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Rotherham General Hospital Requires improvement

Reports


Other CQC inspections of services

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

Inspection carried out on 27-30 September and 12 October 2016

During an inspection to make sure that the improvements required had been made

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 hospital 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. 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 found that, although the trust had made considerable improvements, there remained areas that required further improvement.

Our key findings were as follows:

  • 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.
  • 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.
  • Access to safeguarding supervision was a concern and was in the process of being addressed.
  • 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 the England average. However, on medical wards, there were 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, achieving no mixed sex breaches, 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, 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:

  • 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 also areas of poor practice 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 that facilities on the clinical decision unit are properly maintained in a good state of repair and able to meet patient needs.
  • 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 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).

In addition the trust should:

Medicine

  • Improve the recording of fluid balance to ensure appropriate actions are taken when imbalances are present.
  • Take action to improve compliance with good infection prevention and control practice and procedures.
  • Review provision of hand wash basins in line with relevant guidance e.g. HBN 00-09 IC in the Built Environment and HBN 04-01 Adult inpatient facilities (when wards are being refurbished)

Surgery

  • Continue to review and implement on-site support to junior doctors and advanced nurse practitioners at night.

Critical Care

  • Ensure the Guidelines for the Provision of Intensive Care Services (GPICS) 2015 guidance are implemented.

Maternity

  • The divisional risk management strategy should be reviewed.
  • Review equipment on the delivery suite to ensure it is suitable for use.
  • Review information governance arrangements.

  • Review the use of staff, out of hours, on delivery suite to be the scrub nurse in theatres.
  • Review information systems to ensure they are fit for purpose.
  • Continue to improve mandatory training compliance.
  • Improve the referral to treatment time for gynaecology patients admitted to hospital.

Children and young people

  • Children should be seen in an appropriate environment by staff who are suitably skilled, qualified, and experienced. In particular, in the adult outpatient clinics, on the high dependency unit, on the children’s ward, and in the paediatric dental unit.
  • Children’s and young people’s service should carry out appropriate and timely clinical and nursing audits
  • There should be call buzzers available in all rooms, including the sensory room on the children’s ward.
  • Consider employing a nursing co-ordinator on the neonatal unit, which is recommended as good practice by the Department of Health’s Toolkit for High-quality neonatal services (2009)
  • Staff signatures in care record documentation should be completed and legible/traceable.
  • Review noticeboards in clinical areas to ensure they meet infection control standards.
  • The outside play areas for the children’s ward and children’s OP clinic should be well maintained and fit for children to use.
  • The numbers of SCBU nursing staff that are qualified in speciality should meet the government recommendation of 70%.
  • All staff with direct responsibilities for involvement in reporting and contributing to the assessment of safeguarding concerns should be trained to safeguarding level 3.

Outpatients and diagnostics

  • Continue to review the challenges the environment poses in all departments, particularly orthotics.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 23 -27 February 2015

During a routine inspection

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 29 and was above the trusts target.
  • There had been no Methicillin-resistant Staphylococcus Aureus (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 also found areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • All relevant staff have received appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and living with dementia awareness.

  • All relevant staff are 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 are 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.
  • There are sufficient number of suitably skilled, qualified and experienced staff.
  • The outpatient appointment validation process is completed and actions taken to assess clinical risks to patients of having overdue appointments.

  • The registered person must ensure the environmental risks on the children's ward are assessed and mitigated so that it is safe and secure.
  • They report and investigate incidents in a timely manner and that learning is shared with all staff.
  • Directorate and corporate risk registers are reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals.

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.
  • 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.

Hospital 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

Inspection carried out on 5, 6 June 2013

During a routine inspection

At this inspection we were able to speak with 50 patients and some of their relatives, in total over the two days. This was to ensure we captured the views and experiences of patients who used the service. We also spoke with over 40 staff ranging from care assistants, ward staff, matrons, junior doctors, clinical and medical directors and board members, to assess how they were supported and involved in the trust.

We visited maternity wards, accident and emergency department and admissions wards (B1, B2, B5) over the two days of this visit. We also looked at how the trust managed infection prevention and control . We looked at the way the trust developed policies and procedures and made decisions about how the trust was run and how they communicate with patients, staff and other key stakeholders. We refer to this as governance in the report.

Patient’s who we spoke with on the maternity wards were all positive about the care and treatment they had received. They said they were well informed about the risk and benefits of treatment, they felt their choices and birth plans were respected by staff. Others said their experience had been very good; there were no concerns about staffing on the days of the visit. Women confirmed staff attended to them quickly.

Inspection carried out on 13 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in The Rotherham NHS Foundation Trust Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We visited four wards during this inspection, the wards primarily provided care and treatment to older people.

We spent a period of time observing staff providing care to patients. This method of observation is called the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed six patients on one of the wards for a period of 45 minutes during lunchtime. We recorded their experiences at regular intervals. This included noting the patient’s mood, and how staff interacted with patients, other patients who used services, and the environment.

We saw patients were given the option to use cleansing wipes prior to the meal. Meals were well presented and patients were given the assistance they needed.

The patients with whom we spoke told us that they were treated with dignity and respect. They also confirmed that they were asked what name they wished to be called and their wishes were respected. One patient said “Nurses asked me what I liked to be called. They call me Mrs C this is what I want.”

Patients told us that they were involved in decisions about their care and treatment, and the nurses took time to explain how treatment was given. One patient said “They explain what, why and how about my treatment and keep me informed of progress.”

Patients told us that they were very satisfied with the meals provided while they were in hospital. Patients were provided with a wide choice of food and drink which they selected earlier in the morning. The food was described as “Delicious.” “Choice and variety of food is fantastic.” “It’s substantial when you think of the number and variety of people they cater for.”

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 1 February 2011

During a routine inspection

People told us that they were regularly consulted about their care and treatment. People said the consultants spoke to them on the wards and told them about the treatment and how long they may have to stay in hospital. They told us the staff always respected their dignity and ensured their privacy was maintained. People told us “Physiotherapists and Occupational Therapists helped them to get on their feet and made sure they were safe”.

People told us that they had given consent to the care and treatment they received, although some said they had been really poorly and could not remember much about their admission into the hospital.

People told us they were very well looked after and they rated their care as very good. They said they received help with personal care and the nurses were “like angels”. They said that everyone was working to assist them to go home, which included making plans to help them return home.

One person told us that the food was very good, with lots of choice. People said they could choose to have soup and a sandwich instead of a big meal. Another person told us the food is smashing, with lovely roast dinners. “We get lots of drinks including water and choices of tea and coffee”. “The food is nutritional and was always hot”.