Overall we rated safe and well-led as inadequate and effective, caring and responsive as requires improvement.
When we inspected this service in July 2014 we rated the service overall as requires improvement and the safe, effective and well-led domains as requires improvement. We asked the provider to make improvements. We went back on this visit to check whether these improvements had been made. The inspection was announced and was carried out on the 23, 24 and 25 June 2015.
At the time of the inspection community inpatients at The Mid Yorkshire Hospitals NHS Trust (the trust) was providing accommodation and nursing care for patients in three units; Queen Elizabeth House (QEH), ward A1 at Pinderfields General Hospital and the Kingsdale Unit via a contract with BUPA. We did not visit the Kingsdale Unit as part of this inspection.
Before this visit we had received information of concern about staffing levels at the units, especially at night, staff training and people’s care, treatment and support needs not being met. During our visit we found evidence to support this information.
During the inspection we used different methods to help us understand the experiences of patients using the community inpatients service at the trust. We directly observed how patients were being cared for at both locations, including an evening visit to QEH. We spoke with 14 patients and seven relatives / visitors / family members, who shared their views and experiences of the service with us. We also observed three mealtimes; two lunches (one at each site) and one breakfast (QEH) and attended an early morning handover at each site.
We looked around the premises, including people’s bedrooms, bathrooms, toilets, communal areas, sluice rooms, the kitchen (at QEH) and outside areas. Eleven people’s care records were used to pathway track patients' care. We observed two medication rounds and reviewed 44 medication records. Management records were also looked at, these included; nine staff personal files, policies, procedures, risk registers, audits, accident and incident reports, complaints, staff training records, staff rotas and monitoring charts.
We spoke with 24 staff including two matrons, two team leaders, 11 nurses, seven support workers and therapy staff. We also met with the management team.
During the inspection we found all of the available beds in the units were occupied; there were 26 inpatients at QEH and 18 inpatients on ward A1.
We found care and treatment was not person-centred and did not always meet patients’ needs or reflect their preferences. Patients and relatives told us they had not been involved in planning their care and were not given choices about the activities of daily living; these included mealtimes, access to snacks and drinks outside mealtimes, what time they went to bed and got up and when they could have a bath or shower.
Patients were not always treated with dignity and respect and were not supported to be independent. We observed incidents during the inspection at QEH which did not ensure the privacy and dignity of patients. At the last inspection it was noted that the toilet facilities not designated same sex. This did not comply with the government’s requirement of Dignity in Care. At this inspection we found no changes had been made to the designation of toilets as female or male at QEH. We also found patients were not supported to self-medicate during their stay at the units, to prepare them for discharge.
We did not find any evidence to show that patients had given consent to their care and treatment and patients confirmed they had not been asked to give their consent. Mental capacity assessments were in place in care records, but the service had not complied with the requirements of the Mental Capacity Act 2005 in obtaining consent for those patients who lacked capacity.
We found systems and processes to keep patients safe were unsafe. There were no major incident or business continuity plans in place and staff were unaware of the procedures to follow in the event of an emergency. Fire documents requested were not available, out of date or incorrect. The fire risk assessment provided for inspectors to review at QEH was for Monument House and there were no fire evacuation plans, fire drills, fire safety training or fire risk assessment available on site at QEH. Staff were unable to tell us what they would do in the event of a fire, apart from ring 999. When we asked senior nursing staff about this they were unaware of the problem. Following our inspection we referred our concerns to the West Yorkshire Fire Service for investigation.
We found the call bells at QEH were not always accessible to patients. This meant patients were unable to summon assistance when they needed it. We also found patients at QEH waited a long time for call bells to be answered; one of our inspection team pressed a call bell with a patient in their room and it took longer than 10minutes for staff to attend the room. Four patients told us it regularly took at least 30 minutes for staff to respond when they pressed their call bell.
We found patients at QEH were being deprived of their liberty of movement by physical means without lawful authority in that the doors to the unit and the garden gates were kept locked. One patient at QEH had a deprivation of liberty authorisation in place but none of the patients could leave the unit without staff assistance.
The nutrition and hydration needs of patients were not always being met. Patients were identified at QEH who were at risk of malnutrition and/or dehydration. We saw care plans which documented that food and fluid charts were required to monitor patient’s food and fluid intake. However, we found 15 out of 19 food and fluid charts at QEH had not been completed. One patient identified as at risk of dehydration did not have a food and fluid chart in place. They had also lost weight recently and had not been referred to a dietician.
Premises and equipment used by the service at QEH were not suitable for the purpose for which they were being used and were not properly maintained. The design, layout and lack of maintenance of the QEH premises did not promote people’s wellbeing. For example, the lift at QEH was in a poor state of repair, with frequent breakdowns reported. Seven of the 26 patients resident at QEH during the inspection required at least two staff to hoist them and 19 of the 26 bedrooms were on the first floor. There was also not enough room in the lift at QEH for a bed or stretcher. This meant the premises were not fit for the purpose of caring for frail elderly patients with mobility problems.
People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records relevant to the management of the service were not maintained. A large number of documents were found not to be up to date or were absent. These included policies and procedures, management records, meeting minutes, accident and incident reports, supervision and appraisal records, risk registers, risk assessments and complaints.
We had significant concerns about the assessment and monitoring of the quality of the service provided and the issues we found during the inspection had not been identified by the service’s own management team. There was little evidence of follow up of audits and satisfaction surveys or any systems or processes in place to demonstrate to us the units had an effective quality management system.
There was not enough qualified, skilled and experienced staff to meet patient’s needs safely and in a timely manner. The service used a high proportion of non-permanent staff to fill the frequent gaps in the rotas. These included agency staff and staff from other areas of the trust. The service did not use a dependency or acuity tool to determine what the minimum staffing levels should be based on the dependency needs of the patients.
Training for temporary, new and existing staff required improvement to ensure they had the skills and knowledge required to carry out their duties. Staff did not receive appropriate professional development, supervision and appraisal. We found a significant number of examples which showed that patient care and treatment was affected by the shortages and lack of consistency of staff.
The service did not act in an open and transparent way when a notifiable safety incident resulting in moderate harm had occurred. The problems we found with compliance with the requirements of the duty of candour breached Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the report.