Royal Hallamshire Hospital

We inspected the Royal Hallamshire Hospital as part of the inspection of Sheffield Teaching Hospitals NHS Foundation Trust from 7 to 11 December 2015. We undertook an unannounced inspection on 23 December 2015. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

Overall, we rated Royal Hallamshire Hospital as good. We rated safe, effective, caring and responsive as good; well-led was rated as outstanding.

We rated critical care, maternity and gynaecology and outpatients and diagnostics as outstanding. Emergency and urgent care, medical care and surgery were rated as good. End of life care was rated as requires improvement.

Our key findings were as follows:

• We found the hospital was clean and staff adhered to infection control principles. The trust scored 99% for cleanliness in the patient-led assessments of care environments (PLACE) report for 2015.
• There was a trust- wide infection control accreditation programme in place. This programme set standards for infection prevention and control practice. Most clinical areas had achieved accreditation; plans were in place where this was not the case.
• There had been four cases of MRSA reported by the trust between June 2014 and June 2015.
• There had been six cases of C.difficile between April 2015 and November 2015 at the Royal Hallamshire Hospital. This was a rate in line with the England average per 10,000 bed days. The trust-wide rate of C.difficile was below the trajectory target with 42 cases against a stretch target of 52 cases at the end of November 2015.
• The trust the safer nursing care tool, professional judgement and nursing hours per patient day to determine appropriate levels of staffing. There were some areas where staffing fell below planned levels on a regular basis, although the trust was mitigating risks as far as possible. Recruitment to vacancies was in progress. Staff were able to use bank or agency staff to fill staffing shortfalls.
• Staffing levels within maternity were monitored and reviewed to keep women safe at all times.
• The neonatal unit had gaps in medical staffing; however these gaps were being covered by advanced neonatal nurse practitioners. Nurse staffing on the neonatal unit was not at current recommended staffing levels.
• The trust was committed to the development of advanced nurse practitioners to ensure patient care was maintained and the potential recruitment difficulties to junior doctor posts mitigated. This also allowed good advancement opportunities for nurses. The neonatal unit worked in a family centred way, to promote the confidence of parents in caring for their baby. This helped facilitate the unit’s strategy of early discharge, with the support of the neonatal outreach team and the rapid access clinic. Within the maternity unit, there was excellent multidisciplinary working that promoted integral care.
• Mortality indicators showed no evidence of risk. However, following the inspection, the hospital was identified as an outlier for the incidence of puerperal sepsis. The trust reviewed case notes and responded appropriately: an action plan was put in place.
• Patients were assessed for their nutritional needs. The trust had introduced HANAT (hydration and nutrition assurance toolkit) to encourage good nutrition and hydration best practice in the hospital environment.
• There was a well-established culture of continuous quality improvement. This was supported and assured by robust governance, risk management and quality monitoring. The trust used a Microsystems Coaching Academy which worked well to support small scale service improvements.
• The trust’s vision and values were embedded in practice. These informed performance reviews and staff felt they were meaningful.
• Clinical directorates had individual five year strategies that were linked to trust’s strategy, aims and objectives. The directorate strategies had consideration of the other clinical departments they worked with to deliver high quality care and the assistance required from corporate directorates and other partners.
• There was variation in the quality and completeness of Do Not Attempt Resuscitation (DNACPR) forms.
• There were evidence based nursing care guidelines, which fulfilled the function of care plans, available for reference for a wide range of possible care needs. However, these were not printed and available at the patients’ bedside or with the patients’ care record. Some wards had printed reference files available for staff to use, however we did not observe staff using these. Other wards referred us to the intranet to view these guidelines and again we did not observe staff referring to these. Staff told us computers were not always easily accessible and that new, bank and agency staff did not always have an individual log on. This meant that care plans / guidelines were not always accessible for staff delivering care.

We saw several areas of outstanding practice including:

• Staff in theatre had introduced a learning disability pathway. An operating list was dedicated to patients with a learning disability, if the patient needed more than one procedure this was carried out on the same operating list under the same general anaesthetic.
• The use of duty floor anaesthetist role in theatre, developed in Sheffield, was going to be used by the Royal College of Anaesthetists as a beacon of good practice.
• The operating services, critical care and anaesthesia care group developed “The Magnificent 7” a document outlining seven areas for achievement in the department. The seven areas included zero harm, making every operating minute count and transformation through technology. Each area had a lead, an executive sponsor, an action plan and a review date.
• One of the urology consultants held the most senior position at the European Association of Urology, the international authority on urological research.
• A robot used in urology surgery had given superior outcomes compared to traditional surgical techniques. The robot was used by surgeons across the specialities of urology, ENT and gynaecology.
• The neurosciences directorate introduced an electronic referral tool “Refer a patient.” This shared referral information between the referrer and neurosurgeon who could give an immediate decision and feedback to the referrer.
• The podiatry service had been awarded Customer Service Excellent Award for the 15 consecutive years.
• A neuro simulation team-training programme for anaesthetists was being piloted on neuro critical care. This was training for the whole MDT and aimed to prepare staff for the challenges of managing acutely unwell patients. It introduced staff to crisis resource management non-technical skills.
• An innovative clinic providing medico-legal expertise was available to patients and their families. The service gave access to experienced legal professionals able to give advice across a breadth of areas including managing the personal affairs of a patient.
• The one to one team and specialist midwife clinics gave greater assurance that high risk women continued to have a choice on the care they received in pregnancy.
• The rapid access clinic reduced readmissions of babies with feeding problems.
• The GRIP project responsible for getting research into practice improved services for maternity and gynaecology.
• The termination of pregnancy service gave women continuity of care in an appropriate caring environment. The seven day service gave women choice and improved accessibility.
• The use of the Enhanced Recovery programme in both maternity and gynaecology improved the service for women.
• ‘Devices for Dignity (D4D) Healthcare Co-operative’ was hosted by the trust. This is a national initiative to drive forward innovative products processes and services to help people with long-term conditions’. The Devices for Dignity (D4D) Healthcare Co-operative’ had been recognised with a number of awards including; 2012 Advancing Healthcare Awards and Allied Health Professionals and Healthcare Scientist; Leading Together on Health Award.
• Sheffield ophthalmology was the only centre in the country that carried out stereotactic radiosurgery (SRS). This treatment uses radiation therapy and focuses high-power energy on a small area of the body. The service had been carrying out this procedure for the past 25 years. The service also carried out photodynamic therapy (PDT) to treat cancer and audits showed this treatment had an 85% success rate. Photodynamic therapy is a treatment that uses a drug, called a photosensitizer or photosensitizing agent.
• Staff in the diabetes service had just started a six-year National Institute for Health Research (NIHR) programme to further develop education about type 1 diabetes.
• Histopathology was using digital pathology. Six biomedical scientists at the NGH site had been trained to prepare frozen sections of tissue; this preparation used to be undertaken by histopathology consultants. The biomedical scientists dissect and prepare the samples while on video link to the RHH so that the technique can be checked and quality maintained. Staff scanned and digitally transferred the resulting image to the histopathology consultants at the RHH site. This technique was time efficient and speeded up the process for the patient.
• Cancer services at the trust had won awards from the Health Service Journal and the Nursing Times. For example, in 2014 the service had received the Cancer Care Award.
• The development of the Sheffield 3D imaging lab is unique to the NHS and provides improved quality of scans and detail of brain tumour growth. Images could be processed quicker, in seconds rather up to an hour, saving time and money. The 3D lab was a finalist in the Yorkshire and Humber Medipex NHS Innovation awards.
• In addition to walk in services for general plain film imaging GP’s could refer patients directly for CT, MRI, ultrasound, fluoroscopy and other specialised imaging examinations.
• There was a state of the art Medicines and Healthcare products Regulatory Agency (MHRA) Licenced Radiopharmacy, serving all of the trusts locations.
• Nuclear medicine staff were finalists in the Medipex NHS innovation awards 2014 after developing a new system for diagnosing debilitating digestive disorder that freed up the gamma camera, so reducing patient waiting times.

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

Importantly, the trust must:

• Ensure the safe storage of intravenous fluids.

• Ensure doctors follow policy and best practice guidance in relation to the prescription of oxygen therapy.

• Ensure that guidance is followed in the documentation of fetal heart rate monitoring’s. In 86% of 39 CTG records, there was no data at the start or end of the monitoring, such as the women’s heart rate, clarification that the clock was correct, staff signature and indication for monitoring. Events in labour and review by a second practitioner were not always documented on the monitoring, in accordance with trust guidance (Intrapartum fetal monitoring - CTG, 5.5, 5.6).

• The trust must ensure that DNACPR records are fully completed.

• The trust must ensure a strategy for end of life care is implemented.

In addition the trust should:

• The hospital should ensure that staff have attended mandatory training in accordance with the trust target.

• The MIU should improve the monitoring of time to be seen and total time in department.

• Although the MIU works closely with the A&E at NGH, audits specific to the MIU should be completed to show effectiveness and to monitor improvement to services and treatment offered in this location.

• Review the use of nursing care guidelines and ensure they are consistently available for all staff providing patient care, to enable accountability for care provided.

• The trust should improve the compliance rates for medical and nursing staff receiving an annual appraisal.

• The trust should continue to take action to reduce the number of medical outlier patients across the trust.

• The trust should continue to take action to reduce the number of bed moves patients experience during their hospital stay.

• The trust should try to reduce the movement of staff to clinical areas outside of their speciality.

• The trust should introduce a robust process to share lessons learnt from incidents and mortality and morbidity reviews across directorates and care groups.

• The trust should review the labelling of babies prior to their removal from the obstetric theatre.

• The trust should ensure that the neonatal resuscitaires in labour suite has documented checks. We identified checklists that had signatures missing 22% of the time for the month examined.

• The trust should continue to improve consultant medical staffing on labour ward in accordance with Royal College of Obstetrician and Gynaecologists guidelines.

• The trust should review data collection methods and introduce a system to collect patient outcomes by surgical speciality within care groups.

• The trust should review the waiting times for patients with learning disabilities requiring dental treatment under general anaesthesia against the 18 week standard.

• The trust should ensure appropriate medical and nursing staffing on the neonatal unit to reflect current national guidelines for safe care.

• The trust should review patient centred care planning on the neonatal unit.

• The trust should consider improving the way in which medicines are constituted within the neonatal unit to ensure there is a safe environment to do this, and reduce risk of medicine errors.

• The trust should monitor preferred place of care for patients at the end of life.

• The trust should review access and the environment of the chapel and prayer room.

• The trust should develop standard procedures for completing interventional radiology non-surgical safety checklists for all staff to follow.

• The trust should undertake regular audits of patient electronic records to ensure consistency in the completion of MRI safety checklist and pregnancy checks.

• The trust should review oversight of the area and facilities for patients waiting for transport following the clinic appointments.

• The trust should monitor access to records in the outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals