You are here

Royal Shrewsbury Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 August 2017

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

Royal Shrewsbury Hospital was formed in 1979 after a number of hospitals in the town were closed or merged. The hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for acute and emergency surgery, and has a trauma unit that is part of the region-wide network. It is the main centre for oncology and haematology.

This was a focused inspection, following up our inspection that took place in October 2014. At that time the hospital was rated as requires improvement overall, with caring as good.

We rated Royal Shrewsbury Hospital as requires improvement overall.

  • The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery have been lower than the England overall performance since September 2015.

  • Insufficient numbers of consultants and middle grade doctors were available.

  • Nursing staff vacancies were affecting continuity of care and an acuity tool was not used to assess staffing requirements.

  • The triage process for patients brought in by ambulance was inconsistent and unstructured.

  • Compliance with the trust target for completion of staff appraisals was below the trust target.

  • There were three Never Events relating to retained products following surgery,

  • Current safety thermometer information was not displayed on the wards

  • The maternity specific safety thermometer was not being used to measure compliance with safe quality care.

  • Inconsistencies were identified in the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist.

  • Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection.

  • Mental capacity documentation had not been completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

However, we also saw that:

  • Openness and transparency about safety was encouraged. Incident reporting was embedded among all staff, and feedback was given. Staff were aware of their role in duty of candour.

  • In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Staff were highly motivated and passionate about the care they delivered.

  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

  • Treatment was planned and delivered in line with national guidelines and best practice recommendations

  • Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order

  • It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

  • There was a clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

  • The trust had made end of life care one of its priorities in 2015/2016.

We saw several areas of outstanding practice including:

  • The trust had rolled out the Swan scheme across the trust that included a Swan bereavement suite, Swan rooms, boxes, bags and resource files for staff.

  • The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

  • Virginia Mason Institute (VMI) designed and developed its systems to become widely regarded as one of the safest hospitals in the world. The trust embraced these methodologies and in partnership with VMI, they have developed new initiatives within the hospital. They used the model to create the transforming care institute (TCI). TCI wants an effective approach to transforming healthcare by coachingteams and facilitating continuous improvement.

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

Importantly, the trust must:

  • The trust must ensure ED meets the Department of Health’s target of discharging, admitting or transferring 95% of its patients with four hours of their arrival in the department.

  • The trust must ensure all patients brought in by ambulance are promptly assessed and triaged by a registered nurse.

  • The trust must ensure a suitably qualified member of staff triages all patients, face to face, on their arrival in ED by ambulance.

  • The trust must ensure that it meets the referral to treatment time (RTT) for admitted pathways for surgery.

  • The trust must ensure there are sufficient nursing staff on duty to provide safe care for patients. A patient acuity tool should be used to assess the staffing numbers required for the dependency of the patients

  • The trust must review its medical staffing to ensure sufficient cover is provided to keep patients safe at all times.

  • The trust must ensure that all staff have an understanding of how to assess mental capacity under the Mental Capacity Act 2005 and that assessments are completed, when required.

  • The trust must ensure the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist is improved in theatres

  • The trust must ensure that up to date safety thermometer information is displayed on all wards

In addition the trust should:

  • The trust should ensure all staff received an annual appraisal.

  • The trust should consider using the maternity specific safety thermometer to measure compliance with safe quality care.

  • The trust must ensure they are preventing, detecting and controlling the spread of infections, associated in the mortuary department by ensuring surgical instruments are decontaminated to a high level and there are arrangements in place for regular deep cleaning.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 August 2017

Effective

Good

Updated 16 August 2017

Caring

Good

Updated 16 August 2017

Responsive

Requires improvement

Updated 16 August 2017

Well-led

Requires improvement

Updated 16 August 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 16 August 2017

Women told us that they felt very well cared for and the staff were caring, thoughtful and compassionate. The service was responsive to the requirements of women from the booking-in clinic and at all stages of their journey. There was a range of choices for women during labour. Women told us they felt involved with decisions in their care.

We saw that staff followed good practice with infection prevention and control. Staff were aware of how to report incidents and were encouraged to do so. We saw that staff had opportunities to learn from incidents across the service. Staff had access to and followed policies and procedures that were based on national guidance.

We saw a positive culture within the MLU with strong leadership.

Effective systems of communication were established between the consultant led unit and the MLU, ensuring that effective care and treatment could be delivered.

A full review of the maternity service was ongoing, looking at different ways to improve the service; staff were clear about their role and levels of accountability.

However, the maternity specific safety thermometer was not being used to measure compliance with safe quality care. Staff completion of some topics included in the mandatory training programme was lower than the trust target of 100%. There was no signage on the store room door containing portable Entonox to inform people that compressed gases were stored there. Woman’s notes were not always available when women arrived at the MLU in labour.

Medical care (including older people’s care)

Good

Updated 16 August 2017

Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

Infection control systems and processes were adhered to by all staff and hygiene standards were routinely monitored.

Staff planned and delivered patient’s care and treatment in line with current evidence-based guidance, standards, best practice and legislation.

Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order to continually improve patient care and outcomes.

Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately.

It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

There was clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

However,

attendance levels for mandatory training were noted to be low in most areas in medicine and compliance with the trust target for completion of staff appraisals was below the trust target.

Ward staff were being supported on most shifts by agency and bank staff. There were insufficient consultant capacity (including vacant funded posts) in acute medicine.

Urgent and emergency services (A&E)

Requires improvement

Updated 16 August 2017

  

The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

Insufficient numbers of consultants and middle grade doctors were available. Existing staff had to work additional hours to cover shortfalls in the rota.

The triage process for patients brought in by ambulance was inconsistent and unstructured, and patients were not always triaged face-to-face by a member of clinical staff. Access from the waiting room to treatment areas in the main department was not controlled.

However, incident reporting was embedded among all staff, and feedback was given when requested or deemed necessary.

In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Controlled drugs were stored in line with legislation and best practice guidelines.

Safeguarding training levels were good, and staff demonstrated a thorough understanding of the safeguarding process.

Treatment was planned and delivered in line with national guidelines and best practice recommendations.

Staff spoke very positively about the department’s managers, and told us they were supportive and approachable.

Surgery

Requires improvement

Updated 16 August 2017

Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

Infection control systems and processes were adhered to by all staff and hygiene standards were routinely monitored.

Staff planned and delivered patient’s care and treatment in line with current evidence-based guidance, standards, best practice and legislation.

Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order to continually improve patient care and outcomes.

Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately.

It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

There was clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

However,

attendance levels for mandatory training were noted to be low in most areas in medicine and compliance with the trust target for completion of staff appraisals was below the trust target.

Ward staff were being supported on most shifts by agency and bank staff. There were insufficient consultant capacity (including vacant funded posts) in acute medicine.

Intensive/critical care

Requires improvement

Updated 20 January 2015

Critical care services were found to require improvement overall. The critical care service staff were caring and compassionate and we judged that this domain was good.

There were not enough suitably skilled and experienced staff on the unit, which represented a significant risk to patients. When we highlighted the staffing shortfalls to the trust they took immediate action to ensure that sufficient and appropriate nursing staff were available to care for patients in ICU and HDU.

Critical care services were obtaining good quality outcomes, and patients received treatment that was based on national guidelines. The general capacity of beds in the hospital was a challenge. Bed capacity had also impacted on critical care services both in the availability of the beds within critical care and also delays in discharging patients to other wards.

The trust had two small critical care units and found it difficult to ensure that sufficient and suitably experienced medical and nursing staff for both units were available. There are plans to review the critical care services that are provided by the trust to ensure that safe and effective care and treatment are provided.

Improvements were required to the leadership of the critical care services, to ensure that the management responded appropriately to staff and that the service provided met national core standards.

Services for children & young people

Good

Updated 20 January 2015

Services for children and young people were found to be good. Children received good care from dedicated, caring and well-trained staff who were skilled in working and communicating with children, young people and their families.

The trust had robust arrangements in place to monitor incidents and staff were clear on their responsibilities relating to this. Children who were seriously ill were appropriately escalated for specialised care and this might involve transfer to Princess Royal Hospital at Telford.

Staff were up to date with mandatory training and robust governance arrangements were in place for children and young people’s services and staff were clear on their roles and responsibilities. Staff felt valued and had clear lines of communication through the trust. Staff felt confident in raising concerns and felt listened to regarding ideas to improve services

End of life care

Requires improvement

Updated 16 August 2017

End of life care (EoLC) patients were not always asked where they wanted to be cared for in their last days. There was no specific data on how many people had died in their preferred location or how quick discharge took place for end of life care patients. Not all risks evident in EoLC were recorded on the trusts risk register. Staff were highly motivated and passionate in providing EoLC and that there was a drive for change and improvement of EoLC services at the hospital. There was evidence of good working relationships across all areas of EoLC and staff felt supported by their immediate managers.

Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection. Infection prevention training was not part of mandatory training for mortuary staff and there were no arrangements for the regular deep cleaning of the mortuary environment.

Mental capacity documentation had not been always completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

Staff from the palliative care and EoLC team were not up to date with mandatory training.

However,

The trust had made EoLC one of its priorities in 2015/2016. Staff at all levels and from all departments understood the importance of a dignified death. There was evidence that learning around EoLC was being shared with staff within the trust.

The trust had rolled out the Swan scheme across the hospital, providing resources for staff and practical measures for patients and families that included Swan boxes, bags and end of life information files for staff. A new bereavement suite and three Swan Rooms for EoLC patients were also part of the scheme at the Royal Shrewsbury Hospital. The mortuary department recently had a major refurbishment and was fit for purpose.

Patients had their needs assessed and their care planned in line with evidence-based guidance, standards and best practice. The trust took part in the national end of life care audit. The trust had taken a number of actions in response to the audit. Staff from the palliative care team attended regular multidisciplinary team meetings in specialist areas.

The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an EoLC patient.

Outpatients

Good

Updated 20 January 2015

Overall we rated this service as good. Outpatients and diagnostic imaging services were safe. The trust had prioritised statutory training, but refresher mandatory training had not been completed by the majority of staff. Mandatory training was provided at the trust’s discretion and to ensure compliance with local standards and policies. This meant that the trust could not be confident that staff were following the most recent advice and guidance.

We saw good practice and effective, compassionate care. Patients were very complimentary about all the staff they had come into contact with. Staff were observed to be caring and compassionate in the way they dealt with patients and their families or carers. They were knowledgeable and enthusiastic about the service they provided and this was reflected in how they engaged with people.

We saw good practice and some innovative working and interpretation of NICE guidance to the benefit of patients and the trust. Services were managed well at a local level; appraisals and supervision of practice were completed. Meetings took place between staff and managers. Staff felt supported and they told us they respected their managers.