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The Royal Oldham Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 12 August 2016

The Royal Oldham Hospital is one of the main locations providing inpatient care as part of The Pennine Acute Hospitals NHS Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

The Pennine Acute Hospitals NHS Trust provides services for around 820,000 people in and around the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire. There are approximately 1191 inpatient beds across the trust

We carried out an announced inspection of The Royal Oldham Hospital between 23 February to 3 March 2016 as part of our comprehensive inspection of The Pennine Acute Trust.

Overall, we rated he Royal Oldham Hospital as Inadequate. Improvements were needed to ensure that all services were safe, effective, caring, well led and responsive to people’s needs. Of particular concern were maternity services, services for children and young people and critical care services. We have rated these services as inadequate overall, with a rating of inadequate given for the safe and well-led domains. We also rated urgent and emergency services inadequate for responsive due to concerns in relation to access and flow within the service.

Our key findings were as follows:

Incident reporting

  • An independent review into nine serious incidents in the maternity services at the trust had been completed in January 2015. Following this several recommendations were made about incident reporting. These included; clarifying the process for escalating concerns, a quality check for incident reports to ensure the root cause was clearly established, making recommendations clear and unambiguous and where individual failings had been identified, including leadership failings, reports must demonstrate education and training had been considered. These recommendations had not been put into practice in the management of incidents we reviewed. We saw reports with no recommendations or learning points recorded, staff, including senior managers, were unaware of the outcomes of serious incident investigations and the process for quality checking of reports was not understood by those completing investigations.
  • In the past 12 months the trust had reported 32 serious incidents in maternity services. 21 of these had been reported retrospectively as the need to do so had not been identified through previous review.
  • There was a delay in the management of incidents in the maternity services. Information provided by the trust showed as of 21 February 2016 there were 170 unclosed incidents in maternity and gynaecology services. Failure in the management of incidents was on the trust maternity and gynaecology risk register. This was a failure “to ensure monitoring that serious incident recommendations were appropriately incorporated and executed in actions plans leading to a failure to learn lessons and prevent avoidable harm”. One of the actions to monitor this was “regular auditing of the process” which had a target date of 31 January 2016. At the time of the inspection no audits had taken place.
  • In children and young people’s services there were unacceptable delays in the investigation of serious incidents. Learning from incidents was not effectively shared resulting in serious incidents with similar causal factors recurring. Action plans following serious incidents were not followed up on resulting in identified actions not been addressed and learning from incidents not being effectively embedded.
  • The trust board relied on incident reporting as an assurance mechanism regarding patient safety. However, nursing staff in children’s services told us that incidents were not always reported. During our inspection we observed three incidents that were not reported. Senior nursing staff were aware that staff did not report all incidents.

However:

  • In all other core services we inspected, Staff were aware of the process for reporting any identified risks to patients, staff and visitors. All incidents, accidents and near misses were logged on the trust-wide electronic incident reporting system.
  • Incidents logged on the system were reviewed and investigated to look for improvements to the service. Serious incidents were investigated by staff with the appropriate level of seniority, such as the clinical matron or lead consultant.
  • Incident reports showed that duty of candour guidelines had been applied where serious harm had occurred. This included a formal apology to the patient and their relatives along with an explanation of the remedial steps to be taken to address the issue.
  • If the SPCT noted a high rate of EOL related incidents on a particular ward they would develop a ward based programme to address identified issues. They reported that this approach had been successful in reducing incidents on targeted wards.

Cleanliness and infection control

  • All areas we inspected were visibly clean, tidy and maintained to a good standard. Staff were aware of current infection prevention and control guidelines. Cleaning schedules were in place, with clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
  • There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There were enough hand wash sinks and hand gels. We observed staff following hand hygiene and 'bare below the elbow' guidance. Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care.
  • Staff told us all patients admitted to the hospital were screened for MRSA. Patients identified with diarrhoea and vomiting symptoms were also screened for C.difficile. Patients with recent hospital admissions were also screened for Carbapenemase-producing Enterobacteriaceae (CPE) infections.
  • Services undertook regular audits to monitor compliance against key trust infection control policies such as hand hygiene, use of PPE, isolation precautions.
  • The surgery and anaesthesia division at Oldham reported similar or lower surgical site infection (SSI) rates across all specialities compared to the England average for the last 5 years. However, infections in colorectal operations were slightly higher than the England average.
  • The most recently supplied ICNARC data for the HDU (July to September 2015) showed no cases of unit acquired infections with Methicillin resistant staphylococcus aureus (MRSA) and small numbers of unit acquired Clostridium difficile (C diff). Infection rates were generally better than comparable units.
  • For the same period on the ITU at Royal Oldham, in terms of unit acquired infections in blood for ventilated admissions, performance was comparable with similar units. For elective surgical admissions there were no cases of unit acquired infections in blood. For emergency surgical admissions the last reported case of a unit acquired infection in blood was in quarter one of 2014. Unit acquired MRSA and C diff infection rates were better than comparable units and no cases of MRSA bacteraemia had been reported.

However

  • In medical care services cleaning chemicals were left out in an unlocked room on a number of wards and there were trolleys containing sharp instruments which were not locked away and had been left unattended.
  • Following higher than national incidences of puerperal sepsis in 2013 an action plan had been developed to ensure the rates were reduced. Aseptic non touch technique training was part of this plan. Information from the trust showed 75% of nursing and midwifery staff and 37% of staff in additional clinical services were up to date with this training. This meant not all staff who delivered care were up to date with this training. The trust was not compliant with this action they had identified to prevent puerperal sepsis.
  • On the paediatric and neonatal ward, we found no equipment cleaning logs completed. Nursing staff told us that the expectation was that they cleaned the equipment then returned it to the equipment area. This was not in accordance with the trust’s policy. Similarly, cleaning schedules for paediatric and neonatal areas were not available.

Nursing staffing

  • There were a number of departments in the hospital where there were concerns regarding nurse staffing.This was particularly significant within the critical care, maternity and gynaecology and children and young peoples services
  • We saw that the average sickness rate and staff turnover rate in a number of departments was above the trust target of 4%
  • In urgent and emergency care services the nursing and healthcare support worker staffing levels and skill mix was not sufficient to meet patients’ needs. The existing establishment did not always have the flexibility to cope with the number of patients attending the department, especially during busy periods. An independent nurse staffing review in November 2015 recommended an increase to the current establishment by 15.80 whole time equivalent staff in order to fully meet safe staffing standards.
  • At the end of November 2015 the vacancy rate for nursing staff in medical services trust-wide was 7% and this was recorded on the risk register. There were actions identified to mitigate this risk such as a rolling recruitment programme. Managers knew where there were shortfalls and where there was surplus on other wards so that staff that could be called on if needed and vacancies were being covered by using agency or bank staff.
  • In surgery, staffing figures for January 2016 showed some areas had on occasion only 85% of their allocated establishment of registered nurses on duty during the day. Gaps in the rota were filled with hospital bank shifts and external agency staff. There was high use of agency staff in theatres but even with these staff, staffing establishments were not always maintained.
  • The nurse staffing on both the ITU and HDU failed to meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7. This issue was well known to the trust and was highlighted as a concern in the May 2015 review by the GMCCN.
  • Despite the ITU and HDU units not meeting the standard for nursing cover, they were often asked to supply staff to assist the other critical care areas within the trust.
  • Along with the other critical care units in the trust, the nursing budget was subject to a £140,000 cost improvement plan for the coming year.
  • Nurse staffing levels and skills mix in paediatrics did not reflect Royal College of Nursing (RCN) guidance (August 2013). There were no advanced paediatric life support (APLS) or European paediatric life support (EPLS) trained nursing staff. Only 23.7% of nursing staff were up to date with paediatric immediate life support training.
  • We reviewed neonatal staffing in line with BAPM (British Association of Perinatal Medicine) guidance over the course of a month. In 25.8% of shifts, nurse staffing did not comply with BAPM guidance for the nurse: patient ratio. On average in each of these shifts the unit was understaffed by at least one registered nurse. When we reviewed the planned vs actual staffing information, this showed in 83.3% of shifts the unit was understaffed by on average 2.2 nurses.
  • Neonatal records showed that only 23.9% of nursing staff had current NLS training at the time of our inspection.
  • The trust did not routinely use an acuity tool, as recommended by RCN guidance, at the time of our inspection. However, in December 2015 the trust trialled an acuity tool for one week (19 shifts). At the time of our inspection no plans were in place to introduce an acuity tool.
  • There were insufficient staffing levels to meet the needs of EOL patients with complex care needs at the current levels. There was a trust wide EOLC facilitation team which was based at ROH. This team provided specialist training in the treatment and management for patients approaching the end of their lives. They had provided the training for the IPOC implementation. The actual staffing for this team were below the planned level. This staffing deficit impacted on the team’s ability to roll out the transformation programme and embed the use of Individual Plan of Care (IPOC) across all ROH wards.

However:

  • Nursing staffing levels in outpatients were in line with planned numbers, there was a good staff skill mix and the trust had clear escalation procedures in place where safe staffing levels in clinics could not be established. There were few vacancies in pathology, except in Cytology.

Midwifery staffing

  • The midwifery staff to patient ratio was worse than the England average and the labour ward frequently had lower than the planned number of midwives working. Midwives were not achieving one to one care in labour. Midwife sickness levels were high. Whilst there were some delays in patient care due to low staff numbers these were limited due to staff of all grades working extra hours and through their breaks to support patients.
  • All the midwives and managers we spoke with stated staffing issues were their major concern for the maternity services. This had been recognised by the trust and the “failure to achieve safe staffing levels” was on the risk register. Managers used the red flag system to raise concerns about specific staffing levels. These were documented on the four hourly staffing assessment documentation for all wards. This met the safer staffing guidance.
  • During our inspection staff had requested to divert patients from the labour ward one night due to there being seven midwives instead of nine, the unit was full and a high level of care was provided to a deteriorating patient. Additionally both obstetric theatres had been used. All avenues to increase the staff numbers had proved unsuccessful. This divert was not approved by the on call manager instead they tried to provide a specialist high dependency nurse to the unit but were unsuccessful. Midwives had escalated their concerns that this was unsafe to the manager on call. Following our inspection implementation of the escalation policy was reviewed and assurances given that it would be used proactively when activity on the wards was assessed every four hours or between if necessary.

Medical and surgical staffing

There were a number of departments in the hospital where there were concerns regarding medical staffing. This was particularly significant within the critical care, maternity and gynaecology and children and young peoples services

  • There were medical staffing vacancies in medical services and this was on the trust risk register. There were actions identified to mitigate this risk such as a recruitment programme.
  • The HDU was not led by the intensivist/anaesthetists. It was not clinically led by any designated consultant. It was an open unit with potential referral and admissions from any speciality within the hospital. Consequently this meant that on the HDU many of the standards for critical care as set out in the “Core Standards for Intensive Care “(Nov 2013) the Draft D16 Service Specification for Adult Critical Care and the Guidelines for the Provision of Intensive Care Services (GPICS) Standards.(2015) were not being met.
  • Out of hours cover also varied between the ITU and HDU. For the ITU there was always a consultant on call. The HDU relied upon the on call doctors from the respective parent teams.
  • Information from the trust showed that there had been 135 hours of consultant cover on the labour ward to June 2015. In the past 12 months there had been 5219 births which meant they should have 168 hours cover to meet the 2010 Royal college of Obstetrics and Gynaecology guidelines. Following our inspection, the trust confirmed they would review the consultant workforce to provide more consultant cover at the Oldham site. This would be fully implemented in August 2016.
  • Doctors told us they were concerned about gaps in the consultant resident on call rota on Friday evenings. There was a twilight shift 5pm to 8.30pm from Monday to Thursday; however there was no resident cover for this shift on a Friday which meant there was no resident on call between 5pm Friday and 8am Monday. A consultant was on call from home and two middle grade doctors provided resident cover. Following the inspection the trust confirmed this shift would be covered as a matter of urgency.
  • Facing the Future Standards recommend there should be consultant presence on the ward at self-defined peak times. Hospital staff told us that their peak times were between 4pm and 9pm. The hospital had consultants scheduled to be on site up until 5pm. We raised this issue with the trust. They confirmed that consultant presence during peak times was not in place. The trust advised us that consideration had been given to new rotas as part of the paediatric improvement plan. However, no implementation date had been set at the time of our inspection.
  • Facing the Future Standards recommend that every child who presents with an acute medical problem is seen by a consultant, or equivalent, within 24 hours. In one paediatric serious incident investigation we reviewed this had not occurred and was deemed a causal factor in the delay of diagnosis. The trust did not monitor this standard at the time of our inspection.
  • There was no specialist consultant cover at ROH for palliative care.

However:

  • The ITU was a closed unit, clinically led by intensivist/anaesthetists who were able to gate keep the admissions and discharges. With input from the parent teams as appropriate the clinical care was directed and delivered by the intensivist/anaesthetists.
  • There were no gaps at consultant level in outpatients.
  • The emergency department had sufficient numbers of medical staff with an appropriate skill mix to ensure that patients received the right level of care.
  • Rotas were completed for all medical staff which included out of hours cover for medical admissions and all medical inpatients across all wards. Medical trainees contributed to this rota. The information we reviewed showed medical staffing was appropriate at the time of the inspection.
  • Existing vacancies and shortfalls in surgery were covered by locum, bank or agency staff when required, such staff were provided with local inductions to ensure they understood the hospital’s policies and procedures.

Access and flow

  • Between April 2015 and February 2016, the emergency department consistently failed to meet the Department of Health (DH) target to admit, transfer or discharge 95% of patients within four hours of arrival.
  • The average time to treatment in A&E was consistently worse than the 60 minute DH standard between August 2015 and February 2016. The average total time spent in the emergency department by admitted and non-admitted patients was also higher than the England average during this period.
  • The percentage of emergency admissions waiting between four and 12 hours to be admitted was similar to the England average between August 2014 and June 2015, rising above the average during July 2015 to August 2015.
  • The department failed to meet the DH guidelines relating to trolley waits as nine incidents were reported where patients had trolley waits of more than 12 hours between November 2015 and February 2016. This included five breaches reported during February 2016 indicating a worsening trend. There were no reported 12-hour trolley breaches in the department between February 2015 and October 2015.
  • The emergency department had historically recorded the decision to admit (DTA) time as decision at the point of referral to speciality. Since February 2016, the department was trialling a process where the DTA time was recorded at the point when the decision to admit was made by the emergency department clinician. The change in reporting DTA processes could account for the increased number of 12-hour trolley wait breaches reported by the department.
  • The percentage of patients triaged within 15 minutes averaged 85.7% between February 2015 and September 2015. However, the average between October 2015 and January 2016 indicated a worsening trend in performance.
  • The DH target is that handovers between ambulance and emergency department staff must take place within 15 minutes with no patients waiting more than 30 minutes. The department did not meet this target between April 2015 and January 2016. The data showed there was a rising trend as 70% of delayed handovers took place between October 2015 and January 2016.
  • There were 468 ‘black breaches’ reported by the department between April 2015 and January 2016. Records showed 357 (76%) of these took place in the most recent three months between November 2015 and January 2016.
  • The proportion of patients leaving the department without being seen was within the DH target of 5% but higher (worse) than the England average between February 2015 and January 2016.
  • Between October 2015 and December 2015, the average occupancy rate at the hospital was 98%. Research has shown that when occupancy rates rise above 85%, it can start to affect the quality of care provided to patients and the orderly running of the hospital.
  • Between January 2014 and December 2014 hospital episode data (HES) showed the average length of stay for elective medicine at the hospital was worse than the England average. For non-elective medicine it was better than the England average.
  • In medical care services, information provided by the trust showed there were a large number of patients being cared for in non-speciality beds which may not be best suited to meet their needs.
  • There was a high number of patients who were moved between wards during the night on the acute medical ward and just under half of the patients experienced one or more moves during their stay.
  • There were occasions when people had to stay in the discharge lounge overnight and we saw that a patient had not had a regular review by a doctor whilst on the discharge inpatient unit.
  • Between July 2014 and June 2015 hospital episode data (HES) showed the average length of stay for elective surgery overall at the hospital was marginally worse than the England average. For elective colorectal surgery, the average length of stay was worse than the England average. However for elective vascular surgery and elective trauma and orthopaedic surgery length of stay was better than the England average.
  • For the same period the average length of stay non-elective surgery was marginally worse than the England average. For non-elective trauma and orthopaedic surgery and vascular surgery length of stay was much better than the England average. However, for general surgery the average length of stay worse than the England average.
  • Trust wide from January 2015 to December 2015 895 were cancelled for non-clinical reasons, of those 10 were not treated within 28 days. This was much better than the average rate across England.
  • The readmission rate for surgical patients with 28 days of discharge was much worse than the England average.
  • The British Orthopaedic Association ‘standards for trauma’ (BOAST) recommend that patients with a fractured neck of femur should have reparative surgery within 36 hours of presentation. From April 2015 to January 2016, Oldham met this target in 64.3% of patients on average across those months. This meant that one in three patients failed to have their surgery within the recommended timeframe. This breach of standards is associated with increases the mortality and morbidity outcomes in such patients.
  • Challenges with access and flow within the wider hospital impacted on patients’ discharge from the critical care units. Once a clinical decision has been made that a patient was fit for step down or discharge from critical care there was often a delay in discharge.
  • The figures for April 2014 to March 2015 showed that 36% of patients on the level 3 ITU experienced a delayed discharge and 52% of patients on the level 2 HDU had their discharge delayed. The majority of the delays were between one and three days with the occasional patient waiting as long as a week.
  • In terms of out of hours discharges the ITU was performing much better than comparable units whereas in the HDU, the ICNARC data for July to September 2015 showed that 23% of the discharges occurred out of hours.
  • As a consequence of access and flow issues within the hospital, during the 12 months from December 2014 to December 2015, 16 patients had been ventilated outside the critical care unit.
  • The average length of stay on maternity wards was longer than the trusts’ target with delays in discharges from the postnatal ward, especially out of hours.
  • In outpatient and diagnostic services, the percentage of people waiting more than six weeks for a diagnostic test had been worse than the England average since July 2015.
  • Though it was reported that the numbers of patients waiting longer than 18 weeks from referral to treatment (RTT) was consistently better than the England average and the cancer waiting times for the trust were consistently better than the England average, we have subsequently learned that data collection in the department is not reliable and are not assured that targets are truly at that level. Work is being undertaken with the trust to clarify the current position.
  • The numbers of patients failing to attend their appointments was worse than the England average and there were no clear plans in place to improve this situation.

However:

  • The hospital met the national target time of 18 weeks between referral and treatment for 95.6% of their patients.
  • Hospital bed management meetings were held regularly throughout the day to review and plan patient capacity. We saw that staff were able to review and respond to acute bed availability pressures.
  • The CYP service achieved the national referral to treatment target between April and November 2015 within the paediatric specialities.
  • Bed occupancy in maternity services was lower than the England average. The referral to treatment times and the waiting times for the cancer pathway in gynaecology were met.
  • Rapid discharge processes were in place to ensure patients could be transferred to their preferred place of care in a timely manner.

Leadership and management

  • In the main, staff reported that managers were approachable, visible and that they felt comfortable reporting difficult matters to them. Staff stated that they knew who the executive team and board members were and that they were visible and responsive.
  • The emergency department at the hospital had clearly defined and visible local leadership. There was a lead consultant and clinical matron in place to manage the day-to-day running of the department. The nursing and medical staff told us they understood the reporting structures clearly and that they received good management support.
  • In medical care services, all nursing staff spoke highly of the ward managers as leaders and told us they received good support. We observed good working relationships within all teams.
  • Doctors told us that senior medical staff were accessible and responsive and they received good leadership and support.
  • There were clearly defined leadership roles across the surgery and anaesthesia division. Leadership of each clinical group was through a triumvirate arrangement, which was relatively new to the trust and division. Individual ward managers appeared enthusiastic, competent and hardworking and were well thought of amongst ward staff. Nursing staff told us they felt supported and that there were good working relationships within the teams.
  • The work of the SPCT and EOLC was overseen by the EOLC steering group. This group was chaired by the lead consultant in palliative care. There was trust board involvement in the leadership of the service through the chief nurse and non-executive lead.
  • The SPCT was managed by the Macmillan associate lead cancer/palliative care nurse. There was an operational policy in place for the SPCT which included clear statement of governance structures.
  • It was not clear that the leadership of the service understood the challenges involved in establishing a pilot project for seven day working on current staffing levels

However:

  • Within both critical care units, ITU and HDU there were designated nurse leaders. However, whilst there was a designated clinical lead for the level 3 ITU, there was no similarly designated clinical medical lead for the level 2 HDU facility. The arrangements for admission, discharge, on-going management and responsibility for patient care was different for the level 2 HDU at ROH than for the trust’s other critical care areas, as detailed in the trust’s critical care operational policy (version 5).
  • There was a lack of visible midwifery leadership above ward level although this had improved at the unannounced inspection. There was low morale and a culture of blame in midwifery services.
  • There had been no clinical director in pathology services since October 2015. The clinical lead in cellular pathology had also left and the service manager had no one to report to at the time of inspection. Recruitment for the posts was underway.

We saw several areas of outstanding practice including:

Importantly, the trust must:

Action the hospital MUST take to improve

Urgent and Emergency Services

  • Ensure that patients attending the department are assessed and treated in a timely manner.
  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the Urgent and Emergency department

Medical services

  • Ensure that records are kept secure at all times so that they are only accessed by authorised people.
  • Ensure that all staff are aware of the procedures for capacity assessments and these are completed where necessary
  • Ensure that systems in place to manage controlled drugs are robust especially in the acute medical unit
  • Ensure that assessments of patient’s nutrition and hydration needs are fully completed and patient’s receive appropriate support where necessary
  • Ensure that patients are discharged as soon as they are fit to do so.
  • Ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.

Surgical Services

  • Ensure that the recording and disposal of controlled drugs where the whole of one vial is not prescribed, is in line with trust and Royal Pharmaceutical Society of Great Britain guidance.
  • Ensure that there are sufficient nursing staff on duty to keep patients safe at all times, by working towards filling vacancies and reducing sickness.
  • Ensure that were there is cause to question a patient’s capacity, that this is documented fully in the patient’s record; detailing how and why it has been determined that the person has or does not have capacity and that subsequent documentation which is generated based on that decision such as consent 4 documents or DNACPR are completed accordingly.
  • Ensure that DNACPRs are reviewed regularly particularly when a patient’s condition and prospects have changed dramatically since the decision was made.

Critical care

  • Take action to ensure that level 2 patients on the high dependency unit at the Royal Oldham Hospital are managed in accordance with the national guidance and standards for critical care.
  • Take action to reduce the numbers of delayed and out of hours discharges from both level 2 and level 3 critical care facilities.

Maternity and Gyneacology Services

  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the maternity services. This includes sufficient consultant resident cover in the labour ward.
  • Assess the risks to the health and safety of patients of receiving the care or treatment.
  • Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.
  • Investigate incidents within agree timescales and take action to prevent recurrence

Children and Young People

  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the paediatric and neonatal services. This includes sufficient medical cover.
  • Ensure consideration is given to maintaining children's dignity at all times.
  • Assess the risks to the health and safety of patients of receiving the care or treatment.
  • Ensure the investigation of incidents within agreed timescales and take action to prevent recurrence.
  • Ensure that electrical equipment is appropriately maintained and fit for purpose.

End of life services

  • Take action to ensure that any DNACPR decision is supported by the consent of the patient.
  • Take action to ensure that where a patient appears to lack capacity to consent to a DNACPR decision, a mental capacity assessement must take place prior to the decision being taken.
  • Take action to ensure where a patient has been assessed as lacking capacity to make the DNACPR decision a documented discussion with patient’s family takes place prior to the decision being taken.
  • Take action to recruit to the consultant in palliative medicine position that is currently vacant.

Outpatient and diagnostic services

  • Take action to ensure that staff who work in the Elective Access department receive annual appraisals.

Action the hospital SHOULD take to improve

Urgent and Emergency Services

  • Consider taking appropriate actions to improve the processes for reviewing and managing key risks to the services.
  • Consider taking appropriate actions to improve the processes for monitoring and improving the management of sepsis.

Medical Services

  • Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.
  • Consider the design of the resuscitation trolleys to ensure they are tamper proof
  • Ensure that patient pain is consistently recorded
  • Patients on the discharge unit are regularly reviewed where required
  • Ensure that all staff seek consent for the use of bedrails and if they lack capacity apply the Mental Capacity Act (2005) principals and this is reflected in procedures

Surgical Services

  • Embed a recognised early warning system which gives clear and unambiguous guidance on escalation procedures and care for the deteriorating patient.
  • Ensure compliance with all elements of the NICE clinical guidance 83 concerning the rehabilitation of critically ill patients.
  • Ensure that they take steps to improve compliance with the recommendations of the British Orthopaedic Association standards for Trauma (BOAST) to prevent patients waiting longer than 72 hours before seeing an orthopaedic specialist.

  • Ensure that they take steps to improve compliance with the recommendations of the British Orthopaedic Association standards for Trauma (BOAST) to prevent patients waiting longer than 36 hours before surgery for fractured neck of femur and improve compliance with the hip fracture audit best practice tariffs.
  • Ensure steps are taken to address their very high readmission rates.
  • Ensure they work towards compliance with all of the recommendations of the Faculty of Pain Medicine’s Core Standards for Pain Management (2015).

Critical care

  • Consider that care within the level 2 critical care unit is clinically led by a consultant in intensive care medicine.
  • Consider that there is a supernumerary band 6/7 shift co-ordinator on duty 24/7.
  • Consider that there are standard protocols in place for the administration of intra-venous infusions on the level 2 high dependency unit.
  • Consider that the critical care risks on the risk register are regularly reviewed and updated with actions.
  • Consider that the existing arrangement for the servicing and repair of equipment assures them that all critical care equipment is fit for purpose.
  • Consider how it can embed training on Duty of Candour to all staff.
  • Consider how it can develop and expand the critical care outreach service to provide cover 24/7.
  • Consider how it is going to embed the delirium strategy into the day to day care of patients receiving critical care.
  • Consider how it is going to meet the intensive care society standards for the provision of pharmacy and allied health professional support to the critical care service.

Maternity and Gyneacology Services

  • Consider including actions and sharing lessons learned following the mortality or morbidity meetings to use them to improve practice.
  • Consider having a system to provide feedback, develop actions and share learnings from complaints.
  • Consider how the actions from the maternity improvement plan will continue to be implemented.
  • Consider continuing the actions identified in the action plan of 2013 to prevent puerperal sepsis.
  • Consider introducing a system to check the completion of fluid intake and output charts.
  • Consider implementing an access and exit system on the post natal ward which protects patients.
  • Consider keeping staff mandatory training and that specific to the role they completed up to date at all times.
  • Consider a safety message being delivered at handover
  • Consider multidisciplinary handovers on the labour ward.
  • Consider introducing mechanisms to reduce the delays in induction of labour.
  • Consider how gynaecology patients can receive results following diagnostic procedures in a timely way.
  • Consider implementing actions from audits.
  • Consider how the information on the maternity dashboard can be used to inform and improve practice.
  • Consider making sure all staff appraisals are up to date.
  • Consider how risks are managed.
  • Consider improving the engagement with staff and the public.

Children and Young People

  • Consider including actions and sharing lessons learned following the mortality or morbidity meetings to use them to improve practice.
  • Consider deploying at least two trained members of staff to work in the observation and assessment unit.
  • Consider keeping staff mandatory training and that specific to the role they completed up to date at all times.
  • Consider nursing staff presence at morbidity and mortality meetings.
  • Consider how the hospital is going to meet the facing the future standards
  • Consider implementing actions from audits.
  • Consider how the information on the paediatric and neonatal dashboards can be used to inform and improve practice.
  • Consider making sure all staff appraisals are up to date.
  • Consider how risks are managed.
  • Consider improving the engagement with staff and the public.

End of Life

  • Ensure that DNACPR documentation is completed in accordance with its own trust policy.
  • Consider how it can embed training on Duty of Candour to all staff.
  • Consider how it can develop and expand the critical care outreach service to provide cover 24/7.
  • Consider how it is going to embed the delirium strategy into the day to day care of patients receiving critical care.
  • Consider how it is going to meet the intensive care society standards for the provision of pharmacy and allied health professional support to the critical care service.
  • Consider a full review of the staffing requirements to introduce seven day specialist palliative care services at the hospital.
  • Consider how to respond to the complex symptom control needs of EOL patients out of hours.
  • Consider how to provide training to middle grade doctors about the complex symptom control needs of EOL patients.
  • Consider whether the current SPCT staffing levels are sufficient to meet the current demands on the service.
  • Consider how to involve SPCT in the service developments required to implement the EOL strategy.
  • Consider the level of support and education required from EOLC facilitation team for FGH to embed the use of the IPOC documentation across all its wards.
  • Consider how to develop a sensitive tool to ascertain when incidents occur related to EOL issues.

Outpatients and diagnostics

  • The trust should consider changing the way that patient records are being scanned onto the EVOLVE system so that historic records are prepped and scanned on demand in advance of patient attendance at an outpatient clinic. This system has been seen working well in other trusts and ensures that “active” patient notes are prioritised.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 12 August 2016

Effective

Requires improvement

Updated 12 August 2016

Caring

Good

Updated 12 August 2016

Responsive

Requires improvement

Updated 12 August 2016

Well-led

Inadequate

Updated 12 August 2016

Checks on specific services

Maternity and gynaecology

Inadequate

Updated 12 August 2016

We rated maternity and gynaecology services as inadequate because:

  • There was an unacceptable level of serious incidents with delays in investigations including those resulting in severe harm. There was a failure to effectively investigate and learn from incidents with a lack of openness about outcomes.
  • There was a lack of learning from complaints and a lack of learning and sharing of knowledge from discussions about mortality and morbidity.
  • There was a shortage of midwifery staff which led to some delays in transfers during labour and inductions of labour.
  • There was a lack of actions to make identified improvements in audits of the quality of service provided had taken place.
  • The security system on the post natal ward did not offer sufficient protection from abduction of babies.
  • Midwives and medical staff were not up to date with training and competence for some of the tasks they performed. Most staff were not up to date with appraisals of their performance.
  • There was a lack of clear systems and processes for managing risks and performance of the service.
  • However:
  • Some improvements had been made as a result of the maternity improvement plan including the purchase of necessary equipment.
  • Midwifery and medical staff worked well as a team and provided compassionate care despite the shortage of staff.
  • There was an enthusiasm amongst the staff to improve the services.
  • Gynaecology procedures were provided on an outpatient basis and there was some innovation in this practice.

Medical care (including older people’s care)

Requires improvement

Updated 12 August 2016

We judged medical care services as requires improvement overall because:

  • There were standards for record keeping that required improvement we found records were left unsecured on the acute medical unit and there was a risk personal information was available to members of the public.
  • Resuscitation equipment was not always being checked and equipment could be accessed even though tamper seals were in place. There were a number of pieces of electrical equipment which had out of date safety certificates and oxygen was not being stored in line with guidance.
  • There had been incidents of missing medication on the acute medical unit and training levels in medicines management was low .
  • Staffing levels were largely adequate to meet the needs of patients but there were occasions on wards when there had been a reliance on agency or bank nurses as well as locum doctors.
  • Staff were not always following trust policies and procedures in relation to assessing patients for capacity to provide informed consent and the completion of capacity assessments.
  • There was insufficient bed capacity on occasions to meet the needs of people within the hospital . Some patients had to stay in hospital longer than was needed due to care packages not being in place when they were ready for discharge.
  • Patients were not always supported with hydration and nutrition
  • We saw staff interactions with people were person-centred; but there was limited interaction with patients on ward F10 and the acute medical unit out of the three ward areas visited.
  •  It was unclear if learning was shared wider across other service areas and there were times when complaints took a long time to resolve

However:

  • There were systems in place to protect people from avoidable harm and staff were aware of how to ensure patients’ were safeguarded from abuse.
  • Incidents were reported by staff through effective systems and lessons were learnt and investigation findings and improvements made were fed back to staff at a local level.
  • The hospital was visibly clean and staff followed good hygiene practices.
  • Best practice guidance in relation to care and treatment was usually followed and medical services participated in national and local audits. Action plans were in place if standards were not being met.
  • The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and a leaf symbol to indicate that a patient was frail or elderly. This helped alert staff to people’s needs.
  • All staff knew the trust vision and behavioural framework and said they felt supported and that morale was good.

Urgent and emergency services (A&E)

Requires improvement

Updated 12 August 2016

We judged urgent and emergency services as requires improvement overall because:

  • Patients attending the department experienced extended delays before they received treatment. The emergency department consistently failed to meet the Department of Health (DH) target to admit or discharge 95% of patients within four hours of arrival between April 2015 and February 2016. The overall average of patients that were seen within four hours was 84.38% during this period.
  • The average time to treatment was consistently worse than the 60 minute DH standard between August 2015 and February 2016. The total time patients spent in the department was also higher than the England average during this period. There were nine instances where patients had trolley waits of more than 12 hours in the three months between November 2015 and February 2016.
  • The department failed to achieve the target for ambulance handover within 15 minutes between April 2015 and January 2016. There were 851 handovers that took between 30 and 60 minutes during this period. There were 468 ambulance handovers that took longer than 60 minutes (black breaches) reported by the department between April 2015 and January 2016.
  • The percentage of patients triaged within 15 minutes averaged 85.7% between February 2015 and September 2015. However, the average between October 2015 and January 2016 was 77.9%, indicating a decline in performance. The proportion of patients leaving the department without being seen was within the DH target of 5% but worse than the England average between February 2015 and January 2016. Complaints were not routinely resolved within the trusts specified timelines.
  • The emergency department had sufficient numbers of medical staff. However, there were vacancies in the nursing and healthcare support worker establishment, which meant the staff did not always have the flexibility to cope with the number of patients attending the department, especially during busy periods. An independent nurse staffing review took place during November 2015 and this recommended an increase to the current establishment by 15.80 whole time equivalent staff in order to fully meet safe staffing standards.
  • The main reasons for delays in admission was due to insufficient bed capacity across the hospital, which meant patients that required admission could not be transferred to the wards in a timely manner. An urgent care improvement plan was in place to improve patient flow but key actions listed in the improvement plan were not scheduled for completion until August 2016.
  • The urgent care directorate was formed recently and the clinical director and lead nurse for urgent care services across the trust had only been in post since December 2015 and January 2016 respectively. There was no formal strategy specifically for the service. The clinical governance system allowed key risks to be escalated and reviewed. However, the length of time taken to respond to these risks meant the department did not have a proactive approach to managing these risks.

However:

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises.
  • Care and treatment was provided in line with national clinical guidelines and staff used care pathways effectively. The services participated in national and local clinical audits and performed in line with other hospitals and the England average for most safety and clinical performance measures.
  • Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Mandatory training compliance in the department was 90% and the trusts expected standard of 90% compliance had been achieved.
  • There was effective local leadership and staff spoke positively about the they support received. Patients spoke positively about their care and treatment.

Surgery

Requires improvement

Updated 12 August 2016

We judged surgery as requiring improvement overall because:

  • Staffing levels were low at times. There was a high nurse staffing vacancy rate and high levels of sickness. This meant that on occasions staffing was only 85% of the required level.
  • The early warning system the hospital had adopted was implemented inconsistently and clear procedures for escalate concerns for a deteriorating patient were not embedded.
  • The division did not correctly undertake assessments of mental capacity and consent to treatment in all cases.
  • The service was non-compliant with a number of elements of the NICE clinical guidance 83 concerning the rehabilitation of critically ill patients.
  • The service had very high readmission rates, which were significantly higher (worse) than the England average.

However

  • There was a good culture of reporting incidents and safety issues and investigations were thorough. We saw evidence of learning when things went wrong .
  • The environment was clean and hygienic with low levels of healthcare associated infections.
  • Care was planned and delivered in line with evidence based guidance and best practice. Patient outcomes were good and in some areas the division performed better than other trusts and England averages.
  • Multidisciplinary team working was good with satisfactory access to a range of specialities. Staff were experienced and competent and had the skills to undertake their job effectively.
  • Staff went about their work with a caring and compassionate nature. They protected their privacy and dignity of their patients when providing care and treatment.
  • There was attention to individual patient needs and support for those with complex needs. The ward environment was very good for dementia patients and there was implementation of many of the recommendations from dementia best practice guidance.
  • The surgery and anaesthesia division was well led both on a ward level and at divisional level.

Intensive/critical care

Inadequate

Updated 12 August 2016

We judged critical care as inadequate overall because:

  •  There was no designated clinical medical lead for the level 2 HDU unit. As a consequence of this lack of leadership there were significant shortfalls where the national service specification for critical care (D16) and the GPICS standards were not being met on that unit.
  • The nurse staffing on both the ITU and HDU failed to meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7.
  • There was a critical care outreach team but this did not cover all of the wards and was not delivered 24/7.
  • The hospital was non-compliant with a number of elements of the NICE clinical guidance around the rehabilitation of critically ill patients.
  • There was a problem with delayed (both units) and out of hours discharges (HDU). The ICNARC data for July to September 2015 showed that 23% of the discharges from HDU occurred out of hours.
  • It was not clear how risks to critical care were being managed. The risk register reported risks that had been identified for a number of years but there was a lack of clarity about mitigating actions, progress and review.

However:

  • The units both contributed data to the intensive care national audit and research database (ICNARC). The most recent data showed that mortality rates for both level 2 and 3 areas was in accordance with comparable units.
  • Critical care services were delivered by caring, compassionate and committed staff. We saw patients, their relatives and friends being treated with dignity and respect.

Services for children & young people

Inadequate

Updated 12 August 2016

We ratedChildren and Young peopleservices as inadequate because:

  • Risks were not escalated appropriately and therefore did not gain robust executive scrutiny or the required response to mitigate risks in the longer term.

  • There were unacceptable delays in investigations including those resulting in severe harm.

  • There was a failure to effectively investigate and learn from incidents. There was a lack of learning and sharing of knowledge from discussions about mortality and morbidity.

  • Care and treatment did not always reflect current evidence-based guidance, standards and best practice. .

  • Patients received care from staff that did not have the skills that are needed to deliver effective care. There were very low numbers of nursing staff who had current Paediatric Immediate Life Support (PILS) certification and none had Advanced Paediatric Life Support (APLS) certification. .

  • In paediatrics we saw staff engaging with children and their parents kindly. However, patient’s privacy and dignity were not always upheld.

  • Staff told us there were times when they had to focus on the task they were undertaking rather than treating people as individuals to ensure that essential jobs were done e.g. provision of medications.

  • Friends and family test results were poor, but parents and patients on the ward at the time of our inspection did not support the test’s findings.

  • We found that the needs of the local population were not fully understood when planning this service particularly when considering the number of under two’s that would access the children’s wards.

  • There was no strategy within the service. The paediatric team were following the paediatric improvement plan, however there was no strategy for continuous improvement or sustaining changes resulting from it..

  • Quality and safety were not a top priority for the trust board and decisions were taken that impacted on patient safety.

However

  • On the neonatal unit staff interactions were positive and babies were treated with kindness and compassion.

  • Parents felt supported and involved in the planning and decisions regarding their child’s healthcare.

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.

Outpatients

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.