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The Royal National Orthopaedic Hospital (Stanmore) Requires improvement

The provider of this service has requested a review of one or more of the ratings and they are currently under review. The ratings for this service could change further to completion of the review. This page will be updated in due course.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 August 2014

The Royal National Orthopaedic Hospital – Stanmore is the main location of the Royal National Orthopaedic Hospital NHS Trust. It is the largest specialist orthopaedic hospital in the UK, with 220 beds, and is regarded as a leader in the field of orthopaedics, both in the UK and worldwide. As a national centre of excellence, the trust treats patients from across the country, many of whom have been referred by other hospital consultants for second opinions, or for treatment of complex or rare conditions.

The Royal National Orthopaedic Hospital NHS Trust has been selected as one of the first specialist trusts to be inspected under CQC’s revised inspection approach. It provides surgery, medical care for spinal and rehabilitation patients, critical care and children and young people’s services.

The team of over 30 included CQC inspectors and analysts, doctors, nurses, Experts by Experience and senior NHS managers. The inspection took place on 7, 8 and 9 May 2014.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘outstanding’ for providing caring and effective care but it required improvement for the services to be safe, responsive and well-led.

We rated medical care as ‘outstanding’ and surgery and critical care as ‘good’. However the outpatient services and children and young people’s services ‘requires improvement’.

Our key findings were as follows:

  • The fabric of the building was not fit for purpose – it does not provide an adequate environment to care and treat patients.
  • There was a significant focus on culture, values and behaviours of all staff.
  • Patients praised staff and the good care they received. The NHS Friends and Family Test results were higher than the national average. The response rate was extremely high.
  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Overall staff followed good infection control practices. The hospital was clean and well maintained and infection control rates in the hospital were within a statistically acceptable range.
  • Staffing levels and the skill mix of staff met patients’ needs.
  • The medical care for spinal injury patients and patients receiving rehabilitation was outstanding.
  • Some patients had unnecessary waits at their outpatients appointments.
  • The children and young people’s service was not responsive to their needs.

We saw several areas of outstanding practice including:

  • Outstanding clinical outcomes for patients.
  • Innovative surgery was being carried out to improve patients’ quality of life. For example, limb lengthening for patients with skeletal malformation.
  • The executive board demonstrated leadership and vision for the hospital.
  • Staffing levels and the skill mix of staff met patients’ needs.
  • Effective multidisciplinary working putting the patient first.
  • The services provided by the Spinal Cord Injury Centre (SCIC) and on the Jubilee Rehabilitation Unit (JRU) were consistently person centred and responsive to their needs.
  • A hotel-based rehabilitation programme supporting patients to recover from surgery and have a normal daily life.
  • A ward dedicated to providing wound care to patients with appropriately skilled staff.
  • Some wards had started to use a drink container that attached to equipment and could be kept with patients at all times to ensure patients were kept hydrated, especially during rehabilitation sessions.
  • The training for surgical trainees was excellent
  • The education for children and young people’s was well integrated into the service, and inclusive and innovative teaching methods meant that children and young people could continue to access learning throughout their hospital stays.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The design and layout of the premises is suitable for all service users.
  • To continue focus significantly on culture, values and behaviours of all staff.
  • The paediatric resuscitation equipment is checked regularly to assure it is ready for use if required.
  • The World Health Organisation (WHO) surgical safety checklist is used and completed at each stage of surgery and radiology.
  • Staff that treat children and young people are up-to-date with the appropriate level of safeguarding training.
  • The needs of children and young people are considered in scheduling operations.
  • The learning from incidents is widely shared.

In addition the trust should:

  • Develop the services across seven days.
  • Review its use of opioids prescribed for pain relief for older people as it is recognised as can be a contributory factor in falls and increased confusion.
  • Consider the mechanisms in place for identifying if equipment including mechanical ventilators, cardiac monitors and mattresses used to prevent pressure ulcers are clear to all when testing is needed.
  • Ensure all staff are aware of support mechanisms such as the employee assistance programme. The RCN recommends there should be formal support mechanism available due to the challenging and highly specialised nature of the service provided, particularly with children and young people.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 August 2014

Effective

Outstanding

Updated 15 August 2014

Caring

Outstanding

Updated 15 August 2014

Responsive

Requires improvement

Updated 15 August 2014

Well-led

Requires improvement

Updated 15 August 2014

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 15 August 2014

The medical wards were safe, effective, caring, responsive and well-led.

Staff were very caring and patients were consistently at the heart of their own care. They were involved in all aspects of their care. The service was designed and delivered to meet the all the needs of patients. Patients had access to rehabilitation therapies that assisted them in a normal life following surgery. There was enough staff with the appropriate skills to provide care. Patients had good outcomes and received the care and treatment they required when they needed it. There was good multi-disciplinary working. The local leadership was valued and staff felt supported..

Surgery

Good

Updated 15 August 2014

Overall, patients received safe, effective, compassionate care delivered by knowledgeable, skilled staff. Patients expressed their praise for staff, and their delight and satisfaction in the outcome of their surgery.

The trust is a recognised world leader in treating patients with complex orthopaedic conditions, and has a record of using pioneering treatment to achieve very good outcomes, which were published as part of research programmes. The trust is a tertiary centre, and performs a higher proportion of revisional surgery than other trusts

Adherence to the World Health Organization (WHO) surgical safety checklist was not embedded by all staff carrying out surgery or interventional procedures in theatres and radiology.

Intensive/critical care

Good

Updated 15 August 2014

Patients received appropriate care and treatment in accordance with national guidelines. There were sufficient numbers of staff on duty, and enough equipment to meet patients’ needs. Systems were in place to monitor the quality and safety of patient care provided.

Staff were knowledgeable and compassionate. They were aware of the incident reporting systems and told us that they were encouraged by senior staff to report incidents and raise awareness of patient safety issues. Patients were fully informed and satisfied with the outcomes of their treatment. They told us that they were cared for in a supportive way, and found staff very friendly.

Services for children & young people

Requires improvement

Updated 15 August 2014

The service was effective and caring, however it was not responsive to meet the needs of children and young people and not always safe and well led.

The ward environment was inadequate; it was small and did not provide sufficient facilities. Due to the location of the ward, children and young people ward is the only ward where patients have to be taken outside in order to access and return from theatres.

Leadership within the children and young people’s service was fragmented. Progress of some of the actions following the external review carried out in 2005 and 2009 were not completed and acknowledged by the trust.

Outpatients

Requires improvement

Updated 15 August 2014

The service was safely managed caring, effective but it required improvement in its responsiveness and leadership.

Patients told us that the service was responsive to their clinical needs; however some clinics ran late most of the time. 26% of the clinics started late. There was no key performance indicator for sending out clinic letters following consultation to patients and their GPs. A significant proportion of letters were not sent out for over one month. There was an exception within the trust that letters regarding patients who had cancer would be sent out within 48 hours. The leadership team were aware of the issues but had not addressed them as they were not responsible for the clinical divisions who booked appointments.