Dewsbury District Hospital is part of The Mid Yorkshire Hospitals NHS Trust. During the previous inspection of this service we found evidence that in some areas of the hospital people's privacy dignity and independence were not respected, in one ward there were significant shortfalls in meeting this standard. We judged that this had a major impact on people using the service in that area and have taken enforcement action against the provider to ensure people using this service had their health, safety and welfare protected.

We had received information since the last inspection in the form of complaints and statutory notifications about poor discharge planning, poor care delivery and hygiene issues. Therefore during the inspection we particularly looked at these areas. Overall we found improvements had been made and we found that people’s privacy and dignity had been respected.

We spoke to patients on all the wards we visited. In general, patients were very satisfied with the care and treatment they had received and were very complementary about the attention and attitude of staff towards them.

We spoke with a number of staff and they too were, in the main, positive about working for the Trust and talked about recent improvements particularly the systems in place to ensure there were enough staff on duty.

We visited Ward 4, Neurological rehabilitation; Ward 3 (located on Ward 2) Elderly Medical Care, Maternity, Discharge Lounge and the Short Stay Unit.

We spoke a number of people as part of this inspection. In most of the areas we visited they were positive about their care and about their experience during their time at the hospital. However on one ward people raised concerns with us about communication, the attitude of staff and also about the level of dignity and respect afforded to them.

This visit was undertaken to review the contents of a warning notice issued by the Care Quality Commission on 29 February 2012. The focus of this warning notice was on levels of staffing, therefore we did not speak to people who use the service as part of this follow up visit.

The purpose of this inspection was to check whether Dewsbury and District Hospital had made improvements following an inspection carried out on 21 September 2011 which focused on the maternity and accident and emergency (A&E) services only.

We spoke with two women who had recently given birth. One woman had been admitted during a busy time on the Delivery Suite and was complementary about her experience. She told us that a student nurse had stayed with her throughout the stay and she was visited by the midwife when needed.

The second woman said “Staff were kind and reassuring and it was not like her previous experience when the person looking after her was not nice.”

Both women stated that they were well looked after.

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 Labour Ward which contains the High Dependency Unit (HDU), the Midwifery Led Unit (MLU), Ward 1 (Ante and Post Natal Ward with a Triage Unit) and the Special Care Baby Unit (SCBU). An external midwife joined the CQC inspection team to provide expert experience and information in this area. We also visited the A&E department.

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

“The staff are friendly and explain what they do.”

“I feel safe, the service is brilliant.”

“Staff explain everything clearly and the environment is quiet and clean.”

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

• Staffing levels in the adults’ and children’s emergency departments and the medicine core service did not always meet planned or recommended levels. In medicine 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 division and a heavy reliance on bank and locum staff. From April 2017 to March 2018 there were 4,537 shifts filled by bank staff and 16,353 filled by locum staff.
• Compliance with mandatory training levels did not meet the trust target in medicine and urgent and emergency services
• We found some issues with medicines management; storerooms were unlocked on some of the wards and intravenous fluids containing potassium were not stored separately from other intravenous fluids. There was a lack of monitoring of medicine stocks prior to our inspection and we found out of date and excess stock in some areas. We found the inconsistent use of risk assessments for patients self-administering their medication and we found patients in the discharge lounge had missed medicines or received these late.
• We had concerns about the responsiveness of the emergency department, in relation to initial assessment times and non-clinical patient streaming. Patients also had long waits for admission, transfer and discharge.
• Some staff in the medicine core service did not have a good understanding of mental capacity and best interest decisions and were unclear what constituted deprivation of liberty, when this would apply and how this should be documented or whether a formal application should be made.
• 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.

However:

• We found significant improvements in medicine, where the overall rating improved from requires improvement to good. We found that improvements had been made to clear the backlog of unresolved incidents from the previous inspection; 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.
• 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.
• Leadership, governance and risk management was generally effective, embedded and robust across the services that we inspected
• Staff culture had improved since the last inspection in that we found that staff were more open and engaged.