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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.

Reports


Inspection carried out on 25 September to 24 October 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 18 March 2019
Inspection carried out on 25 September to 24 October 2018 During an inspection of Community health services for children, young people and families Download report PDF | 488.36 KB (opens in a new tab)Download report PDF | 1.89 MB (opens in a new tab)
Service reports published 2 March 2017
Inspection carried out on 27-30 September 2016 During an inspection of Community health services for children, young people and families Download report PDF | 331.11 KB (opens in a new tab)
Inspection carried out on 27-30 September 2016 During an inspection of End of life care Download report PDF | 342.92 KB (opens in a new tab)
Inspection carried out on 27–30 September & 12 October 2016 During an inspection of Community health inpatient services Download report PDF | 355.79 KB (opens in a new tab)
Inspection carried out on 27 – 30 September 2016 During an inspection of Community health services for adults Download report PDF | 296.22 KB (opens in a new tab)
See more service reports published 2 March 2017
Service reports published 14 July 2015
Inspection carried out on 23-27 February 2015 During an inspection of End of life care Download report PDF | 301.11 KB (opens in a new tab)
Inspection carried out on 23-27 Febraury 2015 During an inspection of Community health inpatient services Download report PDF | 333.73 KB (opens in a new tab)
Inspection carried out on 23-27 February 2015 During an inspection of Community health services for adults Download report PDF | 328.78 KB (opens in a new tab)
Inspection carried out on 23-27 February 2015 During an inspection of Community health services for children, young people and families Download report PDF | 344.34 KB (opens in a new tab)
Inspection carried out on 23-27 February 2015 During an inspection of Community dental services Download report PDF | 174.47 KB (opens in a new tab)
See more service reports published 14 July 2015
Inspection carried out on 27 - 30 September and 12 October 2016

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

We carried out a focused follow-up inspection between 27 and 30 September 2016 to confirm whether The Rotherham NHS Foundation Trust had made improvements to its services since our last comprehensive inspection in February 2015. We also undertook an unannounced inspection on 12 October 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected the trust in February 2015, we rated the service as requires improvement. We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good.

There were fourteen breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and 2014. These were in relation to the safety and suitability of premises, staffing, supporting staff, records, consent to care and treatment, complaints, care and welfare of people who use services, dignity and respect, need for consent, cleanliness and infection control, management of medicines, safeguarding people who use services from abuse and assessing and monitoring the quality of service provision.

The trust sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation. At this inspection, we checked whether these actions had been completed. We inspected the services at the Rotherham General Hospital, community inpatients at Oakwood Community Unit and Breathing Space, children’s and adult’s community services and community end of life care. We did not inspect dental services provided by the trust as these were rated as good at the previous inspection.

We found that the trust had made considerable improvements. However, there remained areas that required further improvement. The Rotherham NHS Foundation Trust overall rating of requires improvement remains unchanged. At this inspection we found:

  • The trust had not taken sufficient action raised in the 2015 inspection to ensure DNACPR forms and mental capacity decisions were documented in line with trust policy, national guidance and legislation. We wrote to the trust immediately following our inspection to ensure that action was taken promptly regarding the DNACPR forms and mental capacity decisions. The trust initiated a number of actions, which we will continue to monitor.
  • Staff understanding and application of the Mental Capacity Act 2015 was inconsistent across most of the services inspected.
  • There were concerns about the current pharmacy service and the impact on patient care. We wrote to the trust immediately following our inspection to ensure that action was taken promptly regarding the management of discharge medications and service provision. The trust initiated a number of actions, which we will continue to monitor.
  • Access to safeguarding supervision was a concern and was in the process of being addressed.
  • Staffing levels in the children’s ward and maternity had improved since the previous inspection. However, there remained staffing shortages most notably in the Emergency Department, school nursing and medical wards. There was a high use of medical locum staff in some specialties.
  • Some policies and guidelines were out of date and there was a backlog of incidents in maternity services that had not been reviewed.
  • Audit plans were behind schedule within children’s services.
  • There were some environmental concerns at the time of inspection; the fire escape on critical care was not appropriate and there were some remaining ligature risks on the children’s ward. The trust took immediate action to address these following our inspection.
  • Risk registers were in place, but did not always reflect the risks identified on inspection.
  • The hospital reported no cases of hospital acquired MRSA bacteraemia, 16 cases of C.difficile and nine of MSSA bacteraemia between July 2015 and June 2016. The number of cases of C.difficile and MSSA per 10,000 beds has been mostly below (better than) the England average. However, on medical wards, there were some concerns about infection control practices and facilities in the refurbished areas.
  • There were areas of notable improvement since the previous inspection. These included safeguarding training and awareness, improvements to the short-break service, access to sexual health records and improvements to training data.
  • There had also been improvements in ensuring there were no mixed sex breaches, wherever possible and actions had been implemented to minimise these.
  • We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options and were supported to eat and drink.
  • There were no mortality outliers identified at the trust.

We saw several areas of outstanding practice including:

  • The trust was piloting a new community model of care called the perfect locality. This multiagency /multidisciplinary team approach focused on implementing measures to avoid hospital admissions and facilitate safe discharge of patients already in hospital.
  • BreathingSpace remains the only entirely nurse-led model of care for respiratory inpatients and outpatients in Europe. We found that the culture, care and philosophy of the unit were outstanding.
  • The activities coordinator at Oakwood Community Unit had been employed by the trust and had developed a range of activities including arts and craft, bingo, board games and a monthly themed tea party.

  • The trust staff had direct access to electronic information held by community services through the SEPIA portal, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicines and community services involvement in their care.
  • Safeguarding and liaison had a daily meeting with the Emergency Department to identify any safeguarding issues and concerns.
  • All patients with mental health needs admitted to the children’s ward were reviewed by the CAMHS liaison team/nurse within 24 hours of admission and were followed up after seven days.
  • Staff had successfully offered the use of acupins for the relief of nausea, particularly in gynaecology services.

However, there were areas where the trust needs to make improvements.

Importantly, the trust must:

Urgent and emergency care

  • Ensure there are sufficient numbers of suitable qualified, competent and skilled staff deployed in the department.
  • Ensure all staff are aware of their responsibility to report incidents and ensure learning is shared with all relevant staff.

Medicine

  • Continue to take action to ensure there are sufficient numbers of suitably skilled, qualified and experienced staff.
  • Ensure all relevant staff have received appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and dementia awareness.
  • Ensure all staff have an annual appraisal.
  • Mental capacity assessments and discussions must be clearly documented in patient records.

Critical care

  • Ensure risks are assessed, monitored and managed in a timely manner to ensure safety.
  • Ensure patients’ individual records are held securely on the unit.

Maternity

  • Complete the reviews of maternal and neonatal deaths and implement any further identified actions to support safe practice.
  • Ensure that identified risks are recognised and recorded on the risk register.
  • Ensure that incidents are reviewed and investigated in a timely manner.
  • Ensure staff have access to safeguarding supervision and support.

Children and young people

  • Ensure the policies and procedures for the management of the children’s and young people’s service are up-to-date, regularly reviewed, document controlled and readily accessible to staff.
  • Ensure children and young people’s service risk register reflect current risks, contains appropriate mitigating actions, is monitored and reviewed at appropriate intervals and acted upon.

End of life care

  • Ensure all “do not attempt cardio-pulmonary resuscitation” (DNACPR) decisions are always documented in line with national guidance and legislation.
  • Ensure there is evidence that patients’ capacity has been assessed in line with the requirements of the Mental Capacity Act (2005).

Community adults

  • Must ensure that there are robust local safe systems in place to keep community staff who are lone working safe, in line with trust policy.
  • Must ensure community staff are working in accordance with the Mental Capacity Act code of practice (2005).
  • Must ensure that all risks for community services are included on the directorate risk register and where control measures are identified to mitigate risks, managers have assurance that control measure are effectively in place.

Community end of life care

  • Ensure that all DNACPR forms are completed appropriately and accurately ensuring that mental capacity assessments are completed for patients where it has been assessed they lack capacity.

Community inpatients

  • Ensure that consent to care and treatment is obtained in line with legislation and guidance, including the Mental Capacity Act 2005 for patients who lack capacity. The provider must also ensure that staff are trained to enable them to recognise when patients need support to make decisions and, where appropriate, their mental capacity is assessed and recorded.

Community children, young people and families.

  • Ensure incidents are appropriately categorised, graded and investigated.
  • Ensure that there are sufficient suitably qualified, skilled and experienced staff in the school nursing service to meet the needs of the local population.
  • Ensure the policies and procedures for the management of the children’s and young people’s service are up-to-date, regularly reviewed, document controlled and readily accessible to staff.
  • Ensure that a regular and effective clinical audit schedule is developed.
  • Ensure that steps are taken to increase performance against waiting time targets for therapy services and the child development centre.
  • Ensure that it improves the number of looked after children assessments carried out within the target timescale.
  • Ensure children and young people’s service risk register reflect current risks, contains appropriate mitigating actions, is monitored and reviewed at appropriate intervals and acted upon.

Trust-wide

  • Ensure there are sufficient numbers of suitable qualified, competent and skilled staff deployed in the pharmacy department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 23 - 27 February 2015

During a routine inspection

The Rotherham NHS Foundation Trust provides both acute hospital and community-based health services. The trust served a population of over 257,600 people living in Rotherham and the surrounding areas. In total the trust had 481 beds.

Rotherham is an urban area with a deprivation score of 53rd out of 326 local authorities (with one being the most deprived). This means that Rotherham has a significantly deprived population and is worse than the national average on a range of population health measures.

We inspected The Rotherham NHS Foundation Trust as part of our comprehensive inspection programme. We carried out an announced inspection of Hospital between 23-27 February 2015. At the same time as this inspection, an inspection of the quality and effectiveness of the arrangements that health care services have made to ensure children are safeguarded was also taking place. These inspections are part of a national programme that the Care Quality Commission is currently undertaking. The inspections review health services within local authority areas in England and will case track individual children in each area. We have used some of the information that was identified during this review within our report.

In addition, an unannounced inspection was carried out on 7 March 2015. The purpose of the unannounced inspection was to look at the children’s ward and medical admissions unit at the Rotherham Hospital.

Overall, we rated this trust as “ Requires Improvement” and we noted some outstanding practice and innovation. However improvements were needed to ensure that services were safe, effective, responsive and well led.

Our key findings were as follows:

Cleanliness and Infection Prevention and Control

  • The trust had a dedicated infection control team. They visited the wards at Rotherham Hospital on a daily basis and were highly regarded by the staff we spoke with. The infection control team undertook a range of infection control audits on the wards.
  • We saw that side rooms were used for patients who had, or it was suspected, that patients had infections. Signage to alert staff and visitors of the risk of infection was placed on the doors. On many wards we saw that the doors to these rooms were open, which meant the signage to alert of the possible risk of infection were not immediately evident. Opened doors also increased the spread of infection. We asked to see if there were risk assessments in place for doors to remain open but they weren’t available.
  • We saw there was clear information displayed or provided regarding the use of segregated toilets for the sole use of patients who had, or were suspected of having infections, but segregated use was not enforced. We observed toilets meant for sole use being used by patients who were not considered as being an infection risk. This increased the risk of the spread of infection.
  • We saw many good examples of staff delivering care using best practice but also saw examples where staff action increased the risk of infection. This included one staff member who cleaned a toilet and left the toilet without removing their gloves and aprons and entered a clean area.
  • The incidence of Clostridium difficile infections in 2013/2014 was 28 and was above the trusts target.
  • There had been no Methicillin-resistant Staphylococcus Aureus bacteraemia (MRSA) infections across the trust in the last 12 months.
  • During our inspection we found that generally the hospital was visibly clean.

Nutrition and Hydration

  • Nutritional screening assessments were available in all patient records that we looked at.
  • Patients generally reported that the quantity of food was sufficient but there were variable reports on the quality with most patients telling it was acceptable. Following the inspection, the trust changed its catering contract and it was hoped this would bring new benefits to both staff and patients.
  • Where patients had identified nutritional needs, staff were alerted to this by the use of a red napkin and red jug being placed on their tray. Most patients had the appropriate coloured jug by their beds.
  • Protected meal times were in place to allow time for patients to eat sufficiently. Where relatives or friends supported people to eat, they were encouraged to continue this.
  • Most fluid balance charts we saw were well completed, however the audits on some wards identified that they were at times poorly completed.

Mortality

  • There were no open mortality outlier alerts for the trust at the time of our inspection. Mortality outlier alerts look at patterns of death rates in NHS trusts. Alerts are issued when the number of deaths is higher than usual.
  • The trust reported data for the ‘Summary Hospital - level Mortality Indicator’ (SHMI). The summary hospital-level mortality indictor (SHMI) and the hospital standardized mortality ratio (HSMR) between July 2013 and July 2014 shows no worse than the national average for the number of deaths. The groups with highest excess deaths for the latest SHMI were pneumonia, stroke, mental retardation and senility, renal failure and lung cancer. SHMI and HSMR are ways in which the NHS measures healthcare quality by looking at the death rates from certain conditions in a trust.
  • The trust held monthly mortality review meetings where all unexpected deaths were reviewed.

Staffing

  • Planned staffing levels were not being achieved on a number of wards, particularly those in the medical care service. This was impacting heavily on staff morale, sickness and retention. The trust recognised this and recruitment, including overseas recruitment was underway.

  • The trust was reliant on agency nurses, but tried to use the same agency staff where possible. We were encouraged to see the nurse staffing reports to the trust board and to the Quality Assurance Committee explored the potential for a link between nursing vacancy rates and the incidence of patient falls. A correlation had not been confirmed.
  • Medical staff were in a better position than nurses, although there were some areas of the trust that required an increase.

We found areas of good practice

  • BreathingSpace was an innovative nurse-led unit. The unit had been visited by members of parliament as well as interested parties from across the UK, Japan, China and Belgium. The nurse consultant who led the unit had presented papers at national and international conferences focused on respiratory illnesses.
  • BreathingSpace provided exemplary care to the patients it cared for due to the highly skilled and knowledgeable staff working on the unit. Staff were caring and compassionate and continued their caring role by supporting families after the loss of a loved one. It was an example of an innovative community service that met the needs of the population very well.
  • The trust hosted a photopheresis treatment service which helped patients with conditions where the white blood cells are thought to be the cause of the disease. It is the largest centre outside of London to provide the treatment. We saw a child who had travelled some distance for the treatment during our visit. It was a service that was highly valued by the patients who used it.

We found areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

  • All relevant staff must receive appropriate training and development. This should include, mental capacity, safeguarding adults and children, resuscitation and living with dementia awareness.
  • All relevant staff must be able to assess the capacity and best interests of patients in line with the Mental Capacity Act 2005 and its associated deprivation of liberty safeguards.
  • All do not attempt cardio-pulmonary resuscitation (DNA CPR) forms must be completed in line with the trust’s policy and that patients’ capacity is assessed in line with the requirements of the Mental Capacity Act (2005).
  • The registered person must ensure patients are not cared for in mixed sex wards/departments apart from those areas which are exempt from meeting the national requirements.
  • The registered person must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of patients.
  • The outpatient appointment validation process must be completed and actions taken to assess clinical risks to patients of having overdue appointments.
  • The children's ward environment must be safe and appropriate for children and young people.
  • Incidents must be reported and investigated in a timely manner and that learning is shared with all staff.
  • Directorate and corporate risk registers must be reviewed so they reflect the current identified risks, contain appropriate mitigating actions and that the risks are monitored and reviewed at appropriate intervals.
  • Children and young people using the short break service were not protected against the risks associated with the unsafe use and management of medicines.
  • The provider must ensure that there is effective liaison between the contraception and sexual health service and the school nursing service about individual young people who may be at risk of abuse.
  • Complaints must be dealt with in accordance with the trust policy, national best practice and guidance.
  • Patient records must be kept securely.

In addition the trust should:

Emergency department

  • Complete a review of staffing levels so appropriate numbers of suitably qualified nurses, emergency department assistants, and healthcare assistants are on duty to manage surges in demand.
  • Ensure that all relevant staff are able to attend regular staff meetings.
  • Ensure that there are systems in place that allow for professional sign language interpretation of consultations for profoundly deaf patients who use sign language, either in person or via video link.

Surgery

  • Improve the 18-week referral-to-treatment targets so that patients have access to timely care and treatment.
  • Improve access and flow for patients attending fracture clinic appointments.
  • Minimise the movement of patients from other specialities onto surgical wards, particularly those wards providing elective orthopaedic surgery.

Critical care

  • Make sure that staff have access to up-to-date, evidence-based guidance.
  • Review access to the intensive care unit so it is secure at all times.
  • Ensure that consultant ward rounds take place in accordance with national guidance.

Maternity

  • Review guidance so that the time intervals for recording patient observations are sufficiently frequent to ensure patient safety.
  • Make sure that suitably trained staff are available to provide postoperative recovery care for women.
  • Review documentation so that appropriate prompts are available to identify patient safety needs.
  • Review the process for women with social service involvement, who may require an extended stay on the ward after giving birth.
  • Review the rates of elective caesarean section and those performed following an induction of labour, with appropriate implementation of identified learning.
  • Review access and patient flow on the labour and postnatal wards so there is effective use of resources to ensure that mothers and babies are cared for in the most appropriate place.

Children and young people

  • Review the internal safeguarding processes and implement identified actions.
  • Review the transition arrangements for children and young people for all pathways.
  • Review the leadership of the service so there is access to senior children’s nursing advice.

Outpatients and diagnostic imaging

  • Ensure that sharps are managed in a manner which protects staff and patients from the risk of needle-stick injuries.

Community Inpatient Services

  • Review the care being provided in The Oakwood Community Unit so that patients have the opportunity to engage in social activities as well as promoting their independence.
  • Review reasons for staff working in the community in-patient areas feeling isolated and distanced from the senior leaders in the trust.
  • Review the delay in discharges caused by lack of access to prompt assessments for receiving social care and continuing healthcare and lack of availability of specialist packaging for medicines.

Community Children and Young People's Services

  • Systems for reporting and recording safety concerns, incidents and near misses are used effectively and consistently.
  • Safeguarding supervision should be reviewed to make sure it is robust and effective for all staff that need this.
  • The provider should ensure that the substance misuse pathway is effective in providing appropriate intervention for young people under 16.
  • The provider should ensure that handovers from midwives to health visitors are taking place in a timely and effective way.
  • Review the early attachment service is not over reliant on one practitioner.
  • Review the discharge criteria for the early attachment service are fully defined.
  • Review the IT requirements of staff working in the community so that staff are not hindered by old and inefficient IT equipment.
  • Ensure that all staff working with children, young people and families have received training about the identification and prevention of child sexual exploitation.
  • Ensure that young people have access to contraceptive and sexual health clinics during school holidays.
  • Ensure that waiting time targets are met for physiotherapy non-urgent appointments and child development centre appointments.
  • Ensure that letters to parents and carers include how to get the information in languages other than English.
  • Ensure that information about complaints is captured and shared, including when they are dealt with locally and not recorded on the reporting system.
  • The provider should ensure that risks and concerns within the service are dealt with in an appropriate and timely way.
  • Ensure a consistent approach to obtaining the views of children, young people and families using the service.
  • Strengthen the engagement with staff delivering community health services for children and young people and improve communication about service design and strategy.

Community End of Life Care Services

  • Provide support to staff delivering community end of life and palliative care to report patient safety incidents appropriately and ensure they are able to access training in incident reporting on a regular basis.
  • Strengthen ways of learning from incidents and sharing good practice across the community end of life and palliative care services.
  • Ensure staff visiting patients in their homes to deliver end of life and palliative care are able to access the complete information they need before providing care and treatment.

  • Ensure that staff delivering community end of life and palliative care are able to access appropriate one to one supervision on a regular basis.
  • Strengthen the engagement with staff delivering community end of life and palliative care, and improve communication about service design and strategy.

Community Health Services for Adults

  • Strengthen the engagement with community health services for adults’ staff. 
  • Ensure community staff have access to information relating to people before providing care and treatment.
  • Ensure staff are accessing interpreter services where appropriate.
  • The provider should support community and district nursing staff to report patient safety incidents appropriately.
  • The provider should ensure staff are involved in learning from incidents and good practice is shared across teams and departments.

Trust wide

  • Ensure that information about how to make a complaint or leave a comment is available in alternative formats and languages.
  • Ensure that nursing staff have access to clinical supervision.
  • Ensure that patients who are living with dementia and/or their relatives have the opportunity to give information about their personal circumstances, their preferences and likes and dislikes.
  • Patients’ records are kept securely at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.