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Rotherham General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 July 2015

The Rotherham NHS Foundation Trust provides both acute hospital and community-based health services. The trust served a population of over 257,600 people living in Rotherham and the surrounding areas. In total the trust had 481 beds.

Rotherham is an urban area with a deprivation score of 53rd out of 326 local authorities (with one being the most deprived). This means that Rotherham has a significantly deprived population and is worse than the national average on a range of population health measures.

We inspected The Rotherham NHS Foundation Trust as part of our comprehensive inspection programme. We carried out an announced inspection of Hospital between 23-27 February 2015. At the same time as this inspection, an inspection of the quality and effectiveness of the arrangements that health care services have made to ensure children are safeguarded was also taking place. These inspections are part of a national programme that the Care Quality Commission is currently undertaking. The inspections review health services within local authority areas in England and will case track individual children in each area. We have used some of the information that was identified during this review within our report.

In addition, an unannounced inspection was carried out on 7 March 2015. The purpose of the unannounced inspection was to look at the children’s ward and medical admissions unit at the Rotherham Hospital.

Overall, we rated this trust as “ Requires Improvement” and we noted some outstanding practice and innovation. However improvements were needed to ensure that services were safe, effective, responsive and well led.

Our key findings were as follows:

Cleanliness and Infection Prevention and Control

  • The trust had a dedicated infection control team. They visited the wards at Rotherham Hospital on a daily basis and were highly regarded by the staff we spoke with. The infection control team undertook a range of infection control audits on the wards.
  • We saw that side rooms were used for patients who had, or it was suspected, that patients had infections. Signage to alert staff and visitors of the risk of infection was placed on the doors. On many wards we saw that the doors to these rooms were open, which meant the signage to alert of the possible risk of infection were not immediately evident. Opened doors also increased the spread of infection. We asked to see if there were risk assessments in place for doors to remain open but they weren’t available.
  • We saw there was clear information displayed or provided regarding the use of segregated toilets for the sole use of patients who had, or were suspected of having infections, but segregated use was not enforced. We observed toilets meant for sole use being used by patients who were not considered as being an infection risk. This increased the risk of the spread of infection.
  • We saw many good examples of staff delivering care using best practice but also saw examples where staff action increased the risk of infection. This included one staff member who cleaned a toilet and left the toilet without removing their gloves and aprons and entered a clean area.
  • The incidence of Clostridium difficile infections in 2013/2014 was 29 and was above the trusts target.
  • There had been no Methicillin-resistant Staphylococcus Aureus (MRSA) infections across the trust in the last 12 months. 
  • During our inspection we found that generally the hospital was visibly clean. 

Nutrition and Hydration

  • Nutritional screening assessments were available in all patient records that we looked at.
  • Patients generally reported that the quantity of food was sufficient but there were variable reports on the quality with most patients telling it was acceptable. Following the inspection, the trust changed its catering contract and it was hoped this would bring new benefits to both staff and patients.
  • Where patients had identified nutritional needs, staff were alerted to this by the use of a red napkin and red jug being placed on their tray. Most patients had the appropriate coloured jug by their beds.
  • Protected meal times were in place to allow time for patients to eat sufficiently. Where relatives or friends supported people to eat, they were encouraged to continue this.
  • Most fluid balance charts we saw were well completed, however the audits on some wards identified that they were at times poorly completed.

Mortality

  • There were no open mortality outlier alerts for the trust at the time of our inspection. Mortality outlier alerts look at patterns of death rates in NHS trusts. Alerts are issued when the number of deaths is higher than usual.
  • The trust reported data for the ‘Summary Hospital - level Mortality Indicator’ (SHMI). The summary hospital-level mortality indictor (SHMI) and the hospital standardized mortality ratio (HSMR) between July 2013 and July 2014 shows no worse than the national average for the number of deaths. The groups with highest excess deaths for the latest SHMI were pneumonia, stroke, mental retardation and senility, renal failure and lung cancer. SHMI and HSMR are ways in which the NHS measures healthcare quality by looking at the death rates from certain conditions in a trust.
  • The trust held monthly mortality review meetings where all unexpected deaths were reviewed.

Staffing

  • Planned staffing levels were not being achieved on a number of wards, particularly those in the medical care service. This was impacting heavily on staff morale, sickness and retention. The trust recognised this and recruitment, including overseas recruitment was underway.

  • The trust was reliant on agency nurses, but tried to use the same agency staff where possible. We were encouraged to see the nurse staffing reports to the trust board and to the Quality Assurance Committee explored the potential for a link between nursing vacancy rates and the incidence of patient falls. A correlation had not been confirmed.
  • Medical staff were in a better position than nurses, although there were some areas of the trust that required an increase.

We found areas of good practice.

  • BreathingSpace was an innovative nurse-led unit. The unit had been visited by members of parliament as well as interested parties from across the UK, Japan, China and Belgium. The nurse consultant who led the unit had presented papers at national and international conferences focused on respiratory illnesses.
  • BreathingSpace provided exemplary care to the patients it cared for due to the highly skilled and knowledgeable staff working on the unit. Staff were caring and compassionate and continued their caring role by supporting families after the loss of a loved one. It was an example of an innovative community service that met the needs of the population very well.
  • The trust hosted a photopheresis treatment service which helped patients with conditions where the white blood cells are thought to be the cause of the disease. It is the largest centre outside of London to provide the treatment. We saw a child who had travelled some distance for the treatment during our visit. It was a service that was highly valued by the patients who used it.

We also found areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • All relevant staff have received appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and living with dementia awareness.

  • All relevant staff are able to assess the capacity and best interests of patients in line with the Mental Capacity Act 2005 and its associated deprivation of liberty safeguards.

  • All do not attempt cardio-pulmonary resuscitation (DNA CPR) forms are completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005).

  • The registered person must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements.
  • There are sufficient number of suitably skilled, qualified and experienced staff.
  • The outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments.

  • The registered person must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure.
  • They report and investigate incidents in a timely manner and that learning is shared with all staff.
  • Directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals.

In addition the trust should:

Emergency department

  • Complete a review of staffing levels so appropriate numbers of suitably qualified nurses, emergency department assistants, and healthcare assistants are on duty to manage surges in demand.
  • Ensure that all relevant staff are able to attend regular staff meetings.
  • Ensure that there are systems in place that allow for professional sign language interpretation of consultations for profoundly deaf patients who use sign language, either in person or via video link.

Surgery

  • Improve the 18-week referral-to-treatment targets so that patients have access to timely care and treatment.
  • Improve access and flow for patients attending fracture clinic appointments.
  • Minimise the movement of patients from other specialities onto surgical wards, particularly those wards providing elective orthopaedic surgery.

Critical care

  • Make sure that staff have access to up-to-date, evidence-based guidance.
  • Review access to the intensive care unit so it is secure at all times.
  • Ensure that consultant ward rounds take place in accordance with national guidance.

Maternity

  • Review guidance so that the time intervals for recording patient observations are sufficiently frequent to ensure patient safety.
  • Review documentation so that appropriate prompts are available to identify patient safety needs.
  • Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth.
  • Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning.
  • Review access and patient flow on the labour and postnatal wards so there is effective use of resources to ensure that mothers and babies are cared for in the most appropriate place.

Children and young people

  • Review the internal safeguarding processes and implement identified actions.
  • Review the transition arrangements for children and young people for all pathways.
  • Review the leadership of the service so there is access to senior children’s nursing advice.

Outpatients and diagnostic imaging

  • Ensure that sharps are managed in a manner which protects staff and patients from the risk of needle-stick injuries.

Hospital wide

  • Ensure that information about how to make a complaint or leave a comment is available in alternative formats and languages.
  • Ensure that nursing staff have access to clinical supervision.
  • Ensure that patients who are living with dementia and/or their relatives have the opportunity to give information about their personal circumstances, their preferences and likes and dislikes.
  • Patients’ records are kept securely at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 14 July 2015

Effective

Requires improvement

Updated 14 July 2015

Caring

Good

Updated 14 July 2015

Responsive

Requires improvement

Updated 14 July 2015

Well-led

Requires improvement

Updated 14 July 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 2 March 2017

We found although action was taken to address most of the areas identified at the previous inspection, there were still some areas that required improvement.

There was a backlog of incidents for review and the rate of safeguarding supervision was low and community midwives reported a lack of support.

The trust had identified a number of poor outcomes since late 2015, which included neonatal deaths, stillbirths and maternal deaths. A multidisciplinary review of all the cases was taking place. Maternal incidents since 2014 were being reviewed and neonatal incidents that had occurred from 2015 onwards were also being reviewed.

However, there had been some improvements since the previous inspection. Staffing levels and training had improved and arrangements for assessing and responding to patient risk were in place and monitored.

The rate of emergency caesarean sections had improved and was similar to expected when compared with national rates. The rate of normal deliveries was better than the England average.

There was evidence of good multidisciplinary working.

Medical care (including older people’s care)

Requires improvement

Updated 2 March 2017

We found that the service had made many improvements since our last inspection but there were still some areas requiring further improvement.

Staff shortages were still evident and planned staffing levels were not being achieved on many wards. However, the trust was taking action to cover shifts wherever possible with bank and agency nurses and most staff felt well supported. Staff reported incidents and learning was disseminated using a variety of methods. Mandatory training levels were improved from last year, but were still poor in some areas. Infection prevention, practices and procedures did not always protect against the risk of spreading infection.

Knowledge of the Mental Capacity Act 2005 and its associated deprivation of liberty safeguards was good, but documentation of mental capacity assessments and discussions was poor. Appraisal rates were below trust target. Fluid balance recording needed to be improved.

Although the discharge lounge was still sometimes used as an inpatient ward, there were processes in place to close to discharges if this happened and the unit was appropriately staffed to care for overnight patients. We found that staff were very caring and there had been no mixed sex breaches for this service in the last 12 months.

Each speciality had a vision and direction for their service and business plans were developed regarding sustainability and future development. Ward managers, matrons and senior managers were aware of their risks and mitigations were in place. Risk registers were comprehensive and up to date.

Urgent and emergency services (A&E)

Requires improvement

Updated 2 March 2017

There were insufficient medical and nursing staff employed by the department and staffing levels were often below assessed and planned levels. Nursing and medical shifts frequently went uncovered. There was a heavy reliance on bank, agency and locum staff in the department. Mandatory training levels and appraisals were worse than the trust minimum standard.

Staff did not always identify vulnerable patients and follow safeguarding processes to protect them in a timely manner. This had been recognised and the trust’s safeguarding team were providing training and additional support. Staff were also unclear about the mechanisms in place to support people living with dementia or a learning disability. Although there was a dementia strategy, this was not embedded in practice.

Although the multi-disciplinary staff worked together to ensure the safe treatment of patients, the department did not give the impression of working as a cohesive team. Most staff reported incidents and we saw examples of this, however there was also a culture amongst some staff groups that it was not their responsibility to report patient safety incidents.

The department followed national guidance and had recently introduced established assessment processes, however, some documentation was out of date. For example, some standard operating procedures that allowed nurses to give pain relief and other medication to patients was out of date, meaning some nursing staff could no longer give patients this medication.

We found that the facilities on the clinical decision unit (CDU) meant that patients on the department did not have access to bathing facilities or a shower.

However, there was a clear vision and strategy for the department and staff were aware of planned future developments. Patients who visited the department had their individual needs met. Interpreters were available and there were facilities available to assist disabled patients and those with specific needs.

Staff maintained patients’ privacy and dignity and worked hard to deliver care to patients. Staff treated patients as individuals. The department had evidence-based policies and procedures relating to care, which were easily accessible to staff.

Surgery

Updated 2 March 2017

The trust had taken action on some of the issues raised in the 2015 inspection, for example, staff were confident in reporting incidents and received feedback from incidents. The World Health Organisation (WHO) safer surgery checklist was embedded in practice and additional staff had been recruited. The management of medical outliers was in line with trust policy, there had been no mixed sex accommodation breaches and access and flow had improved in fracture clinic.

Systems and processes for infection control and medicines management were reliable and appropriate.

Senior staff planned and reviewed staffing levels and skill mix to keep people safe from avoidable harm. All wards used an early warning scoring system for the management of deteriorating patients.

Patients’ needs were met through the way services were organised and delivered. The trust’s referral to treatment performance was better than the England average between June 2015 and May 2016.

However, the trust did not have a Hospital at Night team and out of hours senior doctors were not always resident on site to support junior doctors and advanced nurse practitioners.

Intensive/critical care

Updated 2 March 2017

We found there was a culture where patients were at the centre of activities. There was a clear process for escalation, investigation and feedback of incidents. Lessons learnt were shared with staff to minimise them reoccurring. Staff received training in vulnerable adult and children protection. They were confident in safeguarding patients.

Outcomes for patients using this critical care service were measured against similar services; this unit were better in some areas and similar in others. Staff were appropriately qualified.

Staff understood and were able to verbalise the principles of mental capacity act, duty of candour and the unit vision and aims.

At our request at the inspection, the trust took immediate action to ensure the fire evacuation arrangement in place for intensive care unit was fit for purpose. We confirmed this during our unannounced inspection. We also wrote to the trust and they confirmed that fire safety advisors were satisfied with the arrangements in place.

However, due to staff shortages, the nurse coordinator on shift was unable to fulfil their duty of managing, supervising and supporting staff to ensure safety. There was also a lack of a designated pharmacist on the unit.

Patients’ notes were not stored securely within the units to maintain patient confidentiality.

The governance arrangements including maintenance of a risk register and the review process did not promote effective risk control.

Services for children & young people

Requires improvement

Updated 2 March 2017

Compliance with National Institute for Health and Care and Excellence (NICE) standards was variable. The clinical audit schedule was behind schedule and no nursing audits were carried out. More than half (55%) of the policies, procedures and guidelines in use were out of date. Audit data showed most patient outcomes were similar to or better than the England average.

There was a lack of evidence to show there was effective risk management within the service and the vision and strategy was not clearly defined or understood.

There was no nursing co-ordinator on the SCBU as recommended by national guidelines and several vacancies for medical staff. However, the nurse staffing establishment had improved significantly since the last inspection and nationally recognised guidelines were being met on the wards.

Action had been taken since the last inspection and the children’s ward environment was safe and appropriate for children and young people. Access to psychiatric input for children and young people with a mental health needs (CAMHS patients) using the service had improved since the last inspection.There was good evidence of multidisciplinary working across children’s services. Safeguarding procedures were well embedded and understood by staff.

We saw staff treated patients and relatives with kindness and compassion throughout the inspection. Patients and families gave positive feedback about their care and treatment.

End of life care

Updated 2 March 2017

The trust had not taken action on some of the issues raised in the 2015 inspection. DNACPR forms and mental capacity decisions were not documented in line with trust policy, national guidance and legislation. The individualised care plan for adults had been launched in March 2016, however, its use was not yet embedded in practice.

Resources within the specialist palliative care team affected their ability to deliver evidence based care and treatment, specifically in relation to seven day working..

However, staff in the specialist palliative care team were skilled and competent and offered training to all staff groups in end of life care. We saw evidence of good multidisciplinary team working in the hospital, across the community and hospice.

Outpatients

Updated 2 March 2017

The trust had taken action on some of the issues raised in the 2015 inspection, for example, procedures around sharps bins had been updated and were followed and records were now stored securely in clinics.

Mandatory and safeguarding training levels were better than the trust target. Staff understood their responsibility to raise concerns and report incidents. They received feedback from incidents.

However, although some improvements had been made since 2015, but the environment continued to present significant challenges for most departments.

There was a shortage of consultants employed by the trust. Locum staff were employed, however, this had affected continuity of care for patients.

Other CQC inspections of services

Community & mental health inspection reports for Rotherham General Hospital can be found at The Rotherham NHS Foundation Trust.