Dewsbury and District Hospital, Dewsbury

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 90

• Of these how many have an ensuite toilet: 28

• Of these how many have an ensuite toilet and shower or bath: 28

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0

• Does this hospital have a named private unit/service:

Trust Questions

• Does the Trust treat private patients: The Trust occasionally treats private patients.

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Incident reporting The Trust Incident reporting system is used to log these adverse events. The Trust will move to web based incident reporting from October 2011.

• Is there a system for recording operations that were cancelled due to missing notes: 16 operations were cancelled due to case notes missing, 14 were reportable and 2 non-reportable.

• What is the reporting system for operations that were cancelled due to missing notes: The incident is reported to the appropriate surgeon or anaesthetist if notes are not available 48 hours prior to planned surgery and an asessement of the risk to continue or cancel is made. Also following investigation by the appropriate management team to case will be discussed at the weekly Opertions taskforce meeting. The Trust incident reporting system is used to log these adverse events. The Trust will move to web based incident reporting from October 2011.

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: Incident reporting The Trust incident reporting system is used to log these adverse events. The Trust will move to web based incident reporting from October 2011.

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 0

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 16 16 operations were cancelled due to case notes missing, 14 were reportable and 2 non-reportable.

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 40

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 91-99%

• What percentage of patients are risk assessed for venous thromboembolism on admission: 61-90% The CQUIN target agreed for 2010/11 was to achieve 90% in each of the 3 months during quarter 4, this was achieved.

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators:

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): Dr Robert Lane, Associate Director of Medicine, Clinical Governance and Patient Safety is the designated lead.

• Is safety and quality data available on a central platform and actively disseminated to users:

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical and medical

• Are all oncology patients screened at the pre-op assessment clinic: YES

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Culture based in 24-48hrs

• On admission, does topical suppression take place immediately: Immediate topical suppression is undertaken on previous patients who tested positve until the current result is available

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• Protocol for isolating patients with infections: Where a side room is available it is allocated as necessary, however and Isolation Facility Guide with criteria for isolation is available There is an Isolating Facility Guide with criteria for isolation available on the Trust website.

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust prescribe probiotics to any patient groups as a prophylactic measure to reduce C.difficile infections:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea: The Trust has a Infection Risk Assessment linked to the Admission Policy

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit

• Number of beds in the unit: 20

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: Yorkshire and Humber Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 995 995 = ICD 10 codes 161, 163 & 164 as 160 (subarachnoid haemorrhage) and 162 (subdural haemorrhage) are not classed as stroke

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 683

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week :

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment: The Trust has recently had a business case approved to provide a hyper acute stroke service

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week: The Trust operates an ortho-geratiric model of care but does not have meetings at least once a week

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? :

• What is the estimated percentage of all patients that attend the class prior to surgery: 100

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Not able to put a figure on the percentage compliance to this protocol:

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 85

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - audited figure was: 0

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: Not routinely but sometimes

• What is the principle reason for patients not being admitted on the day of surgery: Where patient requirements identify the need for additional support

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: Other (please specify) both hospital and community service is provided and has a multidisciplinary approach

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Counsellor(s)

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week:

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital:

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme: The Trust is currently in the process of undertaking its first survey

Maternity Care

Maternity Sites

• Pontefract General Infirmary - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 3580

• How many babies were born in the unit during the year? (not including home births): 3626

• How many women were booked for a home birth: 0 Data not available.

• How many women had a home birth? (not including births at home by accident): 95 The Trust does not differentiate between planned home births & accidental home births.

• Number of antenatal rooms: 0

• Total antenatal beds: 0

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 4

• Total delivery beds: 4

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 4

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 92

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms: Used on high risk babies.

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: N/A

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Not available

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: Hypnobirth

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 0 Included in Pinderfields figures

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 0 Included in Pinderfields figures

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On call

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On call

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week:

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week:

• Dewsbury and District Hospital - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 0 Within Consultant led numbers.

• How many babies were born in the unit during the year? (not including home births): 0 Within Consultant led numbers

• How many women were booked for a home birth: 0 Data not available.

• How many women had a home birth? (not including births at home by accident): 0

• Number of antenatal rooms: 24 Midwives and Consultants have access to the same number of rooms.

• Total antenatal beds: 24 Midwives and Consultants have access to the same bed base.

• Number of assessment area rooms (for monitoring and / or induction): 5 Midwives and Consultants have access to the same facilities.

• Total assessment area beds: 5 Midwives and Consultants have access to the same facilities.

• Number of delivery rooms: 3

• Total delivery beds: 3

• Number of postnatal rooms: 24 Midwives and Consultants have access to the same number of rooms.

• Total postnatal beds: 24 Midwives and Consultants have access to the same bed base.

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 49

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms: Used on high risk babies.

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: N/A

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: Hypnobirth

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 98.63

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 83.15

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

• Pinderfields General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 20 The Maternity unit at Pinderfields Hospital opened as the Pontefract Maternity Unit Closed

• How many babies were born in the unit during the year? (not including home births): 43

• How many women were booked for a home birth: 0 Data not available.

• How many women had a home birth? (not including births at home by accident): 0

• Number of antenatal rooms: 32 Rooms used for both Antenatal and Postnatal care.

• Total antenatal beds: 32

• Number of assessment area rooms (for monitoring and / or induction): 4

• Total assessment area beds: 4

• Number of delivery rooms: 11

• Total delivery beds: 11

• Number of postnatal rooms: 32 Rooms used for both Antenatal and Postnatal care.

• Total postnatal beds: 32 Rooms used for both Antenatal and Postnatal care.

• Number of rooms in obstetric high dependency unit: 2

• Total obstetric high dependency beds: 2

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 92

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby: Impending at Pinderfields.

• Security measures - cot alarms: Used on high risk babies.

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: N/A

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Not available

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: Hypnobirth

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 126.94

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 114.82

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

• Dewsbury and District Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 3141

• How many babies were born in the unit during the year? (not including home births): 3189

• How many women were booked for a home birth: 0 Data not available.

• How many women had a home birth? (not including births at home by accident): 31 The Trust does not differentiate between planned home births & accidental home births.

• Number of antenatal rooms: 24 Rooms used for both Antenatal and Postnatal care.

• Total antenatal beds: 24

• Number of assessment area rooms (for monitoring and / or induction): 5

• Total assessment area beds: 5

• Number of delivery rooms: 5

• Total delivery beds: 8

• Number of postnatal rooms: 24 Rooms used for both Antenatal and Postnatal care.

• Total postnatal beds: 24 Rooms used for both Antenatal and Postnatal care.

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 1

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 3

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 49

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit: Dewsbury SCBU also has the ability to stabilise neonates prior to transfer to the NICU or NHDU at Pinderfields

• Security measures - ankle bands for the baby:

• Security measures - cot alarms: Used on high risk babies.

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: N/A

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: Hypnobirth

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 0 Included within Midwife led figures for Dewsbury and District Hospital

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 0 Included within Midwife led figures included within Dewsbury and District figures

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups:

• Also available for: Young mothers group run by Teenage Pregnancy midwives Young mothers group run by Teenage Pregnancy Midwives.

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 8-12 Dating Scan undertaken around 12 weeks.

• Scan 2 available between: 20 Anatomy scan undertaken at around 20 weeks.

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: Mid Yorkshire Hospitals NHS Trust