The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report

Twympath Lane Gobowen Oswestry Shropshire SY10 7AG Tel: 01691 404000 Date of inspection visit: 6 – 8 October 2015 Website: www.rjah.nhs.uk Date of publication: 03/03/2016

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Medical care Requires improvement –––

Surgery Good –––

Critical care Requires improvement –––

Services for children and young people Requires improvement –––

Outpatients and diagnostic imaging Requires improvement –––

1 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 Summary of findings

Letter from the Chief Inspector of Hospitals

The Robert Jones & Agnes Hunt Orthopaedic Hospital is part of The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust. The hospital is one of the UK’s five specialist orthopaedic centres. It provides specialist and routine orthopaedic care to its local catchment area, and specialist services both regionally and nationally. 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 patient focussed. 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 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 • 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 reduced reports of stress related sickness. • Exceptional compassionate care by staff on the MCSI who showed high levels of support for individual patients. • 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. However, there were also areas of poor practice where the trust needs to make improvements: Importantly the trust must:

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• 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 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 SBAR 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

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Summary of findings

Our judgements about each of the main services

Service Rating Why have we given this rating? Medical Requires improvement ––– Whilst we found many examples of safe practice, care there were inconsistencies across the service. For example, varied and incomplete reporting and monitoring of near misses and patient safety incidents that could cause patient harm. The extent to which learning from untoward incidents was shared also varied. There were no mortality and morbidity meetings taking place within the medical care services. The trust infection prevention and control processes were not always adhered to, for example non-compliance with hand hygiene and the isolation policy, which could lead to cross contamination. Systems for safe supply and administration of medicines were not always followed. There was a lack of private consultation areas in the gym, and for the clinical psychology consultations. Maintenance issues in the therapies environment had not been addressed in a timely manner. Whilst we saw some good examples of local leadership there were areas where further focus on clinical governance and quality assurance was required. Risks, issues and performance were not always fully recognised, assessed or managed. In particular environmental risks, delays in acquiring additional equipment, and cancelled clinics. Staffing levels and the skill mix of staff met patients’ needs. Staff were caring and compassionate and treated patients with dignity and respect. The services provided by the MCSI were consistently person centred.

Surgery Good ––– Robust risk assessments were completed and reviewed to ensure patients remained safe whilst cared for in the ward environment. Patients we spoke with told us they had been well cared for, were shown respect, treated with dignity and their privacy was protected. They were full of praise for all the staff.

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Summary of findings

The World Health Organization (WHO) surgical safety checklist was embedded by theatre staff. Safety checks of equipment had been completed in ward areas and theatres; records were up to date and signed. 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. Patients with complex conditions were well supported by the staff; their relatives told us they had been fully updated with the care progress. We observed hand hygiene compliance to be poor; the use of hand gel was not widely used and the washing of hands, by nursing and medical staff, in between patients was not always observed. Bare below the elbow was also not conformed to by all staff, at all times. We saw that systems were in place to promote patient safety, and although incident reporting was promoted, learning from incidents was not shared between departments.

Critical care Requires improvement ––– Although there were appropriate medical and nursing staff available to care for adult patients, when a young person was in HDU a paediatric anaesthetic consultant would not necessarily be available to provide appropriate support at all times. Improvement was needed to ensure doctors and outreach staff could make a timely response to identified concerns. Staff had mostly received required mandatory training but needed children’s life support training to ensure they had appropriate skills and competency to respond to a paediatric emergency. Doctor records were not complete and did not always record any review undertaken or revised treatment plan during the evening or out of hours. This may compromise the continuity of patient care. Multidisciplinary working was in place although handovers and ward rounds were not multidisciplinary. There were appropriate systems in place to highlight risks, incidents and near misses. Appropriate actions were taken to ensure lessons were learned. The HDU

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Summary of findings

was clean and there were appropriate systems in place to minimise the risk of cross-infection. The availability and use of equipment was found to be appropriate to meet patient's needs. There were appropriate arrangements for the safe administration and storage of medicines. Patients were treated with compassion and respect. Whenever possible patients and relatives were consulted and informed about the treatment they or their relative would receive. Staff felt valued, respected and supported and staff had appropriate training and development opportunities.

Services for Requires improvement ––– The doctors on duty at the time of our inspection children outside of normal working hours did not have any and young specific paediatric medical training despite people providing cover for children’s services. There was a potential risk that if a child was to deteriorate the doctor may not have the knowledge to recognise this and take appropriate action. Children and young people on Alice ward and within children’s outpatients had the required number of paediatric nurses to care for them. However there were some adult outpatient clinics that young people attended without the support of either a paediatrician or a children’s nurse available. Children’s services used an early warning score to identify deteriorating patients. Data from the system was not automatically displayed on the ward’s large electronic data screen and relied on staff manually searching for any alerts about individual patients. This could cause a delay in the identification of a deteriorating patient. Nurses had not been trained to handover deteriorating patients to doctors using the recommended tool. Not using this structured method may lead to delays in seeking rapid assistance for a sick child. The vision, strategy and values of children’s services were not well developed. Senior management arrangements did not ensure that there was sufficient oversight of children’s services and risks were not always considered and addressed appropriately or in a timely manner.

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Summary of findings

There was an open culture of incident reporting and appropriate systems were in place to investigate and review incidents. We saw that any learning from incidents was shared amongst children’s services. The environment in most parts of children’s and young people’s services was good, with appropriate systems in place to minimise the risk of infection. There were appropriate arrangements for the safe administration and storage of medicines. Children and young people were treated with compassion and respect. Children and their parents were consulted and informed about the treatment they or their child would receive.

Outpatients Requires improvement ––– We were concerned with the lack of oversight of and clinic services in the main outpatients department. diagnostic Clinics were planned which, due to the complex imaging needs of patients, caused undue demand on support services and in turn caused excessive and avoidable waiting for patients. We also found issues with support for staff in imaging and other services. Not all staff followed good practice guidance in relation to hand hygiene and being bare below the elbow when dealing with patients. We found that services were safe, systems were in place which ensured that patients were protected from the risk of infection, medication errors and the risks associated dangerous or poorly maintained equipment. Staff were skilled and experienced in the role. New staff were supported to ensure they developed the required skills. Services were effective, practice was audited and learning shared to improve patient outcomes. Recognised pathways of care, and national guidance were understood and followed. Staff were caring and supported patients to make decisions based on sound clinical options. Staff had a genuine interest in the health and wellbeing of patients. Services were responsive to patient’s individual needs. Systems were in place to support patients with complex needs.

7 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 The Robert Jones & Agnes Hunt Orthopaedic Hospital Detailed findings

Services we looked at Medical care (including older people’s care); Surgery; Critical care; Services for children and young people; Outpatients & Diagnostic Imaging

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Contents

Detailed findings from this inspection Page Background to The Robert Jones & Agnes Hunt Orthopaedic Hospital 9 Our inspection team 9 How we carried out this inspection 10 Facts and data about The Robert Jones & Agnes Hunt Orthopaedic Hospital 10 Our ratings for this hospital 10

Background to The Robert Jones & Agnes Hunt Orthopaedic Hospital

Since the early 1900’s, the hospital has provided The hospital is a specialist centre for the treatment of orthopaedic services and is very proud of its history. The spinal injuries and disorders and also provides specialist hospital is one of the UK’s five specialist orthopaedic treatment for children with musculoskeletal disorders. centres. It provides specialist and routine orthopaedic There are eight inpatient wards including a private care to its local catchment area, and specialist services patient ward; ten operating theatres, including a day case both regionally and nationally. As it is located close to the surgery unit; and full outpatient and diagnostic facilities. Welsh border, it provides local services to people in in They work with partner organisations to provide England and Wales. Health indicators for Shropshire are specialist treatment for bone tumours and community similar or better than the national averages. based rheumatology services. The hospital also hosts some local services such as maternity services. The hospital employs over 1,000 staff and has 219 inpatient beds. There were 15,512 inpatient admissions between April 2014 and March 2015 and 152,471 outpatient attendances in the same period.

Our inspection team

Our inspection team was led by: consultant orthopaedic surgeon, paediatric orthopaedic nurse, consultant paediatrician, rehabilitation nurse, Chair: Michael Marrinan, Executive Medical Director at orthopaedic surgery nurse, consultant anaesthetist, King's College Hospital radiographer, consultant radiologist, outpatients nurse, Head of Hospital Inspections: Tim Cooper, Care Quality director of nursing, medical doctor, physiotherapists. The Commission team also included other experts called Experts by Experience as members of the inspection team. These The team included CQC inspectors and a variety of were people who had experience as patients or users of specialists, including: some of the types of services provided by the trust.

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How we carried out this inspection

We inspected this service as part of the comprehensive During our visits to the trust we held seven planned focus inspection programme and visited the hospital on 7 and 8 groups to allow staff to share their views with the October 2015 as part of our announced inspection. We inspection team. These included all of the professional also visited unannounced to the trust on Thursday 15 clinical and non-clinical staff. Through these groups we October 2015. spoke to well over 150 members of staff. We held two public listening events prior to this We met with the trust executive team both collectively inspection in Shrewsbury and Oswestry. Approximately and on an individual basis, we also met with ward 20 people attended across both sessions to share their managers, service leaders and clinical staff of all grades. views and experiences of the hospital. We also spoke to patients and their relatives and carers we met during our inspection. We visited many clinical areas and observed direct patient care and treatment.

Facts and data about The Robert Jones & Agnes Hunt Orthopaedic Hospital

As at April 2015, the hospital employed 1,131 whole time At the time of the inspection, there had been a total of 7 equivalent staff. Of these, 110 are medical staff and 268 serious incidents reported between May 2014 and April are nursing staff. There are 5 high dependency care beds, 2015, two were unexpected death of inpatient (not in 16 paediatric beds, 67 medical beds and 104 surgical receipt), others included slips, trips and falls and surgical beds. There are a further 15 day surgery beds. There were errors. 15,512 inpatients admissions between April 2014 and There were a total of 1,398 incidents reported via the March 2015 and 152,471 outpatient attendances. As a NRLS (national reporting and learning service), 89% of specialist orthopaedic centre the trust provides services these were classified as “no harm” or low harm incidents. locally, regionally and nationally. The trust reports a similar number of incidents per 100 The trust had revenue of £93 million with a budget admissions when compared to other specialist surplus in 2014/2015 of £1 million. orthopaedic trusts. During 2014/2015 there was one Never Event reported by There has been no MRSA Bacteraemia cases reported by the trust relating to wrong site surgery. the trust since August 2006 and no Clostridium Difficile cases reported since June 2014

Our ratings for this hospital

Our ratings for this hospital are:

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Safe Effective Caring Responsive Well-led Overall

Requires Requires Requires Requires Medical care Good Good improvement improvement improvement improvement Requires Surgery Good Good Good Good Good improvement Requires Requires Requires Requires Critical care Good Good improvement improvement improvement improvement Services for children Requires Requires Requires Requires Good Good and young people improvement improvement improvement improvement Outpatients and Requires Requires Requires Requires Not rated Good diagnostic imaging improvement improvement improvement improvement

Requires Requires Requires Requires Requires Overall Good improvement improvement improvement improvement improvement

Notes 1. We are currently not confident that we are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging.

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Medical care (including older people’s care)

Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

Between January 2014 and December 2014 there were Information about the service 1,900 admissions to the medical care service, of which 62% were day case, 36% elective and 2% emergency. The hospital provided medical services to adults who Most admissions (46%) were for pain management. need treatment of spinal injuries and disorders by interventions other than surgery, people with During our inspection, we spoke with 44 staff members rheumatology disorders, and for those requiring therapy including managers, doctors, nurses and therapists. We and pain management. also spoke with 26 patients, observed care and treatment, and looked at records including patient Medical services includes the Midland Centre for Spinal records. We reviewed performance data submitted by the Injuries (MCSI). This is one of 11 units in the UK trust, including audit results, action plans, policies and designated to receive and treat spinal cord injured management information reports. patients. The MCSI serves a catchment of 10 million from North Wales, Mid Wales, South Mersey, Cheshire and The West Midlands. The MCSI provides a lifelong service to a current population of 3,500 patients and admits on average 380 patients per year, of whom approximately 100 are in the acute phase of injury. There were 67 beds in the medical care service division. This included 44 beds in the MCSI; 15 beds for acute/ rehabilitation on Wrekin Ward and 29 beds for rehabilitation and readmission on Gladstone Ward. Medical services provided a further 23 beds on Sheldon Ward for rehabilitation, up to 4 of which are allocated for rheumatology services. Therapy services are provided in the in-patient wards and the gym, hydrotherapy pool and occupational therapy workshop. A nurse led day care service provides intravenous medication for patients at a treatment lounge on Sheldon Ward and as an outreach service at The Royal Shrewsbury Hospital and Princess Royal Hospital in Telford.

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Medical care (including older people’s care)

Summary of findings Are medical care services safe? Whilst we found many examples of safe practice, there Requires improvement ––– were inconsistencies across the service. For example, varied and incomplete reporting and monitoring of near There were appropriate systems in place to highlight misses and patient safety incidents that could cause risks, incidents and near misses. However these were not patient harm. The extent to which learning from always adhered to. Staff and managers we spoke with untoward incidents was shared also varied. There were told us they did not routinely report non-clinical no mortality and morbidity meetings taking place within incidents. Staff were able to give us examples of actual the medical care services. The trust infection prevention incidents that were not reported. There were no mortality and control processes were not always adhered to, for and morbidity meetings taking place within the medical example non-compliance with hand hygiene and the care services. isolation policy, which could lead to cross contamination. Systems for safe supply and People were not always kept safe from the risk of administration of medicines were not always followed. infection as not all staff complied with the trust infection prevention and control policy. For example, we observed There was a lack of private consultation areas in the there were occasions where uniforms and work wear gym, and for the clinical psychology consultations. impeded effective hand hygiene and hand sanitisers were Maintenance issues in the therapies environment had not routinely used not been addressed in a timely manner. Systems for the safe supply and administration of Whilst we saw some good examples of local leadership medicines were in place but were not fully implemented. there were areas where further focus on clinical For example, there were gaps in arrangements to ensure governance and quality assurance was required. Risks, medicines were stored at the correct temperature. issues and performance were not always fully Written instructions for the supply and administration of recognised, assessed or managed. In particular medicines to groups of patients who may not be environmental risks, delays in acquiring additional individually identified were not regularly reviewed. equipment, and cancelled clinics. The availability and use of equipment was generally Staffing levels and the skill mix of staff met patients’ found to be appropriate to meet patients’ needs. needs. Staff were caring and compassionate and treated However we saw that replacement mattresses designed patients with dignity and respect. The services provided to help prevent pressure ulcers were not acquired in a by the MCSI were consistently person centred. timely manner. There was sufficient staffing to ensure patients were cared for safely. Patients who were at risk of deterioration were monitored and there were systems were in place to ensure that appropriate medical care or specialist nurses responded. Incidents • The medical care services had a good track record for safety and demonstrated a range of systems, processes and standards to keep people safe and safeguard them from abuse.

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Medical care (including older people’s care)

• There were no reported never events in the medical care provided us with three sets of minutes from these services between June 2014 and July 2015. Never events quarterly meetings. The minutes from March 2015 are serious incidents that have the potential to cause demonstrated that medical doctors were in attendance serious patient harm or death and are wholly but not at the last meeting in June 2015. Staff we spoke preventable. with told us that the last mortality and morbidity • There was one serious incident reported on Sheldon meeting specifically for medical care services was held Ward in March 2015: an infection outbreak (Norovirus). in December 2014. This was confirmed when we There was evidence that immediate corrective action requested morbidity and mortality review meeting had been taken in accordance with local policies, minutes for the service and were informed the trust do including temporary closure of the ward. not hold separate meetings for Medicine. This meant • Trust policy stated that near misses and patient safety that reviews and findings from deaths that had incidents should be reported, using an electronic happened in the service were not formally discussed by incident reporting system. All staff we spoke with were junior and senior medical staff. able to access the system, and demonstrated its use to • Between October 2014 and September 2015 the us. mortality rate for the service was below the national • Staff and managers we spoke with told us they did not average. There were no unexpected deaths and 10 routinely report non-clinical incidents. Staff gave expected deaths in that period. examples of actual incidents that were not reported • We spoke with a range of staff about their including problems with booking appointments, a copy understanding of the new regulations concerning duty of a patient letter found in the wrong patient file, bed of candour. Most staff we spoke to had attended ‘being capacity, and staff shortages. This meant that data on open’ training provided by the trust. Staff understood incidents did not fully reflect what was happening and the concept, and some provided examples of where the appropriate actions were not always taken to ensure duty of candour had been applied. For example where a that lessons were learnt to prevent similar incidents patient had developed a pressure ulcer, there was happening again. discussion and written correspondence with the patient • Where incidents were reported, analysis of the root and people acting in their best interest in accordance causes was undertaken and an action plan produced with trust policy. from the evidence. Staff and managers we spoke with Safety thermometer told us there were not always robust arrangements in place to formally monitor the implementation of action • The medical care services participated in the Patient points from incidents, although there was evidence to Safety Thermometer programme which is a tool used to suggest it took place informally. This meant that measure, monitor and analyse patient harm and harm managers could not always be assured that actions free care. Data was gathered and reported on a monthly were carried out. basis to indicate key performance in safety areas such as • Learning points from incidents were shared in some infections, pressure ulcers, venous thromboembolism cases. However we saw that this was variable and that (VTE) screening, and falls. Safety thermometer learning was not generally communicated across the information was incorporated into the medical care service. For example, we saw where an error in ordering services quality performance dashboard which was oxygen had occurred on Sheldon ward. This had clearly displayed in all ward areas we visited. This was resulted in some learning at ward level but was not known locally as the ‘STAR system’. more widely shared to prevent it from happening again • Pressure ulcers, falls and catheter related infections across medical services or the rest of the hospital. Since rates were all better than the national average. Between our inspection, the trust have told us (and we have seen April 2014 and June 2015, there had been a total of six a copy of) an action plan to ensure learning is reported grade 2 (or above) pressure ulcers. In June embedded across the organisation. 2015, there had been six falls, one of which resulted in • A trust process was in place to review mortality and morbidity information that included meetings to undertake reviews and discuss findings. The trust

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harm to the patient. There were no reported cases of signs on the door to inform staff, visitors and other Methicillin-resistant Staphylococcus Aureus (MRSA), and people of the need for isolation precautions. This meant three cases of Clostridium Difficile (C Diff) reported that there was a risk that procedures to prevent cross between November 2013 and June 2015. contamination may not be followed. • Hand sanitising gel was available at entrances to Cleanliness, infection control and hygiene medical services treatment areas. However we did not • Records showed that patients were screened for always see accompanying signs to draw attention to infections such as MRSA prior to admission. Patients their purpose or provide instructions for staff and who screened positive for MRSA had their elective visitors. We observed that staff and visitors were not surgery postponed until they were free of infection. routinely using the sanitising gel. • Staff completed infection prevention and control • The areas we visited were clean and well maintained. training as part of their induction programme and There were cleaning plans in place and we saw that continued learning and development. Staff had met the these were being followed. However, in the target of 87% compliance with the mandatory infection occupational therapy workshop we saw no evidence of prevention and control updates. cleaning instructions or that cleaning had taken place. • The trust infection control policy required that uniforms Environment and equipment and work wear should not impede effective hand • We observed some environmental risks and hygiene, and should not unintentionally come into maintenance issues in the occupational therapy contact with patients during direct patient care activity. workshop. This included open cupboards containing We saw a number of staff not adhering to this policy. chemicals/cleaning fluids and tools no longer in use They included three doctors on a ward round and two stored on the floor in potentially dangerous situations. ward managers. Since our inspection, the trust have We asked for evidence that these risks had been shared with us a comprehensive action plan to improve reported and were being addressed, but none was compliance with the policy. available. We brought this to the attention of the trust • There were adequate hand washing facilities in clinical executive management team who told us that corrective areas. Staff told us there were regular audits of hand action would be taken. When we conducted our hygiene procedures which showed frequent rates of unannounced inspection on 15 October we saw this had 100% compliance. However, during our announced commenced. inspection we saw staff were not always carrying out • Due to the lack of sufficient storage space on Sheldon effective hand hygiene, for example a nurse and a Ward several items of moving and handling equipment doctor not washing their hands. were stored in inappropriate places, which is a potential • There were supplies of personal protective equipment safety risk. For example, one male bathroom was available in clinical areas and we saw the majority of permanently out of use as it was being used as a store staff used it appropriately; however we saw a nurse and room. a doctor did not change or dispose of protective gloves • There was also a lack of sufficient storage space in the and aprons according to the policy. We brought this to therapies environment, which restricted access in case the attention of the ward manager and matron. of an emergency. We brought this to the attention of the • Clinical and personal care equipment that was shared service manager who told us corrective action was between patients was identified with ‘I am clean’ labels underway. to show when it was last cleaned. • All the moving and handling of patients we observed • Where a patient required isolation in a single room was conducted safely with appropriate equipment. because of a known or suspected infection, we saw that • Equipment was serviced and tested in accordance with this was in place. The patient’s record showed that they the trust policies and procedures. Where equipment had been reviewed by the infection control team who was faulty it was labelled ‘Out of Order’ and returned to had provided specialist advice. However there were no the equipment store or supplier for repair or replacement.

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• Resuscitation equipment was accessible and found to Records we looked at showed that patients’ medicines be in good working order. Equipment was generally were prescribed, supplied and administered as checked daily and checks were documented, meaning it instructed, and that patient information was clearly was ready for use. However during our unannounced documented. inspection we found that four out of six daily checks for • Arrangements were in place to record medication errors resuscitation equipment on Sheldon Ward had not been and omitted doses of medicines. On Sheldon Ward, out completed since our announced inspection. We of seven records we looked at where patients had reported our findings to the trust who took action to omitted doses, only one patient record showed the address the shortfall. reasons for omission; for the remaining six patients no • Nursing staff had identified a need for additional reasons were recorded. pressure relieving mattresses in March 2014. At the time • There were no audits of the use of antibiotics for the last of our inspection this mattress was not available. two years. • There were systems in place to allow patients to Medicines self-administer their medicines. Where this was • Clinical pharmacists were accessible and involved in happening we saw that staff were aware of the local patients’ medicine requirements. The pharmacist was policy, and that a record of self-administration was supported by a suitably qualified pharmacy technician made. An assessment of patients’ suitability and their who provided a top up service for ward stock. This agreement to self-administer was documented in their helped identify and manage medicines issues in a notes, and their self-administration status was recorded. timely manner. • We spoke with one patient who had agreed to • Medicines were generally stored securely according to self-administration of medicines, who told us there were trust policy. This included those which require no available keys for patients to lock and unlock their additional security known as controlled drugs (CDs). own medicines’ lockers as the key was kept by the nurse • There was a lack of consistent arrangements in place to in charge. These meant patients were not able to look ensure medicines were always stored at the correct after and administer their own medicines according to temperature. There was no thermometer available to the trust policy. check the temperature, or a record of any temperature Records checks in clinical areas where medicines were stored and prepared. Medicines which required refrigeration • The medical care services used a combination of paper were appropriately stored but we noted that the and electronic records. temperature recordings of the refrigerators were not • We saw that care records and documentation such as completed every day. risk assessments and fluid balance charts were fully • The majority of medicines were supplied and completed, dated, and signed in accordance with trust administered by prescription. In some cases Patient policy. Group Directions (PGDs) were in place. These are written • Physiotherapy records were complete, including instructions for the supply and administration of treatment plans, goal planning and functional medicines to groups of patients who may not be assessments. individually identified before presentation for • Falls were assessed and documented with a treatment. The PGD has a role in ensuring safe and multidisciplinary team (MDT) approach, and further timely administration of medicines. We looked at 15 assessments completed when a patient’s condition PGDs and saw that the review date for all of them had changed. expired, meaning they were not reviewed in line with • Where a do not attempt cardio-pulmonary resuscitation national guidance. This was brought to the attention of (DNACPR) was ordered, we saw that the appropriate managers, following our inspection the trust reported documentation and processes were in place. these had been reviewed and updated. Safeguarding • The medical services used a paper-based system to record the supply and administration of medicines.

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• Staff we spoke with knew how to access safeguarding • A lead nurse (Matron) with overall responsibility for the policies and procedures on the trust’s intranet and nursing service was supported by ward managers and a demonstrated a good understanding of the trust’s team of nurses and support staff. safeguarding policy and the processes involved for • Nursing staffing levels were displayed in each ward area raising a safeguarding alert. and we saw these had been decided upon and • Ninety-nine percent of staff in medical care services had delivered using national guidance. We looked at duty completed level one safeguarding training. rotas and saw that staffing levels were consistent. • When shifts could not be fully staffed from their own Mandatory training staff working within contracted hours, staff worked • Staff we spoke with were aware of the mandatory additional hours through the hospital bank. There was training they were required to undertake. no evidence that agency nurses were used on a regular • Mandatory training provided by the trust covered a basis. range of topics including moving and handling, basic life • Staff, patients and those close to them that we spoke support, hand hygiene, safeguarding adults, equality with perceived the nursing staffing levels to be adequate and diversity, health and safety, and life support. to care for people safely. • Attendance at mandatory training was reported on a • We saw patient safety huddles took place at each shift monthly basis. change on each ward. A safety huddle is a brief face to • The trust set a target of 90% for completion of face meeting attended by different health professions to mandatory training. The medical services reached exchange information about predicted ward activity and compliance of 87% overall. safety. This kept staff informed of safety issues and • Where there was non-compliance with mandatory action required of them. training, a risk assessment was carried out and Medical staffing managers took corrective action. • Medical care was led by a team of six consultants. There Assessing and responding to patient risk was one consultant vacancy; locum doctors provided • National Early Warning Scores (NEWS) were used to cover for vacancies and sickness. calculate certain indicators to monitor whether or not a • There was a higher proportion of consultants and lower patient deteriorated clinically, and if so, whether further proportion of junior doctors compared to the England or new intervention was required. All staff we spoke with average and the average for specialist orthopaedic were aware of how to escalate if there was a trusts. deteriorating patient. • Out of hours medical cover was provided on an on-call • There were care pathways in place to ensure rota basis. Staff we spoke with told us that doctors appropriate and timely care for patients with specific responded in a timely manner when they were needs such as pressure ulcers, management of sepsis contacted. Records we looked at confirmed this (infection) and the management of falls. All the records happened. we looked at showed these were documented in • There was a daily ward round undertaken by the accordance with trust policy. consultant or specialist orthopaedic registrar. In • Doctors were available on-call if a patient required addition there was a handover between shift changes, medical support. and a more comprehensive consultant led • Records showed, and we observed, that nurses multidisciplinary ward round at least once a week. We conducted ‘intentional rounding’ on a two hourly basis, observed these happening in practice. 24 hours a day, where nurses checked whether patients Major incident awareness and training were comfortable and if they had any particular clinical or other needs. • The trust had a business continuity plan in place to ensure clear processes for managing any untoward Nursing staffing events that would cause disruption severe enough to impede the delivery of essential services.

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• The trust had responded to seasonal bed pressures by • Adherence to local policies and procedures was largely the planned opening of extra beds on Sheldon Ward. evident. Pathways were consistently followed and there • Staff could not recall any major incident training or was evidence that staff received and acted upon simulated exercises and we found no evidence this specialist advice where appropriate. Compliance was happened. monitored by ward managers. Pain relief Are medical care services effective? • The multidisciplinary team worked closely with the Good ––– trust’s nurse led acute pain management service for inpatients, and the Oswestry Pain Management Programme. This was an outpatient service for Patients’ needs were assessed and care and treatment management of longer term pain to improve patients’ was guided by evidence based practice. The medical care physical and psychological well-being within existing services participated in local audits, with limited pain limitations. participation in national audits, particularly in relation to • The acute pain team were available from 08.30-19.00, therapies. Services generally reported patient outcomes Monday – Friday. An on call anaesthetist was available that were within the expected range, with no elevated outside of these hours. Information about the service, risks. acute pain standard operating procedures, and further Staff were suitably qualified and had the skills to carry out pain management resources were accessible to ward their roles effectively and in line with best practice staff via the trust intranet, and as a paper copy. guidance. There was good multi-disciplinary team • Patients we spoke with told us their pain was managed working. We found all relevant staff, teams and services well, that they were given pain relieving medicine when were involved in assessing, planning, and delivering they needed it. Nursing staff always checked to see people’s care and treatment, and worked in a whether it was effective. We observed this happen and collaborative way to meet the range and complexity of was documented in patients’ notes. people’s needs. A limited therapy input outside regular • We saw that assessment of patients’ pain were included working hours. in routine observations. Consent to care and treatment was obtained in line with Nutrition and hydration current legislation and guidance, and staff understood • Appropriate arrangements were in place to assess and their role and the processes to follow. Where patients manage people’s nutrition and hydration, and manage lacked the capacity to make their own decisions, staff the risk of dehydration. acted in accordance with the Mental Capacity Act. • Patients we spoke with told us they were offered a There was no integrated care record which meant that choice of food, which was always served at the correct different groups of professionals could not always access temperature and met their requirements. Longer term information in a timely way. patients told us the menu was on a three week rotation cycle and they found the menu repetitive. Evidence-based care and treatment • We observed that drinks were accessible for patients • We found staff were aware of, and were basing practice and that, when needed, people were assisted and on national guidance and information available from provided with eating and drinking aids We saw coloured the National Institute for Health and Care Excellence trays in use to alert staff to patients who required (NICE), and the Royal Colleges. We reviewed policy assistance guidance and standards and saw they were aligned with • Meal times were calm and that meals were issued current best practice. during protected times which patients told us were • Local clinical policies and guidance was available on the respected. We observed this to be the case. trust intranet system. Staff could locate policies when Patient outcomes requested.

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• The medical care services took part in most relevant • Nursing staff demonstrated understanding of the national and local audits. recently introduced revalidation requirements of The • The spinal cord injury specialised service quality Nursing and Midwifery Council (the UK regulator of dashboard for quarter 4 2014/2015, showed the service’s registered nurses and midwives), and correctly stated performance was consistent with the national picture their role and responsibilities. on 13 out of 18 rolling indicators reported. For two • Staff that were required to complete revalidation indictors relating to patients acquiring pressure sores, processes as part of their professional registration were the service performed much better than expected as able to demonstrate compliance with the requirements. they scored zero. For three indicators the trust was Multidisciplinary working worse than expected. These were; mean length of stay in acute phase for level of injury and percentage of bed • There was good multi-disciplinary team working. We days occupied by non-clinical delayed discharge found all relevant staff, teams and services were patients for newly injured and further admission involved in assessing, planning, and delivering people’s patients. care and treatment, and worked in a collaborative way • For the period December 2013 to November 2014, to meet the range and complexity of people’s needs. standardised relative risk of readmission was much • Patients had access to physiotherapists, occupational better than the England average for elective and therapists, psychologists, dietitians, nurses orthopaedic non-elective care; however, it was higher than the doctors, pharmacy staff, speech and language average for elective rheumatology. Risk of readmission therapists and a social worker. for elective care was similar to the average for specialist • A multi professional resettlement and community orthopaedic trusts. liaison team supported and facilitated the discharge Facilities process up to and after the patient’s discharge. We saw that they identified care and equipment requirements, • An independent living area (flat) was available for and acted upon them. patients and those close to them preparing for discharge home to rehearse the tasks needed for Seven-day services independent living. • Medical consultants worked on rotation and were • Equipment was provided on the ward as well as the gym responsible for ensuring the service had adequate so patients could have therapy at times when the gym medical cover at all times. was closed. We saw this being used throughout our visit. • There were on-call arrangements for most services out Competent staff of regular working hours, such as imaging, pharmacy and physiotherapy. • All the staff we spoke with had completed a recent • Physiotherapy was limited to chest and emergency appraisal in accordance with the trust policy. Data we treatments out of hours rather than a full range of reviewed showed that as at June 2015, 100% of nursing services. There were no on call arrangements for staff on the wards had completed their appraisal, 70% of occupational therapists. Staff and patients told us this therapies staff were up to date with their appraisals. meant there was no structured rehabilitation activities • Staff told us they felt supported to undertake additional at weekends or out of hours. training that was identified through their appraisal. • Recently appointed staff we spoke with were positive Access to information about their induction programme and the supervision • Staff ensured that patient care records were maintained they received. We saw evidence that this was planned and transferred in a timely way in line with trust and structured and took place as soon as staff procedures. commenced employment in the trust. This included • There was no integrated care record which meant that temporary (locum or agency) staff. different groups of professionals were not always accessing information in a timely way, although the information was recorded and available.

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• Discharge summaries were provided to GPs to inform had died, practical assistance for a patient to maintain them of the patient’s medical condition and the contact with their employer, and staff working in treatment they were given. partnership with patients at a residential team building event. Consent, Mental Capacity Act and Deprivation of • Patients told they had been well cared for and staff were Liberty Safeguards sensitive to their needs and treated them with kindness, • We saw patients being asked for their agreement to care compassion and respect. and treatment. Understanding and involvement of patients and • All the records we reviewed showed that patients had those close to them consented to the treatment they received, and the forms were clear to understand. • Staff enabled patients to become partners in their care • When we spoke with staff they were aware of their by working together with structured goal setting and the responsibilities in obtaining consent, obtaining a best use of a patient passport containing personal interest assessment if someone lacked mental capacity, information and likes and dislikes. and were knowledgeable regarding Deprivation of • Staff and patients from MCSI had attended an off-site Liberty Safeguard (DoLS) applications. We saw no residential activities event together, which was viewed instances of where a DoLs application or best interest positively by those who had participated. Staff told us it assessment was required during our visit. had improved communication and strengthened relationships between patients and staff. Are medical care services caring? • Patients told us they and their relatives felt included in decisions and were given relevant and timely Good ––– information. We saw evidence of this in patient records. Emotional support We observed positive interactions between staff and • Staff we spoke with described the emotional support patients, and received good feedback from people we available to patients and relatives as supportive and spoke with. Privacy and dignity were upheld. Patients and good. Patients agreed with these comments. relatives felt informed about their care and treatment, • A clinical psychology service was provided for patients and told us they felt well looked after. in the spinal unit that included assessments for anxiety Staff provided good care by understanding what was and depression, and counselling. significant to patients and making arrangements to • A chaplaincy service was available, which provided support them towards independent living. People’s emotional and spiritual support to people of all faiths. emotional support was provided by a range of staff from • One patient told us they and their partner were different professions. particularly well supported during some more difficult days and experiences. We saw some examples of excellent caring in the MCSI such as compassionate care for a patient whose close Are medical care services responsive? relative had died, assisting a patient to maintain contact with their employer, and staff working in partnership with Requires improvement ––– patients at a residential team building event.

Compassionate care Medical care services were not always able to respond to • The Friends and Family Test (FFT) score for medicine in peoples’ needs because of insufficient bed capacity, September 2015 was 100%. FFT scores were consistently problems with delayed discharge for some patients, high for both wards, although response rate were limited planned activities particularly at weekends, and slightly below the national average. some problems with the existing facilities. • We saw some examples of exceptional care: The facilities were not always adequate to meet people’s compassionate care for a patient whose close relative needs. There were insufficient bathroom facilities on 20 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 Medic al c ar e

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Sheldon Ward as they were used to store equipment due Wrekin ward was consistently above the target reaching to a lack of storage space. There was a lack of private 99% in April 2015. Gladstone Ward was generally similar consultation areas in the gym where people attended to the trust target, with a highest rate of 92%. National one to one consultations, and no designated area for evidence suggests that patient care can become consultations with the clinical psychologist. compromised at 85% or above. Sheldon Ward was below the target occupancy for two months and above There was evidence that support with physical disability, target for four months. This meant that medical services learning disability and dementia was available if needed. did not have the capacity to provide a responsive This included the Butterfly Scheme to support people service. living with dementia and the Poppy Lounge, to assist • The medical services dashboard showed that the people requiring memory support. average length of stay was longer than the England Discharge from hospital was a planned event. The average for all individual specialties except elective resettlement and community liaison team worked with spinal injuries and the rehabilitation service. The the multi-disciplinary team and patients to support and average length of stay at the hospital was shorter than facilitate the discharge process. We saw that they the average at other specialist orthopaedic trusts. identified care and equipment requirements, and that • The trust breached the referral to treatment time (RTT) discharge was determined by reaching rehabilitation target in March and April 2015. However by May 2015 the goals. target was being met and performance was better than A nurse led day care service for patients requiring the average for all trusts, including all orthopaedic trusts intravenous medication was provided at three hospital in England. sites which allowed patients to receive treatment near to • Between February and September 2015, 40 patients their homes and without requiring overnight stays in within the medical care services had experienced hospital. extended length of hospital stay due to delayed transfer of care (discharge). There were prevalent reasons which Service planning and delivery to meet the needs of affected all services within the trust: awaiting local people community equipment and adaptations, awaiting • The Midland Centre for Spinal Injuries (MCSI) is one of 11 public funding, waiting for care package in own home units in the UK designated to receive and treat spinal and waiting for a residential home placement. cord injured patients. The MCSI provided services at Meeting people’s individual needs local regional and national level serving a catchment of approximately 10 million people from North Wales, Mid • Privacy and dignity were generally upheld in the Wales, South Mersey, Cheshire and The West Midlands. in-patient areas. One patient on MCSI told us it was Local commissioners described local working better than any other hospital environment they had arrangements as positive. experienced. However, we observed a lack of privacy in the rehabilitation area (gymnasium), where patients • The majority of inpatient rehabilitation programmes ran were undergoing a range of treatment and one to one for either two or three weeks. consultations. The gym was used as a thoroughfare to • All spinal patients had a lifetime link with the spinal other areas. There were no screens between patient service meaning they could attend follow up reviews areas which meant that visual and auditory privacy was with the specialist consultant. not always achievable. We reported this to the trust who Access and flow took action following our inspection. • We saw clinical areas displayed printed health • Staff and managers described problems with access and education literature produced by national organisations flow as the biggest operational risk to the medical care and associated charities and support groups, services and perceived there could be improvements in particularly in relation to spinal injuries, and memory this area. loss. • The trust target for bed occupancy within the medical care services was 87%. From April 2014 to August 2015

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• Although wards provided mixed sex accommodation, the medicine service worked in isolation of each other, bays were separated on a gender basis which we saw with little evidence to demonstrate shared learning. Not was maintained. all staff were able to describe the trust vision, values and • Usual visiting hours were varied on some occasions to strategy. accommodate the needs of patients with extraordinary The risks and issues described by staff were not always circumstances or who were very sick. reported or acted upon in a timely manner, action plans • Due to the lack of space, equipment was being stored in were not always detailed with specified actions or end inappropriate places, which then meant facilities were dates. It was not always possible to assess if the action not always available. For example, a male bathroom on plan had reached its desired effect before the risk was Sheldon Ward was out of use as it was being used as a closed down. store room. • Support for people with physical disability, learning Leaders were not always clear about their roles and disability and dementia was available if needed. accountability for quality, which meant there was not However compliance with completion of dementia always a timely review of risks or corrective action. This awareness training was below the trust standard. was particularly the case where substantive post holders • The service took part in The Butterfly Scheme, which is a were replaced by interim managers system of hospital care for people living with dementia We also saw examples of excellent leadership at ward or requiring memory support. level on the MCSI, where the ward manager had won a • A new facility on Sheldon Ward, known as The Poppy National Patient Safety Award and had significantly Lounge, was opened in December 2014, to mimic the reduced staff sickness levels from 27% to 0.2% in a year. home environment as much as possible to assist people requiring memory support. We saw that the lounge was Vision and strategy for this service used for group activities as well as providing a quiet • The trust had developed and approved an area for people to relax. We also saw that Sheldon ward organisational quality strategy, however there was had been decorated in a way to assist people with mixed feedback across the service about individual memory loss to identify specific areas. alignment with the trust vision and strategy. Staff we Learning from complaints and concerns spoke with told us the current emphasis in the trust was on the new building on site which would provide • The number of written complaints received was 87 in additional operating theatres for surgical services. total for 2014/2015. Seven complaints specifically • The short and long term vision for the medical care related to the medical care services. It was confirmed services was not clear. The strategy for medical care there were no unresolved complaints at the time of our service was not very well developed or articulated and visit. from our discussions with staff the focus for the service • Patients we spoke with had access to the complaints seemed to be based on maintaining the current position information which was clearly displayed. Staff we spoke and lacked ambition. with correctly described the trust complaints and concerns policy and their role in responding. Governance, risk management and quality • We saw a range of compliments and thank you cards in measurement all the areas we visited. • There were systems in place to identify record, manage and mitigate risks. The majority of staff we spoke with Are medical care services well-led? were aware of the importance of reporting risks. However there was varied awareness amongst staff of Requires improvement ––– the issues on the risk register and actions being taken to mitigate risks were not always widely known. Governance arrangements did not always operate • Where there was non-compliance with policies and effectively, with a lack of reliable information about procedures we saw this was not being challenged or services, and inconsistent review of risks. Teams within

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questioned, particularly where staff were not following • Many of the staff we met had been working for the trust infection prevention and control procedures for hand for over 20 years and were described as loyal and hygiene on the ward areas. Audits were not sufficiently committed to the organisation. robust to reflect actual practice. • Recently appointed staff we spoke with told us they felt welcomed, and had experienced a comprehensive and • The integrated performance report had been developed useful induction. in order to assist the service in monitoring the delivery • Staff commented on good communication and the of key performance metrics against local and national benefits of monthly staff meetings. We saw these were targets and communicating any issues to the trust held regularly with a variety of topics discussed. board. The report covered the five key domains of • Within the spinal unit there had been a significant patient safety, patient experience, resources, efficiency reduction in sickness levels from 27% to 0.2% in one and external perception. The overall performance for year. This was attributed to the strong and positive June 2015 demonstrated continued achievement across leadership of the ward manager. many of the key standards Public and staff engagement Leadership of service • The medical care services used a combination of email, • There had been a vacuum of clinical leadership within intranet messages, newsletters and face to face the service. The vacancy of clinical director for the meetings to communicate with staff. medical care services had not been filled since the • The trust had participated in the NHS Staff Survey 2014, previous post holder left in December 2014, although and staff satisfaction was generally comparable to other medical services has been represented at Clinical trusts. Management Board by the clinical leads for medicine • The medical care services encouraged patient feedback and spinal injuries. This had meant that there was no by giving them an inpatient survey and the Friends and stable leadership representation of medical care Family Test. services at senior trust meetings and that accountability • All staff we spoke with felt included in ward/ team for some clinical governance lacked clarity on meetings and perceived them to be useful and meeting occasions. the needs of staff. We saw that staff were encouraged to • There were a number of vacant managerial posts and decide the agenda, and that meetings addressed areas interim staff in post, including the clinical director and for improvement as well as progress reports. Records we matron. Staff said they were unsure how long the looked at showed that ward/ team meetings dealt with current arrangements would be in place for and felt local matters rather than including trust-wide issues. there was a degree of uncertainty. • Staff we spoke with told us they felt well supported by Innovation, improvement and sustainability line managers and leaders. Medical and nursing staff we • Managers told us they were continually working to spoke with gave examples of recently completed innovate and improve their services. leadership training and coaching Staff felt supported in • Staff felt supported in safe innovation such as their learning and development. non-medical prescribing and nurse led pain • In July 2015, a National Patient Safety Award for clinical management and intravenous medication. leadership was won by the Ward Manager of MCSI for • Staff attended external meetings with national and “building sustainable systems and processes and international experts working in spinal injuries, pain creating a team ethos which improves patient care and management and rehabilitation. staff experience“. • A National Patient Safety Award for clinical leadership Culture within the service was won by The Ward Manager at the MCSI for building sustainable systems and processes to improve patient • Staff generally spoke positively about working within the safety. service. They described it as friendly, and open, and told • Staff told us the trust has recently been accepted as part us they would feel confident to raise and escalate of the “Vanguard Scheme”: a joint programme led by concerns. NHS England and NHS Improvement designed to spread

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excellence in hospital services and management across organisations work together on a clinical basis and multiple locations. It aims to formalise the way furthers the work of the Specialist Orthopaedic Alliance. Due to the infancy of this development it remains in an aspirational phase.

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Surgery

Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

We visited all wards, operating theatres and the adult Information about the service preoperative assessment unit; a stand-alone anaesthetic led, multidisciplinary service that ensures patients are fit The surgical division specialised in complex primary for anaesthesia and ready for admission for a surgical andrevision joint replacement. It performs over 2600 joint procedures. replacements each year and the hospital has become one of the leading referral centres for the treatment of difficult We spoke with 53 patients and relatives of people using the joint replacements, revision joint replacements and service and observed interaction between patients and infected joint replacements. The development of new nursing staff. We spoke with 117 members of staff, ranging prostheses and grafting techniques continue to be from student nurses, nurses of all grades, domestic staff, developed with a speciality utilising a range of donor bone doctors and consultant surgeons. We looked at the medical grafts and titanium implants. and care records of 31 patients, observed staff handovers between the multidisciplinary team and reviewed data The hospital provides adult surgical services within 104 held at ward level. surgical beds divided between four inpatient wards. Powys and Clwyd Wards have 28 in-patient beds and provide post-operative care for those patients who require primary or revision joint replacements, pelvic surgery and spinal disorders surgery. Kenyon ward has 32 in-patient beds and provide post-operative care for those patients who require foot, ankle, lower limb, arthroscopic knee, hand, shoulder and upper limb specialised services. Ludlow Unit has 10 private in-patient beds and a private pre-operative clinic for patients requiring a variety of orthopaedic surgery. The unit also has six in-patient beds currently booked for those patients who require diagnosis and treatment for bone and soft tissue cancers and associated bone disease. The theatre suite comprises of ten operating theatres, one of which is for day surgery. There are four main operating theatres which are constructed in a manner unique in Britain at present; the four operating enclosures are suspended from the ceiling of a large barn area within which there is free movement of theatre staff who are able to discuss clinical matters as they arise.

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Summary of findings Are surgery services safe? Robust risk assessments were completed and reviewed Requires improvement ––– to ensure patients remained safe whilst cared for in the ward environment. Patients we spoke with told us they Bare below the elbow and hand washing procedures had been well cared for, were shown respect, treated during the provision of care was not embedded; during with dignity and their privacy was protected. They were extended observation our evidence was further confirmed. full of praise for all the staff. Incident reporting was encouraged; staff reported that they The World Health Organization (WHO) surgical safety received feedback from incidents. However, there was checklist was embedded by theatre staff. Safety checks some inconsistency around who had access to the of equipment had been completed in ward areas and reporting system and the learning from incidents varied theatres; records were up to date and signed. between the wards and departments. Learning from a Never Event in 2014 had not been embedded. A higher proportion of patients undergoing hip and knee replacements reported an improvement in their We saw evidence that patients were appropriately risk condition following their surgery compared to the assessed prior to surgery. The patient pathway began with average of the other specialist orthopaedic trusts. a full pre-assessment which was completed in the designated anaesthetic led unit. The patient consent Patients with complex conditions were well supported processes were completed prior to admission in most by the staff; their relatives told us they had been fully cases and reviewed when the patient was admitted. The updated with the care progress. We observed hand patient records we looked demonstrated a high standard of hygiene compliance to be poor; the use of hand gel was record keeping. We observed the use of the WHO surgical not widely used and the washing of hands, by nursing safety checklist, and found that it was embedded in and medical staff, in between patients was not always practice promoting patient safety. observed. Bare below the elbow was also not conformed to by all staff, at all times. Appropriately skilled staff were available in sufficient numbers to meet the needs of patients; we saw that daily We saw that systems were in place to promote patient reviews of the staffing numbers and skill mix took place by safety, and although incident reporting was promoted, the surgical matron to ensure patient safety. Staff in learning from incidents was not shared between theatres told us they worked additional hours to cover departments. overruns and absences, the trust was aware of this. Incidents • One Never Event was reported in September 2014 as wrong site surgery. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. This event related to a spinal procedure whereby the patient had to return to theatre to correct the error. • We identified that specific standard operating procedures had been written in response to the Never Event but as yet had not been audited to demonstrate that change had been effected. We discussed local learning in theatres from the action plan with the senior surgical division staff. Five staff we spoke with in theatre were unaware of the action plan and any details.

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• Incidents that could have or did harm a patient were MRSA free days were logged which amounted to years. appropriately reported. We saw that incidents were We discussed what other ways the surgical division locally learnt from and any necessary action was taken could demonstrate compliance with infection control to prevent similar incidents from occurring in the future. standards such as hand hygiene audits and • At the time of the inspection, between March 2014 and pre-operative questioning. Some wards displayed this May 2015 there had been five serious incidents reported, for patients and visitors to observe, for example on three of which involved unexpected deaths of Ludlow ward this was displayed on the ward corridor, inpatients, one wrong site surgery and one surgical however on Powys ward this was in the ward manager’s error. We looked at the root cause analysis of the three office. deaths which had been completed for each case in line • On the August 2015 safety score card, six inpatient falls with the trust policy. had been recorded which was below (better than) the • Between September 2014 and August 2015, 732 anticipated level of 10, two pressure ulcers were incidents were reported by surgical services to the recorded which was one above the predicted level and National Reporting and Learning System (NRLS). NRLS is one deep vein thrombosis was reported which was a central database of patient safety incident reports. All below the predicted level of two. Following incidents, information submitted is analysed to identify hazards, patients were reassessed, for example following an risks and opportunities to continuously improve the inpatient fall the patient’s risk assessment was reviewed safety of patient care. Of the these incidents, 62 were and amended. reported as moderate harm, 189 were reported as low • In line with NICE guidelines (QS3), all patients received a harm and 489 were reported as no harm. The most venous thromboembolism (VTE) assessment prior to common category reported was treatment and admission including a bleeding risk, using the clinical procedure. There had been a steady increase in low risk assessment criteria described in the national tool. harm and no harm incidents reported since April 2014. This quality standard covers the reduction in risk of VTE • We identified some inconsistency around which staff in adults admitted as hospital inpatients or formally had access to the incident reporting system. During a admitted to a hospital bed for day-case procedures. focus group we heard that health care assistants did not Mandatory training have access to report incidents; they went to their manager or senior in charge who would report it for • We saw that staff received mandatory training in the them if they thought it appropriate. Staff told us learning trusts safety systems, processes and practices. Staff from incidents varied between the wards and were encouraged to attend within the twelve month departments. Staff did not get to hear of incidents that timescale to ensure their training did not lapse. We saw occurred in other wards or departments. Since our that the ward manager oversaw training records inspection, the trust have told us and we saw, they have relevant to their ward. The training matrix flagged green, established a comprehensive action plan to ensure amber and red for each training item for each member learning is embedded across the organisation. of staff as the timescale drew near, so it could be • Eighteen percent of surgical incidents were reported to monitored. the NRLS more than 60 days after the incident. Of these, • Mandatory training levels were currently at 92% 5% were reported to the NRLS more than 90 days after compliance, marginally above the trust target of 90%. the incident. Safeguarding • We saw the minutes of the multi-professional surgical and anaesthetic morbidity and mortality review • Arrangements were in place to safeguard adults from meetings which took place monthly, these listed the abuse that reflected relevant legislation and the trusts cases that were discussed, the actions to take forward policy and procedure. The staff we spoke with but did not demonstrate how lessons were learnt. understood their responsibilities and they were able to explain the safeguarding policies and procedures. Safety thermometer • Over 80% of staff had completed safeguarding training • Safety thermometer data was recorded at ward level on in 2014/2015. the locally known ‘STAR system’. We identified that • There were no current safeguarding alerts in progress.

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Cleanliness, infection control and hygiene • We saw that all theatres, wards, departments and corridors were exceptionally clean and tidy. • Trust policies for hand hygiene, personal protective • Bariatric equipment was available, safe and appropriate equipment and isolation were in place but we did not for people that required it. evidence that these were adhered to. • Storage was available on the wards, bulky walking aids • Bare below the elbow and hand washing procedures and hoists were managed well and did not appear to during the provision of care was not embedded; on cause a trip hazard whilst we visited the wards. observation our evidence was further confirmed. For • We saw that portable appliance testing (PAT) had been example we observed a patient return from theatre on carried out on the electrical equipment that we Ludlow ward and not once did the three staff members checked. wash or gel their hands. We observed two staff on Powys ward move between patients in two bays and no gel was Medicines applied at any time. We observed staff entering and • People were prescribed antibiotics in accordance with exiting all surgical wards and at no time did the staff their local antibiotic formularies. Local microbiology wash their hands or apply hand gel. We also observed protocols were available and in use for the two consultants at a patient bedsides on Ludlow ward administration of antibiotics. who were not bare below the elbows. Since our • Allergies were clearly documented in the prescribing inspection, the trust have told us they have established document used and patients wore allergy wrist bands to a comprehensive action plan to improve compliance alert staff. with the policy. • Nursing staff were aware of policies on administration of • Hand hygiene audit results consistently demonstrated controlled drugs as per the Nursing and Midwifery 100% compliance all areas. When we investigated this Council standards for medicine management. we heard that the results related to a sample of staff Controlled drug cupboards that we checked were who knew at the time they were being observed. locked, appropriately stocked and tidy. • The trust reported an increase in surgical site infection • Staff understood the arrangements for managing rates in quarter 2 of 2015. The rate jumped from 0.2% in medicines and medical gases and ensured people were quarter 1 to 1.3% in quarter 2 for knee replacements, kept safe including intravenous (IV) fluids and its this is a six-fold increase. There was a three-fold increase storage. over the same time period for hip replacements from • We saw that items were prescribed, recorded, handled, 0.7% to 2.0%. At the time of our inspection, the trust stored securely, dispensed, safely administered and were investigating the reasons for the increase but were disposed of correctly. Ward-based pharmacists checked unable to confirm the source. each patient’s medication chart; highlighting prescribing • The trust reported zero hospital-acquired cases of queries directly with the medical staff. Methicillin-Resistant Staphylococcus Aureus (MRSA). From April 2014 to August 2015 MRSA screening was Records recorded as 100%. • People’s individual care records were written and • From April 2015 to August 2015 there were no managed in a way that kept people safe. Records we Clostridium Difficile (C.Diff) cases reported. looked at were seen to be accurate, complete, legible, Environment and equipment current and stored securely. • Record keeping systems, processes and practices were • Surgical equipment including resuscitation equipment in place and staff demonstrated they adhered to the was available and fit for purpose and checked in line trust policy. with professional guidance. • Pre-operative safety systems, processes and practices • Technology and equipment was used to enhance the were in place to protect people prior to surgery. The delivery of effective care and treatment. For example service ensured that care was managed in accordance foot pressure pads were used to prevent thrombosis with NICE guidelines for example CG3 pre-operative when post-surgery situations caused immobility.

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tests. The processes were monitored and improved Nursing staffing when required. For example risk assessments and • Staffing levels and the skill mix were planned in line with pre-operative assessments were embedded in to the safer staffing tools and guidance. Levels were reviewed patient pathway and audited to ensure compliance. by the ward managers and surgical matron to ensure • On admission all patients were risk assessed to prevent that people received safe care and treatment at all harm, for example moving and handling needs, the risk times. of developing pressure ulcers and prevention of falls. We • Actual staffing levels were in line with the planned levels saw evidence that when a patient’s circumstances had displayed on the ward noticeboards with arrangements altered the assessment was amended, for example after in place for using bank, agency and locum staff to keep during the recovery stage post-surgery. people safe at all times when permanent staffing levels • In the 2015 documentation audit, prescription forms were below the planned numbers. that were audited showed 96% completion by nursing • Staff sickness in the surgical division was recorded as staff. Two charts did not have the last observation or 2.6% which was slightly below the 2.7% trust target. end time. • We saw that nursing and multidisciplinary handovers Assessing and responding to patient risk occurred at shift changeovers and throughout the day. Staff on the wards and in theatres told that during the • Comprehensive risk assessments were carried out for ‘safety huddles’ they were updated with the necessary people who were admitted for surgery. Risk information to plan patient care and ensure they were in management plans were developed in line with trust line with their patient pathway. policy and national guidance. Risks were managed • Link nurses had responsibilities to attend the relevant proactively ensuring the level was monitored and specialist meetings and cascade the updated re-evaluated. In the August safety score card 100% of information to the rest of the ward team. Link nurses patients had received a pressure ulcer assessment and covered many subjects such as end of life, resuscitation, venous thromboembolism (VTE) risk assessment. communication, tissue viability, pain, falls and • The staff demonstrated that they were competent in continence. identifying and responding appropriately to changing risks to people with behaviour that challenges, Medical staffing including deteriorating health and wellbeing using an • There was a higher proportion of consultants (69%) early warning scores for medical emergencies. The compared to the England average (41%) and the recently introduced electronic monitoring system average of specialist orthopaedic trusts (44%). supported the nursing staff in the early recognition and • There was a lower proportion of middle grade doctors management of deteriorating patients. (2%) compared to the England average (11%) and the • During the day time hours medical support was average of the specialist orthopaedic trust (5%). available on site. Ward staff were also supported 24/7 by • There was a lower proportion of registrars (29%) the outreach team from the high dependency unit. compared to the England average (37%) and the • The trust followed the five steps to safer surgery in line average of the specialist orthopaedic trust (38%). with the World Health Organisation (WHO) surgical • There was a lower proportion of junior doctors (0.4%) safety checklist. We saw that the results of the WHO compared to the England average (12%) and the checklist audit for September 2015 was 98% overall. average of the specialist orthopaedic trust (14%). Results for the previous two months were 98% in August • Arrangements were in place for using agency and locum and 99% in July. The checklist identifies three phases of staff when necessary. Medical staff were responsible for an operation, each corresponding to a specific period in updating permanent and locum staff through planned the normal flow of work: Before the induction of handover sessions. anaesthesia ‘sign in’, before the incision of the skin ‘time • Medical staff undertook daily ward rounds and early out’ and before the patient leaves the operating room evening visits to the ward, prior to leaving the building. ‘sign out’. In each phase, a checklist coordinator must Handovers were given to the ‘onsite’ night time medical confirm that the surgery team has completed the listed cover to identify any patients that concerned them. tasks before it proceeds with the operation.

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Major incident awareness and training • Relevant and current evidence-based guidance was followed. Care standards, best practice and legislation • Potential risks were taken into account within the was identified and used to develop the delivery of annual planning of the service. Major incident and services, care and treatment. business continuity plans were in place for seasonal • We saw NICE and other expert and professional bodies fluctuations in demand, the impact of adverse weather, guidance in use on the wards. For example NICE CG50, a or disruption to staffing. guideline for care of the deteriorating patient and how • In the event of an offsite major incident the trust was they should be cared for when this happens was used. confirmed as a site for a minor injury clearing station. Discussions about the implementation of this guideline Arrangements were in place to respond to emergencies were seen in the June 2015 minutes of the ‘deteriorating and internal incidents. The process was practised and patient’ committee meeting which was held quarterly. reviewed a set of action cards was available in the • People had their needs assessed and their care planned hospital switchboard, setting out the duties and and delivered in line with evidence-based, guidance, responsibilities of the staff. standards and best practice. This was monitored by ward managers to ensure compliance. Are surgery services effective? • We saw evidence that staff adhered to local policies and procedures for example the management of blood Good ––– transfusions. It was seen as good practice by the hospital not to give a blood transfusion overnight Outcomes for patients attending the hospital with complex (between 8pm and 8am) unless the patient clinically orthopaedic problems were consistently good. Care required it. pathways and treatment plans were based on national • In line with NICE guidelines people were receiving guidance. intravenous (IV) fluid therapy were cared for by competent staff that were able to assess patients' fluid A higher proportion of patients undergoing hip and knee and electrolyte needs, prescribe and administer IV replacements reported an improvement in their condition fluids, and monitor the patient experience. following their surgery compared to the average of the • Surgical services were managed in accordance with set other specialist orthopaedic trusts. Enhanced recovery principles such as NCEPOD recommendations of programmes were in place for those patients identified as reviewing perioperative care of surgical patients and the suitable candidates, having hip and knee joint replacement NHS Institute for Innovation and Improvement with the surgery. Day case performance was above target with 5102 enhanced recovery programme for elective hip and patients admitted since July 2014. knee anaesthetic guidelines. The average length of stay (four days) was longer than the • The service followed professional guidance in respect of England average (three days) for elective cases. recording medical device implants by submitting data to the national joint register (NJR). However, the trust Nursing staff had the right qualifications, skills and was not fully compliant as checks by an administrator of knowledge to care for their patients through appropriate each NJR form showed many of these forms were not training and a robust appraisal process. We saw that completed appropriately. In September 2015 there were therapists worked in unison with the nursing staff to ensure 69 uncompleted forms which had to be completed optimum multi-disciplinary care and support for their retrospectively to comply with the guidance. patients. Pain relief Coordination between electronic and paper based systems did not always work in partnership. Access to therapy and • Anticipatory analgesia was individually prescribed prior other services was limited outside regular working hours. to patients undergoing treatment or surgery. We heard that short and long acting analgesia were prescribed to Evidence-based care and treatment give the patient maximum comfort levels. • We saw information leaflets for patients were available outlining pain relief following day surgery.

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• Three patients we spoke with told us they had been • The average length of stay (four days) was longer than impressed by the nurse’s quick response when they had the England average (three days) for elective cases. The asked for pain relief. Two patients told us the nurse had average length of stay (nine days) was marginally longer returned later to see if the pain relief had been effective. than the England average (eight days) for non-elective • An acute pain team was available five days a week until trauma and orthopaedics. However the length of stay 7pm. They were supported by the outreach team and on was shorter than the average for the specialist call anaesthetist when necessary. Access to the chronic orthopaedic trusts for both elective (five days) and pain management team was by consultant referral. non-elective trauma and orthopaedics (12 days). • Standardised relative risk of readmission was lower Nutrition and hydration (better) than the England average and also for the • People’s nutrition and hydration needs were assessed specialist orthopaedic trusts for both elective and on admission and we saw that these were monitored non-elective trauma and orthopaedics. throughout their inpatient stay. • The readmission rate in July 2015 was reported at 0.63% • Meal times on all wards were designated ‘protected against a target of less than 1%. Four patients were time’ whereby no visitors attended or ward rounds took readmitted as an emergency within 28 days of their place. initial discharge. • Following surgery people were given appropriate Competent staff anti-emetics for the effective management of nausea and vomiting. • We saw that staff had the right qualifications, skills and • People we spoke with told us they had received regular knowledge and they told us they were keen take on new hot and cold drinks throughout the day. Each patient we responsibilities when necessary. spoke with told us they enjoyed the meals and thought • Staff told us they were encouraged and given the portion sizes were generous. opportunities to develop. For example link nurses were • We saw that food and fluid charts were appropriately encouraged to attend training days and meetings completed for patients identified as ‘at risk’ of relevant to their speciality subject such as diabetes or dehydration or malnutrition. infection control. • We heard that where poor or variable staff performance Patient outcomes was identified the member of staff was managed and • Information about the outcomes of people’s care and supported to improve. treatment was routinely collected and monitored. This • The ward managers identified the learning needs for showed that the intended outcomes for people were staff through annual appraisals. The trust achieved a being achieved and where necessary improvements 96% compliance rate for the number of completed made. appraisals and 97% of doctors were successfully • In the Patient Reported Outcome Measures (PROM’s), a revalidated in 2014-15. higher proportion of patients undergoing hip and knee • We were told that staff clinical competencies were replacements reported an improvement in their observed and some were documented through the condition compared to the average of the specialist appraisal process. Staff appraisals were recorded as orthopaedic trusts. The Oxford Hip Score reported that 100%. Staff we spoke with told us they had all received performance was similar to average. an appraisal and thought the process was valuable. • Enhanced recovery programmes were in place for hip • We saw that continual professional development was and knee joint replacement surgery for those patients discussed as part of the appraisal process and staff told identified as suitable candidates. The programme is us that they were encouraged to attend specialist shown to produce fitter patients, fewer postoperative training if relevant to their role. complications, accelerate the recovery from surgery and • We saw that staff signed a ‘learning agreement’ to improve the quality of the patient experience. ensure they were responsible for their own knowledge • Day case performance was above target. Since July and training progression. 2014, 5102 patients had been admitted to the day case ward.

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• We saw that the Royal College of Surgeons ‘Good • We saw that patients’ capacity to give informed consent Surgical Practice 2014’ reflects the profession’s was assessed. Documentation we reviewed confirmed expectation of all competent surgeons. We saw that the that discussions and assessments had taken place. Staff standards set were followed by all surgeons. we spoke with was able to describe the process and give recent examples. Multidisciplinary working • In most cases patients gave written consent during the • Assessment, planning and delivery of people’s care and pre-admission process. This was checked and reviewed treatment was coordinated to involve all the necessary on admission. Some consultants preferred to gain the staff including members from other teams such as patients consent on admission. physiotherapist and occupational therapists. We saw • A person’s mental capacity to consent to care or that therapists worked in unison with the nursing staff to treatment was assessed and recorded in their notes on ensure optimum care and support for the patients. For admission. example we saw staff worked together to assess and • When people lacked the mental capacity to make a plan ongoing care and treatment in a timely way when decision, we saw that staff made ‘best interests’ people were due to be discharged. decisions in accordance with legislation including • The therapists we spoke with told us they were referral to the mental health team. respected by the nursing and medical staff and that the • Staff understood restraint practices, including how to multidisciplinary team working was embedded in all seek authorisation for a deprivation of liberty. areas. Seven-day services Are surgery services caring?

• Surgery was consultant delivered seven days a week Good ––– with on call availability out of hours. Daily wards rounds took place with almost all patients seen at weekends. • Out of hours imaging, pharmacy and physiotherapy Feedback from patients and their relatives was consistently services was on an on call basis with limited availability good. They told us they were fully informed of the surgical during the daytime at weekends. procedure, care pathway and length of stay prior to being admitted to the hospital. Most people we spoke with had Access to information attended on recommendation due to the reputation of the • We saw that information that was needed to deliver care and treatment. effective care and treatment was available to staff in an We saw that patients with complex needs were well accessible way. Staff told us this included care and risk supported by knowledgeable staff who understood the assessments, care plans, case notes and test results. importance of involving a relative or carer in all plans and • Ongoing care was shared appropriately, in a timely way discussions. Relatives praised the staff for their professional and in line with relevant protocols when people moved yet caring attitude. We heard that patients felt they were between teams and services at times such as referral, well supported emotionally during the inpatient recovery discharge, transfer and transition. stage and rehabilitation process. • The systems that managed information about people who used services supported staff to deliver effective Compassionate care care and treatment the majority of the time. • The average Friends and Family Test (FFT) scores for Coordination between electronic and paper based surgery in February 2015 was 99% which was above the systems did not always work in partnership and this national level. FFT scores were consistently high for caused delays in staff having access to the necessary every ward, though it should be noted that the response records. rate was lowest for Ludlow ward 38%. We were told that Consent, Mental Capacity Act and Deprivation of the staff on Ludlow ward had been reminded by the Liberty Safeguards ward manager to seek patient feedback whenever possible.

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• Between September 2014 and January 2015, a • We saw that patients and those close to them were questionnaire was sent to 850 recent inpatients at the included in multi-disciplinary meetings and ward round trust. Responses were received from 614 inpatients. In discussions eight of the 10 areas covered, patients thought the trust Emotional support was better compared to most other trusts and the remaining two areas the trust was performing about the • Chaplains were available 24 hours a day seven days a same as most other trusts that took part in the survey. week. They represented different denominations and • We observed staff to be professional in their manner had contact with all the major faith communities. whilst in the ward areas, protecting people’s privacy and • Macmillan and local hospice staff supported the ward dignity in a discreet manner. staff when difficult conversations were to take place. • We observed encouragement and reassurance being • We observed staff asking to enter side rooms and given to post-operative patients when mobilising. bathrooms when patients required assistance. Patients • We heard that the trust were able to refer patients to a told us they felt well cared for and that staff had been psychiatric specialists when patients had a mental kind, respectful and professional at all times. health need requiring psychological support or • Patients told us that they thought the call bells were treatment. responded to within good time scales and they had not had to wait an unreasonable amount of time for attention. Are surgery services responsive?

• Relatives we spoke with told us they felt that the care Good ––– was excellent, and they were fully informed about the plan of care and predicted discharge date. Patients with complex conditions were well supported by Understanding and involvement of patients and those the staff. Robust pre-admission processes were embedded close to them and the team were continually looking at ways to increase • Patients we spoke with were fully aware of their their productivity, for example assessments, where treatment plan and discharge date. Most patients we suitable, took place over the telephone. spoke with lived out of the area and had either attended All patients whose operation was cancelled received on another person’s or medical recommendation. treatment within 28 days. The trust’s performance against • In preadmission clinic, we heard clinicians describing this target was better than the England average and the the surgery, plan of care and expected length of stay to average for specialist orthopaedic trusts for every quarter. patients. Patients told us they were given opportunities Translation services were available and information leaflets to ask questions and seek clarification. were available in several different areas around the site. • Patients were allocated a named nurse on each shift. We witnessed staff introducing themselves to patients, We saw that the well organised, multidisciplinary approach in line with the ‘Hello, my name is’ campaign. ensured safe patient discharge. • Patient’s relatives told us they felt informed about the Service planning and delivery to meet the needs of plan of care and that all the staff had been supportive. local people There was evidence written in care records and discharge plans when a patient’s family or those close to • The hospital was one of the main referral centres for the them had been involved. treatment of difficult joint replacements, revision joint • All the patients we spoke told us they were aware of replacements and infected joint replacements. The what was happening to them; they told us they felt development of new prostheses and grafting techniques involved with their care. Patients told us they felt safe continue to be developed with a speciality utilising a and any of their fears had been alleviated by the nursing range of donor bone grafts and titanium implants. There and medical staff. was demand for services locally, regionally and nationally. A significant proportion of patients who attend the hospital have their services commissioned by

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Welsh Health Boards. Commissioners in Wales and • In September 2015, the cancer ‘two week’ wait time for England are working to different metrics regarding the referral and ‘31 day to treatment’ was recorded as 100%, length of time a patient waits for treatment. This means and had been so since June 2014. that the hospital has to plan to ensure these targets are • A large number of the patients who followed a 62 day adhered to. cancer pathway had been referred in from other trusts and were then passed on to other centres for • Staff were aware that patients would travel significant radiotherapy. distances to attend the hospital and planned services to • The trust supplied the recorded monthly percentage for meet their needs. For example, staff ensured that all theatre utilisation. The average percentage over 15 pre-admission tests were completed on the same day. months was 96%. In July internal theatre throughput • Pre-admission clinic staff told us that where possible levels were below plan with 95% of theatre capacity ‘local arrangements’ were made for taking blood being utilised against a target of 96%. Cases per session samples at the patient’s local practice. remained above the target of 2.2 with a ratio of 2.24 in • We heard that when appropriate, pre-admission July. assessments for some patients had been carried out • Between July and September 2015, 15 patients had over the telephone with swabs and sample bottles their operation cancelled for non-clinical reasons. All posted to the patient’s house for them to return. This patients whose operation was cancelled received process had been welcomed by some patients who treatment within 28 days. The trust’s performance were able to continue working whilst planning their against this target was better than the England average admission to hospital. and the average for specialist orthopaedic trusts for Access and flow every quarter. • Discharge arrangements were planned with the patient • Admission processes ensured that the patient was safe and their GP where necessary. We heard that district and well prepared for theatre or treatment. We saw that nurses had attended the ward when complex treatment patient reviews were thorough and informative. Where a or dressings were to be applied in the community. patient was deemed unfit for surgery the reasons were • Delays to discharge were minimal. From February 2015 fully explained and a future plan arranged. to September 2015 there were only seven patients with • Between March and August 2015, the bed occupancy delayed discharge. The seven patients were delayed 47 rate was 76%. days in total. • At the time of the inspection, we were told that 92% of patients with English commissioners were treated Meeting people’s individual needs within the 18 week target period (RTT). However, • Patients with complex needs were risk assessed prior to following the inspection, the trust provided CQC with admission. revised data that showed that 62% of patients with • We saw that patient passports were used. A patient English commissioners were admitted with the target passport provides immediate and important time and 95% were seen but not admitted. information for doctors, nurses and administrative staff • At the time of the inspection, the trust had identified in an easy to read form, promoting a positive experience that one patient with English commissioners had been for people living with learning disabilities and dementia waiting over 52 weeks for treatment. A full root cause going into hospital. analysis was undertaken and reviewed with Shropshire • Staff undertook an audit on the compliance with CCG, where it was confirmed that the patient did not national guidelines for the care of adults with learning suffer harm whilst waiting for treatment. There were disabilities between April and August 2015. The results also five patients with Welsh commissioners who waited showed that 100% of the notes reviewed had a clear over 52-weeks for treatment. It had been identified that entry that the patient had a learning disability, including these patients had medical issues which was the source one that made reference to the use of a care passport. of the delay. As of 30 June 2015, 78% of identified staff had completed the learning disabilities e-learning training.

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• Patients living with a learning disability or dementia • In July 2015, three complaints were received in surgical were encouraged to bring their carer with them to clinic services regarding care on the ward, outcome of the appointments and on admission. operation and consultant’s response at an outpatient • Work on ensuring a dementia-friendly hospital had appointment. We noted these complaints had been continued, with the introduction of the ‘Blue Butterfly responded to in a timely manner. scheme’ and dementia screening for all patients over 75 • Staff told us they attempted to resolve any issues in the pre-operative assessment unit. The Butterfly immediately on the ward to avoid complaints occurring. Scheme allowed people whose memory was We saw that they received feedback from patient permanently affected by dementia to make this clear to comments and complaints in the ward meetings. hospital staff and provided them with a strategy for • We saw notices displayed advertising the patient advice meeting their needs. The patients received more and liaison service (PALS). They provided support to effective and appropriate care, reducing their stress patients, carers and relatives, representing their views levels and increasing their safety and well-being. and resolving local difficulties on the spot by working in • Both clinical and non-clinical staff had undergone partnership with nursing staff. training to enable them to support patients living with dementia. The trust planned to continue this work in Are surgery services well-led? 2015/16 by developing a dementia friendly environment across the organisation. Good ––– • A patient told us that following a discussion with the ward staff they had been admitted the night before their surgery as it would have been difficult to attend for 7am The trust vision was supported by the staff who told us they (normal practice). They told us that the staff were very felt privileged to work in the hospital. We saw elements of caring and responsive to their needs; a nurse had high standards of individualised care delivered by friendly, offered them a cup of tea and a piece of toast just before professional staff. midnight prior to being nil-by-mouth. They went on to The surgical division continually strove to produce a high tell us they felt they were treated as an individual. level service with positive outcomes for their patients. • Translation services were available. Some staff working Robust risk assessments were completed and reviewed to in the hospital were able to translate basic issues; ensure patients remained safe whilst cared for in the ward however during medical consultations specialist environment. translators were booked when appointments were arranged. Feedback related to local leadership was positive; staff told • Equality and diversity issues were managed us they felt valued, listened to and respected by their appropriately. Where it was identified that patients immediate managers. We heard of the compassionate, required support in clinics this was pre-arranged when devoted culture of the staff and the openness that was the appointment was booked, for example sign encouraged when things did not go as planned. Staff felt language or translation services. they were engaged with the local leadership and were • Following surgery people were supported to be mobile aware of the current changes in the executive team. through minimal use of drips and catheters and where Staff showed elements of innovative changes such as the necessary we saw that discreet assistance was offered. telephone pre-admission process and the introduction of • We saw a wealth of advice/information leaflets available the capacity calculator, ensuring clinic time was fully for patients and relatives to read about self-help, utilised. surgical conditions and treatments and access to specialist services. Vision and strategy for this service Learning from complaints and concerns • We heard that staff understood the trust vision to be the leading centre for high quality, sustainable orthopaedic and related care, achieving excellence in both experience and outcomes for their patients.

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• Staff were aware of the role they had to play in achieving • We heard that ward staff felt well supported and the vision and we heard of many examples of high listened to by their managers. The newly appointed standards of care and attention being delivered by matron provided local leadership and visited the wards friendly, professional staff. at least once a day to speak with nursing staff and ward managers. Governance, risk management and quality • Ward staff told us they rarely saw the executives on the measurement ward although they were able to tell us about the recent • There were systems in place to identify record, manage changes that had occurred. We were told that and mitigate risks. The integrated performance report occasionally they had been introduced to a visiting had been developed in order to assist the service in board member. monitoring the delivery of key performance metrics • Where staff were not following infection prevention and against local and national targets and communicating control procedures for hand hygiene we saw that senior any issues to the trust board. The report covered the five medical leaders were not modelling behaviours that key domains of patient safety, patient experience, would lead other staff to follow the policy. resources, efficiency and external perception. The • The matron held monthly ward manager meetings overall performance for July 2015 demonstrated where data from the ‘STAR’ boards was discussed. The continued achievement across the key standards and managers were invited to outline their planned actions scorecard metrics. where deficiencies and non-compliance were evident. • One Never Event was reported in September 2014 as The matron told us future meetings would include wrong site surgery. We identified that specific standard colleagues from human resources and finance operating procedures had been written but the pace of departments to support and develop the ward implementation was slow and the service had not yet managers. audited practice to demonstrate that change had been Culture within the service effected. • The surgical division was aware of its key risks and had • We were told on several occasions by staff that they felt systems in place to control them. The risk register the hospital was very patient focussed, offering (non-theatres) showed that 123 risks were logged; three compassionate care whilst treating patients as of the 30 high risks were rated as “likely to happen”. individuals. Staff told us there was a culture of openness These related to environmental issues such as overflow and honesty with the patients being informed of any of patients in clinics due to lack of space. incident or untoward event. • The risk register for theatres showed that 159 risks were • Many staff we spoke with had worked at the hospital in logged; two of the 69 high risks were also rated as “likely excess of 15 years, which showed their commitment to to happen” and were related to equipment issues. the service. We heard that the staff were encouraged to • Where there was non-compliance with policies and share good practice and success stories but there had procedures we saw this was not being challenged or been a culture of not sharing less positive events. questioned, particularly where staff were not following • Newly employed staff told us they had received a warm infection prevention and control procedures for hand welcome and quickly felt part of the ward team. They hygiene on the ward areas. had completed an induction, had a mentor and felt that the ward manager was approachable. Leadership of service • We heard that staff teams were friendly, sociable and • We saw that the surgical division followed a very morale was generally good. medically led model of leadership. The surgical director Public engagement oversaw the clinical leads and we heard that they were visible, approachable and respected by the medical • There was overall positive feedback from the patients team. we spoke with. We heard many examples of patients • Leadership within theatres was found to be established feeling fully informed, respected and safe. with a positive working environment.

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• Patients told us they felt privileged to be treated at the • Staff we spoke with were fully aware of the recent hospital and many had travelled from another part of changes within the trust; they felt listened to and valued the country to be there; they told us how they supported knowing that they were engaged with the events. the League of Friends in fundraising for the hospital. Innovation, improvement and sustainability • We saw that patients were encouraged to leave feedback about their experience via the FFT and NHS • There was a positive approach towards innovation and choices. improvement and we saw a range of innovations across the service. Staff engagement • The development of new prostheses and grafting • We saw copies of the monthly staff newsletter which techniques continue to be developed with a speciality was delivered to each ward. This was discussed at the utilising a range of donor bone grafts and titanium ward meetings; staff were encouraged to send in stories, implants. events or feedback from training to cascade good news • The newly introduced capacity calculator ensured that and positive working practices. the clinic staffing matched the capacity of anaesthetist/ • Staff were encouraged to attend ward meetings and link medical cover, ensuring that clinic space was fully meetings to keep updated on current issues. utilised. • A telephone helpline was available for all hip and knee replacement patients.

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Critical care

Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Requires improvement –––

nurses, doctors, and managers. We observed care and Information about the service treatment, and looked at the records of eight HDU patients. Before the inspection, we reviewed performance The hospital had a high dependency unit (HDU) with five information about the hospital. beds for patients requiring level two care. Level two care is for patients requiring more detailed observation or intervention, single failing organ system or postoperative care, and higher levels of care. There are four beds in the main ward area and one side room. The unit operates on a 24-hour seven days a week basis and is staffed to the intensive care standards of staffing which is a ratio of one nurse for every two patients. A new HDU facility, which will have seven beds, is currently being built as part of the hospital's new theatre complex and will be completed in early summer 2016. There have been 807 patients admitted to HDU in the last 12 months. Since 1 April 2015, seven children between 13 and 17 years old had been cared for in HDU. The majority of patients who were admitted to the unit were booked elective patients post-operation and require enhanced nursing ward (level one) with a lesser number requiring level two care (high dependency) This means they were usually on the unit for 24-hours. In addition, deteriorating patients from within the hospital may also be admitted. For those patients who require additional support or monitoring on the wards, the unit has a critical care outreach team who go out to patients on the wards, rather than moving the patient to the unit. We visited the HDU during our announced inspection. We spoke with seven patients and 12 staff which included

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Summary of findings Are critical care services safe? Although there were appropriate medical and nursing Requires improvement ––– staff available to care for adult patients, when a young person was in HDU a paediatric anaesthetic consultant Whilst the arrangements for consultant staff did not meet would not necessarily be available to provide intensive care core standards it did meet adult patients' appropriate support in line with national standards, but needs. When a young person was in HDU a paediatric it met the needs of the patients. anaesthetic consultant would not necessarily be available Improvements were needed to ensure doctors and to provide appropriate support in line with national outreach staff could make a timely response to standards, but it met the needs of the patients. The identified concerns. Staff had mostly received required number and skill mix of nursing staff did meet patients’ mandatory training but not all staff had completed needs and intensive care core standards. children’s life support training to ensure they had Doctor records were not always complete and did not appropriate skills and competency to respond to a always record any review undertaken or revised treatment paediatric emergency. Plans were in place to address plan during the evening or out of hours. This may this. compromise the continuity of patient care. Nurse records Doctor records were not always complete and did not were complete and accurately identified patients' always record any review undertaken or revised treatment. treatment plan during the evening or out of hours. This The hospital used an early warning scoring system to may compromise the continuity of patient care. monitor a patient’s condition and identify if they were Multidisciplinary working was in place although deteriorating. There was no assurance that outreach staff handovers and ward rounds were not multidisciplinary. or the doctor on call would receive timely notification of a There were appropriate systems in place to highlight declining score to ensure that they could respond risks, incidents and near misses. Appropriate actions appropriately to identify concerns. were taken to ensure lessons were learned. The HDU Staff were up to date with most mandatory training. Not all was clean and there were appropriate systems in place HDU staff had appropriate paediatric life support training to minimise the risk of cross-infection. The availability and not all outreach staff did had appropriate paediatric and use of equipment was found to be appropriate to life support training to ensure that staff had the meet patient's needs. There were appropriate appropriate skills and competency to effectively respond to arrangements for the safe administration and storage of a paediatric emergency either within HDU or within the medicines. hospital. Patients were treated with compassion and respect. There was an embedded system for reporting, investigating Whenever possible patients and relatives were and learning from incidents and near misses. The consulted and informed about the treatment they or availability and use of equipment was found to be their relative would receive. Staff felt valued, respected appropriate to meet patient’s needs. Resuscitation trolleys and supported and staff had appropriate training and and equipment were accessible and had been checked as development opportunities. per trust policy. There were appropriate arrangements for the safe administration and storage of medicines. Incidents

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• No Never Events were linked to the HDU from 1 May (VTE) screening, and falls. Safety thermometer 2014 to 30 April 2015. A Never Event is a largely information was incorporated into the high dependency preventable serious patient safety incident that should unit quality performance dashboard which was used to not occur if the preventative measures have been provide evidence of assurance to the trust board. implemented. • Pressure ulcers, falls and catheter related infection rates • There were no serious incidents reported to the were all below the national average. Between April 2014 Strategic Executive Information System (STEIS) from 1 and June 2015, there had been no pressure ulcers or May 2014 to 30 April 2015 which were linked to HDU. patient falls with harm and just one catheter urinary • The trust had an established process for reporting tract infection reported. There were no reported cases of incidents and near misses through an electronic Methicillin-resistant Staphylococcus Aureus (MRSA) or reporting system. The HDU had reported 22 incidents Clostridium Difficile (C Diff) reported between from 1 September 2014 and 31 August 2015, eight were September 2014 and August 2015. graded as moderate harm, one low harm and 13 no • The trust had provided all wards and departments with harm. Seven incidents of moderate harm related to the a white board to display patient safety information. access, admission, transfer and discharge of patients However the ward manager explained due to the from HDU. Each incident submitted was reviewed by a location and layout of HDU they had not been able to senior nurse or consultant. The ward manager told us put up their board. The ward manager said that when that any subsequent investigation into the incident was they had moved to the new unit there would be an proportionate to the grading and any harm to the opportunity to display patient safety information. patient involved. Cleanliness, infection control and hygiene • All patient deaths within the hospital and all post operatively within 30 days were reviewed by the clinical • The HDU was clean and well maintained. There were lead for HDU. The findings of the investigation were cleaning plans in place, which identified the frequency reported at the ‘deteriorating patient group’ and reports that cleaning should take place and staff signed to were discussed within the multi-disciplinary clinical confirm when cleaning had been undertaken. Bed effectiveness group and the quality and safety group. cleaning was identified as part of the cleaning schedule. • Nursing staff and doctors we spoke with were aware of • Patients were mostly admitted to HDU with their ward the ‘Duty of Candour’; they told us it was about being bed and the HDU bed was transferred to the bed space honest and apologising if things went wrong. The ward left on the ward. There was no system in place to manager confirmed that the duty of candour was provide assurance that the HDU bed had been cleaned followed and actions were dependent on the level of at the required frequency because of this rotation harm. The ward manager told us that, for example, if a system. We discussed this with the ward manager who patient’s surgery was cancelled because no HDU bed agreed this was problematic and this would be was available, then the anaesthetist would go to see the addressed. patient and apologise and explain the reason why their • Hand sanitising gel was located at the entrance to HDU surgery had to be cancelled. We saw information and at each bed space and throughout the unit. Visible displayed about the ‘Duty of Candour’ and actions that signs were displayed to remind both staff and visitors staff needed to undertake which was dependent of the about hand hygiene were visible. level of harm. • We observed staff were bare below the elbow to aid effective hand hygiene. Staff washed their hands, used Safety thermometer hand gel and personal protective equipment (PPE) • The high dependency unit participated in the Patient appropriately. Effective hand washing alongside the use Safety Thermometer programme which is a tool used to of gloves and aprons help to reduce the risk of measure, monitor and analyse patient harm and harm cross-infection. free care. Data was gathered and reported on a monthly • There were weekly audits which included cleanliness, basis to indicate key performance in safety areas such as hand hygiene, use of PPE, cleaning and the appropriate infections, pressure ulcers, venous thromboembolism

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management of peripheral venous catheters and central Medicines venous cannula. All the audits we saw identified 100% • There were systems and processes in place to ensure compliance with infection prevention procedures and that medicines and intravenous fluids were stored and were undertaken by a senior nurse. administered safely. • There was a monthly mattress audit in HDU. Information • The medicines fridge temperatures, including the provided by the trust for audits between April and minimum and maximum temperatures were recorded September 2015 showed that no mattresses were daily. A regular check of temperatures provided damaged or stained. This provided assurance that assurance that medicines were stored safely, and their mattress contamination had been minimised. effectiveness was not adversely affected. • We saw that infection prevention audits were • There were suitable arrangements in place to store and undertaken bimonthly and included a check on the administer controlled drugs. Stock balances of cleanliness of HDU. The audits confirmed that controlled drugs were correct and two nurses checked appropriate arrangements were in place to reduce the the dosages and identification of the patient before risk of cross infection. medicines were given to the patient. We saw that a • Staff told us that side rooms were used, where possible, check of controlled drug balances was recorded at each as isolation rooms for patients identified as having an shift change. increased infection risk. These rooms could also be • There were additional audits of controlled drugs by used to protect patients with low immunity if needed. pharmacy staff. We observed that when shortfalls were Environment and equipment identified this was shared with staff by the unit manager within the unit’s newsletter to staff. • We saw that that the unit was cramped; there was • We checked a total of five sets of patient medication limited space around beds, limited storage space and charts. All the medication records we checked were the side room was small. It could be difficult when the found to have been completed correctly. unit was fully occupied in an emergency situation to • Emergency medicines were available for use and there ensure essential equipment was accessible for staff. was evidence that these were regularly checked. Staff told us this would not be in an issue in the new • The hospital had an on-site pharmacy and pharmacists HDU currently being built. were available during the day with a call out system in • The unit had a combined adult and paediatric place for emergency cover out of hours. resuscitation trolley with separate equipment. We saw that the resuscitation equipment was regularly checked Records and, when needed, restocked. There was a record of • We looked at eight patients records on the unit. when these checks had been undertaken and by which Paper-based nursing documentation, which included a staff member. record of their observations and risk assessments, was • We saw that equipment had been maintained and present at each bed space. Risk assessments included serviced when required. pressure ulcer risk, nutrition risk, coma scale, and • The ward manager told us that they had the required delirium assessments. We saw that observations were equipment to meet patient’s needs. HDU had five checked and recorded at the required frequency and ventilators should a patient deteriorate and require any deviation from expected results was escalated to stabilisation. There was one portable ventilator to medical staff. ensure that any patients who needed to be moved to • Records were completed and filed in a consistent another hospital whilst on a ventilator could be moved manner to enable staff to easily locate required safely the ward manager confirmed that staff received information about the patient, their treatment and care training in the use of both normal and portable needs. ventilators. • Medical notes we looked at identified the patient’s • An intercom system which visitors used to gain access treatment plan before they left theatre. We also saw that was in place at the entrance of HDU to ensure the area records included details of their review the following day and patients were kept safe and secure. including if the patient was fit for discharge from HDU.

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• We saw that visits by the patients' surgeon or surgical • The ward manager told us that all band six nurses who registrar were consistently recorded. We found that in were ‘shift leaders’ had PILS training to ensure that there four patients records we looked that on at least one was always at least one nurse on duty who could occasion during the evening/ night after their surgery provide life support to children in an emergency. the patient had been seen by an anaesthetist but there • The ward manager also told us that there was a plan for was no record of these visits or revised treatment plan. all outreach staff to have European Paediatric Life Nursing staff confirmed that visits had taken place but Support (EPLS) training to ensure that they were able to had not been recorded. respond appropriately if a child required resuscitation. • Nursing staff said there were times when consultants Currently three staff out of ten staff had completed rang the unit from home to check on a patient and the training. The manager told us that four staff had been record could not be completed by them. However, other booked to attend an EPLS course in January 2016 and reviews of the patient when the anaesthetist was the remaining three staff would be attending present were frequently not recorded. subsequent courses. Safeguarding Assessing and responding to patient risk • The trust policies and procedures were in place for • The hospital used the national early warning score safeguarding children and vulnerable adults. Staff that (NEWS) to identify acutely ill adult patients. A paediatric we spoke with knew how to access safeguarding early warning score (PEWS) was used to identify acutely policies and procedures on the trust’s intranet and were ill children. aware who the adult were and children’s safeguarding • The hospital had an outreach team with one staff leads for the trust were. Staff we spoke told us they had member on duty between 7.30pm and 8am weekday received safeguarding children and vulnerable adults nights and 24 hours a day at the weekends, the training, and confirmed actions that would be outreach team provided advice to wards when they had undertaken to keep people safe. concerns about patients who were deteriorating and • The trust had a target that 90% of staff should have ensured appropriate actions were undertaken and also safeguarding children training. Information provided by followed up patients following their discharge from the trust identified that 100% of HDU staff had received HDU. both level one and level two children’s safeguarding • A patient’s NEWS was calculated from each observation training. One hundred per cent of staff had completed recorded in the patient’s records. The score then level one safeguarding vulnerable adults training and identified deteriorating patients who required further 95% had level two safeguarding vulnerable adults review by a HDU doctor or outreach team. The team/ training. doctor then assessed the patient and a decision was made in relation to their on-going management. Mandatory training • The hospital wards used an electronic system to record • Mandatory training attendance for nursing staff was patient’s observations. In HDU observations were monitored by the matron and ward manager. recorded on this system when patients were initially • The trust had a target of 90% of staff having received all admitted to HDU and two sets of observations before required mandatory training. Training information they returned to the ward. This enabled ward staff to provided by the trust identified that HDU staff had accurately assess changes to observations and when achieved this target for most mandatory training areas needed respond to this to keep patients safe. including health and safety, moving and handling, • The electronic system generated an ’alert’ when the information governance, equality and diversity and NEWS identified increased patient risk. Although this basic life support training. alert was immediately sent to the doctor who was on • Ninety percent of staff had completed advanced life duty for HDU and the outreach team, would have to log support training, 85% intermediate life support training onto the system before any alerts could be read and and 60% paediatric life support (PILS) actioned. If the nurse or doctor was out and about on the wards, they would carry a bleep and staff would use these to alert them to any deteriorating patient; there

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was no remote system for alerting them. There was • There were 12 anaesthetic consultants who worked in limited assurance that outreach staff or the doctor on the HDU on a rota basis. Each consultant provided cover call would receive timely notification of a declining to HDU for 24-hours at a time. Intensive care core score to ensure that they could respond appropriately standards advocate the consistency of consultants in to identify concerns. HDU. However as HDU mainly provided post-operative care for patient for less than 24 hours before they Nursing staffing transferred to the back to the ward, this was less • The required and actual number of nursing staff on duty problematic and met patients’ needs. for each shift was displayed in the HDU. During our visit • Four of the 12 anaesthetists who worked in the HDU the required number of staff were on duty. were paediatric trained. If a child was admitted to HDU, • The unit could accommodate up to five level two a paediatric trained anaesthetist would not necessarily patients and there was always three nursing staff on be on duty for that period but staff would be able to duty to provide care for HDU patients. This met core contact the anaesthetist who anaesthetised the child if standards for intensive care units. required. • Outreach staff told us whilst they were on duty they also • The HDU had a ratio of one consultant for up to five provided “site cover” alongside their role of reviewing patients; this met intensive care core standards of a high risk patients. Staff told us as part of the site cover ratio of not more than 1 to 15. role they were expected to respond to issues such as • In the event of sickness, doctor shifts were covered by ensuring there was suitable ward staff cover if staff rang another doctor providing cover with support from the in sick, obtaining medicines from the out of hours on call anaesthetist. medicines store and responding to security concerns. • The clinical lead for HDU was an experienced There is a potential risk with this arrangement that staff anaesthetic consultant who had intensive care may not be available for deteriorating patients when experience. required if they are dealing with other issues elsewhere • The doctors within HDU had twice daily handovers and in the hospital. a daily ward round. This meant that patients’ health and • As the unit only had five HDU beds there was no recovery was assessed to ensure they received requirement for a supernumerary nurse to be on duty appropriate and timely treatment. under the intensive care core standards. However the • At night, a middle grade doctor who was on site, ward manager was supernumerary for two shifts a week. provided cover for the hospital including HDU. This • When shifts could not be covered by HDU staff working doctor would not necessarily have experience in the their contracted hours, shifts were filled by HDU staff care of children if a child was on the HDU but a working additional hours. The unit did not use agency consultant anaesthetist was on call from home and if staff. needed could be in the hospital within 30 minutes and • If a child required HDU care, either after their operation on-call paediatric support was provided from a local or if they deteriorated whilst on the ward, a children’s acute hospital. qualified nurse from Alice ward would accompany them Major incident awareness and training whilst they were on HDU, in addition to the HDU nurses already on the unit. Staff told us that paediatric nurse • The trust’s major incident policy identified patients cover was arranged by the ward manager on Alice ward would not be directly admitted following a major before the child went to HDU. We spoke with Alice ward incident as the trust does not have an emergency manager who also confirmed this arrangement. department. However the policy identified that the • Nursing staff told us that handovers occurred at least hospital would need to receive patients transferred from twice a day at each shift change. During handovers staff local hospitals as part of their major incident communicated any changes to patient’s condition or procedures. As part of this process, patients who could treatment to ensure that required actions were be discharged from HDU would be moved to free up undertaken to minimise risks to patients. beds for patients who would be transferred. Medical staffing

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• Outreach staff held the hospital bleep out of hours. • Enhanced recovery programmes were in place for hip Information we received from the trust confirmed that and knee joint replacement surgery for those patients all ten outreach staff had received major incident identified as suitable candidates. The programme was training. shown to produce fitter patients, fewer postoperative • Fire evacuation plans and fire exits were clearly complications, accelerate the recovery from surgery and displayed on HDU. We observed staff fire training which improve the quality of the patient experience. HDU also included evacuation of patients on a stretcher and followed the enhanced recovery pathway for identified being moved downstairs. patients. We saw evidence of this in patient’s records we looked at. Are critical care services effective? • There were care pathways in place such as the management of peripheral intravenous central lines, the Requires improvement ––– management of infections and rehabilitation of surgical patients in HDU. We saw that the care pathways were audited to check that they were appropriately followed. People received effective care and treatment based on Results of the audits we saw identified 100% nationally recognised best practice, which met their needs. compliance with required procedures. However the HDU did not contribute data to the Intensive Care National Audit & Research Centre (ICNARC) or similar Pain relief and had not undertaken any local audits, therefore it was • A pain scoring tool was used in HDU. The pain not possible to benchmark its effectiveness against other assessment included patients own scoring of their pain. similar units. There was also a pain scoring tool for people who were There were arrangements in place to ensure that both living with dementia and may not verbally be able to tell nursing and medical staff had appropriate training and staff they were experiencing pain. development opportunities. Staff understood their • Staff told us that they had support from the acute pain responsibilities around the Mental Capacity Act 2005 and team who were available Monday to Friday and would Deprivation of Liberty Safeguards. visit when needed. At other times the outreach team and on call anaesthetist provided advice on treatment Multidisciplinary working was in place although handovers for patient’s pain. and ward rounds were not multidisciplinary Seven-day • The records we looked at confirmed that patients had working was in place for medical, nursing staff and regular pain relief. Patients we spoke with told us staff physiotherapists. There were appropriate care pathways ensured they had the pain relief they needed and they and clinical audit programmes in place to monitor were kept comfortable. adherence with guidance. Nutrition and hydration Evidence-based care and treatment • Patients we spoke with said that the food was tasty and • HDU used a combination of National Institute for Health appropriate for their needs. We observed that drinks and Care Excellence (NICE), Intensive Care Society, were accessible for patients and that, when needed, Faculty of Intensive Care Medicine (FICM) guidelines to nursing staff provided appropriate assistance. determine the treatment it provided. Local policies were • A review and audit of mealtimes in HDU was undertaken written in line with these. in June 2015. The audit included identification of the • There were appropriate and timely arrangements in time taken from delivery of the meal trolley to serving place for deteriorating patients to be reviewed by the meals, whether patients received required assistance, outreach team. The availability of the outreach team had a clear space on their bed table for their meal tray, if and timely review of patients met the requirements of there was any interruption such as a medicine round or NICE guidance using the local guideline new early a visit from a doctor and whether they patients were warning score CG35 Prediction and Detection of happy with the meal provided. The audit identified that Impending Critical Illness in Adults. all these actions were consistently completed.

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• Should the unit have patients who were at risk of • All new nursing staff had a hospital and local induction dehydration or poor nutrition there were appropriate in HDU. They had a four week supernumerary period (six arrangements in place to highlight the risk and actions weeks for newly qualified nurses). New staff were to be taken. assigned mentors. • Policies were in place to enable patients who were • All nurse competencies were checked against standards unable to take oral nutrition or fluids to be given identified by the critical care network. specialist feeds until they could be seen by a dietician. • HDU nursing staff had received support for development This meant that patients were protected against the risk from the nurse consultant. During the absence of the of malnourishment. nurse consultant, staff had support from the ward • The trust had a dietician available Monday to Friday and manager and also the trust practice nurse educator. at weekends they could also seek advice from the • At the end of April 2015, 100% of HDU staff had had an dietician at Shrewsbury and Telford Hospital NHS Trust. appraisal. All staff we spoke with confirmed that they received an annual appraisal. Patient outcomes • The clinical lead said that plans had been developed for • HDU did not contribute data to Intensive Care National consultants who worked in HDU to visit another local Audit and Research Centre (ICNARC), to benchmark the hospital’s critical care unit to review to enable them to service against other similar hospitals and we were not update their competencies. made aware of any local audits carried out by the unit in Multidisciplinary working respect of patient outcomes. • The clinical lead told us eighteen months previously • Staff told us that when needed, physiotherapists they had contacted ICNARC to discuss the possible provided support. However as patient mostly returned inclusion of the unit and the benching of the unit to their ward the day after their surgery, against ICNARC data. They were told at that time as a physiotherapists mostly reviewed their care and small specialist unit providing mainly overnight progress when patients returned to their ward. post-operative care for orthopaedic patients, they would • Staff told us that a microbiologist visited the unit weekly not be able to effectively bench the service. from a local trust. At other times, staff could obtain • However following our inspection we were informed telephone advice. This meant that advice was provided that the clinical lead had contacted ICNARC again and which reflected changing recommendations and was in the process of applying for inclusion to enable immediate changes could be made in response to the service to be bench marked against similar services. national guidelines. However at the time of our inspection we were unable • There were visits to HDU five days a week by a to compare patient outcomes for the HDU against other pharmacist during which the patients’ medicine needs similar hospitals. were reviewed. • Between 1 September 2014 and 31 August 2015 there • There was one outreach team member available had been 27 unexpected readmissions to HDU (3.5%). between 7.30pm and 8am weekdays nights and 24 • Since 1 April 2015 there have been six patients hours a day over the weekend. Staff told us that the transferred to other hospitals to receive level three care availability of the outreach team provided additional (intensive care). support to patients out of hours when there were fewer doctors on site to provide advice and support to very ill Competent staff and deteriorating patients. All patients discharged from • The high dependency unit had 79% of nurses with a HDU were reviewed by the critical care outreach team post registration qualification in critical care which met the night after their discharge from the unit. the required standard of at least 50% of nursing staff • The hospital was part of the critical care network and if a with this qualification. Managers told us that two patent required additional care, a suitable bed within a additional staff members were due to complete this critical care unit would be identified. qualification by June 2016. Seven-day services

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• HDU was open and fully staffed seven days a week, 24-hours a day. Are critical care services caring? • An anaesthetist visited HDU seven days a week. At other times and overnight, cover was provided by the Good ––– consultant anaesthetist on call. • Physiotherapists were available seven days a week Patients received a caring service. Patients were given good although there was a reduced presence the weekends. emotional support, and throughout our inspection we saw • Pathology was available seven days a week. patients treated with compassion and respect. • Radiology and radiography services were led by a consultant who was available for urgent x-rays and Whenever possible patients and relatives were consulted scans seven days a week and during the evening and and informed about the treatment they or their relative overnight. would receive. Patients appreciated that staff pro-actively • The hospital pharmacy was open Monday to Friday and enabled them to maintain contact with their loved ones half day on a Saturday. Staff told us that they were able through use of the unit’s mobile phone. to obtain patients’ medicines seven days a week. Compassionate care Access to information • Patients were positive about staff and the care they • On the HDU nursing notes were kept at the patient’s received on the high dependency unit. One patient told bedside and were accessible by staff at all times. Staff us, “They have been excellent and kept me informed. I could access electronic care and treatment policies and cannot fault them”. A child told us "The nurses are all procedures at all times. very kind and friendly”. • The HDU manager attended the senior sister meeting • Throughout our inspection, we saw patients being with the matron and shared the outcome of these treated with compassion. meetings with staff. Staff meetings were held monthly • Privacy arrangements for patients were acceptable and and there was also a monthly newsletter when we saw that staff were mindful of patients privacy and information was shared with staff in addition to email dignity at all times. We observed staff talking to patients and face to face. and relatives in a respectful and friendly manner. • Between 1 July and 30 September 2015, 26 out of 27 Consent and Mental Capacity Act (96%) of patients who completed the HDU patient • Staff we spoke with were clear about their survey said they were always treated with compassion, responsibilities in relation to gaining consent, including dignity and respect. those people who lacked capacity to consent to their Understanding and involvement of patients and those care and treatment. close to them • Nursing staff told us they had received training about the Mental Capacity Act 2005, as part of their • Patients told us that they had been informed of their safeguarding vulnerable adults training. Information care needs and options for their treatment both during provided by the trust identified that 90% of HDU staff their preadmission assessment and by staff in HDU had received training about the Mental Capacity Act. since their admission. Patients said that staff had Staff understood their responsibilities under the Act and explained their treatment and they had been asked to what actions to take in patients' best interests. provide consent to their treatment and staff had acted in accordance with their wishes. • Patients told us: “I cannot fault them”; “They have all been excellent” and “Best care ever”. • We observed staff during our visit hand over the unit’s portable phone to a patient to speak to their loved ones. The patient said they really appreciated this and

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speaking to them had put assured their loved ones that accommodate patients seven days a week twenty-four they were alright. Staff told us that it was usual practice hours a day. Demand for HDU services was dependant to enable patients to speak to their loved ones. We saw on surgical and medical services so services could be this as good practice. planned to reflect their requirements. • The current HDU had five level two beds. A new HDU Emotional support which will have seven beds and additional space was • Staff were seen to give good emotional support. We saw part of the new theatres build; this will be completed in that staff were reassuring with patients and sensitive to early summer 2016. their emotional needs. Meeting people’s individual needs • A chaplaincy service was available, which provided valuable support to patients and relatives. • The Department of Health required all providers of NHS • The ward manager told us that they could contact the funded care to confirm by 1 April 2011 that they were psychologist on the spinal ward for advice should any compliant with mixed sex accommodation except patient require additional emotional support. where it was in the patient’s best interests or reflected their choice. A breach of ‘mixed sex accommodation’ Are critical care services responsive? refers not only to sleeping arrangements but also bathrooms and toilets and the need for patients to pass Requires improvement ––– through areas for the opposite sex to reach their own facilities. The current facility does not meet these requirements. The current HDU unit had neither toilet nor shower • There was no toilet or shower facility on HDU, although facilities available. Although the majority of patients were a toilet and shower would be available in the new HDU. on the unit for less than 24 hours this arrangement did not • The HDU mainly provided care for adults. Although meet the needs of individuals. since 1 April 2015 seven children between 13 and 17 Facilities for visitors also did not meet individual needs. As years of age had been cared for in there. Staff told us HDU was situated within the recovery area of theatres, that children were cared for in the side ward and were visitors had to first go to the patient’s original ward and had always accompanied by a children’s nurse who was to be accompanied to HDU by hospital staff. If relatives supported if required by HDU staff. Paediatric intensive wished to stay with their loved one there was no rest room care standards are clear that children and adults should or facilities for them to make a hot drink. There was also no not be cared for on the same unit. quiet area or room for relatives to receive bad news. • Privacy curtains were closed and staff were seen to ensure they remained closed to maintain patients’ The accommodation of both children and adults on the dignity. However we observed that whilst a doctor and a same unit was contrary to national guidance. nurse had a trolley behind the privacy screens this Within HDU, suitable support for patients living with meant that the curtains could not be fully closed due to physical and learning disabilities, dementia, or those who the limitation of space. had communication difficulties, was available, if needed. • There was no waiting room, visitor’s room or room where bad news could be broken. However visitors' Service planning and delivery to meet the needs of facilities would be available in the new HDU. local people • HDU had a link nurse for both dementia and learning • HDU provided care for surgical patients who required disabilities. We spoke to the dementia link nurse who increased monitoring and or who had high dependency told us that the ‘butterfly’ scheme had been needs after their surgery and for patients who may implemented in HDU. Link dementia nurses had been deteriorate whilst on the wards. The HDU was staffed to trained in the butterfly scheme and then had disseminated training to other staff to increase staff awareness of dementia. • The link nurse told us that people living with dementia had a passport which provided information about them

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to staff. Butterfly stickers and magnets could be added • Length of stay for patients on the HDU was relatively to patient’s notes including x-ray forms to ensure that all short. In the last six months, 70% of patients remained staff were aware that the person was living with in HDU for less than 24 hours, 19% between 24 and 47 dementia. The link nurse showed us that they had hours and 11% over 48 hours produced a laminated care for quick reference for staff Learning from complaints and concerns which included information about dementia, the butterfly scheme and other agencies which staff could • There had been no complaints about HDU in the last 12 contact for advice. months. • We observed that there were clocks with the time, • Staff told us that if a patient or relative wanted to make whether it was day or night and day to orientate an informal complaint, they would be directed to the patients. The dementia link nurse told us that they had nurse in charge. Staff would direct patients to the introduced the clocks for people living with dementia Patient Advice and Liaison Service if they were unable to and this had been positively received by all patients deal with concerns. Patients would be advised to make • We saw there were boxes of aids to help communication a formal complaint if their concerns could not be with people living with dementia or a learning disability. resolved locally. Staff also told us that whenever possible they involved • Complaints information was included on the scorecards families in the care of people who were living with which were discussed at departmental meetings. On a dementia of a learning disability. monthly basis, senior leadership received a report • Staff confirmed that translation services were available detailing any complaints received. if required. Access and flow Are critical care services well-led?

• Average bed occupancy for HDU from December 2014 to Good ––– May 2015 was 64%. The national average critical care bed/ HDU occupancy was 86%. This meant that there were sufficient beds to meet patient’s need. HDU was well led. Staff working in HDU were aware of the • Staff told us that the majority of admissions to the unit trust’s vision and demonstrated commitment to its were planned and related to their planned surgery. objectives and values. The leadership, governance and Potential admissions to the HDU were discussed with culture of HDU promoted the delivery of high quality the consultant covering HDU prior to their admission. person-centred care. Staff felt valued and respected. Staff were supported by managers and were positive about the • Between 1 September 2014 and 31 August 2015 there care they provided. Financial pressures were managed so have been three operations cancelled because no HDU that they did not compromise the quality of care. There bed was available. was a focus on continuous learning and improvement. Safe • From 1 April 2015 there have been four out of hour’s innovation was supported. transfers from HDU (between 10pm and 06.59 am). • Staff told us that they did not have any delayed Quality received sufficient coverage within department and discharges as patients kept their ward bed and as soon governance meetings. There was an effective process in as the consultant identified they were fit for discharge place to identify, understand, monitor and address current they could be transferred back to their usual ward. and future risks. Performance issues were escalated to the • As the majority of HDU patient admissions were planned relevant managers and quality assurance meetings and to and frequently provided enhanced nurse monitoring the board through clear structures and processes. they were able to manage patient admission. As a result A lack of ICNARC benchmarking data or other patients there had been no non clinical delayed discharges from outcome information meant that the leadership were HDU. unable to fully reflect on the performance of the unit compared to other similar units. Vision and strategy for this service

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• Staff were aware of and understood the vision and trust was able to bench performance and identify any values of the trust and the behaviours that would potential risks of the service. The unit manager told us achieve these values. Staff told us that their vision was that they were developing a business case to fund the to provide excellent patient care to the highest submission of ICNARC data. standard. Leadership of service • The clinical medical lead and ward manager were clear on the strategy for HDU. They told us that HDU mostly • HDU had a clinical medical lead that had intensive/ high provided level one care, which could be met on a ward dependency experience. HDU staff said that the clinical but HDU had higher staffing levels and could provide lead was dynamic. One staff member said, “People enhanced patient monitoring. Some level two care (high listen to him”. A nurse consultant (band 8) who had a dependency) was also provided. The clinical lead told specialist qualification in critical care had overall us that the reason why they were able to provide responsibility for the nursing elements of the services. excellent care was that they knew their limitations and This met core intensive care standards. as a remote unit they had no desire to provide level • The ward manager was supernumerary for two shifts a three care (intensive care). week which was in line with intensive care core standards for a five bedded high dependency unit. Governance, risk management and quality • The leadership drove continuous improvement in measurement patient care, sharing good practice and highlighting • There were monthly department meetings where audit findings with staff and when improvements were complaints, incidents, audits and quality improvement needed. projects were discussed and reviewed and when • We saw that both medical and nursing leadership were needed increased risks were identified and actions put actively involved in quality improvement. For example, in place to minimise any identified risk. the clinical medical lead reviewed all patient deaths • There were systems in place to identify record, manage throughout the hospital and feedback the findings to and mitigate risks. The integrated performance report within the hospitals governance meetings. had been developed in order to assist the service in Culture within the service monitoring the delivery of key performance metrics against local and national targets and communicating • Staff spoke positively about working for the hospital and any issues to the trust board. The report covered the five the unit. All staff told us they would recommend it as a key domains of patient safety, patient experience, place to work or for treatment and that senior staff were resources, efficiency and external perception. The supportive. overall performance for June 2015 demonstrated • Staff commented that they were “a good team”. continued achievement across the key standards • The manager told us that they were proud of their team • The clinical lead for HDU chaired the quarterly and their commitment to high quality patient care. deteriorating patient group meeting and the minutes Public engagement were shared with the clinical effectiveness group and the quality and safety meetings. Learning from meetings • An on-going patient survey provided valuable feedback was shared by the ward manager and included in the from patients and their experiences of care within HDU. staff newsletter. • We saw between July and September 2015 there had • Risks inherent in the delivery of safe care were identified been 28 comment cards received from HDU patients, 27 on the trust’s risk register: the HDU risk register had eight people provided an overall rating as ‘excellent’ and one identified risks of which included: Compromised blood person rated the service as ‘good’. gas analysis during a power failure in HDU, the risks of Staff engagement only two staff available in HDU overnight and inappropriate use of identified equipment. HDU risks • HDU used a combination of face to face contact, a HDU were reviewed at the monthly team meetings. Newsletter and email to engage with staff. • The clinical lead for HDU had explored the possibility of application to submit data to ICNARC to ensure that the

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• Managers were visible on HDU and staff spoke positively Innovation, improvement and sustainability about the nurse consultant and the support they • HDU had a quality improvement plan which provided. demonstrated a commitment to quality care while • Staff told us that the executive team had not always obtaining best value for money. been supportive when they had highlighted concerns • There were appropriate systems in place to review and risks. However staff appreciated the ‘Sit and See’ service delivery and, when needed, ensure that lessons observations which was undertaken by members of the were learned and appropriate actions taken. As a non-executive team and outcomes of the visits that consequence of medication incidents, nursing staff both reinforced good practice but also identified when involved had to complete a reflective practice summary practice may be improved. and learning was shared by the team.

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Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

of nursing and medical records. We reviewed other Information about the service documentation including performance information provided by the trust. We received comments from people The children’s service provides a largely elective service for who contacted us to tell us about their experiences. children on an inpatient and outpatient basis. The service is consultant led and delivered, and centred on Alice ward. Alice ward is a 16 bed unit providing inpatient care for surgical patients and rehabilitation patients. There is a dedicated physiotherapy area and bedroom facilities for parents. The ward offers support from play staff and a teacher. Alice ward is adjacent to the children’s outpatients department. Children are also admitted to the Menzies day case unit, and this is normally restricted to day case community dental patients. From 1 September 2014 to 31 August 2015, 1211 children and young people were admitted to Alice ward. The number of children admitted included 254 children who had day case surgery, 256 had surgery which required overnight care and 701 did not have surgery. Children are referred and treated from primary and secondary services from North and Mid Wales, Shropshire and Telford, Cheshire and further afield. A “hub and spoke“ service is provided where children are seen in peripheral clinics and surgery is undertaken in Oswestry. An emergency service for children is not provided. However, some unscheduled cases are treated, such as specific types of trauma and infections. We spoke with three patients and three relatives. We spoke to 21 staff including consultants, doctors, nurses, domestic and support staff. We observed care and looked at 21 sets

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The environment in most parts of children’s and young Summary of findings people’s services was good, with appropriate systems in place to minimise the risk of infection. There were Paediatric consultant medical cover was not routinely appropriate arrangements for the safe administration available on site during the evening, overnight and at and storage of medicines. the weekends. There was a potential risk that if a child was to deteriorate the doctor may not have the Children and young people were treated with knowledge and skills to recognise this and take compassion and respect. Children and their parents appropriate action. were consulted and informed about the treatment they or their child would receive. The trust had no formal route for highlighting if a child was on a (safeguarding) protection plan and was reliant on the referrers and/or families to share this information. Children and young people on Alice ward and within children’s outpatients had the required number of paediatric nurses to care for them. However there were some adult outpatient clinics that young people attended without the support of either a paediatrician or a children’s nurse available. Children’s services used an early warning score to identify deteriorating patients. Data from the system was not automatically displayed on the ward’s large electronic data screen and relied on staff manually searching for any alerts about individual patients. This could cause a delay in the identification of a deteriorating patient. Nurses had not been trained to handover deteriorating patients to doctors using the recommended tool. Not using this structured method may lead to delays in seeking rapid assistance for a sick child. The vision, strategy and values of children’s services were not well developed. Senior management arrangements did not ensure that there was sufficient oversight of children’s services and risks were not always considered and addressed appropriately or in a timely manner. There was an open culture of incident reporting and appropriate systems were in place to investigate and review incidents. We saw that any learning from incidents was shared amongst children’s services.

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• No never events were linked to the children’s and young Are services for children and young people’s services from 1 May 2014 to 31 July 2015. A people safe? never event is a largely preventable serious patient safety incident that should not occur if the preventative Requires improvement ––– measures have been implemented. • The trust had an established system for reporting incidents and near misses through an electronic The doctors on duty at the time of our inspection, outside reporting system. Paediatric services had reported 57 of normal working hours did not have any specific incidents from 1 September 2014 and 31 August 2015. paediatric medical training despite providing cover for There was one serious incident, and one incident of children’s services. There was a potential risk that if a child moderate harm. was to deteriorate the doctor may not have the knowledge • The serious incident was reported to the Strategic to recognise this and take appropriate action. Executive Information System (STEIS) it related to a The majority of nursing staff had completed the relevant child whose condition had deteriorated after admission paediatric resuscitation training and the hospital was to the ward and subsequently died. The trust had pro-actively working to ensure 100% completeness, carried out a root cause analysis of the incident and had however, a potential risk remained particularly during the made recommended changes to practice. evenings, overnight or at the weekend. • All patient deaths including all post-operative deaths within 30 days were reviewed by the trust. The findings The trust had no formal route for highlighting if a child was of the investigation were reported at the ‘Deteriorating on a (safeguarding) protection plan and was reliant on the Patient Group’ and reports were discussed within the referrers and/or families to share this information. multi-disciplinary clinical effectiveness group and the Children and young people on Alice ward and within quality and safety group. children’s outpatients had the required number of • We saw from the paediatric advisory forum meeting paediatric nurses to care for them. There were some adult minutes that incidents were discussed at a senior level. outpatient clinics that children attended without the Actions were agreed and added to serious incident support of either a paediatrician or a children’s nurse action plans to prevent future risks to patients. The available. action plans were monitored by the clinical risk manager who ensured that actions identified were Children’s services used an early warning score to identify followed up and implemented. deteriorating patients. However the system did not give • Staff told us that learning from incidents took place at direct triggers to alert either medical or nursing staff that ward meetings which were held every month. We saw any patient may be at risk. This could cause a delay in the minutes of ward meetings where discussions had taken identification of a deteriorating patient. Nurses had not place about incidents. Staff received feedback from been trained to handover deteriorating patients to doctors incidents via the electronic incident reporting system using the recommended tool. and through one to one meetings. Newsletters were also There was an open culture of incident reporting and used to highlight learning or changes in practice as a appropriate systems were in place to investigate and result of incidents. review incidents. We saw that any learning from incidents • Knowledge of the requirements of the duty of candour was shared amongst children’s services. There were regulation was mixed. This regulation requires providers appropriate systems in place to safely store and administer of healthcare to be open and transparent with people medicines. using services when things go wrong with care and treatment. The ward manager was able to describe the The environment in most parts of children’s and young duty of candour and we saw an example of when the people’s services was generally good, they were clean with duty of candour had been met. Other staff were not as appropriate systems in place to minimise the risk of infection. Incidents 53 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 Ser vic es f or childr en and young people

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aware but described a culture of openness and • The ward had side rooms that could be used to isolate transparency with patients and their families. They gave potentially infectious patients, in order to prevent examples of when things had gone wrong and cross-infection. Staff told us that, it would be rare for a immediately informing patients or families of this. patient to have infections on the ward. Safety thermometer Environment and equipment • Safety thermometer information was incorporated into • The ward had two resuscitation trolleys; one for adults the quality performance dashboard on Alice ward which (may be used for adults and older children) and one for was used to provide evidence of assurance to the trust children. These trolleys would also be accessed by the board. The dashboard included patient safety adjoining children’s outpatient department in the event information which highlighted ward cleanliness, hand of needing resuscitation equipment. The equipment hygiene, incident reporting, staffing information such as was appropriate for the purpose, correctly stored and staff appraisal, safe staffing levels, bank and agency use regularly checked. and medication errors. This information was displayed • We saw that the door to the staff kitchen on the ward on boards in the ward area. was often left ajar. We saw that dishwasher detergent, • The trust were also in progress of developing ‘STAR’ stored in a large lidded plastic tub marked ‘irritant’, was ratings for each ward, although this had not been on the floor of the kitchen. Three bottles of detergent undertaken at the time of our visit for Alice ward. were at child height in the kitchen. We highlighted this • No pressure ulcers or patient falls with harm or catheter to the ward manager and these items were immediately urinary tract infections had been reported. moved to a different area of the ward, out of the reach of children. There was an electric cooker in the same Cleanliness, infection control and hygiene kitchen which also presented a risk to children. We were • The ward and children’s outpatient area were clean and assured by the ward manager that a lock would be fitted tidy. Staff told us that they cleaned all areas regularly to the kitchen door, allowing access by staff only. This and we were shown a cleaning schedule that confirmed was confirmed by the trust following our visit. this. There was, however, no audit to measure the • The ward had two portable suction machines, used to cleaning. clear a sick child’s airway in an emergency. Both • Hand sanitising gel was available at the entrance to machines were mains-powered only, this risked delays if Alice ward and in children’s outpatients and throughout staff could not immediately plug them in. This had also both units. Signs to remind both staff and visitors about been previously raised as a concern as part of an hand hygiene were visible throughout the unit. The trust external quality review. The ward manager told us that a had a ‘bare below the elbows’ policy. All of the staff we battery powered machine had been delivered, but saw within children’s and young people services would not be in use until 60% of staff had received complied with this. training. It was unclear when this training would be • Staff compliance with hand hygiene was checked by a completed. The use of a battery-powered or manual senior nurse through regular audit and was rated as suction device is recommended by the Resuscitation ‘green’ (acceptable). We saw two examples of these Council (UK). audits from two separate months. We observed that the • We saw that access to the ward was through a locked staff washed their hands appropriately and wore door, by swipe card or by buzzer. This ensured that appropriate personal protective equipment (PPE). patients were secure. Two emergency exit doors could Effective hand washing alongside the use of gloves and be opened from the inside, but we saw activated an aprons reduced the risk of cross-infection. audible alarm, meaning that children should not be • There had been no cases of MRSA or C. Difficile. The able to leave the ward unnoticed. ward manager told us that patients were not screened Medicines prior to their admission. • We saw appropriate arrangements were in place for recording the administration of medicines. We checked

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15 patients’ medicine prescriptions. They all had and nutritional risk were completed and available. We allergies recorded, the weight of the patient and the saw that observations were checked and recorded at doses were seen to be appropriate for national the required frequency and any deviation from expected protocols. results was escalated to medical staff. • We found the children’s ward had appropriate storage • In September 2015, an audit of children’s records was facilities for medicines. There were suitable undertaken to assess whether they were complete arrangements in place to store and administer correctly and complied with safeguarding best practice. controlled drugs. Stock balances of controlled drugs The results of the audit were mostly positive, although a were correct and two nurses checked the dosages and need for all entries in records to be timed was identified. identification of the patient before medicines were We saw minutes of meetings which showed the audit given to the patient. Regular checks of controlled drug findings had been shared with Alice ward and balances were recorded. outpatient staff. The findings were also shared with • We found clinical pharmacists were involved in theatre staff that had a role in the care of children. children’s’ individual medicine requirements which Safeguarding helped identify medicine issues and therefore they could be dealt with immediately. • The trust policies and procedures were in place for • We observed that staff wore red plastic aprons when safeguarding children and vulnerable adults. they were administering medicines which identified • Staff we spoke with knew how to access safeguarding they should not be disturbed. We saw that this was good policies and procedures on the trust’s intranet and were practice and protected patients from potential harm. aware who were the adult and children’s safeguarding • There had been two medication errors within the last leads for the trust. Staff we spoke to told us they had two years. We saw that the trust had investigated these received safeguarding children and vulnerable adults and that no harm had come to the patients involved. training, and confirmed actions that would be The trust also showed that there had been learning from undertaken to keep people safe. these incidents and that staff practice had been • The trust had a target that 90% of all staff should have changed as a result. A recognised medicine link nurse safeguarding children training. Information provided by was on the ward. We spoke with two nurses who told us the trust identified that all (100%) of staff in children’s a noticeboard in the staff room alerted staff to learning services had achieved level one training and 92% had from incidents. achieved level two. Eighty-five percent had achieved • Emergency medicines were available for use and there level three. was evidence that these were regularly checked. • Safeguarding children lead staff should had level four • The hospital had an on-site pharmacy and pharmacists safeguarding training, 100% of required staff had were available during the day with a call out system in completed this training. place for emergency cover out of hours. • Information provided by the trust identified that 100% of staff working within children’s services had level one Records safeguarding vulnerable adults training and 77% had • Children’s services mainly used paper based patient level two safeguarding vulnerable adults training. records, although an electronic record of consultant • The trust had six monthly safeguarding children’s ward rounds was made. Records were completed and meetings. We saw minutes of these meetings and found filed in a consistent manner to enable staff to easily that they were attended by senior nursing and medical locate required information about the patient, their staff within the trust. The meetings discussed policies treatment and care needs. that related to safeguarding children and any identified • We looked at 21 patients records during our announced safeguarding concerns about children and any actions visit. We saw that the records were clear and identified that had been undertaken. the treatment that patients had received and any further • The trust had no formal route for highlighting if a child treatment or follow-up plan within critical care. was on a (safeguarding) protection plan and was reliant • Nursing documentation which included a record of their observations and risk assessment such as pressure ulcer

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on the referrers and/or families to share this • All of the nurses we spoke with had been trained in the information. Staff told us if they had any concerns about use of the Paediatric Early Warning Score (PEWS). We a child, staff were aware they needed to contact the saw that all patients on the ward had their observations child’s local authority to see if they were known to them. recorded on an electronic system and the PEWS was • The ward had recently introduced a ‘safeguarding calculated from this. questions’ sheet to be inserted into the case notes. This • Staff told us that the electronic data, including the PEWS included staff stating whether or not they had concerns was not automatically displayed on the ward’s large about the child on admission, whether there was a child electronic data screen; we saw staff entering these protection plan and if social services were already scores manually. Staff had to scroll through all of the involved with the child. We saw from reading the records patients on the system in order to see if there were any of ten children during our visit that safeguarding alerts about individual patients. This could cause a questions were not routinely asked by nursing or delay in the identification of a deteriorating patient. medical staff. However, when we visited unannounced • The trust’s deteriorating patient policy dated 11 August we found that two of the three children’s records we 2015, included the use of Situation Background looked had the ‘safeguarding questions’ form Assessment and Recommendation (SBAR) tool. This is a completed. structured method for communicating critical • The ward manager told us that they had recently information that required immediate attention and identified that young people regularly attended the action which contributed to effective escalation and sports injury outpatient clinic as patients, but no increased patient safety. Nurses we spoke with had not paediatric nurses worked in this clinic. It is possible that been trained to handover deteriorating patients to safeguarding concerns would not be detected if doctors using SBAR. Not using this structured method paediatric nurses were not involved. may lead to delays in seeking rapid assistance for a sick child. SBAR is recommended as a tool to be used in Mandatory training hospitals by the NHS Institute. • The trust had a target of 90% of staff having received all • The hospital follows the West Midlands Quality Review required mandatory training. Training information Service (WMQRS) “Standards Care of Critically ill & provided by the trust identified that Alice ward staff had Critically Injured Children” guidance. The guidance achieved this target for health and safety, fire safety, states that at least one nurse with up to date paediatric moving and handling, information governance and resuscitation training should be on duty at all times. infection control training. Eight-five percent of staff had Most, but not all nursing staff had completed paediatric completed equalities and diversity training. intermediate life support (PILS) training at the time of • Eighty-four percent of staff had completed paediatric life the inspection, the trust told us that 100% of staff will support training. The trust had identified a target that all have completed training by 28 February 2016. band six/seven (Alice) ward nurses, the lead paediatric • The trust planned for one nurse with advanced recovery ward manager and the paediatric operating paediatric life support training to be on duty every department practitioner should all have for European weekday between 9:00am and 5:00pm. We reviewed the Paediatric Life Support (EPLS). The trust had met this staffing rota for a four-week period and saw this was target. There was a further plan to ensure that all achieved 90% of the time. The trust had a schedule in paediatric nurses, all on call medical staff and all place to ensure that all relevant nursing staff will have outreach staff also had this training. completed advanced paediatric life support (APLS) or • Mandatory training attendance for nursing staff was European paediatric life support training (EPLS) by 31 monitored by the matron and ward manager. January 2016. • In the evening, at night or on the weekend, the outreach Assessing and responding to patient risk team would be called for if a child was deteriorating or if • The trust had a system to assess children who were resuscitation was required. Three of the ten outreach suitable for care at treatment at the hospital. Children who had significant other health problems were not treated at the hospital due to increased risk.

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nursing staff had advanced paediatric resuscitation and cover absences; these nurses were all qualified life support competencies. Plans were in place for the paediatric nurses and had received the trust induction remainder of the staff to undertake European paediatric training. The ward manager told us that these were life support training (EPLS). mostly staff who did not usually work at this hospital • Appropriate consultant paediatrician cover was but who had appropriate skills and experience. provided, Monday to Friday between 8am and 6pm. • We saw from staffing rotas the ward had three registered Outside of these hours, medical cover was provided by a nurses who do not have specialist training as a middle grade doctor covering the hospital. However this paediatric nurse. These nurses were always rostered to doctor would not necessarily have experience in the work with a qualified paediatric nurses when on duty. care of children, or have advanced paediatric • Nursing staff told us that a handover took place at the resuscitation skills. Doctors could access paediatric beginning of every shift when every patient was advice during the evenings and weekends from the on discussed to ensure that all staff were aware of their call paediatrician at a neighbouring hospital and a needs or any concerns. paediatric anaesthetist was available via telephone 24/ Medical staffing 7. • There was a standard operating procedure in place for • We saw that there were two consultant paediatricians, escalating concerns about a deteriorating patient. This one paediatric registrar and three paediatric included transferring to another hospital as necessary. orthopaedic consultants working at the hospital, Staff told us, one patient had been transferred to Monday to Friday between 8am and 6pm. another hospital within the last twelve months. • The WMQRS report said, “The two paediatricians did not • The WMQRS visited the hospital in May 2015, in the provide cross-cover and operating lists involving major subsequent report it noted that outside normal working procedures could take place with no paediatrician on hours there was no-one on site with advanced site. This meant that a doctor who had experience with paediatric resuscitation training who could, if required, children may not be available if there was an emergency lead resuscitation. Without this skill level, it is possible situation with a child. The trust have told us that since that children requiring resuscitation may not receive the our inspection, they have moved to a formalised rota to appropriate treatment. ensure maximum coverage. • The report also identified that an anaesthetist was not • The on duty consultant would review children during available on site after 5pm or at weekends. A consultant the day and then pass on any required information to anaesthetist was on call and could attend within 30 the night team. In addition there was written minutes. An anaesthetist is a key member of the information in the nursing handover sheets if any child hospital team dealing with medical emergencies and had been reviewed by the out of hours medical team stabilising very unwell patients. (during the evening or over the weekend) or if the team • The trust had produced an action plan to address the had accessed advice from on call paediatrician at a concerns of the WMQRS report and are working to nearby trust. We saw that this information was clear and complete it by March 2016. easy to find. Nursing staffing Major incident awareness and training • We saw from staffing rotas that there were four trained • This hospital would not normally receive emergency nurses on during the day and three trained nurses on at patients and had no accident and emergency night which was better than the RCN guidelines of a department. The trust’s major incident policy made minimum of two trained nurses on at all times. In clear that in the case of a major incident at another local addition we saw the staffing ratios with regards to the trust, patients who could be discharged would be to free number of nurses to children under two (1:3) and over up beds for patients who would be transferred from two (1:4) also reflected RCN guidelines. other hospitals which had an accident and emergency • We saw that the number of required staff and the names department and admitted patients during a major of staff on duty was displayed on a noticeboard near to incident. the entrance of the ward. The ward used bank nurses to

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• Fire evacuation plans were clearly displayed on the Pain relief ward. Staff demonstrated to us how the emergency exits • Children and their parents told us that pain was would be used. appropriately controlled. • We checked five patients’ medicine prescriptions. They Are services for children and young all had any allergies recorded, the weight of the patient people effective? and the doses were seen to be appropriate. Pain relief was seen to be given on time and measured against the Requires improvement ––– child’s own pain score. • The play therapists were available on Alice ward and provided valuable distraction therapy for children to Staff told us care pathways were in place although nursing manage their pain. staff struggled to give us examples of audit that gave assurance they were met. As the service did not participate Nutrition and hydration in national audits, it was difficult to benchmark • Children and young people were able to choose what performance against other providers. they wanted to eat from a menu which was ‘child Multidisciplinary working was in place and seven-day friendly’. working was in place for medical, nursing staff and • Alice ward had a kitchen which enabled staff and physiotherapists. parents to make light snacks or obtain other snacks such as fruit, biscuits or other snacks. We observed that There were appropriate arrangements in place to gain snacks were available for children and young people consent from children and young people. Arrangements between meals if they wished. Staff told us that they were also in place to ensure that both nursing and medical replenished the snacks at any time should they need to. staff had appropriate training and development Cold and hot drinks were also readily available and opportunities and to ensure nurses had appropriate basic accessible. competencies. • The staff were aware of how to order specialist menu Evidence-based care and treatment choices, such as vegetarian or gluten-free meals. • The records we reviewed during our inspection showed • Nursing staff told us that care pathways were in use and that any fluid or dietary intake was monitored and were in keeping with the relevant NICE clinical or recorded where necessary for patients. nursing guidance. However they were unable to provide • In order to reduce the risk of allergic reaction, a toaster us with examples of which care pathways and how they had been set aside for gluten free bread and was clearly were assured they were being met. marked as such. This was seen to be good practice. • Children with talipes (‘club foot’) were treated with non-surgical techniques, following the ‘Ponseti Method’. Patient outcomes This was used internationally and was in keeping with • The trust did not admit children in an emergency and as national standards. part of children’s pre admission assessment, children • Policies, procedures and guidelines were available to all with other health problems were seen as high risk and staff via the trust intranet and hard copies were would not be admitted to the hospital. The ward available on the ward. Staff we spoke with knew how to manager explained this was the reason why the trust did access them when necessary. not participate in the paediatric diabetes or asthma • The trust provided us with a copy of the children’s audit. services local audit plan. There was evidence of three • There were no emergency readmissions within two days local audits completed to date during 2015/2016. The of discharge among patients in either the under 1 or the audits looked at hip screening referrals from the 1-17 age groups between February 2014 and January post-natal unit at Wrexham, clinical provision in the 2015. However since then have been two emergency Oswestry Muscle Team and paediatric consent & patient readmissions. experience.

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• The trust were unable to provide us with any other • The hospital pharmacy was open Monday to Friday and audits which measured patient outcomes. half day on a Saturday; Staff told us that they were able to obtain patients’ medicines outside pharmacy Competent staff opening hours. • Nurse competencies were checked against identified Access to information paediatric competencies. The ward manager told us that paediatric nurses had visited another children’s • Patients medical notes were kept securely on the ward specialist trust to review practice. However there was no and outpatients but were accessible for staff at all times check of nurse competencies during these visits or • Staff could access electronic care and treatment policies formal feedback after the visits. and procedures at all times. • At the end of April 2015, 85% of staff (17 out of 20 staff) • The ward manager attended senior sister meeting with who worked with children’s services had an appraisal. the matron and shared the outcome of these meetings All staff we spoke with confirmed that they received an with staff. annual appraisal. • Staff meetings were held monthly to share information with staff. Information was also shared by email or face Multidisciplinary working to face. • Multidisciplinary working was effective, there were daily Consent wards rounds and regular input from key staff. Physiotherapists who had a paediatric qualification and • The trust had an up to date policy in place on obtaining experience had a base on the ward and worked with consent for children. The trust’s approach to assessing children on Alice ward and children’s outpatients. for ‘Gillick competency’ is clearly set out within the • Children’s services did not have access to an policy. This is an assessment for older children occupational therapist that had a paediatric regarding providing their own consent to treatment. qualification/ experience. Staff had been told they • We saw an older child refuse physiotherapy and staff should request an occupational therapist who worked responded appropriately and respected their decision. with adults if they required an occupational therapist. • Within the patients records we looked at, we saw that all • There were visits to Alice ward five days a week by a surgical procedures had been carried out after first pharmacist during which the children’s medicine were gaining appropriate written consent from the child’s reviewed. parents. • Children who needed to transition to adult services • Information provided by the trust identified that 77% of remained under the care of the same orthopaedic staff had received training on the Mental Capacity Act up consultant, ensuring continuity of medical until 31 August 2015. management. Seven-day services Are services for children and young people caring? • Paediatricians were available Monday to Friday during the day between 8am and 6pm. Orthopaedic Good ––– consultants were also mainly available Monday to Friday during the day. • Physiotherapists were available seven days although Children received a caring service. there were less physiotherapy staff available at the Children and their parents were given good emotional weekends. support, and throughout our inspection we saw children • Pathology was available seven days a week. treated with compassion and respect. • Radiology and radiography services were led by a consultant who was available for urgent x-rays and Parents and children were consulted and informed about scans seven days a week and during the evening and the treatment they or their child would receive. overnight. Compassionate care

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• Children and their parents were positive about staff and Staff had sought comments about the provision of the the care they received within children’s services. One service. The wards and department areas were decorated parent told us, “They have been excellent“. Another and equipped with age-appropriate décor, toys and parent said it was the best hospital they had ever been technology for children and their parents. to. A child told us ”The nurses are all friendly”. Service planning and delivery to meet the needs of • We observed staff talking to patients and relatives in a respectful and friendly manner. Throughout our local people inspection, we saw children being treated with • Children were referred and treated from primary and compassion. secondary services from North and Mid Wales, • Between 1 April and 31 August 2015, 96% who Shropshire and Telford, Cheshire and further afield. A responded to a survey said they were extremely likely or “hub and spoke" service was provided where children likely to recommend Alice ward to friends and family. were seen in peripheral clinics and surgery was undertaken in Oswestry. Understanding and involvement of patients and those • The outpatients departments was organised around the close to them care and treatment of children with similar conditions. • Children and parents we spoke with told us that they This meant that specialist assessment and treatment had been informed of their care needs and options for could be targeted at these clinics. their treatment. Access and flow • Children and parents said that staff had explained their treatment and they had been asked to provide consent • Bed occupancy was regularly below the trust target of to their treatment and staff had acted in accordance 87% and not above 73%. Some patients stayed longer with their wishes. One parent told us; “They have kept than the target maximum stay of four days. This may me informed”. have been due to slower recovery than expected; however, there were no reported delayed discharges. Emotional support • We saw and staff confirmed that admissions to Alice • We observed that staff built up trusting relationships ward were planned and related to children and young with children and their parents working in an open and people’s planned surgery or other planned treatment. supportive way. Patients and relatives were given good • Between 1 September 2014 and 31 August 2015, 25 emotional support. operations were cancelled mainly due to childhood • A chaplaincy service was available, which provided illness. There were three operations cancelled due to valuable support to patients and relatives. non-clinical reasons such as illness of the surgeon or • A full time specialist nurse for children with muscular insufficient theatre time. dystrophy was available for advice, education and Meeting people’s individual needs bereavement support. • Alice ward was spacious and provided age-appropriate Are services for children and young accommodation and facilities for babies, children and people responsive? young people in separate areas on the ward. • Parents and carers were encouraged to stay with the children at all times during their stay. There were rooms Good ––– on the ward for parents to sleep and camp beds were also provided for those parents who wanted to sleep The service was responsive to the needs of children and next to their child. Showers, toilets and a kitchen were young people at the hospital. Staff were involved in the also available for parents. planning of the service to ensure it continuously met the • The wards and department areas were decorated with needs of the children and their families. age-appropriate décor and toys for younger children. Wi-Fi was available for all children and their parents. • We were told that the largest single ethnic minority cared for was Welsh speakers. We saw that the signage

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was in both English and Welsh. Some of the staff, Vision and strategy for this service including the play specialist, spoke both English and • The trust had developed and approved an Welsh and we saw staff speaking to Welsh-speaking organisational vision to provide excellent patient care, patients in Welsh. We were told that translators for other however there was mixed feedback across the service languages were available and were used. about individual alignment with the trust vision and • The ward manager told us that one member of staff was strategy. trained in Makaton sign language to help with • Although staff said that they wished to provide high communication with people with learning disabilities. quality patient care, they were unclear about the vision • Privacy arrangements for patients were acceptable. and strategy for the children’s service. There was a lack Privacy curtains were closed and staff were seen to of focus on children’s services at trust level and staff ensure they remained closed to maintain children’s were not aware if paediatrics had a place in the dignity. hospitals long term vision. • Access to Child and Adolescent Mental Health Services (CAMHS) was problematic. Staff told us that there was Governance, risk management and quality no access to funding for CAMHS input for children in the measurement Shropshire area, although some access was available for • Children’s services were mainly within the surgical children from North Wales. division although some parts of children’s service were Learning from complaints and concerns within the medical division. This made it difficult to ensure that children and young people’s care was • There had been no recorded complaints about the coordinated and provided a safe and effective service. paediatric ward in the previous twelve months. • There were systems in place to identify record, manage • Staff we spoke with correctly described the trust and mitigate risks. Children’s services did not have its complaints and concerns policy and their role in own integrated performance report but was included in responding. Staff told us that if someone wanted to the report for surgery. There were regular meetings make an informal complaint, they would be directed to where complaints, incidents, audits and quality the nurse in charge. improvement projects were discussed and reviewed. • The WMQRS visited the hospital in May 2015, in the Are services for children and young subsequent report it raised a number of concerns people well-led? relating to systems and processes in place for responding to assessing and responding to Requires improvement ––– deteriorating patients. The trust had produced an action plan to address the concerns of the WMQRS report but The vision, strategy and values of children’s services were progress has been slow and it is not due for completion not well developed. Staff were not confident that children’s until March 2016. services were part of the long term vision for the hospital • Alice ward had a risk register in place. The register listed and consequently staff morale was mixed. 13 risks, one classified as “high” risk level relating to the storage of medicines and controlled drugs. The other Ward staff spoke positively about support they received risks were a mix of “moderate” and “low”. The risk from their ward manager. However there was a lack of register did include the lack of a paediatrician on site support and leadership for the ward manager who was the 24-hours a day but did not include the lack of a most senior paediatric nurse within the trust. Medical paediatric resuscitation trained nurse on duty 24-hours leadership was focused on orthopaedic surgeons and not a day. paediatricians which also meant a lack of senior insight to the care of children and young people. Leadership of service • Staff we spoke with told us they felt well supported by There were good arrangements in place to seek the views the ward manager. She was highly regarded by the team of children and young people about children’s services. around her.

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• The ward manager was the most senior nurse within the • There were six monthly parent and child focus groups trust with a paediatric qualification. The ward manager which asked young people and their parents about their was the person to review and update paediatric policies experiences of care on Alice ward. with little outside support, review or advice to enable • There was a display in children’s out patients, “Plant them to do so. your ideas’. Young people were asked to give ideas • The West Midlands Quality Review Service report said, about how improvements could be made as plants on a “The role taken by the consultant paediatricians in wall. When the ideas had been actioned the plants were leading the development of services for children was shown to have ‘flowered’. not clear to reviewers”. The findings from our inspection • The ward had used young volunteers from the concurred with this view. Shropshire Young Health Champions to assist in • The clinical lead for children’s services was one of three interviewing for the ward’s new play specialist. They had consultant paediatric orthopaedic surgeons. Day to day also carried out an audit of the environment from a decisions about the ward and children were made by young person’s view; this was called the ’15 step the orthopaedic team. Although there were close challenge’ and identified what the ward looked like from working relationships, paediatricians did not appear to a child’s or young person’s perspective. have been able to influence key issues such as decisions • The patient’s survey included comments both positive about paediatric early warning scores and the use of and where improvements could be made. A response electronic monitoring for children. These decisions had which identified where improvements had been made been made by the orthopaedic consultants and was included against any comment such as; “Food anaesthetists. needed to be more child friendly”. The ward response identified that although a child menu was available the Culture within the service menu had been reviewed and new menu would be • Staff spoke positively about working within children’s introduced on 7 September 2015. Another comment services. They described an open culture, where they stated “a new sterilising facility for baby’s bottles was were encouraged to report incidents, concerns and needed”, the response identified by the ward was that complaints to their manager. Staff felt able to raise any this had been purchased. concerns. Staff engagement • The ward manager told us that they were proud of their team and staff commented that they were “a good • Children’s services used a combination of face to face team”. contact, ward/ team meetings and emails to engage with staff. Public engagement • The ward manager was visible on Alice ward and staff • Children and young people were engaged with the spoke positively about the support they provided. development of the service. We saw that children were Innovation, improvement and sustainability encouraged to comment on their care using a visual board of ‘Pants and Tops’. The child would write positive • The approach to service delivery and improvement was comments on a cut out picture of a shirt (a ‘top’). reactive and focused on short term issues. There was Negative comments would go on a picture of trousers not a culture to encourage innovation or improvement (‘pants’). This had been used by a number of children. and opportunities to do so were not taken.

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Safe Requires improvement –––

Effective Not sufficient evidence to rate –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

month. Between January and June 2015, 11,525 patients Information about the service were seen in the department. This consisted of 4,467 MRI scans, 1,663 CT scans, 3,563 ultrasound scans and 1,832 Outpatient clinics were provided for patients at the main DEXA scans. hospital site and through service level agreements at a number of satellite locations at neighbouring hospitals and During our inspection we spoke with 46 staff, including clinics, the main satellite site being the Royal Shrewsbury porters, cleaners, doctors, nurses, therapists, radiologists, Hospital. Consultants and their teams attend the satellite administrative staff and managers. locations, but facilities and nursing staff were provided by We spoke with 22 patients and reviewed 8 sets of patient the host hospitals. This report concentrates on services notes. provided at and by this hospital. However statistical information may include activity at the other sites where this is reported collectively by the trust. The trust also operated a separate outpatient clinic for private patients. Between January and December 2014 the trust scheduled 196,581 outpatient appointments, 176,915 of which took place at the main hospital site. In addition to general outpatient and spinal unit outpatient services, the trust is also home to specialist services, including the Greater Manchester and Oswestry Sarcoma (GMOS) unit. This is one of only five specialist units in the country dealing with bone and soft tissue sarcomas. The unit received 900 new referrals in 2014/2015. Diagnostic imaging services were sited adjacent to the outpatients department and provided services to the inpatient wards, theatres and to outpatient services. Imaging services included conventional x-ray, computed tomography (CT), dual energy X-ray absorptiometry (DEXA) scans, ultrasound, and magnetic resonance imaging (MRI) scanning. The service saw on average 1,920 patients per

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Summary of findings Are outpatient and diagnostic imaging services safe? We were concerned with the lack of oversight of clinic services in the main outpatients department. Clinics Requires improvement ––– were planned which, due to the complex needs of patients, caused undue demand on support services We observed that very few staff made use of hand and in turn caused excessive and avoidable waiting for cleansing gels which were available in various locations. patients. We also found issues with support for staff in We noted that some medical staff did not follow the trust imaging and other services. infection control policy. Patients did report that staff Not all staff followed good practice guidance in relation washed their hands prior to and following examinations to hand hygiene and being bare below the elbow when and nursing staff were seen to use gloves and aprons where dealing with patients. required. We found that services were safe, systems were in place The outpatients environment was cramped and not which ensured that patients were protected from the suitable for patients using wheelchairs or walking aids, risk of infection, medication errors and the risks however, work was ongoing to remedy this and new associated dangerous or poorly maintained equipment. arrangements would address this issue. Staff were skilled and experienced in the role. New staff Incidents were reported and investigated. Learning was were supported to ensure they developed the required shared with teams and staff were aware of learning from skills. other incidents from across the organisation. Staff were able to demonstrate they understood the importance of Services were effective, practice was audited and reporting and learning incidents. learning shared to improve patient outcomes. Recognised pathways of care, and national guidance Processes were in place to protect people from the risk were understood and followed. associated with inappropriate management of medicines. Staff were caring and supported patients to make Staff levels were sufficient in all areas and they were decisions based on sound clinical options. Staff had a appropriately trained, skilled and experienced to deliver genuine interest in the health and wellbeing of patients. services safely. Services were responsive to patient’s individual needs. Incidents Systems were in place to support patients with complex • The trust used an electronic reporting system to record needs. and review incidents. Between June 2014 and July 2015, a total of 247 incidents were reported by staff in the outpatients and imaging departments. Of these 44 related to imaging and 203 to outpatients. • There had been no ‘never events’ reported in relation to outpatient and diagnostic imaging services between May 2014 and April 2015. Never events are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’. • Two serious incidents had been reported during the same period, both within outpatients. One related to a fall in the hydrotherapy pool and one related to a

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patient who was given the wrong diagnosis. We saw that elbow when dealing with patients. Nursing and these incidents had been properly investigated and healthcare assistants wore uniforms which had short information had been shared with staff through team sleeves. However we saw a number of consultants and meetings. registrars wearing long sleeved shirts and jackets as they • Staff we spoke with understood the need to be open moved between consultation rooms and waiting rooms. and honest with patients. Healthcare assistants and We asked the trust for reports from hand hygiene audits nursing staff said they would advise patients if they but they were not provided. thought something had gone wrong, and they would • Sanitising gel was available to staff and patients at escalate the issues if needed. various locations throughout the department, however • Incidents were discussed at weekly team meetings, this signage was very poor and during our observations we included learning from incidents which had occurred saw that very few patients and their relatives or carers throughout the trust. Many staff we spoke with, used the gel. During one period of observation 23 particularly clinicians and senior nursing staff, were able patients and carers entered the waiting area ‘B’ none to describe learning from incidents which had occurred were seen to use the gel dispensers in that area. in other departments. • Patients we spoke with said they had seen doctors wash • The trust have an incident review committee which their hands before and after examinations. meets monthly to discuss incidents and ensure that • Cleaning schedules were posted on the walls in a learning from them is cascaded back to staff. The number of locations, indicating when cleaning was due outpatients department were represented by the and when it had been done. We saw that schedules had departmental sister. been fully marked up with no missing signatures. • Monthly divisional meetings also took place, we saw • We saw that all disposable curtains were in date and how incidents were a standing agenda item when we clean. Most items of equipment had ‘I’m Clean’ stickers reviewed minutes of these meetings. Outpatients was indicating when they had been cleaned and that they within the surgical division, however the sister also were ready for use. attended the medical division monthly meetings as • Monthly sharps bin audits were completed in the patients using the service were from both disciplines. outpatients department. We saw how the July audit had She described how this provided additional information identified that a number of bins had been used for sharing across the divisions. disposal of general waste. In response the sister had • Staff in diagnostic imaging described instances where introduced a rotation of staff responsible for completing they had submitted incident reports. One example was the audit, to raise understanding and ownership of the where a radiographer x-rayed a patient’s cervical spine problem. The audit sheet was re-designed to enable when it was meant to be the lumbar spine. Another easier identification of the areas where problems were incident involved x-raying the wrong shoulder of a identified and feedback had been given to the nurse patient. The incidents were attributed to unclear writing practitioner to discuss with clinical staff in the area on the request forms where shorthand had been used concerned. by the referrer. Staff said that they were not aware if Environment and equipment anything had been done to prevent a recurrence such as not allowing shorthand. • Outpatients and diagnostic imaging services were in adjacent areas occupying older sections of the hospital Cleanliness, infection control and hygiene building. The older buildings were clean and mostly • We saw that all areas of the hospital we visited tidy. appeared clean and mostly tidy. • We saw two patients in wheelchairs attending • The trust infection control policy required that uniforms outpatient clinics. These patients had to negotiate and work wear should not impede effective hand crowded waiting areas and park themselves at the end hygiene, and should not unintentionally come into of rows of seating. Many other patients used walking contact with patients during direct patient care activity. We observed that not all staff followed this policy in relation to hand hygiene and being bare below the

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aids, sticks, crutches and frames, all of whom had imaging department. The review identified two issues; difficulty negotiating a path between other patients. both within imaging. These were a process for This meant there was a potential risk of slips, trips and key-holder and security of medicines was required to falls by patients in the waiting area. cover both in hours and out of hour’s access and there • We did not see any areas with specialist seating to cater was no refrigerator and monitoring system for the for people with different needs, which would ensure storage of temperature sensitive medication. Both these they were positioned in safe environment. Senior issues had been addressed following the audit. We did nursing staff stated that they had looked at options for not find any medicines issues during our inspection. alternative seating such as large bariatric chairs, but as Records patients sat wherever they felt comfortable, they could not guarantee that any specialist chairs would be • Records audits were completed weekly, we reviewed the available for people who could benefit from them as audit provided by the trust in the pre-inspection data others would most probably have already taken them. request and this showed that 99% of patient’s records • Patient notes in outpatients were held in trolleys which were available for consultant review at the time of were parked in waiting areas or corridors, which further patients' appointments (February 2015). The total restricted access. We saw that movement between number of patients seen that week was 1440. Therefore waiting rooms for staff and patients was a constant 14 patients were seen using their electronic patient process of one party standing to the side to allow the records only. Nursing staff and doctors told us that no other to pass, particularly if one or other used walking patients were turned away by virtue of their written aids or a wheelchair. notes not being available. • Storage and access was a problem in both areas. • Quality of notes was audited weekly within the Imaging had converted an unused shower room into a outpatients department. 15 sets of notes were reviewed storage room. Staff had to contend with a water leak in each week. The system had been introduced in April the room which occurred during the inspection. We saw 2015. Any issues were highlighted by creation of an that systems were in place to respond to such incident on the Datix system. These were reviewed by emergencies, equipment had been removed from the the sister and trends or individual issues were room and maintenance staff were investigating the leak. highlighted. • We saw how plans had been drawn for outpatients to • We saw that patient records were kept in portable take over areas of imaging when they were vacated trolleys in waiting areas and corridors throughout together with a more modern extension which was used outpatient departments. Contents of patient’s notes for pre-operative assessment, which was also due to were not visible to people in the area. Whilst trolley were relocate to the new build. Managers explained it would not locked, staff were in the vicinity of trolleys for the enable better planning of outpatient clinics, and reduce majority of time which meant that the notes were the number of patients in each waiting area which reasonably secure. We did observe short periods when would in turn make the areas more comfortable. the trolleys were unattended. Senior nursing staff told • Resuscitation trolleys were checked and found to be us that staff should be aware that the trolleys should not properly stocked; all items and consumables were in be left unobserved at any time, and they undertook to date as were emergency oxygen cylinders. Regular remind staff of their responsibility in that respect. checks were completed and records were endorsed to • We reviewed eight sets of patient notes. We saw that show that the checks had been completed. notes contained risk assessments and care plans specific to individual patients. These included mobility Medicines and falls assessments, pain assessments and details of • Systems were in place to ensure the safe management, patient allergies. storage and administration of medicines. • We also reviewed records relating to the general running • The trust pharmacy department completed a trust wide of the outpatient and diagnostic imaging departments, audit of medicines management and storage between April 2013 and June 2015. 17 areas were reviewed including the main outpatients department and

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including service and maintenance records for • Resuscitation equipment was available and staff equipment, staff training records and audit results. We demonstrated that they knew the ‘crash call’ number saw that systems were in place to monitor and respond which they rang if urgent medical assistance was to risk. required. • Standard operating procedure in the event of patients Safeguarding becoming ill was to summon an ambulance via 999 and • We saw that all (100%) nursing staff had completed for the patient to be transferred to a neighbouring adult safeguarding training at level 1 and level 2 and hospital with appropriate emergency department. child protection training at level 1 and level 2. • Patients who attended clinics confirmed that they had • In diagnostics, all staff (100%) had completed level 1 been asked about their general health and if there had safeguarding training for adults and level 1 child been any changes to their condition since they were last protection training at level 1. Eighty percent of seen. diagnostic staff had completed safeguarding training for • We saw evidence within patient notes of risk adults at level 2 and 89% for child protection training at assessments which had been completed when patients level 2. All but three out of 34 staff in imaging services attended clinics. These were repeated or updated at had completed level 3 children’s safeguarding. each visit. Patients confirmed that they had been asked • The trust had a named safeguarding lead who was about mobility and falls as part of the process. available for guidance and support. Staff we spoke with • We saw that patient vital signs were recorded, blood all understood the different types of abuse which pressure for rheumatology patients and heart rate along patients might be subjected to. Healthcare assistant with other measurements such as weight. Staff workers knew how to report and escalate concerns. We understood how these enabled them to recognise along were given one example where an elderly patient was with the patient’s own account of their health, if there referred to social services. were signs that their condition was deteriorating. If changes were apparent these were recorded so that Mandatory training doctors could assess patients and provide appropriate • The trust target for mandatory training was 90%. We interventions. viewed the outpatient’s department training log for • Staff described instances where patients had walked September 2015. We saw that 100% of staff had into the outpatients department with untreated general completed training in basic life support, fire safety, injuries. One instance involved a patient with a severed manual handling and equality & diversity. Training in finger. Staff provided first aid and called 999 for the Deprivation of Liberty Standards was 83%, patient to be transferred to an emergency hospital. • Over 94% of staff within diagnostic imaging services had • A student nurse described how they had dealt with a completed their mandatory training although within patient who had fainted when they attended the that, 14 staff had not completed fire safety training, two department. Qualified staff confirmed that the student staff had not completed health and safety training. All had provided appropriate care and arranged further staff had completed adult safeguarding. All but three care for the patient; calling for an ambulance. staff had completed level 3 safeguarding children • Senior nursing staff said that on very rare occasions a training. patient might present at clinic whose condition had clearly deteriorated and required more urgent attention. Assessing and responding to patient risk Such patients were admitted to the hospital under the • The majority of patients who attended the outpatient care of the relevant consultant. When this occurred clinics and imaging services were relative well. Even incident reports were submitted to highlight the in-patients who were transported from wards to receive reasons. x-rays or scans were not usually medically unwell, • In July 2015 the diagnostic imaging services completed therefore it was not a common event for patients to be a review of the service against the Ionising Radiation taken ill whilst in the departments. (Medical Exposure) Regulations 2000 (IRMER) and 2006 amended regulations. Staff were encouraged to update their knowledge prior to the review using on-line

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training services and additional training was introduced • The hospital was not a receiving hospital. Emergency for non-radiological staff who have contact with ionising plans were available on the trust website and action radiation such as theatre nurses. The trust radiation cards were held in the switchboard. The CEO’s office had safety policy was updated however no changes to been designated as the control centre for any major protocols were required. incident which might affect the trust. Nursing staffing Are outpatient and diagnostic imaging • Outpatients nursing services were managed by a services effective? matron who also had responsibility for other areas of the trust. Day to day running of the department was Not sufficient evidence to rate ––– provided by a (band 7) sister who managed a team of five (band 5) qualified nurses and 12 healthcare assistants. We saw evidence that care followed national guidance and • The department was one staff nurse under strength at best practice. Risk assessments were completed for the time of our inspection. The vacancy was out to patients which ensured care and treatment met their recruitment. Vacancies were generally covered by staff individual needs. Audits were completed and learning from working additional hours, or by bank staff, with little these was put into practice to improve services. agency usage. Specialist services were provided which could only be • Imaging services were led by a lead superintendent accessed in a handful of locations nationally, interventions radiographer, supported by a CT superintendent in these services provided effective outcomes for patients. radiographer and an MRI superintendent radiographer, although the latter position was vacant at the time of Staff in outpatients had good access to appraisal and our inspection. The service had a team of 34 training to develop their competencies. We saw effective radiographers or which 12 were band 7 and 15 were multidisciplinary working in a number of areas. band 5 or 6 . A qualified nurse managed a team of five Evidence-based care and treatment healthcare assistants. • We saw that pathways of care followed national Medical staffing guidance and best practice. Patient records contained • Consultants and registrars attended clinics to see specialist assessments such as the Bath Ankylosing patients with appointments. The trust had a total of 113 Spondylitis Disease Activity Index (BASDAI) which helps whole time equivalent doctors. 65% were consultants clinicians determine the effectiveness of drug grade, 7% middle grade and 27% registrar’s. The trust treatments; and the British Society for Rheumatology had very few junior doctors . The skill and experience (BSR) guidelines on disease modifying drugs. mix reflected the specialist services provided by the • The Orthotic Research & Locomotor Assessment Unit trust. (ORLAU) had a national role in orthotic research and gait • We saw that there were sufficient medical staff to enable assessment. Staff described how mobility aids all appointments to be met, some clinics had two or developed in the unit had been copied and developed three patients booked for the same clinic time; however internationally. this enabled patients to access different aspects of their Pain relief treatment during the same period, so one patient might be seen by a nurse, another sent for a follow-up x-ray • Patients whose condition caused them pain told us how whilst the third was seen by the doctor. they had been assessed to determine their level of pain and how they had been provided with a combination of Major incident awareness and training interventions such as medication, occupational therapy and physiotherapy to help them control their pain.

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• Chronic pain clinics took place at the hospital and Competent staff patients could be referred to the Oswestry pain • The general outpatients department had 18 nursing management programme, a residential unit where staff consisting of qualified nurses and healthcare patients received instruction in pain management. assistant staff. Patient outcomes • 100% of nursing staff had a current staff appraisal in place. Staff confirmed that they received a formal • We saw evidence of local and national audit appraisal every year, and an informal appraisal every six engagement. Between June 2014 and May 2015 eleven months. Senior nursing staff advised that informal audits had been completed, nine of which were local appraisals only took place if the member of staff had audits including two physiotherapy audits, One continued to perform to an acceptable standard. If outpatient audit, one x-ray audit, one MRI audit, one issues existed they would undergo a formal appraisal at orthotics audit and three Histopathology audits. six months. National audits included a physiotherapy audit – the • New staff were appraised at two months, six months National Multi Centre Audit for Amputees after and 12 months, following induction. They were able to Treatment for Bone or Soft Tissue Sarcoma, and a describe the induction process and believed the training National Orthotic Managers Advisory Group (NOMAG) and support they received through their induction patient satisfaction survey. prepared them sufficiently to complete their role. • We saw how the NOMAG audit resulted in the service • In addition to mandatory training most healthcare identifying that 42% of patients were not seen within the assistants had completed additional training. One had recommended four weeks of referral. As a result an received training in phlebotomy, ECG and medicines action plan was completed to monitor referral to management. Outpatient clinics were not run on Friday treatment times. afternoons to enable clinical staff to engage in training • At the time of our inspection the trust were not events. participating in the Imaging Services Accreditation • As of June 2015, only 69% of imaging staff had a current Scheme (ISAS). Clinicians reported that accreditation appraisal in place. had been discussed but the system had yet to be engaged with as they thought that robust quality Multidisciplinary working assurance measures were already in place. ISAS is a • The ORLAU provided exemplary multi-disciplinary patient-focused assessment and accreditation working. The service had dedicated staff from a number programme that is designed to help diagnostic imaging of specialities, including orthopaedic surgeons, services ensure that their patients consistently receive bioengineers, physiotherapists, gait laboratory high quality services, delivered by competent staff technicians, orthoptists, engineers and administrative working in safe environments. NHS England set a target staff. Multi-disciplinary meetings took place in relation of 70% of all scientific and diagnostic services to be part to all patients which ensured patient pathways through of an accreditation programme and demonstrate robust the service were managed appropriately and tailored to quality assurance measures by the end of March 2016. meet individual needs. • The ORLAU provided specialised services to children • The tumour unit had two specialist nurses and four and adults with mobility problems. The service provided consultants. Two full-time and one part-time oncology complex mobility aids, designed and manufactured surgeons and one a part-time medical oncologist. The in-house. These aids enabled patients who might team also had a dedicated physiotherapist. The team otherwise be wheelchair bound to stand and walk or held weekly MDT meetings. Cases were also discussed move without fear of falling. at the regional Greater Manchester and Oswestry • Diagnostics reporting between January and June 2015 Sarcoma (GMOS) meetings. showed that across all imaging disciplines an average of 4,453 images per month were processed. 46% were Seven-day services reported immediately or within the first week. 90% of all images were reported on within five weeks.

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Outpatients and diagnostic imaging

• Outpatient services were provided between 9am and • Sixty-eight percent of staff had undertaken training on 5pm Monday to Friday. A number of evening clinics took the Mental Capacity Act. place during the week and clinics also ran on Saturdays, but these were usually extra clinics as opposed to Are outpatient and diagnostic imaging normal working patterns. services caring? • MRI services operated seven days per week. Monday, Friday, Saturday and Sunday 9am to 5pm, and Good ––– Wednesday and Thursdays 8am to 8pm. A call out service operated outside these hours. Before the inspection, CQC received information to suggest that Patients received compassionate care from staff who had a the call out system was ineffective and cumbersome. genuine interest in their health and wellbeing. We saw Following our discussions with the trust, a positive interactions between staff, patients and the people comprehensive review was conducted and systems put who accompanied them. Patients spoke positively about in place to ensure that all staff understood the process. staff. Privacy and dignity were maintained. Patients and their carer’s and relatives were fully involved in planning Access to information and choosing their care and treatment. • All qualified nursing staff and health care assistants had Staff showed they understood what was important to access to the trusts computer systems, where they could patients and were able to support patients accordingly. access policies and procedures and standard operating procedures relating to their role. Compassionate care • Patient records were a combination of electronic and • We saw how staff in the main outpatients department paper records. Staff understood how to access and interacted with patients and the people who update these and where and how to store them. accompanied them. They were respectful and • Information was shared with staff both electronically professional at all times. through email and newsletters and also through team • Staff were unhurried, allowed patients time to respond meetings and supervisions. and provided assistance if they required it. We saw staff • We saw copies of minutes of team meetings, which assist a patient in a wheelchair who was struggling to showed items such as incidents and learning from turn around due to the crowded waiting area. them. Complaints and compliments were standing • We saw a number of instances where staff were clearly items on the agenda. familiar with patients who had attended previously; they Consent, Mental Capacity Act and Deprivation of exchanged friendly conversation and chatted with them Liberty Safeguards as they walked them into treatment or assessment rooms. • Staff we spoke with had an understanding of the Mental • Patients were called by title and family name when Capacity Act and how people’s ability to understand and called into consultations. However no other person therefore consent to care and treatment could change. details or confidential information was discussed Staff told us that they always asked for consent before publically. We saw one instance where a consultant carrying out any examination or procedure. Health care called for a patient and two answered the call. The assistants told us that if they were concerned about the patient’s first name was then used to identify the correct responses they received from patients they should stop patient. and seek advice from nursing staff. • When we spoke with staff it was clear that they had a • Nursing staff were able to describe instances where genuine interest in the patients they cared for. We spoke patients living with dementia had attended and with porters who described how they had taken care clinicians had discussed the proposed treatment with when transporting patients who were in pain; through to the patients and their carer. Decisions were made on the consultants who described being humbled when person’s behalf. They described how such discussions patients returned and described how treatments had were recorded in patient notes to show who had been improved their quality of life. involved and why the decisions had been made.

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• A chaperone service was available to patients in all provided advice and information which helped them areas of outpatients and imaging services. Although understand how their treatment would progress over chaperone service notices were not displayed in all time and the different support they could access if they waiting areas, we noted that they were displayed in required it. treatment rooms and in changing cubicles. • Patients and relatives in the general outpatient area • The National Orthotic Managers Advisory Group confirmed that staff were supportive and had helped (NOMAG) patient satisfaction survey showed that 93% of them feel at ease prior to seeing doctors. They said they patients would recommend the service to friends and had found the doctors to be very knowledgeable which family. had made them feel they were ‘in safe hands’. Unfortunately when staff asked patients in the tumour Understanding and involvement of patients and those unit if they would speak with us, they declined. close to them • Chaplaincy services were available if patients or • Patients told us that they had been fully involved in relatives required them. consultations with nursing and medical staff about their condition and proposed options for treatment. Are outpatient and diagnostic imaging • Many patients described having little choice in the services responsive? options available to them. They did not see this as a criticism but understood that there were limited options Requires improvement ––– for their particular condition other than the one proposed. • Where options for treatment were available patients Clinics were planned on an individual consultant basis; told us that they had been able to make informed there was no oversight of all the clinic activity causing choices and had been able to ask, and were told in undue demand on support services and in turn excessive terms they could understand what the benefits and and avoidable waiting for patients. We saw, and patients disadvantages might be for each option. They felt that we spoke with in clinic, confirmed that they often had to they had been able to make the final decision about wait well in excess of thirty minutes from their appointment what treatment to undertake. time or diagnostic procedure. In some instances staff told • Patients also confirmed that when they attended us it was a regular occurrence for patients to wait over an consultations and were accompanied by family hour for their appointment. The department did not members they had also been able to question options routinely measure how long patients had to wait for and discuss potential outcomes and alternatives. appointments. Emotional support At the time of the inspection, the trust was achieving all the referral to treatment times for patients referred from • Staff described how patients, particularly new patients English commissioners, targets for waiting times for could be anxious about their condition and how their diagnostic appointments were also being achieved. illness or condition might affect their quality of life. Staff described how they would reassure patients and if Meeting the needs of individual patients was a very strong required take them into side rooms and discuss their feature of both imaging and outpatient services. We saw concerns. that in some clinics, patient appointments were planned in • Clinical nurse specialists conducted some clinics and a patient centred way, enabling patients to see multiple had specific training in the issues which patients might specialists at one appointment rather than attending face. We spoke with a specialist nurse in the tumour unit different appointments to see each speciality. who described how patients were anxious to We saw that complaints were recorded and responded to understand what their condition actually means and appropriately; learning from complaints was shared how it will affect their lives. They described how they amongst staff. Service planning and delivery to meet the needs of local people

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• The type and frequency of clinics was planned around by occupational therapy patients with only 1.2 weeks, the preferences of individual consultants, not podiatry patients 3.7 weeks. The longest waits were necessarily patient needs. Consultants would ask their neurology patients 12.1 and paediatric medicine 12.4 secretaries to arrange a clinic for a number of patients weeks. on a particular day, this was communicated to the • Diagnostics waiting time for patients referred from booking clerks who would then contact the patients and Welsh commissioners had a target of 90% of patients to arrange appointment times. These were then passed to be seen within eight weeks. In April 2015, 100% of the outpatients department for them to allocate rooms. patients were being seen within eight weeks. There was no oversight of the system which enabled • Diagnostic waiting times for patients referred from consultants to see what activity was already occurring English commissioners was six weeks with a target of and thereby assess the impact of the clinic on the 99%. We saw that the service achieved 99% or 100% required support services. compliance between April 2014 and June 2015. • Patient appointments in the ORLAU were planned to • Staff told us that all appointments were scheduled to enable multiple interventions from a number of last the same amount of time however some ran over specialities on each visit. This reduced the number of this time, but this was balanced by the number which appointments for each patient, improving the patient took less time. We saw this in action where at one point experience. waiting times had been posted on the waiting room • Most outpatient appointments related to specific issues notice board as 40 minutes. A few hours later we were in and followed set pathways. However we saw how many the same area and it was noted that the waiting time patients were able to engage in several interventions had been changed to 20 minutes. during each visit such as physiotherapy or occupational • The trust had set a target of 90% of x-ray patients to be therapy, imaging services and consultation with their seen within 30 minutes. Data provided by the trust specialist. showed that between April 2014 April 2015, the target • Some patients who had been receiving periodic was only achieved during three of the twelve months. injections from a consultant for their pain relief advised Three further months achieved over 85%. us before the inspection that the trust had contacted • Staff in outpatients and imaging told us that in addition them to advise that they could no longer receive this to the usual clinics there is a scoliosis clinic which is service at the hospital. We were told this was due to the held twice monthly. Patients attending the scoliosis consultant leaving the service and there being no other clinic often require extensive imaging procedures during consultant able to provide the service. Patients had their visit. This usually means that patients waiting for been advised to return to their GP for referral to an imaging in all the clinics find their waiting times are appropriate service. extended. Staff told us that it was not unusual for patients to experience waiting times over an hour and Access and flow half when scoliosis clinics were running. • As at July 2015, patients referred from English • Staff explained that most complaints in outpatients commissioners waited on average 8.9 weeks from related to patient waiting times. We saw that notices referral to treatment (RTT). Due to commissioning had been placed in the waiting rooms apologising for differences between English and Welsh bodies, Welsh delays. RTT times were in some instances in excess of 52 weeks. • The time patients waited to be seen once they arrived at • RTT times were audited in Orthopaedic (9 specialities) clinic was not routinely measured within the main and Non Orthopaedic (17 specialities). Of the nine outpatients department. 1% of patients attending the orthopaedic specialities the shortest waits were ORLAU had to wait longer than 30 minutes to be seen experienced by ‘tumour’ patients 4.6 weeks and the this equates roughly to one patient every two weeks. longest waits were ‘spinal disorders’ at 10.8 weeks. Non • Imaging services failed to meet the 30 minute target for orthopaedic specialities least waiting was experienced 15% of patients; an average of 228 patients per month. Meeting people’s individual needs

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Outpatients and diagnostic imaging

• The Orthotic Research & Locomotor Assessment Unit • Translation services were available through a telephone (ORLAU) assess children and adults with mobility service and face to face interpreters could be arranged if problems. The service included gait assessment and required. rehabilitation engineering facilities. Multi-disciplinary • Specialist clinics such as rheumatology provided teams met to discuss individual patients. They then patients with contact telephone numbers, patients with planned appointments around the needs of that concerns could ring and leave a message and nurse person. If different specialist interventions were specialists would return the calls and discuss concerns required, these were planned so that they could all be and options with patients. The service was also used by completed during one patient visit. This prevented GP’s who were seeking advice on best options for their multiple appointments and multiple trips for patients. patients. Rheumatology received an average of 15 calls • Greater Manchester and Oswestry Sarcoma (GMOS) per day. Staff aimed to return calls within 24hrs on bone and soft tissue sarcoma unit, one of only five weekdays. centres in the country. This was funded direct by NHS • Bed bound patients who were brought to imaging had a England through specialised commissioning. Clinics dedicated bed parking area which could be curtained took place every weekday 8am to 4pm. The service off for privacy, however we noted that the area was received 900 new referrals during last 12 months. We shared with large wheelie bins. Whilst these were clean saw how referrals were assessed to ensure that urgent and were not used for conventional waste, being left cases were identified and prioritised. Staff explained with the rubbish whilst waiting for a procedure was not how patients who first attend are often very frightened conducive to a feeling of wellbeing. When we by their diagnosis. The staff receive specialist training mentioned this to senior staff they undertook to resolve which enables them to support patients and their the issue. families by explaining the disease and how it might Learning from complaints and concerns affect them. Information leaflets were available and patients were signposted to support services. • Patient information leaflets were available in • The National Orthotic Managers Advisory Group outpatients, which included information on how to (NOMAG) patient satisfaction survey showed that only make complaints. The trust patient advice and liaison 40% of patients were provided with written information service (PALs) were available to advise and assist to support the verbal advice provided. As a result an patients who wished to make complaints. action plan was completed to produce additional • Between July 2014 and June 2015, a total of 31 formal information leaflets relating to different forms of complaints had been recorded as outpatient orthotics. Five additional information leaflets were complaints. We saw that complaints were properly produced immediately and new information leaflets recorded and responded to. Of the 31 outpatient were produced as new products were developed. complaints we saw that five related to patients who • A communication box was held in the outpatients were unhappy with the outcome of surgical procedures department which contained various cards and pictures they had received. Other complaints included being which staff used to help them communicate with unhappy with the attitude of staff, incorrect initial patients who had a learning disability or could not diagnosis and cancelled appointments. During the express themselves verbally. Staff explained that same period, diagnostics had received one complaint patients with complex needs usually came with carers which related to costs of private treatment. or relatives who were able to assist with communication • Specialist department’s complaints were listed and understanding for the patient. separately. ORLAU received one complaint, Muscle clinic • One member of staff described how the department one complaint, Metabolic clinic one complaint and had a number of patients who were living with orthotics five complaints. dementia. When these patients attended the staff tried • Staff explained that most complaints in outpatients to ensure that they were always seen by the same related to patient waiting times. The majority of these members of the team which provided a degree of were settled by staff explaining what had caused the continuity for them and reduced their anxiety. delay. In response to the number of complaints we saw

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that notices had been placed in the waiting rooms identified the patients from their lists, sent details to the apologising for delays. However, this does not booking clerks and letters were sent out. Only then were demonstrate learning from complaints or demonstrate the details sent to the outpatients department for that work has been undertaken to address the cause. allocation of rooms and entry in the written diary. • We saw how complaints were discussed at senior • Although consultant staff may have felt that clinics nursing and allied health professionals meetings. The appeared to function satisfactorily, it was having a minutes of the March 2015 meeting showed how a negative impact on the patient experience, especially at complaint had been shared with the meeting as a peak times because waiting areas were so full, and they ‘Patient Story’ and related to a patient who had fallen had to wait excessive lengths of time to be seen. This and complained about staff response. The complaint was particularly evident when we visited the Scoliosis was read out and learning shared amongst the staff. clinic. Governance, risk management and quality Are outpatient and diagnostic imaging measurement services well-led? • There were systems in place to enable department managers to identify and respond to issues affecting the Requires improvement ––– service. Regular team meetings took place where staff were able to raise concerns or receive feedback or We did not see evidence of strategic oversight of the updates. Monthly incident review committee meetings number and type of clinics booked by consultants. This led and monthly divisional meetings took place. to specialist clinics running alongside general clinics and • Outpatients did not have their own integrated an adverse impact on the patient experience. performance reports but were included in the respective report for surgery and medicine. This meant the Staff were aware of the trust vision and felt supported by department was unable to monitor and measure its local managers, but there were some isolated cases where own performance. Diagnostics does have its own staff did not feel fully supported. Staff and managers were performance report. proud of the services they delivered and this was reflected • Staff were encouraged to discuss concerns and where in the culture of the respective departments we visited. risks were identified which affected staff, patients, Each department had an up to date risk register in place visitors or the provision of services. These were assessed that reflected local concerns and issues. We saw that steps and entered onto the departmental risk registers. More had been taken to mitigate risks where possible. Local serious risks were escalated to the trust risk register for audits were also undertaken. There was good engagement overview at executive level. with staff and patients. • Outpatients had a total of 28 risks on their register, none were classified as major risks and only four were Vision and strategy for this service moderate, These included difficulty in recruitment, • Staff in outpatients and in diagnostic imaging were insufficient and inappropriate waiting areas, security of aware of the trusts vision and the values of Friendly, patient notes and lack of consultation rooms for new Caring, Excellence, Professional and Respect which they consultants/clinics. We saw evidence of how these were expected to follow. Staff understood their role issues had been reviewed and actions taken to mitigate within the organisation and how this contributed to the the concerns. trust’s values. • Diagnostics had a total of 44 risks, with three classified • There was no overall policy for scheduling clinics and as major risks and 16 moderate. The major risks were; arranging patient appointment times. The system for lack of a director for Histopathology, accommodation arranging outpatient clinics operated without any senior for the ultrasound scanner and risk of the ultrasound management overview of how this might affect other scanner failing. The moderate risks included clinics or demands on staffing. Consultants’ secretaries contingency planning for possible breakdown of MRI

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and CT equipment and capacity issues with year on year • The League of Friends operated a café in the atrium of increase in demand. We saw that actions and options the main entrance and provide an information service to had been put in place or proposed which mitigated the patients and their relatives. On 30 June 2015 the Robert risks until solutions were available. Jones and Agnes Hunt league of friends were presented • Therapies had a total of 24 risks, many of which related with the Queens Award for Voluntary Service. to services outside the hospital, there were no major Staff engagement risks and seven moderate risks; these included three issues relating to the hydrotherapy pool – access issues • Staff in most areas told us they felt supported in their for wheelchair users, risk of falls for ambulant patients role. Individual teams held team meetings and some and difficulty with cleaning areas which corroded to engaged in staff away-days to develop team work and prevent infection risk. engage with training events. • Local audits were completed in relation to working • Staff were encouraged to develop, train and maintain practices; these were reviewed within departments and their professional registration where appropriate. overseen by directorate heads. Learning from these was • Staff confirmed that they had 1 to 1 meetings with their fed back at team meetings and action plans completed line managers, and were able to approach their line to address shortfalls. managers for advice guidance and support. • Most staff we spoke with had access to the trust Leadership of service computer systems and received emails and newsletters. • Staff told us that local managers were supportive of The outpatient’s sister described how she passed on their work, understood their issues and represented information to staff who did not have access to their needs. The majority of staff believed they could computer systems, during handovers or informal raise issues if they needed to and would be dealt with meetings. fairly and openly. Innovation, improvement and sustainability • We observed excellent interactions between staff of all disciplines and at all levels. Although we also heard of • Nuclear medicine was under review in relation to the isolated incidents where senior managers had been less viability of its continuing to function from the trust. The supportive, particularly of staff in junior roles. Where department saw in the region of 1,000 patients per year. staff raised concerns, we fed them back to the trust’s The cost of renewal and maintenance of equipment executive management team who gave us assurances together with the high skill level of staff required to work that these issues would be further investigated. in the department meant that expenditure far outstripped the income generated. Senior managers Culture within the service were in consultation with neighbouring trusts and • Senior managers and clinicians were proud of their planned ultimately to transfer patients who required teams and credited them with being responsible for the this service to the nearest alternative hospital based on positive patient outcomes and favourable patient patient’s location and hospital location. feedback. • ORLAU had explored innovative approaches to service • Staff of all disciplines were proud of their work and keen delivery through service level agreements with NHS and to explain how they worked and how this affected their charity partners and by supporting services off site. The patients. There was an air of ownership in what staff did department was active in the translation of research and a belief that it not only helped the patients but also into clinical practice through funded research projects that it contributed to the trust. and academic partnerships. Staff had been involved in International/National collaborations in service Public engagement development, training (ESMAC teaching and National • The trust had a number of patient groups which held School of Health Science (NSHCS) MSc delivery) and regular meetings which were attended by hospital staff quality standards implementation (ISO 9001/CMAS/ including members of the executive team.

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iCEPSS). ORLAU has developed local models for translating trust policies into practice, for example evaluating local stress levels and assessing developments against trust values.

76 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 Outst anding pr actic e and ar as f or impr ovement

Outstanding practice and areas for improvement

Outstanding practice

• In July 2015, a National Patient Safety Award for • The HDU had proactively taken steps to support clinical leadership was won by the Ward Manager of patients living with dementia. For example, MCSI for building sustainable systems and processes. individual clocks within HDU which identify the time Staff sickness levels on MCSI had reduced from 27% and day of the week which helps with orientation. to 0.2%during 2014-2015. This was largely attributed • On the children’s ward, to reduce the risk of an to the strong leadership of the ward manager which allergic reaction, a toaster had been set aside for had positively impacted on the team and reduced gluten free bread and was clearly marked as such. reports of stress related sickness. • The children’s ward had used innovative approaches • Staff on the MCSI had shown exceptional to collecting children’s views about services compassionate care in supporting a patient who was including, ‘Pants and Tops’ and the seedling to bereaved during their admission period and in flower display . practical assistance to help a patient to maintain contact with their employer. The Orthotic Research & Locomotor Assessment Unit was excellent, providing innovative interventions to improve • In the High Dependency Unit, staff enabled patients patient mobility, including occupational and physio to maintain contact with their loved ones via the therapies, as well as mechanical aids which were unit’s portable phone which was brought to the designed and manufactured on site. patients' bedside. This enabled patients to keep in touch especially if the patient lived some distance from the hospital and relatives were not able to visit.

Areas for improvement

Action the hospital MUST take to improve practices, using methods that are robust and improve signage of isolation procedures, hand • The hospital must ensure that there are robust and washing instructions, and use of hand sanitisers in suitable arrangements to provided paediatric all clinical areas and corridors. medical cover during the evenings, overnight and at the weekend to ensure that they can respond in an • The hospital must ensure that staff caring for appropriate, safe and timely way to deteriorating children are able to identify, report and treat and seriously ill children. deteriorating and seriously ill children. This includes being familiar with SBAR and its use in alerting the • The hospital must ensure that all incidents, including medical team to emergencies. non-clinical incidents are reported by all staff. Learning points from complaints and incidents • The hospital must ensure that patient’s medical should be shared across directorates and all action notes in HDU include a record of all doctor visits and plans monitored to improve the quality of care and any revision to the patient’s treatment plan. develop services. • The hospital must ensure that there is at least one • The hospital must improve hand hygiene standards team member with up to date paediatric and ensure that all staff in all areas are adhering to resuscitation training on duty at all times on Alice trust policy. The trust must also audit hand hygiene ward and all staff who may be required to respond to a paediatric medical emergency also have up to date paediatric resuscitation training.

77 The Robert Jones & Agnes Hunt Orthopaedic Hospital Quality Report 03/03/2016 Outst anding pr actic e and ar as f or impr ovement

Outstanding practice and areas for improvement

• The hospital must ensure that resuscitation • The hospital should arrange and monitor attendance equipment is fit for purpose and urgently seek to at trust wide medicines safety committee meetings provide battery-powered suction machines for Alice to enable discussion of best practice and share ward. learning from concerns, risks and incidents • The hospital should ensure that paediatric care • The hospital should review and update PGDs in line pathways are routinely audited in order to monitor with national guidance through the approved trust compliance with nationally recognised best practice. processes. • The hospital should ensure that outpatient clinics • The hospital should ensure that HDU contribute data are planned in such a way to prevent excessive to Intensive Care National Audit and Research Centre demand on support services or other clinic areas (ICNARC) or a similar organisation to benchmark the which in turn impacts adversely on patient waiting service against other similar hospitals. times. • The hospital should be aware of where children are Action the hospital SHOULD take to improve seen and treated. Where possible, children should be seen in the paediatric outpatient department, where • The hospital should re-establish mortality and the environment is suitable and where staff have morbidity meetings in the medicines division to appropriate training in caring for children. review deaths as part of professional learning for doctors. • The hospital should review arrangements for therapy provision at weekends to ensure patients have • The hospital should make arrangements to improve adequate access 7-days a week. privacy in the therapies gym and ensure there is a regular programme of environmental audits and • The hospital should review the leadership facilities and address non-compliance in a timely arrangements for the children’s services to ensure the way. ward manager has sufficient managerial and professional support.

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