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Pinderfields Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 December 2018

Our rating of services stayed the same. We rated them as requires improvement because:

  • Staffing did not always meet planned or recommended levels in urgent and emergency services and medical services. In medicine we found that there were a high number of registered nurse vacancies and fill rates were low on some wards. There was a shortage of junior doctors in the medicine division and a heavy reliance on bank and locum staff.
  • In urgent and emergency services we found that recording of national early warning scores was inconsistent. There had been improvements in the recording of scores for adults; however we found gaps in the recording of observations for children.
  • The layout of the emergency department meant that patients could not always be observed adequately by staff.
  • We were concerned about the responsiveness of the urgent and emergency services at the hospital. From April 2017 to March 2018 the service had not met the standard for patients being admitted, transferred or discharged within four hours of arrival and the percentage of patients waiting more than four hours from the decision to admit until being admitted was consistently higher than the England average.
  • The number of out of hours bed moves within medical services remained high.
  • Across the hospital we found that paper copies of Patient Group Directions (PGD) were out of date and were not signed by individual members of staff, as required by the relevant trust policy.
  • In maternity services we saw there were generally sufficient maternity staff within the trust when measured against national guidelines and minimum recommendations. However, we were not assured that staff were allocated properly across the service to meet service need. We saw that high proportions of women booked for planned inductions of labour experienced significant delays.
  • 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.
  • Referral to treatment times 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:

  • We found significant improvements in medicine and critical care, where overall ratings improved for both services. In medicine, improvements had been made to clear the backlog of unresolved incidents from the previous inspection; to share learning and ensure staff received feedback; to improve record-keeping and the frequency of risk assessments and to improve the escalation of deteriorating patients.
  • The trust had undertaken a lot of work to reduce the risk of patient falls. Initiatives included; having a corporate falls work stream with a dedicated falls lead for the trust. Patients were risk assessed for falls and the trust had worked hard to improve communication regarding patient risk. They were also trialling a number of other initiatives such as ‘tagging’ and use of coloured identity bands to reduce the incidence of falls.
  • Staff cared for patients with kindness and compassion. We saw some examples of staff providing outstanding care for patients and their relatives in critical care services.
  • Leadership, governance and risk management was generally effective, embedded and robust across the services that we inspected
  • We generally saw good overall core mandatory training and role specific training completion rates compared to trust targets.
  • Learning from incidents had improved. Staff understood their responsibilities to raise concerns and report incidents. There were good mechanisms to feedback and share learning from incidents with staff.
  • Staff culture had improved since the last inspection in that we found that staff were more open and engaged.
Inspection areas

Safe

Requires improvement

Updated 7 December 2018

Effective

Good

Updated 7 December 2018

Caring

Good

Updated 7 December 2018

Responsive

Requires improvement

Updated 7 December 2018

Well-led

Good

Updated 7 December 2018

Checks on specific services

Critical care

Good

Updated 7 December 2018

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

  • The service showed a good track record in safety. There had been no never events, one serious incident and the incidents reported had mainly resulted in low or no harm and themes had been responded to. Staff understood their responsibilities to raise concerns and report incidents and to be open and honest when things went wrong. Managers investigated incidents and shared lessons learned.
  • Systems and processes in infection control, medicines management, patient records and the monitoring, assessing and responding to risk were reliable and appropriate to keep patients safe.
  • Consultant cover had increased and changed to block working, to promote continuity of care, multidisciplinary staffing levels were in line with the Guidelines for the Provision of Intensive Care Services (GPICS) standards. Nurse staffing levels and skill mix were planned and reviewed to keep people safe.
  • The service provided mandatory training in key skills and role-specific skills and the number of critical care staff who completed this, met the trust targets of 95% and 85%, respectively.
  • There was a system in place to ensure all nursing and medical staff had an up to date appraisal and 99% of staff had received an appraisal compared to the trust target of 85%.
  • Staff of different kinds worked together as a team to benefit patients. Multidisciplinary staffing, including physiotherapy and pharmacy were appropriate for the size of the unit, in line with GPICS recommendations.
  • Patient outcomes were in line with similar units. The service compared local results with those of other services to learn from them.
  • The unit’s non clinical transfers and delayed discharge rates were in line with or better than similar units. The out of hours discharge to the ward rate was in line with or better than similar units.
  • The outreach team provided a follow-up clinic to support critical care patients following discharge from hospital, in line with the Guidelines for the Provision of Intensive Care Services (GPICS) standard.
  • Staff cared for patients with compassion at all times. Feedback from patients and families was consistently positive. Patients and relatives told us staff treated them well and with kindness, that they felt well-informed and staff communicated with them in a way they could understand.
  • Staff provided emotional support to patients to minimise their distress; they encouraged families to complete patient diaries, which were used for reflection in follow-up clinics and staff co-ordinated a monthly patient and family-led support group to help people come to terms with their experience of critical care.
  • We observed a strong, visible person-centred culture inspired by the nursing and clinical leadership.
  • The service engaged patients and families to plan and improve services. The unit had shown a dedication to listening to and involving patients and families. This was reflected in changes to the physical environment, the draft service strategy, the introduction of ‘care packs’ for relatives unexpectedly staying overnight, memory boxes and ongoing support for patients and families after discharge and in trying times.

However:

  • The service did not prescribe oxygen for patients in line with national guidance.
  • The service was not yet fully compliant with all the Guidelines for the Provision of Intensive Care Services (GPICS) standards.
  • The number of staff in the service with a post registration qualification in critical care was 39%, which was not in line with the GPICS minimum of 50%. This had reduced since the last inspection. Managers acknowledged this was due to staff turnover resulting from the service reconfiguration in September 2017 and had a plan in place to mitigate and improve this over two years.
  • Patients were not always discharged to a general ward within four hours of the decision to do so. This was not in line with GPICS standards, however there had not been any mixed sex breaches.
  • There was a need to strengthen governance arrangements and ensure outcomes and learning from management meetings are shared with staff, including the MDT, to promote service improvement.

Outpatients and diagnostic imaging

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. Managers told us clinical validation had occurred on some waiting lists, for example in areas of ophthalmology. However, this had not occurred on all backlogs or waiting lists for appointments across the trust.

No specialties were above the England average for non-admitted RTT (percentage within 18 weeks). The trust had 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.

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. The Did Not Attend (DNA) rate in outpatients was lower than the England average.

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. 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.

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.

Urgent and emergency services

Requires improvement

Updated 7 December 2018

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

  • Staffing did not always meet planned or recommended levels.
  • The department often became overcrowded and its layout made patient observation difficult.
  • Mandatory training compliance did not meet the trust target.
  • We had concerns about initial assessment times and non-clinical patient streaming.
  • Patients had long waits for treatment and admission.
  • We found out of date paper copies of patient group directions and equipment.
  • We had concerns about patient confidentiality.
  • Patients’ privacy and dignity was not always maintained.
  • Patient documentation was not completed consistently.
  • Performance in Royal College of Emergency Medicine (RCEM) audits was mixed.
  • Response from other specialities was not always timely.
  • Staff perception of risk was not consistent with the risk register
  • We were not assured that cubicle curtains were changed regularly.

However:

  • The clinical educator was focused on improving staff training.
  • There was a designated nurse focused on patient flow in the department.
  • Triage training and supervision had improved.
  • Staff appraisal rates were above the trust standard.
  • The department was clean and tidy.
  • The trust had plans in place to update patient group directions (PGDs), which allow certain medicines to be administered without a prescription from a doctor.
  • Staff reported incidents and incident outcomes influenced learning.
  • The children’s ED was separate and secure.
  • Sepsis management had improved.
  • Patient safety checklists were in use.
  • All levels of staff worked well together, sharing information and using evidence based practice.
  • Staff were caring, compassionate and respectful.
  • We saw good examples of leadership, support and culture in the department.
  • Work was ongoing to address issues with speciality referral.

Maternity

Requires improvement

Updated 7 December 2018

We rated the service as requires improvement because:

  • The senior management team had changed since our previous inspection, and was relatively new. We saw evidence the team had made progress with evaluating the changes necessary to improve quality of care. However, we were not always assured of robust action planning, or that changes were being implemented at a sufficient pace.
  • Except for community midwife caseloads, we saw there was sufficient maternity staff within the trust when measured against national guidelines and minimum recommendations. However, we were not assured that staff were allocated properly across the service to meet service need.
  • We saw high proportions of women booked for planned inductions of labour experienced significant delays.
  • The storing, ordering and disposal of medicines was in line with current guidance and regulations. However, we identified that some printed copies of patient group directions, that allowed midwives to administer certain 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.
  • We saw performance in antenatal service, triage, and induction of labour service areas appeared to negatively affect some women’s experiences of care. Similarly, some staff raised concerns about capacity and workload in these areas. We also had concerns about the quality of (hospital) postnatal care and support provided to some women.

However:

  • 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. We saw all eligible maternity staff at the trust had received an appraisal.
  • There were high emergency training completion rates. Emergency equipment was in date and checked regularly. Since our last inspection, the service had implemented a comprehensive programme of skills and drills training in all clinical areas.
  • Outcomes for women and babies were typically good, and in line with trust targets or regional averages.
  • At our previous inspection, we found the service was learning from incidents, but not informing staff why practice had changed. During our recent inspection, staff were able to describe learning from incidents and we saw learning shared across the service. There was evidence of learning from complaints, which were investigated and closed in a timely manner.

Outpatients

Requires improvement

Updated 7 December 2018

  • 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 responsive to patients with additional needs and made efforts to ensure they were catered for.
  • 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.

Maternity and gynaecology

Requires improvement

Updated 13 October 2017

Midwifery staffing was below nationally recommended levels, at 1:31. Following our previous inspection the service reviewed staffing using a recognised acuity tool and this identified a shortfall of 18 whole time equivalent midwives.

Attendance of midwifery and medical staff at obstetric emergency training was below required levels.

Since the reconfiguration of services at the Pinderfields site, staff told us there had not been any skills and drills in clinical areas namely the birth centre and ward 18. There was also a lack of clinical audit since the reconfiguration of services. Staff voiced concern about the monitoring of vulnerable women on the antenatal and postnatal ward; this was due to a lack of ward rounds by some consultants.

There was little information for women whose first language was not English, some staff were not aware this could be accessed on the trust intranet system.

The risk register contained a large number of risks, and many had a review date in the past. This led to concern that there was a lack of oversight by senior managers.

However:

The service had successfully reconfigured to provide consultant-led maternity care on one hospital site. The community midwifery caseloads were the same as national recommendations, and the services had plans in place to improve midwifery staffing by 2020.

Following our previous inspection there were robust practices in place to check emergency equipment.

The service had successfully bid for Department of Health Safety training and had allocated the funding appropriately.

We found good multidisciplinary working between midwifery and medical staff. Women were positive about the care they received; we observed good and friendly interactions between staff, women, and relatives.

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

Medical care (including older people’s care)

Good

Updated 7 December 2018

  • We found effective leadership throughout medical care services at ward level and above. Staff spoke positively about their local and divisional leadership and said they were well supported. Staff said the culture had improved and was more open.
  • The Division of Medicine had a clear vision and strategy which was linked to those of the trust. They had recently implemented a new model of care with the acute hospital reconfiguration which centralised acute in-patient services at Pinderfields Hospital. This had led to improvements in patient flow through the hospital.
  • At the inspection in May 2017 we found the environment cluttered with extra capacity beds above the ward base beds. There were no extra capacity beds found at this inspection and the environment was well organised and clutter free.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. At the previous inspection we were concerned that caring for patients in extra capacity beds led to their privacy and dignity being compromised. At this inspection we saw that patients were treated with respect and their privacy and dignity was maintained.
  • Learning from incidents had improved. There were good mechanisms to feedback and share learning from incidents with staff across the division. This included one to one feedback, safety huddles and briefings, staff meetings and a two weekly safety bulletin circulated to all staff. The division had resolved their backlog of unresolved incidents.
  • The trust had undertaken a lot of work to reduce the risk of patient falls. Initiatives included; having a corporate falls work stream with a dedicated falls lead for the trust. Patients were risk assessed for falls and the trust had worked hard to improve communication regarding patient risk. They were also trialling a number of other initiatives such as ‘tagging’ and use of coloured identity bands, to reduce the incidence of falls.
  • The standard of nursing documentation and record keeping had improved and equipment was in good working order and had been safety tested and checked according to manufacturer’s recommendations.
  • Since our last inspection the provision of food and drink for patients had improved. 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. All patients had drinks within reach. Provision was made for patients requiring a specialised diet or for those who had cultural and other preferences.
  • There was good multidisciplinary team working and we saw positive working relationships between professions. There was good access to psychiatric liaison services and access to other specialist staff, such as psychologists.
  • The service took account of patients’ individual needs. There was a lead nurse for dementia and a learning disability liaison specialist nurse. We saw that reasonable adjustments were made, such as open visiting and overnight stay for relatives/carers.

However:

  • Nurse staffing levels were still an issue. The division had a high number of registered nurse vacancies and fill rates were low on some wards. To minimise the risk to patient care, the division had over recruited to health care assistants had developed new roles within the unqualified nursing staff to bridge gaps in staffing.
  • There was a shortage of junior doctors in the division and a heavy reliance on bank and locum staff. From April 2017 to March 2018 there were 4,537 shifts filled by bank staff and 16,353 filled by locum staff. Medical and nursing staff said there were a high proportion of unfilled shifts which often resulted in delayed discharges as the junior doctors needed to prioritise more urgent work.
  • We found that paper copies of Patient Group Directions (PGD) on the oncology ward, which allowed nurses to administer certain medicines without a prescription, were out of date and the individual authorisation form attached to the PGDs was not signed by staff. We also found the inconsistent use of risk assessments for patients self-administering their medication.
  • Staff understood the basic principles of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS); however, 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.
  • The number of out of hours bed moves between the hours of 10pm and 7am were high. Data provided by the trust indicated there were 960 bed moves at night across 24 wards between October 2017 and March 2018, with 867 ward moves at night at Pinderfields Hospital. The average number of moves per ward ranged from none to 34. Although there was a cut off time of 10pm for bed moves, staff told us that moves after 10pm often occurred.

Surgery

Good

Updated 13 October 2017

We observed the treatment of patients to be compassionate, dignified, and respectful throughout our inspection.

There were systems in place to identify themes from incidents and near miss events. The division held regular emergency surgery and elective care business unit meetings where serious incidents were discussed, investigations analysed, and changes to practice identified.

During 2015/16, the surgical division prioritised 33 level one clinical audits covering a range of specialties. Outcomes from each audit were reported to the trust’s quality panels and directorate operational team meetings.

Between December 2015 and November 2016 the average length of stay for surgical elective patients at trust level, as well as at Pinderfields General Hospital, was lower than the England average at 3.1 days and 2.6 days respectively, compared to 3.3 days for the England average. 

For the period Q4 2014/15 to Q3 2016/17, the trust cancelled 726 surgeries. Of the 726 cancellations, 1% were not treated within 28 days. The trusts performance has been consistently better than the England average for the period. Across the trust, there were 54,683 surgical admissions from December 2015 to November 2016. Readmission rates had reduced and improved.

There were clear and embedded governance processes in place to monitor the service provided. A clear responsibility and accountability framework had been established. Leadership at each level was visible. Staff had confidence in the new leadership and felt they were be listened to. Complaints were responded to in a timely manner and learning was taken forward to develop future practice.

However:

National Early Warning Score (NEWS) audits in March 2017 showed that 59% of observations were recorded which was down from 67% in the previous audit cycle. 

The qualified nursing staff levels required across all surgical wards at Pinderfields General Hospital was 335.9 whole time equivalent (WTE) for March 2017. The number of qualified staff in post were 309.87 WTE. The areas with the largest staffing vacancies were in theatres (16.2 WTE), the plastics and burns surgical services (6.23 WTE) and gate 33 (4.17 WTE).

Nursing staff had not met all mandatory training targets. Medical staff did not reach the 95% target for any of the trusts core training, including safeguarding.

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.

Services for children & young people

Good

Updated 13 October 2017

Staff understood their responsibilities for reporting incidents. There were incident reporting mechanisms in place and staff received feedback. There were safeguarding systems and processes in place and staff were accessing the required level of training.

Care was planned and delivered in line with evidence-based practice. Staff had the skills required to carry out their roles effectively. Children’s services had employed advanced nurse practitioners.

Children, young people and their parents were involved with their care, given information in a way they could understand and allowed time to ask questions.

Staff were friendly, caring, helpful and provided emotional support. Services were planned and delivered in a way that met the needs of the children and young people.

Children and young people could access the right care at the right time. There were processes in place for the transition in to adult services and they had recently appointed a lead nurse for transition services. There were effective governance processes in place and the leadership team understood the risks to their service.

However:

Staffing numbers did not meet national recommendations on a number of occasions. Staffing levels and patient acuity were reviewed twice a day and staff were moved between the different children’s areas to provide support where needed. However, although this provided support to some areas it meant that other areas were not meeting the national recommendations

Staff did not receive regular safeguarding supervision as recommended in the Royal College of Nursing (RCN) guidance, although it was offered on a case need basis.

The menus provided were not child friendly and staff had difficulties accessing food suitable for children out of hours.

Equipment had no indication of when electronic testing was due and relied on staff contacting medical physics. Service leads told us that there had been a decision to reintroduce the labeling of equipment.

End of life care

Good

Updated 13 October 2017

Nurse and consultant staffing levels for the specialist palliative care team were at full complement and reviewed daily to keep people safe at all times. Any staff shortages were responded to quickly and adequately. Specialist palliative care nurses were available and each ward had an end of life link nurse.

We saw evidence that compliance with infection control and environmental cleaning standards were monitored regularly and maintained in the mortuary.

Risks to people, who use services were assessed, monitored and managed on a day-to-day basis. Staff used a community-wide electronic patient record system accessible to the multidisciplinary team caring for the patient including hospital staff, community staff and most GPs. They also had access to EPaCCS (Electronic Palliative Care Coordination System). which enabled the recording and sharing of people’s care preferences and key details about end of life care.

End of life care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. There was a comprehensive audit programme in place against national standards for end of life care.

The trust included a session on end of life care in the core mandatory training programme for ward nursing staff. The service was planning to introduce the Gold Standard Framework to hospital staff on eleven wards in 2017.

For those palliative care patients who were already known to the service and admitted to the hospital for care and treatment, 93% were followed up by contacting the ward within 24 hours to assess the need for specialist palliative care assessment.

There was a 24-hour seven-day rota for palliative care consultant cover and this was accessed by nursing staff in the hospital when palliative care specialist advice was required out-of-hours. Access to specialist palliative care nurses was Monday to Friday at the time of inspection, but recruitment was underway to expand to a seven-day service.

We observed a caring and compassionate approach from palliative care team members and ward nursing staff during their interactions with patients and family members. We saw how family members were supported in understanding and managing symptoms by being involved in discussions with members of the specialist palliative care team during their assessment of the patient in the hospital. Chaplaincy and drop in services were also available.

The trust was working to create a local end of life care strategy with the clinical commissioning group and other stakeholders. There were clinical networks in place linking the hospices, hospital and community services to ensure effective communication as the patient moved between services.

The quality of leadership for end of life care had improved since the last inspection. Structures, processes, and systems of accountability, including the governance and management of joint working arrangements were clearly set out, understood and effective. The leadership was knowledgeable about quality issues and priorities within end of life care, understood what the challenges were and took action to address them. Risk issues such as achieving rapid discharge were escalated to the relevant committees and the board through clear structures and processes.

However:

Staff we spoke to were not all familiar with the Duty of Candour and when it was implemented.

An end of life care plan had been introduced, but there was no regular audit to determine what percentage of end of life inpatients had the care plan in place. We were unable to assess the level of performance in achieving fast track discharges for end of life patients due to lack of evidence; no audit work had been done to measure performance in this area since the last inspection.

The weekly specialist palliative care team (SPCT) multidisciplinary meeting included SPCT nurses and palliative care consultants but no other discipline such as allied health care professionals, pharmacy, or the chaplaincy.

People were supported to make decisions about resuscitation but, where appropriate, their mental capacity assessment was not always recorded.

There was no regular internal performance reporting to directorate or board management to demonstrate improvement in areas such as quality of care, achieving preferred place of death, referral management and rapid discharge of end of life patients.

Other CQC inspections of services

Community & mental health inspection reports for Pinderfields Hospital can be found at The Mid Yorkshire Hospitals NHS Trust.