The Robert Jones & Agnes Hunt Hospital

Updated 21 February 2019

The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is a specialist orthopaedic centre. It provides specialist and routine orthopaedic care to its local catchment area, and specialist services both regionally and nationally.

The organisation is a single site hospital based in Oswestry, Shropshire, close to the border with Wales. As such, the trust serves the people of both England and Wales, as well as acting as a national healthcare provider. It also hosts some local services which support the communities in and around Oswestry.

The hospital is a specialist centre for the treatment of spinal injuries and disorders, and also provides specialist treatment for children with musculoskeletal disorders. Additionally, the trust works with partner organisations to provide specialist treatment for bone tumours and community based rheumatology services.

The trust is part of the National Orthopaedic Alliance (NOA), an acute care collaboration vanguard designed to improve orthopaedic care quality across England.

(Source: Trust Website)

Updated 21 February 2019

Our rating of services improved. We rated it them as good because:

• Our rating of safe was overall. Services managed patient safety incidents well. Services had sufficient numbers of permanent staff with the right qualifications, training and experience to keep people safe from avoidable harm and abuse. Services controlled infection risk well.

• Our rating of effective was good overall. Services monitored the effectiveness of care and treatment and used the findings to improve them. Staff were competent to carry out their role. Patients were supported to live healthier lives and manage their own care and wellbeing needs where appropriate.

• Our rating of caring was outstanding overall. Staff exceeded the expectations of patients and family members in their passion for patient care. Staff worked in a creative and innovative manner to provide exceptional, strong and caring emotional support that exceeded patients’ expectations to minimise their distress. Staff consistently involved and empowered patients and those close to them as active partners in their care and treatment.

• Our rating of responsive was good overall. Services took account of patients’ individual needs and planned and provided services in a way that met the needs of local people and the specialist needs of people within the region who were living with spinal injuries.

• Our rating of well-led was good overall. Managers at all levels in the trust had the right skills and abilities to run a service providing high quality sustainable care. There was a vision in place for what the trust wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

Updated 21 February 2019

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service had suitable premises and equipment and looked after them well.
• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
• An effective early warning system was in place to identify deteriorating patients and appropriate action was taken in response to this.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.

• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

• Arrangements were in place to ensure patients could access medical support seven days a week. The service was in the process of reviewing the provision of seven-day therapy to the medical wards.

• Patients were supported to live healthier lives and manage their own care and wellbeing needs where appropriate.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

• Staff consistently exceeded the expectations of patients and family members in their passion for patient care. They were committed to patients’ progress, and were motivated and inspired to provide kind and dignified care that supported patient needs on every level.
• Staff on all the medical wards consistently focused not only on patients’ physical health and comfort, but also their emotional wellbeing. Sometimes, staff used their own time to facilitate trips to events off site to ensure patients emotional wellbeing needs were met.
• Staff worked in a creative and innovative manner to provide exceptional, strong and caring emotional support that exceeded patients’ expectations to minimise their distress.

• Staff consistently involved and empowered patients and those close to them as active partners in their care and treatment.

• The service planned and provided services in a way that met the needs of local people and the specialist needs of people within the region who were living with spinal injuries.
• The service took account of patients’ individual needs.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

• Managers at all levels in the trust had the right skills and abilities to run a service providing high quality sustainable care.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

• The service provided mandatory training in key skills to all staff. However, staff did not always complete mandatory training in a timely manner.
• People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with the English average. However, the service was working proactively towards addressing these delays.

Updated 21 February 2019

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

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

• The service provided care and treatment based on national guidance and evidence of its effectiveness.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

• Staff always cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

• The trust planned and provided services in a way that met the needs of local people.

• Managers had the right skills and abilities to run a service providing high-quality sustainable care.

• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

• Out of hours paediatric consultant support was only available via telephone.

• A ligature point risk assessment had been carried out however not all risks had been mitigated. We highlighted further risks during the inspection which the service took immediate action to mitigate.
• Limited printed information was available in other languages.

Updated 21 February 2019

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

• Mandatory training compliance rates among nursing and medical staff were below the trust target, which included compliance with sepsis training.
• The outreach team only provided limited cover at times as a result of responding to pressures hospital wide.
• All arrangements relating to medical staffing were not formalised which meant it was unclear if patients always received safe care and treatment.
• Handover, shift change and ward round arrangements between duty consultant anaesthetists were not in line with recommendations and standards.
• There was limited assurance relating to medicine management practices.
• Existing trust policies, procedures and protocols were not always up to date.
• Awareness of all necessary policies, procedures and protocols was not always possessed by all members of staff.
• Although there was participation in quality improvement initiatives, it was limited and only implemented recently.
• Limited information on outcome measures was being monitored, recorded or assessed.
• There was limited participation in clinical audit however, the service has been involved in the self-assessment for the West Midlands Critical Care Network.
• The high dependency unit was not currently benchmarking themselves against similar units apart from using ICNARC data.
• Although appraisals took place within the unit, not everyone had received one which meant there were gaps in the arrangements for supporting and managing staff to deliver effective care and treatment. There was no clinical nurse educator, monthly one to ones and clinical supervision did not take place so it was unclear whether there were effective processes for identifying the learning needs of all staff.
• Not all services on the high dependency unit were available seven days a week.
• The systems for evidencing all staff complied with the Mental Capacity Act were ineffective.
• People were always discharged to the most appropriate place but not always at the right time.
• There was limited specialist critical care knowledge among the leadership team.
• Action being taken to address the challenges faced by the high dependency unit was limited.
• Ensuring sustainable and effective leadership within the high dependency unit for all elements of the service was not a priority.
• There was no clear plan on how the vision for the high dependency unit was going to be achieved.
• Governance arrangements did not function effectively or interact with each other appropriately. All appropriate information did not appear to be shared, discussed and reviewed by all appropriate persons.
• Specific governance arrangements with the high dependency unit were lacking.
• There were ineffective assurance systems and processes for ensuring performance issues were escalated appropriately.
• There was a lack of assurance all risks associated with the high dependency unit had been identified, recorded and mitigated. Most risks had been identified but action to mitigate them was limited.
• Service performance measures were being reported but there was no evidence they were being effectively monitored or used to improve practice.

However;

• Training and regular updates in the systems and processes which helped to keep people safe were available to staff.
• Safeguarding systems, processes and practices were effective and staff demonstrating good understanding of their responsibilities.
• Cleanliness and hygiene were well maintained and there were reliable systems to prevent and protect people from healthcare-associated infections.
• Premises and facilities were designed and used to keep people safe.
• Appropriate risk assessments were carried out for patients.
• Nursing staffing arrangements ensured people received safe care and treatment. For example, nursing to patient ratios were compliant with standards.
• Patients’ individual care records were written and managed in a way that kept them safe.
• Medicines management kept people safe but pharmacy support was not in line with best practice.
• Care and treatment provided by the service was delivered in line with legislation, standards and evidence based guidance and patients had timely access to initial assessment, test results, diagnosis and treatment.
• The needs of patients were assessed, monitored and met, which included patients’ nutrition, hydration and pain.
• Some information was collected and monitored in relation to patient outcomes. The data showed the intended outcomes for patients were being achieved.
• Nursing staff had the right qualifications to deliver effective care, support and treatment.
• In general, there was good multidisciplinary working as different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
• Patients’ personal, cultural, social and religious needs were understood by staff and were taken into account when care was delivered.
• Staff were respectful and considerate.
• Patient satisfaction within the high dependency unit was excellent.
• Staff always made patients aware of who they were and why they were visiting them.
• Confidentiality was respected when conversations about patient care took place.
• Patients were able to understand their care, treatment and condition as conversations with clinical staff were clear and uncomplicated.
• Patients’ relatives, loved ones and carers were kept informed of what was happening. They were always identified, welcomed and treated as important partners in the delivery of their care.
• The service provided reflected the needs of the population served and were designed and planned to meet patients’ needs.
• Facilities and premises were appropriate for the services delivered. Translation services were available to patients whose first language was not English.
• Services were delivered to ensure they were accessible and responsive to patients with complex needs.
• Patient dignity and respect were protected.
• Pathways into the high dependency unit were effective and action was taken to minimise the length of time people had to wait for care, treatment and advice.
• There were minimal delayed discharges from the unit and patients were usually discharged in accordance with national standards.
• Complaints were handled effectively and confidentially, with complainants provided with regular updates.
• Staff felt local leaders were visible, supportive and approachable.
• The trust had a clear set of values, with quality and sustainability as the top priorities.
• Staff felt supported, respected, valued and proud to work in the high dependency unit.
• Patients were given the opportunity to provide feedback about their care.
• Staff appeared to be actively engaged.

Updated 21 February 2019

We previously inspected diagnostics jointly with outpatients so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• The service had suitable premises and equipment and looked after them well.

• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

• The service mostly followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.

• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

• The service made sure staff were competent for their roles. Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

• Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.

• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

• Staff provided emotional support to patients to minimise their distress.

• Staff involved patients and those close to them in decisions about their care and treatment

• The trust planned and provided services in a way that met the needs of local people.

• The service took account of patients’ individual needs.

• People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

• The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However,

• Although the service provided mandatory training in key skills to all staff and had systems in place to ensure compliance, not all staff were fully complaint.

• Not all staff were up to date with safeguarding training.
• There was an increase in patient safety incidents on Mondays and Tuesdays due to these being the busiest days of the week.

• Staff did not display radiation signs in theatre areas to alert people that radiation was in use for interventional procedures.

Updated 21 February 2019

We previously inspected outpatients jointly with diagnostics so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

• People were protected from avoidable harm and abuse. The service met legal requirements.
• People were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met through the way services were organised and delivered.
• The leadership, governance and culture promoted the delivery of high quality person centred care.

Updated 21 February 2019

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

• There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service made sure staff were competent for their roles.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Patients told us they felt involved in their own care and treatment as staff took time to explain what was happening and why.
• We saw examples where staff had gone above and beyond what was expected to support patients.
• The trust planned and provided services in a way that met the needs of local people.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Managers and senior leaders had the right skills to perform their roles effectively.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• There was evidence of improved culture across the service and there was strong leadership.
• Staff told us they felt supported, respected, valued and were proud to work at the trust.
• The trust had developed a quality improvement process to monitor care standards and identify improvements. The Sustaining Quality Through Assessment and Review (STAR) assessment is a trust wide approach in monitoring quality standards of patient care within the clinical environment.
• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research, and innovation.

However:

• In some cases, the mandatory training compliance was below the trust target of 92%.
• Although there was a review underway, we found that several trust policies required reviewing and were therefore out of date at the time of inspection.
• Mostly we found staffing levels were good and any risk was managed well, however, we saw a potential risk for senior cover at night, should there be more than one emergency that occurred at the same time.