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Royal Shrewsbury Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 29 November 2018

Our rating of services went down. We rated them as inadequate because:

  • Our rating of safe was inadequate overall. Services did not always manage patient safety incidents well. The deteriorating patient was not always recognised within urgent and emergency care services to ensure appropriate and timely care was provided. Not all services had sufficient numbers of permanent staff with the right qualifications, training and experience to keep people safe from avoidable harm and abuse. Staff completion data for mandatory training did not meet the trust targets, including Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. There was no data available for adult safeguarding training for medical staff.
  • Our rating of effective remained requires improvement overall. Services monitored the effectiveness of care and treatment and used the findings to improve them. However, effective action was not always taken in response to poor audit results to drive improvement.
  • Our rating of caring remained as good overall. Staff delivered compassionate care and patients’ privacy and dignity was maintained.
  • Our rating of responsive remained as requires improvement overall. The trust did not always plan and provide services in a way that met the needs of local people. Not all services always took into account the individual needs of patients.
  • Our rating of well-led went down to inadequate overall. Staff reported a disconnect between them and the senior management team and board. There were systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, timely and effective action was not always taken to mitigate risk. The trust did not always use a systematic approach to continually improve the quality of its services or safeguard high standards of care by creating an environment in which excellence in clinical care would flourish.

Inspection areas

Safe

Inadequate

Updated 29 November 2018

Effective

Requires improvement

Updated 29 November 2018

Caring

Good

Updated 29 November 2018

Responsive

Requires improvement

Updated 29 November 2018

Well-led

Inadequate

Updated 29 November 2018

Checks on specific services

Critical care

Requires improvement

Updated 29 November 2018

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

  • The critical care unit did not meet current standards and there were not timely plans in place to address this.
  • Although there had been improvements to nursing and medical staffing which now meet core intensive care standards, staffing of allied health professionals continued not to meet the required standards.
  • Arrangements to ensure the availability of the hospital at night team were not robust and meant that sufficient staff were not always available to assess and treat deteriorating ward patients.

  • The number and availability of allied healthcare professionals to provide care and treatment for critical care patients did not meet the required standards.

  • Most staff were competent to undertake their roles. However, appropriate arrangements were needed to ensure the continuing development of critical care staff to meet intensive care standards.
  • Multidisciplinary team (MDT) working was not always joined up across critical care. Health professionals (doctors, nurses and allied health professionals) had separate handovers which meant there was not discussion amongst all critical care health professionals for a full and rounded review of patients.
  • Staff compliance with Mental Capacity Act (MCA) and Deprivation of Liberty training was extremely low.
  • Consent to care and treatment was not always sought in line with legislation and guidance. Staff did not have sufficient knowledge or understanding of mental capacity act and deprivation of liberty safeguards. Because of this regulation had been breached and we were aware that one patient had been restrained, sedated and ventilated without the required safeguards in place.
  • Although patient’s admission to critical care was mostly timely patient’s discharge from critical care was frequently delayed which also resulted in mix sex accommodation breaches.
  • The trust planned to provide a modern critical care unit however the identified timescale was not realistic and meant that the needs of local people were not fully or appropriately met.
  • Managers within critical care had the right skills and abilities to provide the service. However, there was lack of overarching managerial arrangements to ensure a coordinated critical care service for doctors across both the trust’s hospitals to provide safe, high-quality and sustainable care.
  • Managers within the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, there was a need to ensure this was consistently displayed by other managers outside critical care.
  • There was an inconsistent approach to service delivery and improvement. Managers, who worked within critical care identified where risks were and where improvements were needed to meet required standards. However, the response from more senior managers was slow and failed to recognize the needs of a critical care service and its patients.

  • Although the service provided mandatory training in key skills for all staff most medical staff had not completed it.

However:

  • Patients were treated with kindness and compassion and they and their loved ones were involved in decisions about their care and treatment.
  • There were sufficient nurses and doctors available with the right skills, training and experience to provide the right care and treatment within critical care.
  • Most nursing and ancillary staff had received required mandatory training including safeguarding training. Compliance with mandatory training had improved as staff were able to access to mandatory training and had resulted in critical care unit achieving the diamond exemplar award (the trusts highest quality award).
  • Arrangements for the prescribing, administration and storage of medicines were appropriate.
  • There were appropriate systems in place to report incidents and staff were mostly confident to do so.
  • The service treated concerns and complaints seriously, investigated them and when needed lessons were identified and learnt.

Outpatients and diagnostic imaging

Good

Updated 20 January 2015

Overall we rated this service as good. Outpatients and diagnostic imaging services were safe. The trust had prioritised statutory training, but refresher mandatory training had not been completed by the majority of staff. Mandatory training was provided at the trust’s discretion and to ensure compliance with local standards and policies. This meant that the trust could not be confident that staff were following the most recent advice and guidance.

We saw good practice and effective, compassionate care. Patients were very complimentary about all the staff they had come into contact with. Staff were observed to be caring and compassionate in the way they dealt with patients and their families or carers. They were knowledgeable and enthusiastic about the service they provided and this was reflected in how they engaged with people.

We saw good practice and some innovative working and interpretation of NICE guidance to the benefit of patients and the trust. Services were managed well at a local level; appraisals and supervision of practice were completed. Meetings took place between staff and managers. Staff felt supported and they told us they respected their managers.

Urgent and emergency services

Inadequate

Updated 29 November 2018

Our rating of this service went down. We rated it as inadequate because:

  • The service did not have enough nursing or medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm.
  • We found that medical staff were not up to date with safeguarding level 3 training.
  • We found that there was conflicting information with regard to the sepsis bleep system. There were posters declaring that in the event of a patient having sepsis, staff were to call an allocated bleep number, to alert a senior clinician. We found that this system was not in use due to the shortage of medical staff available to hold the bleep. We were not assured that all staff would know the bleep was not always in use. This applied specifically to agency staff and anyone visiting the ED.
  • Waiting times and arrangements to admit, treat and discharge patients were not in line with good practice.
  • We saw on several occasions that patients had been waiting for over four hours to be transferred, admitted or discharged from the ED. We noted patients had been waiting longer to be admitted to a ward and in three cases we saw that patients had waited over 12 hours.
  • We found that that patients were potentially at risk due to a lack of insight and intervention from some senior leaders. Local leadership was mostly good, however, staff told us there were some inconsistencies, depending on who was managing any given day.
  • The trust did not use a systematic approach to continually improve the quality of its services. Governance processes were inconsistent and although concerns were identified, action plans were not robust enough to improve the situation.
  • We found that although some concerns regarding ED were on the risk register; the executive team at the trust were unaware of certain decisions that had been taken more locally.

However,

  • Staff provided emotional support to patients to minimise their distress. We saw examples of good care being given by doctors, nursing and other healthcare staff. Patients were included in conversations about their care.
  • Despite low morale experienced within the department, staff consistently told us they enjoyed their work and were passionate about helping patients. Overall, they felt they could approach their manager, or other staff, if they had a problem or concern.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. We saw good multidisciplinary working practices were evident within the department.

Maternity

Requires improvement

Updated 29 November 2018

  • At our last inspection the service was rated GOOD overall in all five domains. In this inspection the service was rated as Inadequate in safe, Requires Improvement in effective, responsive and Well Led and Good in caring. This means that maternity services are rated Requires Improvement overall.
  • Our rating of this service went down. We rated it as requires improvement because:
  • The environment of the Shrewsbury MLU was unfit for purpose in that the temporary environment was cramped with five services working alongside each other within a small area. This posed a fire risk and infection control issues.
  • There was no clear process for accessing medical reviews of women who presented on the Day Assessment Unit (DAU) as being high risk or risk had increased. Medical reviews could not always be accessed in a timely way. There was no defined pathway for supporting women with reduced fetal movements.
  • The service did not assess, monitor or manage women with high risk pregnancies in the correct environment with the support of medical staff. This meant that if risks were identified there was a delay in transferring women to the obstetric led unit.

  • There was a shortage of midwives mainly due to sickness and maternity leave.
  • A number of NICE guidelines and operational policies were out of date.

  • The service treated concerns and complaints seriously, but investigations and outcomes were not always completed in a timely manner nor in line with the trust’s own complaints policy
  • The Head of Midwifery (HOM) did not have direct access to the board. This was not in line with recommendations from ‘Spotlight on Maternity’ 2016.
  • Local leaders felt disconnected from senior leaders.
  • There was a lack of clear strategy for staff at all levels of the service.
  • The scrutiny of the midwifery service had been extensive since the last inspection and was still on going. The numerous reviews and action plans were distracting managers from service progression.
  • The trust did not have robust systems to identify risks, plans to eliminate or reduce them, and cope with both the expected and unexpected.
  • The trusts vision and values was not always shared with staff’s understanding of these.

However:

  • Staff were kind, caring and considerate and women were happy with the care they were receiving.
  • Staff were competent and were supported to develop their skills and knowledge
  • There was a new governance team and staff could see improvements in governance
  • Incidents were reported and investigated and staff said feedback to them had improved
  • The introduction of ‘safety huddles’ presented staff with a daily opportunity to discuss work load, acuity, risks and incidents.
  • Staff thought local management was good and they felt supported by the local managers.

Maternity and gynaecology

Good

Updated 16 August 2017

Women told us that they felt very well cared for and the staff were caring, thoughtful and compassionate. The service was responsive to the requirements of women from the booking-in clinic and at all stages of their journey. There was a range of choices for women during labour. Women told us they felt involved with decisions in their care.

We saw that staff followed good practice with infection prevention and control. Staff were aware of how to report incidents and were encouraged to do so. We saw that staff had opportunities to learn from incidents across the service. Staff had access to and followed policies and procedures that were based on national guidance.

We saw a positive culture within the MLU with strong leadership.

Effective systems of communication were established between the consultant led unit and the MLU, ensuring that effective care and treatment could be delivered.

A full review of the maternity service was ongoing, looking at different ways to improve the service; staff were clear about their role and levels of accountability.

However, the maternity specific safety thermometer was not being used to measure compliance with safe quality care. Staff completion of some topics included in the mandatory training programme was lower than the trust target of 100%. There was no signage on the store room door containing portable Entonox to inform people that compressed gases were stored there. Woman’s notes were not always available when women arrived at the MLU in labour.

Medical care (including older people’s care)

Requires improvement

Updated 29 November 2018

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

  • Staff completion data for mandatory training did not meet the trust targets.
  • Staff training levels for safeguarding were poor. Only 68% of nurses and 5% of medical staff had completed the module Safeguarding Adults Level 2.
  • Infection prevention and control practices were not consistently adhered to within the hospital. Staff did not always wear appropriate personal protective equipment (PPE) and side room doors for infectious patients were consistently left open.
  • We were not assured that the service had suitable environments and maintained equipment in a timely way. We saw that the dirty utility facilities on the dialysis unit were in a state of disrepair and there was no piped oxygen on the renal unit. The trust-wide medical devices register showed that amount of equipment had not been seen to be serviced within set timelines.
  • We were not assured that risks to patients were always managed positively within the service. Whilst staff within the service used systems to identify deteriorating patients, there was a lack of consistency in sepsis management, a lack of awareness around dietary risks on the renal ward and inappropriate risk assessments for additional patients on wards.
  • The service did not always follow best practice when preparing, giving, and storing medicines.
  • Staff did not understand their roles and responsibilities under the Mental Health Act 1983. They did not know how to support patients in providing them with their rights under Section 2 of the Act.
  • Care and treatment did not always reflect current-evidence based guidance standards. Implementation of evidence-based guidance was variable, we reviewed a sample of four clinical guidelines and saw that two were out of date.
  • Outcomes for people who use services were below expectations compared with similar services. The service did not meet the national aspirational standards in the National Audit of Inpatient falls and performed significantly worse in some metrics than the national average in the 2017 Lung Cancer Audit.
  • There was a lack of knowledge among nursing and medical staff regarding outcomes and action plans from audits.
  • We were not assured that the staff had the skills and knowledge to manage issues arising from patients with learning disabilities. No member of staff in the medicine core service had received training on patients with learning disabilities in the last 12 months.
  • We were not assured that the trust had effective systems in place to identify all risks. We identified a number of risks on our inspection that did not feature on the trusts risk register including: the low rates of administering antibiotics within one hour of identifying patients with suspected sepsis, the equipment maintenance concerns we identified and the extremely low safeguarding and mandatory training rates.
  • The safety performance of the service had deteriorated since our previous inspection. Since our previous inspection mandatory training rates, safeguarding rates and equipment maintenance had deteriorated. We were concerned that there was not a focus on these issues from the service’s leaders.

Surgery

Requires improvement

Updated 29 November 2018

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

At the last inspection it was rated as requires improvement overall including safe, responsive and well led. It was rated as good for effective and caring. We looked at the changes surgical services had made to improve the service during this inspection.

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

  • The management of sepsis was still being embedded; audits showed low compliance with the treatment process.
  • Mandatory training was provided however the service did not ensure that all levels of staff attended within the timeframe, set at the beginning of the year.
  • Although staff understood how to protect patients from abuse, low safeguarding training completion rates did not assure us that staff were updated and competent.
  • The service had did not have sufficient permanent staff with the right qualifications, training and experience to keep people safe.
  • Patient records were not securely stored to maintain patient confidentiality.
  • Boarding of patients was instigated by the trust to keep patients safe when there was no space in the emergency department. We identified inappropriate, undignified boarding of patients during the inspection.
  • A seven-day service was not fully integrated for scheduled care.

However:

  • Patients were appropriately assessed before surgery and safety measures were in place to monitor their well-being during and after surgery.
  • All clinical staff we spoke with demonstrated a good understanding and knowledge of the principles of patient consent.
  • Nursing staff used national early warning scores (NEWS) to assess and monitor a patient’s condition electronically and in paper format.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.

  • Patients told us they had been given enough food and drink to meet their needs and improve their health.
  • We found that there was an established multidisciplinary team (MDT); teams worked well together to improve the effectiveness and timeliness of care.
  • Patient feedback was positive about care and compassion; patients told us they felt safe.
  • The environment was clean and tidy but in need of some repair.

Services for children & young people

Good

Updated 20 January 2015

Services for children and young people were found to be good. Children received good care from dedicated, caring and well-trained staff who were skilled in working and communicating with children, young people and their families.

The trust had robust arrangements in place to monitor incidents and staff were clear on their responsibilities relating to this. Children who were seriously ill were appropriately escalated for specialised care and this might involve transfer to Princess Royal Hospital at Telford.

Staff were up to date with mandatory training and robust governance arrangements were in place for children and young people’s services and staff were clear on their roles and responsibilities. Staff felt valued and had clear lines of communication through the trust. Staff felt confident in raising concerns and felt listened to regarding ideas to improve services

End of life care

Requires improvement

Updated 29 November 2018

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

  • End of life care (EoLC) and specialist palliative care (SPC) lacked overall coherence, consistency and embeddedness in clinical areas. Services were shared between two teams that were not resourced to provide a seven-day service in line with national guidance. Out of hours support was tenuous, not clearly understood by key staff and lacked a stable, effective governance structure. This was not a reflection of the dedication of the teams of nurses, champions, volunteers and consultants delivering services; their ability to deliver a high standard of care was significantly diluted by the extent of their responsibilities and lack of capacity.
  • There were limited audits in place for the service, which meant staff could not accurately benchmark care. Where audits were in place, they did not always establish an accurate assessment of care. For example, the mortuary-based care after death audit could not establish clinical reasons for instances where staff had not fully complied with trust policy.
  • The use of the network end of life plan documentation was inconsistent and sporadic and there was no evidence of improvement since our last inspection in 2016. The 2017 audit of this documentation identified areas for significant improvement, including in recording of staff designations, clinical decisions, involvement of patients and factors contributing to end of life treatment plans.
  • Nurse and consultant staffing levels did not meet national standards for minimum levels of service. Staff routinely worked cross-site covering large areas of responsibilities and in some cases with more than one job role.
  • There were significant shortfalls in governance and quality assurance that were not reflective of the dedication, competence and passion of clinical staff.
  • There was limited evidence that membership of a specialist network resulted in improved standards of care or patient outcomes. Internal audits also demonstrated few improvements, including in relation to the preparation of bodies for the mortuary to standards significantly below trust standards.
  • The EoLC team demonstrated a sustained effort in implementing an improvement action plan that resulted from our last inspection and feedback from peer reviews and input from other organisations. However, there was limited evidence of structured, substantive support from the trust.
  • There was a need for broad, sustained and substantial improvements in the consistency, quality, use and availability of patient records and care plans from the general medical teams.
  • Standards of practice in relation to the Mental Capacity Act (2005) and mental capacity assessments more generally were highly variable and there was no system in place to effectively correct the poor track record of some clinicians or services. A review of care of patients living with a learning disability who died in the hospital highlighted a series of missed opportunities.
  • The trust did not have a system for identifying and tracking incidents specifically relating to this service. The decision to involve the EoLC or SPC teams was subjective and themes in complaints, including around lack of capacity and transport, remained unaddressed.
  • Survey and audit results indicated a need for improved consistency and standards in the provision of care after death. EoLC and SPCT teams demonstrated awareness of this and were delivering training to staff to address it.
  • The hospital could not meet the trust policy of issuing a medical certificate of cause of death (MCCD) by the end of the certifying doctor’s shift or by 12pm the following day. Relatives provided feedback over a six-month period of significant delays in obtaining an MCCD, which were compounded by a lack of capacity in the bereavement office that resulted in lengthy delays in communication.
  • Service-level teams, including clinical leads, had demonstrably contributed to the expansion, development and improvement of significant areas of the service. However, this was not reflected in leadership or governance at trust level. As a result staff routinely worked over their capacity, the service could not meet demand and there were gaps in quality and performance assurance.

However, we also found areas of good practice:

  • Staff routinely exceeded patient and relative’s expectations during the final hours of life and relatives referred to the attention to detail demonstrated by staff. This included facilitating a hospital visit from a patient’s pet and escorting a patient to the hospital’s tranquil garden in their bed during their final hours.
  • Staff delivering EoLC and SPCT services, including front-line staff supporting them, acknowledged the need for sustained and broad improvement. They were participating in the National Audit of Care at the End of Life (NACEL) and the NHS Improvement end of life care hospital improvement project (ELCHIP) as part of a broad strategy to improve standards and quality.
  • EoLC and SPC clinical nurse specialists and lead consultants had designed and implemented a wide range of training sessions for staff at all levels of the organisation. This was designed to significantly improve knowledge, understanding and quality of care and reflected the need to substantively improve consistency in practice.
  • Staff demonstrated significant and sustained proactivity in securing funding and services from external organisations to improve the service for patients and their relatives. This included in working together to overcome internal challenges and barriers to service development.
  • Improvements to the compassion and sensitivity of care and communication shown by staff were evident throughout the service.
  • The EoLC lead facilitator was leading an education programme for staff in area nursing homes to provide patients with more options for places of care that would not require a hospital inpatient stay.
  • EoLC staff had provided resources for each ward to help them in the delivery of care. This included reference checklists, signposting to multidisciplinary services, links national and trust standards and contact details for other organisations. This was in addition to supplying each ward with Swan scheme resources to help provide individualised care to people and reflected the work of the specialist teams to address the lack of capacity by empowering ward teams to deliver more responsive EoLC.
  • The EoLC facilitator team played a key role in the advocacy and promotion of end of life services and had arranged health promotion engagement activities to raise the service profile.