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The Royal Orthopaedic Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 December 2015

We undertook this inspection 28 and 29 July 2015 as a focused follow-up to an inspection we completed in June 2014. At that inspection the core services of Critical Care, which was a High Dependency Unit (HDU) at this trust and Outpatients Department (OPD) both had an Inadequate rating in one domain. This was within Safe for HDU and Responsive for OPD. Both services were rated as Requires Improvement overall. The trust received a follow-up inspection of those services to provide assurance that improvements had been made. Although diagnostics and imaging forms part of the OPD inspection the main issues had been in OPD, therefore the focus of this report was there. The inspection took place at this trust’s one site which has the same name as the trust.

At the end of 2014 there were some issues relating to staff and medications, which the trust shared with us at the time. This resulted in some changes in staffing in governance and a wholesale review and change of processes regarding controlled medication. For this reason a pharmacist inspector joined the inspection team. We wanted to review the governance and the controlled medication processes. We received some whistle-blower allegations prior and during the inspection which we also had an opportunity to review within the remit of this inspection.

A further visit was arranged to view documents relating to Duty of Candour (Regulation 20). During that visit on the 05 August we visited OPD, X-ray waiting area, and the previously private ward.

At this inspection the two core services were rated as Required Improvement. However, we did see improvements in both core services. We noted that the trust responded to our concerns raised at the previous inspection, but we found that other issues impacted on their ability to meet the regulations. This has been reflected in the ratings.

Within HDU all the ratings remained the same as the previous inspection. Although the issues identified were different this time they had a significant impact across a number of domains.

Within OPD the result for safe remained the same. The responsive domain had improved from inadequate to requires improvement. This demonstrated that the trust had worked hard to improve the services for people and where the rating is requires improvement there is still some improvement work to be done. We have recognised within the reports that the trust has identified work streams to address the on-going improvement work. As part of the improvement work within OPD the trust had upgraded the patient administration system, to ensure it was compatible with the planned management information system due winter 2015.

Our key findings were as follows:

  • Staffing of HDU with regards to children was not suitable. We found that children were being cared for within the unit but not always by a paediatric trained member of staff, nor were the facilities suitable for children.
  • Within both core services we found that infection control practices were well embedded, and staff followed trust policy and procedures.
  • We found that although the trust and its staff worked to the essence of the regulations of the Duty of Candour, in being open and transparent when things went wrong, they did not meet all of the requirements of that regulation.
  • Multi-disciplinary working was effective in improving patient experience within the hospital.
  • 100% of staff in both core services had received their appraisals, which was higher than the hospital’s overall rate.

We saw several areas of outstanding practice including:

  • The unit manager had ensured that staff were both aware and understood the values of the trust. A post box had been put on the unit to enable staff to identify what the values meant to them in their work on HDU. Staff views on the values displayed on a noticeboard and had also been discussed during staff meetings.
  • Within Outpatients we observed that some clinicians were dictating letters to GP’s and other services onto an electronic system for same day delivery, in the presence of the patient before the patient left the clinic.

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

  • Safeguarding training compliance rate needed to be improved in OPD, for both adults and children only reaching the trust target for awareness training.

  • Privacy and dignity was compromised with the unacceptable arrangements regarding the toilet and washing facilities available for patients in HDU. There was only one toilet available for patients (adults and children, staff and visitors).
  • The trust needed to ensure it could upload the information in the Intensive Care National Audit & Research Centre, so it could be benchmarked against other similar trusts.
  • Within OPD management reports needed to be available to monitor clinic wait times and cancellations. There needed to be an agreed process which all staff followed in the event of a clinic being cancelled.

We were very concerned about care of children in the HDU, therefore have followed our processes to ensure that the trust takes appropriate action to improve the situation we found at inspection. Our specific concerns relate to:

  • Medical and nursing cover must be improved on HDU when children are accommodated.
  • Children must be cared for in an appropriate environment when requiring HDU care.

Importantly, the trust must:

  • The trust must improve local leaders’ understanding of the processes involved in exercising the duty of candour, in particular what they should expect beyond ward level and at a practical level, including record keeping.
  • The trust must ensure sufficient staff are trained in safeguarding adults and children in OPD.
  • The trust must improve the flow through the OPD so patients are not kept waiting for appointments.
  • The trust must embed management arrangements within the OPD to ensure a firmer grip on the process of clinic booking and patient flow to improve waiting times for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 October 2014

Effective

Good

Updated 16 October 2014

Caring

Good

Updated 16 October 2014

Responsive

Requires improvement

Updated 16 October 2014

Well-led

Requires improvement

Updated 16 October 2014

Checks on specific services

Medical care (including older people’s care)

Good

Updated 16 October 2014

Care and treatment in the medical services were based on published guidance and there was evidence that outcomes for patients were positive. Staffing levels had been set and were maintained by the use of bank and agency staff. Patients who deteriorated were cared for although there were concerns raised with the amount of medical support available out of hours. Patients we spoke with told us they had been treated with dignity, shown respect and had been well cared for by staff.

We found that there was good local leadership and services were planned to meet the needs of patients and had reacted to busy periods. There was good multidisciplinary working however discharge and transfer arrangements were not fully effective. The environment and equipment were visibly clean and infection control practices were good.

Surgery

Good

Updated 16 October 2014

A highly skilled, caring team provided a wide range of surgical services treating patients with complex orthopaedic conditions. Patient safety was promoted and protected by the use of risk assessments and incident reporting and there was local learning from incidents. The risks of infection were well controlled and monitored.

Patients told us that they had been cared for by compassionate, friendly staff and were kept fully informed about all aspects of their care. Treatment outcomes were effective and the service participated in national audits and submitted to national data bases to benchmark their performance where possible. Patients were very likely to recommend the service to family and friends. There were patient access and flow issues throughout the patient journey which caused delays in discharge from the theatre recovery and high dependency unit to an identified vacant bed on the wards.

We saw surgical wards were well led and supported by directorate managers and matrons. In theatres there had been long term use of interim managers however permanent staff recruitment had been undertaken and a new directorate manager had started in post.

Intensive/critical care

Requires improvement

Updated 4 January 2017

Overall, we found some improvements in the safety of paediatric care provision and within the leadership of this service since our last inspection in 2015. The trust was preparing to build a new purpose-built HDU ward, staff reported incidents and received feedback, medicines were stored appropriately, and the wards we visited were visibly clean. However, staff did not always follow hand hygiene procedures and resuscitation trolleys were not checked daily as per trust policy.

Although we noted some improvements, there continued to be a lack of strategy, policies and procedures and robust governance processes for the care of children. The trust developed an extensive action plan following the RCPCH review, which linked with the trust’s existing HDU action plan following our 2015 inspection. We raised concerns about the pace of the completion of some actions.

Staff we spoke with welcomed the improvements required for paediatric care and senior management thought the trust was in a state of cultural change, one open to scrutiny and challenge.

The trust demonstrated that they were engaging with staff, the public, external stakeholders, and the local children’s acute healthcare provider to improve the care of children at the trust. Significant improvements were required for the care of children with spinal deformities relating to the number on the waiting list. The resolution of this was complex and required the input and co-operation of several stakeholders.

HDU changes within the inspection action plan had been dependent upon people resource, financial and commissioning constraints and required detailed discussion and planning, including external stakeholders.

Compliance with the duty of candour regulation had significantly improved with the development of a tracking tool and we saw evidence of its effectiveness.

Services for children & young people

Good

Updated 16 October 2014

Children and young people received safe, compassionate and effective care from appropriately trained and competent staff. Care and treatment was based on national guidelines and directives and were monitored for quality and effectiveness.

Children and young people and their parents/carers were treated with dignity and respect. Parents and carers were satisfied with the care and treatment delivered to their children and told us they felt included and involved. Staff were positive about working in the family care division of the trust and felt supported and valued in their roles by line managers. Risks were managed at a local and trust level.

The children’s ward was being refurbished and due to re-open in July 2014. The temporary ward for children and young people was cramped with limited facilities for them and their families and carers.

Outpatients

Requires improvement

Updated 4 December 2015

We found outpatients & diagnostic imaging services required improvement. There were systems in place and in use for; reporting and learning from incidents, hygiene prevention and control, safe management of medicines, management of patients records. Risks to patients were identified and safely managed. OPD and radiology services were appropriately staffed. However sickness levels among staff had risen to a high level in June 2015.

The CQC does not currently provide a rating for the effectiveness of outpatients & diagnostic imaging services. We found the trust could not show us how effective some of its OPD systems were for patients. It did not have a clear picture of clinic cancellations and waiting times for clinics were variable. Compared to the other orthopaedic trusts, there was a high follow- up patient to new patient ratio in this trust at 4:73. The trust said this was caused by the complexity of surgery required by patients who were sent there from outside the West Midlands. Most patients told us they were satisfied with their consultations, their treatment and plan including pain relief. Skilled nursing, medical and therapy staff worked together to provide the services.

We found that outpatients & diagnostic imaging services were caring. There was a system in place for patients who needed or wanted a chaperone during their consultations and treatment and support for patients to check in. Patients told us all types of staff treated them with respect and dignity and took care over their privacy and personal information. Doctors explained test results and answered patient’s questions. They discussed a clear treatment plan with each patient taking into account their personal circumstances.

We found that outpatients & diagnostic imaging services needed to improve how they responded to patient’s needs. The OPD was a new building designed for outpatient’s services and was very busy. Patients got help to find their way around and to book in from volunteers. Staff understood how to help patients with dementia and implementing dementia patient ‘pathways’ was planned by the trust. However, the particular help that patients with learning disability might need in the outpatients services was not in place. Most patients got appointments in the OPD in an acceptable length of time after their GP had asked for one. Patients could also get urgent and rapid appointments when they needed them. However, the clinic booking system was complicated and ‘block booking’ of patients for appointment slots was happening for some clinics. This led to different waiting times for some patients especially when doctors had not referred ahead for x ray. The cancer service was better organised and also MRI scan reports were ready same day. Patients were helped to complain about the service in the OPD if they needed to.

We found the trust needed to improve how outpatients and diagnostic imaging services were led and managed. The trust had a vision for its future and we saw this information displayed in the main entrance of the OPD for patients. Many changes had taken place since our last inspection but improvements were recent and needed more time to show if they would work. Governance arrangements had been made stronger. Some areas were still weak around how the OPD was able to check how good its services were and improve them safely. Some work to improve this had been started but the improvements around how consultants ran their clinic appointments was patchy and needed firmer management. The trust wanted to hear patient’s views about the service. Staff enjoyed working for the trust and felt involved in making improvements in the OPD services.