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Royal Shrewsbury Hospital Requires improvement

Reports


Inspection carried out on 12 – 15 December 2016

During an inspection to make sure that the improvements required had been made

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

Royal Shrewsbury Hospital was formed in 1979 after a number of hospitals in the town were closed or merged. The hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for acute and emergency surgery, and has a trauma unit that is part of the region-wide network. It is the main centre for oncology and haematology.

This was a focused inspection, following up our inspection that took place in October 2014. At that time the hospital was rated as requires improvement overall, with caring as good.

We rated Royal Shrewsbury Hospital as requires improvement overall.

  • The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery have been lower than the England overall performance since September 2015.

  • Insufficient numbers of consultants and middle grade doctors were available.

  • Nursing staff vacancies were affecting continuity of care and an acuity tool was not used to assess staffing requirements.

  • The triage process for patients brought in by ambulance was inconsistent and unstructured.

  • Compliance with the trust target for completion of staff appraisals was below the trust target.

  • There were three Never Events relating to retained products following surgery,

  • Current safety thermometer information was not displayed on the wards

  • The maternity specific safety thermometer was not being used to measure compliance with safe quality care.

  • Inconsistencies were identified in the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist.

  • Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection.

  • Mental capacity documentation had not been completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

However, we also saw that:

  • Openness and transparency about safety was encouraged. Incident reporting was embedded among all staff, and feedback was given. Staff were aware of their role in duty of candour.

  • In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Staff were highly motivated and passionate about the care they delivered.

  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

  • Treatment was planned and delivered in line with national guidelines and best practice recommendations

  • Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order

  • It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

  • There was a clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

  • The trust had made end of life care one of its priorities in 2015/2016.

We saw several areas of outstanding practice including:

  • The trust had rolled out the Swan scheme across the trust that included a Swan bereavement suite, Swan rooms, boxes, bags and resource files for staff.

  • The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

  • Virginia Mason Institute (VMI) designed and developed its systems to become widely regarded as one of the safest hospitals in the world. The trust embraced these methodologies and in partnership with VMI, they have developed new initiatives within the hospital. They used the model to create the transforming care institute (TCI). TCI wants an effective approach to transforming healthcare by coachingteams and facilitating continuous improvement.

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

Importantly, the trust must:

  • The trust must ensure ED meets the Department of Health’s target of discharging, admitting or transferring 95% of its patients with four hours of their arrival in the department.

  • The trust must ensure all patients brought in by ambulance are promptly assessed and triaged by a registered nurse.

  • The trust must ensure a suitably qualified member of staff triages all patients, face to face, on their arrival in ED by ambulance.

  • The trust must ensure that it meets the referral to treatment time (RTT) for admitted pathways for surgery.

  • The trust must ensure there are sufficient nursing staff on duty to provide safe care for patients. A patient acuity tool should be used to assess the staffing numbers required for the dependency of the patients

  • The trust must review its medical staffing to ensure sufficient cover is provided to keep patients safe at all times.

  • The trust must ensure that all staff have an understanding of how to assess mental capacity under the Mental Capacity Act 2005 and that assessments are completed, when required.

  • The trust must ensure the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist is improved in theatres

  • The trust must ensure that up to date safety thermometer information is displayed on all wards

In addition the trust should:

  • The trust should ensure all staff received an annual appraisal.

  • The trust should consider using the maternity specific safety thermometer to measure compliance with safe quality care.

  • The trust must ensure they are preventing, detecting and controlling the spread of infections, associated in the mortuary department by ensuring surgical instruments are decontaminated to a high level and there are arrangements in place for regular deep cleaning.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14-16 and 27 October 2014

During a routine inspection

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

Royal Shrewsbury Hospital was formed in 1979 after a number of hospitals in the town were closed or merged. The hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for acute and emergency surgery, and has a trauma unit that is part of the region-wide network. It is the main centre for oncology and haematology.

We carried out this comprehensive inspection because the trust had been flagged as a potential risk on CQC’s intelligent monitoring system. The inspection took place between 14 and 16 October 2014, with an unannounced inspection on 27 October.

Overall, this trust requires improvement. We found that services for children and young people, maternity and gynaecology, and outpatients were good. Urgent and emergency care, critical care, surgery, medicine and end of life care services required some improvements to ensure a good service was provided to patients. Caring for patients was good, but requires improvement in providing safe care, effective care, being responsive to patients’ needs and being well-led in some areas.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The hospital was visibly clean and well maintained. Infection control rates in the hospital were lower when compared with those of other hospitals.
  • Patients’ experiences of care was good and the NHS Friends and Family test was in line with the national average for most inpatient wards, but was better than the national average for A&E.
  • The trust had recently opened the Shropshire Women’s and Children’s Centre at the Princess Royal site, and all consultant-led maternity services and inpatient paediatrics had moved across from the Royal Shrewsbury site. We found that this had had a positive impact on these services.
  • The trust has consistently not met the national target for treating 95% of patients attending A&E within four hours. At Royal Shrewsbury Hospital some improvements were also needed in the safe, effective and well led domains in A&E.
  • There was some good care delivered in the medical wards, but high staff vacancies and heavy reliance on bank and agency staff was putting considerable pressure on the existing staff.
  • We were concerned about ward 31 at Royal Shrewsbury Hospital, which was being used for day surgery patients while the purpose-built day surgery unit was being used for inpatients. The heating had not been switched on and there was no emergency call bell and staffing on this ward was a concern. Although the trust addressed these issues immediately when we brought them to their attention, this arrangement does not provide day-case patients with an effective service.
  • The hospital was not meeting the Core Standards for Intensive Care Units. We were concerned about nurse staffing levels and asked the trust to look at the situation immediately. During our unannounced inspection we were pleased to see the trust had responded.
  • The trust had recognised that end of life care needed to be improved and had begun working towards this, but we found much more progress was needed. We were concerned about the safety and effectiveness of the mortuary arrangements at Royal Shrewsbury Hospital in that the maintenance of this area was poor and it could not cope with the current demands placed on the service.

We saw several areas of outstanding practice, including:

  • The trust had good safeguarding procedures in place. The safeguarding team had links in every department where children were seen, with safeguarding information shared across the trust.
  • The trust had appointed an Independent Domestic Violence Advisor. The post had been supported through funding from the Police Crime Commissioner because of the excellent outcomes for people recorded by the trust. Referrals from the trust to the Multi Agency Risk Assessment Conference had been endorsed as excellent practice by Coordinated Action against Domestic Abuse (CAADA). CAADA a national charity supporting a multi-agency and risk-led response to domestic abuse.

We raised some of the urgent issues at the time of our inspection and the trust has taken action to address the equipment staffing needs within accident and emergency and critical care areas.

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

Importantly, the trust must:

  • The trust must review the levels of nursing staff across A&E critical care and end of life services to ensure they are safe and meet the requirements of the service.

  • Ensure that all staff are consistently reporting incidents and that staff receive feedback on all incidents raised so that further service development and learning can take place.

  • Ensure that staff are able to access mandatory training in all areas.
  • Ensure that accident and emergency and all surgical wards are able to access all the necessary equipment to provide safe and effective care.
  • Review pathways of care for patients in surgery to ensure they reflect current good practice guidelines and recommendations.
  • Ensure that mortuary services are safe through maintenance and security of this area.

There were also areas of practice where the trust should take action:

  • Review the availability of support staff across the seven-day week to improve outcomes for patients.
  • Review the achievements and actions taken to address the targets set nationally within A&E and across audits in medicine and in end of life care.
  • Review the specific equipment required to support an effective service for those people living with dementia.
  • Review medicines storage in surgery.
  • Review the capacity and flow within surgery and critical care to reduce waiting times and improve services to patients.
  • Review the provision of the end of life service to ensure that patients can access this service throughout the week.
  • Review the communication between senior managers and staff to ensure that initiatives and issues are captured.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 23 October 2013

During a routine inspection

The unannounced inspection was carried out by a team of five inspectors in addition to a specialist advisor and an Expert by Experience. We visited six wards where concerns had been raised through a variety of sources. Concerns were mainly around people’s care, treatment and involvement and the lack of respect for privacy and dignity. People had also raised concerns in relation to how the trust had managed their complaints.

We spoke with patients and staff on all of the wards we visited and spent time observing how care and support was delivered. Our findings were very mixed with some marked differences between wards. There were differences in leadership and therefore effectiveness of systems and processes. We identified a range of concerns about consultation and involvement of patients, documentation of care planning and evaluation and key issues such as ‘do not attempt resuscitation’ (DNAR) orders.

Prior to our inspection the trust had acknowledged that capacity pressures across the hospital were impacting on people’s experiences. They were actively addressing the challenges with health and social care partners. There was also recognition of the issues we identified during our inspection and action was being taken. A member of staff told us that increased admissions had resulted in “huge pressures placed on the workforce”.

Overall patients described very positive experiences of their care and treatment. Comments included, “I couldn’t be treated any better if I was the King” and, “The care from the doctors is very good and the nurses are excellent”. Most patients we spoke with told us that staff respected their privacy and dignity. Other patients commented that improvements were needed in how staff involved them in discussions and decisions about their care and treatment, for example their diagnosis, progress and discharge arrangements.

Patients we spoke with were not aware of how to make a formal complaint, although they told us they had not had cause to complain. We found information about complaints was not readily accessible for patients and their representatives. We saw the trust had responded to complaints but letters did not contain information for people on what to do if they were unsatisfied with the response provided by the trust. We found the trust had started to redress the identified backlog of complaints and the shortfalls in processes and acknowledged it was very much “work in progress”.

During a check to make sure that the improvements required had been made

At our last inspection of the hospital we found that assessments, care plans and risk assessments had not been individualised or comprehensive which may have impacted on people’s needs being met appropriately and effectively. We have reviewed the evidence given to us by the Trust who confirmed they are now compliant with this outcome.

Inspection carried out on 16 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in Royal Shrewsbury Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a second CQC inspector, practising professional and an expert by experience, who has personal experience of using or caring for someone who uses this type of service.

We visited two wards providing adult inpatient care across the hospital. We spoke with nine patients who were receiving a service, two relatives and 10 staff from different disciplines. Patients we spoke with shared positive experiences about the care they received and how they were treated. They told us staff were respectful, promoted their privacy and dignity and kept them well informed about their care and treatment.

Patients were complimentary about the meals and food choices available. They told us their meals were served hot, were appetising and well presented. Where patients required assistance with eating, we saw staff provide support discreetly and respectfully. Patients who required specific meals to meet their dietary needs told us they were provided with the “right” food.

Patients told us they were well cared for and said they felt safe. They described staff as competent and caring. One patient said, “Everyone is wonderful here. They treat you properly and are very respectful.” Patients told us they were confident in raising any concerns with the staff.

Patients considered there was generally enough staff on duty to meet their needs. All but one person told us that staff attended to their call bells in a timely manner. One patient commented, “The staff are rushed off their feet here but I’m not kept waiting”. Another patient said, “The staff know what they are doing”. Staff were confident that numbers and skill mix could be changed in order to meet any changing circumstances of patient care.

Patients told us staff regularly spoke with them prior to completing their records. We saw evidence of good incident reporting processes in place. However, the current system for recording patient information was not integrated or unified. The trust had already identified this as an area requiring improvement.

Inspection carried out on 11 October 2011

During a routine inspection

The inspection was unannounced and consisted of a team of three inspectors in the morning and four inspectors in the afternoon. We visited four wards providing adult inpatient care across the hospital. We spoke with 38 people who were receiving a service, three representatives and 10 staff from different disciplines. Most people we spoke with shared positive experiences about the care, treatment and support they had received. They said they were treated with dignity and respect; that staff asked before helping them with personal care tasks and explained what they were doing when carrying out tests or procedures. They told us staff responded to their needs in a timely manner most of the time.

Most people told us they were consulted about their care and treatment. Although one person told us that they had waited all day for an operation only to be told by a Housekeeper that their operation had been cancelled and served a meal they disliked. We saw a person being discharged and observed positive interaction by a member of staff wishing them a safe onward journey.

Overall we found that staff had a good knowledge of people's needs. However we found that assessments, care plans and risk assessments were not individualised or comprehensive. Most people we spoke with said that their needs were being met. Although we did not find that outcomes for people were poor, we did find that care plans and risk assessments were not being reviewed and monitored sufficiently to ensure appropriate treatment was consistent.

People told us the food was generally good with sufficient choice and support when needed. However, we observed one older person, who was a vegetarian, being assisted to eat a meat dish. A notice was displayed above their bed indicating their specific dietary preference, however there was nothing documented in their care plan in relation to their dietary requirements. We saw the staff member take swift action to rectify the situation.

People told us that they felt safe in the care of staff and that they had not observed any poor practice during their stay. Although not everyone had knowledge of the complaints procedure, they told us they would raise concerns with the staff on duty. People who had raised concerns told us these had been dealt with in a timely manner.

Most people told us there were sufficient staff and skill mix to meet their individual needs although at times staff were “stretched” and that this can impact on their care and treatment. People said staff were competent, attentive and caring.

Inspection carried out on 29 March 2011

During a themed inspection looking at Dignity and Nutrition

Overall people told us that staff involve them in their care, treatment and support and that their privacy and dignity is respected. Most people told us that staff call them by their preferred form of address and respond to their needs quickly. They said that staff are kind and explain what they are doing. One person said, “The staff are very careful how they handle me” another person said, “One time I was being washed and they left me in the middle of my wash to attend to someone else. I was left about half an hour”.

People said they are offered a good choice of food but this is not always the option they actually receive. Most people told us they felt their nutritional needs and dietary preferences were well met. All but one person we spoke with was happy with the food portions and how their food was presented. One person said, “I’m quite impressed with the food and the care is fantastic. The staff are very good at offering lots of drinks. They really are doing it very well”.

Inspection carried out on 1 July and 1 September 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.