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Dewsbury and District Hospital Requires improvement

Reports


Inspection carried out on 11, 16-19, 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 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

Inspection carried out on 23-25 June 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.

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 hadn’t improved or had deteriorated since our last inspection.

  • The trust had responded to previous staffing concerns and was actively recruiting to fill posts. Staffing levels throughout the trust were planned and monitored. However there were areas where there were significant nurse staffing shortages and these were impacting on patient care and treatment particularly on the medical care wards, community inpatient services and in the specialist palliative care team. There was also shortage of medical staff within end of life services.

  • We found that most areas we visited were clean however there were areas in accident and emergency departments at Pinderfields and Dewsbury District Hospital and in the mortuary at Dewsbury and District Hospital that were not clean and infection control procedures had not been followed.

  • Patients nutritional and hydration needs were not always assessed using the Malnutrition Universal Screening Tool (MUST). At our inspections we found that not all fluid balance and nutrition charts were fully completed which meant staff could not always assess the hydration and nutritional status of patients and respond appropriately where patients needed additional support.

  • The trust had consistently not achieved the national standard for percentage of patients discharged, admitted or transferred within four hours of arrival to A&E. Pinderfields had not met the 95% standard for the previous 12 months and Dewsbury District Hospital had not met the 95% target for the previous 6 months.

  • There was a governance structure which informed the board of directors. This was developed and implemented in 2014.

  • The trust had a vision for the future called “meeting the challenge”. This was detailed in the trust’s five year strategic plan 2014/15- 2018/19. The trust had developed an overarching strategy called “striving for excellence” which was detailed in the five year strategy. Underpinning the strategy there w 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 mental capacity act and deprivation of liberty safeguards.

  • The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines, and that oxygen is prescribed in line with national guidance.

  • The trust must ensure that infection control procedures are followed in relation to hand hygiene, the use of personal protective equipment and cleaning of equipment.

  • The trust must ensure staff follow the trust’s policy and best practice guidance on DNA CPR decisions when the patient’s condition changes or on the transfer of medical responsibility.

  • The trust must ensure there are improvements in referral to treatment times and accident and emergency performance indicators to meet national standards to protect patients from the risks of delayed treatment and care. The trust must also ensure ambulance handover target times are achieved to lessen the detrimental impact on patients.

  • The trust must ensure in all services resuscitation and emergency equipment is checked on a daily basis in order to ensure the safety of service users.

  • The trust must improve the discharge process for patients who may be entering a terminal phase of illness with only a short prognosis.

In addition the trust should:

  • The trust should continue to review the prevalence of pressure ulcers and ensure appropriate actions are implemented to address the issue.

  • The trust should continue to improve interdepartmental learning and strengthen governance arrangements within the accident and emergency departments.

  • The trust should review the use of emergency theatres and improve the processes to prioritise patients in need of emergency surgery.

  • The trust should take action to reduce the number of last minute planned operations cancelled for non-clinical reasons.

  • The trust should ensure staff are involved and informed of service changes and re-design.

  • 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

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

Inspection carried out on 28, 29, 30 May 2013

During a routine inspection

Dewsbury Hospital is part of the Mid Yorkshire Hospitals NHS Trust. During the previous inspection we had found evidence that the hospital did not always monitor and assess the quality of their service. We judged this had a minor impact on patients 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.

A team of inspectors with an expert by experience visited Dewsbury District Hospital between 28 and 30 May 2013. We inspected Ward 2, Ward 5 and Ward 8, Medical Assessment Unit (MAU) and Short Stay Unit (SSU).

We found 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 Wards 2 and 5 elderly care wards, we judged patients did not always receive appropriate care and treatment and there were staff shortages. We did not receive evidence that showed action had been taken by senior managers when these shortages were highlighted by ward staff. We were therefore unable to judge what action had been taken by senior managers in response to these shortages. We also had concerns about the care plans for patients because they were often difficult to follow, task orientated and not person centred.

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

Inspection carried out on 21, 28 February 2013

During an inspection in response to concerns

This inspection was carried out as a result of concerns raised with us anonymously about the staffing arrangements and the operation of an escalation ward used in where the hospital had insufficient bed space as a result of winter pressures.

We visited this ward (Ward 9) early in the morning so that we could assess staffing levels and observe the handover of care from one shift to another. We found that there were insufficient staff, inconsistent staffing and lack of leadership and management of the ward. We found shortfalls in the auditing and governance of the ward and as a consequence the environment was poor and the storage and administration of medication disorganised.

As a result of our findings we issued an urgent compliance action letter. The Trust took swift action to rectify the shortfalls we had found. We returned to the hospital the following week and found improvements in the organisation, staffing and management arrangements of the ward including the environment and medication. We have asked to be kept regularly informed about the operation of the ward to ensure improvements are maintained.

Inspection carried out on 12 November 2012

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

Dewsbury District Hospital is part of The Mid Yorkshire Hospitals NHS Trust. During the previous inspection of this service we found evidence that in some areas of the hospital people's privacy dignity and independence were not respected, in one ward there were significant shortfalls in meeting this standard. We judged that this had a major impact on people using the service in that area and have taken enforcement action against the provider to ensure people using this service had their health, safety and welfare protected.

We had received information since the last inspection in the form of complaints and statutory notifications about poor discharge planning, poor care delivery and hygiene issues. Therefore during the inspection we particularly looked at these areas. Overall we found improvements had been made and we found that people’s privacy and dignity had been respected.

We spoke to patients on all the wards we visited. In general, patients were very satisfied with the care and treatment they had received and were very complementary about the attention and attitude of staff towards them.

We spoke with a number of staff and they too were, in the main, positive about working for the Trust and talked about recent improvements particularly the systems in place to ensure there were enough staff on duty.

We visited Ward 4, Neurological rehabilitation; Ward 3 (located on Ward 2) Elderly Medical Care, Maternity, Discharge Lounge and the Short Stay Unit.

Inspection carried out on 3 July 2012

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

We spoke a number of people as part of this inspection. In most of the areas we visited they were positive about their care and about their experience during their time at the hospital. However on one ward people raised concerns with us about communication, the attitude of staff and also about the level of dignity and respect afforded to them.

Inspection carried out on 10 April 2012

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

This visit was undertaken to review the contents of a warning notice issued by the Care Quality Commission on 29 February 2012. The focus of this warning notice was on levels of staffing, therefore we did not speak to people who use the service as part of this follow up visit.

Inspection carried out on 10 February 2012

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

The purpose of this inspection was to check whether Dewsbury and District Hospital had made improvements following an inspection carried out on 21 September 2011 which focused on the maternity and accident and emergency (A&E) services only.

We spoke with two women who had recently given birth. One woman had been admitted during a busy time on the Delivery Suite and was complementary about her experience. She told us that a student nurse had stayed with her throughout the stay and she was visited by the midwife when needed.

The second woman said “Staff were kind and reassuring and it was not like her previous experience when the person looking after her was not nice.”

Both women stated that they were well looked after.

Inspection carried out on 21 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 Labour Ward which contains the High Dependency Unit (HDU), the Midwifery Led Unit (MLU), Ward 1 (Ante and Post Natal Ward with a Triage Unit) and the Special Care Baby Unit (SCBU). An external midwife joined the CQC inspection team to provide expert experience and information in this area. We also visited the A&E department.

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

“The staff are friendly and explain what they do.”

“I feel safe, the service is brilliant.”

“Staff explain everything clearly and the environment is quiet and clean.”

Inspection carried out on 31 August and 22 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.