The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is one of the UK’s five specialist orthopaedic centres. It provides specialist and routine orthopaedic care to its local catchment area, and specialist orthopaedic care regionally and nationally.
At the time of our inspection, the trust’s executive team was experiencing a period of significant change. The Chief Executive had resigned her post one week prior to the inspection and the Director of Finance was covering this role on an interim basis. The Interim Director of Operations had been in post for three weeks and the Director of Nursing was due to leave her post at the end of the month.
In March 2015, it was identified that the trust had been over-stating its position against the referral to treatment (RTT) target of 18-weeks. An external review was commissioned to look at the processes, controls and governance arrangements around some of the criteria for inclusion and exclusion that had been used by the trust. The report determined that the exclusions applied by the trust were not in line with practice at other organisations and there were gaps in roles and reporting arrangements. This was the second time that the trust had been investigated for issue relating to RTT. A second report was commissioned which focused on the operational context, leadership and cultural issues around the RTT misreporting. This report had not been published at the time of our inspection.
We inspected this hospital in October 2015 as part of the comprehensive inspection programme. We inspected all of the core services provided by the hospital. We visited the hospital on 6, 7 and 8 October as part of our announced inspection. We also visited unannounced to the hospital on Thursday 15th October 2015.
Overall we have rated this hospital as requires improvement. We saw that services were caring and compassionate and staff were prepared to go that extra mile for patients. We saw a number of areas that required improvement for them to be assessed as safe, effective and responsive. We saw that leadership of services in some areas also required improvement.
Our key findings were as follows:
- Staff were proud of the hospital and its national and international reputation. There was good team working within and across disciplines, staff groups recognised and understood the importance of each other’s roles. Staff told us they felt supported by their managers.
- There was a culture of reporting incidents and good local learning, however, not all non-clinical and zero harm incidents were being routinely reported and there was limited learning across the organisation.
- The hospital performed well against the safety thermometer targets and had not reported a case of Clostridium Difficile since June 2014.
- Staffing levels on the wards reflected national guidelines and there was very limited reliance on agency workers.
- There was good use of guidelines and patients were very positive about their outcomes.
- We were concerned that not all staff were following recognised national best practice in infection control, particularly bare below the elbows and the use of hand gels, although we did observe staff washing their hands
- There were qualified Paediatricians on duty during the day, but medical out of hours cover for paediatric services was not provided by staff with paediatric training, not all staff had life support training to the appropriate level to respond to paediatric patients.
- There was no oversight of the planning of outpatient clinics, this meant that at times, support services such as x-ray were stretched and patients were subject to excessive waiting times for tests and clinic appointments.
We saw several areas of outstanding practice
- Award winning leadership of MCSI by the ward manager which had positively impacted on the team and anecdotally reduced reports of stress related sickness.
- Exceptional compassionate care by staff on the MCSI who showed high levels of support for individual patients.
- Outcomes for patients attending the hospital with complex orthopaedic problems were consistently good. A higher proportion of patients undergoing hip and knee replacements reported an improvement in their condition following their surgery compared to the average of the other specialist orthopaedic trusts.
- The proactive approach taken to support patients living with dementia, particularly on the HDU
- Innovative ways of engaging with children and young people about services in collecting views about services and using young volunteers to assist in interviewing for new staff.
- The Orthotic Research & Locomotor Assessment Unit provided innovative interventions to improve patient mobility, including occupational and physio therapies, as well as mechanical aids which were designed and manufactured on site.
However, there were also areas of poor practice where the trust needs to make improvements:
Importantly the trust must:
- The hospital must ensure that all incidents, including non-clinical incidents are reported by all staff. Learning points from complaints and incidents should be shared across directorates and all action plans monitored to improve the quality of care and develop services.
- The hospital must improve hand hygiene standards and ensure that all staff in all areas are adhering to trust policy. The trust must also audit hand hygiene practices, using methods that are robust and improve signage of isolation procedures, hand washing instructions, and use of hand sanitisers in all clinical areas and corridors.
- The hospital must ensure that there are robust and suitable arrangements to provided paediatric medical cover during the evenings, overnight and at the weekend to ensure that they can respond in an appropriate, safe and timely way to deteriorating and seriously ill children.
- The hospital must ensure that staff caring for children are able to identify, report and treat deteriorating and seriously ill children. This includes being familiar with the SBAR technique and its use in alerting the medical team to emergencies.
- The hospital must ensure that patient’s medical notes in HDU include a record of all doctor visits and any revision to the patient’s treatment plan.
- The hospital must ensure that there is at least one team member with up to date paediatric resuscitation training on duty at all times on Alice ward and all staff that may be required to respond to a paediatric medical emergency also have up to date paediatric resuscitation training.
- The hospital must ensure that resuscitation equipment is fit for purpose and urgently seek to provide battery-powered suction machines for Alice ward.
- The hospital should ensure that paediatric care pathways are routinely audited in order to monitor compliance with nationally recognised best practice.
- The hospital should ensure that outpatient clinics are planned in such a way to prevent excessive demand on support services or other clinic areas which in turn impacts adversely on patient waiting times.
Professor Sir Mike Richards
Chief Inspector of Hospitals