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The Royal Orthopaedic Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 17 May 2018

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

  • There were sufficient numbers of nursing staff with the right qualifications, skills, training and experience to provide the right care and treatment in all the areas we visited.
  • Staff understood and fulfilled their responsibility to raise concerns and report incidents.
  • We saw excellent multi-disciplinary working across the hospital that was respectful and professional. There was a team work culture.
  • Staff were consistently kind, caring and respectful towards patients and their relatives. Feedback from patients confirmed that staff treated them with compassion.
  • Staff in all areas clearly understood how to protect patients from abuse. We saw improved staff awareness and promotion of safeguarding displays around the hospital since our last inspection.
  • Dementia and learning disability care had significantly improved since our last inspection.
  • Concerns and complaints were taken seriously, investigated appropriately and lessons were learnt from the results, which were shared with staff.
  • A positive culture was promoted by leaders at all levels and staff understood how they contributed to the trust values.
  • We found local leadership to be knowledgeable about issues and priorities for the quality and sustainability for their services, and had a good understanding of the challenges they faced. We saw they were responding to address these challenges and this work was ongoing.
  • Despite the suspension national referral to treatment target (RTT) reporting in June 2017, we saw honest and transparent action to address breaches during the previous 12 months. The trust took swift action and sought stakeholder support and was meeting the planned trajectory to meet the target.
  • The ROCS team had a positive impact on length of stay for patients requiring long-term intravenous therapy. Patients who were assessed as not requiring a hospital bed received their intravenous therapy at home.
  • The trust was in the process of quality improvement projects such as ‘perfecting pathways’ to improve patient care. These projects were encouraging staff to be innovative in their own departments to effect change and improvement.
  • The trust’s research and development team was proactive in research trials and used advanced clinical technology to improve the outcomes for patients with bone tumours and soft tissue sarcomas. We saw examples of patients offered less invasive procedures based on innovative research findings.

However:

  • We found in both medical care and outpatients that there was a lack of shared learning when things went wrong. Some staff were not aware of the term ‘never event’ despite the trust in 2016 having three surgical never events. Understanding of the term duty of candour varied across the trust despite the provision of training.
  • The trust used several IT systems that did not interface with each other which meant that there was duplication of information and extra workload for staff. Not all staff had the required access for all systems and many staff we spoke with were frustrated with the different systems to record patient information which could cause delays.
  • The trust faced data quality issues and was in the process of identifying and rectifying outdated databases to ensure robust and accurate data management.
  • Staff were not knowledgeable or confident in providing care to patients detained under the Mental Health Act. There was a lack of supporting information, policies and guidance for staff to follow to ensure patients additional mental health needs were met.
  • The Bone Infection Unit had the potential to be an outstanding service however, there was a lack of strategy, outcome monitoring and service evaluation and therefore could not demonstrate service effectiveness.
  • The electronic staff record did not hold latest compliance data which meant local managers kept local records additionally to this causing extra work and therefore the system ineffective. Training data was not provided to us to demonstrate compliance rates for individual modules.
  • Not all staff had access to additional education to support their roles for example specialist oncology training and mentorship training.
  • Interpretation services to provide language support to patients who required it was not consistently used across all services.
  • Patient records were not consistently secure within the outpatients department.
  • Despite significant improvement work to address patient wait times in outpatients, we observed long patient waits, cancelled appointments and overbooked clinics. This was a concern in our previous inspection.
Inspection areas

Safe

Good

Updated 17 May 2018

Effective

Good

Updated 17 May 2018

Caring

Good

Updated 17 May 2018

Responsive

Good

Updated 17 May 2018

Well-led

Good

Updated 17 May 2018

Checks on specific services

Outpatients and diagnostic imaging

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.

Outpatients

Good

Updated 17 May 2018

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

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • Staff understood how to protect patients from abuse, had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
  • The service made sure staff were competent for their roles. Managers worked with staff to provide support and monitor the effectiveness of the service. Staff felt involved in the appraisal process.
  • Staff cared for patients with care and compassion. Feedback from patients confirmed that staff treated them well and with kindness and involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people. Extending clinic times and flexing the length of appointments to meet the individual.
  • People could access the service when they needed it. Staff worked hard to provide patients with appointments that suited their needs and reduce any unnecessary stress.
  • The service took account of patients’ individual needs offering interpreter services and quiet rooms.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

  • Lessons learned from trust wide incidents were not shared. Staff were unable to describe duty of candour and were unaware of learning from recent incidents.
  • Patient records were not kept in a secure environment.
  • The premises provided little space for wheelchair users.
  • Trust policies were not kept up to date and there was no policy covering the Mental Health Act. The service followed the 2008 Mental Health Act Code of Practice which had been superseded by the 2015 edition.

Medical care (including older people’s care)

Good

Updated 17 May 2018

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

  • Staff understood how to protect patients from abuse, had training on how to recognise and report abuse. There were systems and processes in place to support staff in safeguarding patients.
  • There were clearly defined and embedded processes, systems and standard operating procedures for ensuring cleanliness and hygiene.
  • Staff carried out comprehensive patient risk assessments and risk management plans were in line with national guidance.
  • Records were accurate, complete and up to date, legible and securely stored.
  • Staff understood and fulfilled their responsibility to raise concerns and report incidents including being open and honest with patients when things went wrong.
  • Incidents were reported and investigated appropriately and lessons learned and shared locally.
  • The hospital had lower than expected risk of readmission compared to the England average.
  • There was effective and co-ordinated multi-disciplinary team working across the service that ensured patient care was assessed, planned and delivered based on individual needs.
  • Staff cared for patients with care and compassion. Feedback from patients confirmed that staff treated them with kindness and involved them and those close to them in decisions about their care and treatment.
  • The ROCS team visited patients at home to deliver intravenous therapy. Without this service patients would have to stay in hospital for the duration of the treatment, therefore occupying a hospital bed.
  • We found that the service had improved dementia assessments and communication aids for those with disabilities since our last inspection.
  • We saw honest and transparent action to address breaches in the national referral to treatment (RTT) targets during the previous 12 months. The trust was meeting the planned trajectory to meet the target. The arrangements for recording and managing risks and actions to reduce risk were resilient. The recorded risks on the medical service risk register were aligned to what staff had said was on their “worry list”.
  • Local leaders were knowledgeable about issues and priorities for the quality and sustainability of the service, and had a good understanding of the challenges they faced. We saw they were responding to address these challenges and this work was ongoing.
  • The service was transparent and open with all relevant stakeholders about performance and building a shared understanding of challenges to the system.

However;

  • Staff were not aware of the term ‘never event’ or of the never events that occurred in 2016. There was a clear lack of shared learning trust-wide.
  • The trust used several IT systems that did not interface with each other which meant that there was duplication of information and extra workload for staff. Not all staff had the required access for all systems.
  • Staff did not understand the principle of duty of candour despite the trust providing  training as part of mandatory training days.
  • Staff were not knowledgeable or confident in providing care to patients detained under the Mental Health Act. There was a lack of supporting information and guidance for staff to follow to ensure patients additional mental health needs were met.
  • A lack of medical cover on weekends affected patient access to pain relief.
  • The Bone Infection Unit was not monitoring patient outcome data and therefore could not demonstrate the service effectiveness.
  • As previously found in our last inspection, staff did not have access to professional development for example, specialist oncology training and mentorship training for staff.
  • Not all staff utilised translation services to support patient communication needs.

Surgery

Good

Updated 17 May 2018

  • The service prescribed, gave, recorded and stored medicines well.
  • Staff kept appropriate records of patients care and treatment. Records were clear, up-to-date and available to staff providing care.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service planned for emergencies and staff understood their roles if one should happen.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff of different disciplines worked together as a team to benefit patients. Doctors, nurses and therapists supported each other to provide good care.
  • Staff cared for patients with compassion and provided emotional support to minimise their distress. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service took account of patient’s individual needs.
  • The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • Managers at all levels had the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had effective systems for identifying and reducing risks.
  • The service engaged with patients and staff to improve the service provided.
  • There were planned theatre closures in April 2018 to carry out essential maintenance.

However:

  • There was an inconsistent approach to the end of day WHO checklist debriefs and did not always follow best practice guidance for completion.
  • New systems and processes were implemented following two serious untoward incidents relating to, ‘stop before you block’ but there was no date set for a re- audit to ensure compliance with best practice.
  • Some staff did not find the appraisal process beneficial and described the process as ‘stagnant’.
  • All staff we spoke with were frustrated with the different systems to record patient information which could cause delays accessing information.

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.