16 November 2022
Mid Yorkshire provides care for over half a million people every year, in their homes, in the community and across three hospital sites at Pontefract, Dewsbury and Pinderfields. In addition, the trust provides two specialist regional services: burns and spinal injuries. The trust is made up of a team of 9,200 staff.
The Pinderfields Hospital building was opened in 2011; is the largest of the trust’s three hospitals and is the main site for patients requiring acute care. A range of inpatient, outpatient, diagnostic and maternity services are provided. The hospital provides both urgent and emergency care as well as services such as elective surgery. Pinderfields is the busiest hospital within the trust. In any one year there may be over 127,000 attendances to the A&E and over 58,000 emergency admissions.
Dewsbury and District Hospital provides services, usually for patients living in the North Kirklees district. The hospital provides urgent and emergency care, diagnostics, elective care, midwife services and care of the elderly services. The hospital treats over 340,000 patients every year.
Pontefract Hospital opened in 2011 and focuses on urgent care, elective, diagnostics and rehabilitation services.
The trust works in partnership with two local authorities, two integrated care system (ICSs) commissioners and a wide range of other providers, including voluntary and private sector organisations. It also works as a member of the West Yorkshire and Harrogate Partnership, which is the Integrated Care System within which the Trust resides.
We carried out an unannounced inspection of Mid Yorkshire NHS Hospital Trust services provided by this trust over a two-month period as part of our continual checks on the safety and quality of healthcare services. At the 2018 inspection we rated the trust overall as requires improvement. Our inspection was prompted by concerns about the quality and safety of services. We also conducted an inspection of the trust’s leadership and governance.
From the 29 March to the 30 March 2022 we inspected the Urgent and Emergency Care Centres at Pinderfields Hospital and Dewsbury and District Hospital as part of the urgent and emergency care services review in West Yorkshire. Medical services were also inspected at both hospital sites.
From the 26 April to the 28 April 2022 we inspected maternity and children’s services at Pinderfields and Dewsbury and District Hospitals and commenced a well led review of the trust. The Urgent and Emergency Care and Medical teams also returned to the trust to complete the inspections in both areas at Pinderfields and Dewsbury and District Hospitals.
Whilst we inspected during the COVID 19 pandemic the risks and concerns identified by CQC during the inspection were not the result of the immediate pressures faced by the trust as a result of this. The trust had reported the long-lasting impact of the COVID 19 pandemic for the preceding two years. These included the significant impact on staffing, including sickness and the identification and redeployment of clinically vulnerable staff, the prolonged period of command and control arrangements and service remodelling.
At the time of inspection, the trust was responding to the Omicron-wave of the pandemic and was caring for a high number of patients who were COVID-19 positive. The trust had stepped up its strategic oversight and management according to protocol. Immediately prior to the March 2022 inspection.
We did not inspect critical care, end of life care, surgery or outpatients at Pinderfields or end of life care, surgery or outpatients at Dewsbury and District Hospitals. We also did not inspect community health services for adults or community dental services. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.
At this inspection we found the core service ratings for maternity at the Pinderfields Hospital had improved from requires improvement in 2018 to good in the inspection of April 2022. Urgent and emergency care and maternity at the Dewsbury and District Hospital remained the same, whilst, the core service ratings for medicine had deteriorated since our previous inspection in 2018.
As part of this inspection, the trust formally notified CQC that it no longer provided medical care at Pontefract Hospital and we have retired the ratings for this core service at this location. This led to a change in the overall rating for effective at Pontefract Hospital which changed from requires improvement to good.
Our rating of services stayed the same. We rated them as requires improvement because:
- Safe and responsive were rated as requires improvement.
- We rated urgent and emergency care and medicine at Pinderfields and Dewsbury and District Hospitals as requires improvement.
- We rated caring as good in all areas except medicine at Dewsbury and District Hospital where caring was rated as requires improvement.
- We rated effective and well-led as good for the trust overall from our inspection of the trust's senior management, leadership and governance.
How we carried out the inspection
The team that carried out this inspection comprised of a CQC head of hospital inspection, two inspection managers, one inspector and an inspection planner. In addition, there were two pharmacist specialists, three executive reviewers and two specialist advisers experienced in executive leadership of NHS trusts. The inspection team was overseen by Sarah Dronsfield, Head of Hospital Inspection. The core service inspection teams included inspectors and specialist advisers.
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.
- 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.
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.
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.
- 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.