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Provider: Sheffield Teaching Hospitals NHS Foundation Trust Good

On 14 November 2018, we published a report on how well Sheffield Teaching Hospitals NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 14 November 2018

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

  • We rated responsive as outstanding and we rated safe, effective, caring and well-led as good.
  • The Northern General hospital was rated as Good overall as both urgent and emergency care and end of life had improved. Responsiveness was outstanding at this site which was an improvement.
  • In rating the trust, we took into account the current ratings of the other services not inspected this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • We rated well-led at the trust level as good.
Inspection areas

Safe

Good

Updated 14 November 2018

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

  • Nurse staffing had improved in the emergency department at NGH. Actual nurse staffing levels in the ED coincided with planned level following a £1.2m investment in additional staffing approved by the trust board in February 2016 which meant nursing and support staff had increased by 25% since our previous inspection.
  • Staff in ED applied safeguarding procedures for adults appropriately supported by the safeguarding lead. Safeguarding link nurses supported staff with safeguarding matters on the wards. Staff understood safeguarding and what to do if they were concerned.
  • Staff had high levels of compliance with mandatory training and safeguarding training. In areas where compliance was lower than the trust’s standard we saw staff booked to receive training which supported staff in keeping patients safe.
  • The services managed patient safety incidents well. All the staff we spoke with, including medical staff, were aware of how to report incidents and gave examples of what types of things they would report. Management of incidents had improved in ED.
  • Records completed by the specialist palliative care team showed a holistic review of patients’ needs and were completed in line with the staffs’ registered bodies. Records were stored securely.
  • All specialist palliative care nurses were non-medical prescribers which meant medicines could be prescribed for patients in a timely manner to safely manage and support symptom control.
  • The services we did not inspect at this inspection had been rated as good following the 2015 inspection.

However:

  • Although we were informed that the trust was reviewing the requirements for the major trauma centre to include consultant staff 24 hours and seven days per week, we remained concerned that the major trauma standards were being breached and this had not been resolved in a timely way following our previous inspection.
  • NHS England’s quality dashboard for June 2018 showed that for May 2018, the latest month for which comparative data was available at inspection, 11.1 % of ambulance handover delays were for more than 60 minutes, which was worse than other trusts in the South Yorkshire area.
  • Standards of hygiene were not maintained consistently within the ED at NGH. We observed poor handwashing in frequency and technique. Equipment was not always being cleaned between patients. Some areas did not have cleaning wipes or cleaning liquids available.
  • Patients arriving by ambulance were not always booked into the emergency department in a timely manner. Between February 2017 and January 2018, the trust reported 218 “black breaches.” A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff.
  • The emergency department did not consistently follow policy and best practice guidance for the prescription of oxygen therapy and the completion of patient records related to oxygen therapy.
  • A review of the staffing on the wards we visited showed that between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on nightshift was below 75% Robert Hadfield 3 and 4, and Brearley 6. Also, between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on dayshift was below 75% on Brearley 5 and 6.
  • Safety thermometer information and nurse staffing levels were not on public display and could only be viewed by nursing and medical staff.

Effective

Good

Updated 14 November 2018

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

  • There had been improvements in end of life care which was rated as Good.
  • There was evidence of good multidisciplinary working throughout the trust. Staff with specialist skills and knowledge worked well together to benefit patients.
  • Appraisals for both medical and nursing staff were above the trust target. In ED we saw that personal development reviews included interaction to support the staff member’s development and an action log was completed and signed within two weeks of the appraisal. A structured induction programme was in place for new staff.
  • Sepsis outcomes showed a considerable improvement in ED. Outcomes for sepsis patients included the patient’s experience of their stay in hospital. A sepsis study day was in development.
  • We saw that staff had an understanding of consent and gained consent prior to performing care.
  • Care and treatment was based on national guidance and there was evidence of the effectiveness of this through participation in national and local audits, reviews of outcomes and actions taken to improve services.
  • Patients told us their pain was well-managed. Staff made sure patients had enough to eat and drink to meet their needs and improve their health. A neighbouring mental health trust provided support for patients experiencing ill mental health within the emergency department. The mental health trust had maintained a presence in the department 24 hours a day, seven days a week.

However:

  • There was a lack of evidence of mental capacity assessments and best interest decisions in the patients’ notes we reviewed on the medical wards at NGH and RHH.
  • There were not robust arrangements in place to support patients with mental health needs on the medical wards including managing and recording Deprivation of Liberty Safeguards and making sure that hospital managers discharged their specific powers and duties according to the provisions of the Mental Health Act 1983.
  • From January 2017 to December 2017, patients at Northern General Hospital had a higher than expected risk of readmission for elective admissions and a higher than expected risk of readmission for non-elective admissions when compared to the England average.
  • The trust had participated in the 2017 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 54%, which did not meet the audit minimum standard of 90%. The 2015 figure was 80%.
  • Although the emergency department participated in the national RCEM audits to benchmark its practice, results of audits which previously demonstrated mainly poor outcomes required further action. Action plans were in place to address this.

Caring

Good

Updated 14 November 2018

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

  • Caring was rated as outstanding at Weston Park.
  • Patients told us that they received compassionate care and that staff supported their emotional needs.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives we spoke with told us they felt well informed by doctors and nursing staff about their condition, treatment options and plan of care.
  • Spiritual and pastoral support was available to patients from the hospital chaplaincy service.
  • The trust’s friends and family test (FFT) from March 2017 to February 2018 scored the same as the England average for recommending the trust as a place to receive care and the response rate was better than the England average and showed consistently positive results.

Responsive

Outstanding

Updated 14 November 2018

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

  • Responsiveness at NGH and Weston Park were outstanding overall, which was an improvement.
  • Services were planned in a way to meet the individual’s needs and the local population.
  • The trust had applied measures to manage access and flow in the ED.
  • The initial assessment unit in ED had been upgraded and a new helipad had been opened adjacent to the emergency department, the GP collaborative had been relocated adjacent to the department which supported the streaming of patients 24 hours a day, seven days per week.
  • A revised ‘front door’ arrangement was implemented from November 2017 which supported timely diagnostics, decision-making and prompt treatment for the patient.
  • Patients knew how to complain, and staff knew how to deal with complaints they received. Complaints were investigated, and learning was shared.
  • We saw that reasonable adjustments were made for people with more complex needs such as those with learning disabilities.
  • Between August 2016 and July 2017, the trust’s referral to treatment time (RTT) for admitted pathways for surgery was slightly better than the England average with a stable trend over the 12 months.

However:

  • NHS England’s quality dashboard for June 2018 showed that for May 2018, 88.8% of patients were seen within four hours of arrival, which was worse than other trusts in the South Yorkshire area.
  • The trust had a higher than planned level of delayed discharges but was actively working with providers to manage this.

Well-led

Good

Updated 14 November 2018

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

  • We found effective leadership throughout the services at ward level and above. Staff spoke highly of their line managers and told us they felt listened to. Leadership of the urgent and emergency care services had been recently strengthened with the appointment of a nurse director and matron.
  • The care groups/directorates had plans which were aligned to the trust’s strategic plan and aimed to meet the needs of the local population. A clear vision and operational plan was in place for the continued development of the emergency department. The three-year strategy for the care group for acute and emergency medicine included an analysis of planned operational performance and resource requirements to achieve the vision and key objectives for the department.
  • We found a positive culture with staff being open, honest, and willing to share information with us on inspection. We found good relationships between staff and they told us they worked well together to overcome challenges.
  • There was a governance structure in place with integrated performance reports and supporting dashboards. Managers monitored performance and used the results to help improve care.
  • Risks were identified and managed within directorates although we identified some risks within medical care at Weston Park that were not effectively managed. There was a process for escalating risks from wards/services to the directorate and above although some of the “extreme” risks were not included on the integrated risk and assurance report at board level.
  • We found evidence of good engagement with patients and carers, staff and local organisations to plan and manage services. There was effective collaborative working with partner organisations.
  • We found a culture of continuous improvement and service development. There was a commitment to developing staff and improving services for patients.
Assessment of the use of resources

Use of resources summary

Good

Updated 14 November 2018

Combined rating
Checks on specific services

Community health inpatient services

Good

Updated 9 June 2016

Overall rating for this core service. Good 

We rated Beech Hill as good overall, however we rated the unit as requires improvement for safe. The unit used an electronic reporting system for incidents and near misses. All staff we spoke with knew how to use the system. We found that medicines were securely stored on the unit. All areas of the unit looked visibly clean, well maintained and infection prevention and control measures were embedded on the unit. Staff took a proactive approach to safeguarding. We saw effective handovers and shift changes; however, we had some concerns about staffing levels. Rosters for night duties indicated that there was one registered nurse and one care support worker on each ward, with a second care support worker who worked between the two wards. Rosters also showed that the minimum planned staffing levels were not always met. The wards were on separate floors. Senior staff we spoke with told us that increased numbers of patients were being referred back to the acute hospitals because they were not medically fit. Staff were not using a recognised early warning tool to recognise a deteriorating patient. This was because there was an expectation on the unit that patients were medically fit. Therefore staff used their observations and clinical judgement. We also found that resuscitation equipment was not always checked in line with the trust’s policy and it was not always possible to identify if equipment was clean.

We rated effective as good because people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were receiving adequate pain relief, nutrition and hydration. There was participation in relevant local and national audits, including clinical audits and other monitoring activities such as reviews of services, benchmarking, peer review and service accreditation to improve services for patients. There was a centrally hosted clinical computer system, which allowed all members of the MDT to access and share records. Staff received a comprehensive trust induction programme and timely appraisals. Staff were also supported with professional development. Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005. We saw evidence that patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. Deprivation of Liberty was recognised and acted on in a timely and appropriate manner.

We rated caring as outstanding. We found that feedback we received from patients was consistently positive about the way nursing and therapy staff treated them. Patients told us that staff went the extra mile. Staff and patients confirmed that the unit had a flexible approach to care. We saw that the staff were highly motivated and inspired to offer care that was kind, promoted people’s dignity, and involved them in planning their care. Patients said that staff were lovely, could not do enough for them, attended to every wish and were caring, compassionate, sensitive and supportive. Relationships between patients, those close to them and staff were strong, caring and supportive. Patients and their families’ personal, cultural, social and religious needs were seen as a priority by all staff. Activities such as singing, arts and crafts were arranged to prevent social isolation and boredom. Patients said that they felt ‘safe and secure’.

We rated responsive as good. We found that the services were planned and delivered in a way that meets the needs of the local population. The needs of different people were taken into account when planning and delivering services. Staff told us that they respect the equality and diversity of their patients. Patients and families we spoke with confirmed this. The facilities and premises were appropriate for the services being delivered. We spoke with the matron and found that there was an openness and transparency in how complaints were dealt with. Complaints and concerns were taken seriously, responded to in a timely way and listened to. Improvements were made to the quality of care as a result of complaints and concerns.

We rated well led as good because the trust had a clear statement of vision and values, driven by quality and safety, which was recognised and integrated within the unit. Staff we spoke to were aware of and based their care around the trusts PROUD values. There was good interaction between the board and the unit. Senior staff shared details of the board and governance meetings with staff on the unit. Senior staff were visible, approachable and supportive to staff and patients. Leaders were actively engaged with staff, people who used services and their representatives and stakeholders. Therapy staff told us that they were proud of how the team worked together to achieve targets and ’go the extra mile’. There was a strong focus on continuous learning and improvement at all staff levels. Staff shared innovations and improvement work that they were involved with.

Community end of life care

Good

Updated 14 November 2018

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

  • We rated safe, effective, caring, responsive and well-led as good.
  • Staff caring for patients at the end of their life were aware of how and when to report incidents, including safeguarding concerns. We saw that staff received feedback and lessons learned were shared.
  • Staff practiced safe infection control techniques.
  • Staff caring for patients at the end of their life assessed patients and escalated their care to the specialist team when necessary.
  • Guidelines, pathways and policies were produced in line with national best practice guidelines and recommendations.
  • There was sufficient numbers of skilled staff to care for patients at the end of their life. The service was available seven days a week 24 hours a day.
  • Staff understood the importance of seeking patient consent before providing care and treatment and showed a good understanding of the mental capacity act and deprivation of liberty safeguards.
  • Relatives we spoke with gave consistently positive feedback. Staff spoke about the patients they cared for in a caring, compassionate and respectful way.
  • Patients and their relatives told us that they were involved in planning their care and that communication with staff was good.
  • Staff provided emotional support to patients and their loved ones.
  • Services were planned in conjunction with external partners, across the whole of the health system to meet the needs of local people.
  • We saw numerous positive examples of initiatives to meet the individual needs of patients at the end of their life.
  • There was a clear leadership structure and strategy for end of life care. Staff told us that their line managers were visible, approachable and supportive.
  • Local governance arrangements were robust and the team was aware of the risks to their service.
  • We saw numerous examples of engagement, improvements and innovation.

However:

  • The trust had implemented processes to record whether patients preferred place of death was achieved and if not why not, they had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring if patients achieved their wishes. However, we found establishing patients’ preferred place of care was seen as a priority.

Community dental services

Outstanding

Updated 9 June 2016

We rated the community dental services at this trust as outstanding. This was because:

  • Staff protected patients from abuse and avoidable harm. A specialist dentist working in the service had contributed to the development of theresource website ‘child protection and the dental team’, initially funded by the Department of Health and now hosted by the British Dental Association. This resource is used nationally by general dental practice teams for the effective management of safeguarding children in dental practice. Systems for identifying, investigating and learning from patient safety incidents were in place. Infection control procedures were in place. The environment and equipment were clean and well maintained and medicines and emergency equipment was available at each site we visited to deal with medical emergencies. However, due to the age and design of the Manor clinic the delivery of optimal care to patients who were confined to a wheelchair was difficult.

  • The dental services were effective and focused on patients’ and their oral health care. We saw several examples of innovative care approaches including the provision of care to the most vulnerable members of society. Those vulnerable members included Sheffield’s homeless community who were treated through the The service could meet patients’ needs because of the flexible attitude of all service members. In collaboration with commissioners of dental services and dental public health consultants, Sheffield community dental service developed a domiciliary service called Residential Oral Care Sheffield (ROCS). Senior dentists and the oral health promotion team in the service work in partnership with local general dental practitioners to deliver effective dental care to 90 care homes in Sheffield.

  • Patients, relatives and carers said they had positive experiences of care within the service. We saw good examples of staff providing compassionate and effective care. We also saw effective interactions taking place between individual staff members. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed their dedication to what they did.

  • Staff responded to patients’ needs at each clinic we visited. The service kept treatment delays for routine dental treatment within reasonable limits through effective resource management. Effective multidisciplinary team working ensured the service provided patients with care that met their needs and at the right time. We saw specialist dental teams delivering dental care to mental health services, the homeless of Sheffield, the spinal injuries unit and special schools.

  • The community dental service was well led. Organisational, governance and risk management structures were in place. The service’s operational management team was visible and the working culture appeared open and transparent. Staff were aware of ‘PROUD’ and the organisation’s vision and way forward and they said they felt well supported and that they could raise any concerns.

  • The Sheffield community dental service had achieved national profile status in community dentistry through a number of innovative projects. The clinical lead was instrumental in developing a ‘case mix’ tool kit that is used to describe the complexity of the patients treated in the community dental services. Commissioners of dental services when commissioning community dental services use this tool kit as a national benchmark. Commissioners also use the tool kit as a key performance indicator when judging the effectiveness of a community dental service.

Community health services for adults

Outstanding

Updated 9 June 2016

Overall rating for this core service Outstanding

Overall we found services for community adults to be outstanding.

There were robust methods of reporting, investigating and learning from incidents and near misses that staff understood and embedded in their daily work. There was a risk register in place that ensured potential risks were known, assessed and appropriate controls were implemented. Pharmacists worked with community teams and had written and reviewed standard operating procedures to improve safety around medicines.Compliance with mandatory training was generally high and we observed good infection control practices. We found that staffing levels met the needs of patients.

We found care and treatment was evidenced based with pathways of care based on National Institute of Clinical Excellence (NICE) guidelines. There were excellent examples of multi-professional teams working closely together for the benefit of patients. Referrals to community services were managed by the Single Point of Access (SPA) service, which established the most appropriate service for the patient. Staff had good access to records using laptops with 4G and used an electronic patient record system allowing information to be shared between professionals. Staff we spoke to had a good level of knowledge about the Mental Capacity Act and Deprivation of Liberty Safeguards.

Caring was good. We found staff were genuinely caring and passionate about the care they provided to patients. Patients we spoke to all said they were extremely happy with the care they received and felt they were always treated with compassion. Patient’s relatives said they thought the care provided had been excellent and staff had been caring and responsive. We observed staff treating patients with dignity and respect. Patients and their relatives were involved in their care. We observed treatment and support options being discussed with patients and their families before gaining consent and agreement. Emotional support was made available for example; mental health services aligned to the active recovery team provided talking therapies for patients and could signpost patients to other agencies. We saw staff putting on overshoes when entering patients home in wet weather. We thought this was extremely considerate.

Community services were exceptionally responsive. There was close working with commissioners to provide services along coordinated pathways of care. We saw good examples of community services working closely and planning services with the acute hospitals to provide integrated care to patients. The active recovery team had redesigned the traditional model of assessing to discharge to the more patient centred approach of discharge to assess. The first ward to implement discharge to assess had a sustained reduction in length of stay of 7 days. Access to services via the single point of access was excellent, ensuring patients were seen by the right professional at the right time at a venue of their choice. Staff were aware of cultural differences. Patient information leaflets were available in different languages and there was good access to interpreting services. Community nursing teams had a dedicated member of staff who was the dementia link. Staff we spoke to had completed dementia training and could describe how they would provide extra support for patients living with dementia. There was shared learning from complaints and we saw evidence that changes were made in response to complaints.

Community services were extremely well led. Senior managers could articulate their vison and strategy and shared this with staff. There was strong leadership at both senior and local level. Staff spoke highly of their managers and felt well supported and listened too. Senior managers were often seen and staff said they were approachable. Staff engagement was outstanding. The trust used different methods of engaging the staff such as the ‘listening into action’ events and ‘you said we did’ initiatives. Staff were consulted with and encouraged to lead on service development and change and they felt empowered and valued. There was a positive culture of service improvement and we found innovative services along pathways of care, which reached across both hospitals, and community services.