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Inspection Summary


Overall summary & rating

Good

Updated 23 August 2018

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

  • There were commendable examples of compassionate care; we saw staff go the extra mile several times and their care and support exceeded good care standards in some circumstances. There was a strong, visible person-centred culture. Discussions between staff and patients were carried out in a compassionate and supportive way; staff provided reassurance and information appropriate for the individual patient and their family.
  • Pathways of care were focussed on the individual patient and involved collaboration with other service providers to meet the needs of patients and to ensure continuity of care.
  • Patients with a learning disability, those living with dementia, and bariatric patients could access services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined-up way within the hospital.
  • Patients we spoke with all felt involved in their care and had been provided with information to help them make informed decisions about their care.
  • Patients were protected from abuse because staff had received training in safeguarding; there was a multi-disciplinary safeguarding team who provided comprehensive support to front line staff.
  • Patients, families, and staff were supported by the delirium and dementia outreach team (DDOT). The team supported patients with, or at risk of cognitive difficulties. There was support for carers and families in the form of information, education, and specialist advice. Therapeutic activities were provided for patients and the DDOT team visited wards across the trust to support cognitively frail in-patients who could not leave the acute areas. A follow up outpatient clinic was provided for patients who had experienced delirium.
  • The psychiatric liaison team supported patients with mental health needs who were cared for in all areas of the hospital. The team also provided training to staff in order to support their learning.
  • There were established multidisciplinary team (MDT) meetings for discussion of patients on specific pathways or with complex needs, this included attendance from nursing and medical staff, allied health professionals, and social workers.
  • There was collaborative working with the local authority to promote timely safe discharges from hospital.
  • There had been pharmacy initiatives which had been developed to support the needs of frail older people.
  • There was strong clinical leadership in the areas we inspected and a strong sense of teamwork within different groups of staff who worked cohesively together for the benefit of patients. Leaders were visible, approachable, and responsive and promoted cohesive working and a positive culture.
  • Staff generally felt that managers communicated well with them and kept them informed about the management of the wards and service changes.
  • Staff were encouraged to report incidents. We saw evidence from actions plans and root cause analysis that staff had identified and investigated serious incidents appropriately.
  • Local risk registers were in place which highlighted current risks and actions being taken to reduce the risk. Risks were discussed at governance meetings and we saw escalation of the risks to senior managers and clinical leads within the directorates.
  • Changes in practice were based on national guidelines and best practice and were audited to ensure they were embedded throughout the clinical areas.
  • There had been improvements in the recruitment of nursing and medical staff.
  • Wards, department and public areas were clean and tidy. Cleanliness scores were displayed in the clinical areas. All clinical equipment was clean and ready for use.

However;

  • Nurse staffing levels were consistently poor in some medical, elderly and surgical wards. There were unfilled shifts in acute areas; staff were moved from wards with higher levels of staffing to cover those working with less than safe levels. This impacted on the safety and quality of patient care.
  • Infection control procedures were not always followed in relation to hand hygiene, the use of personal protective equipment; staff were not always ‘bare below the elbow’. This posed a risk to patients.
  • Resuscitation and emergency equipment was not always checked regularly to ensure medicines and equipment was safe to use and within date.
  • There was inconsistent practice across wards regarding the management of medicines, for example drug fridge temperatures were not consistently recorded on some wards. Controlled drugs were not always checked as per the hospital policy.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and there was a need to improve compliance with mandatory training.
  • Some national audit results were poor and clinical areas were not meeting standards.
  • The trust was much worse than the England average for unplanned re-attendance rates in the emergency department.
  • Lessons learned after two never events in 2017 were not shared across all surgical areas after each of the events.
  • Some clinical policies and guidelines were past their review date. This meant staff did not always have the most up to date guidance to follow.

Inspection areas

Safe

Requires improvement

Updated 23 August 2018

Effective

Good

Updated 23 August 2018

Caring

Good

Updated 23 August 2018

Responsive

Good

Updated 23 August 2018

Well-led

Good

Updated 23 August 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 20 January 2015

We rated outpatients as good. The care and treatment received by patients in the outpatient departments within the hospital was safe, effective, caring, responsive and well-led. Patients were happy with the care they received and found the service to be caring and compassionate.

Staff were well trained and supported and worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm, because policies and procedures were in place to ensure that this was managed appropriately.

Patients were given follow-up appointments when they should receive them. Staff were listened to, and patients were engaged with and their opinions actively sought.

On the whole, the services offered were delivered in an innovative way to respond to patients’ needs and ensure that the departments worked effectively and efficiently.

Maternity

Good

Updated 23 August 2018

We previously inspected maternity services jointly with gynaecology services and rated the service overall as good. We cannot compare our new ratings below directly with our previous ratings because at this inspection we only looked at maternity services.

We rated the service as good because:

  • The senior leadership team running the service were highly visible, approachable, and responsive and worked as a cohesive team to promote a positive culture.
  • The average percentage for one to one care in established labour was 94%, this had improved from the last inspection.
  • Staff knew how to report incidents and were encouraged to do so. We saw evidence, from action plans, root cause analyses and from reviewing minutes of meetings, that serious incidents were identified and investigated appropriately and lessons shared.
  • In theatres the service used a maternity modified World Health Organisation surgical safety checklist and monitored compliance.
  • Changes in practice were based on national guidelines and best practice and audited to ensure they were embedded throughout the team.
  • Patient outcomes were mostly in line with national averages when compared to similar services.
  • Apart from the antenatal day unit and clinics, a full seven-day service was provided which patients could access directly without having to go through their GP.
  • Patients we spoke with all felt involved in their care and had been provided with information to allow them to make informed decisions.
  • Staff were compassionate and caring and, for those patients experiencing a pregnancy loss, there were counselling and bereavement services available together with a sympathetically equipped bereavement suite.
  • The trust served a community with a wide range of needs and there were effective systems in place to ensure effective communication.

However;

  • As at April 2018, recommended midwifery to birth ratios were not met. The service did not meet the national benchmarking for midwifery staffing. The Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour set by the Royal College of Obstetricians and Gynaecologists (RCOG), recommend a ratio of 1:28. The ratio of midwives to births was 1:29.
  • The number of babies with an Apgar score of less than seven at five minutes was marginally higher than the England average. However, the service had put action plans in place to address this and initial investigations showed there was no harm caused to babies.
  • Staff told us many clinical guidelines were past their review date. The service had prioritised updating those guidelines affected by national guidance, so those beyond the review date were the guidelines little used by staff. Work to ensure all guidelines were updated was on-going and the service had put this piece of work on its risk register.

Maternity and gynaecology

Good

Updated 20 January 2015

We rated maternity services as good. The maternity department provided safe and effective care in accordance with recommended practices. Arrangements were in place to manage and monitor infection control, medicines and safeguarding procedures.

The maternity service used national evidence-based guidelines to determine the care and treatment it provided. There was a multidisciplinary approach that involved a range of providers across healthcare systems to enable services to respond to the needs of women. The service participated in national and local audits.

Resources, including equipment and staffing, were sufficient to meet the needs of women, although the ratio of midwives to women in labour was slightly lower than nationally recommended levels. Additional midwives were being recruited to address the staffing shortfalls. Medical staffing was in line national recommendations.

There were occasions where capacity interrupted the provision of services in antenatal care and access to theatre for elective caesarean sections. This meant that women experienced longer waiting times or their operations were delayed. The maternity service had carried out service reviews, and plans were in place to improve these areas.

The individual needs of women were taken into account in planning the level of support throughout their pregnancies. Feedback from women about the standard of care they received was positive.

The service was well-led. There was an open and transparent culture that encouraged reporting and learning from adverse events. Staff showed a strong commitment to patient care and treatment. There was evidence of public and staff engagement, and action had been taken following real-time feedback from women and staff. The service had been nominated for a number of awards in innovation and service improvement.

Medical care (including older people’s care)

Good

Updated 23 August 2018

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

  • Patients were protected from abuse because staff had received training in safeguarding, there was a named nurse for safeguarding, and staff reported good support from the psychiatric liaison team. The psychiatric liaison team offered staff training to wards as requested.
  • Wards and departments were clean and ward cleanliness scores were displayed in the wards. All clinical equipment was clean and labelled providing assurance of cleanliness.
  • Discussions between staff and patients were carried out in a compassionate and supportive way, staff provided reassurance and information appropriate for the patient.
  • Completion rates for mandatory training were seen as a priority by the senior management team and had improved at the time of inspection.
  • Patient observations were recorded appropriately on the electronic system and concerns about deteriorating patients were escalated in accordance with guidance.
  • A process was in place to ensure that patient group directions (PGDs) were effectively managed.
  • Electronic and paper care plan documentation and risk assessments were fully completed and fluid, food and rounding charts were completed appropriately.
  • Hospital results were better than the England and Wales average for eight of the nine standards relating to discharge.
  • Staff and patients were supported by the delirium and dementia outreach team (DDOT). The team supported patients with, or at risk of cognitive difficulties. There was support for carers and families in the form of information, education, and specialist advice. Therapeutic activates were provided for patients and the DDOT team visited wards across the trust to support cognitively frail in-patients who could not leave the acute areas. A follow up outpatient clinic was provided for patients who had experienced delirium.
  • The division used innovative approaches to provide pathways of care that were focussed on the individual and involved collaboration with other service providers designed to meet the needs of patients through co-ordination of services to ensure continuity of care.
  • The trust had worked with the local authority to ensure continuity of discharge from hospital and had developed a ‘discharge hub’.
  • Facilities and premises were innovatively designed to meet the complex needs of patients and provide treatment in a conducive environment.
  • The division provided outreach clinics to enable patient access to services and appointments in a way and at a time that suits them.
  • Initiatives such as the ‘Screening tool of older persons prescriptions in frail adults with limited life expectancy’ (STOPPFrail) had been developed to meet the needs of vulnerable patients.
  • Staff showed a good understanding of mental capacity and referred to it as being decision and time specific.
  • The average length of stay for medical elective patients at Sunderland Royal Hospital was lower than the England average.
  • The trust had been consistently below (0.06-0.12 falls per 1000 bed days) the national average (0.19) for patients suffering harm from a fall in hospital.
  • The trust’s referral to treatment time (RTT) for admitted pathways for medicine (91%) was above the England average (89%).
  • The division had developed a consultant led chest pain assessment unit for the rapid diagnosis of chest pain.
  • A frailty and community geriatrics service had been introduced which identified older patients with frailty attending the hospital.
  • We saw the division proactively identified the changing needs and preferences of patients and responded appropriately, e.g. home haemodialysis
  • The division of medicine had a clear and effective management structure in place with clear lines of responsibility and accountability.
  • Staff felt that managers communicated well with them and kept them informed about the management of the wards and service changes.
  • Senior staff were motivated and enthusiastic about their roles and had clear direction with plans in relation to improving patient care.

However;

  • Staffing levels were reviewed three times each day and staff were moved from wards with higher levels of staffing to cover those working at less than safe levels. This was designed to ensure patient safety but had caused concern over the lack of continuity of care from staff moved at short notice to unfamiliar wards.
  • Fill rates for qualified nurses and non-qualified care staff varied in the six months before inspection and did not rise above 77% for qualified staff during the day and 81% at night. These shortfalls in qualified nurse staff had been met by an increase in non-qualified care staff (113% during the day and 103% at night).
  • Ward managers told us that staffing was not based on a specific patient acuity tool and this led to inconsistency.
  • We found inconsistent practice across wards regarding the management of medicines, e.g. fridge temperatures were not recorded on some wards
  • The heart failure audit identified input from a consultant cardiologist was lower than the England and Wales average.
  • The lung cancer audit identified the proportion of patients seen by a cancer nurse specialist was 83%, which was worse than the audit minimum standard of 90%. (After our inspection, the trust told us a large proportion of lung cancer patients were admitted for palliative care and therefore not seen by the lung cancer nurse specialist).
  • The friends and family test response rate for medicine at Sunderland Royal Hospital was worse than the England average and specific strategies were not in place to increase the response rate.
  • For medical non-elective patients, the average length of stay was 7.7 days, which is higher than England average of 6.6 days.
  • The trust took an average of 28 days to investigate and close complaints; this slightly worse than the trust complaints policy where the aim was to close them within 25 days.

Urgent and emergency services (A&E)

Good

Updated 23 August 2018

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

  • A system had been put in place to ensure that patients had an initial assessment on arrival to the department within 15 minutes by nurses who had undergone triage training.
  • Policies and procedures online were reviewed and up to date.
  • There were outstanding examples of caring, compassionate care and maintaining privacy and dignity. We saw staff go the extra mile several times and their care and support exceeded good care standards. The caring relationships were highly valued by staff and promoted by the matron. There was a strong, visible person-centred culture.
  • Patients and families were involved in the decision making on their care in a way that they understood.
  • Services were planned in a way to meet the individual’s needs.
  • Patients with a learning disability, those living with dementia, and bariatric patients could access emergency services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined-up way from within the department.
  • The emergency department had designated mental health assessment that met best practice guidance for a safe metal health assessment room. Staff assessed patients who presented at the rooms that had no ligature points. Staff routinely carried personal alarms.
  • Complaints were managed in line with the trust’s policy timescales.
  • There was a sense of teamwork within the department and operational staff worked together in partnership to provide effective leadership.
  • Senior clinical leadership was visible in the department during our inspection and attended the department to support staff during our inspection.

However;

  • Infection control procedures were not always followed in relation to hand hygiene and use of personal protective equipment.
  • Resuscitation and emergency equipment was not checked regularly to ensure medicines and equipment had not expired.
  • Mandatory training was not always completed by medical or nursing staff in a timely manner and the department needed to improve compliance with mandatory training.
  • The department needed to improve compliance with appraisal rates in the department.
  • National audit results were poor and the department was not meeting most of the standards. Further local audit work was underway to ensure that audit compliance improved.
  • The trust was much worse than the England average for unplanned re-attendance rates.

Surgery

Good

Updated 23 August 2018

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

  • There was a senior team in the surgery division covering business and clinical leadership. We found that this team was cohesive and promoted a positive culture in the service.
  • Staff were encouraged, and knew how, to report incidents. We saw evidence from actions plans and root cause analysis that staff identified and investigated serious incidents appropriately.
  • The surgical division had risk registers in place. These highlighted current risks and documented mitigating actions to reduce the risk. Risks were discussed at governance meetings and we saw escalation of the risks to senior managers and clinical leads within the division/trust.
  • Completion of the World Health Organisation surgical safety checklist was monitored and regularly met trust targets.
  • Recruitment of nursing and medical staff had improved with wait lists for some theatre posts.
  • Changes in practice were based on national guidelines and best practice and were audited to ensure they were embedded throughout the team.
  • Themes and trends of complaints were monitored by the matron and shared with staff through one to one discussions, emails, ward rounds and team meetings.
  • There were established multidisciplinary team (MDT) meetings for discussion of patients on specific pathways or with complex needs, this included attendance from consultants, specialist nurses, allied health professionals and radiologists.
  • All patients at Sunderland Royal Hospital had a lower than expected risk of readmission for non-elective admissions when compared to the England average.
  • Patient reported outcome measures (PROMS) were about the same as the England average.
  • Surgical consultants provided a seven-day service. Consultants were available on call out of hours and would attend when required to see patients at weekends. The trust’s pharmacy provided a seven-day service from 8am to 8pm. We found that patients had access, seven days per week, to diagnostic services – for example, x-rays.
  • Patients we spoke to all felt involved in their care and had been provided with information to allow them to make informed decisions.
  • The trust served a community with a wide range of needs and translation services were available for people whose first language was not English. The trust had access to a braille translation service, induction loop, and British sign language signing service. We saw that information leaflets were also available in a pictorial and easy-read format and described what to expect when undergoing surgery and post-operative care.
  • We observed positive, kind and caring interactions on the wards and between staff and patients.
  • We identified good examples of continuous improvement and innovation, such as improvements in patient flow and performance in theatres, and the introduction of loop gastric bypass.

However;

  • Data showed that between 1 October 2017 and 31 March 2018 the wards D41, D42 and D48 had 56.6%, 44.5% and 63% (consecutively) unfilled shifts.
  • In accordance with the Serious Incident Framework 2015, the trust reported six serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from January 2017 to December 2017. These included: surgical/invasive procedure incident meeting SI criteria with three (50% of total incidents); pressure ulcer meeting SI criteria with two (33% of total incidents) and slips/trips/falls meeting SI criteria with one (17% of total incidents).
  • From January 2017 to December 2017, the trust reported two incidents classified as never events for surgery. These were both surgical/invasive procedure incidents meeting serious incident (SI) criteria.
  • Never event lessons learned were not shared across all surgical directorates following every incident.
  • Fridge temperatures were not always checked and recorded daily. We saw numerous occasions from April 2017 when medicine fridge checks had been missed.
  • We saw clean equipment stored in ward sluice rooms next to bagged dirty linen.
  • Staff told us that monitoring equipment was outdated and starting to fail which was causing problems. We were also advised that the division was part way through the tendering process to replace the older equipment, and had tested equipment on a trial basis. Risk was managed by using parts from the machines no longer in use.

Intensive/critical care

Good

Updated 20 January 2015

We rated critical care as good. The critical care service was safe, effective, caring, responsive and well-led. The ratings for each of these varied, but in terms of patient outcomes and quality of care these were particularly strong areas.

The unit had a positive safety culture, responded well to incidents and ensured that practice continually improved and developed in line with best practice guidance. The unit, with its innovative design, provided a modern environment in which to deliver intensive and high dependency care.

The effectiveness of the service was shown by the positive outcome data for patients, and the unit performed well in comparison with other similar units. The skills and expertise of the medical and nursing team were to a high standard, and all consultants were trained in intensive care medicine. The size of the nursing team had recently been increased, this had negatively affected the skill mix as there was an increased proportion of nurses who had not yet achieved competence in ICCU specialist skills.

The healthcare team was caring and compassionate, as proved through our observations and speaking with patients and relatives. Excellent support services were available for patients and relatives, and the views of patients and relatives were effectively gathered in a variety of ways.

The service was able to effectively respond to changes in service demand. This was partly due to the ability of the unit to easily flex between intensive and high dependency care provision, and the responsiveness of the staff. Delays for patients in accessing critical care were minimal, but delayed discharges from the unit to the ward were becoming an increasing problem.

The culture within the service was open and transparent and there was a tangible drive to provide the best high standards of care. Staff spoke positively about the leadership team and the open communication. Engagement with both staff and the public was good, and there were good examples of where feedback about the service had altered practice for the better.

Services for children & young people

Good

Updated 20 January 2015

We rated services for children and young people as good. In the areas of safety, effectiveness , caring, and responsive, services for children and young people were good, and in ‘well-led’ they were outstanding.

The children’s services actively monitored safety, risk and cleanliness. Nurse staffing levels did not meet nationally recognised guidelines, although this did not have a negative impact on patient care. There were challenges regarding some medical staffing levels, but these were being managed. Children’s services made improvements to care and treatment where these had been identified using programmes of assessment or in response to national guidelines. Children, young people and parents told us they received compassionate care with good emotional support. They felt they were fully informed and involved in decisions relating to the patient’s treatment and care.

We found that the children’s service provided good access to and flow within its services. This was achieved in part through close collaborative working between the directorate of paediatrics and emergency medicine, which had developed a shared medical consultant staffing approach that included consultant staff qualified in paediatric emergency medicine. We also found that the service had a range of facilities and approaches to ensure that the needs of local families were met.

The service had a clear vision and strategy and was led by a strong management team who worked together. The service regularly implemented innovative improvements with the aim of constantly improving the delivery of care for children and families. The service had facilitated the inspection of services by a team of young inspectors, which was excellent practice.

We found a positive, open and friendly culture at the service. Staff placed the child and the family at the centre of care delivery, and this was seen as a priority and everyone’s responsibility.

End of life care

Good

Updated 20 January 2015

Overall, we rated end of life care as good. Care and treatment received by patients at the end of their lives was effective, caring and well-led. Patients and relatives were happy with the care being given and found it to be caring and compassionate. Staff were well trained and supported and worked within nationally agreed guidance to ensure that patients received the most appropriate care and treatment for their conditions. Patients were protected from the risk of harm, because policies were in place to make sure that any additional support needs were met. Staff were aware of these policies and how to follow them.

Syringe drivers used in the hospital were not compatible with those used in the community. This sometimes led to delays in treatment as not all ward staff were not trained in the community equipment used. There had been no incidents reported in relation to this.

Patients were, on the whole, protected from receiving unsafe care, because medical records were available. There was, however, some room for improvement in the standard of record keeping in relation to ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders, because some of the records reviewed were not fully completed.

The services offered were delivered in an innovative way to respond to patients’ needs and ensure that the department worked effectively and efficiently.