Pinderfields Hospital

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. At Pinderfields, the trust had approximately 643 general and acute beds, 58 beds in Maternity and 17 in Critical care. The trust also employed 7,948 staff, of which 5,295 were based at Pinderfields. This included 629 medical staff and 2,045 nursing staff.

We carried out a comprehensive inspection of the trust between 16-19 May 2017. This included unannounced visits to the trust on 11, 22 May and 5 June 2017. 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 inspections 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.

At the inspection in July 2015 and our follow up unannounced inspections, we found that the trust was in breach of regulations relating to safe care and treatment of patients, addressing patients nutritional needs, safe staffing, and governance. We issued requirement notices to the trust in respect of these breaches.

Our key findings from our inspection in May 2017 are as follows. We rated Pinderfields Hospital as requires improvement, because;

• Nurse and medical staffing numbers were a concern. Staffing levels did not meet national guidance in a number of areas. Planned staffing levels were not achieved on any of the medical wards we visited during our inspection. There were a number of senior medical vacancies and a heavy reliance upon locum staffing. There were regular rota gaps, a number of which went unfilled or were backfilled by ‘other’ grades.
• We found examples of patient safety being compromised as a direct result of low staffing numbers. This was compounded by current demand and extra capacity being staffed from within the existing nurse compliment. This included a failure to escalate deteriorating patients in line with trust and national guidance and a lack of understanding and implementation of sepsis protocols.
• Access and flow within the hospital was a challenge with a number of medical outliers on wards, and a large number of patient moves occurring after 10.00pm. Patients had long waits in the emergency department once a decision to admit them had been made. This was predominantly due to the lack of beds available to admit patients in to the trust, although mental health patients were also affected.

• We found that as nursing staff were working under such pressure in medicine, they were not always able to give the level of care to their patients that they would have liked. We also found that nursing care plans did not reflect the individual needs of their patients, and not all patients felt involved in their care.

• The ward environment did not lend itself to additional patient beds in non-designated bed spaces. Privacy and dignity of patients being cared for in extra capacity beds was compromised. Staff commented how utilisation of extra capacity beds on wards restricted space to deliver care, impinged on neighbouring patients bed areas and was hazardous due to a lack of nurse call bells and inadequate screening. Divisional leaders recognised this affected the quality of the patient experience.
• Not all staff had completed mandatory training and the trust was not meeting its target of 95% for all modules of mandatory training. Not all staff had completed the appropriate level of safeguarding training. Many services had not met the target rates for staff undergoing appraisals.
• The completion of nursing documentation was inconsistent and did not always follow best practice guidance. We saw that patients whose condition had deteriorated were not always escalated appropriately. Recording of pain scores and National Early Warning Scores (NEWS) was not consistent and some audits identified a deterioration in compliance with recording NEWS scores.

• We found trust policies with regards to infection prevention and control were not always being followed. The trust had exceeded their target for the number of cases of clostridium difficile.

• Staff knowledge and understanding of deprivation of liberty safeguards and the Mental Capacity Act principles was variable. There was confusion around the internal processes and in the completion of the associated documentation. Patients were subject to restrictions of liberty. There was an inconsistent assessment of patient capacity and therefore uncertainty in assurances around patient ability to consent to care and treatment decisions.

• We were not assured that learning from incidents was being shared with staff. There was also a backlog of incidents awaiting investigation. This meant there were potential risks which had not been investigated, and learning undertaken. Information was not shared consistently. Consequently learning from incidents was not embedded with all staff. Staff we spoke to were not all familiar with the duty of candour and when it was implemented.

• The trust showed poor performance in a number of national patient outcome data audits. The trust also had six active mortality outliers in which the division of medicine were involved.

• 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.

• There were issues regarding referral to treatment indicators and waiting lists for appointments. There was an appointment backlog which had deteriorated since the last inspection and was at 19,647 patients waiting more than three months for a follow up appointment. Managers told us clinical validation had occurred on some waiting lists, for example in areas of ophthalmology. However, this had not occurred on all backlogs or waiting lists for appointments across the trust. Between February 2016 and January 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance.

• We were concerned over the lack of oversight of endoscopy services despite a recovery plan being in place. There were large numbers of patients attending the endoscopy unit having their procedure cancelled on the day. Data also showed an increasing trend of patients waiting for diagnostic testing within endoscopy, of which 493 had breached the six-week threshold.

• Divisional managers in medicine recognised the additional beds currently in use across the division compounded by staffing shortages caused dissatisfaction with staff and destabilised ward leadership. Staff morale was variable across the division.
• There was a lack of assurance that staff were competent to use medical devices and equipment. There was also little assurance that electronic equipment had an annual safety check.
• There was a lack of internal audit and scrutiny in some services and limited assurance that all services were adequately measuring quality and patient outcomes. Some risk register contained risks with review dates in the past or unidentified risks. This led to concern that the risk registers were not always appropriately scrutinised.
• The critical care service was not compliant with the Guidelines for the Provision of Intensive Care Services (GPICS) standards in a number of areas.

However;

• Patients received care and treatment that was caring and compassionate from staff who were working hard to make sure that patient experience was positive and supportive. Staff were passionate and driven to deliver quality patient care that they considered a priority. We observed kind, compassionate and caring interactions with patients and they commented positively about the care they received. There were positive and dynamic initiatives to support vulnerable patients living with dementia and for those with additional needs because of learning difficulties. Specialist equipment was available for bariatric patients and patients with physical disability. There was access to pastoral support for patients of any or no religion. Staff were also able to demonstrate compassion, respect and an understanding of preserving the dignity and privacy of patients following death.

• The medicine division had appointed Safety Support Workers to support the existing nursing compliment. A number of additional registered nurse appointments had been made and were due to commence in the summer 2016.

• There had been a reduction in some patient harms reported, namely category three and four pressure ulcers and falls with harm. The division had reinforced their objective to reduce patient harms further with the appointment of a Falls Lead.

• Staff understood their responsibilities to raise concerns and report incidents. When an incident occurred it would be recorded on an electronic system for reporting incidents. We saw evidence that Root Cause Analyses (RCA) of serious incidents were comprehensive
• We observed nursing and medical staff gaining consent from patients prior to any care or procedure being carried out. We observed the ‘Five Steps to Safer Surgery’ checklist being used appropriately in theatre and saw completed preoperative checklists and consent documentation in patient’s notes.
• Policies and guidelines were evidence based and easy for staff to access. We saw many examples of good multidisciplinary working across different areas. We observed good interaction and communication between doctors, nurses and medical crews. Service planning was collaborative and focused around the needs of patients. There was sympathetic engagement with staff and patients around the reconfiguration of some services.

• During 2015/16, the surgical division prioritised 33 level one clinical audits covering a range of specialties. Outcomes from each audit were reported to the trust’s quality panels and directorate operational team meetings.

• Managers were able to describe their focus on addressing issues with the referral to treatment indicators and reducing waiting times. There were referral to treatment recovery plans in place for various specialties. The Did Not Attend (DNA) rate was lower than the England average.

• The emergency department was aware of its problems and risks and had changed practice and processes in an attempt to tackle them, such as by the introduction of new nursing roles to support ambulance handovers and manage the flow of patients through the department.

• The trust had made changes to the way services are organised to the provision of surgery, concentrating emergency and complex surgery on the Pinderfields Hospital site. This met national guidance of separating planned and urgent care. Between December 2015 and November 2016 the average length of stay for surgical elective patients was lower than the England average. Readmission rates had reduced and improved.

• The maternity service had successfully reconfigured to provide consultant-led maternity care on one hospital site. The community midwifery caseloads were the same as national recommendations, and the services had plans in place to improve midwifery staffing by 2020.

• Children and young people could access the right care at the right time. There were processes in place for the transition in to adult services and they had recently appointed a lead nurse for transition services.

• Staff used a community-wide electronic patient record system accessible to the multidisciplinary team caring for the patient including hospital staff, community staff and most GPs. They also had access to EPaCCS (Electronic Palliative Care Coordination System), which enabled the recording and sharing of people’s care preferences and key details about end of life care.

• Leadership of the critical care service was in line with GPICS standards. The service was actively involved in the regional critical care operational delivery network and the acute hospital reconfiguration.

• Staff reported a positive change in culture with the new management team and felt more engaged. Leadership at each level was visible, staff had confidence in the leadership. Management could describe the risks to the services and the ways they were mitigating these risks.

• Staff praised the executive management team of the trust. Staff were positive about the future and felt that problems were now more open and being addressed.

We saw several areas of outstanding practice including:

• The emergency department had introduced an ambulance handover nurse. This had led to a significant reduction in ambulance handover times.
• The facilities on the spinal unit for rehabilitation and therapies were modern, current and progressive.
• The cardiology e-consultation service 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. 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 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.

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 patient’s 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.

In addition the trust should:

• Ensure that all staff have annual appraisals.
• Ensure staff are aware of the duty of candour regulations.
• Ensure prescribers detail the indications for antimicrobials and ensure review dates are adhered to.
• Ensure it reviews the compliance with Guidelines for the Provision of Intensive Care Services and the plans to meet the standards.
• Ensure appropriate precautions are taken for patients requiring isolation and that the need for isolation is regularly reviewed and communicated to all staff.
• Ensure reported incidents are investigated in a robust and timely manner and the current backlog of outstanding incidents are managed safely and concluded.
• Ensure staff are informed of lessons learnt from patient harms and patient safety incidents.
• Ensure work is undertaken to reduce the number of patients requiring endoscopies being cancelled on the day of their procedure.
• Ensure quality and performance is measured effectively.
• Ensure it develops and shares with staff a longer term critical care strategy beyond the acute hospital reconfiguration.
• Ensure risks are identified and reviewed appropriately.
• Ensure staff in maternity services are trained and competent in obstetric emergencies, to include a programme of skills and drills held in all clinical areas.
• Ensure visible assurance that all electronic equipment has been safety checked and assurance that staff are competent in the use of all medical devices.
• Continue to focus on achieving A&E standards and ensure that improved performance against standard is maintained.
• Ensure that records are completed fully and that records are stored securely.
• Ensure that all appropriate staff have undergone APLS training.
• Work with the trust’s non-medical prescribing governance group to ensure that all non-medical prescribers are supported to prescribe within their competencies.
• Ensure that staff triage training is robust and that staff carrying out triage are experienced ED clinicians.
• Ensure patients have access to leaflets in alternative formats such as large print, Braille or other languages.
• Ensure it completes the outstanding actions remaining from RCEM audits to ensure the quality of care in the department is meeting the RCEM standards.
• Ensure that the cross site governance processes introduced in January 2017 become embedded in practice.
• Consider an analysis of the increased reporting of clostridium difficile cases across the division.
• Ensure all relevant staff are informed of oxygen prescribing standards.
• Apply the trust wide pain assessment documentation consistently on wards.
• Ensure whiteboards being used at the patient bed head contain the correct information.
• Ensure all patients and family members are fully informed and involved in all discharge arrangements and future care discussions at the earliest opportunity.
• Consider an analysis of the processes involved in obtaining timely social care assessments for patients on divisional wards.
• Consider a review of the current governance processes for the Regional Spinal Unit.
• Continue with improvement in staff engagement activity specifically around the acute healthcare reconfiguration and current service demands.
• Ensure divisional meetings are quorate and all agenda items are discussed/minuted accordingly.
• Improve the proportion of patients having hip fracture surgery on the day or day after admission.
• Continue to monitor and improve compliance with the ‘Five steps to safer surgery’.
• Reduce the management of medical patients on surgical wards.
• Reduce the number of patients boarding on PACU and discharging home directly from PACU.
• Reduce the usage of extra capacity beds on surgical wards.
• Ensure there is evidence of appropriate local induction for agency staff.
• Ensure their safeguarding children policy is up to date.
• Ensure that staff have regular safeguarding supervision.
• Ensure that children have access to child friendly menus.
• Consider limiting access to their milk rooms and fridges, to prevent unauthorised access to feeds.
• Ensure that staff are following the medicines management policy and that fridge and room temperatures are appropriately recorded.
• Ensure that resuscitation equipment is checked daily and appropriately recorded.
• Ensure plans for clinical validation across specialties where there are waiting list backlogs are progressed and risks are managed and mitigated.
• Audit and report the implementation of the end of life care plan and performance in fast track discharge.
• Ensure regular internal performance reporting on End of Life care to directorate or board management to demonstrate improvement in areas such as quality of care, preferred place of death, referral management and rapid discharge of end of life patients.

Professor Edward Baker

Chief Inspector of Hospitals