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Sunderland Royal Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 January 2015

Sunderland Royal Hospital is one of two acute hospitals forming City Hospitals Sunderland NHS Foundation Trust. The trust provides acute hospital services to a population of around 350,000 people across the Tyne and Wear and Durham area. In total, the trust has 855 beds across two hospitals and employs around 4,923 staff. Sunderland Royal Hospital has 833 beds.

Sunderland Royal Hospital provides medical, surgical, critical care, maternity, children’s and young people’s services for people across the Tyne and Wear and Durham area. The hospital also provides accident and emergency (A&E) and outpatient services.

We inspected Sunderland Royal Hospital as part of the comprehensive inspection of City Hospitals Sunderland NHS Foundation Trust, which includes this hospital and Sunderland Eye Infirmary. We inspected Sunderland Royal Hospital on 17, 18 and 19 September and 2 October 2014.

We carried out this comprehensive inspection because the Care Quality Commission (CQC) had placed City Hospitals Sunderland NHS Foundation Trust in risk band 2 in the CQC’s Intelligent Monitoring system.

Overall, we rated Sunderland Royal Hospital as requires improvement. We rated it good for being effective, caring and well-led, but it requires improvement in providing safe and responsive care.

We rated A&E, surgical services, critical care, maternity, services for young people, end of life care and outpatient services as good, with medical care as requiring improvement.

Our key findings were as follows:

  • Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. Rates of Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the trust.
  • Patients were able to access suitable nutrition and hydration, including special diets. Patients reported that, on the whole, they were content with the quality and quantity of food.
  • Processes were in place for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs.
  • There was effective communication and collaboration between multidisciplinary teams.
  • There were staff shortages, particularly on the medical wards, mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank and locum staff were being used to fill any deficits in staff numbers.
  • The trust had an overall elevated risk for the Hospital Standardised Mortality Ratio, which was higher than expected for weekend mortality as well as for weekday mortality. It was working with other trusts in the region and with NHS England to improve its mortality rates.

We saw several areas of outstanding practice, including:

  • Close collaborative working between the directorate of paediatrics and emergency medicine, which had developed a shared medical consultant staffing approach that included consultant staff qualified in paediatric emergency medicine.
  • The directorate of paediatrics had facilitated the inspection of the service by a team of young people.
  • The use of telehealth in maternity services. This system enabled women to monitor their blood glucose levels and blood pressure in their own homes, avoiding unnecessary visits to hospital.
  • The compassion shown to families if their family member died while on critical care. Nurses placed a locket of hair and the rings of the patient in a small silver bag, and handed a printed card to the family expressing sympathy from the staff on the critical care unit.

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

Importantly, the trust must:

  • Ensure that there are sufficient qualified, skilled and experienced nursing and medical staff, particularly on medical wards, including provision of staff out of hours, on bank holidays and at weekends.
  • Ensure that staff are suitably skilled and supported through the completion of mandatory training and appraisals, particularly in the A&E department.
  • Ensure that medicines are managed appropriately. Medicines were not always started promptly when a patient was admitted at the weekend, and controlled drugs incidents were not appropriately investigated and reported within the hospital.
  • Ensure that there is appropriate pharmacist support to ward and units, including with the reconciliation of medication.
  • Ensure that patients are placed on the most appropriate ward to meet their needs.
  • Ensure that the hospital fully complies with the four-hour wait standard in accident and emergency (A&E) and meets the standard that ambulance patients should be handed over within 15 minutes of arrival in the department.
  • Continue to review and reduce the mortality outliers for the Summary Hospital-level Mortality Indicator (SHMI) within the trust.
  • Ensure that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders are signed by the appropriate medical professionals, and that discussions with patients or family members are recorded.
  • Ensure that patient observation and monitoring charts for nutrition and hydration are fully and appropriately completed on medical wards.

However, we found that there was an area of poor practice that was a trust-wide issue resulting in a compliance action at trust level. This is reported in the trust provider report, which states:

The trust must:

  • Ensure that patient group directions (PGDs), which are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment, are updated and monitored in line with trust policy

In addition, the trust should:

  • Review the training of competency of staff who care for patients being discharged to the community with syringe drivers in place. This will ensure that patients are not taken off one piece of equipment before discharge and then connected to the other equipment used in the community.
  • Provide training on the grading of incidents and ensure that there are effective incident feedback mechanisms in place so that lessons can be learnt.
  • Review the arrangements over the storage and supply of surgical instruments to ensure that there is appropriate provision of equipment.
  • Review the storage and provision of linen in ward areas so that staff are assured that it is clean before use.
  • Review staffing in the specialist palliative care team in accordance with commissioning guidance.
  • Have in place assurance that training, supervision, appraisals and revalidation are monitored for the specialist palliative care team, who are employed by a different trust.
  • Collect and monitor information regarding patients dying in their preferred place of death.

  • Have mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatient department.
  • Introduce patient surveys specific to the outpatient department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 20 January 2015

Effective

Good

Updated 20 January 2015

Caring

Good

Updated 20 January 2015

Responsive

Requires improvement

Updated 20 January 2015

Well-led

Good

Updated 20 January 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 20 January 2015

We rated maternity services as good. The maternity department provided safe and effective care in accordance with recommended practices. Arrangements were in place to manage and monitor infection control, medicines and safeguarding procedures.

The maternity service used national evidence-based guidelines to determine the care and treatment it provided. There was a multidisciplinary approach that involved a range of providers across healthcare systems to enable services to respond to the needs of women. The service participated in national and local audits.

Resources, including equipment and staffing, were sufficient to meet the needs of women, although the ratio of midwives to women in labour was slightly lower than nationally recommended levels. Additional midwives were being recruited to address the staffing shortfalls. Medical staffing was in line national recommendations.

There were occasions where capacity interrupted the provision of services in antenatal care and access to theatre for elective caesarean sections. This meant that women experienced longer waiting times or their operations were delayed. The maternity service had carried out service reviews, and plans were in place to improve these areas.

The individual needs of women were taken into account in planning the level of support throughout their pregnancies. Feedback from women about the standard of care they received was positive.

The service was well-led. There was an open and transparent culture that encouraged reporting and learning from adverse events. Staff showed a strong commitment to patient care and treatment. There was evidence of public and staff engagement, and action had been taken following real-time feedback from women and staff. The service had been nominated for a number of awards in innovation and service improvement.

Medical care (including older people’s care)

Requires improvement

Updated 20 January 2015

Overall, we rated medical care as requiring improvement. The medical division required improvement across the ‘safe’, ‘effective’, ‘responsive’ and ‘well-led’ domains; however, ‘caring’ was found to be good.

Staffing levels did not meet those in the National Institute for Health and Care Excellence (NICE) guidance for staffing levels. The medical division was addressing some of the concerns regarding staffing levels and skill mix; staff recruitment was in progress to fill vacancies. We found that staff were very busy, and many reported doing extra hours to cover staffing shortfalls.

Medicines were not always managed appropriately. We found that medicines were not always started promptly when a patient was admitted over the weekend, due to lack of pharmacy staff at weekends. Controlled drugs incidents were not appropriately investigated and reported within the service.

Systems were in place to ensure that all people were monitored effectively; however, some documentation was poorly completed.

Care was provided in line with national best practice guidelines. The trust was identified as having mortality outliers for the Summary Hospital-level Mortality Indicator (SHMI) and the Risk-adjusted Mortality Index (RAMI) for some medical conditions. It was working with other trusts in the region and with NHS England to improve its mortality rates. There were good arrangements for multidisciplinary working within the medical division.

The hospital was meeting national waiting time targets. However, we found that bed management was not always well organised across the hospital, which meant that although patients often felt well looked after, they were not always placed on the most appropriate ward for their needs.

There were good arrangements for multidisciplinary working within the medical division.

Patients reported being treated with dignity and respect. We observed staff being polite to patients and involving them in their care.

Urgent and emergency services (A&E)

Good

Updated 20 January 2015

Overall, we rated accident and emergency (A&E) as good. A&E was good in the ‘safe’, ‘effective’, ‘caring’ and ‘well-led’ domains, however required improvement in the ‘responsive’ domain. Systems were in place for investigating incidents, learning and sharing lessons learnt. Levels of nursing staff were good.

We found that the design of the department made it difficult for staff in the ‘majors’ area to fully observe patients when the department was busy. The resuscitation area was also cramped when it was full with patients. The general design of the department also prevented a fully effective flow of patients. However, the trust was aware of these issues and is addressing them by building a new department with fully developed flows and co-located diagnostic services.

We found poor levels of compliance with mandatory training, especially among medical staff.

We found a significant amount of clinical auditing, which was complemented by auditing of performance measures. The service took part in the nationally recognised Trauma Audit & Research Network (TARN) and College of Emergency Medicine (CEM) audits.

The department used nurse practitioners in an effective way to manage minor injuries and illness, and more serious cases in the ‘majors’ area. An example of effective multidisciplinary working was the rapid assessment, interface and discharge (RAID) initiative, which had been implemented in coordination with the local mental health trust; this involved providing a 24-hour service for patients with mental health conditions.

The majority of patients told us that they found staff to be caring and compassionate. Patients told us that both medical and nursing staff fully involved them in the decision-making process.

Between 2013 and 2014 the trust had not been able to fully comply with the four-hour wait standard or to meet the standard that ambulance patients should be handed over within 15 minutes of arrival. In 2013/14 and the first quarter of 2014/15, the trust failed to meet the standard for 95% of patients to be admitted, transferred or discharged from A&E within four hours. It was evident that the trust had taken action in an attempt to address these deficiencies. These actions included improving access to mental health professionals, and creating a neurology ‘hot clinic’. However, these continuing pieces of work have not yet addressed the breaches of the four-hour or ambulance handover wait standards.

The trust had a fully developed long term strategy for creating a new A&E department, which would be ready in 2016. In addition, the July 2014 A&E performance and quality report showed that service planning was taking place in an attempt to improve the care being offered in the department.

We found good communication between management and staff. However, we found little evidence of the involvement of the public in the day-to-day running of the A&E department.

Surgery

Good

Updated 20 January 2015

We rated surgery as good.

Effective arrangements were in place for reporting patient and staff incidents.

Staffing establishments and the skill mix were regularly reviewed to maintain optimum staffing levels.

Arrangements were in place for the effective prevention and control of infection and the management of medicines. Checks were carried out on equipment in the daily checks for anaesthetic equipment. Care records were completed accurately and clearly.

Processes were in place for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs. Surgical services participated in national clinical audits and reviews to improve patient outcomes. Mortality indicators were within expected ranges.

Processes were in place to identify the learning needs of staff and opportunities for professional development. There was effective communication and collaboration between multidisciplinary teams.

We observed positive, kind and caring interactions on the wards and between staff and patients. Patients spoke positively about the standard of care they had received.

Services were available to support patients, particularly those who lacked capacity to access the services they needed.

Staff felt supported and had seen positive changes to improve patient care.

Systems were in place to plan and deliver services to meet the needs of local people. The service recognised the importance of the views of patients and the public, and mechanisms were in place to hear and act on their feedback.

Intensive/critical care

Good

Updated 20 January 2015

We rated critical care as good. The critical care service was safe, effective, caring, responsive and well-led. The ratings for each of these varied, but in terms of patient outcomes and quality of care these were particularly strong areas.

The unit had a positive safety culture, responded well to incidents and ensured that practice continually improved and developed in line with best practice guidance. The unit, with its innovative design, provided a modern environment in which to deliver intensive and high dependency care.

The effectiveness of the service was shown by the positive outcome data for patients, and the unit performed well in comparison with other similar units. The skills and expertise of the medical and nursing team were to a high standard, and all consultants were trained in intensive care medicine. The size of the nursing team had recently been increased, this had negatively affected the skill mix as there was an increased proportion of nurses who had not yet achieved competence in ICCU specialist skills.

The healthcare team was caring and compassionate, as proved through our observations and speaking with patients and relatives. Excellent support services were available for patients and relatives, and the views of patients and relatives were effectively gathered in a variety of ways.

The service was able to effectively respond to changes in service demand. This was partly due to the ability of the unit to easily flex between intensive and high dependency care provision, and the responsiveness of the staff. Delays for patients in accessing critical care were minimal, but delayed discharges from the unit to the ward were becoming an increasing problem.

The culture within the service was open and transparent and there was a tangible drive to provide the best high standards of care. Staff spoke positively about the leadership team and the open communication. Engagement with both staff and the public was good, and there were good examples of where feedback about the service had altered practice for the better.

Services for children & young people

Good

Updated 20 January 2015

We rated services for children and young people as good. In the areas of safety, effectiveness , caring, and responsive, services for children and young people were good, and in ‘well-led’ they were outstanding.

The children’s services actively monitored safety, risk and cleanliness. Nurse staffing levels did not meet nationally recognised guidelines, although this did not have a negative impact on patient care. There were challenges regarding some medical staffing levels, but these were being managed. Children’s services made improvements to care and treatment where these had been identified using programmes of assessment or in response to national guidelines. Children, young people and parents told us they received compassionate care with good emotional support. They felt they were fully informed and involved in decisions relating to the patient’s treatment and care.

We found that the children’s service provided good access to and flow within its services. This was achieved in part through close collaborative working between the directorate of paediatrics and emergency medicine, which had developed a shared medical consultant staffing approach that included consultant staff qualified in paediatric emergency medicine. We also found that the service had a range of facilities and approaches to ensure that the needs of local families were met.

The service had a clear vision and strategy and was led by a strong management team who worked together. The service regularly implemented innovative improvements with the aim of constantly improving the delivery of care for children and families. The service had facilitated the inspection of services by a team of young inspectors, which was excellent practice.

We found a positive, open and friendly culture at the service. Staff placed the child and the family at the centre of care delivery, and this was seen as a priority and everyone’s responsibility.

End of life care

Good

Updated 20 January 2015

Overall, we rated end of life care as good. Care and treatment received by patients at the end of their lives was effective, caring and well-led. Patients and relatives were happy with the care being given and found it to be caring and compassionate. Staff were well trained and supported and worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm, because policies were in place to make sure that any additional support needs were met. Staff were aware of these policies and how to follow them.

Syringe drivers used in the hospital were not compatible with those used in the community. This sometimes led to delays in treatment as not all ward staff were not trained in the community equipment used. There had been no incidents reported in relation to this.

Patients were, on the whole, protected from receiving unsafe care, because medical records were available. There was, however, some room for improvement in the standard of record keeping in relation to ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders, because some of the records reviewed were not fully completed.

The services offered were delivered in an innovative way to respond to patients’ needs and ensure that the department worked effectively and efficiently.

Outpatients

Good

Updated 20 January 2015

We rated outpatients as good. The care and treatment received by patients in the outpatient departments within the hospital was safe, effective, caring, responsive and well-led. Patients were happy with the care they received and found the service to be caring and compassionate.

Staff were well trained and supported and worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm, because policies and procedures were in place to ensure that this was managed appropriately.

Patients were given follow-up appointments when they should receive them. Staff were listened to, and patients were engaged with and their opinions actively sought.

On the whole, the services offered were delivered in an innovative way to respond to patients’ needs and ensure that the departments worked effectively and efficiently.