Pinderfields Hospital is part of the Mid Yorkshire Hospitals NHS Trust. During our previous inspection in May 2013 we had found evidence that in some areas of the hospital the service was failing to ensure people were protected against the risks of receiving inappropriate or unsafe care or treatment. We judged this had a moderate impact on people who used the service and we issued a formal warning telling the provider they must improve by 27 August 2013.

We received an action plan from the Trust which showed the improvements they were putting in place. We carried out this inspection to check that the required improvements had been made in relation to Outcome 4 (Regulation 9). We had also received concerning information about the care provided on Gate 43 and Gate 12 (the wards in the hospital are refered to as Gates) and included those wards in this inspection.

This inspection also included part of a themed inspection programme specifically looking at the quality of care provided to support people living with dementia to maintain their physical and mental health and wellbeing. The programme looked at how providers worked together to provide care and at people’s experiences of moving between care homes and hospital. This included consideration of the care experienced by patients with dementia on Gates 41 and 42.

This inspection was carried out by a team of inspectors, a specialist advisor in dementia care and an expert by experience. In making our assessment we visited and gathered information from Gates 41, 42 and 43 (Acute Elderly Care); Gate 12 (Acute Assessment Unit); Gate A1 (Short Stay Elderly) and the Discharge Lounge.

Overall we found improvements had been made to the care patients received on the wards we visited. Staff were better informed about patients’ needs through robust handover processes. We found there had been some improvements with the recording of information within the care records and we could identify from the daily evaluation records that patients were receiving the care they required. However, we found there was a lack of consistency in how care records were completed, reviewed and updated. The Trust were in the process of piloting new nursing assessment and care planning documentation which was planned to be rolled out across the hospital in January 2014.

We found although the care of patients with dementia had become a priority area for the Trust this was at the initial stages of planning and review. Staff we spoke with were keen to improve the experience for patients with dementia but had not had opportunity to implement planned changes.

The cooperation between professionals within the Trust was working to secure timely interventions for patients with dementia in relation to their wider health issues. We found the cooperation between hospital staff and external agencies was more varied and sometimes beyond the control of hospital staff.

As part of the dementia themed inspection we left comment cards on Gates 41 and 42 for a period of one week. We received the comments back a week after the inspection visit. The feedback was mixed with some positive comments about the care provided to the patients on both wards. However, there were also some concerns raised about staffing levels on Gate 41 and how this impacted on the care patients with dementia received. We shared these comments with the Trust and asked them to investigate and address the issues raised. We did not assess staffing as part of this visit, however a further inspection will take place in the New Year when staffing will be reviewed. The feedback we received from the comment cards will be taken into consideration when planning the inspection.

People we spoke with on the day surgical unit were generally positive about the care that they had received during their stay. They felt that staff had treated them kindly and that they felt well cared for.

People we spoke with did make comments about the environment on the day surgical unit. They mentioned the lack of things to do for inpatients on the unit, that the unit was noisy and not dark at night and made some comments on the food available to inpatients.

We spoke to a number of patients as part of our inspection. All of the people we spoke to were positive about the care that they had received. They told us that the staff kept them well informed and that they felt involved in all aspects of decisions about their care while they were in hospital.

The purpose of this inspection was to review compliance with the areas of concern as identified during a visit conducted on 22 September 2011.

We did not speak with any people who use the services during the course of this inspection.

The purpose of this inspection was to review compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, focussing on the maternity services as well as the accident and emergency (A&E) services only.

As part of the review of maternity services we visited the Antenatal / Postnatal Ward, the Neonatal Intensive Care Unit and the Labour Ward which also houses the High Dependency Unit (HDU). An external midwife joined the CQC inspection team to provide expert experience and information in this area.

We also reviewed the A&E services which consists of the Rapid Assessment area, the Paediatric Injuries area, the Resuscitation area, the Major Injuries area and the Minor Injuries area.

Patients we spoke with were generally positive about their experiences and complimented both the services and staff at the hospital. Patients said:

“We are happy with everything.”

“The service me and my baby have received has been wonderful.”

“I would definitely come back here if I was pregnant.”

We did not speak to people who use the services as part of this follow-up review.

Our rating of services stayed the same. We rated them as requires improvement because:

• Staffing did not always meet planned or recommended levels in urgent and emergency services and medical services. In medicine we found that there were a high number of registered nurse vacancies and fill rates were low on some wards. There was a shortage of junior doctors in the medicine division and a heavy reliance on bank and locum staff.
• In urgent and emergency services we found that recording of national early warning scores was inconsistent. There had been improvements in the recording of scores for adults; however we found gaps in the recording of observations for children.
• The layout of the emergency department meant that patients could not always be observed adequately by staff.
• We were concerned about the responsiveness of the urgent and emergency services at the hospital. From April 2017 to March 2018 the service had not met the standard for patients being admitted, transferred or discharged within four hours of arrival and the percentage of patients waiting more than four hours from the decision to admit until being admitted was consistently higher than the England average.
• The number of out of hours bed moves within medical services remained high.
• Across the hospital we found that paper copies of Patient Group Directions (PGD) were out of date and were not signed by individual members of staff, as required by the relevant trust policy.
• In maternity services we saw there were generally sufficient maternity staff within the trust when measured against national guidelines and minimum recommendations. However, we were not assured that staff were allocated properly across the service to meet service need. We saw that high proportions of women booked for planned inductions of labour experienced significant delays.
• In the outpatients service there was a backlog of 18,374 patients waiting for follow up appointments. Although the backlog of patients waiting for follow up appointments had improved slightly since our last inspection we were concerned about the slow pace of clearing the backlog and it was not clear what the trajectories were for clearing the backlog. In addition, the trust could not provide evidence that clinical validation had taken place on all patients in the backlog.
• Referral to treatment times were worse than the England overall performance, however there had been a steady increase in performance and there had been an improvement since the last inspection.

However:

• We found significant improvements in medicine and critical care, where overall ratings improved for both services. In medicine, improvements had been made to clear the backlog of unresolved incidents from the previous inspection; to share learning and ensure staff received feedback; to improve record-keeping and the frequency of risk assessments and to improve the escalation of deteriorating patients.
• The trust had undertaken a lot of work to reduce the risk of patient falls. Initiatives included; having a corporate falls work stream with a dedicated falls lead for the trust. Patients were risk assessed for falls and the trust had worked hard to improve communication regarding patient risk. They were also trialling a number of other initiatives such as ‘tagging’ and use of coloured identity bands to reduce the incidence of falls.
• Staff cared for patients with kindness and compassion. We saw some examples of staff providing outstanding care for patients and their relatives in critical care services.
• Leadership, governance and risk management was generally effective, embedded and robust across the services that we inspected
• We generally saw good overall core mandatory training and role specific training completion rates compared to trust targets.
• Learning from incidents had improved. Staff understood their responsibilities to raise concerns and report incidents. There were good mechanisms to feedback and share learning from incidents with staff.
• Staff culture had improved since the last inspection in that we found that staff were more open and engaged.