All inspections: The Rotherham NHS Foundation Trust

The leadership of the trust had significantly improved since our last inspection in 2018 but this was not yet enough to make an impact on the rating. Staff including the trust chair, who we interviewed at the last inspection, were overall very positive about the changes in leadership. Members of the board articulated they felt much more enabled, supported, listened to and empowered to undertake their roles than previously.

The leadership team led by the new CEO and chair had identified that the trust needed to develop their own plans to improve the people of Rotherham’s experience of services and this was a message we heard consistently throughout our inspection.

The trust had recognised that there was a need, because of the changes within the healthcare system, the impact of COVID-19 and the changes in the trust itself over recent years, to update and refresh the vision and strategy and hoped to take this to board in September 2021. The CEO articulated a clear vision of what the trust wanted to achieve. A new strategy was being developed with input from the wider system and local staff about how this was going to be achieved.

It was recognised by the board there had been challenges regarding the trust's organisational culture over the last few years. To address this, targeted and focused work had been undertaken with the board and executive team, including input from facilitators to identify issues to establish open and honest strong working relationships.

The trust had made good progress in strengthening its operational financial management and governance arrangements but there was further work needed to understand the scale of any underlying deficit supported by a credible analysis of the key drivers.

Whilst the improvements in leadership and culture were evident since our previous inspection, the trust recognised more work needed to be done to embed service improvements and for these changes to be reflected in positive patient outcomes.

When inspecting the core services at the trust we saw that some of the changes that had happened at a senior level in the organisation had not yet become embedded at ward/department level. There continued to be a slow progress in some areas against our previous inspection findings particularly in urgent and emergency care and medicine. All divisions had a triumvirate management team in place, however, not all posts were fully recruited to support this. Additional posts had only very recently been recruited to, such as quality improvement matrons and the deputy director of quality assurance.

The trust promoted equality and diversity in daily work and mainly provided opportunities for career development. However, the trust currently had no formal staff networks.

The aim of the trust was to work within the system and create partnerships with the local community as well as accessing NHS support to establish the trust as a supportive, diverse and inclusive employer for all the Rotherham community.

A significant level work had been done within the trust to improve the governance. Several initiatives had been put in place to improve governance at the trust. Including 'Safe and Sound', 'Perfect Ward' and the employment of quality improvement matrons.

The arrangements for some areas of governance were very new and at the time of the inspection it was not possible to fully evidence their effectiveness and the impact these changes would have. In some core services not all staff were clear about their roles and accountabilities and processes were not always completed in a timely manner. However, plans had been put in place to create the conditions and structures for effective governance in the trust.

Medicines optimisation within the trust required further development. The trust medicines optimisation strategy was out of date and had not been reviewed or renewed from April 2020. The trust did not have a pharmacy business plan, workforce plan or strategy specific to the pharmacy team. Medicines reconciliation rates within 24 hours consistently fell below the national average. There was no seven-day clinical pharmacy service. Multidisciplinary attendance at key medicines committees was not always in place with two out of the last four meetings not meeting quoracy.

Work was underway to embed the medicines safety officer role into trust governance processes. The controlled drug accountable officer role required further embedding and oversight to ensure that governance arrangements highlighted and took action on areas of concern found during the core service inspection. This was still an issue when we revisited during our well-led inspection.

We raised our concerns during our inspection and following the inspection, the trust provided an action plan which aimed to review medicines management, oversight, audit and governance processes within the trust.

Leaders and teams identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. However, systems to manage performance effectively were not always implemented.

In interviews with members of the Executive and Senior Leaders team people were all clear about the trust's risks and articulated a coherent consistent narrative. These included mortality, medical and nursing staffing and Child Adolescent Mental Health (CAMH) services.

However, the performance dashboard used in core services were at a high level and did not focus on the detail of quality or highlight specific concerns about patient care. Also, we were not assured in all core services that senior leaders had enough oversight of performance targets which could have a negative impact on patients' care and experience of services.

Information and data overall were well managed across the trust. New systems had been developed to improve patient outcomes such as 'Perfect Ward', these were introduced in a phased way and learning taken at each stage to improve the system. However, we did see instances on wards and departments where patient information was not stored securely.

Leaders and staff actively and openly engaged with patients', staff, the public and local organisations to plan and manage services. They collaborated with partner organisations and operated a system approach to help improve services for patients'.

The trust provided evidence of continued engagement with patient groups despite the pandemic and acted on their feedback.

The trust were committed to continually learning and improving services. Quality improvement methods had been introduced and staff understood the skills needed to use them, but these improvements were not fully embedded in all areas at the time of the inspection.

The Rotherham NHS Foundation Trust was awarded foundation status in 2005 and provides a wide range of acute and community health services to the people of Rotherham (population approximately 261,000). The trust provides the full range of services expected of a district general hospital including urgent and emergency care, maternity, paediatrics, surgery, medicine, critical care and community services for both children and adults.

Previous reports relating to this trust can be found here: https://www.cqc.org.uk/provider/RFR

We carried out a focused inspection at The Rotherham NHS Foundation Trust on 7- 10 July 2020 to review the processes, procedures and practices for safeguarding children and young people. We looked at parts of the safe and well-led domains.

We did not rate services because this was a focused, short notice inspection in response to specific areas of concern. We inspected safeguarding processes in community services for children and young people and in urgent and emergency care, the children’s ward and children’s assessment unit, and maternity services. We also looked at the wider oversight and management of safeguarding children and young people across the trust.

Following our inspection, we put our concerns formally in writing to the trust and asked that urgent actions be put in place to mitigate the risks to children and young people.

The trust provided a detailed response including improvement actions already taken or planned, all actions were due for completion by November 2020. This provided assurance that sufficient action had been taken to mitigate any immediate risks to patient safety. We will continue to monitor this information through our routine engagement with the trust.

We found:

Staff understood how to protect patients from abuse. Most, but not all staff had training on how to recognise and report abuse and they knew how to apply it, but the systems and processes they used made this difficult.
Leaders did not operate effective governance processes throughout the service and with partner organisations. Staff did not always take opportunities to meet, discuss and learn from the performance of the service.

Our rating of the trust stayed the same. We rated it as requires improvement because:

We rated safe, effective and well-led as requires improvement, and rated caring and responsive as good. All ratings were the same as the previous inspection except for responsive, which had improved one rating.
Rotherham General Hospital was rated as requires improvement overall. Safe, effective, responsive and well-led remained as requires improvement and caring remained good.
Community Healthcare Services remained as requires improvement overall. We inspected one core service (community healthcare services for children and young people) at this inspection and the overall ratings for effective and well-led remained as requires improvement while safe, caring and responsive remained as good.
The trust was rated as requires improvement overall at its first comprehensive CQC inspection in July 2015. The outcome from a second inspection in March 2017 produced the same overall rating and the trust continued this trend. Issues we identified at previous inspections, such as culture, mandatory training compliance, staffing and high caseloads for practitioners in the 0-19 service had demonstrated the trust had not fully addressed ongoing concerns. There was evidence of some progress and the trust recognised further improvement was required.
In addition, we also undertook a focussed unannounced inspection in July 2018 and found that appropriate and timely action had not been taken to address the immediate concerns.

Our rating of this service stayed the same. We rated it as requires improvement because:

At our last inspection we rated safe, effective, responsive and well led as requires improvement. Caring was rated as good.
At this inspection we rated safe, effective and well led as requires improvement. Caring and responsive were rated as good.
Practitioners in the 0-19 service were holding high caseloads. There was a risk that records were not contemporaneous as high workloads meant that some practitioners were not completing their records in a timely manner. These issues had also been identified at our last inspection.
There was no oversight of safeguarding referrals and in the sexual health service there were no safeguarding alerts on the electronic patient record. This meant that children and young people’s records may not be complete and staff may not be immediately aware of a vulnerable child.
The 0-19 service were failing to meet some of their performance targets. Antenatal contacts, six to eight week contacts and health screening at school entry were all below target. This had been a concern at our last inspection.
There was a limited number of audits in place and there was no audit plan.
There was no process in place for regular clinical supervision and staff had varying experiences of receiving clinical supervision. This had been identified at our last inspection.
Looked after children were not receiving initial health needs assessments in a timely manner.
There had been a slow pace of change since moving to a 0-19 team and changes were not fully embedded. Staff were still working as separate health visiting and school nursing teams. Several changes in the management team meant that changes had not been driven forward. The service was moving to skill mix teams and competencies were written for the different staff bands, however, at the time of our inspection these competencies were not yet in place.

However;

The new service leads were aware of the challenges to the service and there was a work plan in place for 2018/2019. The work plan incorporated workstreams including audit and clinical supervision. The service was working closely with the clinical commissioning group and the local authority to plan and deliver services.
Staff were kind and caring. Their focus was on supporting children, young people and their families. There was effective multidisciplinary working, both internally and externally.
New services, such as the paediatric acute rapid response outreach team (PARROT) had been set up to support unwell children in the home and avoid hospital admissions.
The service had a vision and strategy and there were governance systems in place.
The service provided care based on evidence based guidance and staff had access to up to date policies and guidance.
Learning from incidents and complaints were shared at staff meetings. Presentations from the meetings were shared with staff. Service leads were attempting to engage with staff to keep them up to date with service development.

We carried out a focused follow-up inspection between 27 and 30 September 2016 to confirm whether The Rotherham NHS Foundation Trust had made improvements to its services since our last comprehensive inspection in February 2015. We also undertook an unannounced inspection on 12 October 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected the trust in February 2015, we rated the service as requires improvement. We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good.

There were fourteen breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and 2014. These were in relation to the safety and suitability of premises, staffing, supporting staff, records, consent to care and treatment, complaints, care and welfare of people who use services, dignity and respect, need for consent, cleanliness and infection control, management of medicines, safeguarding people who use services from abuse and assessing and monitoring the quality of service provision.

The trust sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation. At this inspection, we checked whether these actions had been completed. We inspected the services at the Rotherham General Hospital, community inpatients at Oakwood Community Unit and Breathing Space, children’s and adult’s community services and community end of life care. We did not inspect dental services provided by the trust as these were rated as good at the previous inspection.

We found that the trust had made considerable improvements. However, there remained areas that required further improvement. The Rotherham NHS Foundation Trust overall rating of requires improvement remains unchanged. At this inspection we found:

The trust had not taken sufficient action raised in the 2015 inspection to ensure DNACPR forms and mental capacity decisions were documented in line with trust policy, national guidance and legislation. We wrote to the trust immediately following our inspection to ensure that action was taken promptly regarding the DNACPR forms and mental capacity decisions. The trust initiated a number of actions, which we will continue to monitor.
Staff understanding and application of the Mental Capacity Act 2015 was inconsistent across most of the services inspected.
There were concerns about the current pharmacy service and the impact on patient care. We wrote to the trust immediately following our inspection to ensure that action was taken promptly regarding the management of discharge medications and service provision. The trust initiated a number of actions, which we will continue to monitor.
Access to safeguarding supervision was a concern and was in the process of being addressed.
Staffing levels in the children’s ward and maternity had improved since the previous inspection. However, there remained staffing shortages most notably in the Emergency Department, school nursing and medical wards. There was a high use of medical locum staff in some specialties.
Some policies and guidelines were out of date and there was a backlog of incidents in maternity services that had not been reviewed.
Audit plans were behind schedule within children’s services.
There were some environmental concerns at the time of inspection; the fire escape on critical care was not appropriate and there were some remaining ligature risks on the children’s ward. The trust took immediate action to address these following our inspection.
Risk registers were in place, but did not always reflect the risks identified on inspection.
The hospital reported no cases of hospital acquired MRSA bacteraemia, 16 cases of C.difficile and nine of MSSA bacteraemia between July 2015 and June 2016. The number of cases of C.difficile and MSSA per 10,000 beds has been mostly below (better than) the England average. However, on medical wards, there were some concerns about infection control practices and facilities in the refurbished areas.
There were areas of notable improvement since the previous inspection. These included safeguarding training and awareness, improvements to the short-break service, access to sexual health records and improvements to training data.
There had also been improvements in ensuring there were no mixed sex breaches, wherever possible and actions had been implemented to minimise these.
We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options and were supported to eat and drink.
There were no mortality outliers identified at the trust.

We saw several areas of outstanding practice including:

The trust was piloting a new community model of care called the perfect locality. This multiagency /multidisciplinary team approach focused on implementing measures to avoid hospital admissions and facilitate safe discharge of patients already in hospital.
BreathingSpace remains the only entirely nurse-led model of care for respiratory inpatients and outpatients in Europe. We found that the culture, care and philosophy of the unit were outstanding.
The activities coordinator at Oakwood Community Unit had been employed by the trust and had developed a range of activities including arts and craft, bingo, board games and a monthly themed tea party.

The trust staff had direct access to electronic information held by community services through the SEPIA portal, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicines and community services involvement in their care.
Safeguarding and liaison had a daily meeting with the Emergency Department to identify any safeguarding issues and concerns.
All patients with mental health needs admitted to the children’s ward were reviewed by the CAMHS liaison team/nurse within 24 hours of admission and were followed up after seven days.
Staff had successfully offered the use of acupins for the relief of nausea, particularly in gynaecology services.

However, there were areas where the trust needs to make improvements.

Importantly, the trust must:

Urgent and emergency care

Ensure there are sufficient numbers of suitable qualified, competent and skilled staff deployed in the department.
Ensure all staff are aware of their responsibility to report incidents and ensure learning is shared with all relevant staff.

Medicine

Continue to take action to ensure there are sufficient numbers of suitably skilled, qualified and experienced staff.
Ensure all relevant staff have received appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and dementia awareness.
Ensure all staff have an annual appraisal.
Mental capacity assessments and discussions must be clearly documented in patient records.

Critical care

Ensure risks are assessed, monitored and managed in a timely manner to ensure safety.
Ensure patients’ individual records are held securely on the unit.

Maternity

Complete the reviews of maternal and neonatal deaths and implement any further identified actions to support safe practice.
Ensure that identified risks are recognised and recorded on the risk register.
Ensure that incidents are reviewed and investigated in a timely manner.
Ensure staff have access to safeguarding supervision and support.

Children and young people

Ensure the policies and procedures for the management of the children’s and young people’s service are up-to-date, regularly reviewed, document controlled and readily accessible to staff.
Ensure children and young people’s service risk register reflect current risks, contains appropriate mitigating actions, is monitored and reviewed at appropriate intervals and acted upon.

End of life care

Ensure all “do not attempt cardio-pulmonary resuscitation” (DNACPR) decisions are always documented in line with national guidance and legislation.
Ensure there is evidence that patients’ capacity has been assessed in line with the requirements of the Mental Capacity Act (2005).

Community adults

Must ensure that there are robust local safe systems in place to keep community staff who are lone working safe, in line with trust policy.
Must ensure community staff are working in accordance with the Mental Capacity Act code of practice (2005).
Must ensure that all risks for community services are included on the directorate risk register and where control measures are identified to mitigate risks, managers have assurance that control measure are effectively in place.

Community end of life care

Ensure that all DNACPR forms are completed appropriately and accurately ensuring that mental capacity assessments are completed for patients where it has been assessed they lack capacity.

Community inpatients

Ensure that consent to care and treatment is obtained in line with legislation and guidance, including the Mental Capacity Act 2005 for patients who lack capacity. The provider must also ensure that staff are trained to enable them to recognise when patients need support to make decisions and, where appropriate, their mental capacity is assessed and recorded.

Community children, young people and families.

Ensure incidents are appropriately categorised, graded and investigated.
Ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population.
Ensure the policies and procedures for the management of the children’s and young people’s service are up-to-date, regularly reviewed, document controlled and readily accessible to staff.
Ensure that a regular and effective clinical audit schedule is developed.
Ensure that steps are taken to increase performance against waiting time targets for therapy services and the child development centre.
Ensure that it improves the number of looked after children assessments carried out within the target timescale.
Ensure children and young people’s service risk register reflect current risks, contains appropriate mitigating actions, is monitored and reviewed at appropriate intervals and acted upon.

Trust-wide

Ensure there are sufficient numbers of suitable qualified, competent and skilled staff deployed in the pharmacy department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Information about the service

Community services joined The Rotherham NHS Foundation Trust in 2011 as part of the transforming community services programme, designed to move care out of hospitals and closer to people's homes.

The trust provides both acute and community based health services to the people of Rotherham with a population of approximately 259,000. The majority of community services for adults were managed within the division of integrated medicine; however, therapy staff were managed within the clinical support division and podiatry within the surgery division.

The trust provides a range of community health services for adults, working across seven localities from the following sites; Rotherham Community Health Centre, Aston Customer Service Centre, North Anston Medical Centre, Health Village, Park Rehabilitation Centre, Rawmarsh Customer Service Centre, Maltby Joint Service Centre, Wickersley Health Centre and patients homes. Community inpatient services are provided at Oakwood Community Unit and Breathing Space.

During our visit we inspected a range of services including, the continence advisory service, community nursing services, the care home liaison team, the integrated rapid response team, musculoskeletal clinical assessment and treatment service, the domiciliary therapy team and the falls and fracture prevention service. We also visited the care co-ordination centre.

We spoke with 40 members of staff including, community matrons, community nurses, clinical support workers, therapists, community physicians, managers, administration staff and student nurses. We observed care being provided in patient’s homes. We spoke with 15 patients and looked at 10 patient records. We also held focus groups with community staff and reviewed performance information from, and about, the trust.

Community services for adults had previously been inspected as part of a comprehensive inspection in February 2015 and was rated overall as requires improvement. Safe, effective and well led were rated as requires improvement, caring and responsive were rated as good.

At this inspection, we focused on whether the services were safe, effective and well led.

Overall rating for this core service

We carried out this inspection because when we inspected the service in February 2015, we rated the service as requires improvement. We asked the provider to make improvements following that inspection.

At this inspection, we rated community services for children, young people and families as requires improvement because;

Incidents were not always appropriately categorised or graded and we saw that staff within the service had a limited understanding of the duty of candour. The risk register was not always regularly updated or maintained and did not contain evidence that mitigating actions were regularly monitored. The trust did not routinely share learning from informal concerns. This had also been highlighted at our previous inspection.
There was a risk that medical records were not contemporaneous. There was very limited use of telemedicine or technology to help in delivering effective care.
School nursing staff told us they were carrying high caseloads and that staff had left since the time of our previous inspection. Our previous inspection also identified concerns about staffing and caseloads within the service.
The service was failing to meet performance targets in regard to the national health child programme. Some services were not meeting referral to treatment target times for initial appointments and there were lengthy waits for appointments following initial appointments. These issues had also been highlighted at our previous inspection.
There were limited examples of regular or robust audit or outcome monitoring in place to ensure that the service was assured it was providing effective care and treatment. This had also been highlighted at our previous inspection.
There was a risk that trust policies and guidance did not reflect current best practice due to the number of policies and guidance documents reported as being beyond their review date. We saw a lack of child friendly leaflets and information available in clinic areas.
The service was not meeting the needs of looked after children and there were delays in child protection information being available to staff. Patient information was not routinely provided in a range of languages. There was a risk that instructions on how to access information in other languages would not be understood by young people and families that did not speak English as their first language. This had also been highlighted at our previous inspection.
The service had not yet developed a clear vision or strategy to reflect how services would be provided across the local area.
Staff in the 0-19 pathway told us that they did not feel that feedback was valued or acted on in regard to the 0-19 tender process. There was a lack of formal public or staff engagement outside of the 0-19 tender process in order to drive improvements and make changes to services. Parents of children waiting to access services were unsure how to access emotional support and told us they felt they ‘slipped between the cracks’.

However:

Staff told us that there had a been positive improvements in the culture within the service since our last inspection.
The trust had made significant improvements to the medicines management and environment in the short break service. The trust had significantly improved the percentage of staff undergoing a formal appraisal. The trust had also taken steps to ensure that access to child and adolescent sexual health services were available to young people outside of school term times.
Safeguarding and mandatory training figures were also high. Staff were receiving clinical and safeguarding supervision, although this was not always done in the manner outlined in trust policies.
There was effective multidisciplinary working amongst different teams within the service and wider health and social care services. Services were planned to meet the needs of children, young people, and families. Regular team and service level meetings took place to allow governance issues to be discussed and we saw learning from formal complaints was shared with staff. Staff spoke positively about the support provided by their teams and immediate management.
Children, young people and their families told us that staff were caring and supportive and we observed staff providing kind and compassionate care. Staff involved children, young people, and their families in care planning and provided tailored advice and guidance to ensure clinical needs were understood. The service received consistently high scores in the NHS Friends and Family Test and we saw that staff treated children, young people, and their families with dignity and respect.

We rated this core service as good for safe, effective, responsive and well led. We rated caring as outstanding. This was because safety performance data was good; patients were protected from avoidable harm and abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Managers shared the learning from incidents. Record keeping was good. The environments were fit for purpose and equipment was available. Medicines were stored, prescribed and administered safely.

Although we were concerned that consent to care and treatment, at the Oakwood Community Unit, was not obtained in line with legislation and guidance, including the Mental Capacity Act 2005 for patients who lacked capacity, we saw that patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were prescribed and administered pain relief in a timely manner. Staff providing care were competent and skilled and there was evidence of strong multidisciplinary team working.

Friends and family test results were 100% positive for both units. Feedback we received from patients and their relatives and carers was consistently positive. We observed consistently caring, sensitive and compassionate staff. Patients and their families were supported psychologically and emotionally.

Services had been planned and developed in a way that met the needs of the local population and teams were highly responsive to the needs of the patients in their care. The introduction of an activities coordinator at Oakwood Community Unit had ‘transformed the service’. We saw that vulnerable patients including those living with dementia were supported.

All teams were aware of the trust vision and values and we saw robust strategic plans for both services. Governance, risk management and quality measurement processes were embedded in the teams. Staff we spoke with told us that senior staff were visible and supportive. We found that staff in all teams were consistently positive, friendly, helpful and approachable in all areas we visited. All staff were team focused. We saw examples of innovation, improvement and sustainability.

Overall rating for this core service

We carried out this inspection because when we inspected the service in February 2015, we rated the service as requires improvement. We asked the provider to make improvements following that inspection.

At this inspection, we rated services for community end of life as requires improvement, because;

The use of the end of life individualised care plan for adults was not embedded into practice and not used by all the services that provided end of life care. Managers within the community nursing service had recently began to review the use of the document in April 2016 and evidence on inspection showed that the document was not fully completed. Audits for community end of life were not embedded and actions were required to improve the quality of care provided in the community. These included staff completing and discussing advanced care planning to reduce the need for patients to be admitted to hospital unnecessarily.

Staff had completed mental capacity training, however ‘do not attempt cardiopulmonary resuscitation (DNACPRs) were not completed appropriately for patients who lacked capacity and mental capacity forms and assessments were not completed. This was identified as a risk within the CQC comprehensive inspection in February 2015. Policies required to be reviewed in line with national guidance and the trust’s timescales; these included DNACPR policy and syringe driver policy.

The trust still needed to build on the work they had commenced for the end of life strategy. For example, they needed to improve advanced care planning and implementation and embedding the individualised end of life care plan. These areas were not included as risks on the risk register. Preferred place of care was not always recorded on the patient’s record which would identify where they wanted to be cared for within the last few days of life.

Ongoing communication was still required to aid integration of the acute and community services.

The trust had made some improvements from the CQC inspection in February 2015. These included staff reporting incidents and receiving feedback from the trust. Incidents were now shared across various methods. Safety huddles were held to discuss staffing levels and to look at the allocation of staff when required. Procedures were in place for patients whose visits required to be rearranged and patients who wanted visits would be seen. Staff could access patient’s electronic records and further software had been added to the laptops to use in areas with connectivity issues. The implementation of the care co-ordination centre allowed patients to access a professional at any time who would contact the appropriate team.

We also saw that anticipatory medication was provided to patients and staff could prescribe medication quickly for patient’s whose symptoms could not be controlled. Staff managed patient’s pain and nutritional needs and completed the appropriate assessments. Equipment was available for patients and staff would often pre-empt and ensure equipment was at the patient’s house incase it was required.

All community areas provided good links with GPs and the palliative care team to manage the patients. Some GP surgeries were on the same patient electronic system and could see the care records provided by the community services.

Staff provided compassionate and supportive care within the home and ward environment. Patients were encouraged to be involved in decision making about their end of life care needs. Staff communicated well and worked together to plan the care and treatment.

Senior staff in all community settings could complete fast track forms; this enabled care to be put in place quickly for patients whose condition was deteriorating and may have requested their preferred place of death at home.

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

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

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

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

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

Our key findings were as follows:

Cleanliness and Infection Prevention and Control

The trust had a dedicated infection control team. They visited the wards at Rotherham Hospital on a daily basis and were highly regarded by the staff we spoke with. The infection control team undertook a range of infection control audits on the wards.
We saw that side rooms were used for patients who had, or it was suspected, that patients had infections. Signage to alert staff and visitors of the risk of infection was placed on the doors. On many wards we saw that the doors to these rooms were open, which meant the signage to alert of the possible risk of infection were not immediately evident. Opened doors also increased the spread of infection. We asked to see if there were risk assessments in place for doors to remain open but they weren’t available.
We saw there was clear information displayed or provided regarding the use of segregated toilets for the sole use of patients who had, or were suspected of having infections, but segregated use was not enforced. We observed toilets meant for sole use being used by patients who were not considered as being an infection risk. This increased the risk of the spread of infection.
We saw many good examples of staff delivering care using best practice but also saw examples where staff action increased the risk of infection. This included one staff member who cleaned a toilet and left the toilet without removing their gloves and aprons and entered a clean area.
The incidence of Clostridium difficile infections in 2013/2014 was 28 and was above the trusts target.
There had been no Methicillin-resistant Staphylococcus Aureus bacteraemia (MRSA) infections across the trust in the last 12 months.
During our inspection we found that generally the hospital was visibly clean.

Nutrition and Hydration

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

Mortality

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

Staffing

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

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

We found areas of good practice

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

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

Importantly, the trust must ensure that:

All relevant staff must receive appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and living with dementia awareness.
All relevant staff must be able to assess the capacity and best interests of patients in line with the Mental Capacity Act 2005 and its associated deprivation of liberty safeguards.
All do not attempt cardio-pulmonary resuscitation (DNA CPR) forms must be completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005).
The registered person must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements.
The registered person must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients.
The outpatient appointment validation process must be completed and actions taken to assess clinical risks to patients of having overdue appointments.
The children's ward environment must be safe and appropriate for children and young people.
Incidents must be reported and investigated in a timely manner and that learning is shared with all staff.
Directorate and corporate risk registers must be reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals.
Children and young people using the short break service were not protected against the risks associated with the unsafe use and management of medicines.
The provider must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse.
Complaints must be dealt with in accordance with the trust policy, national best practice and guidance.
Patient records must be kept securely.

In addition the trust should:

Emergency department

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

Surgery

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

Critical care

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

Maternity

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

Children and young people

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

Outpatients and diagnostic imaging

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

Community Inpatient Services

Review the care being provided in The Oakwood Community Unit so that patients have the opportunity to engage in social activities as well as promoting their independence.
Review reasons for staff working in the community in-patient areas feeling isolated and distanced from the senior leaders in the trust.
Review the delay in discharges caused by lack of access to prompt assessments for receiving social care and continuing healthcare and lack of availability of specialist packaging for medicines.

Community Children and Young People's Services

Systems for reporting and recording safety concerns, incidents and near misses are used effectively and consistently.
Safeguarding supervision should be reviewed to make sure it is robust and effective for all staff that need this.
The provider should ensure that the substance misuse pathway is effective in providing appropriate intervention for young people under 16.
The provider should ensure that handovers from midwives to health visitors are taking place in a timely and effective way.
Review the early attachment service is not over reliant on one practitioner.
Review the discharge criteria for the early attachment service are fully defined.
Review the IT requirements of staff working in the community so that staff are not hindered by old and inefficient IT equipment.
Ensure that all staff working with children, young people and families have received training about the identification and prevention of child sexual exploitation.
Ensure that young people have access to contraceptive and sexual health clinics during school holidays.
Ensure that waiting time targets are met for physiotherapy non-urgent appointments and child development centre appointments.
Ensure that letters to parents and carers include how to get the information in languages other than English.
Ensure that information about complaints is captured and shared, including when they are dealt with locally and not recorded on the reporting system.
The provider should ensure that risks and concerns within the service are dealt with in an appropriate and timely way.
Ensure a consistent approach to obtaining the views of children, young people and families using the service.
Strengthen the engagement with staff delivering community health services for children and young people and improve communication about service design and strategy.

Community End of Life Care Services

Provide support to staff delivering community end of life and palliative care to report patient safety incidents appropriately and ensure they are able to access training in incident reporting on a regular basis.
Strengthen ways of learning from incidents and sharing good practice across the community end of life and palliative care services.
Ensure staff visiting patients in their homes to deliver end of life and palliative care are able to access the complete information they need before providing care and treatment.

Ensure that staff delivering community end of life and palliative care are able to access appropriate one to one supervision on a regular basis.
Strengthen the engagement with staff delivering community end of life and palliative care, and improve communication about service design and strategy.

Community Health Services for Adults

Strengthen the engagement with community health services for adults’ staff.
Ensure community staff have access to information relating to people before providing care and treatment.
Ensure staff are accessing interpreter services where appropriate.
The provider should support community and district nursing staff to report patient safety incidents appropriately.
The provider should ensure staff are involved in learning from incidents and good practice is shared across teams and departments.

Trust wide

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Staff did not always report patient safety incidents and did not always receive feedback about incident investigations, and there was inconsistent sharing and learning across the service in order to improve practice.

District nursing teams were under-staffed and taking on increasing workloads. Fast response, intermediate care and, community matrons supported the district nursing teams, and we saw that all staff were dedicated to providing a good service for patients. However, staffing shortfalls meant that nurses could not attend mandatory and other training. Although there were governance structures in place to monitor and manage risks associated with district nursing staffing levels, demands on the service had not been addressed.

Arrangements to minimise risks to patients were in place and we saw elements of good practice including clean clinic areas, good infection prevention and control practice, a good understanding of safeguarding procedures and, the use of independent and community nurse prescribers.

Care was delivered in line with the trust policies and procedures, national guidance and, NICE quality standards and access to care and treatment and, outcomes for people were positive.

People who received care were treated with compassion and respect. We saw staff worked hard to ensure people received a high standard of care. All the patients people we spoke with were consistently positive about the care they received.

During our inspection we met with some dedicated, innovative staff who demonstrated the values of the trust, were passionate about their jobs and, were proud of their work but felt ‘ignored’ by the acute trust. Staff morale was low and many staff felt de-valued.

The Rotherham NHS Foundation Trust provides community in-patient services in two locations; Oakwood Community Unit and BreathingSpace. These were two very different units in the way they were run and managed.

Incident reporting was used routinely and lessons were learned from the incidents raised. The knowledge of duty of candour and staff receiving safeguarding training varied between the units. Staffing levels in the Oakwood Community Unit were acceptable; when necessary flexible or agency nursing staff were used although further medical support was required at times. Storage of confidential waste in the Oakwood Community Unit was not always appropriate. There are no national guidelines for community inpatient nurse staffing levels. There was a system in place for staff to escalate any concerns about patients dependency and staffing levels.

Policies and procedures had been developed in line with national guidance and care pathways were in place for patients with specific diseases. Outcomes for patients at BreathingSpace compared very well with other services provided nationally.

Assessments for social care and continuing healthcare were sometimes delayed and there was a lack of consistency in how people’s mental capacity to make decisions was assessed. Although training had not been a high priority in the recent past in the Oakwood Community Unit, plans were in place to address this. All permanent staff in BreathingSpace were highly skilled and knowledgeable.

Staff treated patients with compassion, dignity and respect. Patients told us they felt emotionally supported by the staff. Staff communicated very well with patients and their relatives and supported them to be as independent as possible. Patients felt informed about their discharge arrangements. The care provided at BreathingSpace was exceptionally good and nursing staff were very knowledgeable about the care they were providing.

BreathingSpace was a specialist unit for patients experiencing an acute phase of a chronic respiratory illness. Both services acknowledged patients different needs although patients could become socially isolated. Access to specialist packaging for patient’s medication to take home could cause delays. Patients’ concerns and complaints were dealt with at unit level by a senior member of staff and discussed at unit meetings.

Community inpatient staff varied in their vision of the future direction of the units they worked in. Whilst the majority of staff in the Oakwood Community Unit knew of the changes to the service, in BreathingSpace senior staff were concerned about the unit’s future despite it being very successful and held in high esteem by the patients it served. Staff felt able to raise issues with managers, if required. Senior managers from the trust visited the units on occasions. Staff felt well supported by their line managers and were proud of the service they worked in.

The Rotherham Hospitals NHS Foundation Trust provided a range of community health services for children, young people and families in the Rotherham area.

We inspected the following regulated activities that the trust is registered with CQC to provide:

Diagnostic and screening procedures
Family planning
Treatment of disease, disorder or injury

During our inspection we spoke with 18 parents or carers, children and young people. We spoke with a range of staff, 46 in total, including health visitors, school nurses, community nurses, nursery nurses, doctors, therapists, and administration staff. We observed clinics with community paediatricians and therapy staff. We accompanied health visitors on home visits.

The systems in place for reporting and recording safety concerns, incidents and near misses were not used effectively or consistently. Staff did not always receive feedback about the action taken when they reported issues. There were gaps and inconsistencies in safeguarding systems and processes. Complete and robust information was not always available for multi-agency decisions about children at risk of abuse.

There were no appropriate arrangements in place for the safe management of medicines in the short break service. There were practices that put children using the short break service at increased risk of acquiring an infection.

Some key outcomes for children, young people and families using the service were regularly below expectations. Outcomes of care and treatment were not always consistently or robustly monitored.

Staff had the right qualifications, skills, knowledge and experience to do their job. However, staff were not always supported to have training to help them to develop additional skills and expertise. Staff working away from their office bases were hindered by old and ineffective IT equipment.

Care and treatment of children and young people was planned and delivered in line with current evidence based guidance, standards and best practice. Consent to care and treatment was generally obtained in line with relevant guidance and legislation. However, staff were not always aware of the need to obtain consent for sharing information.

There were examples of collaborative and effective multi-disciplinary and multi-agency working to meet the needs of children and young people using the service. However, this was not consistent in all areas of the service as there were some gaps and missed opportunities.

Feedback from those using the service was positive about how they were treated by staff and about how they were involved in making decisions with the support they needed.

Waiting time targets were not met for physiotherapy non-urgent appointments and child development centre appointments. This meant that children and young people were experiencing delays in receiving treatment and support for their health needs.

Other services were planned and delivered in a way that met the needs of the local population. Examples of these included the Family Nurse Partnership, the audiology service, and a health visitor service for children, young people and families who were asylum seekers.

The risks and issues described by staff did not always correspond to those reported to and understood by their leaders. Leaders in the service were not always clear about their roles and their accountability for quality. The need to develop leaders was not consistently identified and appropriate action was not always taken to support them.

Staff did not feel actively engaged or empowered. When staff raised concerns or ideas for improvement, they felt they were not always taken seriously.

There was an inconsistent approach to obtaining the views of children, young people and families using the service.

The Rotherham NHS Foundation Trust did not provide specialist community palliative or end of life care. This was commissioned by the Rotherham Clinical Commissioning Group from the Rotherham Hospice. The trust provided general end of life care in the community. Care was predominantly given by community nurses in patients own homes. End of life care could also be provided in the trusts community inpatient units, BreathingSpace and the Oakwood Community Unit. We visited these sites and went on home visits with district nurses from the community nursing team. We spoke with patients, carers and staff including community nurses, district nurses, matrons, health care assistants and doctors.

Staff did not always report patient safety incidents and did not always receive feedback about incident investigations and there was little sharing and learning across the service in order to improve practice. Staff working in the community providing palliative and end of life care for people at home reported difficulties in connecting to their remote working devices. This meant they could not always access current information about their patients’ care and treatment plans.

We found that staff had received very little or no training in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), and assessments had not always been appropriately undertaken when a patient was said to lack capacity as a reason for not discussing Do Not Attempt CardioPulmonary Resuscitation (DNA CPR) decisions with them.

Arrangements to minimise risks to patients were in place with appropriate measures taken to prevent falls and pressure ulcers. We saw elements of good practice including good infection prevention and control practice and, the use of independent and community nurse prescribers.

There had been an investment in the staffing of community nurses and it had seen an increase in nurses. Despite this, community nursing staff were working under significant pressure because of their workloads. All staff we observed demonstrated calm compassion and were passionate about ensuring patients received good end of life care. Community nurses were not always able to fulfil supportive visits to patients requiring palliative and end of life care because of their workload.

District nurses told us they would be the first point of call for patients on their caseload who required end of life care. We saw evidence that some patients found it difficult to get through to the district nurses via the telephone number they had been given.

Community staff delivering end of life care felt they were not always listened to and many staff expressed community services were the poor relation compared to acute services and that the two had not been integrated.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.