City Hospitals Sunderland NHS Foundation Trust provides services at two acute hospitals, Sunderland Royal Hospital and Sunderland Eye Infirmary. The trust also provides services at one general practice, Church View General Practice. The trust provides acute hospital services to a population of around 350,000 people across the Tyne, Wear and Durham area. In total the trust has 855 beds across two hospital sites and employs around 4,923 staff.
Sunderland Royal Hospital, which has 833 beds, provides accident and emergency services, medical, surgical, critical care, maternity, children’s and young people’s services. Sunderland Eye Infirmary, which has 22 beds, provides ophthalmology care and treatment in ophthalmic surgery and specialist accident and emergency care. Both hospital sites provide outpatients’ services.
Church View General Practice was inspected at the same time as the acute services by the Care Quality Commission’s Primary Medical Services Directorate team. The findings of this inspection are reported separately to the inspection of the acute services.
We inspected City Hospitals Sunderland NHS Foundation Trust as part of our comprehensive inspection programme. We inspected Sunderland Royal Hospital and Sunderland Eye Infirmary on 16, 17, 18 and 19 September 2014. We also undertook an unannounced inspection on 2 October 2014.
We carried out this in-depth inspection because the trust was placed in risk band 2 in the Care Quality Commission’s (CQC) intelligent monitoring system.
We inspected the following core services:
- Sunderland Royal Hospital – accident and emergency, medical, surgical, critical care, maternity, children’s and young people’s services, end of life and outpatients’ services.
- Sunderland Eye Infirmary – accident and emergency, surgical and outpatients’ services.
Overall, the trust was rated as good. Safety and responsive were rated as requires improvement but all other domains - effectiveness, caring and well led were rated as good.
The trust had an established and stable senior leadership team who staff reported were visible and approachable. There was a clear vision and strategy for the future provision of services, which involved consultation with staff within the trust and fostered innovative practice development.
There were reporting mechanisms from the ward to the Trust Board and clear governance systems within the trust, which included effective communication mechanisms from the Trust Board to the various wards and departments, as well across divisions, services and hospitals. Risk was generally well managed, although the trust faced challenges over the recruitment of medical and nursing staff particularly in the medical wards, which will be compounded by the budget deficit going into next year. Further development was required over the investigating, grading and feeding back from incident reporting.
Staff and public engagement was good, and mechanisms were in place to involve the local service users in decisions about the development of services and feedback on experiences of services received. Staff felt engaged and involved in the development of their services, although some medical staff did not feel fully consulted. Staff expressed pride in the services they provided with the patient’s care as central to their values.
Our key findings were as follows:
- The trust had an overall elevated risk for the Hospital Standardised Mortality Ratio, which was higher than expected for weekend mortality as well as for weekday mortality. It was working with other trusts in the region and with NHS England to improve its mortality rates.
- There were arrangements in place to manage and monitor the prevention and control of infection. There was a dedicated team to support staff and ensure policies and procedures were implemented. We found all areas visited visibly clean. Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C.difficile) rates were within an acceptable range for the size of trust.
- There were staff shortages at Sunderland Royal Hospital, particularly on the medical wards, mainly due to vacancies for nursing and medical staff. The trust was actively recruiting, the staffing establishment had been reviewed and kept under regular review. In the meantime, bank and locum staff were being used to fill any deficit in numbers.
- There were no concerns about staffing levels or skill mix at Sunderland Eye Infirmary. The staffing establishments and skill mix were maintained and kept under regular review.
- There were arrangements in place for reporting incidents, but improvements were required to improve the investigation processes, including the timeliness and training around root cause analysis and grading of incidents.
- Patients were able to access suitable nutrition and hydration including special diets. Patients reported that on the whole they were content with the quality and quantity of food.
- Patients were provided with care in a compassionate manner and treated with dignity and respect.
- Access and flow within the children’s service was effective, which was achieved in part through close collaborative working between the directorate of paediatrics and emergency medicine. A shared medical consultant staffing approach, which included consultant staff qualified in paediatric emergency medicine, had been developed. The service had a range of facilities and approaches to ensure that the needs of local families were met.
- The children’s and young people’s service had a clear vision and strategy and the well led domain was rated as outstanding with a strong management team who worked together. The service regularly implemented innovative improvements. The service had facilitated the inspection of services by a team of young inspectors, which was excellent practice.
- Staff in the critical care unit demonstrated compassion and empathy to patients and their families. Patients were invited to meetings in the unit to give their stories and provide feedback about their experiences with the aim of improving patient experience on the unit. There was a range of support services provided for patients after they left critical care to ensure they received the right psychological and emotional support to aid recovery.
- Processes were in place for the implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs.
- There was effective communication and collaboration between multidisciplinary teams.
- On the whole, the importance of patients’ and public views were recognised and mechanisms were in place to hear and act on patients’ feedback. The trust was working on improving the complaint procedures, particularly around investigations and timing of responses.
We saw several areas of outstanding practice including:
Sunderland Royal Hospital
- There was close collaborative working between the directorate of paediatrics and emergency medicine, which had developed a shared medical consultant staffing approach, including consultant staff qualified in paediatric emergency medicine.
- The directorate of paediatrics had facilitated the inspection of the service by a team of young service user inspectors.
- The use of the tele-health system in maternity services enabled women to monitor blood glucose levels and blood pressure in their own homes avoiding unnecessary visits to hospital.
- The compassion expressed to families if their family member died whilst on the critical care unit. For example, - nurses placed a locket of hair and the rings of the patient in a small silver bag and handed a printed card to the family with sympathy from the staff at the critical care unit.
Sunderland Eye Infirmary
- The enhanced recovery pathway for cataract surgery and the role of the primary nurse were viewed as an excellent development of the service and resulted in individual surgeon’s cataract audits showing consistently high visual acuity outcomes against bench mark standards (UK Cataract National Dataset Audit).
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must for Sunderland Royal Hospital:
- Ensure that there are sufficient qualified, skilled and experienced nursing and medical staff, particularly on medical wards and children’s services. This is to include provision of staff out of hours, bank holidays and at weekends.
- Ensure that staff are suitably skilled and supported through the completion of mandatory training and appraisals particularly in the accident and emergency department (A&E) at Sunderland Royal Hospital.
- Ensure that medicines are managed appropriately. Medicines were not always started promptly when a patient was admitted over the weekend and incidents involved Controlled Drugs (CDs) were not always appropriately investigated and reported within the service.
- Ensure that there is appropriate pharmacist support to ward and units, including with the reconciliation of medication.
- At Sunderland Royal Hospital - ensure that patients are placed on the most appropriate ward to meet their clinical needs.
- In the accident and emergency department at Sunderland Royal Hospital ensure that the hospital fully complies with the four hour wait standard and the 15 minute hand over time for patients arriving by ambulance.
- Continue to review and reduce the mortality outliers for the Summary Hospital-level Mortality Indicator (SHMI) within the trust.
- Ensure that the ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) orders are signed by the appropriate medical professional and that discussions with patients or family members are recorded.
- Ensure that patient observation and monitoring charts for nutrition and hydration are fully and appropriately completed particularly on medical wards.
For both hospitals, the trust must:
- Ensure that Patient Group Directives (PGDs), which are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment, are updated and monitored in line with trust policy.
- Ensure that incidents are investigated, graded and reported appropriately to ensure that lessons can be learnt to improve the safety and quality of services.
In addition, for Sunderland Royal Hospital the trust should:
- Train staff to use the syringe drivers used in the community when transferring end of life patients into the community. Thereby, ensuring that patients are not taken off one piece of equipment prior to discharge and then connected to the other equipment used in the community.
- Provide training on the grading of incidents and ensure that there are effective incident feedback mechanisms in place so that lessons can be learnt.
- Review the arrangements over the storage and supply of surgical instruments to ensure that there is appropriate provision of equipment.
- Review the storage and provision of linen in ward areas so that staff are assured that it is clean before use.
- Ensure that there is assurance systems in place regarding the training, supervision, appraisal and revalidation of the specialist palliative care team who are employed by a different trust.
- Review the specialist palliative care team in accordance with the Commissioning Guidance for Specialist Palliative Care.
For the Sunderland Eye Infirmary, the trust should:
- Review the storage of medical records.
- Review the participation in audits, including clinical audits in the A&E department.
- Review the arrangements for the role of the Eye Infirmary when dealing with major incident/events across the trust.
- Review the practice of recording patient concerns in the electronic nursing evaluation, in line with best practice guidance.
For both hospitals, the trust should:
- Seek ways to further increase the engagement of clinicians in complaint and investigation processes.
- Put in place mechanisms for reviewing and if necessary updating patient information, particularly in the outpatient departments.
- Introduce patient surveys specific to the outpatient department.
Professor Sir Mike Richards
Chief Inspector of Hospitals