Dewsbury and District Hospital

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 Dewsbury, the trust had approximately 233 general and acute beds, four beds in Maternity and 8 in Critical care. The trust also employed  7,948 staff of which 1,517 were based at Dewsbury and included 126  medical staff 622 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:

• 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. We found examples of patient safety being compromised as a direct result of low staffing numbers. 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. 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.

• 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. 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.

• 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.

• 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.

• 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 registers contained risks with review dates in the past. This led to concern that the risk registers were not always appropriately scrutinised.
• There was no specific mental health assessment room in the emergency department. This did not meet not meet the Section 136 room guidelines (a designated place of safety) under the Mental Health Act 1983. Staff were not aware of the NHS Protect guidance on distressed patients.
• Families who had been discussed at the multi-agency risk assessment panel (MARAC) were not flagged on the electronic system so could not be identified as being at risk of domestic abuse.

• The critical care service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas. The unit used cameras to monitor patients in the side rooms. The use of the cameras was not in line with trust policy or national guidance.

However;

• Nursing staff showed care and compassion towards patients. Patients and relatives were supported, treated with dignity and respect, and were involved in their care. We did receive positive feedback from some patients and recognition of how hard the nursing staff were working. Staff were also able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death.

• There had been a significant piece of work undertaken to reduce the incident of falls. This had been very successful with the number of falls resulting in severe harm or death reducing by 72%. Falls bands were visible on patients.

• 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.

• 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 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. The average length of stay for elective and non-elective medical patients was below the England average.

• 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.

• 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. Staff spoke of an open culture. Management could describe the risks to the services and the ways they were mitigating these risks.

We saw several areas of outstanding practice including:

• The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• The emergency department had introduced an ambulance handover nurse. This had led to a significant reduction in ambulance handover times.
• The trust had a new electronic process with remote monitoring to alert staff to fridge temperatures being below recommended levels to store drugs.
• Panic buttons had been installed for staff to use in the emergency department if they felt in any danger from patients, visitors or anyone walking into the department. The panic buttons had been installed in direct response to and following a review of a serious incident which occurred in the department.
• We saw evidence of the risk assessment in patients` notes and falls bands were visible on patients. This enabled all staff in the hospital to identify patients at risk of fall no matter where they were in the hospital.

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

• Ensure the end of life time provide regular internal performance reporting 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.

• Ensure VTE risk assessments are completed and the target of 95% is achieved.

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

• Ensure care plans are individualised and reflect the needs of their patients.

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

• Ensure that families who had been discussed at the multi-agency risk assessment panel. (MARAC) are flagged on the electronic system so they can be identified as being at risk of domestic abuse.

• Ensure that there is a specific mental health assessment room that meets the Section 136 room guidelines (a designated place of safety) under the Mental Health Act 1983.

• Ensure staff are aware of the NHS Protect guidance on distressed patients to ensure that patients with mental health problems would be treated appropriately.

• Ensure a risk assessment is undertaken with regards to access to the staircase via the fire exit on ward 2.

• Consider relocating the resuscitation trolley on ward 4 to ensure it can be easily access in an emergency.

• Ensure that staff are following the medicines management policy and that fridge and room temperatures are appropriately recorded.

• Improve the rate of missed medicines doses.

• Ensure the use of cameras in critical care is reviewed and in line with trust policy and national guidance.

• Ensure that children are recovered from day case surgery in a child friendly environment.

• Ensure there are systems in place for the recording of transfer bag checks.

• 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.

Professor Edward Baker

Chief Inspector of Hospitals