Mid Yorkshire Teaching NHS Trust

We carried out a follow-up inspection from 16 to 19 May 2017 to confirm whether The Mid Yorkshire Hospitals NHS Trust had made improvements to its services since our last inspection in June 2015. We also undertook a unannounced inspections on 11 and 22 May and 5 June 2017.

To get to the heart of patients’ experiences of care and treatment we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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 inspection 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.

When we last inspected this trust in June 2015, we rated services as ’requires improvement’. We rated safe as inadequate, effective, responsive, and well-led as requires improvement. We rated caring as good.

There were four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, safe care and treatment, good governance, and meeting nutritional and hydration needs.

The trust sent us an action plan telling us how it would ensure that it had made improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

We found that the trust had improved in some areas, particularly within community services. However, it remains rated as 'requires improvement' overall, with safe, effective, responsive, and well-led rated as 'requires improvement', and caring rated as 'good'.

Our key findings were as follows:

• The trust had systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care. However, a number of registered nurse shifts across the trust remained unfilled despite these escalation processes. This was a significant concern within medical care wards where actual nurse staffing figures were significantly below establishment planned numbers evidence by poor fill rates. Some staffing escalation procedures within this division added little to the staffing situation.
• Within the medical care division across the trust, staff shortages impacted on the ability of ward staff to provide the level of care they would like to. As a result of working under such pressure and time constraints we did observe some care which was not of an acceptable standard. Some patients also reported this was affecting the length of time it took for call bells to be answered.
• At Pinderfields Hospital privacy and dignity of patients being cared for in extra capacity beds was compromised. Divisional leaders recognised this impacted on the quality of the patient experience.
• At Dewsbury Hospital we were very concerned that patients were not having observations monitored or had appropriate escalation when there was elevated NEWS scores.
• Staff across most specialties were not meeting the trust’s mandatory training targets.
• Patient outcomes from national audit data were variable. Overall, heart failure, myocardial infarction and diabetes outcomes were worse than national average. The trust was an outlier in a number of mortality alerts across divisional services. The trust has six active mortality outlier alerts as at 3 April 2017.
• Within medical care services, the meal time initiative to support patient nutrition and hydration was not robust. Nursing documentation to support nutrition and hydration was poor.
• Staff knowledge and understanding of deprivation of liberty safeguards and the Mental Capacity Act principles was variable across some services within the trust.
• Access and flow, across the emergency department, medical care and surgical services, and outpatients remained a significant challenge.
• The emergency department was failing to meet the majority of national standards relating to Accident and Emergency performance. However, recent information showed that this was improving.
• The use of extra-capacity beds in existing bays within medical care wards, particularly in Pinderfields Hospital was impacting negatively on patient experience and at times compromising privacy and dignity.
• Medical boarders were impacting in most clinical areas within the trust.
• There were a considerable number of patient moves after 10pm causing distress, inconvenience and confusion to many patients. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.
• There were issues regarding referral to treatment indicators and waiting lists for appointments. The backlog of patients waiting for first and follow up appointments across the trust outpatient departments had deteriorated since the last inspection.
• The senior team was aware of the challenges and issues within the organisation and had developed strategies and tightened governance processes to meet these challenges. However, these needed embedding the pace of this improvement needed to increase.
• There was some improvement in strengthening of governance processes across the trust. However, within some services, particularly medical care and critical care, there were gaps in effective capturing of risk issues and in how the services monitored quality and performance.
• Governance and assurance processes within the medical care division, for the care and management of patients, did not support the provision of safe care, quality outcomes and positive patient experience on these wards.

However:

• Overall, the culture within the trust had improved since the last inspection and there were indications of a positive cultural shift.
• There was effective multi-disciplinary (MDT) working to secure good outcomes and seamless care for patients across the trust.
• Community services within the trust had improved since our last inspection.

We saw several areas of outstanding practice including:

• The emergency departments had introduced an ambulance handover nurse. This had led to a significant reduction in ambulance handover times.
• The facilities at Pinderfields Hospital on the spinal unit for rehabilitation and therapies were modern, current and progressive.
• The cardiology e-consultation service at Pinderfields Hospital which provided a prompt and efficient source of contact for primary care referrers who sought guidance on care, treatment and management of patients with cardiology conditions.
• The proactive engagement initiatives used by the dementia team involving the wider community to raise awareness of the needs of people living with dementia. The use of technology to support therapeutic engagement and interaction with patients, stimulating activity and reducing environmental conflict.
• The Plastic Surgery Assessment Unit was developed November 2016 at Pinderfields Hospital. This was designed to improve the patient experience and ensure capacity was maintained for the assessment of ambulatory patients that required a plastic surgery assessment by assessing patients direct from the emergency department. Faster pre-theatre assessment was provided which helped ensure treatment was delivered quicker. The surgical division had reduced pressures on Surgical Assessment Unit (SAU) by taking the bulk of ambulatory plastics patients out of SAU.
• The burns unit play specialist ran a burns club, which provided psychological support to children and their families. This included an annual camp and two family therapy weekends a year.
• The maternity service at Pinderfields Hospital had implemented the role of ‘Flow Midwife’, a senior member of staff who had oversight of the service during the day. The aim of this role was to ensure a smooth flow of patients throughout the unit; this included the risk of transfers from the stand-alone birth centres and concerns with the discharging of patients from the postnatal ward and labour suite.
• There was 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 trust had a new electronic process with remote monitoring to alert staff to fridge temperatures being below recommended levels to store drugs.
• At Dewsbury Hospital 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 patients 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.

Professor Edward Baker

Chief Inspector of Hospitals

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.

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.

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.