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Dewsbury and District Hospital Requires improvement

We are carrying out checks at Dewsbury and District 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 it them as requires improvement because:

  • Staffing levels in the adults’ and children’s emergency departments and the medicine core service did not always meet planned or recommended levels. In medicine 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 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.
  • Compliance with mandatory training levels did not meet the trust target in medicine and urgent and emergency services
  • We found some issues with medicines management; storerooms were unlocked on some of the wards and intravenous fluids containing potassium were not stored separately from other intravenous fluids. There was a lack of monitoring of medicine stocks prior to our inspection and we found out of date and excess stock in some areas. We found the inconsistent use of risk assessments for patients self-administering their medication and we found patients in the discharge lounge had missed medicines or received these late.
  • We had concerns about the responsiveness of the emergency department, in relation to initial assessment times and non-clinical patient streaming. Patients also had long waits for admission, transfer and discharge.
  • Some staff in the medicine core service did not have a good understanding of mental capacity and best interest decisions and were unclear what constituted deprivation of liberty, when this would apply and how this should be documented or whether a formal application should be made.
  • In the outpatients service there was a backlog of 18,374 patients waiting for follow up appointments. Although the backlog of patients waiting for follow up appointments had improved slightly since our last inspection we were concerned about the slow pace of clearing the backlog and it was not clear what the trajectories were for clearing the backlog. In addition, the trust could not provide evidence that clinical validation had taken place on all patients in the backlog.

However:

  • We found significant improvements in medicine, where the overall rating improved from requires improvement to good. We found that improvements had been made to clear the backlog of unresolved incidents from the previous inspection; 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.
  • 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.
  • Leadership, governance and risk management was generally effective, embedded and robust across the services that we inspected
  • 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

Requires improvement

Updated 13 October 2017

The service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas, for example, supernumerary nurse staffing, out of hours medical cover and continuity of care and multidisciplinary staffing. The environment and facilities did not comply with national standards. 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. The service could not provide assurance that staff’s training and competence with equipment was up to date.

The actual nurse staffing did not meet the planned nurse staffing numbers. The service used agency staff regularly and there was limited evidence to support their induction on the unit. The process for the multidisciplinary team and critical care outreach team to receive feedback from incidents on the unit was unclear.

The service did not have an audit lead or audit strategy.

There was limited evidence that the service measured quality. There was no evidence that senior staff had reviewed some risks and their controls had been reviewed.

However;

Patients and relatives were supported, treated with dignity and respect, and were involved in their care.

Leadership of the service was in line with GPICS standards. Staff spoke of an open culture and were proud of the team work on the unit. The service was actively involved in the regional critical care operational delivery network and the acute hospital reconfiguration.

Staff understood their responsibilities to raise concerns and report incidents. Staff assessed, monitored and completed risk assessments and met patients’ needs in a timely way. Patient outcomes were mostly in line with similar units. Fifty five percent of staff in the service had a post registration qualification in critical care. This was in line with GPICS minimum recommendation of 50%.

Outpatients and diagnostic imaging

Requires improvement

Updated 13 October 2017

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.

No specialties were above the England average for non-admitted referral to treatment (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.

Although senior managers could describe the duty of candour, it was not well understood across all staff groups. 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.

Areas we visited were visibly clean and tidy. Medicines checked were stored securely and medicines checked 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 mostly ensured privacy and dignity was maintained. Diagnostic services were delivered by caring, committed and compassionate staff.

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.

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. Most staff we spoke with told us managers and team leaders were available, supportive and visible. Staff we spoke with told us there was effective teamwork within teams and there was a culture of openness and honesty.

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 levels in the adults’ and children’s EDs did not always meet planned or recommended levels.
  • 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 admission, transfer and discharge.
  • Sepsis management was not consistent.
  • We found out of date equipment, medicines and policies, and senior staff did not have oversight of these.
  • The mental health assessment room was not ligature free.
  • We had concerns about major incident plans and training.
  • Staff had concerns about department security.
  • We had concerns about unauthorised access to patients’ information.
  • Families at risk were not flagged.
  • Patient documentation was not completed consistently.
  • Local people were not aware of the change in ED services.

However:

  • The clinical educator was focused on improving staff training.
  • Triage training and supervision had improved.
  • The main 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.
  • Patient safety checklists were in use.
  • All levels of staff worked well together using evidence based practice.
  • Staff were caring, compassionate and respectful.
  • We saw good examples of care for patients living with mental health problems and dementia.
  • We saw good examples of leadership and support in the department.

Maternity

Good

Updated 7 December 2018

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

  • We saw good overall core mandatory training completion rates (93%), and role specific training completion rates (87%) compared to trust targets (95% and 85% respectively). Safeguarding training completion rates surpassed trust target and were 93%, against a trust target of 85%. Staff could clearly describe safeguarding reporting procedures and felt confident making referrals.
  • Emergency equipment service checks were in date. Since our last inspection, the service had implemented a comprehensive programme of skills and drills training in all clinical areas.
  • There had been no serious incidents reported in maternity services at this location in the 12 months prior to our inspection. We found lessons learned following incident investigations were shared in different formats, and staff were able to describe learning from these incidents.
  • Outcomes for women were typically good and outcomes for babies were better than trust targets and regional averages.
  • Over a one-year period, maternity services at the location received a comparatively low number of formal complaints (11) and a relatively high number of formal compliments (52). We saw evidence of learning from complaints, which were investigated in a timely manner.
  • All staff received an appraisal. Midwifery advisors were on call 24-hours for independent advice and support. Across the trust, there were midwives available for support and guidance and with special interests as part of their role.

However:

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

Outpatients

Requires improvement

Updated 7 December 2018

We rated this service as requires improvement because:

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

However:

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

Maternity and gynaecology

Good

Updated 13 October 2017

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

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

We found good multidisciplinary working between midwifery and medical staff. We observed good and friendly interactions between staff, women and relatives. There was sympathetic engagement with staff and patients around the reconfiguration of maternity services.

The service had a comprehensive business plan, which included plans to increase staffing levels including specialist midwifery posts. The service had reviewed staffing using a recognised acuity tool and this identified a shortfall of 18 whole time equivalent midwives. The service had an agreed plan to fill these posts over three years.

However:

There was a lack of assurance that staff were competent to use medical devices. There was also little assurance that electronic equipment had an annual safety check. We were not assured of the competence of staff with regard to basic skills such as cannulation and perineal suturing.

Community midwifery caseload numbers were above the national recommendations. Attendance of community and birth centre midwives at obstetric emergency training was below the trust target of 95% at 86%. 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 registers contained a large number of risks, and many had a review date in the past. This led to concern that the risk registers were not appropriately scrutinised.

Medical care (including older people’s care)

Good

Updated 7 December 2018

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

  • 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 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. All 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.
  • Provision of food and drink had improved and patients’ pain was managed well. The service regularly reviewed the effectiveness of care and treatment through local and national audit and used their findings to improve them.
  • Appraisal rates for staff working in medical care services on 30 June 2018 were 85% which met the trust target. Staff received additional training to ensure they were competent in their roles. Multi-disciplinary staff with specialist skills and knowledge worked well together to provide effective patient care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment and staff provided emotional support to patients to minimise their distress.
  • Medical services had been reconfigured since our last inspection and the leadership team were confident that this had led to improvements in patient flow through the hospitals.
  • The service took account of patients’ individual needs and cultural beliefs. They treated complaints seriously and learned from them to make improvements to services.
  • We found effective leadership throughout medical care services and there was a clear vision and strategy. Staff and public were engaged in the service and had been involved in the reconfiguration of services.
  • Staff said the culture had improved and was more open. Governance arrangements were in place and we found effective systems for identifying and managing risks.

However;

  • The division still had a high number of registered nurse vacancies and fill rates were low on some wards. 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.
  • Compliance with mandatory training levels did not meet the trust target for core mandatory and role specific training. Monthly audits, from April 2018 to June 2018, on the medical wards 6, 6b (8), 10, 15 and 20 (CDU) showed that aseptic non- touch technique (ANTT) compliance was regularly below the expected standard of 95%.
  • We found some issues with medicines management; storerooms were unlocked on some of the wards and intravenous fluids containing potassium were not stored separately from other intravenous fluids. There was a lack of monitoring of medicine stocks prior to our inspection and we found out of date and excess stock in some areas. We found the inconsistent use of risk assessments for patients self-administering their medication and we found patients in the discharge lounge had missed medicines received these late.
  • Not all staff had a good understanding of mental capacity and best interest decisions and were unclear what constituted deprivation of liberty, when this would apply and how this should be documented or whether a formal application made.
  • The ambulatory care unit did not have specific suitability criteria or a triage system in place so could not be assured that patients were always suitable for assessment and treatment at this site. It was sometimes difficult for staff in ambulatory care and on the wards to arrange timely transfer to Pinderfields hospital.
  • We found a lack of leadership and ownership regarding the ambulatory care service and the discharge lounge at DDH.

Surgery

Good

Updated 13 October 2017

Senior nursing staff had daily responsibility for safe and effective nurse staffing levels and staffing guidelines with clear escalation procedures were in place. Appropriate risk assessments were completed accurately for falls, pressure ulcers National Early Warning Scores (NEWS), sepsis screening and malnutrition. Staff were aware of escalation procedures.

We saw evidence that Root Cause Analyses (RCA) of serious incidents were comprehensive and highlighted immediate actions taken, chronology of events, findings, care and delivery problems, root causes, recommendations, lessons learned and action plans.

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.

Patients had good outcomes as they received effective care and treatment to meet their needs. The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care.

Leadership at each level was visible, staff had confidence in the leadership. There were clear governance processes in place to monitor the service provided. The division handled 97% of complaints within trust timescales (95% target).

However:

Medical staff did not reach the trust 95% target for mandatory core training completion, this included safeguarding.

Across the division, NEWS audits (March 2017) showed that 59% of observations were recorded which were worse than the 67% compliance rate in the previous audit. There were 108 missed medications recorded between March 2016 and February 2017 across the surgical division.

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. Staff had the skills required to carry out their roles effectively. Children’s services had employed advanced nurse practitioners.

Care was planned and delivered in line with evidence-based practice. 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, although they were not as well developed as at Pinderfields, due to commissioning arrangements. A lead nurse for the trust had recently been appointed.

There were effective governance processes and the leadership team understood the risks to their service.

However:

Staffing for children’s day case surgery did not meet Royal College of Nursing (RCN) guidance and there were no specific plans in place if the staff member on duty called in sick at the start of a shift.

Although there were safeguarding systems and processes in place, staff were not meeting the trust target for safeguarding training and did not receive regular safeguarding supervision.

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 labelling 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. Staff delivering end of life and specialist palliative care understood their responsibilities with regard to reporting incidents. Staff we spoke with told us that when an incident occurred it would be recorded on an electronic system for reporting incidents.

We viewed body store protocols and spoke with body store and porter staff about the transfer of the deceased. Staff told us that the equipment available for the transfer of the deceased was adequate and we saw that this included bariatric equipment.

The trust had developed a care of the dying patient (CDP) care plan that provided prompts and guidance for ward based staff when caring for someone at the end of life. We observed the use of these and saw that information was recorded and shared appropriately and that the plans were completed.

We saw that the specialist palliative care nurses worked closely with medical staff on the wards to support the prescription of anticipatory medicines The guidance the specialist nurses provided was in line with the end of life care guidelines and was delivered in a way that focused on developing practice and confidence in junior doctors around prescribing anticipatory medicines.

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.

We observed the use of syringe drivers on the wards and saw that regular administration safety checks were being recorded. Ward staff told us that syringe drivers were available when they needed them.

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.

Staff were able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death. Body store staff told us there was always a member of staff on call out of hours. This service was available for families who requested to visit during an evening or a weekend.

We observed staff caring for patients in a way that respected their individual choices and beliefs and we saw that records included sections to record patient choices and beliefs so that these were widely communicated between the teams.

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.

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. There was no 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.

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.

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 service reported that 73% of all new referrals were seen within 24 hours of being referred to the team.