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The Royal Oldham Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 March 2018

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

A summary of our findings about this location appears in the overall summary.

Inspection areas

Safe

Requires improvement

Updated 1 March 2018

Effective

Requires improvement

Updated 1 March 2018

Caring

Good

Updated 1 March 2018

Responsive

Requires improvement

Updated 1 March 2018

Well-led

Requires improvement

Updated 1 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 12 August 2016

We rated outpatients and diagnostic imaging services Good overall because:

  • Staff were confident about raising incidents and encouraged to do so.
  • Principles of duty of candour when things went wrong were followed patients received an apology, full explanation and were supported going forward.
  • The departments inspected were visibly clean and we observed staff following good practice guidance in relation to the control and prevention of infection.
  • Equipment was clean and in good work order. Medicines were stored and checked appropriately.
  • There were appropriate protocols for safeguarding vulnerable adults and children and staff were aware of their roles and responsibilities in regard to safeguarding.
  • Staff in outpatients and diagnostic services demonstrated good team working (including multidisciplinary working) and were competent and well trained.
  • Staffing levels were appropriate to meet patient needs
  • Outpatient and diagnostic services were delivered by caring, committed and compassionate staff who treated people with dignity and respect.
  • .The number of patients waiting longer than 18 weeks from referral to treatment (RTT) was consistently better than the England average. The cancer waiting times for the trust were consistently better than the England average.

However,

  • The trust reported in their missed cancer diagnoses action plan that they had produced a leaflet and banners to support and empower patients, to ask about the tests they have undergone and that these had been distributed in all sites in outpatients and radiology. During the inspection, we were unable to find the leaflets in clinics and staff had not heard about them.
  • The paper notes we reviewed contained limited information, were out of sequence and in some cases were illegible also not all notes had been scanned and paper notes were still in use for some patients..
  • At November 2015 there was a staffing shortfall of 5.4wte Band 5 radiographers and 1wte Band 8a Manager. The department was actively recruiting 6 student radiographers
  • We found there was no set of local rules and  risk assessments to hand in a number of  departments. They had not been printed off and signed by staff so there was no indication that they were aware of, and had an understanding, of the rules.
  • Lucy Pugh Outpatients Department was located at the bottom of a very steep slope and was not safely accessible externally to those who were not steady on their feet or in the event of inclement weather. To enter the department internally via lift access involved a long walk through the hospital.

Maternity and gynaecology

Good

Updated 1 March 2018

We previously inspected maternity jointly with gynaecology, so we cannot compare our new ratings directly with previous ratings.

Maternity services had improved since the last inspection in several areas. We rated maternity as good overall although work was still required in some areas.

  • Staff did not complete Maternity Early Warning Scores assessments within the prescribed timescale to detect deterioration in a woman’s condition. This included when assessments indicated there was a risk to the woman.
  • The World Health Organisations’ surgical safety checklist was not always fully completed and the procedure in theatre we observed did not follow the guidance.
  • Staff did not consistently follow the trust schedule for checking all equipment was present and in working order. This included resuscitation equipment for women and babies.
  • Following community midwife visits, including booking, there were delays in recording patient information onto a computer system, which could be accessed by other health professionals.
  • Staff did not always provide pain relief to women when they needed it on the post-natal ward.
  • Complaints were not being managed within the timescales set out in the trust’s policy.

However:

  • The service provided mandatory and obstetric specific training in key skills to all staff and most staff had completed it.
  • The service now 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 managed patient safety incidents well. This had improved since the last inspection.
  • Women reported good support with feeding their baby in the way they chose. Trained staff offered this support on a one to one basis when required.
  • Staff worked together as a team to benefit patients.
  • Staff cared for patients with compassion. 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 treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The leadership of the maternity services had changed and improved since the last inspection.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. This was a positive change since the last inspection.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service had suitable premises and equipment.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.

Medical care (including older people’s care)

Requires improvement

Updated 1 March 2018

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

  • Patient records were not consistently completed in order to monitor the care provided. The records did not consistently show what care patients had received or what plans were in place to meet their individual needs.
  • Risks identified for patients were not consistently recognised and addressed.
  • The service did not consistently have enough staff with the right qualifications, skills, training and experience to mitigate risks to patients and to provide the right care and treatment. Staffing arrangements did not always take into account where patients required additional support from nursing staff.
  • Although the majority of staff recognised and reported incidents particularly around safety, some staff we spoke with had not reported instances around staffing numbers. As a result the trust would not have all the information they needed to appropriately monitor staffing levels.
  • The arrangements to ensure that patients’ mental capacity were not appropriately assessed and their individual rights protected were not consistently applied in order to make sure that a valid consent was obtained for care and treatment.
  • Patients waited for beds on a ward suited to their needs. Patients were delayed from discharge and bed moves at night took place on a regular basis, which was not in line with trust policy.
  • Medicines were not correctly stored as storage temperatures exceed those recommended by the manufacture.
  • Managers did not make sure that staff had completed training they needed as part of their job roles.
  • Some staff spoke with identified that they felt the culture within the service was not supportive and they were not given the correct assistance in order to be able to safely complete their duties.

However

  • The service had improved on many of the issues for action highlighted in the previous inspection. There was a clear vision and strategy, that was available throughout the service and staff were aware of.
  • The medical division had governance, risk management and quality measures in place to improve patient care, safety and outcomes.
  • The use of arrangements to recognise and act on changes to the patients’ medical condition; such as for the use of early warning scores were effectively used. Deteriorating patients were appropriately referred for medical review in order that they received timely and appropriate treatment.
  • Complaints were investigated and completed in a timely way with the learning discussed and changes to the service provided influenced by the findings of the complaints.
  • Patients were cared for by staff that were observed to be kind, caring and compassionate. Patients spoke positively about the support and care that they received from staff overall.
  • The discharge lounge had made a number of adaptations to meet the complex needs of patients.

There were systems and processes in place to reduce the risk of harm to patients.

Urgent and emergency services (A&E)

Good

Updated 1 March 2018

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

  • The service was delivered by staff that were competent, trained and supported by their managers, and in sufficient nursing numbers, to provide safe and effective care. Staff of all disciplines and grades worked together to meet the needs of their patients.
  • The service controlled infection risks, and maintained the facilities and equipment appropriately.
  • A learning culture encouraged staff to recognise and report patient safety incidents and safeguarding concerns. Incidents, complaints and concerns were managed appropriately.
  • The service used local and national audits to identify areas of weakness, to develop improvement plans, and to increase the effectiveness and responsiveness of the department.
  • The service’s performance on a range of measures, including clinical measures, was broadly in line with other urgent and emergency services or was improving. The number of patients waiting between four and twelve hours, or more than twelve hours, had significantly improved.
  • Staff were compassionate in their delivery of care. They helped patients to understand the care being provided and included them in discussions about their care. Staff supported the emotional needs of their patients.
  • The service worked with the local commissioners and other agencies to plan, deliver and further develop the urgent and emergency services offered to meet the needs of the local community.
  • Leaders across the directorate, division, and hospital had a strategy for the service, were visible, and supported their staff. Leaders understood the risks and challenges to the service.

However:

  • Although improving, the service did not have enough consultant medical staff to provide 16‑hour cover, seven days a week.
  • The service’s ability to provide timely care to children was impacted, at times of high demand, by the limitations of the physical capacity of the paediatric department.
  • Although improving, the service did not achieve the national four-hour decision to admit, transfer or discharge target, nor did it consistently meet its externally agreed improvement trajectory target. The service did not meet its unplanned seven-day re-attendance target.
  • Children and young people were not consistently assessed in the paediatric department using the ‘think family’ approach. There was no designated place of safety room for children experiencing mental health related symptoms.
  • Staff did not always know, or have the training in, how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

Surgery

Requires improvement

Updated 1 March 2018

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

  • There was a recognition by senior managers that there had been an under reporting of incidents; a trust-wide system had been implemented that was not fully embedded.
  • National guidance recommends that staff in theatre are trained in advanced life support; however, staff had only received the mandatory basic life support training.
  • The World Health Organisation Surgical Safety Checklist was not always completed.
  • Nursing and medical staff had been recruited, however, staffing remained a concern for the trust and any shortfalls were supplemented with bank and agency.
  • The ward patient boards included details of patients, however, these were not consistent and details could be seen by others visiting the wards. In addition, we observed that bedside handover of patient care included details that could be overheard by other patients.
  • Senior managers acknowledged that waiting times for certain specialities was a challenge with operations being cancelled for non-clinical reasons.
  • We found that the service did not investigate complaints in a timely way, although managers recognised this.
  • Staff engagement had improved however there remained some cultural challenges with surgeons, but the senior team were fully aware of this.

However:

  • The trust shared information about safety, including infections and staffing, with patients and visitors on their ‘open and honest’ boards. All areas we visited were visibly clean and free from clutter. There were processes in place for the maintenance of equipment.
  • The trust managed medication well and records of patients were secure and completed appropriately.
  • Staff understood how to keep patients safe and who to contact for any safeguarding concerns.
  • Staff received mandatory training and the service monitored compliance rates weekly.
  • There was a major incident plan specific to this site that staff were familiar with.
  • We observed staff caring for patients sensitively and appropriately to their individual needs. Feedback from patients confirmed that staff were very kind, supportive and caring. There were good processes in place for caring for patients who were vulnerable.
  • The average length of stay for patients was generally similar to the England average for both elective and non-elective surgery.
  • We observed supportive leadership on the wards and managers were keen to highlight good practice. Matrons were visible on the wards and monitored daily staffing requirements. The trust values were prominently displayed in corridor areas. There was a surgical strategy in place and action plans to address concerns.
  • Managers promoted a positive culture across the trust and were now more visible.
  • The trust was committed to improving services by learning. Information was disseminated through safety briefings and bulletins, although it was not clear if this was trust-wide.

Intensive/critical care

Requires improvement

Updated 1 March 2018

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

  • Medical staff were not meeting trust targets for a number of mandatory training modules.
  • We observed a number of lapses in infection risk control and the premises were not compliant with the minimum amount of space required per bed.
  • There were staffing shortfalls, meaning that the service was not meeting a number of the core standards for critical care units.
  • We observed that the time of admission to admit the patient to the unit was not consistently recorded on patient records and it was not possible to tell whether admission was within four hours of the decision to admit.
  • Staff reported that they had not received appropriate training on the new incident reporting system.
  • Patients did not receive input from a psychologist and did not have access to a follow-up clinic or other post-discharge support.
  • There was no weekend cover of allied health professionals such as dietitians or speech and language therapists. Although there was a business case in place to increase staffing numbers, there had been little progress in this since our last inspection.
  • The level of out-of-hours discharges remained a concern in the high dependency unit and had worsened.
  • There was no medical leadership on the high dependency unit for 14 hours a day.
  • Staffing levels had reduced morale on the unit and staff reported that they did not feel supported and valued.
  • Systems for continually improving the quality of services were not yet fully embedded and directorate meetings were not always taking place when they should be and actions identified in mortality review meetings were not followed up and completed.
  • There were gaps and inconsistencies in the risk register.
  • Staff reported that they received little feedback from engagement events and there was no recent evidence of patient feedback about the unit.

However:

  • Staff understood how to protect patients from abuse; patients were appropriately risk assessed and the service planned for emergencies.
  • Equipment was looked after well and medicines were stored and prescribed appropriately.
  • Care and treatment was based on national guidance and evidence of its effectiveness and patients received adequate pain relief, nutrition and hydration.
  • Staff received appraisals though appraisal rates were slightly below the trust target of 90%. Staff worked together as a team to benefit patients.
  • Staff were compassionate, involved patients and those close to them in decisions and provided emotional support.
  • There were few complaints against the unit. Complaints were treated seriously, investigated and lessons were learned and shared.
  • Staff reported improvements since the introduction of a director management team into each care organisation and that senior managers were more visible and accessible.
  • There were a set of vision and values in place and an improvement plan for the service.
  • Information was collected, analysed and managed to support activities and make improvements.

Services for children & young people

Requires improvement

Updated 1 March 2018

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

  • The service did not consistently have enough staff with the right qualifications, skills, training and experience to mitigate risks to patients and to provide the right care and treatment. Staff were moved from other areas to cover gaps and staffing on the High Dependency Unit did not always meet planned staffing levels.
  • The service did not have robust systems and processes in place to learn from incidents and effectively share learning and improve practices.
  • The service did not always prescribe, record and give medicines well, which had resulted in 14 incidents over a six month period.
  • A number of clinical guidelines were not reviewed in line with timescales.
  • Systems for identifying risks, planning to eliminate or reduce them had not yet been embedded.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff cared for patients with compassion; staff treated children with kindness and reassurance.
  • Managers and clinical leaders had started to engage well with patients, staff, and the public and local organisations and had introduced systems and processes to improve the service.

End of life care

Requires improvement

Updated 12 August 2016

We rated End of life services as requires improvement because:

  • There was no seven day service for SPCT out of hours and we identified three instances when patients suffered for longer than they should have.

  • Do not attempt resuscitation documentation (DNACPR) was not completed according to trust policy on a number of occasions, particularly with regards to patients who lacked capacity.

  • The individual plan of care, which replaced the Liverpool care pathway, although developed, was not sufficiently embedded into all ROH wards

  • There were depleted staffing levels of the SPCT at ROH and there were insufficient staff to implement a full range of services.

  • There was a vacant post for the specialist consultant in palliative care.

  • EOL patients were not always cared for in ward side rooms

However;

  • There was a policy and procedure for reporting of incidents and all staff were aware of how to complete incident reports.

  • There was evidence of anticipatory prescribing for pain and symptom control in medical notes.

  • End of life services were caring. We observed staff delivering care with kindness, compassion and respect. Relatives told us that the care their loved ones received was excellent, that pain was monitored regularly and they were treated with dignity.

  • There was a multi-faith spiritual care team, who were trained to provide non-religious support to those patients and relatives who were not religious.

  • The SPCT had a good understanding of the needs of the local population, worked as part of the multidisciplinary team and had good links with palliative care services in the community.

  • Religious and cultural requirements were adhered to when patients died and when they were transferred to the mortuary.