The Care Quality Commission
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The Royal Orthopaedic Hospital NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

15 Oct to 17 Oct, 12 Nov 2019

During a routine inspection

During our inspection, we inspected surgery and critical care. We did not inspect medical care, services for children and young people or outpatients at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

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

  • Both core services were rated as good across all domains, safe, effective, caring, responsive and well-led.

Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – ww.cqc.org.uk/provider/RRJ/reports.

23 January 2018

During a routine inspection

Our rating of services improved. We rated them as good because:

Outpatients improved one rating from requires improvement to good for safe and responsive but stayed the same for well-led as requires improvement. Responsiveness for surgery and medicine improved from requires improvement to good, meaning both services were good in all five domains.

Our decision on the overall ratings take into account the relative size of services and we use our professional judgement to reach a fair and balanced rating.

We have deviated from the standard aggregation rating rules for the safe domain overall. This is because during engagement we have seen improvements following inspection of the critical care core service. However, one of the drivers for the ratings related to the trust providing care to children in the HDU. The trust had given notice and at planning and delivery of this inspection, the transition was planned for 2018. However at time of publication the transition may take place late 2018 or sometime in 2019. The service is receiving close scrutiny from all stakeholders to agree the transition of service. Therefore, we have taken this into account when aggregating the ratings.

Overall we found:

  • Incidents were recognised and reported as per the trust policy. Investigations were undertaken where required and learning was shared within the area where the incident took place.
  • The duty of candour regulations were met, monitored and reviewed regularly to ensure all parts were undertaken.
  • Staff was well supported to recognise and report any safeguarding issues suspected. Staff had received training and felt confident, along with the support from the safeguarding team. We saw that reminder materials were on display around the location site.
  • Infection control practices were demonstrated and adhered to by staff. They were supported by an infection control team. The trust had been rated green (good) following a external review at the end of 2017.
  • There was generally enough nursing and medical staff to meet patient’s needs. Where there was a shortage, the trust used bank and agency nurses, and locums to boost medical staffing numbers.
  • The hospital participated in quality improvement initiatives and recorded their outcomes. This enabled them to benchmark both locally and nationally. The effectiveness of surgery was supported by data relating to patients recorded outcomes. Hip replacement performance was better than the England average. We also noted lower than England average readmission rates.
  • Within surgery, we saw seven day services offered including physiotherapy and occupational therapy. Medical staff were available on a rota six days a week and on call on Sundays and overnight. Pharmacy and radiology services were available six days a week and were available on call for the seventh day.
  • All the core services we inspected described that patients said staff treated them with kindness, respect, compassion and dignity.
  • Patients were supported emotionally by staff, counselling was available where needed. Chaperones were available in outpatients when patients requested it.
  • The trust scores for Friends and family test questions July 2017 was 98% for inpatients and 96% for outpatients.
  • Clinic waiting times had improved since our last inspection. Although this still required on-going improvement for specialities such as oncology.
  • The trust had employed a lead learning disability practitioner. They visited patients prior to their admission at their own home, to alleviate any anxieties. Staff made adjustments to support patients living with dementia also. A physiotherapist was undertaking a project to reduce falls and improve bathrooms with a particular focus on patients living with dementia.
  • Dementia care and staff awareness had improved since our last inspection.
  • Discharge planning started early on in the patient’s journey, such as at pre admission stage.
  • The complaints process supported patients to make the hospital aware of issues and the opportunity to improve. Patients were made aware of their right to complain, but staff were empowered to try and resolve issues locally.
  • The trust values were excellence, respect, compassion, pride, openness and innovation. During the inspection the inspection team felt that staff demonstrated these values.
  • The vision and strategy were in place, and included a nursing strategy, a learning disability strategy and a quality strategy for example. The strategies were further underpinned by seven work streams which supported the staff to deliver good quality care.
  • The trust was in a transitional phase where they were exploring with the Birmingham and Solihull Sustainability and Transformation Programs (STP) and other stakeholders, what the future service provision would be. A strategic outline case had been undertaken to help identify future opportunities.

  • The trust recently updated the governance structure, despite this, staff felt that information flowed from ward to board effectively. We saw that management functioned well with well-defined roles and channels for sharing information.

  • Since the last inspection governance improvements had taken place for example we saw the incorporation of a Children's board, round table reviews following serious incidents and training to improve root cause analysis investigations.

  • Our observation of the board meetings demonstrated good challenge by its members. A Board assurance framework report and corporate risk register were regularly reviewed, via the committee structure and board.
  • Staff spoke positively about both their local management and the senior management. Executive management was much more visible and staff felt they were more approachable. Although there had been changes in the executive over the last year staff told us they were unconcerned and felt the changes had been positive and enabled stronger support.
  • Staff were supported to be innovative to identify areas of improvements that would impact positively on patient's experience.
  • The trust had a strong research department, which screened every patient for eligibility to be part of a research project. We saw programs which were demonstrating positive results for both patients and the trust.

However:

  • Staff expressed frustration with various IT systems and processes. This impacted upon both staff and patients. We noted issues with software systems not interfacing with each other, and staff inputting data, without the ability to pull reports on effectiveness.

  • The trust had made improvements in IT structures and processes however, the trust acknowledged there were gaps in delivery and had faced data quality issues since the last inspection.

  • Opportunities were lost to ensure widespread learning from serious incidents and never events were shared across the hospital. Learning was shared locally where incidents occurred but we found within outpatients and medicine staff were not aware of the identified learning.

  • Policies and procedures which staff would refer to for best practice guidance required review and some required updating. However, we did see appropriate risk assessments to ensure those which required clinical or operational change were updated first.
  • Although staff were competent and had access to most of the training they needed, staff on the medical ward wanted more training with complex patients e.g. oncology training and mentorship.
  • The referral to treatment times for non-admitted and incomplete pathways and oncology had been inaccurately reported by the trust due to IT/ data quality issues and staff understanding of the principles. The trust made their stakeholders aware and stopped reporting until they were confident the figures were correct. At the time of our inspection the trust was accurately reporting again.
  • Finance was a risk in the medium term, which is one reason for identifying additional income streams. However, all cost improvement programs had associated strong quality impact assessments in place.
  • Public engagement required re- energising; for instance, we noted the trust charity needed further overview to improve its performance.
  • The trust needed to improve the administration relating to the fit and proper persons regulation to demonstrate compliance effectively. The activity was not in line with the trusts own policy.
  • Senior Medical and nursing staff wanted access to more leadership development programmes.

28-29 July and 05 August 2015

During an inspection looking at part of the service

Please note that the overall rating for the trust remains requires improvement; the follow up inspection ratings have been taken into account and this has resulted in no change to the overall hospital rating.

We undertook this inspection 28 and 29 July 2015 as a focused follow-up to an inspection we completed in June 2014. At that inspection the core services of Critical Care, which was a High Dependency Unit (HDU) at this trust and Outpatients Department (OPD) both had an Inadequate rating in one domain. This was within Safe for HDU and Responsive for OPD. Both services were rated as Requires Improvement overall. The trust received a follow-up inspection of those services to provide assurance that improvements had been made. Although diagnostics and imaging forms part of the OPD inspection the main issues had been in OPD, therefore the focus of this report was there. The inspection took place at this trust’s one site which has the same name as the trust.

At the end of 2014 there were some issues relating to staff and medications, which the trust shared with us at the time. This resulted in some changes in staffing in governance and a wholesale review and change of processes regarding controlled medication. For this reason a pharmacist inspector joined the inspection team. We wanted to review the governance and the controlled medication processes. We received some whistle-blower allegations prior and during the inspection which we also had an opportunity to review within the remit of this inspection.

A further visit was arranged to view documents relating to Duty of Candour (Regulation 20). During that visit on the 05 August we visited OPD, X-ray waiting area, and the previously private ward.

At this inspection the two core services were rated as Required Improvement. However, we did see improvements in both core services. We noted that the trust responded to our concerns raised at the previous inspection, but we found that other issues impacted on their ability to meet the regulations. This has been reflected in the ratings.

Within HDU all the ratings remained the same as the previous inspection. Although the issues identified were different this time they had a significant impact across a number of domains.

Within OPD the result for safe remained the same. The responsive domain had improved from inadequate to requires improvement.   This demonstrated that the trust had worked hard to improve the services for people and where the rating is requires improvement there is still some improvement work to be done.  We have recognised within the reports that the trust has identified work streams to address the on-going improvement work. As part of the improvement work within OPD the trust had upgraded the patient administration system, to ensure it was compatible with the planned management information system due winter 2015.

Our key findings were as follows:

  • Staffing of HDU with regards to children was not suitable. We found that children were being cared for within the unit but not always by a paediatric trained member of staff, nor were the facilities suitable for children.
  • Within both core services we found that infection control practices were well embedded, and staff followed trust policy and procedures.
  • We found that although the trust and its staff worked to the essence of the regulations of the Duty of Candour, in being open and transparent when things went wrong, they did not meet all of the requirements of that regulation.
  • Multi-disciplinary working was effective in improving patient experience within the hospital.
  • 100% of staff in both core services had received their appraisals, which was higher than the hospital’s overall rate.

We saw several areas of outstanding practice including:

  • The unit manager had ensured that staff were both aware and understood the values of the trust. A post box had been put on the unit to enable staff to identify what the values meant to them in their work on HDU. Staff views on the values displayed on a noticeboard and had also been discussed during staff meetings.
  • Within Outpatients we observed that some clinicians were dictating letters to GP’s and other services onto an electronic system for same day delivery, in the presence of the patient before the patient left the clinic.

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

  • Safeguarding training compliance rate needed to be improved in OPD, for both adults and children only reaching the trust target for awareness training.
  • Privacy and dignity was compromised with the unacceptable arrangements regarding the toilet and washing facilities available for patients in HDU. There was only one toilet available for patients (adults and children, staff and visitors).
  • The trust needed to ensure it could upload the information in the Intensive Care National Audit & Research Centre, so it could be benchmarked against other similar trusts.
  • Within OPD management reports needed to be available to monitor clinic wait times and cancellations. There needed to be an agreed process which all staff followed in the event of a clinic being cancelled.

We were very concerned about care of children in the HDU, therefore have followed our processes to ensure that the trust takes appropriate action to improve the situation we found at inspection. Our specific concerns relate to:

  • Medical and nursing cover must be improved on HDU when children are accommodated.
  • Children must be cared for in an appropriate environment when requiring HDU care.

Importantly, the trust must:

  • The trust must improve local leaders’ understanding of the processes involved in exercising the duty of candour, in particular what they should expect beyond ward level and at a practical level, including record keeping.
  • The trust must ensure sufficient staff are trained in safeguarding adults and children in OPD.
  • The trust must improve the flow through the OPD so patients are not kept waiting for appointments.
  • The trust must embed management arrangements within the OPD to ensure a firmer grip on the process of clinic booking and patient flow to improve waiting times for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

17 October 2014

During a routine inspection

The Royal Orthopaedic Hospital NHS Foundation Trust is a small, specialist teaching hospital offering planned orthopaedic surgery with 135 beds. The trust provides services to the city of Birmingham with a population of around 1,073,045 and nationally from Cornwall to Scotland. Patient care is delivered by specialist teams and other clinical professionals who look after patients with complex bone and joint disorders. The trust provides services such as joint replacement, spinal work and bone tumour treatment as well as orthopaedic and oncology treatment to children under 16.

The trust became a foundation trust in 2007 and the senior management team and there have been significant changes to the trust board in the last 12 months including a new chair and chief executive.

The Royal Orthopaedic Hospital NHS Foundation Trust was selected for inspection as one of the first specialist trusts to be inspected under the CQC’s revised inspection approach. It provides surgery, medical care, oncology, rehabilitation, critical care and children and young people’s services. We carried out an announced inspection of The Royal Orthopaedic Hospital on 4 and 5 June 2014 and an unannounced visit on 24 June 2014. The Royal Orthopaedic Hospital is the trust’s only location.

Overall, we rated the trust as ‘requires improvement’. We rated it ‘good’ for providing effective and caring services, but it required improvement for the services to be safe, responsive and well-led. We rated the core services of medical care, surgery and children and young people’s services as ‘good’ and critical care and outpatient services as ‘requires improvement’.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Staff followed good infection control practices. The hospital was clean and well maintained and infection control rates in the hospital were low.
  • Patients’ experiences of care were good and the NHS Friends and Family Test (FFT) results were higher than the national average for all areas. However, people attending for outpatient appointments rarely, if ever, saw the medical staff at their appointed time.
  • The number of pressure ulcers, falls and catheter related infections was significantly lower than the England average. The hospital monitored harm-free care in all patient areas, except recently in HDU, and had taken action that was reducing these avoidable harms.
  • Medicines were being safely stored and managed in the wards. However, in the outpatient department (OPD) there were concerns relating to the storage and stock control of controlled drugs, where legal requirements were not met.
  • Incidents were reported but not all staff received feedback; nor were lessons learned widely shared across the services.
  • The high dependency unit (HDU) did not have equipment available to support a deteriorating patient for up to 24 hours or until transfer to another provider’s Intensive Care Unit (ICU) was arranged. The trust addressed this immediately and equipment was on site and available within 24 hours of the issue being escalated.
  • Ward rounds in the HDU were not routinely undertaken by the on-call consultant anaesthetists at weekends. The trust took action within 24 hours of the information being escalated, although it was noted that senior managers had been aware of this for some time.
  • Several senior posts were being covered by interim managers. Recruitment had been ongoing and we saw that external candidates had been appointed to several of the posts and were scheduled to start work in the near future.

We saw several areas of outstanding practice including:

  • The Royal Orthopaedic Community Service provided services within a 24.5 mile radius of the hospital to support the early discharge of patients from hospital.
  • The trust had established patient pre-assessment clinics for surgery, which were available at the same time as their outpatient appointment.
  • Outreach clinics were held by the ortho- oncologists in Leeds, Sheffield, Manchester, Liverpool, Bristol and Cardiff to improve patient access and avoid patients and relatives or carers having to travel long distances.
  • The trust provided pioneering treatments to patients with very complex orthopaedic conditions. Surgeons were using silver coated implants to reduce infection. Other treatments achieving outstanding outcomes for patients included the ITAP (Intraosseous Transcutaneous Amputation Prosthesis) implant to attach prosthetic limbs and the use of motorised extendable implants for children and young people.
  • Surgeons were using computer navigation based on importing CT/MRI scans to develop a 3D model to remove tumours of the pelvis to ensure maximum removal and clear margins to reduce incidence of reoccurrence from 25% to 10%.

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

Importantly, the trust must ensure:

  • Medicines are managed at all times in line with legal requirements.
  • Equipment is properly checked and maintained in accordance with electrical safety requirements.
  • A chaperone policy is developed and chaperones made available to support patients’ privacy and dignity.
  • Confidential patient information and records are not left unsupervised in unrestricted public areas of the outpatients department.
  • Appointments are organised for all clinics to reduce waiting times for patients and improve their experience in the outpatients department.
  • Letters to GPs and other referring bodies are sent out within set timescales to ensure effective communication.

In addition the trust should ensure:

  • Resuscitation equipment is routinely checked in accordance with the trust’s procedures and records of the checks are kept in outpatients.
  • There is managerial oversight of all outpatient services to ensure the efficient and effective operation of the department and to ensure patients’ experiences of care are improved.
  • Discharge arrangements to facilitate early identification and availability of beds for patients admitted on the day of surgery are improved.
  • The implementation of Enhanced Recovery Programmes to reduce patient length of stay in hospital and promote greater patient involvement in their care.
  • When the reception desk is closed, there is clear, visible signage to direct patients and visitors from the main entrance to other departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.