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Provider: The Mid Yorkshire Hospitals NHS Trust Requires improvement

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

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

Read more about use of resources ratings

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

Reports


Inspection carried out on 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.


CQC inspections of services

Service reports published 13 October 2017
Inspection carried out on 16 - 19 May 2017 During an inspection of Community health services for adults Download report PDF | 346.5 KB (opens in a new tab)
Inspection carried out on 16 -19 May 2017 During an inspection of Community health inpatient services Download report PDF | 371.83 KB (opens in a new tab)
Inspection carried out on 16 - 19 May 2017 During an inspection of Community dental services Download report PDF | 355.06 KB (opens in a new tab)
See more service reports published 13 October 2017
Service reports published 3 December 2015
Inspection carried out on 23-25 June 2015 During an inspection of Community health inpatient services Download report PDF | 408.34 KB (opens in a new tab)
Inspection carried out on 30 October 2017

During an inspection to make sure that the improvements required had been made

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

Inspection carried out on 11, 16-19, 22 May and 5 June 2017

During an inspection to make sure that the improvements required had been made

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

Inspection carried out on 23-25 June 2015, 3 July 2015, 25 August 2015, 22 September 2015

During an inspection to make sure that the improvements required had been made

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

Inspection carried out on 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 asrequires improvementoverall. 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. Thishas 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 ofrisk 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

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Intelligent Monitoring

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Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

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