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Pontefract Hospital Requires improvement

We are carrying out checks at Pontefract Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 11 May, 16-19 May, 22 May and 5 June 2017

During an inspection to make sure that the improvements required had been made

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 carried out on 23-25 June 2015, 3 July 2015

During an inspection to make sure that the improvements required had been made

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. In total, the trust had approximately 1,116 beds and 6,698 staff.

We carried out a follow up inspection of the trust between 23-25 June 2015 in response to a previous inspection as part of our comprehensive inspection programme of The Mid Yorkshire Hospitals NHS Trust in July 2014. In addition, an unannounced inspection was carried out on 3 July 2015. The purpose of the unannounced inspection was to look at the emergency department at Pontefract General Infirmary out of hours.

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. We therefore did not inspect the majority of community services or critical care at Pinderfields Hospital as part of the follow up inspection. In addition not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

Following the announced inspection in June 2015 CQC received a number of concerns and on further analysis of additional evidence an unannounced focussed inspection took place on the 25 August 2015 on Gates 20, 41, 42 and 43 at Pinderfields Hospital. The focus of the inspection was to look at staffing levels, missed patient care and poor experiences of care. At the inspection we had serious concerns regarding the nurse staffing levels on Gates 20, 41, 42 and 43 which had impacted on the care patients received. We also had concerns regarding the management and escalation of risk and where actions had been implemented these had not always been monitored or sustained.

After the unannounced inspection on 25 August 2015 we wrote to the trust and asked them to provide information on how the trust intended to protect patients at risk of harm both immediately and going forward. The trust provided information to CQC which highlighted what immediate actions they had taken to support nurse staffing on the wards.

We visited Gates 20, 41, 42 and 43 on the evening of 22 September 2015 to check that improvements had been made. We found additional support staff had been put in place to support registered nurses on the ward and measures had been put in place to ensure patients received the care they needed.

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.

Our key findings from the follow up inspection in July 2015 were as follows:

  • We found within the trust there had been improvements in some of the services and this had meant a positive change in the ratings from the previous CQC inspection notably within outpatients and diagnostic services. In some domains in key services we noted improvements from our previous inspection findings but other factors had impacted on the rating so the rating had stayed the same. However we found in medical care, end of life services and community inpatients they either had not improved or had deteriorated since our last inspection.
  • The trust had responded to previous staffing concerns and was actively recruiting to fill posts. Staffing levels throughout the trust were planned and monitored. However there were areas where there were significant nurse staffing shortages and these were impacting on patient care and treatment particularly on the medical care wards, community inpatient services and in the specialist palliative care team. There was also shortage of medical staff within end of life services.
  • We found that most areas we visited were clean however there were areas in accident and emergency departments at Pinderfields and Dewsbury District Hospital and in the mortuary at Dewsbury and District Hospital that were not clean and infection control procedures had not been followed.
  • Patients nutritional and hydration needs were not always assessed using the Malnutrition Universal Screening Tool (MUST). At our inspections we found that not all fluid balance and nutrition charts were fully completed which meant staff could not always assess the hydration and nutritional status of patients and respond appropriately where patients needed additional support.
  • The trust had consistently not achieved the national standard for percentage of patients discharged, admitted or transferred within four hours of arrival to A&E. Pinderfields had not met the 95% standard for the previous 12 months and Dewsbury District Hospital had not met the 95% target for the previous 6 months.
  • There was a governance structure which informed the board of directors. This was developed and implemented in 2014.
  • The trust had a vision for the future called “meeting the challenge”. This was detailed in the trust’s five year strategic plan 2014/15- 2018/19. The trust had developed an overarching strategy called “striving for excellence” which was detailed in the five year strategy. Underpinning the strategy there were five breakthrough aims which had key metrics against them so the trust could measure their performance against these.

We saw areas of good practice including:

  • There had been a turnaround of the outpatient service which had included the standardisation of processes, following up of the backlog of outpatients, compliance with performance targets and a restructuring across the other services. As a result the 9,501 backlog of overdue outpatient appointments we found at our inspection in July 2014 had reduced to three patients in June 2015.
  • Across services in the trust 'listening into action' events had been held to support staff to transform their services by removing barriers that get in the way of providing the best care to patients and their families. Overall in the NHS staff survey 2014 the trust had improved scores on 59 questions compared to the results in the 2013 survey.
  • Most of the staff we spoke with told us they felt the culture within the organisation had changed and that there was a desire to improve from the senior management team, management was better, communication had improved and there was more clinical engagement.

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

Importantly, the trust must:

  • 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 be able to demonstrate they follow and adhere to the ten expectations from the national quality board.
  • The trust must ensure policies and procedures to monitor safe staffing levels are understood and followed.
  • The trust must strengthen the systems in place to regularly assess and monitor the quality of care provided to patients.
  • The trust must ensure where actions are implemented to reduce risks these are monitored and sustained.
  • The trust must ensure all patients identified at risk of falls have appropriate assessment of their needs and appropriate levels of care are implemented and documented.
  • The trust must ensure there are improvements in the monitoring and assessment of patient’s nutrition and hydration needs to ensure patients’ needs are adequately met.
  • 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 the mental capacity act and deprivation of liberty safeguards.
  • The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines, and that oxygen is prescribed in line with national guidance.
  • The trust must ensure that infection control procedures are followed in relation to hand hygiene, the use of personal protective equipment and cleaning of equipment.
  • The trust must ensure staff follow the trust’s policy and best practice guidance on DNA CPR decisions when the patient’s condition changes or on the transfer of medical responsibility.
  • The trust must ensure there are improvements in referral to treatment times and accident and emergency performance indicators to meet national standards to protect patients from the risks of delayed treatment and care. The trust must also ensure ambulance handover target times are achieved to lessen the detrimental impact on patients.
  • The trust must ensure in all services resuscitation and emergency equipment is checked on a daily basis in order to ensure the safety of service users.
  • The trust must improve the discharge process for patients who may be entering a terminal phase of illness with only a short prognosis.

In addition the trust should:

  • The trust should continue to review the prevalence of pressure ulcers and ensure appropriate actions are implemented to address the issue.
  • The trust should continue to improve interdepartmental learning and strengthen governance arrangements within the accident and emergency departments.
  • The trust should review the use of emergency theatres and improve the processes to prioritise patients in need of emergency surgery.
  • The trust should take action to reduce the number of last minute planned operations cancelled for non-clinical reasons.
  • The trust should ensure staff are involved and informed of service changes and re-design.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 29 May 2013

During a routine inspection

Pontefract Hospital is part of the Mid Yorkshire Hospitals NHS Trust. This inspection was carried out over one day by a team of inspectors and an Expert by Experience as part of our scheduled programme.

We visited the stroke rehabilitation unit, an orthopaedic ward and the outpatients department.

We found that patients were receiving good care in the areas of the hospital that we visited. Overall patients gave positive feedback on the care and treatment they received. We found that the relocation of the stroke unit had had an impact on how therapy services were delivered, which we consider should be reviewed. We also found that communication about delays in appointment times in outpatients could be improved. We reviewed staffing in the areas we visited and found staffing levels were sufficient. We found satisfactory systems were in place to manage complaints and no evidence to suggest that quality assurance processes were not being implemented, for example, assessing and managing risk.

Inspection carried out on 12 November 2012

During a routine inspection

Pontefract Hospital is part of The Mid Yorkshire Hospitals NHS Trust. This inspection was carried out by a team of inspectors as part of our scheduled programme. We had received information in the form of complaints and statutory notifications since the last inspection which lead us to follow up on reports of poor discharge planning and poor care delivery.

We visited the Accident and Emergency Department, Care Closer to Home and the Day Surgery Unit.

People told us they were spoken to respectfully by staff and that their privacy and dignity was maintained as much as possible.

We spoke with two people who were due for discharge and they told us they had been informed about ongoing help they would receive once they had returned home

Two people in the day surgery unit told us they were provided with information about their care and that their opinions were taken into account when the day surgery was planned.

We spoke with staff who were knowledgeable about their area of expertise and could demonstrate a good understanding and applications of policies and procedures to support effective service delivery. Our observations of staff over all departments visited were that of a competent work force which provided dignity, privacy and respect to patients.

We looked at a number of records including patient records and found them to be relevant to the treatment the patient was receiving, up to date and accurate

Inspection carried out on 31 August and 18 October 2010

During a routine inspection

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.