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Russells Hall Hospital Requires improvement

The rating for ‘Maternity and gynaecology’ shown on this page does not reflect our latest judgement of services at Russells Hall Hospital. We now inspect maternity and gynaecology services separately.

At our inspection, in December 2017, we rated the maternity services as good. We did not inspect the gynaecology services.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 April 2018

Our inspection of the trust covered only this hospital and community services. What we found is summarised within the overall summary.

Inspection areas

Safe

Requires improvement

Updated 18 April 2018

Effective

Requires improvement

Updated 18 April 2018

Caring

Good

Updated 18 April 2018

Responsive

Requires improvement

Updated 18 April 2018

Well-led

Requires improvement

Updated 18 April 2018

Checks on specific services

Critical care

Requires improvement

Updated 18 April 2018

  • The intensivist team did not have oversight of all patients admitted to surgical high dependency. Individual surgeons oversaw the care of patients within surgical high dependency, which is not in line with the Guidance for the Provision of Critical Care Services 2015 (GPICS) standards.
  • Critical care had not embedded shared governance across all areas. Senior staff in the intensive care unit and surgical high dependency unit did share some information with medical high dependency.
  • The critical care units had begun to collect and submit national data. The intensive care unit and medical high dependency unit had submitted data for a number of years; however, the surgical high dependency had begun to submit to Intensive Care National Audit and Research Centre (ICNARC) in October 2017.
  • We found a lack of intensivist leadership within the surgical high dependency unit
  • Senior staff had a lack of understanding about Duty of Candour, and how and when this should be exercised.
  • We found senior staff did not recognise and report all risks within the critical care service. Risk registers did not reflect all the risks within each unit.
  • The surgical high dependency unit (SHDU) did not meet the requirements of the Department of Health, Health Building Note 04-02: Critical Care Units for the size and layout of a four bedded critical care bay, with limited space within bed areas. This did not promote the privacy and dignity of patients. We observed staff knocking into each other when multiple bed spaces had curtains pulled round. We observed staff knocking into curtains and allowing others to see into the bed space due to the lack of manoeuvrability within the unit. The trust was aware of this and had begun risk assessing the environment within SHDU
  • We found storage across medical and surgical high dependency units and on intensive care limited. Intensive care stored equipment in empty bed spaces due to a lack of storage.
  • A consultant trained in critical care medicine did not routinely review all patients on the surgical high dependency.
  • The medical high dependency unit had a shortage of suitably trained consultants to deliver on site care seven days a week.
  • We had concerns over the number of suitably trained medical staff available overnight to cover the medical high dependency unit.
  • Senior staff told us ICU and SHDU had one incident in 2017 that met the serious incident threshold. We identified other incidents that met the threshold of a serious incident; however, the trust had not investigated or reported these appropriately.
  • The service did not demonstrate how staff used the data that was collected to improve patient outcomes.
  • We found a mixed approach to multidisciplinary working across critical care. On surgical high dependency, individual surgeons lead the care for patients with intensivist input requested on an as required basis. This is not in line with the Guidelines for the Provision of Critical Care Services 2015 (GPICS).
  • The service did not have a dedicated pharmacist for each critical care area. A microbiologist did not attend daily ward rounds in line with GPICS; however a consultant microbiologist was available for advice
  • The environment on surgical high dependency did not promote the dignity of patients during personal care or examinations.
  • We found limited facilities to occupy patients across critical care, resulting in patients not having activities to undertake during the day. We also found this during the previous inspection with little improvement during this inspection.

However:

  • We found changes across critical care in response to the previous inspection. For example, new screens had been ordered for the surgical high dependency unit and intensive care unit to protect and promote the privacy and dignity of patients.
  • We found local leaders were visible and staff felt supported by unit managers, matrons and senior doctors.
  • Nurse staffing on medical high dependency, surgical high dependency and intensive care was sufficient to meet patient needs and national standards.
  • We found staff across critical care treated patients and relatives with kindness, compassion and empathy.
  • Staff provided appropriate emotional support to patients and families. We observed compassionate support given to families of patients at the end of life.
  • We found patients were involved in decision-making processes about their care. Staff involved relatives, where appropriate, in the decision-making process about the patients care

Outpatients and diagnostic imaging

Good

Updated 3 December 2014

Most people told us that the services they used were responsive to their needs. However, in some areas of the outpatient department, patients’ needs were not being met. There were problems in ophthalmology with the appointments system, overcrowding in the phlebotomy (blood collection) clinics at Russells Hall and Corbett Hospitals and, issues identified with parking provision at Russells Hall.

Overall, patients received a safe service. They were protected as far as possible from harm or abuse. Staffing levels were good and the Trust demonstrated a commitment to ensuring staff were up to date with mandatory training. Managing risk across the outpatient department had not been consistent; information and good practice in relation to slips, trips and falls had not been widely shared across the department.

Treatment was generally effective. We found that patients were satisfied with outpatient treatment. Difficulties with the transport arrangements to and from outpatient appointments had been identified and the Trust was working towards their key performance indicator of 95% of patients arriving and leaving the outpatient department on time.

Staff at all three sites, including outpatient services for children and young people, told us some clinics used reminder calls and texts and a partial booking service to achieve good rates of appointment attendance.

We observed good collaborative working within the multidisciplinary team. Examples included nurse-led clinics, clinics led by allied health professionals and multidisciplinary clinics.

Patients said that staff were caring, kind and compassionate. We observed that staff treated patients respectfully and with dignity.

We identified some excellent practice that targeted patients’ specific needs in an empathetic manner. This included the Eye Clinic Liaison Officer (ECLO) and the Care of Next Infant (CONI) programme in the outpatient clinic for children and young people.

Most of the staff we spoke with described strong, supportive leadership at board level and an organisational culture that empowered staff at all levels of the organisation.

Urgent and emergency services

Inadequate

Updated 17 October 2018

We Previously inspected all of this core service in December 2017and it was rated inadequate overall. This inspection was not rated as we specifically looked at the safe aspects of our key lines of enquiry. Therefore the overall rating for the entire department in December 2017 still stands.

  • Patients presenting to the emergency department still did not always receive a robust assessment of their clinical presentation and condition during the triage process.

  • There was still a lack of accountability for the safety of patients pre- and post-triage who were located within the waiting room.

  • Staff were still unable to describe what ‘fit to sit’ meant or any criteria for this assessment and patients were left unattended in this area.

  • The electronic tracking system did now allow for patients to be assigned correctly within the department but staff did not monitor this effectively.

  • We remained concerned about how quickly and appropriately staff were responding to patients with serious and deteriorating conditions.

  • Some patients with suspected sepsis were still not being identified or managed appropriately.

  • Staff continued to be frustrated at the focus on sepsis and did not fully engage with the need to assess for sepsis.

  • Staff were still not always using clinical judgement alongside NEWS scoring criteria.

  • Care records were still not always written and managed in a way that kept patients safe.

  • There was insufficient senior medical and specialist oversight and in reach to the department. This affected the safety and management of patients.

However

  • Some staff could recognise signs of sepsis and deterioration and acted on this appropriately.

  • The ambulance triage area was functioning more effectively with clear and appropriate medical input and leadership.

  • Some improvement in patient flow through the ambulance triage assessment area were seen.

  • AEC was well run and escalated patients that they couldn’t manage.

Maternity

Good

Updated 18 April 2018

We rated this service as good because:

  • We saw there had been an improvement in the incident reporting process since our last inspection. Staff could demonstrate that learning outcomes were shared and in particular in response to the findings of the Quality Improvement Board report.
  • Cleanliness and infection, prevention and control procedures were good throughout the maternity department. All areas in the department were clean and tidy. The infection prevention and control audit results in maternity from April 2017 to November 2017 showed there had been no cases of C. Difficile, MRSA or MSSA during this time period.
  • Maternity staff had appropriate qualifications, skills, knowledge and experience to provide safe care and treatment to women and their babies.
  • In maternity services medical and dental staff met the trust’s mandatory training target of 90% with 95% compliance overall. However, nursing and midwifery staff mandatory training compliance fell just below the target with 85% compliance overall.
  • Patient records were securely stored in lockable trollies, which was an improvement from our last inspection. We also saw records were completed appropriately.
  • We saw the service had arrangements in place to safeguard women who had undergone or were at risk of female genital mutilation (FGM).
  • The maternity department had a dedicated security guard and entry to the unit was gained via an intercom and camera system.
  • The service offered an enhanced recovery programme designed to help women recover more quickly from caesarean sections.
  • All comments we received from women and their families about their care within the maternity department was positive. Women confirmed staff treated them with dignity, respect and compassion.
  • Eight student midwives would be taking up substantive posts at the hospital once they had completed their training.
  • Pain relief was readily available for women. Some midwives had conducted aromatherapy training as another method of relaxation and pain relief for women during labour.
  • There was good multidisciplinary (MDT) working between the maternity service and other services at the trust. This ensured the needs of women and their babies were met.
  • The clinical audit programme had improved since our last inspection. However, we were not assured it was yet fully embedded within the service. However, a consultant had taken on the responsibility as an audit lead for the service.
  • Translation services were accessible if required. Information in a variety of different languages and larger print was available on the unit and to download from the trust’s website.
  • The Lead Community Midwife was working with health visitors from the Black County Partnership to provide a clinic specifically tailored to the needs of Romanian women and children with face-to-face interpreters to ensure pregnant women were receiving regular antenatal care. This clinic had a drop in facility and was proving very popular with increasing numbers of women attending regularly.
  • Telephone support was available to women before and following their appointment at the Early Assessment pregnancy Clinic (EPAC) and colposcopy appointments.
  • The risk register for the department accurately reflected the main risks to the department and senior staff regularly reviewed the risks.
  • Staff told us service leaders were approachable and visible on the unit. Senior staff confirmed they had an open door policy for all staff.
  • Staff understood the vision and strategy for the service. The strategy within maternity took into consideration the Black Country maternity care arrangements to meet the needs of women in the local region.
  • The senior midwifery team in maternity had implemented a consultant governance lead role and allocated medical leadership time had been increased for the service.
  • The maternity matron for outpatients, community, and the midwifery led unit, had been offered the committee member role of midwife on the Postnatal Care Guidelines Committee of the National Guideline Alliance.
  • The maternity service had a frenulotomy training programme. Frenulotomy is a procedure that separates a baby’s tongue-tie.
  • The service used charitable funds to refund women who want a home pool birth.

However:

  • The service did not have a dedicated bereavement suite or specialist bereavement midwife. However, we saw the service had developed plans to convert some of the delivery rooms to accommodate a dedicated bereavement suite for women and their families.
  • From July 2016 to June 2017, the trust had a ratio of one midwife to every 28 women. This is lower than the England average of one midwife to every 27 women. During our inspection, senior staff told us the current midwife to birth ratio was 1:29.4. However, the service could demonstrate women requiring one-to-one care on both the midwife led unit and delivery suite consistently received it. Senior staff were putting measures in place to increase staffing levels as soon as possible. In addition, the service was implementing the use of the Birthrate Plus acuity tool to give them real time information about the acuity needs in the in-patient areas within the department.
  • From April 2016 to March 2017 the total number of caesareans at 1,389 (32.8%) was higher than the England average at 27.4%. For the same time period, the standardised elective caesarean section rate was higher than expected. There were 14.7% (622) elective caesareans compared to an England average of 11.9%.
  • Nursing and midwifery staff working within maternity failed to meet the target for safeguarding adults or safeguarding children level 3, with 163 of the 211 eligible staff members (77%) completing adults safeguarding and 166 of the 210 eligible staff members (79%) completing level 3 children’s training.
  • As of June 2017 Mental Capacity Act (MCA) and Mental Health Act (MHA) training had been completed by 17% of staff within maternity. This did not meet the trust target of 90%.
  • During this inspection, we found the service still had eight guidelines requiring review or amendments. However, senior staff ensured staff were sighted on any changes of guidelines or procedures that affected their practice. Senior managers told us they had plans to improve the process for the management and review of procedures in maternity

Maternity and gynaecology

Requires improvement

Updated 3 December 2014

We were concerned with some elements of the service regarding safety; specifically that the arrangements for covering shifts were unsustainable and these were putting pressure on the existing staff. Additionally, we saw that categorisation of incidents and recording of data were at times inaccurate. This prevented the service analysing incidents and learning from these. We also saw the quality of data recorded on the maternity dashboard was variable.

The maternity department had failed to meet some of its indicators on the maternity dashboard, for example, elective caesareans had been higher than expected in recent months. The department was meeting other targets, for example, majority of women booked by 12 weeks of pregnancy – while performance against other indicators varied each month.

We found that staffing levels sometimes fell below the expected numbers and that there had been an increase in the number of staffing-related incidents reported.

We saw that there were processes in place for individual staff members to learn from incidents they had reported or been directly involved with. However, not all incidents were categorised correctly and information did not always flow through accurately to reports and the performance dashboard (an electronic performance reporting and tracking system). Also, the sharing of learning outcomes required improvement.

The women we spoke with were happy with the care they had received. They found the staff to be friendly and helpful and communicated well about their care and treatment.

There was a clear care pathway in the maternity unit, according to women’s clinical needs. Women felt that the level of communication from midwives and doctors was good and they felt listened to and well supported.

The layout of the department meant that women and their new-born babies could be cared for in an environment which promoted their privacy during their stay.

We saw that the maternity department had performed well in feedback from patients through the Maternity Survey and that there was a process for handling complaints, although we saw that one complainant had not received an accurate response.

Staff working within the department generally felt well supported by management and thought that they worked in an open and transparent environment.

Medical care (including older people’s care)

Good

Updated 18 April 2018

  • Medical care wards were designed to ensure access, flow and discharge was effective while keeping good patient outcomes and safety in mind.
  • The department had good systems and processes in place to manage sepsis by introducing bundles, sepsis leads and direct dial numbers to contact the right people who were required to intervene.
  • Staff had maintained their caring and supportive approach when dealing with patients despite significant increases in pressure as a result of staffing pressures. Feedback from people who used medical care wards was overwhelmingly positive.
  • Manager’s, senior nursing staff and clinicians worked closely together to identify areas where the service and patient experience could improve.
  • Staff worked well as teams and felt supported by managers and felt valued by the trust as employees.
  • There were quality boards throughout medical care and quality information shared with teams, patients and relatives to keep them up to date with what was happening on the wards.

However:

  • Staffing remained an issue and there were a significant number of vacancies and bank and agency work across medical care wards. However, this was managed well and bank staff were well inducted into all areas were they worked.
  • The trust did not always engage with national audits. There was evidence of how the service had reviewed local audit results and implemented changes to improve performance.
  • Staff did not always meet targets for completion of mandatory training.
  • Staff did not always carry out full safety checks in the catheter laboratory of all countable items during operative procedures. For example, they carried sharps checks but did not swab count which would be good practice.
  • Patient medicines were not always appropriately disposed of to avoid harm

Surgery

Good

Updated 3 December 2014

We visited six wards, the Pre-operative assessment clinic and the Oral surgery department.  We also visited the day surgery unit and main theatres at Russells Hall Hospital and the day case unit at Corbett Hospital which included the waiting area, ward and theatre. We observed care provided both pre- and post-operatively at both locations. We discussed the never events – mistakes that are so serious they should never happen – that had occurred in the surgical department with staff in the theatres. We also held focus groups and 121 discussions with nurses, junior doctors, consultants and heads of services.

Services in the surgical department were safe for most patients. There were appropriate systems in place to report incidents and concerns and take necessary actions when needed. The Trust had reported two surgical never events, between December 2012 and January 2014. We found that new procedures were in place to minimise further risks as part of lessons learned from these incidents.

The surgical safety checks at Russells Hall Hospital were completed, as per clinical guidance.  The surgical department had good adherence to national and professional infection control and cleanliness guidance.

Patients in all areas of the surgical department complimented staff on their caring approach. Patients’ needs were assessed, and care planned and delivered in line with best practice guidance. Assessments started in the preoperative assessment clinic and continued during the patients’ hospital stay.

Staffing levels had improved and the Trust was continuing to actively recruit staff. Staffing levels were found to reflect patients’ needs. There were arrangements in place to check the competency of staff, their training needs and practice. However there was a need to recommence competency checks for staff who worked in the day case unit at Corbett Hospital to demonstrate that safe and appropriate care continued to be provided in this area.

The Dudley Group NHS Foundation Trust was responsive to patient’s needs to ensure that they had access to timely treatment. Staff were proud of their achievements to reduce pressure ulcers, improve the management for diabetic patients who had surgery, the reduction in the number of patient falls and the management of patients who had a fractured neck of femur.

We found that the surgical department was well led. There were appropriate leadership arrangements at all levels within the surgical department and staff felt supported by their managers. Staff were committed to reviewing and auditing to continually improve the care and treatment that patients received.

Services for children & young people

Requires improvement

Updated 18 April 2018

  • We identified concerns about the robustness of delivery of the safeguarding service. Whilst ward staff demonstrated a good understanding of safeguarding, and we saw evidence of referrals and actions made and taken, medical staff cover did not meet national guidance.
  • We saw both medical and nursing staffing levels did not meet requirements consistently. Concerns surrounding medical staffing were recorded on the trust risk register and actions had been taken to mitigate this risk. Similarly nursing staffing did not consistently meet required levels; actions had been put in place to mitigate this however the concerns over staffing were longstanding.
  • We saw that the neonatal units did not have enough hand wash basins per cot area to meet hygiene regulations.
  • There was no transition policy to manage young people transitioning to adult services. Unless a child was already known to paediatric services or children and adolescent mental health services; any 16 to 18 year old went straight onto an adult ward upon admission to the hospital. Therefore, they may not receive specialist paediatric support as required.
  • We saw the children and young people’s service did not undertake a full range of national audits. Patient outcomes and audit results varied. For example, data for the National Paediatric Diabetes Audit in the 2015/16 showed that Russells Hall Hospital performed worse than the England average.

  • We saw the paediatric outpatient department had a large backlog of patients awaiting appointments for specific services. This waiting list was 90 weeks long for specific services at the time of inspection. The trust had actioned some changes to help manage this such as Saturday clinics.
  • During the inspection, we found the children and young people’s service was not represented at board level. This may have impacted upon highlighting and addressing risks to the service in a timely manner. We saw some risks on the trust risk register had been identified for significant periods of time before action had been taken.
  • We saw medical staff did not consistently attend clinical governance meetings leading to gaps in sharing of information.
  • However, we also saw evidence of good practice.
  • Incidents were reported and acted upon. Staff were aware of the incident reporting procedure and gave examples of incidents that had been reported and investigated.
  • We saw that staff monitored patients in case of deterioration in their condition using the National Early Warning Score (NEWS) and Paediatric Early Warning Score (PEWS).
  • We saw multidisciplinary working was improved since the last CQC inspection. Allied health provision such as speech and language therapists were more embedded into the service.
  • Another improvement since the last CQC inspection was that of appraisal completion rates. We saw at the time of the inspection, 95% of staff within the children and young people’s service had received an appraisal.
  • We saw consistently good examples of care provided to patients throughout our inspection. Staff strove to be kind and compassionate, and we saw new indicatives to promote a calm and caring atmosphere such a garden area designed to engage with patients with learning disabilities; although all children could access this.
  • We saw the service placed emphasis on being responsive to individual needs. A staff member trained to support patients with learning disabilities supported staff, patients and parents and carers with advice and guidance. A sensory room was well equipped to enable children with learning disabilities or difficulties to engage with staff. Interpreters could be sourced for patients and parents who did not speak English.
  • We saw that local leadership of the children and young people’s service was supportive; with staff confident to raise concerns and questions. We saw local management shared information and learning with staff through a variety of mediums and encouraged staff to be directly involved with local projects.
  • We saw that the children and young people service at the trust was part of a neonatal network with other trusts within the Black Country and Staffordshire and Shropshire which met every three months. Therefore, shared learning and continuous development was enabled and encouraged.

End of life care

Good

Updated 3 December 2014

We found that improvements were required to ensure patients were always as safe as possible and received care and treatment that met their needs in relation to do not attempt resuscitation (DNACPR) processes.  A DNACPR policy and procedure was in place, however, we noted a number of concerns in relation to how this had been implemented.

We noted an occasion where there was no evidence that DNACPR decisions had been reviewed and an occasion when a DNACPR decision had not been endorsed by a consultant within the timescale specified within the Trust’s policy, although a discussion with a consultant had previously taken place.

The specialist palliative care team provided support and advice to health professionals working within the hospital and in the community. This ensured a coordinated multidisciplinary approach to end of life care. We found that patients who were receiving end of life care without the need for support from the palliative care team also received a good standard of care.

Patients and their families told us that staff were available at the times they needed them and said that personnel were caring, kind and compassionate. We observed staff treat patients respectfully and with dignity.

The services offered by the chaplaincy, mortuary and bereavement services were considered to be excellent.

Staff we spoke with described strong, supportive leadership at Trust Board level and an organisational culture that empowered staff at all levels of the organisation.

Most people told us that the end of life service was responsive to their needs. From patients’ care notes we found that patients’ healthcare needs were regularly reviewed. Pain relief, symptom management, nutrition and hydration were being provided according to patients’ needs. Most patients and relatives we spoke with told us that they felt involved in decisions made about their care and treatment and care records confirmed this.

Other CQC inspections of services

Community & mental health inspection reports for Russells Hall Hospital can be found at The Dudley Group NHS Foundation Trust.