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Provider: The Mid Yorkshire Hospitals NHS Trust Requires improvement

On 7 December 2018, we published a report on how well The Mid Yorkshire Hospitals NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 December 2018

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

  • We rated safe, responsive and well-led as requires improvement, effective and caring were rated as good. Our rating for effective improved since the last inspection from requires improvement to good.
  • At this inspection, we inspected five core services. Urgent and emergency care and outpatient services were rated requires improvement across the three sites. Medical services were rated requires improvement at Pontefract hospital and the ratings improved from requires improvement to good at the other two sites. Maternity services were rated requires improvement at Pinderfields hospital and good at the other two sites. The rating for critical care services improved from requires improvement to good.
  • In rating the trust, we took in to account the current ratings of the services that we did not inspect during this inspection but that we had rated in our previous inspection.

  • We rated well-led for the trust overall as requires improvement. This was not an aggregation of the core service ratings for well-led.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RXF/reports.

Inspection areas

Safe

Requires improvement

Updated 7 December 2018

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

  • The trust did not always have the appropriate numbers of nursing staff and junior doctors to ensure patients received safe care and treatment within some services. The trust was mitigating this risk with use of additional staff roles and bank and agency staff.
  • We were concerned about patient risk assessment and patient records on the Pontefract Medical Stroke Rehabilitation Unit at Pontefract Hospital. We did not see evidence that patient risk assessments for falls, pressure damage and nutrition were updated weekly or following transfer to the unit. We found that staff kept poor records of patients’ care and treatment. Records were not completed to a good standard and we found incomplete and misfiled notes
  • We found some services were not managing the storage of medicines in line with trust guidance. We also found paper copies of patient group directions (PGDs) which allow nurses to administer certain medicines without a prescription from a doctor, had not always been signed or updated
  • We found that mandatory training compliance had improved since our last inspection, but still did not meet the trust’s target in some services.
  • There remained a significant backlog of patients waiting for follow up appointments.

However:

  • We found a significant improvement, particularly in medical services, in the management of deteriorating patients.
  • In most services we found an improvement in the sharing of learning following incidents.
  • We found clinical areas to be clean and tidy and free from clutter.
  • Procedures were in place to refer and safeguard adults and children from abuse. Staff felt confident in identifying and escalating any potential safeguarding concerns.

Effective

Good

Updated 7 December 2018

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

  • Care and treatment provided was based on national guidance such as the National Institute for Health and Care Excellence (NICE) guidelines and the Royal College’s guidance.

  • The trust participated in local and national audits to improve patient outcomes. Audit results were used to benchmark and compare with other trusts locally and nationally.
  • Appraisal rates had improved and met or exceeded trust targets in all services inspected.
  • Patient outcomes across the services were in line with regional and national averages. Improvements had also been made in some areas, for example, the trust rating had improved to B in the Sentinel Stroke National Audit.

However:

  • Although we found that understanding around mental capacity was generally much improved, the documentation to support decision making was not always completed.
  • Within maternity services there were significant delays in local audit activity.
  • Within urgent and emergency care services there was mixed performance in relation to RCEM audits and we found the management of sepsis did not always follow best practice guidance.

Caring

Good

Updated 7 December 2018

Our rating of caring stayed the same. We rated it as good because:

  • Feedback from the patients and relatives we spoke with was positive. We observed staff providing care which was kind and compassionate. The privacy and dignity of patients in the majority of services was maintained.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • There was consideration and thought given to the emotional needs of patients. Spiritual and pastoral support was available to patients from the hospital chaplaincy service.
  • There were some examples of outstanding care being given to patients and their relatives in the critical care service.

However:

  • Recent local survey data in maternity services highlighted some concerns about the quality of postnatal (hospital) care and support provided.
  • We found that nurse staffing was impacting the ability of staff to provide compassionate care on the Pontefract Medical Stroke Rehabilitation Unit, for example, we observed call bells ringing for more than five minutes and patients calling out for help.

Responsive

Requires improvement

Updated 7 December 2018

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

  • At our previous inspection we had concerns about the number of patients overdue their outpatient appointment. During this inspection we found there was still a significant backlog of patients waiting for follow-up appointments.
  • The previous inspection found issues with referral to treatment indicators. During this inspection we found that referral to treatment indicators were not met across all specialities.
  • Patient flow through the hospitals remained an issue in some areas. We had concerns about initial assessment times and non-clinical patient streaming.
  • The number of out of hours bed moves within medical services remained high.
  • We found delays in care in maternity for women requiring induction of labour or planned artificial rupture of membranes.

However:

  • There were no additional capacity beds open within medical services and a very small number of medical outliers across the three sites. A discharge hub and dedicated discharge team supported timely discharges.
  • We found that care was planned to meet the individual needs of patients. We found strong links with mental health teams and there were systems in place to support patients with mental health needs, patients with learning disabilities or living with dementia.
  • We found complaints were managed well and in a timely way.

Well-led

Requires improvement

Updated 7 December 2018

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • At this inspection we saw improvements in some of the trust’s services but urgent and emergency care and medical services at Pontefract hospital had deteriorated since our previous inspection.
  • We found some examples of where the board and leaders were not fully sighted on some of the risks in the organisation. This did not give us assurance about the flow of information and escalation of risk from ‘ward to board.’
  • Whilst we did see evidence of board development activities taking place, further work was needed to put more focus on strategic overview and to further formalise the board development programme and to establish effective clinical leadership and accountability throughout the divisional structures.

However:

  • There was strong, visible and effective leadership across the services we inspected.
  • We found significant improvements in the culture of the organisation. Staff reported an open and supportive culture where concerns could be escalated.
  • There were divisional performance reports produced which contained performance measures and information about the quality of patient care. The report enabled the senior management team to have oversight of each service.
Checks on specific services

Community health inpatient services

Good

Updated 13 October 2017

We carried out this inspection because, when we inspected the service in June 2015, we rated the service as inadequate overall. Safe and well led were rated as inadequate, effective, caring and responsive were rated as requires improvement.

Actions the trust were told they must take were:

  • 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.
  • ensure robust major incident and business continuity plans are in place and understood by staff. This must include fire safety at Queen Elizabeth House.
  • strengthen the systems in place to regularly assess and monitor the quality of care provided to patients.
  • ensure where actions are implemented to reduce risks these are monitored and sustained.
  • ensure there are improvements in the monitoring and assessment of patient’s nutrition and hydration needs to ensure patients’ needs are adequately met.
  • ensure all staff have completed mandatory training, role specific training and had an annual appraisal.
  • continue to strengthen staff knowledge and training in relation to the mental capacity act and deprivation of liberty safeguards.
  • ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines.
  • 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.

At this inspection we rated this service as good because:

  • The service had taken action on the issues we raised at the last inspection and we saw many improvements. Staffing levels had improved and all vacant posts had been appointed to. Staff compliance with appraisals and mandatory training was high and exceeded trust standards in most areas.
  • Staff engagement and morale had also improved on the unit since our last inspection. Staff were proud of their service and the improvements which had been made. Patient engagement had improved with the introduction of the three day patient survey.
  • There was more stable local leadership and managers and staff were clear on the vision and purpose of the unit and their role within it.
  • Systems and processes to keep patients safe were in place. Fire safety management had been inadequate; however, on this visit we found it to be robust and well managed.
  • There were clear governance arrangements and processes for managing risk. We saw evidence of continuous improvement.
  • Staff were caring; we saw patients were treated with dignity and respect. Call bells had been installed in the lounge within patients reach and were responded to promptly. Patients were protected from the risks of inadequate nutrition and hydration.
  • Positive changes had been made to the unit to ensure it met the needs of patients living with dementia.
  • There had been many positive changes to the environment since our last visit. A programme of improvements had been carried out, which included upgrading and redecoration of bedrooms and bathrooms. The outside space had also been improved which enabled patients to sit outside or help with gardening as part of their therapy.
  • Toilets facilities were clearly identified as male or female with interchangeable signage. Equipment was clean and had been well maintained.
  • Medicines were safely stored, recorded and administered and resuscitation and emergency equipment was checked daily.
  • A clear referral criterion to the service was in place and there was a robust process for reviewing referrals to ensure they were appropriate.
  • Staff compliance with MCA training at WICU was good and exceeded the trust standard. Systems were in place to record patient consent.

However;

  • We still had concerns about building this service was provided in. Although the environment had been much improved and safety risks managed and minimised, the building was still not ideal for the provision of intermediate care. Space for storage was very limited and the lift was still unreliable and too small. There was no separate treatment room for dressings and other clinical activities to be undertaken and no room for private conversations with relatives.
  • Skin integrity checks were carried out by the registered nurses on the night shift. We found they were not always documenting that checks had been carried out and were sometimes documenting ‘not seen’.
  • Drugs for emergency use were not kept in the resuscitation bags and we were concerned that this could cause delays in treatment.
  • Supervision for nursing staff at the unit was poor. The unit reported that from April 2016 to March 2017 only 19 supervision sessions out of 84 took place, which was 35%.
  • The local risk register was in need of updating. We noticed that some of the review dates were overdue, for example, three risks were due to be updated in November 2016 and the register still contained risks relevant to the PICU, which had been closed at the end of March 2017.
  • Staff sickness and turnover was high at the unit. During the period March 2016 to February 2017 the average sickness rate at the WICU for nursing staff was 13%, which was higher than the trust standard of 4%. For the same period, staff turnover rate was 21%, which was higher than the trust standard of 12%. The unit manager and the matron recognised the high sickness rate was an issue and were in the process of addressing this with the support of the human resources team.

Community health services for adults

Good

Updated 13 October 2017

Overall rating for this core service: GOOD

We rated services for community health services for adults as good, because:

  • Staff were aware of their safeguarding responsibilities and procedures. We checked records and found them to be documented appropriately with the correct assessments in place. Senior staff had identified that record keeping needed to improve following the review of notes, as a result training took place and reviews of records showed an improvement in the records. Nutritional assessments were completed.

  • Multidisciplinary and multiagency meetings occurred within different adult community services which discussed the ongoing care and needs of the patients. Referral criteria’s and a single point of contact was in place were in place for patients and professionals could access the services. Ongoing work was in place to develop further multiagency working where professionals would be co-located in the same room.

  • Patients and relatives felt involved in their care and thought staff were compassionate about the care they provided. This was reflected in the response rate for the Friends and Family Test and the high percentage of respondents that would recommend the service.

  • The trust was responsive to patient’s individual needs and planned to meet the local population. Services were developed around the patient, for example the district nurse clinics where patients had open access to attend the most appropriate one for them.

  • Patients were seen promptly and extra patients were visited on the day as needed. Response teams were available to prevent hospital admissions and to ensure that the patient was safe at home in their own environment. A package of care could be provided to patients for early discharge from hospital to encourage independence.

  • Senior management were aware of the issues within adult community nursing teams and steps had been taken recently to support and provide leadership. This included the movement of senior nurses and development of action plans. Staff had been involved in group sessions to look at the challenges within the service and solutions. From this an action plan was developed to work through the issues identified.

However:

  • Targets set by the trust for NHS Safety Thermometer, harmful incident reporting and mandatory training figures were not achieved. Incident reporting was completed by staff who received feedback, however there was inconsistencies into which incidents they would complete these for.

  • There was no transcribing policy in place for staff to transcribe from the patient’s referral to the medication sheet. Also there were different medication sheets used within the community for staff to document they had administered medication.

  • The majority of adult community nursing teams had vacancies and sickness rates significantly higher than the trust target. Some teams had vacancies for a long period of time with no extra staff to provide support. We saw that the sickness level and vacancies had reduced in recent months and steps had been taken to improve this. However at the time of inspection we were not able to see the full benefit of the changes.

  • Further work needed to be undertaken to ensure that the correct data was extracted from the IT system to provide assurances that the correct response times were being met.

Community dental services

Good

Updated 13 October 2017

Overall rating for this core service: GOOD

We rated community dental services at the trust overall as good because:

  • The service was safe with systems in place to support staff to provide safe care to patients. Staff knew how to report incidents and learn from them. The service protected children and adults using the service by use of a safeguarding process and trained all staff in safeguarding. The environment was visibly clean, with monthly reviews of the risk of infection and regular checking and maintenance of equipment. The records of patients were detailed, legible and stored securely. Management and storage of medicines were safe. Staff were up-to-date with their mandatory training although some staff had to complete consent training.
  • The service was effective in providing a referral based service for its local community. The service provided care and treatment in accordance with national guidance. It addressed patient outcomes through an active oral health promotion team, by collecting data for its commissioners, running audits and by acting on the results of audits to improve the service. Pain relief was available for patients and patients received information about nutrition and hydration. The service had an effective process in place to accept patients into the service. Patients were transferred appropriately to a local hospital and discharged safely back to the care of their general dental practitioner. Staff were competent and many staff had secured additional qualifications beyond their core role or were in the process of doing so. Staff had ready access to information they needed to do their job effectively and all staff had received Mental Capacity Act training to support staff in obtaining consent from patients who were unable to consent themselves.
  • The service was caring. Patients, carers and parents we spoke with, in addition to feedback from patients that we reviewed, demonstrated staff were passionate about providing the best care for their patients. During our inspection, we observed staff providing compassionate care to patients with re-assurance given to patients who were anxious. All patients or parents/guardians/carers of patients who we spoke with were positive about their experience of the service and we saw confirmation of this from written feedback from patients that we reviewed. Staff took care to understand their patients. Staff demonstrated this by obtaining new skills to help them communicate with patients, by creating easy read picture leaflets, or in the way they arranged appointments, or by working with external agencies to create bespoke pathways for particular patients. Staff showed how they provided emotional support to their patients. For instance, at a home visit we observed, we saw how staff provided the patient with the time they needed to feel comfortable before proceeding with their assessment of the patient.
  • The service was responsive to the needs of its patients. The service had created a dental prevention unit when the oral health promotion team had its funding withdrawn. It ensured extra training for nursing staff so they could provide fluoride varnishes. It also operated a general anaesthetic list for adults/children/those with special needs, at both Pinderfields and Pontefract hospitals. The service engaged with its commissioners to ensure that the service it provides met the needs of people in its local area. All staff were up-to-date with their equality and diversity training and we saw the service embraced equality and diversity in its built environment (where possible), its equipment, and by its use of interpretation services. The service was committed to meeting the needs of vulnerable people who otherwise would not receive appropriate dental care and tried to ensure that patients received the right care at the right time. The service learned from complaints and feedback from its patients, with compliments and complaints being a regular item for discussion at the six weekly team briefs.
  • The service was well-led at a local level by an experienced clinical lead that oversaw the governance procedures and managed risks appropriately. We found adequate governance, risk management and quality measurement on inspection to support the delivery of a quality service. The wider dental team was motivated and the culture was generally positive in spite of uncertainty created by an ongoing procurement exercise. The service engaged with both the public and staff and was seeking to innovate and improve to make it sustainable for the future. Staff supported the clinical lead to help shape the service and provided a training opportunity for two dental foundation students. The service's focus was on putting the patient first although its vision and strategy was in development. We saw at each clinic the nine principles of the General Dental Council were displayed which put patient safety and care at its core.