All inspections: The Royal Orthopaedic Hospital

During our inspection, we inspected surgery and critical care. We did not inspect medical care, services for children and young people or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

Our rating of services stayed the same. We rated it them as good because:

Our rating for safe remained good overall. The service addressed the improvements we suggested in our last inspection. It had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. However, staff did not always have training in key skills including all required levels of safeguarding training.
Our rating for effective remained good overall. Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Our rating for caring remained good overall. Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
Our rating for responsive remained good overall. The service planned care to meet the needs of local people and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment. However, the environment had not been adapted to meet the needs of patients living with dementia.
Our rating for well led remained good overall. Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually

Our rating of services improved. We rated it them as good because:

There were sufficient numbers of nursing staff with the right qualifications, skills, training and experience to provide the right care and treatment in all the areas we visited.
Staff understood and fulfilled their responsibility to raise concerns and report incidents.
We saw excellent multi-disciplinary working across the hospital that was respectful and professional. There was a team work culture.
Staff were consistently kind, caring and respectful towards patients and their relatives. Feedback from patients confirmed that staff treated them with compassion.
Staff in all areas clearly understood how to protect patients from abuse. We saw improved staff awareness and promotion of safeguarding displays around the hospital since our last inspection.
Dementia and learning disability care had significantly improved since our last inspection.
Concerns and complaints were taken seriously, investigated appropriately and lessons were learnt from the results, which were shared with staff.
A positive culture was promoted by leaders at all levels and staff understood how they contributed to the trust values.
We found local leadership to be knowledgeable about issues and priorities for the quality and sustainability for their services, and had a good understanding of the challenges they faced. We saw they were responding to address these challenges and this work was ongoing.
Despite the suspension national referral to treatment target (RTT) reporting in June 2017, we saw honest and transparent action to address breaches during the previous 12 months. The trust took swift action and sought stakeholder support and was meeting the planned trajectory to meet the target.
The ROCS team had a positive impact on length of stay for patients requiring long-term intravenous therapy. Patients who were assessed as not requiring a hospital bed received their intravenous therapy at home.
The trust was in the process of quality improvement projects such as ‘perfecting pathways’ to improve patient care. These projects were encouraging staff to be innovative in their own departments to effect change and improvement.
The trust’s research and development team was proactive in research trials and used advanced clinical technology to improve the outcomes for patients with bone tumours and soft tissue sarcomas. We saw examples of patients offered less invasive procedures based on innovative research findings.

However:

We found in both medical care and outpatients that there was a lack of shared learning when things went wrong. Some staff were not aware of the term ‘never event’ despite the trust in 2016 having three surgical never events. Understanding of the term duty of candour varied across the trust despite the provision of training.
The trust used several IT systems that did not interface with each other which meant that there was duplication of information and extra workload for staff. Not all staff had the required access for all systems and many staff we spoke with were frustrated with the different systems to record patient information which could cause delays.
The trust faced data quality issues and was in the process of identifying and rectifying outdated databases to ensure robust and accurate data management.
Staff were not knowledgeable or confident in providing care to patients detained under the Mental Health Act. There was a lack of supporting information, policies and guidance for staff to follow to ensure patients additional mental health needs were met.
The Bone Infection Unit had the potential to be an outstanding service however, there was a lack of strategy, outcome monitoring and service evaluation and therefore could not demonstrate service effectiveness.
The electronic staff record did not hold latest compliance data which meant local managers kept local records additionally to this causing extra work and therefore the system ineffective. Training data was not provided to us to demonstrate compliance rates for individual modules.
Not all staff had access to additional education to support their roles for example specialist oncology training and mentorship training.
Interpretation services to provide language support to patients who required it was not consistently used across all services.
Patient records were not consistently secure within the outpatients department.
Despite significant improvement work to address patient wait times in outpatients, we observed long patient waits, cancelled appointments and overbooked clinics. This was a concern in our previous inspection.

We undertook this unannounced inspection on 20th July 2016 which was a focused inspection of the high dependency unit (HDU) specifically looking at paediatric care.

We last inspected The Royal Orthopaedic Hospital in July 2015 when we conducted a focused follow up inspection of HDU (as part of the critical care core service) and the outpatients department (OPD). This was because we identified concerns in 2014 with one of the five questions in each area rated as inadequate.

Following the focused inspection in July 2015, we saw improvements in HDU however; we rated the service as requires improvement. The ratings remained the same for HDU as in 2014; however, the issues identified were different and had an impact across the five domains.

There were significant concerns specifically the care of children at the trust including paediatric nursing and medical cover and the HDU environment. We therefore told the trust they must take action to improve both of these areas of concern. Other areas of concern that the trust were required to act upon included contribution of data to Intensive Care National Audit and Research Centre (ICNARC) or similar, to benchmark the service against other similar hospitals, to address the HDU toilet facilities so that they are single sex and can accommodate children and multi-disciplinary ward rounds and handovers should take place.

In view of the paediatric care concerns identified, during a meeting with a Deputy Chief Inspector, it was agreed that the trust commission a review by the Royal College of Paediatrics and Child Health (RCPCH) of their paediatric service. The trust accepted this and the review took place in March 2016 with the report following in June 2016.

The report described many recommendations with some serious concerns relating to non-compliance with national professional guidance. Of greatest concern were the continued absence of paediatrician support and the governance processes relating to activity involving children and young people.

Since the publication of the 2015 report, the trust has put a comprehensive action plan in place to address the issues identified. This action plan is ongoing with several actions outstanding.

The reason for this focused inspection was following receipt of the RCPCH report and action plan from the trust on 21st June 2016, which raised some concerns with us. Our concerns related to the action plan, to address all the areas of improvement required which were extensive. We decided we needed to visit on-site to better understand how the trust was going to address the recommendations and make timely improvements.

In view of the focused inspection with the aim to gain assurance of paediatric care in HDU only, we did not rate this service.

We spoke with 22 staff in total including nursing and medical staff, local and senior management. We visited HDU and the governance department but also spoke to nursing staff who worked on the children’s ward (ward 11).

Our key findings were as follows:

The trust had made improvements with paediatric nursing cover with plans to increase provision in line with national guidance.
Medical cover remained a concern as identified both CQC and the RCPCH; however, the escalation process for the deteriorating child had been strengthened.
We found a printing error on the Paediatric Early Warning Score (PEWS) chart.Regular staff did not follow the printed advice so children were not at risk. However new or temporary staff may have used the form as printed and this could put children at risk.
The trust did not have a fully realised children’s strategy to achieve the vision or a senior leader with paediatric experience. Plans were in place to address these.
The main door into HDU was broken and had been an issue for some time. This was both a security risk and at times prevented staff from entering with their security passes.
Governance processes around care of the child require improvement in particular, incident reporting and exposure at quality and safety meetings.
We observed poor hand hygiene on HDU, with clinical staff entering the unit failing to wash their hands or use hand gel.
The manager of HDU was new to post within the two weeks prior to our inspection.
Staff were welcoming of the changes to paediatric care and felt improvements were necessary.
Some improvements we saw since the July 2015 inspection related to medicines safety, and environmental plans for HDU.

The trust should:

Act upon the recommendations of the RCPCH to develop and implement policies in a timely manner.
Implement a fit for purpose PEWS chart immediately to detect the deteriorating child.

Please note the requirement notices served in the report published December 2015 still apply and the trust is still working on the action plan associated with them.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We undertook this inspection 28 and 29 July 2015 as a focused follow-up to an inspection we completed in June 2014. At that inspection the core services of Critical Care, which was a High Dependency Unit (HDU) at this trust and Outpatients Department (OPD) both had an Inadequate rating in one domain. This was within Safe for HDU and Responsive for OPD. Both services were rated as Requires Improvement overall. The trust received a follow-up inspection of those services to provide assurance that improvements had been made. Although diagnostics and imaging forms part of the OPD inspection the main issues had been in OPD, therefore the focus of this report was there. The inspection took place at this trust’s one site which has the same name as the trust.

At the end of 2014 there were some issues relating to staff and medications, which the trust shared with us at the time. This resulted in some changes in staffing in governance and a wholesale review and change of processes regarding controlled medication. For this reason a pharmacist inspector joined the inspection team. We wanted to review the governance and the controlled medication processes. We received some whistle-blower allegations prior and during the inspection which we also had an opportunity to review within the remit of this inspection.

A further visit was arranged to view documents relating to Duty of Candour (Regulation 20). During that visit on the 05 August we visited OPD, X-ray waiting area, and the previously private ward.

At this inspection the two core services were rated as Required Improvement. However, we did see improvements in both core services. We noted that the trust responded to our concerns raised at the previous inspection, but we found that other issues impacted on their ability to meet the regulations. This has been reflected in the ratings.

Within HDU all the ratings remained the same as the previous inspection. Although the issues identified were different this time they had a significant impact across a number of domains.

Within OPD the result for safe remained the same. The responsive domain had improved from inadequate to requires improvement. This demonstrated that the trust had worked hard to improve the services for people and where the rating is requires improvement there is still some improvement work to be done. We have recognised within the reports that the trust has identified work streams to address the on-going improvement work. As part of the improvement work within OPD the trust had upgraded the patient administration system, to ensure it was compatible with the planned management information system due winter 2015.

Our key findings were as follows:

Staffing of HDU with regards to children was not suitable. We found that children were being cared for within the unit but not always by a paediatric trained member of staff, nor were the facilities suitable for children.
Within both core services we found that infection control practices were well embedded, and staff followed trust policy and procedures.
We found that although the trust and its staff worked to the essence of the regulations of the Duty of Candour, in being open and transparent when things went wrong, they did not meet all of the requirements of that regulation.
Multi-disciplinary working was effective in improving patient experience within the hospital.
100% of staff in both core services had received their appraisals, which was higher than the hospital’s overall rate.

We saw several areas of outstanding practice including:

The unit manager had ensured that staff were both aware and understood the values of the trust. A post box had been put on the unit to enable staff to identify what the values meant to them in their work on HDU. Staff views on the values displayed on a noticeboard and had also been discussed during staff meetings.
Within Outpatients we observed that some clinicians were dictating letters to GP’s and other services onto an electronic system for same day delivery, in the presence of the patient before the patient left the clinic.

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

Safeguarding training compliance rate needed to be improved in OPD, for both adults and children only reaching the trust target for awareness training.

Privacy and dignity was compromised with the unacceptable arrangements regarding the toilet and washing facilities available for patients in HDU. There was only one toilet available for patients (adults and children, staff and visitors).
The trust needed to ensure it could upload the information in the Intensive Care National Audit & Research Centre, so it could be benchmarked against other similar trusts.
Within OPD management reports needed to be available to monitor clinic wait times and cancellations. There needed to be an agreed process which all staff followed in the event of a clinic being cancelled.

We were very concerned about care of children in the HDU, therefore have followed our processes to ensure that the trust takes appropriate action to improve the situation we found at inspection. Our specific concerns relate to:

Medical and nursing cover must be improved on HDU when children are accommodated.
Children must be cared for in an appropriate environment when requiring HDU care.

Importantly, the trust must:

The trust must improve local leaders’ understanding of the processes involved in exercising the duty of candour, in particular what they should expect beyond ward level and at a practical level, including record keeping.
The trust must ensure sufficient staff are trained in safeguarding adults and children in OPD.
The trust must improve the flow through the OPD so patients are not kept waiting for appointments.
The trust must embed management arrangements within the OPD to ensure a firmer grip on the process of clinic booking and patient flow to improve waiting times for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Royal Orthopaedic Hospital NHS Foundation Trust is a small, specialist teaching hospital offering planned orthopaedic surgery with 135 beds. The trust provides services to the city of Birmingham with a population of around 1,073,045 and nationally from Cornwall to Scotland. Patient care is delivered by specialist teams and other clinical professionals who look after patients with bone and joint disorders. The trust provides services such as joint replacement, spinal work and bone tumour treatment, as well as orthopaedic and oncology treatment to children under 16.

The trust became a foundation trust in 2007 and there have been significant changes to the senior management team and board in the last 12 months, including a new chair and chief executive.

We carried out this comprehensive inspection because The Royal Orthopaedic Hospital NHS Foundation Trust was selected for inspection as an example of a specialist trust, to enable us to pilot a slightly modified inspection methodology. We carried out an announced inspection of The Royal Orthopaedic Hospital on 4 and 5 June 2014 and an unannounced visit on 24 June 2014. The Royal Orthopaedic Hospital is the trust’s only location.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing effective and caring services, but it required improvement for the services to be safe, responsive and well-led. We rated the core services of medical care, surgery and children and young people’s services as ‘good’ and critical care and outpatient services as ‘requires improvement’.

Our key findings were as follows:

Staff were caring and compassionate and treated patients with dignity and respect.
Staff followed good infection control practices. The hospital was clean and well maintained and infection control rates in the hospital were low.
Patients’ experiences of care were good and the NHS Friends and Family Test (FFT) results were higher than the national average for all areas. However, people attending for outpatient appointments rarely, if ever, saw the medical staff at their appointed time.
The number of pressure ulcers, falls and catheter related infections was significantly lower than the England average. The hospital monitored harm-free care in all patient areas, except recently in HDU, and had taken action that was reducing these avoidable harms.
Medicines were being safely stored and managed in the wards. However, in the outpatient department (OPD) there were concerns relating to the storage and stock control of controlled drugs, where legal requirements were not met.
Incidents were reported but not all staff received feedback; nor were lessons learned widely shared across the services.
The high dependency unit (HDU) did not have equipment available to support a deteriorating patient for up to 24 hours or until transfer to another provider’s Intensive Care Unit (ICU) was arranged. The trust addressed this immediately and equipment was on site and available within 24 hours of the issue being escalated.
Ward rounds in the HDU were not routinely undertaken by the on-call consultant anaesthetists at weekends. The trust took action within 24 hours of the information being escalated, although it was noted that senior managers had been aware of this for some time.
Several senior posts were being covered by interim managers. Recruitment had been ongoing and we saw that external candidates had been appointed to several of the posts and were scheduled to start work in the near future.

We saw several areas of outstanding practice including:

The Royal Orthopaedic Community Service provided services within a 24.5 mile radius of the hospital to support the early discharge of patients from hospital.
The trust had established patient pre-assessment clinics for surgery, which were available at the same time as their OPD appointment.
Outreach clinics were held by the ortho-oncologists in Leeds, Sheffield, Manchester, Liverpool, Bristol and Cardiff to improve patient access and avoid patients and relatives or carers having to travel long distances.
The trust provided pioneering treatments to patients with very complex orthopaedic conditions. Surgeons were using silver coated implants to reduce infection. Other treatments achieving outstanding outcomes for patients included the ITAP implant to attach prosthetic limbs and the use of motorised extendable implants for children and young people.
Surgeons were using computer navigation based on importing CT/MRI scans to develop a 3D model to remove tumours of the pelvis to ensure maximum removal and clear margins to reduce incidence of reoccurrence from 25% to 10%.

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

Importantly, the trust must ensure:

Medicines are managed at all times in line with legal requirements.
Equipment is properly checked and maintained in accordance with electrical safety requirements.
A chaperone policy is developed and chaperones made available to support patients’ privacy and dignity.
Confidential patient information and records are not left unsupervised in unrestricted public areas of the outpatients department.
Appointments are organised for all clinics to reduce waiting times for patients and improve their experience in the outpatients department.
Letters to GPs and other referring bodies are sent out within set timescales to ensure effective communication.

In addition the trust should ensure:

Resuscitation equipment is checked in accordance with the trust’s procedures and records of the checks are kept.
There is managerial oversight of all outpatient department services to ensure the efficient and effective operation of the department and to ensure patients’ experiences of care are improved.
Discharge arrangements are improved to facilitate early identification and availability of beds for patients admitted on the day of surgery.
The implementation of the Enhanced Recovery Programmes to reduce patient length of stay in hospital and promote patients’ involvement in their care.
When the reception desk is closed, there is visible signage to direct patients and visitors from the main entrance to other departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

To conduct this inspection we spoke to 34 people and 39 staff. We reviewed care documents and other documents provided by the trust.

People received care and treatment which met their needs. We found that assessments and planning of care was appropriate to people's needs. Treatment plans were followed and delivered. Risks were identified and actions were put in place to minimise them. Regular monitoring of people's conditions was undertaken and changes in care were delivered meaning the care was responsive.

The level of patient information and education was good. Most people had a good understanding of their treatment and what actions they needed to undertake to improve their health outcomes. Arrangements in place for people who needed interpreters were not robust and meant that interpreters were not always available when needed. People did make positive comments about care they received, and included: 'Staff very caring, they treat me with respect' and 'I'm very, very pleased with the service I've received on this and other visits.'

Vulnerable children and people were safeguarded by the arrangements in place within the trust. Staff understood their responsibilities and received training in recognising and reporting suspected abuse. The safeguarding team had undertaken activities to raise awareness about recognising and reporting concerns not only amongst the staff but amongst visitors to the trust.

The trust supported staff to improve their skills and qualifications. Induction and mandatory training was offered to all staff to support their skills within their specialist areas. Staff had opportunities to receive support from their line managers.

The trust undertook auditing and monitoring activities to identify any issues and to improve the service offered. Feedback was sought by the trust from people using the service and staff to inform their monitoring activities. We found that complaints and comments made were taken seriously and investigated with the findings and feedback shared with the complainant. Root cause analysis was undertaken to understand why incidents had taken place so that any learning could be shared with staff to prevent similar incidents or reoccurrence.

Information was shared about the performance of the hospital at unit meetings on a regular basis. Staff were given opportunities to make suggestions about how changes which could result in improved services for people.

This inspection was completed by a pharmacy inspector. The purpose of the inspection was to follow up on the concerns raised at the inspection on the 11 December 2012 regarding the management of medicines. We found that the Trust had carried out the necessary improvements and we found procedures were in place to reduce the risk associated with the management of medicines.

The inspection was led by one of five CQC inspectors and included a pharmacy inspector. During our inspection we spoke with a total of eleven people who were using the service and four relatives. We looked at the care and treatment that people were receiving within: Theatres, the High Dependency Unit, Ward One and on Ward 11 (children's ward) and the discharge lounge. We spoke with staff who covered a range of different roles.

The majority of feedback we received was positive about the care and treatment people had received. One person told us, 'You hear such horrible stories about hospitals but I cannot fault them here.' We noted that in some instances care records did not always contain adequate information about people's care needs.

People told us they had given consent where it was applicable and that the information they were given was detailed and that staff explained everything to them. Parents of children receiving treatment advised that explanations about treatment were given to children by staff and that this had assisted in reducing anxieties of their children. There were usually enough qualified, skilled and experienced staff to meet people's needs.

People said they would be happy to raise any concerns they had with staff.

We found that the systems for managing medicines were not sufficiently robust. Action was needed to ensure care and treatment was always planned or delivered in a way that ensured people's safety.

The focus of our site visit was in the theatre and recovery departments. This followed a number of serious incidents, including two never events that had occurred in the operating theatres. Never events are serious, largely preventable patient safety incidents that should not occur if the available controls and checks have been completed.

We visited most of the theatres and the recovery areas in the theatre department. We also spent time following patients from the wards into theatre and looked at the medicines arrangements for patients being discharged. During our time on site, we talked to staff and reviewed a range of trust records and records of care for people who use services. We were able to speak with four patients in the high dependency unit and the discharge lounge. During our visit to the theatre department and recovery areas, we were unable to speak with many patients as they were still sleepy following their surgery. We were able to speak with one patient who told us "They are fantastic", "They explain things very well", and "I can't praise them enough."

During this review, we had discussions with local health commissioners, who shared our concerns about the quality and safety of care. A separate visit to ward areas at the hospital was completed by commissioners. They reviewed two of the wards. Overall, they found that there were good standards of care in these areas.

People we spoke to were mostly positive about their experiences of care and treatment on both wards. They told us that they were treated with respect. People we spoke to said they had no concerns or complaints about their care or treatment at the hospital.

People stated that they were kept informed and were involved in making decisions about treatment options. One person told us ' I have been kept fully informed of all aspects of my treatment including what will happen on my discharge'.

The majority of people spoken with told us that staff always came when they needed them. One person told us ' There are no problems with waiting, staff respond promptly'.

Most people told us that they were happy with the food they received. Some people told us that they hadn't been asked what their food likes or dislikes were but that there was an adequate choice of meals.

Comments from people included 'There's enough choice, the meal today was nice' and 'Food is nice and plated on proper plates not plastic ones'.

People told us that meal times were unhurried and quiet and staff make sure visitors leave the ward during the meal time.

The Royal Orthopaedic Hospital

All Inspections

15 Oct to 17 Oct, 12 Nov 2019

During a routine inspection

23 January 2018

During a routine inspection

20/07/2016

During an inspection looking at part of the service

Professor Sir Mike Richards

28-29 July and 05 August 2015

During an inspection looking at part of the service

Professor Sir Mike Richards

4, 5 and 24 June 2014

During a routine inspection

Professor Sir Mike Richards

14, 15, 17 January 2014

During a routine inspection

4 June 2013

During an inspection looking at part of the service

11 December 2012

During a routine inspection

1 December 2011

During an inspection in response to concerns

25 May 2011 and 18 September 2012

During a themed inspection looking at Dignity and Nutrition