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Doncaster Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 July 2018

Our rating of the hospital stayed the same. We rated the hospital as requires improvement because overall the domains of safe, effective and well led required improvement whilst caring and responsive we rated as good.

Inspection areas

Safe

Requires improvement

Updated 23 October 2015

Effective

Requires improvement

Updated 23 October 2015

Caring

Good

Updated 23 October 2015

Responsive

Requires improvement

Updated 23 October 2015

Well-led

Good

Updated 23 October 2015

Checks on specific services

Critical care

Good

Updated 23 October 2015

Overall critical care services at Doncaster Royal Infirmary were judged as good.

There were many positive aspects to the unit. Caring was good: patients stated they were well cared for and surveys supported this. Care was effectively delivered by the multidisciplinary team utilising best practice. The service was well led overall, though as a relatively new care group unit further focus was required on the development of the unit in terms of space and facilities.

The service met the individual needs of patients whilst they were on the unit. Early discharges and out-of-hours discharges were similar to other units, and out of hours discharges to the ward were slightly above that of other similar units. There were some concerns regarding patients being discharged from the critical care unit delayed by over four hours.

Within safety, concerns were identified with regard to the environment and the risks associated with evacuation in the event of a fire and distance from other services that were required for the effective functioning of the unit. The poor use of storage and the impact this had on infection prevention risks and the practices for nursing patients with infections.

Outpatients and diagnostic imaging

Requires improvement

Updated 23 October 2015

We rated outpatients and diagnostic and imaging as requires improvement. Safe and well-led required improvement; effective was inspected but not rated and caring and responsive were good.

There is a legal requirement to protect the public from unnecessary radiation exposure. We saw that there were doors with no signage that had unrestricted entry to x-ray controlled areas. This was raised with the trust and referred to the Health and Safety Executive. Not all areas had been addressed when we revisited as part of an unannounced inspection 10 days later. There were effective systems to report incidents. However, in some areas we were unable to identify clear systems and processes to evidence post incident feedback, shared learning and changes in practice resulting from incidents. Imaging and nursing staff reported that a safety handover of the patients from the wards did not occur. Inpatients were left waiting in beds on the main corridor of the department with no escort. This practice potentially created safety risks.

Records showed the number of staff that had received mandatory training and an annual appraisal was below the trust compliance target of 85%, particularly in outpatients. We saw patient personal information and medical records were mostly managed safely and securely. However there was limited evidence of audit to demonstrate effectiveness. This included IR(ME)R related audits. Radiation Exposure/ DRLs were not audited regularly. Patient’s records were not routinely audited.

All of the patients we spoke with across the department told us they were very happy with the services provided. The management team were in the process of reviewing capacity and demand for outpatient clinics. Most referral to treatment targets were met including all cancer related targets. There was no centrally held list of all patients requiring a review or follow-up appointment. Medical imaging was not meeting the 6 week target referral to treatment target; however improvements had been made.

Staff we spoke with were aware of the trust overall vision and strategy and were positive about the recent and future management of medical imaging and outpatients. An outpatient’s services strategy had been drafted however, this lacked detail. A review of outpatient services had started to audit the current outpatient service delivery and clinical work streams but this was not yet completed. There were limited key performance indicators for outpatients. Radiology discrepancy and peer review meetings were inconsistent with the Royal College of Radiology (RCR) Standards.

Urgent and emergency services

Requires improvement

Updated 10 July 2018

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

  • We found that some of the concerns identified in the last inspection, remained concerns during this inspection.
  • During the last inspection, we had concerns as to the triaging and initial assessment of patients. At this inspection, we found the trust had changed the process by combining it with initial booking of patients into the department but we still saw extended waits to initial assessment for both patients who walked into the department and those who arrived by ambulance which were a risk to patient safety.
  • Ambulance turnaround times should be within 30 minutes, allowing ambulance staff to handover the patients to the hospital staff and be available for further emergency and urgent calls. From November 2016 to October 2017, there were 29-37% of journeys with turnaround times over 30 minutes at Doncaster Royal Infirmary.
  • At the previous inspection, we found nurse staffing was insufficient for the safe operation of the service. During this inspection, we found that staffing had improved but the service did not always have enough nursing staff of the right level to keep patients safe from avoidable harm.
  • The previous inspection highlighted a shortage of medical staff and during this inspection; we found the service did not always have enough medical staff of the right level to keep patients safe from avoidable harm.
  • The previous inspection highlighted that the overflow areas in the ‘majors’ areas were cramped and did not support patient privacy. We found during this inspection the ambulance handover bays and the overflow areas in the blue and green zones were cramped and did not provide confidentiality, privacy or dignity for patients. We saw patients nursed in close proximity to each other, in an open area as all the cubicles were full.
  • At the previous inspection, staff were not up to date with mandatory training. During this inspection, we found not all medical and nursing staff were up to date with mandatory training, including safeguarding.
  • The previous inspection highlighted that in ED medical staff were not up to date with adult and paediatric life support training. At this inspection we found that this had not changed. We had concerns about safety because nursing and medical staff were not up to date with advanced life support skills. Data from the trust showed that 64% of nursing staff had not undertaken intermediate life support training, 69% of nursing staff had not received advanced life support training and 83% of medical staff had not received advanced life support training.
  • Compliance was low for paediatric immediate life support; there was 48% (49 out of 103) nurses trained and for paediatric advanced life support there were 56% (6 out of 16) nursing staff trained. There was only 22.5% (6 out of 40) medical staff compliant for paediatric advanced life support training.
  • Staff we spoke with told us they had not received any specific training regarding caring for patients with mental health conditions, learning disabilities, autism or dementia.
  • The service did not always manage medicines well.
  • Although the service had a separate room to assess patients with mental health needs, it did not conform to the Psychiatric Liaison Accreditation Network (PLAN) standards. None of the risks in the rooms were considered or recognised by the staff.
  • We found staff were not always able to identify and respond appropriately to patients who were at risk of deterioration.
  • From October 2016 to September 2017, the trust reported one incident classified as a never event and four serious incidents. We found there was a backlog of incidents within the emergency care group that required reviewing; this had a risk to patient safety, as actions to prevent these incidents happening again could be delayed.
  • We found that some areas in the department were cluttered, as there was not adequate storage space for equipment. The majority of mattresses were damaged which posed an infection risk.
  • We found gaps in the daily checking of emergency equipment.
  • We found none of the pathways we looked at had review dates.
  • The emergency department had participated in a number of audits to benchmark their performance against the Royal College of Emergency Medicine (RCEM) standards. The trust was failing to meet many of the standards.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • From April 2016 to March 2017, 51% of staff within urgent and emergency care at the trust had received an appraisal compared to a trust target of 90%.
  • From October 2016 and September 2017, the trust’s unplanned re-attendance rate to A&E within seven days was consistently worse than the national standard of 5% but generally better than the England average.
  • The service did not meet the Department of Health’s target of 95% of patients admitted, transferred, or discharged within four hours of arrival at the department. The trust did not meet the standard from November 2016 to October 2017.
  • From October 2016 to September 2017, the trust’s monthly median total time in A&E for all patients was consistently worse than the England average.
  • The risks on the risk register did not match all the risks identified during the inspection.
  • From September 2016 to August 2017, there were 101 complaints about urgent and emergency care services. The trust took an average of 61 working days to investigate and close complaints; this is not in line with their complaints policy.
  • Although there was a paediatric sepsis screening tool we saw that a paediatric advanced warning score (PAWS), used for early recognition of children who were becoming unwell, was not always calculated and therefore might not alert staff, to allow early identification and prompt treatment for children who may be deteriorating.

However:

  • The service had improved on some of the issues highlighted in the last inspection.
  • Staff kept patients safe from harm and abuse. They understood and followed procedures to protect vulnerable adults or children.
  • Staff worked together as a team for the benefit of patients. We saw good multidisciplinary team working.
  • Staff cared for patients with compassion and respect. We received positive feedback from patients and carers.
  • The data for median time from arrival to initial assessment was better than the overall England median across the entire 12 month period from October 2016 to September 2017. However, this data may not have been accurate as the time measured started at the point the patient spoke with the nurse at reception and did not take account of the time they had waited in the queue before being registered and assessed. This may have affected the accuracy of other quality standards.
  • From November 2016 to October 2017, the Trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was better than the England average. Over the 12 months from November 2016 and October 2017, no patients waited more than 12 hours from the decision to admit until being admitted.
  • The department had strong links with the community mental health teams, community learning disability team and the child adolescent mental health teams.
  • The local leadership was strong, supportive and staff felt they were listened to and valued.
  • The trust had developed a three year Strategic Plan for Urgent and Emergency care services.
  • We found the culture of the department open and inclusive.
  • The trust had governance structures in place and each care group had their own governance meetings, which each department meeting fed into.
  • Work was supported by the national Emergency Care Intensive Support Team and a system-wide improvement programme to try to sustain improvements in ED performance.

Maternity

Requires improvement

Updated 10 July 2018

We rated the service as requires improvement because:

  • We rated safe and effective as requires improvement. We rated caring, responsive and well led as good.
  • The service was not meeting their target of 90% for women receiving one to one care in labour.
  • At the previous inspection, a large number of staff had not received mandatory training in a number of subjects. At this inspection, we found medical staff continued to be non-compliant for mandatory training.
  • Both medical and midwifery staff were not meeting the target for safeguarding training.
  • Nursing staff we spoke with told us that the induction of labour procedures varied depending on the doctor who saw the patient, this meant the induction of labour policy was not followed consistently on both sites at the time of our inspection. Following our inspection the trust introduced an audit process. Several trust policies were past their date of review. However, the trust was aware of this and a policy review group was in place. We were assured by the management team that the out of date policies would be updated quickly.
  • When we inspected in 2015, staff told us they had not had an appraisal in the preceding 12 months. At this inspection, we found the trust continued not to meet its appraisal target of 90% compliance for nursing and medical staff.
  • Some staff told us there was disconnect between ward level staff and the service leads. They said morale was low and some staff felt senior managers had not engaged with them sufficiently about proposed changes; including staffing, ward and location rotation.

However:

  • There were robust incident management processes. Learning from incidents and investigations were shared with staff at team meetings and individually with their managers. The trust produced a monthly staff update, which included learning from incidents and good practice.
  • Consultant cover on labour ward was in line with current guidance and the ratio of midwife to birth ratio was slightly better than the national average.
  • To meet women’s needs specialist midwives were employed by the service. This included specialists for teenage pregnancies, antenatal screening, safeguarding, bereavement, diabetes and infant feeding. Specialist support was also available through the learning disabilities specialist nurses and perinatal mental health consultant.
  • External audits took place and these included the National Maternity and Perinatal audit. Action plans were produced and working groups were set up to address the actions identified.
  • Procedures were in place to refer and safeguard adults and children from abuse and staff were aware of the procedures to follow. This included referral to the mental health team.

Maternity and gynaecology

Requires improvement

Updated 23 October 2015

Overall maternity and gynaecology services require improvement.

Midwifery and nursing staffing levels at Doncaster Royal Infirmary did not always meet the ratio recommended (Safer Childbirth RCOG 2007). The interim head of midwifery met with the director of nursing on a monthly basis to discuss staffing levels and plans for ensuring the service had appropriate capacity and capability to meet the needs of women. The hospital had a safe staffing escalation policy which included a process to be followed in the event of sudden staffing shortfalls.

The maternity unit closed eight times between July 2013 and December 2014. In March 2015, the EPAU was closed for five days due to staffing problems.

Medical staffing was in line with national recommendations for the number of births. However, there were two consultant and two middle grade vacancies. Medical staff told us this could impact on their workload.

Participation in mandatory training was between 0% and 100%. It was variable across all the wards, clinics and departments. Training attendance for infection prevention and control was very poor, as it was for resuscitation, fire safety and information governance. Participation in safeguarding adults and children training was variable in the unit and was between 75%- 100%.

There was a multidisciplinary approach to the care and needs of women. We observed examples of considerate and compassionate approaches in the care and treatment of women. Feedback from women about the standard of care they received was positive. Women were treated with kindness, dignity and respect during their care and treatment.

The individual needs of women were taken into account when planning the support needed during their pregnancy, although there were a high proportion of induced births and non-elective caesarean sections. The number of home births was lower than the England average.

On the whole, maternity ward areas were visibly clean and equipment was in date and in working order. Medicines were managed appropriately.

The gynaecology services were negatively impacted upon by the number of patients outlying on the ward from other specialties.

Arrangements were in place to safeguard women and children from abuse, but some staff were not fully aware of the procedures around domestic abuse. Serious incidents were monitored and action taken when things went wrong. There was an open and transparent culture that encouraged reporting and learning from adverse incidents

The maternity and gynaecology services were led by a committed team. Consultants told us that midwifery management of the service was very good. The hospital has recently been awarded the highest level of the UNICEF Baby Friendly Initiative.

Medical care (including older people’s care)

Good

Updated 10 July 2018

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

  • We rated safe, effective, caring, responsive and well- led as good.
  • Staff were aware of how and when to report incidents including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • All areas we visited were clean and well- maintained. Staff practiced safe infection control techniques and we saw predominantly positive audit results.
  • Staff assessed patients for risk of deterioration and escalated their care when necessary.
  • We saw safe medical and nurse staffing levels in place.
  • We saw good examples of multidisciplinary working. The trust performed better than the England average in a number of national audits.
  • Staff told us they were encouraged and supported to professionally develop.
  • We saw staff seeking patient consent before providing care and treatment. We saw that capacity assessments were completed for some, but not all, patients.
  • Patients, relatives and carers we spoke with gave consistently positive feedback: patients told us they felt safe on the wards and that staff were caring and compassionate.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff were emotionally supportive to patients and their loved ones. Friends and family test responses were predominantly positive.
  • Services were planned to meet the needs of local people. Consultants were available seven days per week.
  • Care and treatment for vulnerable patients, such as those living with dementia or a learning disability, were seen as a priority. We saw numerous positive examples of initiatives in place for these patients.
  • There was a clear leadership structure. Staff told us that their line managers were visible, approachable and supportive. We saw positive leadership at ward and team level.
  • Staff were aware of the trust’s vision and values, Local governance arrangements were robust. Ward managers attended care group governance meetings. Ward managers were aware of the risks to their service.
  • We saw numerous examples of improvements and innovation.

However:

  • There was low compliance in some mandatory training modules for medical staff.
  • There was a high percentage of nurse bank and agency use on some wards and not all patients were seen by a consultant within 14 hours of being admitted to the hospital in line with national guidance.
  • The service did not ensure VTE assessments were routinely reviewed within 24 hours in line with NICE guidelines.
  • We found that some patient pathways were out-of-date for review and did not have any references to nationally recognised, evidence-based, best-practice guidance.
  • The trusts performance was worse than the England average for the national heart failure audit and the national lung cancer audit.
  • Appraisal rates had improved since our inspection in 2015, however they remained lower than the trust target on some wards.
  • Consent to care and treatment was not always obtained in line with legislation for patients who lacked capacity.
  • The trust reported high numbers of delayed discharges and was not monitoring patient bed moves at night.

Surgery

Good

Updated 23 October 2015

Incidents were reported and effectively investigated, and lessons were learned. The wards and departments were mostly clean and well maintained. However, there were worn floors and dust and dirt on trolleys and autoclaves in the theatre sterile supply unit. We found medicines and records were managed appropriately. The service responded appropriately to clinical risk in patients, although not all staff had received safeguarding training. There were some shortages of nursing and surgical staff; the trust were aware of this and were actively recruiting to fill the vacancies.

We found evidence-based care and treatment which was audited in the wards and departments. There was a system for the provision of pain relief to patients although it had been identified there were delays in the provision of analgesia to patients referred to the surgical assessment ward by their GPs. We found effective systems for the provision of nutrition and hydration to patients. Patient outcomes data did not show the trust to be an outlier in any area of practice.

Mandatory training records showed compliance with the 85% target for achievement of this was poor. However, the majority of staff we spoke with told us they were up-to-date with their mandatory training. There were systems in place for yearly appraisal. We found that the surgery services were caring and that patients received compassionate care. We found evidence of service planning and delivery to meet the needs of local people.

The percentage of patients waiting to start treatment (incomplete pathway) within 18 weeks from point of referral to treatment was better than the national target, however the number of patients who had to wait longer than 18 weeks from referral to treatment (admitted) breached the operational standard.

We found that the trust had systems in place that assisted in meeting the needs of people who used the service.

The surgical care groups at Doncaster were well-led with a vision and strategy for the service and systems of governance, risk management and quality measurement in place.

Services for children & young people

Good

Updated 10 July 2018

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

  • We rated effective, caring, responsive and well led as good. Safe was rated as requires improvement.
  • Sepsis screening tools were used and all the records of patients we saw with suspected sepsis were managed appropriately.
  • Care and treatment was based on national guidance and the service monitored the effectiveness of care and treatment.
  • Staff cared for patients with kindness and compassion, ensuring they involved patients and their families. Feedback we received about the services from patients and their families was positive.
  • The service was responsive to the needs of the individual children and young people who used it.
  • Children’s services were actively involved with the Integrated Care System (ICS) to plan care to reflect the needs of the local population.
  • There were effective governance systems and processes in place. Regular review of the risk register took place.

However:

  • Safeguarding training rates were below the trust target.
  • There were no individual risk assessment tools to ensure the effective management of children and young people with mental health needs. Not all staff had received training in caring for children and adolescents with mental health conditions, but this had started to be addressed.
  • Actual staffing levels did not meet planned levels and the nurse to patient ratio exceeded the Royal College of Nursing (RCN) guidance (2013).
  • We observed that staff were not always using personal protective equipment or following appropriate hand hygiene practices.
  • There were environment issues, such as out of order shower cubicles on the children’s unit, water damaged ceiling tiles and protruding wires on the neonatal unit and condemned televisions were being stored in the adolescent room on the children’s ward.
  • We observed medicines left unattended.

End of life care

Good

Updated 23 October 2015

We saw that end of life care services were safe, caring, responsive and well led. However, we saw that improvements were required in order for services to be effective. Hotel services staff were not adequately trained or supported in the receipt of bodies to the mortuary and we were not assured by the trust’s arrangements for the storage of bodies in the mortuary in a way that respected the dignity of patient’s after death. The trust needed to have a more systematic approach to recording mental capacity assessments in relation to DNACPR decisions where patients were unable to be involved in these discussions.

We observed specialist nurses and medical staff providing specialist support in a timely way that was aimed at developing the skills of non-specialist staff and ensuring the quality of end of life care. Specialist palliative care nurses provided a seven day face to face assessment service. We were told that staff were caring and compassionate and we saw the service was responsive to patients’ needs. There were prompt referral responses from the specialist palliative care team and a good focus on preferred place of care and fast track discharge for patients at the end of life wishing to be at home.

Action had been taken against the issues identified in audits including the National Care of the Dying Audit. The implementation of the last days of life individual plan of care (IPOC) had been closely monitored by the end of life care coordinator with continuous reviews and feedback in place to develop this. The development of an electronic referral/alert system had seen an increase in referrals to the end of life care team in a timely manner. A business case had been developed as a result and the trust board had committed investment in expanding the end of life service as a result. The trust had a clear vision and strategy for end of life care services and participated in regional discussions and collaboration in relation to strategic planning and delivery of services to improve end of life care in the region.