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Inspection Summary


Overall summary & rating

Good

Updated 9 June 2016

We inspected the Royal Hallamshire Hospital as part of the inspection of Sheffield Teaching Hospitals NHS Foundation Trust from 7 to 11 December 2015. We undertook an unannounced inspection on 23 December 2015. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

Overall, we rated Royal Hallamshire Hospital as good. We rated safe, effective, caring and responsive as good; well-led was rated as outstanding.

We rated critical care, maternity and gynaecology and outpatients and diagnostics as outstanding. Emergency and urgent care, medical care and surgery were rated as good. End of life care was rated as requires improvement.

Our key findings were as follows:

  • We found the hospital was clean and staff adhered to infection control principles. The trust scored 99% for cleanliness in the patient-led assessments of care environments (PLACE) report for 2015.
  • There was a trust- wide infection control accreditation programme in place. This programme set standards for infection prevention and control practice. Most clinical areas had achieved accreditation; plans were in place where this was not the case.
  • There had been four cases of MRSA reported by the trust between June 2014 and June 2015.
  • There had been six cases of C.difficile between April 2015 and November 2015 at the Royal Hallamshire Hospital. This was a rate in line with the England average per 10,000 bed days. The trust-wide rate of C.difficile was below the trajectory target with 42 cases against a stretch target of 52 cases at the end of November 2015.
  • The trust the safer nursing care tool, professional judgement and nursing hours per patient day to determine appropriate levels of staffing. There were some areas where staffing fell below planned levels on a regular basis, although the trust was mitigating risks as far as possible. Recruitment to vacancies was in progress. Staff were able to use bank or agency staff to fill staffing shortfalls.
  • Staffing levels within maternity were monitored and reviewed to keep women safe at all times.
  • The neonatal unit had gaps in medical staffing; however these gaps were being covered by advanced neonatal nurse practitioners. Nurse staffing on the neonatal unit was not at current recommended staffing levels.
  • The trust was committed to the development of advanced nurse practitioners to ensure patient care was maintained and the potential recruitment difficulties to junior doctor posts mitigated. This also allowed good advancement opportunities for nurses. The neonatal unit worked in a family centred way, to promote the confidence of parents in caring for their baby. This helped facilitate the unit’s strategy of early discharge, with the support of the neonatal outreach team and the rapid access clinic. Within the maternity unit, there was excellent multidisciplinary working that promoted integral care.
  • Mortality indicators showed no evidence of risk. However, following the inspection, the hospital was identified as an outlier for the incidence of puerperal sepsis. The trust reviewed case notes and responded appropriately: an action plan was put in place.
  • Patients were assessed for their nutritional needs. The trust had introduced HANAT (hydration and nutrition assurance toolkit) to encourage good nutrition and hydration best practice in the hospital environment.
  • There was a well-established culture of continuous quality improvement. This was supported and assured by robust governance, risk management and quality monitoring. The trust used a Microsystems Coaching Academy which worked well to support small scale service improvements.
  • The trust’s vision and values were embedded in practice. These informed performance reviews and staff felt they were meaningful.
  • Clinical directorates had individual five year strategies that were linked to trust’s strategy, aims and objectives. The directorate strategies had consideration of the other clinical departments they worked with to deliver high quality care and the assistance required from corporate directorates and other partners.
  • There was variation in the quality and completeness of Do Not Attempt Resuscitation (DNACPR) forms.
  • There were evidence based nursing care guidelines, which fulfilled the function of care plans, available for reference for a wide range of possible care needs. However, these were not printed and available at the patients’ bedside or with the patients’ care record. Some wards had printed reference files available for staff to use, however we did not observe staff using these. Other wards referred us to the intranet to view these guidelines and again we did not observe staff referring to these. Staff told us computers were not always easily accessible and that new, bank and agency staff did not always have an individual log on. This meant that care plans / guidelines were not always accessible for staff delivering care.

We saw several areas of outstanding practice including:

  • Staff in theatre had introduced a learning disability pathway. An operating list was dedicated to patients with a learning disability, if the patient needed more than one procedure this was carried out on the same operating list under the same general anaesthetic.
  • The use of duty floor anaesthetist role in theatre, developed in Sheffield, was going to be used by the Royal College of Anaesthetists as a beacon of good practice.
  • The operating services, critical care and anaesthesia care group developed “The Magnificent 7” a document outlining seven areas for achievement in the department. The seven areas included zero harm, making every operating minute count and transformation through technology. Each area had a lead, an executive sponsor, an action plan and a review date.
  • One of the urology consultants held the most senior position at the European Association of Urology, the international authority on urological research.
  • A robot used in urology surgery had given superior outcomes compared to traditional surgical techniques. The robot was used by surgeons across the specialities of urology, ENT and gynaecology.
  • The neurosciences directorate introduced an electronic referral tool “Refer a patient.” This shared referral information between the referrer and neurosurgeon who could give an immediate decision and feedback to the referrer.
  • The podiatry service had been awarded Customer Service Excellent Award for the 15 consecutive years.
  • A neuro simulation team-training programme for anaesthetists was being piloted on neuro critical care. This was training for the whole MDT and aimed to prepare staff for the challenges of managing acutely unwell patients. It introduced staff to crisis resource management non-technical skills.
  • An innovative clinic providing medico-legal expertise was available to patients and their families. The service gave access to experienced legal professionals able to give advice across a breadth of areas including managing the personal affairs of a patient.
  • The one to one team and specialist midwife clinics gave greater assurance that high risk women continued to have a choice on the care they received in pregnancy.
  • The rapid access clinic reduced readmissions of babies with feeding problems.
  • The GRIP project responsible for getting research into practice improved services for maternity and gynaecology.
  • The termination of pregnancy service gave women continuity of care in an appropriate caring environment. The seven day service gave women choice and improved accessibility.
  • The use of the Enhanced Recovery programme in both maternity and gynaecology improved the service for women.
  • ‘Devices for Dignity (D4D) Healthcare Co-operative’ was hosted by the trust. This is a national initiative to drive forward innovative products processes and services to help people with long-term conditions’. The Devices for Dignity (D4D) Healthcare Co-operative’ had been recognised with a number of awards including; 2012 Advancing Healthcare Awards and Allied Health Professionals and Healthcare Scientist; Leading Together on Health Award.
  • Sheffield ophthalmology was the only centre in the country that carried out stereotactic radiosurgery (SRS). This treatment uses radiation therapy and focuses high-power energy on a small area of the body. The service had been carrying out this procedure for the past 25 years. The service also carried out photodynamic therapy (PDT) to treat cancer and audits showed this treatment had an 85% success rate. Photodynamic therapy is a treatment that uses a drug, called a photosensitizer or photosensitizing agent.
  • Staff in the diabetes service had just started a six-year National Institute for Health Research (NIHR) programme to further develop education about type 1 diabetes.
  • Histopathology was using digital pathology. Six biomedical scientists at the NGH site had been trained to prepare frozen sections of tissue; this preparation used to be undertaken by histopathology consultants. The biomedical scientists dissect and prepare the samples while on video link to the RHH so that the technique can be checked and quality maintained. Staff scanned and digitally transferred the resulting image to the histopathology consultants at the RHH site. This technique was time efficient and speeded up the process for the patient.
  • Cancer services at the trust had won awards from the Health Service Journal and the Nursing Times. For example, in 2014 the service had received the Cancer Care Award.
  • The development of the Sheffield 3D imaging lab is unique to the NHS and provides improved quality of scans and detail of brain tumour growth. Images could be processed quicker, in seconds rather up to an hour, saving time and money. The 3D lab was a finalist in the Yorkshire and Humber Medipex NHS Innovation awards.
  • In addition to walk in services for general plain film imaging GP’s could refer patients directly for CT, MRI, ultrasound, fluoroscopy and other specialised imaging examinations.
  • There was a state of the art Medicines and Healthcare products Regulatory Agency (MHRA) Licenced Radiopharmacy, serving all of the trusts locations.
  • Nuclear medicine staff were finalists in the Medipex NHS innovation awards 2014 after developing a new system for diagnosing debilitating digestive disorder that freed up the gamma camera, so reducing patient waiting times.

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

Importantly, the trust must:

  • Ensure the safe storage of intravenous fluids.

  • Ensure doctors follow policy and best practice guidance in relation to the prescription of oxygen therapy.

  • Ensure that guidance is followed in the documentation of fetal heart rate monitoring’s. In 86% of 39 CTG records, there was no data at the start or end of the monitoring, such as the women’s heart rate, clarification that the clock was correct, staff signature and indication for monitoring. Events in labour and review by a second practitioner were not always documented on the monitoring, in accordance with trust guidance (Intrapartum fetal monitoring - CTG, 5.5, 5.6).

  • The trust must ensure that DNACPR records are fully completed.

  • The trust must ensure a strategy for end of life care is implemented.

In addition the trust should:

  • The hospital should ensure that staff have attended mandatory training in accordance with the trust target.

  • The MIU should improve the monitoring of time to be seen and total time in department.

  • Although the MIU works closely with the A&E at NGH, audits specific to the MIU should be completed to show effectiveness and to monitor improvement to services and treatment offered in this location.

  • Review the use of nursing care guidelines and ensure they are consistently available for all staff providing patient care, to enable accountability for care provided.

  • The trust should improve the compliance rates for medical and nursing staff receiving an annual appraisal.

  • The trust should continue to take action to reduce the number of medical outlier patients across the trust.

  • The trust should continue to take action to reduce the number of bed moves patients experience during their hospital stay.

  • The trust should try to reduce the movement of staff to clinical areas outside of their speciality.

  • The trust should introduce a robust process to share lessons learnt from incidents and mortality and morbidity reviews across directorates and care groups.

  • The trust should review the labelling of babies prior to their removal from the obstetric theatre.

  • The trust should ensure that the neonatal resuscitaires in labour suite has documented checks. We identified checklists that had signatures missing 22% of the time for the month examined.

  • The trust should continue to improve consultant medical staffing on labour ward in accordance with Royal College of Obstetrician and Gynaecologists guidelines.

  • The trust should review data collection methods and introduce a system to collect patient outcomes by surgical speciality within care groups.

  • The trust should review the waiting times for patients with learning disabilities requiring dental treatment under general anaesthesia against the 18 week standard.

  • The trust should ensure appropriate medical and nursing staffing on the neonatal unit to reflect current national guidelines for safe care.

  • The trust should review patient centred care planning on the neonatal unit.

  • The trust should consider improving the way in which medicines are constituted within the neonatal unit to ensure there is a safe environment to do this, and reduce risk of medicine errors.

  • The trust should monitor preferred place of care for patients at the end of life.

  • The trust should review access and the environment of the chapel and prayer room.

  • The trust should develop standard procedures for completing interventional radiology non-surgical safety checklists for all staff to follow.

  • The trust should undertake regular audits of patient electronic records to ensure consistency in the completion of MRI safety checklist and pregnancy checks.

  • The trust should review oversight of the area and facilities for patients waiting for transport following the clinic appointments.

  • The trust should monitor access to records in the outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 9 June 2016

Effective

Good

Updated 9 June 2016

Caring

Good

Updated 9 June 2016

Responsive

Good

Updated 9 June 2016

Well-led

Outstanding

Updated 9 June 2016

Checks on specific services

Maternity and gynaecology

Outstanding

Updated 9 June 2016

Overall we rated maternity and gynaecology services as outstanding. Patients were protected from the risk of avoidable harm and when concerns were identified staff had the knowledge and skills to take appropriate action. Incidents were recorded, investigated and, where necessary actions were taken to prevent reoccurrence.

Staff delivered evidence based care and treatment and followed NHS England and National Institute for Health and Care Excellence (NICE) national guidelines. Staffing levels were monitored and reviewed to keep women safe.

There was excellent multidisciplinary working that promoted integral care. Staff worked together to make changes to improve the outcomes for women and babies.

Staff were thoughtful and responded compassionately to women, treating them with kindness dignity and respect. Partner and relatives felt included in the care given.

The variety of specialist services in maternity and gynaecology met the needs of women both locally and nationally.

People’s individual needs and preferences were central to the planning and delivery of tailored services. The importance of flexibility, choice and continuity of care was reflected in the services.

Leaders and senior managers had an inspiring shared purpose, they strove to deliver and motivate staff to succeed. They were motivated, visible and accessible and participated in the day-to-day running of the service.

Medical care (including older people’s care)

Good

Updated 9 June 2016

There was good evidence that safety issues were identified and addressed, incidents were investigated appropriately and improvement actions implemented. There was good management of escalation of deteriorating patients. There was no evidence of increased risk of mortality in any of the medical specialities.

There was good evidence of effective multi-disciplinary team working and good provision of seven-day services. Patients pain relief and nutritional needs were met. There was good evidence of learning from audits and the improvements being made. Staff received training relevant to their role to develop expertise. Staff had a good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. However, appraisal rates for both nursing and medical staff were below the trust’s targets.

We observed staff in all areas treating patients with kindness and respect. Privacy and dignity was maintained at all times and patients were satisfied with the services and care delivered.

There were many examples of service planning and delivery to improve services for patients. However, high numbers of patients were moved to a ward outside of their speciality ward and 20% of patients were moved twice or more during their hospital stay. The process for transferring and receiving patients from NGH was not robust and could lead to delayed review and treatment or investigation of patients.

All services had a clear vision and strategy for service delivery and improvement. There were clear governance structures and managers were confident about how to escalate risk. Managers and staff had a good understanding of the risks their services faced and mitigated against these wherever possible. There was strong leadership of services and wards from clinicians and ward managers.

There was a well-embedded culture of learning and improvement and there were examples of innovation, improvement and sustainability.

However, there were some areas of poor practice relating to medicines management. There were some areas where staffing fell below planned levels, although the trust was mitigating risks as far as possible. Compliance with mandatory training was below trust targets in some areas and across staff groups and there were some concerns about accessibility of nursing care guidelines (care plans).

Urgent and emergency services (A&E)

Good

Updated 9 June 2016

The provision of urgent and emergency services at the RHH is of a consistently high standard. The service provided was safe, in that it protected service users from avoidable harm and abuse. Staff provided care in environments that were suitable and well maintained.

People’s care and treatment had good outcomes, was based on the best available evidence and promoted good quality of life. Staff were highly qualified, experienced and worked in specialist roles effectively and efficiently.

The services available were carried out by staff in a caring, compassionate and respectful way, with dignity at the forefront of treatment.

The urgent and emergency care services available at the RHH were not twenty four hour services, but were available every day of the week except Christmas day. Services met the needs of the community served, and alternative services were available when the MIU was closed. Services took account of the needs of different people, including those with complex needs and strived to remove barriers and offer timely, effective care to all.

The urgent and emergency services were run effectively, by dedicated leaders with a clear vision and strategy.

Surgery

Good

Updated 9 June 2016

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, there was limited evidence of learning from incidents across directorates at ward level.

Systems and processes for infection control, medicines management and patient records were mostly reliable and appropriate to keep patients safe. Staffing levels and skill mix were planned and reviewed to keep people safe. Staff recognised and responded promptly and appropriately to risks and deteriorating patients, including overnight and at weekends.

Care and treatment was planned and delivered in line with evidence based guidance and best practice. The service participated in relevant local and national audits. Patient outcomes were monitored. Staff were qualified and had the skills they needed to carry out their roles effectively. They were supported to maintain and further develop their professional skills and experience.

Patients were treated with dignity and respect and involved in their care and their needs were met through the way services were organised and delivered.

Directorates had clear strategies driven by quality and safety aligned to the trust’s vision and values. Governance structures and processes within the directorates functioned effectively. There was a high level of staff engagement and satisfaction.

Intensive/critical care

Outstanding

Updated 9 June 2016

Openness and transparency about safety was encouraged and staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Performance showed a good track record and steady improvements in safety. Staffing levels and skill mix were planned and reviewed to keep people safe at all times.

There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. The systems to manage and share the information (needed to deliver effective care) was fully integrated and provided real-time information across teams and services. Staff were qualified and had the skills they needed to carry out their roles effectively.

Patients were treated with kindness, dignity and respect. Governance and performance management arrangement were proactively reviewed and reflected best practice. There was collaboration and support across all areas with a common focus on improving quality of care and patient experience. Leadership strategies were in place to ensure good care delivery within a supportive and open environment. There were high levels of staff satisfaction. Staff were proud of their units and spoke highly of the culture. The services proactively engaged and involved staff and ensured that the voices of all staff were heard and acted on. Staff innovation was supported.

Services for children & young people

Good

Updated 9 June 2016

Overall, we rated the service as good. The service had a good culture of incident reporting, and there was evidence of lessons learnt from incidents. The neonatal unit had implemented a programme of simulation training to apply changes in practice following learning from incidents. The service promoted a culture of improvement. There were competency frameworks for nursing staff and medical staff received good clinical support and training.

The neonatal unit worked in a family centred way, to promote the confidence of parents in caring for their baby. This helped facilitate the unit’s strategy of early discharge, with the support of the neonatal outreach team and the rapid access clinic.

Staff working at the trust were aware of the trust’s values and there was a strategy to promote staff engagement. There was a supportive culture, with open door access to senior management. Staff participated in the research activity of the service.

The neonatal unit had gaps in medical staffing; however these gaps were being covered by advanced neonatal nurse practitioners. Nurse staffing levels did not meet the current national guidelines and were not achieving national recommendations for staff having a qualification in speciality.

The environment of the unit was not ideal and was not compliant with Government best practice guidelines. However, work was underway to commence reconfiguration of the unit to address the constrictions on space.

End of life care

Requires improvement

Updated 9 June 2016

We found do not attempt cardiopulmonary resuscitation (DNACPR) decisions were not always made in line with national guidance and legislation. The trust did not monitor if patient choice around preferred place of care or death was met. The chapel was noisy and the Muslim prayer room was poorly signed. There was no internal strategy in place for end of life care at the trust. In response to the 2013 review of the Liverpool Care pathway, the trust had produced guidance. However, this had not been made available until October 2015.

However, we also found patients received safe care and treatment, which met their needs. The specialist palliative care team of nurses and doctors were skilled and knowledgeable. In the year from April 2014 – 2015, over 97% patients were seen within 24 hours of referral to the specialist palliative care team. There was seven day cover from the team. There was evidence of compassionate and understanding care on all the wards at the hospital.

Outpatients

Outstanding

Updated 9 June 2016

The services had a positive safety culture; there were clear management responsibilities and accountability for safety and governance. The services promoted continuous quality improvement.

There were enough qualified, skilled and experienced staff to meet people’s needs. Staff received good support, staff appraisals and mandatory training was up to date.

Radiology services provided well-established, highly regarded training programmes for medical staff at every stage of their five-year programme and for student radiographers from local universities.

All of the staff were passionate about their work and staff teams worked well together to provide an excellent experience for their patients. All of the patients and relatives we spoke with gave positive feedback about the staff and the services.

Staff were aware of the trust values; there was good staff engagement and an open culture. Staff participated in research activities and there were numerous examples of innovation and improvement.