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Rotherham General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 December 2019

We carried out a focussed unannounced inspection of the urgent and emergency care services at Rotherham General Hospital on 19-21 August 2019. This inspection was to follow up concerns identified at our previous inspection in September 2018. In September 2018, we had concerns around the staffing of the paediatric area and the effect this had on children’s care and treatment, incident reporting, safeguarding practices and leadership of the department.

We inspected all five domains - safe, effective, caring, responsive and well led. At our previous inspection, safe and well-led had been rated as inadequate. Effective, caring and responsive were rated as requires improvement. This inspection was to see whether the required improvements had been made.

Our rating of this service improved. We rated it as Requires improvement overall. Safe and well led had improved and were rated as requires improvement. Caring had improved and was rated as good. Effective and responsive had stayed the same and were rated as requires improvement.

We found that;

  • Paediatric staffing had improved significantly since our last inspection and we no longer felt that the unit was unsafe. There were enough doctors and nurses in the area to ensure children received prompt treatment.

  • There was a new leadership team in the department. Experienced, visible leaders were working to raise morale and improve culture and we saw evidence that their work was starting to have an impact.

  • At the last CQC inspection we found that care and treatment did not always reflect current evidence-based guidance. We saw evidence that this had improved and staff had developed new pathways and were using NICE guidelines to achieve outcomes for patients.

  • Audit planning had improved since our last inspection and there were now plans in place for more external and local audits than at our last visit.

  • Staff showed a caring attitude towards patients and we saw examples of empathetic, supportive care. At our last inspection we found it had been difficult for staff to offer the levels of care and support they might have wished. This had improved and we saw that staff treated their patients with compassion.

However:

  • Safeguarding children and adults remained a concern and staff did not always recognise abuse and did not always demonstrate professional curiosity. While this had improved since our last inspection, and quality assurance processes were now in place, there was still work to be done to further embed this.

  • There remained a disconnect between the paediatric area of UECC and the rest of children’s inpatient services. This was something that staff were aware of and working to address.

  • There were still long waits for some patients to be seen by a doctor.

  • Flow remained an issue and the trust was not meeting targets for patients being admitted, transferred or discharged into and out of the department. Incident data showed that some people were not being reviewed by specialist medical staff when needed.

  • Complaints were still taking longer than the trust target to resolve.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Requires improvement

Updated 20 December 2019

Our rating of safe improved. We rated it as Requires improvement because:

  • At the last CQC inspection in September 2018, we found safety was not given sufficient priority and there were substantial and frequent staff shortages. At this inspection, we found evidence of improvement, particularly in relation to paediatric nurse staffing. Senior managers had taken appropriate action, however further work was required to ensure adult nurse staffing establishments met the requirements of the service.

  • At the last CQC inspection, we found there was insufficient attention to safeguarding children and adults. Staff did not always recognise abuse and did not always demonstrate professional curiosity. At this inspection we found evidence of improvement. Safeguarding training for nurses and healthcare support workers was good, however compliance for medical staff was low. The quality assurance process to monitor and ensure children and young people were being appropriately safeguarded still required further improvement to embed it fully within UECC and managers were sighted on the work that still needed to be done.

  • At our last inspection we found staff did not assess, monitor or manage risks to people who used the services in a timely manner. Opportunities to prevent or minimise harm were missed because patients had long waits for initial assessment and for treatment. At this inspection we found evidence of improvement, although this needed further time to embed, and there were still waits of over 60 minutes for patients to first be seen by a doctor.

  • Although mandatory training compliance had improved for nursing staff and healthcare support workers, medical staff compliance was low.

However:

  • At the last CQC inspection in September 2018, we had concerns that there was not always a doctor present within the paediatric department. At this inspection we found that this had been rectified, and there was a new procedure to ensure robust oversight of the clinical decision-making process if a doctor had to leave the paediatric unit to support the adult unit at any time.

  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and managed clinical waste well.

Effective

Requires improvement

Updated 20 December 2019

Our rating of effective stayed the same. We rated it as Requires improvement because:

  • Although we saw some improvement in participation in external audits and benchmarking, further work was required on action plan production and embedding systems within the unit.

  • Not all policies were up to date. Just over half (65%) of trust policies were in date, which meant that there was a chance staff were not using the most up to date guidance when treating patients.

  • Although staff understood their responsibilities to patients in relation to the Mental Capacity Act (MCA), assessed capacity when appropriate and necessary and ensured patients were involved in discussions about their care and treatment, they had not received specific mental health training (outside of that included in the safeguarding training module). The trust had undertaken a training needs analysis for MCA training and had plans to implement separate training from April 2020.

  • From June 2018 to May 2019, although the trust’s unplanned re-attendance rate to A&E within seven days did not meet the national standard of 5% it was better than the England average.

  • The department was not achieving RCEM audit standards (2016/17 audit).

However;

  • At the last CQC inspection in September 2018, participation in external audits and benchmarking was limited and at this inspection, we saw some evidence of improvement.

  • At the last CQC inspection in September 2018, we found care and treatment did not always reflect current evidence-based guidance, standards and best practice. At this inspection, we saw evidence of improvement. Staff in the department used a variety of pathways and NICE guidelines together with Royal College of Emergency Medicine (RCEM) guidance to support them to achieve effective outcomes for patients in their care.

  • At the last CQC inspection, patients were not always offered food and drinks and pain scores were not consistently recorded or reassessed. At this inspection, we saw patients being offered drinks and snacks. Patients were given pain relief if they needed it and, although pain scores were not always reassessed, they were recorded at initial assessment.

  • At the last CQC inspection, there were gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. At this inspection, the appraisal rate was 89%. The unit held weekly teaching sessions, carried out simulation training and competency training was available (in addition to mandatory training) such as by attending clinical skills courses or CRUMPET (cross speciality multidisciplinary paediatric emergency training).

Caring

Good

Updated 20 December 2019

Our rating of caring improved. We rated it as Good because:

  • At the last CQC inspection in September 2018, staffing pressures meant staff could not always offer the level of care and support they wanted to. At this inspection, we saw evidence of improvement.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.

  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Responsive

Requires improvement

Updated 20 December 2019

Our rating of responsive stayed the same. We rated it as Requires improvement because:

  • Although managers were working collaboratively with staff and external agencies and taking appropriate action to improve and manage flow within the unit, triage time was consistently below 15 minutes (on average), and the time to be seen by a doctor remained high.

  • The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet the standard for any month over the12-monthperiod from June 2018 to May 2019.

  • Some patients were spending a long time in the department as a result of increased demand and waiting for beds, and specialists did not always review patients in a timely way. The number of people leaving before being seen remained above target. (9% against a target of 5%).

  • Incident data showed that some people were not being seen by specialists in the department within a reasonable timescale and that this had the potential for harm.

  • Although managers were taking appropriate action to manage and improve the complaints process, current performance for responding to and resolving complaints was below target.

However:

  • From June 2018 to May 2019 the trust’s monthly median total time in UECC for all patients was similar to the England average.

  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.

  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.

  • The trust had access to interpreting services for people whose first language was not English.

Well-led

Requires improvement

Updated 20 December 2019

Our rating of well-led improved. We rated it as Requires improvement because:

  • In response to the concerns we raised at the last inspection , there were changes in the leadership team and immediate action was taken to strengthen and improve the management of the unit. The newly-formed management team were aware that further progress was required to embed improvement and change within the UECC.

  • Although the new leadership team was more visible, managers recognised further work was required to embed the new leadership model within the unit.

  • At the last CQC inspection in September 2018, we found that, although the department had a medium and long-term strategy, managers had failed to address immediate safety concerns in the department. At this inspection we found evidence of improvement. Senior leaders had taken immediate action in response to the concerns we raised to keep patients safe and improve the management of risks within the department.

  • At the previous CQC inspection in 2018, we had concerns about the culture of the department. At this inspection we found evidence of improvement. Although senior leaders were fully sighted on the issues and concerns and had taken steps to manage and improve the culture of the department, they recognised more work was required to embed the cultural changes.

However:

  • The department had an integrated IT system to present overarching information about the department. This was innovative and designed in house by a member of trust staff.

  • Clinical governance meetings took place regularly. We saw meeting minutes that showed staff discussed, incidents, complaints, the risk register, safeguarding, action plans and any other areas of concern in the department.

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 18 March 2019

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

  • Staffing shortages were still evident with low fill rates for registered nurses on most medical wards and gaps on the junior doctors’ rota, which meant that medical wards were often below the minimum staffing level.
  • Medicines were not always well managed. We found a high level of missed doses and gaps in medicines administration charts where staff had not signed or entered a code to indicate the reason a medicine had not been given.
  • We found limited examples of staff engagement. Senior managers told us they wanted projects to be clinically led and would get staff involved in the early stages, however, we found examples where not all clinical staff were involved in plans for service changes.
  • Staff told us the leadership team did not always listen and act when they raised concerns about patient safety.
  • There was poor compliance with mandatory training and this was identified as an issue at our previous inspection. The trust set a target of 85% for completion of mandatory training and this target was not met in seven out of nine mandatory training modules.
  • Not all staff received an annual appraisal with their line manager. The overall compliance rate for the division in August 2018 was 64.7% compared to the trust target of 90%.
  • Although staff demonstrated a good understanding of the relevant consent and decision-making requirements of the Mental Capacity Act 2005, mental capacity assessment documentation was brief and did not always demonstrate the rationale behind the decision. Decisions made in a patient’s best interest where a patient was deemed to lack capacity gave little detail of who made the decision or the options considered.
  • There was no specific risk assessment tool to identify and manage risks associated with a patient’s mental health to keep them safe. The documentation we saw did not reflect any specific assessment or intervention plan relating to patients’ mental health and did not identify any subsequent risk management plans to address challenging behaviours.

However;

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We saw that patients were treated with respect and their privacy and dignity was maintained.
  • The division had a clear vision and strategy which was linked to those of the trust. The service was committed to delivering an acute care transformation programme which included the reconfiguration of the acute assessment unit, the ambulatory care pathway and the frailty pathway.
  • The service managed flow through the hospital well. There were no extra capacity beds open at the time of our inspection and measures were in place to facilitate the timely discharge of patients back to their homes.
  • We found staff morale to be generally good. Staff supported each other well and there was good team work. We observed good rapport between staff of different professions and teams we spoke with were proud of the services they provided to patients.
  • Staff with specialist skills and knowledge worked well together to provide effective patient care. Staff spoke positively about multidisciplinary team working and we observed good working relationships between professions.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. There was an agreed procedure in place to ensure the service complied with national guidance.
  • There were good mechanisms in place to report, feedback and learn from incidents.

Services for children & young people

Good

Updated 18 March 2019

Our overall rating of this service improved. We rated it as good because:

  • We rated safe, effective, caring, responsive and well-led as good.
  • The children’s service had a strategy to provide outstanding care provision for children, young people and their families.
  • They had a governance structure and managers shared information with staff who were aware of the risks of the organisation, and the actions taken to address or mitigate the risks.
  • Staff spoke positively about the leadership across the service. They told us the culture had improved since we visited in 2016; there was an open culture where staff were encouraged to raise concerns.
  • The service had taken appropriate action in response to most of the issues identified at the previous inspection. Policies and procedures were in date and complied with relevant standards and guidance.
  • Staff protected children and young people from avoidable harm and abuse. There were systems and processes to safeguard children and young people.
  • The proportion of consultant staff reported to be working at the trust was higher than the England average in May 2018, and the proportion of junior (foundation year 1-2) staff was the same. The sickness rate was below the trust target and there were no vacancies.
  • Qualified nursing staff reported the staffing levels had improved since our inspection in 2016. The nursing and care staff fill rates on the special care baby unit, paediatric assessment unit and ward exceeded or were just slightly below the planned levels.
  • The wards, clinics and departments were clean. Staff managed medicines safely and the quality of healthcare records was good.
  • Audit data showed most patient outcomes were the same as other trusts, or better than expected.
  • Families were positive about the service they received. They described staff as being caring, compassionate, understanding and supportive.
  • Effective multidisciplinary team working practices were in place, and joint medical and nursing records were kept in providing the continuity of patient care. Medical and nursing staff worked closely together and with other allied healthcare professionals such as dieticians, health visitors and GPs.
  • Face to face interpreters were available, and leaflets were available in languages other than English.

However;

  • Not all staff received face to face safeguarding level three training in line with the intercollegiate document, Safeguarding Children and Young People.
  • The percentage of staff qualified in specialty in the special care baby unit was not in line with the British Association of Perinatal Medicine (BAPM) standards and the nurse in charge was not supernumerary.
  • Not all staff were up to date with the advanced paediatric life support training.
  • Complaints were not all closed in line with the timescales of the trust complaints policy.
  • The refrigerator temperatures in the high dependency room were not always recorded.
  • Staff had limited knowledge of the Mental Capacity Act.

Critical care

Updated 2 March 2017

We found there was a culture where patients were at the centre of activities. There was a clear process for escalation, investigation and feedback of incidents. Lessons learnt were shared with staff to minimise them reoccurring. Staff received training in vulnerable adult and children protection. They were confident in safeguarding patients.

Outcomes for patients using this critical care service were measured against similar services; this unit were better in some areas and similar in others. Staff were appropriately qualified.

Staff understood and were able to verbalise the principles of mental capacity act, duty of candour and the unit vision and aims.

At our request at the inspection, the trust took immediate action to ensure the fire evacuation arrangement in place for intensive care unit was fit for purpose. We confirmed this during our unannounced inspection. We also wrote to the trust and they confirmed that fire safety advisors were satisfied with the arrangements in place.

However, due to staff shortages, the nurse coordinator on shift was unable to fulfil their duty of managing, supervising and supporting staff to ensure safety. There was also a lack of a designated pharmacist on the unit.

Patients’ notes were not stored securely within the units to maintain patient confidentiality.

The governance arrangements including maintenance of a risk register and the review process did not promote effective risk control.

End of life care

Updated 2 March 2017

The trust had not taken action on some of the issues raised in the 2015 inspection. DNACPR forms and mental capacity decisions were not documented in line with trust policy, national guidance and legislation. The individualised care plan for adults had been launched in March 2016, however, its use was not yet embedded in practice.

Resources within the specialist palliative care team affected their ability to deliver evidence based care and treatment, specifically in relation to seven day working..

However, staff in the specialist palliative care team were skilled and competent and offered training to all staff groups in end of life care. We saw evidence of good multidisciplinary team working in the hospital, across the community and hospice.

Outpatients and diagnostic imaging

Updated 2 March 2017

The trust had taken action on some of the issues raised in the 2015 inspection, for example, procedures around sharps bins had been updated and were followed and records were now stored securely in clinics.

Mandatory and safeguarding training levels were better than the trust target. Staff understood their responsibility to raise concerns and report incidents. They received feedback from incidents.

However, although some improvements had been made since 2015, but the environment continued to present significant challenges for most departments.

There was a shortage of consultants employed by the trust. Locum staff were employed, however, this had affected continuity of care for patients.

Surgery

Updated 2 March 2017

The trust had taken action on some of the issues raised in the 2015 inspection, for example, staff were confident in reporting incidents and received feedback from incidents. The World Health Organisation (WHO) safer surgery checklist was embedded in practice and additional staff had been recruited. The management of medical outliers was in line with trust policy, there had been no mixed sex accommodation breaches and access and flow had improved in fracture clinic.

Systems and processes for infection control and medicines management were reliable and appropriate.

Senior staff planned and reviewed staffing levels and skill mix to keep people safe from avoidable harm. All wards used an early warning scoring system for the management of deteriorating patients.

Patients’ needs were met through the way services were organised and delivered. The trust’s referral to treatment performance was better than the England average between June 2015 and May 2016.

However, the trust did not have a Hospital at Night team and out of hours senior doctors were not always resident on site to support junior doctors and advanced nurse practitioners.

Urgent and emergency services

Requires improvement

Updated 20 December 2019

We rated this service as requires improvement. Safe was rated as requires improvement. Effective, responsive and well led were rated as requires improvement. Caring was rated as good.

Maternity

Requires improvement

Updated 18 March 2019

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated maternity as requires improvement because:

  • Not all risks identified in meeting minutes had been escalated to the risk register.

Midwifery staffing was a cause for concern to staff on delivery suite and midwives were frequently brought from other areas to provide cover. Staff told us they had been advised not to incident report shortages in staffing and extra working when called in as part of escalation methods because nothing could be changed.

Midwives with clinical lead roles were regularly required to work clinically to make up numbers for qualified midwives and this meant they did not always complete specialist topics such as audits.

Although managers had produced a documented maternity strategy with the aim to adopt a community based continuity of caring model, not all staff felt fully engaged in the development of the strategy. Some staff were anxious about future plans and raised concerns that community teams were already stretched due to high caseloads and extra shifts in delivery suite.

There had been some instability in maternity leadership and differences in management styles had affected staff morale.

There was poor communication between delivery suite and postnatal ward teams and some women and partners gave negative feedback about their care during their stay on the postnatal ward.

There had been a reduction in specialist midwives, although staff told us the service had been remodelled to meet the needs of vulnerable women.

The induction of labour rate remained high, averaging at 32% compared to the current national guidance rate of less than 25%.  Staff attributed this to high comorbidity rates and the reduction in caesarean sections. There were no clear plans to reduce this rate.

Antenatal clinics were over-booked especially in relation to diabetic clinics and they regularly ran late. There was no scanning consultant available at several clinics. The trust told us scanning was provided by the sonography team and scanning clinics were always available alongside all clinics. However, staff told us there were often very long waits.

Teams such as the ward and delivery suite appeared to work in isolation and this became apparent through patient comments about lack of communication, delayed discharges and information available to them.

As at our previous inspection, medical staffing mandatory training compliance rates remained low and most did not meet the trust target.

Although staff had a good understanding of safeguarding for vulnerable women and babies, training compliance for safeguarding children level three was below the trust target for all staff grades.

Although new staff were supernumerary and worked through a preceptorship package, midwives acting up in senior roles had no formal training or competency checks.

No staff groups met the trust appraisal rate target and some specialty trainees were dissatisfied with the level of clinical supervision they received.

  • The trust’s bed occupancy rate for maternity from February 2017 to June 2018 was 83%, compared to the England average of 58%. This could mean staff had more patients to care for on a regular basis.
  • Home births were not being encouraged due to the continuing shortage of community midwifery staff regularly available on-call.
  • Discharge delays from the postnatal ward were a concern for women, their families and staff. These were a regular occurrence and had been identified in patient feedback from the 2017 CQC maternity survey, the Royal College of Obstetricians and Gynaecologists (RCOG) clinical visit, and noted by senior staff but very few actions had been taken to address the problem.
  • Patient information leaflets and guidance within them were out of date and printed information sheets were of poor quality.
  • The service did not currently meet the National Guideline Alliance guidelines commissioned by the Royal College of Obstetricians and Gynaecologists with respect to smoking outcomes. They did not offer scanning to term where growth and fetal birth defects were monitored more frequently through the course of pregnancy. Some women had opted to have maternity care at a nearby Trust that could offer scanning to term.
  • Records showed complaints were not dealt with within timeframes set down in trust policy. The average time taken to investigate and close complaints was 43 days when trust policy stated all complaints should be resolved within 30 days.
  • There was no obvious display of learning activities or continuous professional development (CPD) events.
  • Junior midwives had no clear understanding of how information and data from dashboards could be used to drive improvement and we saw no evidence of staff engagement in quality improvement strategies.
  • There were no clear pathways or encouragement seen for fostering innovation or improvements to the service across different levels within the teams, although there had been some clinical innovation.

However;

Governance processes had improved. The service had a clear governance framework with staff assigned specific roles that ensured quality performance.

  • The trust had implemented a process to review and investigate incidents and complaints. They reviewed maternal and neonatal deaths in regular formal meetings and completed action plans showing how and when learning had been identified to implement and support safe practice.
  • At our last inspection we told the trust they must ensure staff have access to safeguarding supervision and support. At this inspection there was evidence of safeguarding support in case reviews and supervision was recorded electronically for all caseload holding midwives.
  • All staff completed skills training and emergency drills.

All equipment on the delivery suite had undergone checks and calibration to ensure it was safe and suitable for use.

Patient records were legible, detailed, signed, and safely stored.

Staff used the World Health Organisation (WHO) safety checklist, modified for maternity.

We saw evidence the unit used the ‘fresh eyes’ approach to review fetal heart tracings.

Medicines were stored safely and securely and prescription records had been completed to a high standard.

  • The rates for elective and emergency caesarean sections were similar to or better than the England average.
  • At our last inspection we noted there was no clear information governance process in place but at this inspection it had improved.
  • We asked the trust to review information systems to ensure they were fit for purpose and we found staff had access to sufficient and up to date information through the trust intranet.
  • The trust continued to improve mandatory training compliance for midwives and met most trust targets.
  • Midwifery and medical staff worked together ensuring women received care which met their needs and we saw a range of examples of multidisciplinary team working.
  • The trust’s most recent maternity Friends and Family test performance was similar to or better than the England average.
  • Risks to patient safety, staffing and the environment had been identified and recorded on the risk register. Staff followed the risk assessment process and actions were recorded and risks closed appropriately.
  • There was a good level of emotional and mental health support. A bereavement midwife worked to support women and families and women with a suspected mental health illness were cared for in partnership with the perinatal mental health team.
  • The service provided specialist clinics including a gestational diabetic clinic and an anaesthetist specialist clinic to reduce patient risks caused by obesity in pregnancy.

Staff were open and honest and we saw examples where duty of candour had been used.

  • An Afterthoughts service provided women with a means to give verbal feedback on their experiences and ask questions about their clinical care.
  • Staff had been trained to carry out New Infant Physical Examinations (NIPE) in clinics on the postnatal ward or the community, thus reducing length of stay and increasing bed capacity on the postnatal ward.
  • Teams had implemented the use of balloon catheters to improve women’s experience during induction of labour and Acupins to prevent sickness during pregnancy.
Other CQC inspections of services

Community & mental health inspection reports for Rotherham General Hospital can be found at The Rotherham NHS Foundation Trust.