation had taken place on all patients in the backlog.

However:

  • All the areas we visited in the hospital appeared clean and well organised. Equipment was in good working order and safety tested.
  • Staff were aware of the processes to follow to report incidents and safeguarding concerns. Learning from incidents was shared between teams.
  • We saw good overall core mandatory training and role specific training completion rates compared to trust targets. Staff could clearly describe safeguarding reporting procedures and felt confident making referrals.
  • Care and treatment was based on national guidance.
  • Staff were caring, compassionate and treated patients with dignity and respect.
Inspection areas

Safe

Requires improvement

Updated 7 December 2018

Effective

Requires improvement

Updated 7 December 2018

Caring

Good

Updated 7 December 2018

Responsive

Good

Updated 7 December 2018

Well-led

Requires improvement

Updated 7 December 2018

Checks on specific services

Urgent and emergency services

Requires improvement

Updated 7 December 2018

Our overall rating of the service was requires improvement because:

  • The unit did not always have enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm. The unit manager was not able to match staffing levels to patient need and was not able to increase staffing when care demands rose.
  • Risks within the unit were not clearly identified and we did not see evidence of these being escalated where appropriate.
  • We did not receive assurance of performance in clinical audits. There was limited patient outcome data and audits conducted in the department.
  • Although there was a streaming and triage process in place in the unit; a clinical review of patients by clinical staff was not always undertaken in a timely way.
  • Rooms used for assessment of patients with mental health conditions were not ligature free and did not have access to equipment to summon for help if required.
  • Resuscitation equipment was not safely managed. Some equipment was out of date.
  • Paper copies of patient group directions (PGD) used in the department for various medicines including ibuprofen, paracetamol, cocodamol etc. had not been reviewed since 2014 and had not been signed by all staff working in the unit. As such medicines were being administered to patients without prescriptions.
  • Information we reviewed from the trust showed that the service did not have robust governance procedures in relation to monitoring of the private GP contract, the service did not hold the information on the current level of DBS compliance or training compliance for the GP.
  • The division had moved with pace to implement the UTC. However, we did not receive assurance regarding patient outcomes.

However:

  • The unit was visibly clean and well organised. Equipment was in good working order and safety tested.
  • Staff were caring, compassionate and treated patients with dignity and respect. We spoke with three patients and one relative who were satisfied with the care and treatment they received.
  • We were supplied with performance reports for the unit. The reports showed that the UTC performed well against the overall emergency care standard.
  • There was good leadership at unit level. Staff we spoke to were aware of the changes in the unit and had been involved in the consultation and planning process.

Maternity

Good

Updated 7 December 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated the service as good because:

  • We saw good overall core mandatory training and role specific training completion rates compared to trust targets. Safeguarding training completion rates surpassed trust targets. Staff could clearly describe safeguarding reporting procedures and felt confident making referrals.
  • Emergency equipment service checks were in date. Since our last inspection, the service had implemented a comprehensive programme of skills and drills training in all clinical areas.
  • There had been no serious incidents reported at maternity services at this location in the 12 months prior to our inspection. We found lessons learned following incident investigations were shared in different formats, and staff were able to describe learning from these incidents.
  • Outcomes for women were typically good and outcomes for babies were better than trust targets and regional averages.
  • Over a one-year period, maternity services at the location received a comparatively low number of formal complaints (three) and a relatively high number of formal compliments (32). We saw evidence of learning from complaints, which were investigated in a timely manner.
  • All staff received an appraisal. Midwifery advisors were on call 24-hours for independent advice and support. Across the trust, there were midwives available for support and guidance and with special interests as part of their role.

However:

  • Except for community midwife caseloads, we saw there was sufficient maternity staff within the trust when measured against national guidelines and minimum recommendations. The trust was aware of staffing shortfalls, and there were plans to look at areas of concern. However, we were not assured that staff were allocated properly across the service to meet service need.
  • Across the trust, antenatal services experienced difficulty offering women follow-on clinic and day unit review appointments.
  • The storage, ordering and disposal of medicines was in line with current guidance and regulations. However, we saw some paper copies of patient group directions, that allowed nurses to administer medicines without a prescription, were out of date.
  • At our previous inspection, we found a lack of local audit activity to encourage continuous improvement. At our recent inspection, we saw good progress with prioritisation of activities for completion. However, we noted significant delays with the local maternity audit programme overall.

Outpatients

Requires improvement

Updated 7 December 2018

We rated this service as requires improvement because:

  • Although the backlog of patients waiting for follow up appointments had improved slightly since our last inspection, there was still a backlog of 18,374 at 22 July 2018.
  • There was a process in place for administrative and clinical validation of waiting lists. However, the trust could not provide evidence that clinical validation had taken place on all patients in the backlog.
  • Despite specialities having agreed response plans, it was not clear what the trajectories were for clearing the backlogs.
  • Referral to treatment times (RTT) were worse than the England overall performance; however there had been a steady increase in performance and there had been an improvement since the last inspection.

However:

  • Staff were aware of the processes to follow to report incidents and safeguarding concerns. Learning was shared between teams.
  • Staffing levels were flexed to cover clinics and the outpatient departments were staffed by multidisciplinary teams that worked effectively together.
  • Patients attending the department received care and treatment that was evidence based and followed national guidance. Staff had access to policies and guidance.
  • Staff provided compassionate care to patients and patients were kept informed and given choices in their care.
  • The service was well led with leaders who were visible and approachable.
  • Staff spoke positively about working for the service, they felt well supported and spoke about good teamwork.
  • Leaders were aware of the issues within the service and there were good governance processes in place.

Medical care (including older people’s care)

Requires improvement

Updated 7 December 2018

We rated it as requires improvement because:

  • The unit did not always have enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Ward managers could not always match staffing levels to patient need and could not increase staffing when care demands arose.
  • Staff kept poor records of patients’ care and treatment. Records were not completed to a good standard and we found incomplete and misfiled notes. We did not see evidence that patient risk assessments for falls, pressure damage and nutrition were updated weekly or following transfer to the unit.
  • The service did not manage medicines well. We found some medicines were not in date and there was an excessive amount of stock.
  • Staff did not always have time to give compassionate care to patients because nurse staff levels were so low. We noted call bells ringing for more than five minutes and patients were calling out for help.
  • Although mealtimes were protected and we saw consistent use of the red jug and tray to identify patients who needed assistance with their food and drink; there were not always enough staff to ensure those patients who needed assistance with their meals received it. Some of the housekeeping staff worked additional hours to help with meals when nurse staffing levels were low.
  • The service did not always take account of patients’ individual needs. There were a high number of patients on the ward with dementia, yet the environment was not dementia friendly and there were no specific adjustments made for these patients.
  • There were no team meetings on the unit which did not give staff the opportunity to discuss issues and concerns which needed escalating. There was no forum where shared learning from incidents and complaints could be discussed. With the exception of the email bulletins sent to staff by the ward manager, there was no mechanism to pass information down to staff.
  • Although staff understood the basic principles of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS), we saw limited examples of mental capacity assessments or decisions made in line with the principles of the MCA. Where patients lacked capacity, recording that the decision was in the patient’s best interests was not consistent.

However:

  • All ward areas we visited appeared visibly clean and well organised. Equipment was in good working order and safety tested.
  • Staff with specialist skills and knowledge worked well together to benefit patients. We saw good multidisciplinary working on the unit between nursing, therapy and social care staff.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. There was an agreed procedure in place to ensure the service complied with national guidance.
  • The unit had a dedicated discharge liaison nurse and discharge co-ordinator who worked with social care providers and voluntary organisations to ensure the safe and timely discharge of patients from the unit.
  • The Division of Medicine had a clear strategy. They had recently implemented a new model of care with the acute hospital reconfiguration. Staff we spoke with were aware of this and had been involved in the consultation and planning process.