All inspections: Sherwood Forest Hospitals NHS Foundation Trust

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

We rated safe, effective, responsive and well led as good and caring as outstanding for core services, the trusts well led was rated as good. We rated eight of the trust services as good and one, which was end of life care at Newark hospital as requires improvement overall.

We rated well led for the trust as good overall.

During this inspection, we did not inspect, urgent and emergency care, medical care including older people’s care service, maternity services, outpatients, diagnostic imaging, or community inpatient care.

The ratings we published following the previous inspections are part of the overall rating awarded to the trust this time.

Overall, we rated caring as outstanding, effective, responsive and well-led as good and safe as requires improvement. In rating the trust, we took into account the current ratings of the five services not inspected this time.
During this inspection we rated 10 core services with all being rated as good overall.
We rated well-led for the trust overall as good.

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

There were multiple examples of how staff exceeded patient expectations and provided individualised, compassionate care that significantly improved individual experiences.
There had been demonstrable, substantial improvements in the areas we previously found for improvement that were under each ward team’s control. This included stabilised leadership, improvements in training and induction and a reduction in the use of agency staff.
All areas of the patient-led assessment of the care environment in 2017 demonstrated improvements from the previous year.
Audit and benchmarking programmes had been implemented to improve how the hospital evidenced patient outcomes.
Improvements in discharge coordination were being led by a complex discharge specialist and there was evidence of consistent, embedded multidisciplinary liaison to improve patient care.
Rehabilitation was at the heart of care and treatment in the hospital and staff, both clinical and non-clinical, had taken on additional training to be able to provide extended roles.
Services and ward environments were structured to facilitate socialisation amongst patients, reduce the risk of isolation and promote a welcoming environment for relatives.
Opportunities for staff progression and development had significantly improved and a dedicated clinical nurse educator was leading a substantial education programme for trainee nurse associates.

However:

At our last inspection in July 2016 we found therapies teams were unable to provide services outside of core Monday to Friday hours. This remained the case and patients admitted at weekends had limited access to care planning and therapies exercises. Some nursing staff had completed training to provide basic interim therapies assessments for patients.
Local governance processes worked well but there was limited evidence that some of the overarching governance strategies at a trust level had a positive impact. This included the morbidity and mortality arrangements and the use of the divisional risk register.
The Chatsworth ward therapies team were unable to carry out audits or research due to restrictions on their capacity.

We inspected Sherwood Forest Hospitals NHS Foundation Trust on 18, 19 & 20 July 2016. This was a focused unannounced follow up inspection to check progress against our findings from our last inspection of June 2015. We inspected:

Emergency and Urgent Care Services at Kings Mill Hospital and Newark Hospital looking only at the safety of these services.
Medical Services at Kings Mill Hospital, Newark Hospital and Mansfield Community Hospital looking only at the safety and effectiveness of these services.
Maternity Services at Kings Mill Hospital and Newark Hospital looking only at the safety of these services.
Outpatient (but not diagnostic) Services at Kings Mill Hospital and Newark Hospital looking only at the safety of these services.

We rated the safety of emergency and urgent care services, medical services, maternity services and outpatient services as good. We rated the effectiveness of medical services as requiring improvement.

Our key findings were as follows:

The trust had systems in place for incident reporting, investigating and monitoring. Lessons learnt were shared with staff to prevent similar incidents happening again.

The wards and clinical areas were visibly clean and there were systems to monitor and manage the risk of the spread of infection.
There were systems, processes and standard operating procedures in place to ensure records, medicines management and maintenance of equipment was given sufficient priority. Emergency resuscitation equipment was checked daily. However, oxygen cylinders were not stored in accordance with Health and Safety Executive (HSE) guidance at Mansfield Community Hospital. At Newark Hospital 73 out of 183 pieces of equipment used by the outpatient services were recorded as not having received a scheduled annual check. However some of the items had been reported missing but not removed from the check list and most of the remainder were items issued to patients but not returned. The maintenance organisation was working with Respiratory Specialist nurses to manage these items within the community. Also at Newark Hospital on medical wards there was no standardised system for highlighting when equipment was clean and ready for use.

Whilst we saw high numbers of nursing staff vacancies on medical wards and high use of bank and agency staff, levels of staffing and skill mix of staff was managed appropriately and recruitment was underway.
Nursing staff levels and skill mix in the emergency department and minor injuries unit were planned, implemented and reviewed to keep people safe at all times. Any staff shortages were responded to quickly and adequately. However, when all the patient beds in the resuscitation area of the emergency department were fully occupied nursing staff levels were insufficient.

Patients received the correct treatment in a timely manner. There were well embedded systems in place to recognise a deteriorating patient and we saw evidence of patients being assessed, monitored and managed for a variety of potential risks. Staff knowledge of sepsis and the ability to identify a patient who was at risk of developing sepsis was improving with high numbers of staff completing the sepsis training.
When something went wrong, patients received a sincere and timely apology and were told about any actions taken to improve processes to prevent the same thing happening again.
Since our last inspection, the outpatient service had made significant improvements in reviewing patient outcomes and reducing the number of overdue appointments.
The inspection team had concerns regarding staffing and booking arrangements for ophthalmology outpatient clinics. Ophthalmology had the largest numbers of incidents reported and the largest numbers of patients overdue for an appointment. Staff raised concerns regarding the conduct of medical staff in ophthalmology clinics.
We found patients’ care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation and outcomes for medical patients were mostly within expectations when compared with similar services. However, there was minimal data collected on patient outcomes for medical services at Newark hospital and Mansfield Community Hospital which meant care could not be benchmarked against other providers.
Patients’ symptoms of pain were suitably managed and staff were mostly proactive in assessing the patient’s nutrition and hydration needs.
There were systems to assess, monitor and mitigate risks to patients as well as systems to monitor and improve the quality and safety of services. Now the systems and processes are in place the trust needs to ensure they are fully sustained and part of the organisational culture.

We saw several areas of outstanding practice including:

Since our last inspection in June 2015 the trust had demonstrated significant improvements in the management of the deteriorating patient and the treatment of sepsis. Across medical care services staff identified and responded appropriately to changing risks to deteriorating patients. Where patients had met the trust criteria for sepsis screening, patients were screened appropriately.
The ‘EGO’ pathway which had been implemented for those patients admitted with a minor orthopaedic injury who also had comorbidities that were medical care related.

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

Importantly, the trust must:

Ensure staff understand the requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards in relation to their roles and responsibilities.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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

There was a robust and open culture towards reporting of incidents and we saw evidence of staff learning from investigations, however there were some delays in reviewing incidents but a plan was in place to address this. Staff were aware of their responsibilities to safeguard patients from avoidable harm and suitably reported any concerns.
Staffing levels were mostly maintained with the use of bank and agency staff, although there were occasions staff provision was affected as some patients required one to one care and it had not been possible to rota on extra staff.
The wards and clinical areas were visibly clean and systems to monitor and manage the risk of the spread of infection were in place. Equipment was available and was serviced to ensure it was safe to use. Oxygen cylinders were not being stored in accordance with Health and Safety Executive (HSE) guidance.

Effectiveness of medical services was rated as requiring improvement because:

There was minimal evidence available for demonstrating patient outcomes at this hospital which made it difficult to benchmark the effectiveness of the care given against other providers.
At our last inspection of Mansfield Community Hospital in June 2015 we found staff did not always understand the requirements of the Mental Capacity Act 2005 in relation to their roles and responsibilities. At this inspection we found medical and nursing staff understood the principles and application of the Mental Capacity Act 2005, however, training was not extended to health care assistants who delivered care to patients.

Sherwood Forest Hospitals provides medical care (including older people’s care) at Mansfield Community Hospital as part of the specialist medicine division. Mansfield Community Hospital has three medical wards; Oakham Ward and Lindhurst Ward with 24 beds each and Chatsworth Rehabilitation Ward with 16 beds.

Between January 2015 and December 2015 there were 45 admissions to the hospital. Most admissions were planned admissions for rehabilitation care and treatment.

This was a focused inspection following a comprehensive inspection that had taken place in June 2015. At that time, medical care at Mansfield Community Hospital was rated overall as requires improvement. As The effectiveness of the service was rated as inadequate with safety, responsiveness and well led rated as requires improvement with caring rated as good.

During our inspection of this hospital we spoke with 4 patients, and 13 staff. We looked at the medical and nursing records of six patients. We spoke with medical staff, junior and senior nursing staff, allied health professionals, healthcare workers, and housekeepers.

Sherwood Forest Hospitals NHS Foundation Trust was formed in 2001, and achieved foundation status in 2007. Sherwood Forest Hospitals is the main acute hospital trust for the local population, providing care for people across north and mid-Nottinghamshire, as well as parts of Derbyshire and Lincolnshire. There are four registered locations. King’s Mill Hospital in Sutton-in-Ashfield is the main acute hospital site. It provides 546 inpatient beds (more than half in single-occupancy en-suite rooms), 11 operating theatres, and a 24 hour emergency department. Each year there are more than 45,000 inpatient admissions and 36,000 day case patients; 100,000 patients attend the emergency department, around 3,500 babies are delivered, and more than 390,000 people attend outpatient and therapy appointments in the King’s Treatment Centre.

Newark Hospital provides a range of treatments, including consultant-led outpatient services, planned inpatient care, two operating theatres for day-case surgery, endoscopy, diagnostic and therapy services, and a 24 hour Minor Injuries Unit & Urgent Care Centre. There were 47 beds available across two medical wards. The day case surgery ward had facilities for up to 30 patients.

Mansfield Community Services provided three medical wards with a total of 64 beds, largely for rehabilitation, and a range of outpatient and diagnostic services. There were dedicated therapy, psychology, dietetics and speech and language services and a small outreach service. Nurse specialists for Osteoporosis and Parkinson’s disease were based at the hospital and the Geriatric Medicine team offered dedicated outpatient clinics for these services.

The trust provides some outpatient services at Ashfield Health Village, including general surgery, urology and audiology. We did not inspect this location.

In February 2013, the trust was identified as being one of the 14 healthcare providers in England which had higher than expected mortality rates. This led to the trust being reviewed by Professor Sir Bruce Keogh, NHS Medical Director for England and the trust was subsequently placed into “Special Measures” by Monitor, the independent regulator of NHS foundation trusts.

The CQC undertook a first comprehensive inspection of the trust in April 2014. Although some improvements had been made, the CQC recommended the trust remained in special measures and gave an overall rating of ‘Requires Improvement.’ We judged the provider was not meeting seven out of 16 essential standards of quality and safety.

As part of this comprehensive inspection, we carried out an announced inspection visit from 16 to 19 June 2015 and three unannounced visits on 7, 9 and 30 June 2015. We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, physiotherapists, occupational therapists, pharmacists, domestic staff, and porters. We also spoke with staff individually.

We have rated this trust as inadequate. We made judgements about thirteen services across the trust as well as making judgements about the five key questions that we ask. We rated the key questions for safety and leadership as “inadequate".” We rated the key questions, for effective and responsive as “requires improvement” and we rated the key question for caring as “good".”

At Kings Mill Hospital we rated the surgery and children and young people’s services to be good. The critical care, maternity and gynaecology, and end of life care services required improvement. We rated the urgent and emergency services, medical care, and the outpatients and diagnostic imaging service as inadequate.

At Newark Hospital we rated the surgical services to require improvement, and the minor injury unit, medical care, and the outpatients and diagnostic imaging service to be inadequate.

At Mansfield Hospital we rated the medical service to require improvement.

Our key findings were as follows:

Staff were kind and caring and treated people with dignity and respect, but there were some instances where improvements were required. In some cases a greater emphasis was needed on providing care that was based on people’s individual needs rather than as tasks.

There had been 54 cases of clostridium difficile (c. diff) infections in 2014/2015. C diff is an infective bacteria that causes diarrhoea, and can make patients very ill. This was worse than the national average and above the trust’s target, which was a total of 48 cases per year. Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections. MRSA rates for the hospital were low with one case recorded between 2014 and 2015. Routine screening of patients for MRSA was completed with further screening repeated after 21 days. We found the hospitals to be clean, hygienic, and well maintained.

Nursing and midwifery staffing had increased since 2013 and it had been a focus of the Executive Director of Nursing. Midwifery staffing levels were almost meeting the national recommended levels of 1:28. Planned nurse staffing levels were in accordance with the levels of nursing staff they had assessed as being required. There was an escalation process in place if staffing levels did not meet the planned levels, but staff did not always feel this resulted in a change. We saw some occasions where patients were not able to receive their assessed level of care due to shortages of healthcare assistant staff provided by the harms team (a team used to provide additional nursing care for patients who had greater levels of dependency).

In May 2015 there were 94.89 whole time equivalent (WTE) registered nurse vacancies. This was a high risk on the trust’s risk register. A recruitment programme was ongoing and changes had been made to speed up the recruitment process. Overseas recruitment had taken place.

There were medical staffing vacancies and there was a high use of locum medical staff.

Patients’ pain was well managed and women in labour received a choice of pain relief. Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.

Monitoring by the Care Quality Commission had identified areas where medical care was considered a statistical outlier when compared with other hospitals. The trust reported on their mortality indicators using the Summary Hospital- level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR). These indicate if more patients are dying than would be expected. The data for the trust was higher than would be expected and its overall level of HSMR was 120.67. This had been reported to the trust board and it was one of the trust’s top three objectives for improvement.

There have been longstanding concerns about the management of patients with sepsis. This is a severe infection which spreads in the bloodstream. In 2010 and 2012 we raised mortality outlier alerts with the trust, when information showed there were a higher number of deaths than expected for patients with sepsis. The trust had identified a third mortality outlier for patients with sepsis in the period April 2014 to January 2015. Our analysis of the data from April 2014 to February 2015 found 88 deaths of patients with a diagnosis of “unspecified septicaemia” compared with an expected number of 58. The death rate for patients with this diagnosis was 32%, almost twice as much as the England rate of 17%.

Some of the services in the trust participated in national audits and outcomes varied. Outcomes for women in labour were good, although the trust was significantly higher for induced births. They did not understand the reason for this high rate.

Like many trusts in England, their hospitals were busy. Bed occupancy rates were high and were consistently above 90% which was above the England average of 88%. It is generally accepted that when occupancy rates rise above 85%, this can affect the quality of care and the orderly running of the hospital. There were initiatives in place to reduce bed occupancy and improve the flow of patients through the hospital. Delayed discharges were a problem across the trust.

The trust were not meeting the national targets set regarding patients access to treatment and they had failed to meet the 18 week target for access to treatment for admitted and non-admitted patients. The trust were however meeting the standard for patients being admitted, referred or discharged from the A&E department within four hours.

There was a vision and strategy for the trust but staff were not able to articulate this to us. The priority for the organisation was to come out of special measures. There was a strategy for Newark Hospital but staff were frustrated by lack of pace to deliver this vision and felt there was poor leadership in relation to the vision and strategy. Morale amongst staff, particularly those in more junior levels was poor at Newark Hospital. Newark Hospital provided the trust with a range of opportunities to deliver new models of care but we saw little evidence that these opportunities were being taken forward.

Staff generally felt they were well supported at their ward or department level. Staff at Newark and Mansfield Hospitals felt separate from the rest of the trust.

We found the executive leaders in the trust were not always sighted on the risks that we had identified, or where they had they did not consider them to be significant. Evidence presented to us demonstrated how the trust had received assurance that was not presented accurately which meant a false picture was being presented to the trust board.

We saw several areas of outstanding practice including:

There was some innovative work taking place at King’s Mill Hospital where the trust had developed a new changing facility for patients with complex disabilities. The facility offered a large changing area that would meet the needs of patients with profound disabilities.

Staff went out of their way to meet the needs of their patients on the critical care unit. Some patients could be moved on their beds out of the critical care unit to an outdoor area. Staff told us they tried to do this when possible as patients appreciated being outside and away from the unit. Staff had been able to allow visiting by patients’ pet dogs in this way.
The trust had implemented regular "Appraisal Clinics," for consultant medical staff. Doctors could discuss any issues about their appraisal and receive support and advice. An "Appraisers Forum," also took place every quarter where discussions about the quality of appraisals and feedback from the appraisers took place.

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

Importantly, the trust must:

Kings Mill Hospital

Ensure all staff receive training in safeguarding children and vulnerable adults. The training must be at an appropriate level for the role and responsibilities of individual staff.
Ensure staff are appropriately trained to provide the care and support needed by patients at risk of self-harm.
Ensure staff receive effective and appropriate guidance and training about the assessment and treatment of sepsis.
Ensure staff understand the requirements of the Mental Capacity Act 2005 in relation to their role and responsibilities.
Ensure all patients in the emergency department are able to summon help if they need it.
Ensure all patients over the age of 75 have a cognitive assessment when arriving in the emergency department.
Ensure learning from complaints is shared with staff in the emergency department which leads to improvement in care.
Ensure the governance framework in the emergency department clearly identifies risks, responsibilities and actions required to manage those risks within a stated timeframe.
Ensure systems and processes are effective in identifying where quality and safety are being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to outpatient appointment issues.
Ensure any remedial actions taken to address outpatient appointment issues are regularly audited to give assurances improvement has taken place.
Ensure patients in the critical care unit are routinely and properly assessed for delirium.
Ensure the provision of level two critical care on Ward 43 includes nursing staffing levels in line with the ‘Core Standards for Intensive Care Units’ published by the Intensive Care Society and the commissioners expectations.
Ensure patients requiring critical care at level two on Ward 43 are cared for by appropriately trained staff in line with the ‘Core Standards for Intensive Care Units’ published by the Intensive Care Society.
Ensure staff delivering end of life care receive suitable training and development.
Ensure all patients at the end of life receive care and treatment in line with current local and national guidance and evidence based best practice.
Ensure the quality of the service provided by the specialist palliative care team is monitored to ensure the service is meeting the needs of patients throughout the trust.
Ensure risks for end of life care services are specifically identified, and effectively monitored and reviewed with appropriate action taken.
Ensure that the resuscitation trolleys and their equipment are checked, properly maintained and fit for purpose in all clinical areas in the children’s and young people’s service.
Ensure that medication is monitored, in date and fit for purpose in all clinical areas of the children’s and young people’s service.
Ensure emergency lifesaving equipment in the maternity service is checked regularly and consistently to ensure it is safe to use and properly maintained.
Ensure staff have the appropriate competence and skills to provide the required care and treatment to women using the maternity and gynaecology service. Specifically, women who are acutely ill or who are recovering from a general or local anaesthetic.
Ensure patients in the medical care wards receive person-centred care and treatment to meet their needs and reflect their personal preferences, including patients living with dementia and those with a learning disability.
Ensure all staff working in the medical care service receive appropriate supervision, appraisal and training to enable them to fulfil the requirements of their role.
Ensure patients in the medical wards are treated with dignity and respect at all times.
Ensure sufficient provision of hand gel dispensers within the emergency department.
Ensure adequate provision of defibrillators and cardiac monitoring equipment within the emergency department.

Newark Hospital

Ensure medicines are always safely managed in line with trust policies, current legislation and best practice guidance.
Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance.
Ensure staff receive effective and appropriate guidance and training about the assessment and treatment of sepsis.
Ensure staff understand the requirements of the Mental Capacity Act 2005 in relation to their role and responsibilities.
Ensure all equipment, including emergency lifesaving equipment, is sufficient and safe for use in the minor injuries unit.
Ensure safe care for patients with mental health conditions at the minor injuries unit and especially those who may self-harm or have suicidal intent.
Ensure staff have the appropriate qualifications, competence, skills and experience to care for and treat children safely in the minor injuries unit.
Ensure the inter-facility transfer protocol with East Midlands Ambulance Service is updated and is effective in providing safe and timely care for patients at the minor injuries unit.
Ensure there are effectively operated systems to assess, monitor and improve the quality and safety of the services provided in the minor injuries unit.
Ensure systems and processes are effective in identifying where quality and safety are being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to outpatient appointment issues
Ensure robust and effective governance links and oversight are established and maintained between outpatient services at Newark and Kings Mill Hospitals.
Ensure the quality of the service provided by the specialist palliative care team is effectively monitored and reviewed to ensure the service is meeting the needs of patients throughout the trust.
Ensure risks for end of life care services are specifically identified, and effectively monitored and reviewed with appropriate action taken.
Ensure that pacemaker devices removed from deceased patients are safely and promptly disposed of.

Mansfield Hospital

Ensure staff have opportunities to learn from incidents across the trust.
Ensure medicines are safely administered to patients in line with local policies and procedures and current legislation.
Ensure care plans are individual and specific to the patient to ensure staff are aware how to deliver care to patients which meets their needs.
Ensure the care of patients living with dementia is in line with current guidance and recognised good practice.
Ensure patients’ mental capacity to make decisions is assessed in line with current guidance and legislation.
Ensure the sepsis care pathway is followed so that patients with sepsis are identified and treatment is delivered.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated it as requires improvement because:

Systems and processes were not always reliable or appropriate to keep patients safe. Medicines administration practice did not always ensure patients had received their medicines correctly.

Care and treatment did not always reflect current evidence-based guidance, standards and best practice. Care plans did not reflect the patient’s individual needs and preferences. Patients did not always have sufficient support to ensure their nutritional needs were met. There was no effective pathway in use to identify and treat sepsis in patients.

Patients’ mental capacity to make decisions was not assessed in line with guidance and legislation. There was little evidence that patients and their relatives had been involved in the decision-making process.

The flow of patients through the hospital was affected by inappropriate admissions and delayed discharges. Patients transferred from Kings Mill Hospital were not always suitable for the rehabilitative care provided at Mansfield Community Hospital. There were delays in discharges where patients were waiting for community care services to be arranged.

The care for patients living with dementia did not meet current guidance and recognised good practice. There were no learning disability care pathways in place to inform staff how to support patients with a learning disability.

Recognised safer staffing nursing staff levels were not met for afternoon or night shifts. Recruitment was underway to address this. Staff were unclear about the vision or strategy for Mansfield Community Hospital. There was an increasingly diverse use of beds which meant the identity and role of the hospital was not clear.

Safety incidents were reported, and appropriate action taken. Staff had feedback and learning from local incidents, but not from incidents at Kings Mill Hospital.

The hospital appeared to be clean and there were systems in place to manage the prevention and spread of infection. There were effective multidisciplinary working relationships to support patients’ progress towards discharge. Staff had access to training to ensure they were competent to meet patients’ needs. Patients told us they were encouraged to be independent and were also well supported by staff when they needed care. Staff generally treated patients in a kind and respectful manner.

There were three wards providing medical care, including older people’s care, at Mansfield Community Hospital. They were part of the Sherwood Forest Hospitals NHS Foundation Trust’s division of emergency care and medicine.

There were 141 admissions to medical care services at Mansfield Community Hospital in 2014/15. Most admissions (91%) were transfers from Kings Mill Hospital for rehabilitation and treatment. The remainder of patients were planned admissions who were admitted from the community or from other hospitals. planned admissions for rehabilitative care and treatment.

During our inspection we visited all the wards providing medical services at Mansfield Community Hospital: Oakham Ward and Lindhurst Ward with 24 beds each and Chatsworth Rehabilitation Ward with 16 beds.

We spoke with 22 patients, 25 staff, eight visiting relatives/friends and one paid carer. We also looked at the care plans and associated records of 13 patients.