You are here

Provider: The Rotherham NHS Foundation Trust Requires improvement

On 31 January 2019, we published a report on how well The Rotherham NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement  
  • Combined rating: Requires Improvement  

Read more about use of resources ratings

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 March 2019

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

  • We rated safe, effective and well-led as requires improvement, and rated caring and responsive as good. All ratings were the same as the previous inspection except for responsive, which had improved one rating.
  • Rotherham General Hospital was rated as requires improvement overall. Safe, effective, responsive and well-led remained as requires improvement and caring remained good.
  • Community Healthcare Services remained as requires improvement overall. We inspected one core service (community healthcare services for children and young people) at this inspection and the overall ratings for effective and well-led remained as requires improvement while safe, caring and responsive remained as good.
  • The trust was rated as requires improvement overall at its first comprehensive CQC inspection in July 2015. The outcome from a second inspection in March 2017 produced the same overall rating and the trust continued this trend. Issues we identified at previous inspections, such as culture, mandatory training compliance, staffing and high caseloads for practitioners in the 0-19 service had demonstrated the trust had not fully addressed ongoing concerns. There was evidence of some progress and the trust recognised further improvement was required.
  • In addition, we also undertook a focussed unannounced inspection in July 2018 and found that appropriate and timely action had not been taken to address the immediate concerns.

Inspection areas

Safe

Requires improvement

Updated 18 March 2019

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

  • There were significant concerns within urgent and emergency care services that impacted upon patient safety. The service was rated as inadequate for safe, which was down one rating from the previous inspection. There was a shortage of suitable skilled staff and not all staff had the right skills, knowledge and experience to do the job they were asked to do.
  • Patients had long waits to be assessed in the emergency department and there had been serious incidents resulting in patient harm due to those delays. Senior staff had not made any correlation between staffing levels and the number of serious incidents and had not taken timely action in response to the concerns raised by staff.
  • Nurse staffing was an ongoing issue, particularly within medical wards. Fill rates were low on some wards and there was a high number of nurse vacancies across the trust. In the maternity service, midwives were frequently deployed from other areas to support the delivery suite, and there had been a reduction in specialist midwives to meet the needs of vulnerable women.
  • There was a shortage of junior doctors and medical wards were frequently below the minimum levels. Locum and bank staff were utilised to cover shortfalls and the trust did not have substantive consultants in post in stroke and gastroenterology services.
  • There was poor compliance with mandatory training across some core services, which was identified as a concern at the previous inspection. The majority of core services inspected did not meet the 85% trust target.
  • Although the medicines omission rate (missed doses) was largely in line with national data the proportion of critical medicines missed remained higher than average. There was a lack of ownership regarding medicines safety at ward level and incidents of medicines causing harm placed the trust at the top end of the interquartile range [NHS England Medicines Optimisation Dashboard]. Some wards did not receive a regular clinical pharmacy service and there was no dedicated pharmacist in the emergency department. Patient harm through non-adherence to medicines standards, policies, processes and guidance was added to the pharmacy and medicines management risk register in August 2018 with an initial and current risk rating of 15 (significant).
  • Safeguarding adults and children was not always given sufficient priority and there was a lack of strategic oversight of the issues we identified during this inspection. We found the quality of safeguarding referrals was poor in some services, looked after children did not receive initial health assessments in a timely manner, and safeguarding training did not comply with the Royal College of Paediatric and Child Health intercollegiate document.

However;

  • We found evidence of improvement in maternity and services for children and young people in relation to incident reporting. There was no backlog of incidents for review in maternity and there were systems to share learning with staff.
  • There were processes in place to safeguard children and adults from abuse and risk of harm. Staff understood their responsibilities and could articulate what action they would take. However, in community healthcare services for children and young people, there was minimal oversight of safeguarding children referrals and no process for quality assurance.
  • Wards and departments were visibly clean and met infection control standards.
  • The trust used a sepsis screening tool, staff had access to sepsis guidelines and followed the nationally recognised sepsis pathway to care for patients.

Effective

Requires improvement

Updated 18 March 2019

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

  • In urgent and emergency care services, care and treatment did not always reflect evidence-based guidance. The service did not meet Royal College of Emergency Medicine audit standards, which was a concern at the previous inspection.
  • Health visiting and school nursing services continued to fail to meet performance targets, although an improvement plan was in place and the service prioritised the needs of vulnerable families.
  • Not all staff had received an appraisal and there were some gaps in support arrangements, such as clinical supervision and professional development. Some staff spoke negatively about the quality of their annual appraisal. In the 2017 NHS Staff Survey, 94% reported they had received an appraisal within the last 12 months. However, only 15% stated it had helped them improve how they did their job, while 24% reported the review made them feel their work was valued. This was worse than the national average.
  • Although staff understood their responsibilities towards patients in relation to the requirements of the Mental Capacity Act, the assessment documentation was brief, lacked detail and did not demonstrate the rationale behind the decision.
  • Not all patients felt their pain was managed appropriately. In the urgent and emergency care service, pain scores were not consistenty recorded or reassessed, while women and staff in maternity told us the service did not always offer pain relief in a timely way.

However;

  • There had been improvements in medical care and services for children and young people which were rated as good.
  • The maternity service had made improvements and regularly reviewed clinical outcomes in formal meetings. Policies and procedures were up to date and there a review system in place.
  • There was evidence of good multidisciplinary working throughout the trust. Staff with specialist skills and knowledge worked well together to benefit patients.
  • Staff understood consent requirements for adults, children and young people and gained consent prior to performing care.

Caring

Good

Updated 18 March 2019

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

  • Staff were caring and compassionate and worked in partnership with patients, relatives and carers.
  • Staff recognised the important of people’s privacy and dignity and treated patients, relatives and carers with respect and kindness, and involved them in their care.
  • Staff communicated with people and provided information in a way that they could understand.
  • Patients told us they received compassionate care and that staff supported their emotional needs.
  • Results from the Friends and Family test were better that the England average for recommending the trust as a place to receive care for most of the time period from August 2017 to July 2018.

However;

  • Feedback from relatives of patients attending the emergency department was mixed. Although staff cared about patients and worked hard to meet their needs, due to staffing pressures, they acknowledged they could not always offer the level of care and support they wanted to.

Responsive

Good

Updated 18 March 2019

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

  • There had been improvements in services for children and young people (acute and community) which were rated as good.
  • Services were planned and delivered in a way to meet the individual’s needs and the local population. Services took account of people with complex needs and there was access to specialist support and expertise.
  • Care and treatment was co-ordinated with other services and other providers and reasonable adjustments were made where appropriate.
  • The management of medical outliers had improved since our last inspection. There were clear arrangements for the daily review of medical patients cared for on non-medical wards.
  • Patients knew how to complain, and staff knew how to deal with complaints they received. Complaints were investigated, and learning was shared.
  • The trust had applied measures to manage flow in medical wards. A new frailty team had helped prevent unnecessary admissions and reduce length of stay in hospital.

However;

  • Flow arrangements within the urgent and emergency care centre (UECC) were less responsive. Patients often had long waits, from the decision to admit to actual admission on a ward. In addition, the median time for arrival to treatment in the UECC, and the number of patients who left the department before being seen, was worse than the national average.
  • The looked after children (LAC) service did not meet the statutory initial health needs assessment target of 20 working days from the date of becoming looked after. This was also identified as an issue at our last inspection. There was an inter-agency action plan to address the timeliness of the assessments. Regular assurance reports were provided to the service manager and the quality assurance committee.

Well-led

Requires improvement

Updated 18 March 2019

Our rating of well-led stayed the same. We rated it as requires improvement because:

  • Our rating of urgent and emergency care services went down one rating to inadequate. The leadership team had failed to identify significant safety concerns within the department and failed to address those already identified.
  • Our rating of medical care went down one rating to requires improvement. The divisional leadership did not always listen to concerns raised by staff, or take appropriate action.
  • Staff did not always feel listened to by their immediate managers and, although managers, including the executive leadership team, felt they had an ‘open door’ arrangement, frontline staff described a lack of visibility and inaccessibility.
  • There was a governance structure in place with integrated performance reports and supporting dashboards, which were embedded at corporate and divisional level, and used to support the overall performance framework. However, managers recognised the need to introduce more consistent practice within the four divisions.
  • Although there were systems to identify, record and manage risk within each service, the process for escalating and de-escalating risk was not fully embedded within the trust. This was particularly evident within the urgent and emergency care centre where there was a lack of timely action in response to the ongoing patient safety concerns we identified within the unit.
  • Staff did not feel engaged with senior leaders. Results from the NHS Staff Survey 2017 reported 30% of staff who responded felt that communication between senior management and staff was effective. Only 25% of all responders felt that senior managers tried to involve staff in important decisions whilst 23% reported senior managers acted on staff feedback.
  • The culture of the organisation was reported as improving from a low base. In urgent and emergency care services, we found the culture was defensive and not open or transparent. The trust had updated its Whistleblowing policy to ensure staff members raising concerns were protected and supported and to prevent any discrimination consequently. In addition, there was an acting freedom to speak up guardian who was proactive and had lots of ideas for improvement and development, including better engagement with staff.

However;

  • There had been improvements in maternity services and in services for children and young people (acute), which were rated as good.
  • The trust had a five-year strategy with five strategic themes and three core values, linked the priorities of the wider health economy across South Yorkshire and Bassetlaw. The trust worked collaboratively with all key stakeholders across the regional Integrated Care System. However, the trust lacked some key supporting strategies to support the implementation of its vision, such as patient experience and equality and diversity.
  • At executive level, the recent focus on finance and performance had improved financial performance and performance against the 62-day standard, which had been done in the context of ensuring that patients and quality were the trust’s priority. The commissioning of the external quality governance review in 2018, demonstrated the importance that the trust placed on strengthening quality and clinical governance.
  • The trust had achieved national recognition for several initiatives that have improved patient care, such as Acupin therapy, which supported women experiencing nausea and vomiting in pregnancy.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 18 March 2019

Combined rating
Checks on specific services

Community dental services

Good

Updated 14 July 2015

Community health services for children, young people and families

Requires improvement

Updated 18 March 2019

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

  • At our last inspection we rated safe, effective, responsive and well led as requires improvement. Caring was rated as good.
  • At this inspection we rated safe, effective and well led as requires improvement. Caring and responsive were rated as good.
  • Practitioners in the 0-19 service were holding high caseloads. There was a risk that records were not contemporaneous as high workloads meant that some practitioners were not completing their records in a timely manner. These issues had also been identified at our last inspection.
  • There was no oversight of safeguarding referrals and in the sexual health service there were no safeguarding alerts on the electronic patient record. This meant that children and young people’s records may not be complete and staff may not be immediately aware of a vulnerable child.
  • The 0-19 service were failing to meet some of their performance targets. Antenatal contacts, six to eight week contacts and health screening at school entry were all below target. This had been a concern at our last inspection.
  • There was a limited number of audits in place and there was no audit plan.
  • There was no process in place for regular clinical supervision and staff had varying experiences of receiving clinical supervision. This had been identified at our last inspection.
  • Looked after children were not receiving initial health needs assessments in a timely manner.
  • There had been a slow pace of change since moving to a 0-19 team and changes were not fully embedded. Staff were still working as separate health visiting and school nursing teams. Several changes in the management team meant that changes had not been driven forward. The service was moving to skill mix teams and competencies were written for the different staff bands, however, at the time of our inspection these competencies were not yet in place.

However;

  • The new service leads were aware of the challenges to the service and there was a work plan in place for 2018/2019. The work plan incorporated workstreams including audit and clinical supervision. The service was working closely with the clinical commissioning group and the local authority to plan and deliver services.
  • Staff were kind and caring. Their focus was on supporting children, young people and their families. There was effective multidisciplinary working, both internally and externally.
  • New services, such as the paediatric acute rapid response outreach team (PARROT) had been set up to support unwell children in the home and avoid hospital admissions.
  • The service had a vision and strategy and there were governance systems in place.
  • The service provided care based on evidence based guidance and staff had access to up to date policies and guidance.
  • Learning from incidents and complaints were shared at staff meetings. Presentations from the meetings were shared with staff. Service leads were attempting to engage with staff to keep them up to date with service development.

End of life care

Requires improvement

Updated 2 March 2017

Overall rating for this core service

We carried out this inspection because when we inspected the service in February 2015, we rated the service as requires improvement. We asked the provider to make improvements following that inspection.

At this inspection, we rated services for community end of life as requires improvement, because;

The use of the end of life individualised care plan for adults was not embedded into practice and not used by all the services that provided end of life care. Managers within the community nursing service had recently began to review the use of the document in April 2016 and evidence on inspection showed that the document was not fully completed. Audits for community end of life were not embedded and actions were required to improve the quality of care provided in the community. These included staff completing and discussing advanced care planning to reduce the need for patients to be admitted to hospital unnecessarily.

Staff had completed mental capacity training, however ‘do not attempt cardiopulmonary resuscitation (DNACPRs) were not completed appropriately for patients who lacked capacity and mental capacity forms and assessments were not completed. This was identified as a risk within the CQC comprehensive inspection in February 2015. Policies required to be reviewed in line with national guidance and the trust’s timescales; these included DNACPR policy and syringe driver policy.

The trust still needed to build on the work they had commenced for the end of life strategy. For example, they needed to improve advanced care planning and implementation and embedding the individualised end of life care plan. These areas were not included as risks on the risk register. Preferred place of care was not always recorded on the patient’s record which would identify where they wanted to be cared for within the last few days of life.

Ongoing communication was still required to aid integration of the acute and community services.

The trust had made some improvements from the CQC inspection in February 2015. These included staff reporting incidents and receiving feedback from the trust. Incidents were now shared across various methods. Safety huddles were held to discuss staffing levels and to look at the allocation of staff when required. Procedures were in place for patients whose visits required to be rearranged and patients who wanted visits would be seen. Staff could access patient’s electronic records and further software had been added to the laptops to use in areas with connectivity issues. The implementation of the care co-ordination centre allowed patients to access a professional at any time who would contact the appropriate team.

We also saw that anticipatory medication was provided to patients and staff could prescribe medication quickly for patient’s whose symptoms could not be controlled. Staff managed patient’s pain and nutritional needs and completed the appropriate assessments. Equipment was available for patients and staff would often pre-empt and ensure equipment was at the patient’s house incase it was required.

All community areas provided good links with GPs and the palliative care team to manage the patients. Some GP surgeries were on the same patient electronic system and could see the care records provided by the community services.

Staff provided compassionate and supportive care within the home and ward environment. Patients were encouraged to be involved in decision making about their end of life care needs. Staff communicated well and worked together to plan the care and treatment.

Senior staff in all community settings could complete fast track forms; this enabled care to be put in place quickly for patients whose condition was deteriorating and may have requested their preferred place of death at home.

Community health inpatient services

Good

Updated 2 March 2017

We rated this core service as good for safe, effective, responsive and well led. We rated caring as outstanding. This was because safety performance data was good; patients were protected from avoidable harm and abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Managers shared the learning from incidents. Record keeping was good. The environments were fit for purpose and equipment was available. Medicines were stored, prescribed and administered safely.

Although we were concerned that consent to care and treatment, at the Oakwood Community Unit, was not obtained in line with legislation and guidance, including the Mental Capacity Act 2005 for patients who lacked capacity, we saw that patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were prescribed and administered pain relief in a timely manner. Staff providing care were competent and skilled and there was evidence of strong multidisciplinary team working.

Friends and family test results were 100% positive for both units. Feedback we received from patients and their relatives and carers was consistently positive. We observed consistently caring, sensitive and compassionate staff. Patients and their families were supported psychologically and emotionally.

Services had been planned and developed in a way that met the needs of the local population and teams were highly responsive to the needs of the patients in their care. The introduction of an activities coordinator at Oakwood Community Unit had ‘transformed the service’. We saw that vulnerable patients including those living with dementia were supported.

All teams were aware of the trust vision and values and we saw robust strategic plans for both services. Governance, risk management and quality measurement processes were embedded in the teams. Staff we spoke with told us that senior staff were visible and supportive. We found that staff in all teams were consistently positive, friendly, helpful and approachable in all areas we visited. All staff were team focused. We saw examples of innovation, improvement and sustainability.

Community health services for adults

Updated 2 March 2017

Information about the service

Community services joined The Rotherham NHS Foundation Trust in 2011 as part of the transforming community services programme, designed to move care out of hospitals and closer to people's homes.

The trust provides both acute and community based health services to the people of Rotherham with a population of approximately 259,000. The majority of community services for adults were managed within the division of integrated medicine; however, therapy staff were managed within the clinical support division and podiatry within the surgery division.

The trust provides a range of community health services for adults, working across seven localities from the following sites; Rotherham Community Health Centre, Aston Customer Service Centre, North Anston Medical Centre, Health Village, Park Rehabilitation Centre, Rawmarsh Customer Service Centre, Maltby Joint Service Centre, Wickersley Health Centre and patients homes. Community inpatient services are provided at Oakwood Community Unit and Breathing Space.

During our visit we inspected a range of services including, the continence advisory service, community nursing services, the care home liaison team, the integrated rapid response team, musculoskeletal clinical assessment and treatment service, the domiciliary therapy team and the falls and fracture prevention service. We also visited the care co-ordination centre.

We spoke with 40 members of staff including, community matrons, community nurses, clinical support workers, therapists, community physicians, managers, administration staff and student nurses. We observed care being provided in patient’s homes. We spoke with 15 patients and looked at 10 patient records. We also held focus groups with community staff and reviewed performance information from, and about, the trust.

Community services for adults had previously been inspected as part of a comprehensive inspection in February 2015 and was rated overall as requires improvement. Safe, effective and well led were rated as requires improvement, caring and responsive were rated as good.

At this inspection, we focused on whether the services were safe, effective and well led.