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Rotherham General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 September 2020

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 Rotherham General Hospital 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 urgent and emergency care, the children’s ward and children’s assessment unit, maternity services and community services for children and young people. 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, and 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:

  • Case records we reviewed showed there were missed opportunities to safeguard children and young people.
  • Staff understood their responsibilities for safeguarding children and young people. However, the trust’s safeguarding children processes, procedures and practices did not adequately support the identification and protection of children and young people who may be at risk of harm.
  • Four different recording systems were in use across the trust to capture children and young people’s information. Gaps between systems, and a reliance on staff to remember to check all the systems to build up a full picture of care, meant that sometimes information was missed or not shared with everyone, and children and young people were exposed to the risk of harm.
  • Safeguarding governance systems and processes were not effective. Trust-wide safeguarding meetings were not prioritised by all staff and were often poorly attended. Issues with the effectiveness of these meetings had not been raised through the appropriate governance processes.
  • At times staff lacked professional curiosity and did not always follow established systems and processes to recognise and identify child protection issues.
  • Safeguarding training levels had improved since the last CQC inspection but remained below the trust target, particularly for medical and dental staff.
  • There was an overreliance on individual members of the safeguarding team to ensure that processes to keep children and young people safe were implemented. For example, safeguarding huddle meetings did not take place when a member of the team was not able to lead them, and there were no huddles at weekends when the safeguarding team were not on duty.
  • Staff were not supported by regular, formal safeguarding peer review meetings and were not always involved in joint meetings with other agencies to provide input into decision-making for children and young people.
  • Learning from incidents was not embedded to ensure that children and young people were protected from similar harm. Even when learning materials had been circulated following incidents, we saw that the same types of incident were still occurring at the time of this inspection.

However:

  • The trust’s safeguarding children reporting, systems and practices in urgent and emergency care had significantly improved since our last visit.
Inspection areas

Safe

Requires improvement

Updated 22 September 2020

Effective

Requires improvement

Updated 22 September 2020

Caring

Good

Updated 22 September 2020

Responsive

Requires improvement

Updated 22 September 2020

Well-led

Requires improvement

Updated 22 September 2020

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 22 September 2020

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.

Critical care

Requires improvement

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

Good

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

Good

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

Requires improvement

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 22 September 2020

Staff understood how to protect patients from abuse. 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.

Maternity

Requires improvement

Updated 22 September 2020

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.

Other CQC inspections of services

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