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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.

Reports


Other CQC inspections of services

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

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 Pinderfields, the trust had approximately 643 general and acute beds, 58 beds in Maternity and 17 in Critical care. The trust also employed 7,948 staff, of which 5,295 were based at Pinderfields. This included 629 medical staff and 2,045 nursing staff.

We carried out a comprehensive inspection of the trust between 16-19 May 2017. This included unannounced visits to the trust on 11, 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 Pinderfields Hospital as requires improvement, because;

  • Nurse and medical staffing numbers were a concern. Staffing levels did not meet national guidance in a number of areas. Planned staffing levels were not achieved on any of the medical wards we visited during our inspection. There were a number of senior medical vacancies and a heavy reliance upon locum staffing. There were regular rota gaps, a number of which went unfilled or were backfilled by ‘other’ grades.
  • We found examples of patient safety being compromised as a direct result of low staffing numbers. This was compounded by current demand and extra capacity being staffed from within the existing nurse compliment. This included a failure to escalate deteriorating patients in line with trust and national guidance and a lack of understanding and implementation of sepsis protocols.
  • Access and flow within the hospital was a challenge with a number of medical outliers on wards, and a large number of patient moves occurring after 10.00pm. 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.

  • We found that as nursing staff were working under such pressure in medicine, they were not always able to give the level of care to their patients that they would have liked. We also found that nursing care plans did not reflect the individual needs of their patients, and not all patients felt involved in their care.

  • The ward environment did not lend itself to additional patient beds in non-designated bed spaces. Privacy and dignity of patients being cared for in extra capacity beds was compromised. Staff commented how utilisation of extra capacity beds on wards restricted space to deliver care, impinged on neighbouring patients bed areas and was hazardous due to a lack of nurse call bells and inadequate screening. Divisional leaders recognised this affected the quality of the patient experience.
  • Not all staff had completed mandatory training and the trust was not meeting its target of 95% for all modules of mandatory training. Not all staff had completed the appropriate level of safeguarding training. Many services had not met the target rates for staff undergoing appraisals.
  • The completion of nursing documentation was inconsistent and did not always follow best practice guidance. We saw that patients whose condition had deteriorated were not always escalated appropriately. 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 found trust policies with regards to infection prevention and control were not always being followed. The trust had exceeded their target for the number of cases of clostridium difficile.

  • Staff knowledge and understanding of deprivation of liberty safeguards and the Mental Capacity Act principles was variable. There was confusion around the internal processes and in the completion of the associated documentation. Patients were subject to restrictions of liberty. There was an inconsistent assessment of patient capacity and therefore uncertainty in assurances around patient ability to consent to care and treatment decisions.

  • We were not assured that learning from incidents was being shared with staff. There was also a backlog of incidents awaiting investigation. This meant there were potential risks which had not been investigated, and learning undertaken. Information was not shared consistently. Consequently learning from incidents was not embedded with all staff. Staff we spoke to were not all familiar with the duty of candour and when it was implemented.

  • The trust showed poor performance in a number of national patient outcome data audits. The trust also had six active mortality outliers in which the division of medicine were involved.

  • The emergency department was failing to meet the majority of national standards relating to Accident and Emergency performance. However, recent information showed that this was improving.

  • There were issues regarding referral to treatment 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. 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.

  • We were concerned over the lack of oversight of endoscopy services despite a recovery plan being in place. There were large numbers of patients attending the endoscopy unit having their procedure cancelled on the day. Data also showed an increasing trend of patients waiting for diagnostic testing within endoscopy, of which 493 had breached the six-week threshold.

  • Divisional managers in medicine recognised the additional beds currently in use across the division compounded by staffing shortages caused dissatisfaction with staff and destabilised ward leadership. Staff morale was variable across the division.
  • There was a lack of assurance that staff were competent to use medical devices and equipment. There was also little assurance that electronic equipment had an annual safety check.
  • There was a lack of internal audit and scrutiny in some services and limited assurance that all services were adequately measuring quality and patient outcomes. Some risk register contained risks with review dates in the past or unidentified risks. This led to concern that the risk registers were not always appropriately scrutinised.
  • The critical care service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas.

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 passionate and driven to deliver quality patient care that they considered a priority. We observed kind, compassionate and caring interactions with patients and they commented positively about the care they received. There were positive and dynamic initiatives to support vulnerable patients living with dementia and for those with additional needs because of learning difficulties. 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 were also able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death.

  • The medicine division had appointed Safety Support Workers to support the existing nursing compliment. A number of additional registered nurse appointments had been made and were due to commence in the summer 2016.

  • There had been a reduction in some patient harms reported, namely category three and four pressure ulcers and falls with harm. The division had reinforced their objective to reduce patient harms further with the appointment of a Falls Lead.

  • Staff understood their responsibilities to raise concerns and report incidents. When an incident occurred it would be recorded on an electronic system for reporting incidents. We saw evidence that Root Cause Analyses (RCA) of serious incidents were comprehensive
  • We observed nursing and medical staff gaining consent from patients prior to any care or procedure being carried out. 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.
  • Policies and guidelines were evidence based and easy for staff to access. We saw many examples of good multidisciplinary working across different areas. We observed good interaction and communication between doctors, nurses and medical crews. Service planning was collaborative and focused around the needs of patients. There was sympathetic engagement with staff and patients around the reconfiguration of some services.

  • 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.

  • Managers were able to describe their focus on addressing issues with the referral to treatment indicators and reducing 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.

  • The emergency department was aware of its problems and risks and had changed practice and processes in an attempt to tackle them, such as by the introduction of new nursing roles to support ambulance handovers and manage the flow of patients through the department.

  • 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. Between December 2015 and November 2016 the average length of stay for surgical elective patients was lower than the England average. Readmission rates had reduced and improved.

  • The maternity 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.

  • 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.

  • 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.

  • Leadership of the critical care service was in line with GPICS standards. The service was actively involved in the regional critical care operational delivery network and the acute hospital reconfiguration.

  • Staff reported a positive change in culture with the new management team and felt more engaged. Leadership at each level was visible, staff had confidence in the leadership. Management could describe the risks to the services and the ways they were mitigating these risks.

  • Staff praised the executive management team of the trust. Staff were positive about the future and felt that problems were now more open and being addressed.

We saw several areas of outstanding practice including:

  • The emergency department had introduced an ambulance handover nurse. This had led to a significant reduction in ambulance handover times.
  • The facilities on the spinal unit for rehabilitation and therapies were modern, current and progressive.
  • The cardiology e-consultation service which provided a prompt and efficient source of contact for primary care referrers who sought guidance on care, treatment and management of patients with cardiology conditions;
  • The proactive engagement initiatives used by the dementia team involving the wider community to raise awareness of the needs of people living with dementia. The use of technology to support therapeutic engagement and interaction with patients, stimulating activity and reducing environmental conflict.

  • The Plastic Surgery Assessment Unit was developed November 2016. This was designed to improve the patient experience and ensure capacity was maintained for the assessment of ambulatory patients that required a plastic surgery assessment by assessing patients direct from the emergency department. Faster pre-theatre assessment was provided which helped ensure treatment was delivered quicker. The surgical division had reduced pressures on Surgical Assessment Unit (SAU) by taking the bulk of ambulatory plastics patients out of SAU.
  • The burns unit play specialist ran a burns club, which provided psychological support to children and their families. This included an annual camp and two family therapy weekends a year.
  • The maternity service had implemented the role of ‘Flow Midwife’, a senior member of staff who had oversight of the service during the day. The aim of this role was to ensure a smooth flow of patients throughout the unit; this included the risk of transfers from the stand-alone birth centres and concerns with the discharging of patients from the postnatal ward and labour suite.

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

Importantly, the trust must:

  • Ensure that there are suitably skilled staff available taking into account best practice, national guidelines and patients’ dependency levels.
  • Ensure that there is effective escalation and monitoring of deteriorating patients.
  • Ensure that there is effective assessment of the risk of patients falling.
  • Ensure that the privacy and dignity of patients being nursed in bays where extra capacity beds are present is not compromised.
  • Ensure that there is effective monitoring and assessment of patient’s nutritional and hydration needs to ensure these needs are met.
  • Ensure that there is a robust assessment of patients’ mental capacity in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Ensure that mandatory training levels are meeting the trust standard.

In addition the trust should:

  • Ensure that all staff have annual appraisals.
  • Ensure staff are aware of the duty of candour regulations.
  • Ensure prescribers detail the indications for antimicrobials and ensure review dates are adhered to.
  • Ensure it reviews the compliance with Guidelines for the Provision of Intensive Care Services and the plans to meet the standards.
  • Ensure appropriate precautions are taken for patients requiring isolation and that the need for isolation is regularly reviewed and communicated to all staff.
  • Ensure reported incidents are investigated in a robust and timely manner and the current backlog of outstanding incidents are managed safely and concluded.
  • Ensure staff are informed of lessons learnt from patient harms and patient safety incidents.
  • Ensure work is undertaken to reduce the number of patients requiring endoscopies being cancelled on the day of their procedure.
  • Ensure quality and performance is measured effectively.
  • Ensure it develops and shares with staff a longer term critical care strategy beyond the acute hospital reconfiguration.
  • Ensure risks are identified and reviewed appropriately.
  • Ensure staff in maternity services are trained and competent in obstetric emergencies, to include a programme of skills and drills held in all clinical areas.
  • Ensure visible assurance that all electronic equipment has been safety checked and assurance that staff are competent in the use of all medical devices.
  • 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 all appropriate staff have undergone APLS training.
  • Work with the trust’s non-medical prescribing governance group to ensure that all non-medical prescribers are supported to prescribe within their competencies.
  • Ensure that staff triage training is robust and that staff carrying out triage are experienced ED clinicians.
  • Ensure patients have access to leaflets in alternative formats such as large print, Braille or other languages.
  • Ensure it completes the outstanding actions remaining from RCEM audits to ensure the quality of care in the department is meeting the RCEM standards.
  • Ensure that the cross site governance processes introduced in January 2017 become embedded in practice.
  • Consider an analysis of the increased reporting of clostridium difficile cases across the division.
  • Ensure all relevant staff are informed of oxygen prescribing standards.
  • Apply the trust wide pain assessment documentation consistently on wards.
  • Ensure whiteboards being used at the patient bed head contain the correct information.
  • Ensure all patients and family members are fully informed and involved in all discharge arrangements and future care discussions at the earliest opportunity.
  • Consider an analysis of the processes involved in obtaining timely social care assessments for patients on divisional wards.
  • Consider a review of the current governance processes for the Regional Spinal Unit.
  • Continue with improvement in staff engagement activity specifically around the acute healthcare reconfiguration and current service demands.
  • Ensure divisional meetings are quorate and all agenda items are discussed/minuted accordingly.
  • Improve the proportion of patients having hip fracture surgery on the day or day after admission.
  • Continue to monitor and improve compliance with the ‘Five steps to safer surgery’.
  • Reduce the management of medical patients on surgical wards.
  • Reduce the number of patients boarding on PACU and discharging home directly from PACU.
  • Reduce the usage of extra capacity beds on surgical wards.
  • Ensure there is evidence of appropriate local induction for agency staff.
  • Ensure their safeguarding children policy is up to date.
  • Ensure that staff have regular safeguarding supervision.
  • Ensure that children have access to child friendly menus.
  • Consider limiting access to their milk rooms and fridges, to prevent unauthorised access to feeds.
  • Ensure that staff are following the medicines management policy and that fridge and room temperatures are appropriately recorded.
  • Ensure that resuscitation equipment is checked daily and appropriately recorded.
  • Ensure plans for clinical validation across specialties where there are waiting list backlogs are progressed and risks are managed and mitigated.
  • Audit and report the implementation of the end of life care plan and performance in fast track discharge.
  • Ensure regular internal performance reporting on End of Life care to directorate or board management to demonstrate improvement in areas such as quality of care, preferred place of death, referral management and rapid discharge of end of life patients.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 23-25 June 2015, 25 August 2015, 22 September 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 a 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 and to meet their needs.
  • The trust must ensure there are improvements in the number of fractured neck of femur patients being admitted to orthopaedic care within 4 hours and surgery within 48 hours.
  • 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.
  • The trust should take actions to address the historical management–clinician divides that had not been resolved amongst certain surgical specialities.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 15–18 July and 27 July 2014

During a routine inspection

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 around 325,837 people and Kirklees with around 422,458 people. The trust employs around 8,060 members of staff, including 755 medical & dental staff.

The acute services are provided in three hospitals, Pinderfields Hospital, Dewsbury District Hospital and Pontefract Hospital. Pinderfields Hospital is situated in Wakefield and serves a population of 325,837 with approximately 639 beds.

There were plans in progress for the reconfiguration of services at the trust with the aim of centralising children’s services; consultant led maternity services and acute emergency services at Pinderfields Hospital. This had caused a level of anxiety amongst both the local population and the staff working at the trust. This new clinical strategy was subject to consultation.

We inspected the trust from 15 to 18 July and undertook an unannounced inspection on 27 July 2014. We inspected this trust as part of our in-depth hospital inspection programme. We chose this trust because it was considered a high risk service.

Overall, we rated Pinderfields Hospital as requires improvement. We rated it good for being caring and required improvement for being effective, being responsive to patient’s needs and being well-led. But we rated it inadequate for providing safe care.

We rated critical care services as good. Accident and emergency, surgery, maternity, end of life care and children and young people’s services were rated as requires improvement. We rated medical care and outpatients as inadequate.

Our key findings were as follows:

We observed areas of good practice including:

  • Generally patients being cared for on the wards gave positive feedback about their experiences.
  • There were arrangements in place to manage and monitor the prevention and control of infection. We found all areas we visited to be clean.
  • The urology department had been recognised nationally for the use of green light laser surgery, which is a minimally invasive procedure for prostate symptoms. The procedure enabled patients to return home within a few hours and return to normal activities within days.

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

Importantly, the trust must:

  • Ensure that the reporting of performance, risk and unsafe care and treatment is robust and timely to the Trust Board so that appropriate decisions can be made and actions taken to address or mitigate risk to patient safety.
  • Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
  • Address the backlog of outpatient appointments, including follow-ups, to ensure patients are not waiting considerable amounts of time for assessment and/or treatment.
  • Ensure clinical deteriorations in the patient’s condition are monitored and acted upon for patients who are in the backlog of outpatient appointments.
  • Review the ‘did not attend’ in outpatients’ clinics and put in steps to address issues identified.
  • Ensure the procedures for documenting the involvement of patients and relatives in ‘Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) are in accordance with best practice at all times.
  • 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. 
  • Ensure recommendations from serious incidents and never events are monitored to ensure changes to practice are implemented and sustained in the long term.
  • Ensure there are improvements in referral to treatment times to meet national standards
  • Review the skills and experience of staff working with children in the A&E departments, special care baby unit and children’s outpatients’ clinics to meet national and best practice recommendations.
  • Ensure staff are clear about which procedures to follow in relation to assessing capacity and consent for patients who may have variable mental capacity. This would ensure staff act in the best interests of the patient in accordance with the Mental Capacity Act 2005 and this is recorded appropriately.
  • Ensure staff are aware of the Deprivation of Liberty Safeguards and apply them in practice where appropriate.
  • Ensure all staff attend and complete mandatory training and role specific training, particularly for safeguarding and resuscitation. In addition ensure all staff working in urgent care settings undertake where appropriate have level 3 safeguarding training.
  • Ensure staff receive training on caring for patients living with dementia in clinical areas where patients living with dementia access services. In addition where appropriate ensure staff are trained on the End of Life care plan booklet and updated on the trust’s new policy
  • Ensure that issues with replacing pathology equipment are addressed to ensure that equipment is fit for purpose.
  • Ensure the pharmacy department is able to deliver an adequate clinical pharmacy service to all wards.
  • Ensure staff are trained and competent with medication storage, handling and administration.
  • Ensure controlled drugs are administered, stored and disposed of in accordance with trust policy, national guidance and legislation.
  • Ensure in all clinical areas minimum and maximum fridge temperatures are recorded to ensure medications are stored within the correct temperature range and remain safe and effective to use.
  • Ensure equipment in the Accident and emergency department is appropriately cleaned and labelled and then stored in an appropriate environment.
  • Ensure all anaesthetic equipment in theatres and resuscitation equipment in clinical areas are checked in accordance with best practice guidelines.
  • Ensure that the Five steps to safer surgery (World Health Organisation) is embedded in theatre practice.
  • Review the access and provision of sterile equipment and trays in theatres to ensure that they are delivered in good time.
  • Ensure there are improvements in the number of Fractured Neck of Femur patients being admitted to orthopaedic care within 4 hours and surgery within 48 hours
  • Ensure ambulance handover target times are achieved to lessen the detrimental impact on patients.
  • Ensure improvements are made in reducing the backlog of clinical dictation and discharge letters to GP’s and other departments.
  • Review and make improvements in the access and flow of patients receiving surgical care. 
  • Review the arrangements over the oversight of Gate 20 acute respiratory care unit to ensure there is appropriate critical care medical oversight in accordance with the Critical Care Core Standards (2013).
  • Ensure the recommendations from the mortuary review are implemented and monitored to ensure compliance.
  • Ensure staff in ward areas follow the correct procedures in identifying infection control concerns in deceased patients to protect staff in the mortuary against the risks of infection.
  • Ensure staff follow the correct procedures to make sure the patient is correctly identified at all times, including when deceased.
  • Ensure the high prevalence of pressure ulcers is reviewed and understood and appropriate actions are implemented to address the issue.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27 November 2013

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

Pinderfields Hospital is part of the Mid Yorkshire Hospitals NHS Trust. During our previous inspection in May 2013 we had found evidence that in some areas of the hospital the service was failing to ensure people were protected against the risks of receiving inappropriate or unsafe care or treatment. We judged this had a moderate impact on people who used the service and we issued a formal warning telling the provider they must improve by 27 August 2013.

We received an action plan from the Trust which showed the improvements they were putting in place. We carried out this inspection to check that the required improvements had been made in relation to Outcome 4 (Regulation 9). We had also received concerning information about the care provided on Gate 43 and Gate 12 (the wards in the hospital are refered to as Gates) and included those wards in this inspection.

This inspection also included part of a themed inspection programme specifically looking at the quality of care provided to support people living with dementia to maintain their physical and mental health and wellbeing. The programme looked at how providers worked together to provide care and at people’s experiences of moving between care homes and hospital. This included consideration of the care experienced by patients with dementia on Gates 41 and 42.

This inspection was carried out by a team of inspectors, a specialist advisor in dementia care and an expert by experience. In making our assessment we visited and gathered information from Gates 41, 42 and 43 (Acute Elderly Care); Gate 12 (Acute Assessment Unit); Gate A1 (Short Stay Elderly) and the Discharge Lounge.

Overall we found improvements had been made to the care patients received on the wards we visited. Staff were better informed about patients’ needs through robust handover processes. We found there had been some improvements with the recording of information within the care records and we could identify from the daily evaluation records that patients were receiving the care they required. However, we found there was a lack of consistency in how care records were completed, reviewed and updated. The Trust were in the process of piloting new nursing assessment and care planning documentation which was planned to be rolled out across the hospital in January 2014.

We found although the care of patients with dementia had become a priority area for the Trust this was at the initial stages of planning and review. Staff we spoke with were keen to improve the experience for patients with dementia but had not had opportunity to implement planned changes.

The cooperation between professionals within the Trust was working to secure timely interventions for patients with dementia in relation to their wider health issues. We found the cooperation between hospital staff and external agencies was more varied and sometimes beyond the control of hospital staff.

As part of the dementia themed inspection we left comment cards on Gates 41 and 42 for a period of one week. We received the comments back a week after the inspection visit. The feedback was mixed with some positive comments about the care provided to the patients on both wards. However, there were also some concerns raised about staffing levels on Gate 41 and how this impacted on the care patients with dementia received. We shared these comments with the Trust and asked them to investigate and address the issues raised. We did not assess staffing as part of this visit, however a further inspection will take place in the New Year when staffing will be reviewed. The feedback we received from the comment cards will be taken into consideration when planning the inspection.

Inspection carried out on 28, 29, 30 May 2013

During a routine inspection

Pinderfields Hospital is part of the Mid Yorkshire Hospitals NHS Trust. During the previous inspection we had found evidence that in some areas of the hospital people did not always experience care, treatment and support that met their needs and protected their rights. We judged this had a minor impact on people using the service and asked the provider to take action.

We received information since the last inspection from complaints and statutory notifications about insufficient staffing, poor attitude of some staff, inadequate care and support and lack of privacy and dignity. These related mainly to the elderly care wards. We also received concerning information about delays in correspondence being sent out to patients and GPs following outpatient appointments.

This inspection was carried out by a team of inspectors, a specialist advisor in governance and an expert by experience. In making our assessment we visited and used information from the Gate 40 Day Surgery Unit; Gates 41 and 42 Elderly Medicine; Gate 12 Acute Assessment Unit; Gate 38 General Medicine; Gate A1 Short Stay Elderly & Discharge Lounge; Gate A2 Elderly Short Stay and Gate 8a - Outpatients Cardiology and Neurology.

We found there were some examples of good care being provided to people and a number of patients told us about their positive experience in the hospital. However particularly on Gates 41 and 42 the elderly care wards, we judged that patients did not always receive appropriate care and treatment and there were staff shortages. We also judged action was not taken by more senior managers when these staff shortages were highlighted by ward staff.

Of the areas visited we decided to focus on specific outcome areas, which is why not all areas visited are reported on under each outcome.

Inspection carried out on 12, 13 November 2012

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

Pinderfields Hospital is part of The Mid Yorkshire Hospitals NHS Trust. During the previous inspection we had found evidence that in some areas of the hospital people’s privacy, dignity and independence was not respected. We judged this to have a major impact on people using the service and asked the provider to take action.

We also received information since the last inspection from complaints and statutory notifications about poor discharge planning, poor care delivery and hygiene issues.

This inspection was carried out by a team of inspectors and an expert by experience. In making our assessment we visited and used information from the Discharge Lounge, Gate 41 elderly medicine; Gate 43 - Cardiology; Gate 11 Coronary Care Unit; Gate 12 AAU – Acute Assessment; Outpatient Ophthalmology; Gate 20 respiratory medicine; Gate 40 Day surgery; and Gate 37 surgical assessment. Of the areas visited we decided to focus on specific outcome areas which is why not all areas visited are reported on under each outcome.

Overall we found improvements had been made however, we still had some concerns about the care and treatment patients were receiving, particularly during the admission and discharge experience of patients stay in hospital and patients receiving outpatient treatment.

Patients admitted on longer stay wards patients told us they were very satisfied with the care and treatment they had received and that their privacy and dignity had been maintained.

Inspection carried out on 5 September 2012

During an inspection in response to concerns

People we spoke with on the day surgical unit were generally positive about the care that they had received during their stay. They felt that staff had treated them kindly and that they felt well cared for.

People we spoke with did make comments about the environment on the day surgical unit. They mentioned the lack of things to do for inpatients on the unit, that the unit was noisy and not dark at night and made some comments on the food available to inpatients.

Inspection carried out on 4 July 2012

During an inspection in response to concerns

We spoke to a number of patients as part of our inspection. All of the people we spoke to were positive about the care that they had received. They told us that the staff kept them well informed and that they felt involved in all aspects of decisions about their care while they were in hospital.

Inspection carried out on 9 February 2012

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

The purpose of this inspection was to review compliance with the areas of concern as identified during a visit conducted on 22 September 2011.

We did not speak with any people who use the services during the course of this inspection.

Inspection carried out on 20 September 2011

During a routine inspection

The purpose of this inspection was to review compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, focussing on the maternity services as well as the accident and emergency (A&E) services only.

As part of the review of maternity services we visited the Antenatal / Postnatal Ward, the Neonatal Intensive Care Unit and the Labour Ward which also houses the High Dependency Unit (HDU). An external midwife joined the CQC inspection team to provide expert experience and information in this area.

We also reviewed the A&E services which consists of the Rapid Assessment area, the Paediatric Injuries area, the Resuscitation area, the Major Injuries area and the Minor Injuries area.

Patients we spoke with were generally positive about their experiences and complimented both the services and staff at the hospital. Patients said:

“We are happy with everything.”

“The service me and my baby have received has been wonderful.”

“I would definitely come back here if I was pregnant.”

Inspection carried out on 30 June 2011

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

We did not speak to people who use the services as part of this follow-up review.

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.