• Organisation
  • SERVICE PROVIDER

Mid Yorkshire Teaching NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

26 -28 April 2022

During an inspection of Community health inpatient services

We carried out this short unannounced, focused inspection at the same time as CQC inspected a range of urgent and emergency care services in West Yorkshire. To understand the experience of patients accessing the intermediate care unit in Wakefield we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback. As part of this focused inspection we looked at the Wakefield team who are located at Pontefract hospital and considered how they were supporting the wider urgent and emergency care pathway.

This inspection was not rated

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

29th to 31st March 2022 and 26th to 28th April 2022

During a routine inspection

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.

However:

  • 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.

3 Jul to 2 Aug 2018

During a routine inspection

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.

30 October 2017

During an inspection looking at part of the service

We carried out a focused inspection on 30 October 2017 to follow up on warning notice issued to the Trust in June 2017. This identified concerns and areas for improvement in the medical division at Pinderfields and Dewsbury and District hospitals.

The background to the warning notice is that we carried out a follow-up inspection from 16 to 19 May 2017 to confirm whether The Mid Yorkshire Hospitals NHS Trust (MYNHST) had made improvements to its services since our last inspection in June 2015. We also undertook unannounced inspections on 11 and 22 May and 5 June 2017. The inspection took place as part of our comprehensive inspection programme.

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.

At our inspection in May 2017, we found that the trust had improved in some areas, particularly within community services. However, it remained rated as 'requires improvement' overall, with safe, effective, responsive, and well-led rated as 'requires improvement', and caring rated as 'good'.

Following our inspection we issued a warning notice to the Trust in regard to breaches of regulations within the medical care directorate at the Pinderfields and Dewsbury and District hospital sites. The warning notice was issued on 19 June 2017 and identified the following concerns and areas for improvement:

  • There was a lack of suitably skilled staff taking into account best practice, national guidelines and patients’ dependency levels.

  • There was a lack of effective escalation and monitoring of deteriorating patients. There was also a lack of effective assessment of the risk of patients falling.

  • The use of extra capacity beds and late night bed moves caused the privacy and dignity of patients being nursed in bays where extra capacity beds were present to be compromised.

  • There was a lack of effective monitoring and assessment of patient’s nutritional and hydration needs to ensure these needs were met.

  • There was a lack of robust assessment of patients’ mental capacity in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.

We carried out an unannounced visit to the trust on 30 October 2017 to check on progress that had been made against our warning notice. This focused on the specific issues we had raised and found the following areas of improvement:

  • Staffing fill rates had generally increased across medical wards at both hospitals sites. The trust also had medium and long-term plans in place to recruit further nurse and healthcare support staff.

  • We saw that national early warning (NEWS) scores were consistently recorded and escalated for patients we reviewed. An audit programme had also been commenced to further monitor and improve compliance.

  • We saw that falls risk assessments were consistently completed for patients we reviewed. An audit programme had also been commenced to further monitor and improve compliance.

  • Fluid and nutrition charts at Pinderfields were generally completed appropriately. An audit programme had also been commenced to further monitor and improve compliance.

  • The use of extra capacity beds had significantly reduced since the time of our initial inspection. Bed moves after 10.00pm had also significantly reduced and were now recorded as incidents. This had resulted in a positive impact on the privacy and dignity of patients receiving care.

  • The trust had increased awareness of mental capacity with staff via learning materials and visits from the safeguarding team. Mental capacity ‘champions’ had been identified in ward areas and an audit programme was scheduled to begin.

However;

  • Staffing remained challenging in some areas, with some wards not meeting the 80% fill rate.

  • Fluid and nutrition charts for patients we reviewed at Dewsbury were not fully completed.

  • It remained difficult to easily identify in the medical and nursing records where an assessment of capacity had been made/documented. The documentation surrounding capacity assessments varied according to the care pathway and lacked consistency. We saw that the majority of patients requiring capacity scoring or assessment did not have completed documentation.

Professor Sir Mike Richards

Chief Inspector of Hospitals

11, 16-19, 22 May and 5 June 2017

During an inspection looking at part of the service

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

16 - 19 May 2017

During an inspection of Community dental services

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.

16 -19 May 2017

During an inspection of Community health inpatient services

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.

16 - 19 May 2017

During an inspection of Community health services for adults

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.

23-25 June 2015, 3 July 2015, 25 August 2015, 22 September 2015

During an inspection looking at part of the service

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.

Following the announced inspection in June 2015 CQC received a number of concerns and on further analysis of additional evidence an unannounced focussed inspection took place on the 25 August 2015 on Gates 20, 41, 42 and 43 at Pinderfields Hospital. The focus of the inspection was to look at staffing levels, missed patient care and poor experiences of care. At the inspection we had serious concerns regarding the nurse staffing levels on Gates 20, 41, 42 and 43 which had impacted on the care patients received. We also had concerns regarding the management and escalation of risk and where actions had been implemented these had not always been monitored or sustained.

After the unannounced inspection on 25 August 2015 we wrote to the trust and asked them to provide information on how the trust intended to protect patients at risk of harm both immediately and going forward. The trust provided information to CQC which highlighted what immediate actions they had taken to support nurse staffing on the wards.

We visited Gates 20, 41, 42 and 43 on the evening of 22 September 2015 to check that improvements had been made. We found additional support staff had been put in place to support registered nurses on the ward and measures had been put in place to ensure patients received the care they needed.

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 had not 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 were 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 the 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 ensure there are improvements in the number of fractured neck of femur patients being admitted to orthopaedic care within 4 hours and surgery within 48 hours.
  • The trust must improve the discharge process for patients who may be entering a terminal phase of illness with only a short prognosis.
  • The trust must ensure robust major incident and business continuity plans are in place and understood by staff. This must include fire safety at QEH.

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.
  • The trust should ensure in community inpatient services there is a referral criteria for the service and in-reach assessments are carried out consistently to improve the admission and referral process.
  • The trust should ensure toilet facilities in community inpatient services are designated same sex, in order to comply with the government’s requirement of Dignity in Care.
  • The trust should ensure care and treatment of service users is only provided with the consent of the relevant person.
  • The trust should ensure patients receive person-centred care and are treated with dignity and respect.
  • The trust should ensure the equipment and premises are suitable for the purpose for which they are being used and are appropriately maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

23-25 June 2015

During an inspection of Community health inpatient services

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.

15-18 and 27 July 2014

During a routine inspection

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 around 325,837 people and Kirklees with around 422,458 people. The trust employs around 8,060 members of staff, including 755 medical & dental staff.

The acute services are provided in three hospitals, Pinderfields Hospital, Dewsbury and District Hospital and Pontefract Hospital. Pinderfields Hospital is situated in Wakefield and has approximately 639 beds. Dewsbury District Hospital is situated in Dewsbury and has approximately 358 beds. Pontefract Hospital is situated in Pontefract and has approximately 50 inpatient beds.

Community health services are provided across Wakefield District from a number of locations. The services are designed to mirror the seven GP networks in the district. This trust does not provide community services to the Kirklees area.

There were on-going plans for the reconfiguration of hospital services within North Kirklees and Wakefield, with a central hub for children’s services; consultant led maternity services and acute emergency services located at Pinderfields General Hospital and a more local, elective service at Dewsbury and District Hospital and Pontefract Hospital. This had caused a level of anxiety amongst both the local population and the staff working at the trust. This new clinical strategy was subject to consultation.

The trust had been on the verge of administration up to two years earlier with a large underlying financial deficit, which had a significant impact on the provision of services. There had been changes at executive level over the last two years. The Chair and Chief Executive had originally been bought in to oversee an improvement and recovery programme, as the trust had been on the verge of administration. Changes had led to a leaner senior management structure. The director of finance has developed a financial plan supported by robust quality impact assessments and was confident that the financial gains made over the recent months could be sustained and improved upon.

Changes within management had been implemented at all levels of the organisation, which led to a feeling of instability in some areas. This manifested itself in low staff morale, demonstrated in poor staff survey results. Some areas expressed optimism for the future.

We inspected the trust from 15 to 18 July 2014 and undertook an unannounced inspection on 27 July 2014. We inspected this trust as part of our in-depth hospital inspection programme. We chose this trust because it was considered a high risk service.

We inspected the following core services:

  • Acute services: At Pinderfields Hospital and Dewsbury and District Hospital – accident and emergency, medical care (including older people’s care), surgery, critical care, services for children and young people, end of life care and outpatients. At Pontefract Hospital – accident and emergency, medical care (including older people’s care), surgery, maternity and outpatients.
  • Community health services – children, young people and families, community adult in-patient services, end of life services and community adult services.
  • Community dental services

Our key findings were as follows:

The trust was rated as requires improvement overall. Safety was rated inadequate, effectiveness required improvement, caring was rated as good, responsiveness required improvement and being well led required improvement.

During the inspection, we had significant concerns about staff shortages and risk to patient safety on Gate 20 (a medical ward) at Pinderfields Hospital. We immediately drew this to the attention of the trust, which took action in the form of closing 6 beds on the ward to bring the ratio of nursing staff to patients to acceptable levels of 1:8. We observed this had been maintained at our unannounced visit on the 27 July 2014. However, following our unannounced inspection, we received concerning information that there were still issues over staffing on this ward. As a result, we required the trust to provide daily information on patient and staff numbers and assurance over actions taken when staffing numbers fell below expected levels. Daily escalation mechanisms were put in place with a dedicated matron to lead on this. We continued to require daily updates from the trust regarding Gate 20 and have now handed the oversight of this to the NHS Trust Development Authority, who have been supporting the trust.

The trust put in actions to address concerns over Gate 20 and other concerns raised within this report and presented these at the Quality Summit on 13 October 2014. At the summit the trust gave assurance that they had taken immediate action to address serious concerns including the application of the Safer Nursing Tool, benchmarking practice over staffing with other trusts, appointing a Mental Capacity Act 2005 advisor, improved training and additional auditing systems.

The Care Quality Commission has a range of enforcement powers it can use under the Health and Social Care Act 2008 and associated regulations. The Care Quality Commission has required the trust to provide information on the actions taken to address issues identified since the inspection including progress with those yet to be completed. This has been used to inform decisions over appropriate regulatory actions regarding identified breaches of regulation.

In addition to the above we found:

For the acute services,

  • We found the staff caring for patients were compassionate and treated people with dignity and respect. However, due to the significant staff shortages and movement of staff between areas, there was a level of frustration as staff were aware that they were not providing the quality service they aspired to provide. Staff morale was generally low across the acute services within the trust.
  • New arrangements in governance and the management of risk had recently been introduced, but had yet to be embedded. It was too early to assess whether these new initiatives would deliver sustainable improvements.
  • The reporting and standard of information relating to the level of risk to patients to the Trust Board was not always timely or robust.
  • There was no evidence of risk for in-hospital mortality using the hospital standardised mortality ratio indicators or the summary hospital-level mortality indicator.
  • Areas we visited were visibly clean. Infection rates for Clostridium difficile and Methicillin-Sensitive Staphylococcus Aureus were better than expected levels. Methicillin-Resistant Staphylococcus Aureus rates were worse than the expected levels.
  • Staffing levels and skill mix were identified as a significant concern across a number of services and locations.
  • The plans for the reconfiguration of children’s services lacked clarity regarding the number of bed changes and how to staff these changes.
  • There were no policies and processes to facilitate the development of adolescent transition services for those who needed to move to adult services.
  • There was a significant backlog of outpatient appointments, which meant that patients were waiting considerable amounts of time for assessment and treatment. There had been a validation process in place, which had reduced the numbers waiting, but this had not addressed the risks to patients whose condition may be deteriorating.
  • We had serious concerns about the number of patients waiting to be admitted for treatment (the target for the referral to treatment at 18 weeks was not being met).
  • The appropriate arrangements were not always in place for dealing with the storage, handling, administration and recording of medication.
  • Equipment replacement and maintenance systems were not always effective. We had particular concerns over the analysing equipment within the pathology services.
  • The trust was performing worse than the England average for a number of national audits, including the Myocardial Ischemia (heart attack) National Audit Project and the National Diabetes Inpatient Audit.
  • The trust was performing worse than the average for the development of pressure sores and catheter-acquired infections.
  • There were inconsistencies in record keeping including decisions over whether to attempt cardio-pulmonary resuscitation.
  • We had serious concerns about the way Mental Capacity Act 2005 assessments were undertaken and the lack of staff awareness and knowledge of the Mental Capacity Act 2005.
  • Generally the trust was meeting the 95% target for patients being treated within four hours in A&E however there were some occasions when they didn’t meet this.
  • The trust had identified that the time patients were waiting in A&E to be handed over from the ambulance staff was a concern.
  • The trust had medical patients, often 20 to 30 a day, on surgical wards, which  meant there was a risk that they may be cared for by staff who may not have been trained in the appropriate medical speciality.
  • There was a large backlog of typing for clinical notes and delays in discharge letters to GPs.
  • The trust was not consistently meeting the nationally agreed operational standards for referral to treatment within 18 weeks for non-admitted patients.
  • There were high numbers of complaints regarding outpatients going back many months, reporting distress and frustration at delays in accessing appointments, multiple cancellations of appointments, changes in location of appointments and the poor communication with the services.

In addition, for the community services,

  • Patients were treated with compassion, dignity and respect across all the services.
  • There were sufficient numbers of suitably trained staff to meet the needs of patients in most areas; however we had concerns that the staffing levels within the intermediate inpatient units were consistently below agreed staffing levels and patients were having to wait to have their needs met.
  • Where there had been incidents reported, these had been investigated, practice changed and information disseminated to staff.
  • Staff adhered to local policies and procedures and followed national guidance.
  • Audits were undertaken and outcomes for patients were monitored. We saw that the majority of audits were positive and that action plans had been identified in areas where results were less positive.
  • There was good multidisciplinary working in most of the areas we inspected.
  • Staff were responsive to the needs of patients and able to meet targets such as community therapists visiting patients within 30 minutes of an urgent referral.
  • Routine community services’ performance information was identified by senior managers as an area of development.
  • Staff were positive about local leadership of services. However, there were interim arrangements, particularly in the community inpatient services and staff were concerned about the sustainability of improvements.
  • A few community services teams felt integrated with the rest of the trust. However, some felt they were not part of the wider trust.

We saw several areas of outstanding practice including:

  • The development and provision of an integrated, multidisciplinary community health and care services for adults with complex needs. The team was newly created and had already seen over 400 patients. The team was made up of community matrons and nursing staff, therapists, dedicated social workers a full time pharmacist and the independent/charity sector. This meant the team was able to address patients’ needs from assistance with shopping through to social care packages and intensive therapy, pharmacy and nursing input.
  • Health visiting teams had implemented a link health visitor role to liaise about safeguarding with GPs, to work closely with GP practices to promote effective communication and share good practice.
  • Staff within the children’s community end of life care team (Jigsaw) demonstrated outstanding compassion and commitment. They helped parents and families create physical memories of their child such as a plaster cast of their child’s hand so they continued to have a hand to hold.
  • The urology department had been recognised nationally for the use of green light laser surgery, which is a minimally invasive procedure for prostate symptoms. The procedure enabled patients to return home within a few hours and return to normal activities within days.
  • Patients discharged from the critical care unit were invited to attend a monthly outpatient clinic run by staff from the critical care service. Patients could be referred from the clinic for psychological support if this was needed.
  • The children’s hospital-based service had developed a ‘patient group directions competency assessment’ support package for the nursing team. The package ensured the nurse had read and understood patient group directions before testing their knowledge and understanding.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that the reporting of risk and unsafe care and treatment is robust and timely to the Trust Board so that appropriate decisions can be made and actions taken to address or mitigate risk to patient safety.
  • Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
  • Address the backlog of outpatient appointments, including follow-ups, to ensure patients are not waiting considerable amounts of time for assessment and/or treatment.
  • Ensure clinical deteriorations in the patient’s condition are monitored and acted upon for patients who are in the backlog of outpatient appointments.
  • Review the ‘did not attend’ in outpatients’ clinics and put in steps to address issues identified.
  • Ensure the procedures for documenting the involvement of patients and relatives in ‘Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) are in accordance with national guidance and best practice at all times.
  • 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. 
  • Ensure recommendations from serious incidents and never events are monitored to ensure changes to practice are implemented and sustained in the long term.
  • Ensure there are improvements in referral to treatment times to meet national standards
  • Review the skills and experience of staff working with children in the A&E departments, special care baby unit and children’s outpatients’ clinics to meet national and best practice recommendations.
  • Ensure staff are clear about which procedures to follow in relation to assessing capacity and consent for patients who may have variable mental capacity. This would ensure staff act in the best interests of the patient in accordance with the Mental Capacity Act 2005 and this is recorded appropriately.
  • Ensure staff are aware of the Deprivation of Liberty Safeguards and apply them in practice where appropriate.
  • Ensure all staff attend and complete mandatory training and role specific training, particularly for resuscitation and safeguarding; staff working in urgent care settings  where appropriate  undertake Level 3 safeguarding training.
  • Ensure staff receive training on caring for patients living with dementia in clinical areas where patients living with dementia access services. In addition, where appropriate ensure staff are trained on the End of Life care plan booklet and updated on the trust’s new policy.
  • Ensure that issues with replacing pathology equipment are addressed to ensure that equipment is fit for purpose.
  • Ensure the pharmacy department is able to deliver an adequate clinical pharmacy service to all wards.
  • Ensure staff are trained and competent with medication storage, handling and administration.
  • Ensure controlled drugs are administered, stored and disposed of in accordance with trust policy, national guidance and legislation.
  • Ensure in all clinical areas minimum and maximum fridge temperatures are recorded to ensure medications are stored within the correct temperature range and remain safe and effective to use.
  • Ensure equipment in the Accident and Emergency department is appropriately cleaned and labelled and then stored in an appropriate environment.
  • Ensure all anaesthetic equipment in theatres and resuscitation equipment in clinical areas are checked in accordance with best practice guidelines.
  • Ensure that the Five steps to safer surgery (World Health Organisation) are embedded in theatre practice.
  • Review the access and provision of sterile equipment and trays in theatres to ensure that they are delivered in good time.
  • Ensure there are improvements in the number of Fractured Neck of Femur patients being admitted to orthopaedic care within 4 hours and surgery within 48 hours
  • Ensure ambulance handover target times are achieved to lessen the detrimental impact on patients.
  • Ensure improvements are made in reducing the backlog of clinical dictation and discharge letters to GP’s and other departments.
  • Review and make improvements in the access and flow of patients receiving surgical care. 
  • Review the arrangements over the oversight of Gate 20 acute respiratory care unit to ensure there is appropriate critical care medical oversight in accordance with the Critical Care Core Standards (2013).
  • Ensure the recommendations from the mortuary review are implemented and monitored to ensure compliance.
  • Ensure staff in ward areas follow the correct procedures in identifying infection control concerns in deceased patients to protect staff in the mortuary against the risks of infection.
  • Ensure staff follow the correct procedures to make sure the patient is correctly identified at all times, including when deceased.
  • Ensure the high prevalence of pressure ulcers is reviewed and understood and appropriate actions are implemented to address the issue.
  • Ensure actions are taken to address the poor decorative state of the mortuary to ensure effective and thorough cleaning can be undertaken at Dewsbury and District Hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.