Sheffield Teaching Hospitals NHS Foundation Trust
Evidence appendix Royal Hallamshire Hospital Date of inspection visit: Glossop Road 12 – 14 June and 13 -15 July 2018 Sheffield S10 2JF Date of publication: 31 October 2018 Tel: 0114 271 1900 www.sth.nhs.uk
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust
Acute hospital sites at the trust
A list of the acute hospitals at the trust is below.
Name of Details of any specialist services Geographical acute Address provided at the site area served hospital site General and specialist medical and surgical services are based at this site. They include cardiac, orthopaedics, Northern General burns, plastic surgery, spinal injuries, Northern Hospital, Herries gastroenterology and renal. Sheffield and General Road, Sheffield, region Hospital S5 7AU The Accident and Emergency department is on site here and is one of three Major Trauma Centres in Yorkshire and Humber.
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General and specialist medical and surgical services are based at this site. There is also a neurosciences department, including a stereotactic radiosurgery centre; a large tropical medicine and infectious diseases unit; an ophthalmology centre, gynaecology and a specialist haematology centre.
Royal Hallamshire Royal The Jessop Wing is on this site and is Hospital, Glossop Sheffield and Hallamshire the maternity unit within the trust Road, Sheffield, region Hospital providing tertiary maternity services. S10 2JF There is a consultant led labour ward, advanced obstetric care unit and a midwifery led care unit plus one inpatient antenatal ward and two inpatient postnatal wards. There are neonatal intensive care facilities for Sheffield babies and those transferred from other units in the region. There is also an assisted conception unit. This is one of four dedicated UK cancer hospitals. It provides outpatient and Weston Park 160,000 patients inpatient care including provision of Weston Park Hospital, Whitham each year. chemotherapy and radiotherapy Hospital Road, Sheffield, Sheffield and treatments for patients from across the S10 2SJ region region. There are also outreach services provided within other local hospitals. This dental teaching hospital is linked to the University of Sheffield School of The Charles Clinical Dentistry providing specialist Clifford Wellesley Road, dental services for Sheffield and the Sheffield Dental Sheffield, S10 2SZ surrounding areas. Community and Hospital special care dentistry provides dental care in community settings. (Source: Routine Provider Information Request (RPIR) P2 – Sites)
Community sites at the trust The trust provides community services at 21 sites across Sheffield and the surrounding areas. Community services provided at the sites are listed below: • Adult physiotherapy • Continence clinics • Dental services • Community nursing and therapy • Podiatry • Renal dialysis clinic • Tuberculosis treatment • Tissue viability clinics • Foot care surgery/treatment • Pulmonary and respiratory condition support • GP collaborative (Out of hours service)
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Background to the trust The trust is one of the UK’s largest providers of hospital and community-based healthcare. It provides a comprehensive range of local services to the residents of Sheffield, South Yorkshire, Mid Yorkshire and North Derbyshire and some highly specialist services to all parts of England. The trust has 16,500 employees and a budget of over £1billion. (Source: Routine Provider Information Request (RPIR) Acute – Context)
Facts and data about the trust The trust has 1,669 inpatient and critical care beds across 68 wards and operates approximately 3,796 outpatient clinics and 145 community clinics per week. (Source: Routine Provider Information Request (RPIR) P2 – Sites)
Patient numbers From December 2016 to November 2017 across the trust there were: • 1,801,834 outpatient attendances • 213,895 inpatient admissions • 16,211 planned elective surgical cases • 147,997 attendances at the accident and emergency department • 6,580 deliveries (Source: Hospital Episodes Statistics December 2016 – November 2017)
Is this organisation well-led? Leadership
The trust had a very experienced leadership team and stable board with the qualifications, skills, abilities, and commitment to provide high-quality services. They worked well together as a unitary board.
The board had been stable for many years, especially the executive members with the CEO being in post since 2004. The only recent appointment was that of the director of strategy and planning who joined the trust in February 2018. However, significant executive change was about to take place with the CEO retiring in July 2018 and the chief nurse retiring in August 2018. At the time of the inspection the trust had advertised the CEO vacancy but had chosen not to appoint; a further recruitment round was planned for autumn 2018. The chief nurse post had been recruited to with the new post holder due to start in October 2018; this would provide some continuity as the person had previously worked at the trust as deputy chief nurse.
There was an experienced chairman who had been in post since 2012 and prior to that had chaired another NHS organisation. The non-executive director posts were all filled with the newest appointment being a clinician who started in November 2017.
We reviewed six directors’ files (three non-executive and three executive) to determine whether appropriate steps had been taken to complete employment checks for executive and non- executive board members in line with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role.
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We found that the trust’s policy for FPPR was in date and met the requirements of the regulation. Directors completed annual self-declaration forms to confirm that they complied with the regulation. These were all up to date in the six files we reviewed.
We found that none of the directors had evidence within their personnel file of the qualitative assessment and values-based assessment they had undergone as part of the recruitment process. This was not in line with the trust’s own policy.
One of the non-executive director files we reviewed did not contain evidence that they had been subject to all the appropriate fit and proper person checks.
The diversity of the Board members is outlined in the table below. The CEO and Chair both acknowledged the lack of British Minority Ethnic (BME) representation on the Board: • Of the executive board members at the trust, none were BME and 55% were male. • Of the non-executive board members, none were BME and 37% were female.
Staff group BME % Female %
Executive directors 0% 55%
Non-executive directors 0% 37%
All board members 0% 47% (Source: Routine Provider Information Request (RPIR) – P64 Board Members - Diversity and list)
The trust had recognised the need for increased diversity within its leadership succession pipeline, especially at board level and had developed a system wide approach to improving workforce race equality. This included reverse mentoring of members of the trust’s board. Reverse mentoring refers to an initiative in which senior staff are paired with and mentored by younger employees on various topics such as BME, technology and social media. The trust was using this in terms of developing a greater understanding and appreciation of the challenges facing BME staff. The trust was also working towards achieving the Athena SWAN charter to boost women’s access/success to career development and leadership. The Athena SWAN Charter evolved from work between the Athena Project and the Scientific Women’s Academic Network (SWAN), to advance the representation of women in science, technology, engineering, medicine and mathematics.
There were clear priorities for ensuring sustainable, inclusive and effective leadership; there was a multi-layered approach to leadership development within the trust which includes succession planning. There was a workforce strategy “Making it Personal” and evidence of development programmes for staff. All staff groups and bands have supported access to leadership and development opportunities. The leadership/management development opportunities included a well-established nationally recognised Level 3 accredited award in Leadership & Management, an ‘Effective Management Series’ programme, and bespoke work on psychometrics preferences for leadership styles and team working. There was also a system to offer staff internal and regional coaching and mentoring. To enable flexible provision the trust had over 30 leadership/ management focussed e-learning packages for staff to access at a time and place to suit them. In addition, there was a focus on innovation and quality improvement leadership capability with the local development of the Sheffield Microsystems Coaching Academy and Listening into Action programmes. Both emphasised the opportunity for systemic leadership and innovation through high impact engagement.
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The trust was developing new workforce models and multidisciplinary roles. It was working with local colleges and universities to improve the staff skill set and fill gaps in recruitment, for example, advanced nurse practitioners. The trust was also training physician associates.
The board had an understanding of the broader health challenges locally and nationally and were aware of the risks. There was active inclusion in the developing health and social care landscape through the leadership and involvement of directors and other staff in the South Yorkshire and Bassetlaw Integrated Care System (ICS) and its working groups. The trust board had reviewed its executive structures and appointed a deputy CEO to focus operationally; this created headroom for the CEO to focus on the external strategic developments within the ICS and nationally.
The immediate structure below the board was the trust executive group (TEG) and the management board which included the clinical and operational directors from the care groups.
Operationally the trust had a devolved leadership structure which was run through ten clinical care groups; acute and emergency medicine; medicine and pharmacy services; OSCCA (operating services, critical care and anaesthesia); specialised cancer, medicine and rehabilitation: South Yorkshire regional services; LEGION (laboratory medicine, medical imaging and medical physics, obstetrics, gynaecology and neonatology); head and neck; surgical services; combined community and acute; and musculo-skeletal care group. Most of the groups had a number of specialised clinical directorates within them. There were 27 clinical directorates and six corporate directorates. Each group/directorate was led by a team made up of clinical directors, a nurse director and an operations director who were supported by matrons and service managers together with HR, finance and other support services. At the last inspection the leadership for end of life care services and the emergency department had required improvement. At this inspection there was evidence of significant improvement in the leadership and management of these services.
The Chief Pharmacist was aware of the challenges to the quality and sustainability of the pharmacy service, and plans were in place to address these. They were visible and accessible to all staff. Senior staff were provided with appropriate development opportunities which contributed to effective succession planning.
There was a clear leadership structure for the GP Collaborative (Sheffield Out of Hours Service). Staff reported into an operational director and governance team. Leaders said they felt very supported and that there were clear communication channels and that there were clear lines of accountability. They felt all staff understood their roles/responsibilities.
Vision and strategy
The board and senior leadership team had set a clear cohesive vision and values (PROUD) that were at the heart of all the work within the organisation. The vision was “To be recognised as the best provider of health, clinical research and education in the UK and a strong contributor to the aspiration of Sheffield to be a vibrant and health city”. Staff understood what the vision and values were and their role in achieving them.
The trust had recently refreshed its five year trust strategy (Making a Difference Corporate strategy 2017–2020) in light of the changing environment nationally and locally. It had originally been developed in 2012 and was refreshed following consultation with staff and wider
20171116 900885 Post-inspection Evidence appendix template v3 Page 5 stakeholders. The vision and values remained the same with some changes to the strategic objectives. It had five strategic aims: deliver the best clinical outcomes, provide patient-centred services, employ caring and cared for staff, spend public money wisely and deliver excellent research, education and innovation. In addition, the board agreed a timeframe of three years to update the strategy with ongoing annual reviews.
There were underpinning strategies in place which were either trust-wide, at group/directorate or service level. There were other key enabling strategies and plans to support the trust’s vision and overarching strategy. Examples of these included the trust’s quality strategy (2017-2020), the information and technology strategy which was approved in June 2013 and refreshed in 2016; estate strategy; financial plans; and a workforce strategy “Making it personal” which was launched in July 2018. Since the last inspection the trust had developed and was implementing an end of life care strategy.
The corporate strategy and its operational plans were effectively monitored and reviewed by the Board, its committee’s and through each of the care groups’ governance processes. However, some of the implementation plans were not well developed, such as IT mobile working and implementation of the dementia strategy. We were told that the trust was intending to produce a specific dementia plan at trust level within six months of the inspection.
Each clinical and corporate directorate had a strategic plan which was reviewed in light of the changes to the corporate strategy. The trust had six-monthly reviews with the directorates; we saw the six-month progress report against the delivery of the corporate objectives which was presented to the Trust Executive Group and the Board in October 2017 and a review of progress against the corporate objectives 2017/18 and planned corporate objectives 2018/19 in May 2018. NHSI has assessed the 2018/19 plans as realistic and deliverable.
There was a quality board, chaired by the medical director which was put in place to oversee the Trust’s overarching quality strategy. Membership included trust governors, local Healthwatch and voluntary sector representation. This group fed direct into the board’s healthcare governance committee.
The corporate strategy and its supporting strategies were linked into the wider health economy of the South Yorkshire and Bassetlaw Integrated Care System which had five place-based partnerships operating within it, one of which was the Sheffield local authority area – the Sheffield accountable care partnership.
The ICS had eight priority areas: • Healthy lives, living well and prevention • Primary and community care • Mental health and learning disabilities • Urgent and emergency care • Elective care and diagnostics • Maternity and children’s services • Cancer • Non-clinical support functions.
In addition to this the ICS had in 2018 completed an independent hospital services review which focussed on five key service areas. These were: urgent and emergency care; maternity; care of the acutely ill child; gastroenterology and endoscopy and; stroke. At the time of the inspection
20171116 900885 Post-inspection Evidence appendix template v3 Page 6 there were very few specific examples the board could give to articulate what difference the ICS had made to patients.
The Board members we spoke with were aware of the national, regional and local challenges and opportunities for the health care system and how they saw the trust operating within it.
The trust had strategies in place for meeting the needs of patients with a mental health, learning disability, autism or dementia diagnosis. Some of these were city-wide strategies that the trust had helped develop and signed up to. The trust had recognised that the care of patients with mental health needs in an acute setting was an issue. There was an executive director board lead for mental health and the trust had a mental health strategy in place that was to be revised following publication of a city-wide strategy during 2018. Mental health was also highlighted as a corporate risk with appropriate mitigating actions identified to reduce the risk. The team reviewing the strategy was multidisciplinary and included the trust, clinical commissioning group, liaison mental health strategy included representation from the trust, psychiatry, police and other interested parties such as training, Mental Capacity Act and Mental Health Act lead, learning disabilities lead and department of psychological services. There was a memorandum of understanding between trust and the local NHS mental health provider regarding the psychiatric liaison service and Mental Health Act management.
The trust had a medicines optimisation strategy in place to 2020, which also incorporated the Hospital Pharmacy Transformation Plan. In addition, there was a ‘plan on a page’ for the current financial year. There was a staff engagement strategy, and staff were aware of the vision and values of the pharmacy service and their role in achieving them.
Culture
The trust’s strategy, vision and values underpinned a culture which was patient centred. Staff felt positive and proud about working for the trust and their team. There was a clear message around balancing quality with financial performance.
There was a relatively stable workforce. The board members, senior management team and care group management teams appeared to work well together with constructive challenge and mutual respect. There was a drive to improve the health and care of patients within the local area.
Most staff we spoke with during our inspections said they felt positive and proud to work in the organisation and that they were supported by their managers. Action was taken to address concerns highlighted by the staff groups and to address behaviour and performance that was inconsistent with the vision and values. The most significant area where this varied was feedback from medical staff, especially junior doctors about working at Weston Park. The trust had recognised this, and actions were being put in place to address these concerns. There was also mixed feedback from consultants particularly at the NGH who told us that concerns that they had raised had not been acted upon.
Overall, there were positive results from the 2017 staff survey (see tables below). There were 15 key findings similar to the average, 13 better than average and four that were below the average for all acute trusts. The 2017 staff survey indicated that 81% of staff would recommend the trust as a place to be treated against 69% nationally and 68% of staff would recommend the trust as a place to work against 59% nationally.
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The trust had 15 key finding that were similar to the average compared to all acute trusts in the 2017 NHS Staff Survey:
Key Finding Trust Score National Average
KF11. % appraised in last 12 months 88% 86%
KF28. & witnessing potentially harmful errors, near 29% 29% misses or incidents in last month
KF29. % reporting errors, near misses or incidents 91% 91% witnessed in last month
KF17. % feeling unwell due to work related stress in last 37% 38% 12 months
KF18. % attending work in last 3 months despite feeling 52% 53% unwell because they felt pressure
KF15. % satisfied with the opportunities for flexible 51% working patterns 51%
KF3. % agreeing that their role makes a difference to 90% 90% patients/ service users
KF22. % experiencing physical violence from patients, 14% 14% relatives or the public in last 12 months
KF12. Quality of appraisals 3.12 3.11
KF13. Quality of non-mandatory training, learning or 4.04 4.06 development
KF8. Staff satisfaction with level of responsibility and 3.90 3.89 involvement
KF9. Effective team working 3.74 3.74
KF10. Support from immediate managers 3.78 3.76
KF2. Staff satisfaction with the quality of work and care 3.93 3.90 they able to deliver
KF32. Effective use of patient/service user feedback 3.73 3.69
The trust had four key findings worse than the average compared to all acute trusts in the 2017 NHS Staff Survey as outlined in the table below:
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Key Finding Trust Score National Average KF7.% able to contribute towards improvements at work 68% 70% KF24. % reporting most recent experience of violence 62% 67% KF27. % reporting most recent experience of harassment, bullying or abuse 43% 47% KF4. Staff motivation at work 3.87 3.91 Note – none of the key findings in the table above were in the worst 20% of trusts
The trust had 13 key finding that were better than average compared to all acute trusts in the 2017 NHS Staff Survey:
Key Finding Trust Score National Average
KF20. % experiencing discrimination at work in last 12 8% 10% months
KF21. % believing the organisation provides equal 88% 85% opportunities for career progression/ promotion
KF16. % working extra hours 66% 71%
KF6. % reporting good communication between senior 39% 33% management and staff
KF23. % experiencing physical violence from staff in last 2% 2% 12 months
KF25. % experiencing harassment, bullying or abuse from 23% 27% patients, relatives or the public in last 12 months
KF26. % Experiencing harassment, bullying or abuse 20% 24% from staff in last 12 months
KF30. Fairness and effectiveness of procedures for 3.80 3.73 reporting errors, near misses and incidents
KF31. Staff confidence and security in reporting unsafe 3.73 3.67 clinical practice
KF19. Org and mgmt. interest in and action on health and 3.68 3.63 wellbeing
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KF1. Staff recommendation of the organisation as a place 3.92 3.75 to work or receive treatment
KF14. Staff satisfaction with resourcing and support 3.39 3.27
KF5. Recognition and value of staff by managers and the 3.51 3.44 organisation
(Source: NHS Staff Survey 2017)
The 2017 survey results indicated that the percentage of BME staff experiencing harassment, bullying or abuse from staff, patients or relatives in the past 12 months at this trust was similar to 2016 and was better than the England average. The percentage of staff believing that the organisation provided equal opportunities for career progression had improved for BME staff at the trust but remained worse than for white staff. The percentage of staff who had personally experienced discrimination at work was better than the national average. There were statistically significant differences between BME and white staff scores for all four of the WRES survey questions with the exception of KF25. “Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months”.
The scores presented below are the un-weighted question level score for question Q17b and un- weighted scores for Key Findings 25, 26, and 21, split between White and Black and Minority Ethnic (BME) staff, as required for the Workforce Race Equality Standard. In order to preserve the anonymity of individual staff, a score is replaced with a dash if the staff group in question contributed fewer than 11 responses to that score.
(Source: NHS Staff Survey 2017)
Staff Diversity and the Workforce Race Equality Standard The trust had worked with local partners to develop a system wide strategy to improve the experience of BME staff. However, at the time of the inspection the trust had not extended this work to other protected characteristics. Following the inspection, the trust provided a paper which had been discussed at the Trust executive group on the 4 July 2018 which stated that by the end
20171116 900885 Post-inspection Evidence appendix template v3 Page 10 of March 2019 the trust would have installed an Equality, Diversity and Inclusion Committee which would be responsible for the development, implementation, monitoring, and review of policy, planning, procedures and practice to support the ED&I agenda for patients and related equality policies in relation to workforce.
They had been supported in this work during 2016 by the national NHS director for Workforce Race Equality Standard (WRES) implementation. A document summarising progress to date had been produced “Improving workforce race equality: A system wide approach”. The trust acknowledged that they were in the “foothills” of achieving this strategic ambition but had plans in place to do so. Data from the document indicated that the workforce at the trust was not yet representative of the population it served. The workforce was 13% BME compared with the local population which was 19%. In addition, the trust has internally benchmarked WRES data for each directorate in order to highlight areas with low/high BME numbers and the percentages by pay band. The trust had a WRES) action plan for 2017-2020; there were clear actions with identified leads and timescales. WRES meetings to monitor the plan were in place. We were told that that trust had chosen to prioritise race equality first as this was the largest minority in the workforce. The trust had held a BME focus group with approximately 200 attendees.
Friends and Family test The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the services they have used, giving the opportunity to feedback on their experiences of care and treatment.
From March 2017 to February 2018 the trust scored the same as the England average for recommending the trust as a place to receive care.
(Source: NHS England)
Sickness absence rates The trust’s sickness absence levels from September 2016 to July 2017 were worse than the England average from January to March 2017 however from March to November 2017 performance improved. The trust’s trend over time reflected the national trend.
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(Source: NHS Digital)
General Medical Council – National Training Scheme Survey In the 2018 General Medical Council Training Scheme Survey the trust performed as expected for all indicators.
Survey area This trust Overall Satisfaction
Clinical Supervision
Clinical Supervision out of hours
Reporting systems
Work Load
Teamwork
Handover
Supportive environment
Induction
Adequate Experience
Curriculum Coverage
Educational Governance
Educational Supervision
Feedback
Local Teaching
Regional Teaching
Study Leave
(Source: General Medical Council National Training Scheme Survey)
The culture of the trust centred on the needs and experience of people who used services. This was clearly demonstrated from observations of care within the core services we inspected and at service level and above when planning for changes to services or tendering for new services.
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There was a culture of openness and honesty at all levels within the organisation. Staff we spoke with had a low threshold for reporting incidents which indicated an open and transparent culture.
Of the NHS trusts in Yorkshire and Humber, Sheffield Teaching NHS Foundation Trust showed one of the lowest rates of harm per 1000 bed days between November 2017 and April 2018. However, on comparative data the trust was also flagged for potential under-reporting of serious incidents.
Duty of candour was applied effectively within the incidents we reviewed. There was a section at the start of each serious incident investigation report that included whether the patient /carer/family had been informed of the incident; whether it was documented in medical records and whether a verbal apology had been given and documented in medical and nursing notes. Staff we spoke with said they were able to raise concerns without fear of retribution. Within the 2017 staff survey the percentage of staff reporting errors, near misses or incidents witnessed in the last month was 91% which was the same as nationally and the staff confidence and security in reporting unsafe clinical practice (3.73) was better than the national average (3.67).
There was one Freedom to speak up guardian in place at the time of the inspection; the role was previously shared with a colleague until they retired at the end of April 2018. These two staff had been allocated the role as part of their staff governor duties to give a degree of independence; there was no dedicated time allocated to these roles. At the time of the inspection the CEO and chairman told us that the guardian role was being reviewed with a view to providing some dedicated time to those people in the role. We were told there would be an expansion of guardians to five. The role was introduced in January 2017 and staff received training in June 2017. The trust was also introducing advocates to support the guardian role. About 130 staff had applied; and at the time of the inspection about 28 people had been trained and more training was scheduled for autumn 2018.
The trust and the guardians promoted the ‘raising concerns at work’ policy. The role has been promoted using various communications including posters and emails. There was a Freedom to Speak Up steering group which met every month, and included a NED, the HR director and other HR representatives.
We were told that in 2017/18 the trust had eight cases reported under ‘Raising Concerns’ (six of these were via the guardian and two were anonymous). To June 2018 there had been two concerns raised, one through the guardian and one anonymous. Compared with other trusts this is a relatively low figure; it was not clear if this was because staff had other mechanisms to raise concerns.
At the time of the inspection the guardian of safe working had been in place for two years. There was evidence that junior doctors were using the guardian and reporting issues to them. Examples of how the trust had responded to concerns raised were shared with us. We were told that the guardian was an “independent person” within the trust whose role bridged between senior management and junior doctors. Quarterly and annual reports were presented to the board. A junior doctor’s forum had been set up as a platform for formally raising problems.
There was an effective values-based appraisal system in place with opportunities for staff to identity their own training needs. The trust indicated that for each directorate a breakdown per person and per department was provided so that any appraisal shortfalls could be addressed. Data from the trust indicated that the trust had an achievement rate of 80% plus consistently for a
20171116 900885 Post-inspection Evidence appendix template v3 Page 13 number of months up to February 2018 and that each directorate had an action plan associated with achieving its target. Three directorates had almost reached 80% with the majority between 80-90%. From the June 2018 board minutes, it was noted that for the period May 2017 to April 2018, the trust had achieved the 90% target for the number of appraisals carried out. Appraisal data as of December 2017 indicated that 87% of non-medical staff and 84% of medical staff had received an appraisal.
There was evidence that staff were encouraged to report incidents involving medicines, and there was an open no-blame culture around incident reporting supported by the Medicines Safety Officer. Staff received a meaningful appraisal which also included conversations about career development. Appraisal rates for pharmacy staff were over 95%.
Within the GP Collaborative (Sheffield Out of Hours Service) the employed staff had an annual appraisal where career development discussed, and all staff had monthly one to one meetings with their manager. There was support for the GPs and assistance with their revalidation. There was a robust induction process including for the GPs working within the collaborative.
The clinical director (therapeutics & palliative care) told us that there was no mandatory training for staff to respond to mental health needs, learning disabilities, autism or dementia. Training was job specific needs led. A training needs analysis was undertaken for each job role and the training identified formed part of the Personal Achievement Learning Management System (PALMS) and became an annual process. The nurse director (head and neck), who was the learning disabilities lead, confirmed that learning disability training is not mandatory but safeguarding adults was and this included sections on learning disabilities. There was a learning disabilities awareness and hidden impairments e-learning course on PALMS. The medical director informed us that a pilot of mental health first aid training had been delivered to a cohort of staff.
Governance
The trust had effective structures, systems and processes in place to support the delivery of its strategy including board committees, divisional committees and team meetings. Leaders regularly reviewed these structures. Most staff at all levels were clear about their roles and understood what they were accountable for, and to whom.
There were six board committees in place: Healthcare governance; Finance and performance; Audit; HR and OD; Nominations and remuneration; and the Working together committee in common. There was also the trust executive group (TEG). There were working groups under each of the committees. For example, the mortality governance committee and the patient experience committee were managed through the Healthcare governance committee. Each committee had a non-executive chair and members with executive members in attendance. There was clear accountability within each board committee.
The trust carried out the first part of an external Well-led governance review in 2015, and no material concerns were noted. The need for a further review was risk-assessed in 2017 and the trust decided not to proceed. The trust was expecting to self-assess as ‘Good’ or ‘Outstanding’ in a review conducted by internal audit in 2018 and will re-assess the need for an external follow up later in the year.
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The key points from the healthcare governance committee were reported to each board meeting. Information from other committees such as the HR and OD committee was also included in the integrated performance report presented to the board. Until recently workforce issues had been managed through the finance and performance committee however a decision had to be taken to create a separate HR and OD committee to allow more time and focus on this area.
There was a trust-wide systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. Actions identified from clinical audits were monitored by the clinical effectiveness committee which reported to the board’s healthcare governance committee. Actions from internal audit were monitored by the trust’s governance team and audit committee to ensure implementation and review.
There was an effective governance structure within the pharmacy department led by the pharmacy management board. The chief pharmacist was a clinical director and was accountable to the medical director. There was a clear line of sight to the Trust Executive Group. Medicines incidents were reviewed at a monthly medicines safety committee. The Medicines Safety Officer role was trust-wide and well embedded. The trust had outsourced its outpatient dispensing and this was governed and managed appropriately.
Staff at the GP Collaborative (Sheffield Out of Hours Service) understood and were able to explain the governance structure up to board level. There were clear lines of accountability including GP Collaborative Governance meetings/monthly partnership meetings with other providers/trust services, for example the 111 service and ED.
Arrangements with partners and third-party providers were governed and managed to encourage appropriate interaction and promote coordinated, person-centred care. A partnership arrangement was in place for the provision of psychiatric liaison services with appropriate governance arrangements.
The trust had a combined board assurance framework and corporate risk register which was called the “Integrated risk and assurance report” (IRAR). This detailed any risk and gaps in the risk controls which impacted upon the trust’s corporate strategy “Making a difference 2017-2020”. The risks were identified against each of the five aims of the strategy which were as follows:
• Deliver the best clinical outcomes • Provide patient centred services • Employ caring and cared for staff • Spend public money wisely • Deliver excellent research, education and innovation
The IRAR was reviewed regularly, usually quarterly, by the board, its committees and the executive team to ensure it was current and related to the trust’s overarching vision and strategy. Whilst it was clear that the IRAR addressed the risks to the corporate strategy not all the operational risks identified as “extreme” (scoring 15 or above) by the directorates were included in the IRAR or brought to the attention of the board (see further detail below under Management of risk).
Management of risk, issues and performance
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Whilst there were systems in place to manage risks there appeared to be a lack of awareness and timely action at board level for some of the issues which we identified at inspection: such as, extreme risks on directorate risk registers; an outpatient follow up backlog; limited action plans for improvement to dementia care; the trust not being able to record numbers of sepsis cases within the organisation or provide sepsis returns to national audit; no named doctor for safeguarding children and the safeguarding policy for children was out of date. However, the chief nurse was aware of the out of date policy and action was being taken to address this and ensure it was compliant with current national guidance.
Arrangements were in place at directorate level for identifying, recording and managing risks. We found that recorded risks were mostly aligned with what directorate staff said were on their ‘worry list’ apart from some risk identified within medical services at Weston Park. However, we found on inspection that not all “extreme” operational risks were brought to the attention of the board. The risk registers for each of the core services we inspected had “extreme” risks identified that were not included in the IRAR. We asked board members about these risks and most board members were unaware of them and could not explain to us at the time why they were not on the IRAR. For example, the failure to ensure that the trust met the commissioning criteria to be a major trauma centre. Our concern was about the length of time the trust was taking to address its non- compliance with the national guidelines for medical staffing of a major trauma centre despite being commissioned to provide this service for a number of years. We were told that a board committee would be agreeing this at the end of July 2018.
When we raised this with the trust they said that there was a trust wide risk validation group which reviewed risks coming up from the directorates that were scored as a four or above. If risks were validated by the group or scored four or more then the risk became part of a monthly report to the TEG. In addition, consideration of any new risks and whether they needed to form part of the IRAR included a review of the scale of the risk, the number of areas it affected and extent to which it required strategic board of directors’ ownership and that the decision was not based solely on the score but a combination of these factors. We were also told that at any point in time board members could ask for access the full risk register. It stated in the trust’s “Guidelines to identify, assess, action and monitor risks” that new extreme risks were to be reported to Safety and risk management board and to trust executive group and board of directors via the IRAR. We did not see evidence these guidelines had been followed in terms of reporting to the board of directors.
In 2015 the trust had found a large cohort of patient pathways that had not been followed up and at the time of the inspection there was still a backlog of over 25,300 patient pathways. Board members we spoke with were could not tell us about the ongoing risk of the backlog of patient pathways that had not been followed up or provide assurance about any clinical validation procedures. This risk was not on the June 2018 IRAR; however, they were aware of it in terms of a previously identified risk and an update presented to the private part of the Board in March 2018. We also found the backlog was not routinely included within the trust performance reports.
Following the inspection, the trust provided information which indicated that a validation exercise was undertaken to manage the very long waits within this cohort and this was successfully completed around September 2016. As of September 2016, the backlog had been reduced to 83,135 overdue reviews. As of the 31 March 2018 this had further reduced to 29,963. Of these there were 2,431 that had been overdue for more than a year, almost half of which were in gastroenterology. A task and finish group was established with representation from each care group and chaired by a non-executive. The group focused on the development of a standard operating procedure and training for staff to ensure that review patients could be captured on the 20171116 900885 Post-inspection Evidence appendix template v3 Page 16 patient administration system (PAS) in a consistent way. The standard operating procedure was completed in June 2017. Each care group/directorate had developed an action plan to manage all patients waiting greater than three months for review and to ensure that the review waiting time did not extend beyond three months in future. Information provided by the trust stated that the care groups had prioritised the review of lists to ensure that clinical risks had been minimised. For example, ophthalmology had targeted their glaucoma lists and surgical services had targeted their cancer surveillance patients. Clinical teams were actively involved in reviewing the patients that were waiting. The plans indicated that all but four directorates would have eliminated their backlog by September 2018 with the remainder by March 2019. As part of the inspection we reviewed serious incidents, one of these incidents related to a patient where there had been delays in follow-up appointments and subsequent diagnosis.
There were performance management structures in place at board and group/directorate level. There were integrated performance reports (IPR) which were discussed within the groups/directorates, at committee and board level on a monthly basis. The IPR included exception reporting where the standards set for the trust were below target. The exception report included a brief summary of actions taken as part of any recovery plans. There was a suite of other dashboards that sat below the IPR that the trust had developed (see section on information management below).
Each clinical directorate had a strategic plan covering three years and annual business plans. There was a system in place for an annual assessment/performance review of each directorate plan which was based on operational performance, delivery of business plan priorities and the strategic aims of the organisation. The executive met with the directorate leads to ensure performance was on track and if not what remedial actions were being taken to improve it. As part of this process each directorate was risk rated in terms of its performance and this guided how many of these performance meetings were held per year. There was a three-stage process in place which included development of directorate improvement plans and formal reviews of directorates. We saw evidence of this process from acute and emergency medicine
Processes were in place to monitor the performance and quality of the pharmacy service, and this was reviewed twice yearly by the Trust Executive Group. A risk register was in place which was reviewed at regular intervals. All risks were assigned a review date and appropriate actions were taken to mitigate known risks.
We were told that the GP Collaborative (Sheffield Out of Hours Service) had monthly performance meetings and actions were taken as required. An example given was call answering times. Data for May 2018 showed approximately 41% of calls were handled by clinical triage (with no need for an appointment) effectively. This was lower than 54% in June 2017, it was noted that ED now booked directly into the service and 111 now also booked directly into the service. The GP Clinical lead monitored the GP under and over performance of call handling. This was discussed with them individually. Both the clinical manager and clinical GP lead reviewed 1% of consultations for clinical performance to ensure the system working.
The trust’s approach to recruitment had proved effective. As a consequence of this, the trust had significantly reduced the amount of agency spend in line with NHSI reduction trajectories which subsequently supported the recruitment of a substantive and stable workforce; helping to drive further improvements in quality and safety for their patients.
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Following the concerns raised with the trust from the unannounced CQC inspection in June 2018, the trust provided us with a summary of the actions taken to address the immediate concerns raised.
Finances Overview Finances were reviewed monthly at the finance and performance committee and included in the board’s integrated performance report. The board had a sound understanding of the current financial position and the challenges and risks to it both in this financial year and going forward for the next two to five years.
The trust had delivered its agreed control total in 2016/17 and 2017/18, exceeding the latter by £4.2m (however this excluded STF (sustainability and transformation funding)). The trust had a current CIP (cost improvement programme) target of 2.4%, which was slightly higher than prior year targets. The trust did not have a medium/long term financial plan other than the broad strategic aim of remaining within financial balance. The trust was not reliant on any external cash support.
We were told that cost improvement/efficiency plans were developed from the directorates upwards and were clinically driven. There was ongoing monthly monitoring of efficiency plans and plans were risk rated on a scale of one to five regarding the ability to deliver the expected savings.
Feedback from board members indicated that financial decisions were made in the context of understanding how the quality of services may be affected. Non-clinicians we spoke with on the board had a good understanding of the clinical services. Board members told us that if the medical director or the chief nurse said “stop” to any financial proposal because of clinical concerns the proposal was stopped. We were given examples of this on inspection.
The table below provides a summary of the trust’s actual and projected finances over a four-year period from 2015/16.
Historical data Projections Previous Last Financial This Financial Next Financial Financial metrics Financial Year Year (2016/17) Year (2017/18) Year (2018/19) (2015/16) Income £1,004,281k £1,058,882k £1,058,104k £1,066,690k
Surplus (deficit) (£7,679k) £5,766k (£3,602k) (£1,670k)
Full Costs £1,011,960k £1,053,116k £1,061,706k £1,068,360k
Budget (or budget £1,015,054k £1,058,221k £1,061,706k £1,068,360k deficit) (Source: Routine Provider Information Request (RPIR) – P69 Finances)
Information management
There was evidence of a holistic understanding of performance, which sufficiently covered information on quality, operations and finances. There was an information and technology strategy in place to support the development and use of intelligent information. We were told that there had been no cyber breaches of the trust’s IT systems.
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There were clear service performance measures in place, through the integrated performance report (IPR). These were reported and monitored at a number of levels within the trust including at board, committee and directorate levels and provided accessible and understandable data and commentary to assist staff in maintaining clinical quality and performance.
The IPR had been in development at the last inspection and was now fully operational. The trust was also developing real time data through new dashboards. These included a nursing and midwifery dashboard; nurses had been involved in agreeing the parameters for this. Through the dashboard information could be drilled down to patient level, ward level, directorate or care group. These were based on patient safety indicators to help identify concerns and improve safe care. The indicators included hospital acquired infections; falls, medication errors, and pressure ulcers.
Other recently developed dashboards to monitor performance included an A&E scorecard, a seamless surgery dashboard and an admin and safety dashboard. We were told that the latter was to help identify that administrative and clerical staff were a key part of patient care and safety such as ensuring timely referrals, outpatient appointments and discharges home. There was work ongoing to develop a single house-style to the dashboards to improve accessibility and usage.
The information systems we reviewed did not provide significant information on trajectories and forecasting, therefore they could not effectively measure for intending improvement moving forward or how realistic recovery plans were when a target was not being met.
Staff had sufficient access to performance information, and there was appropriate challenge. This was evidenced from reviewing the papers for the board, board committees and directorate level meetings. We also saw this in the meetings we attended such as the board and the healthcare governance committee.
Information technology systems were used to monitor and improve the quality of care; new ones were also being developed and implemented by the trust which would improve the correlation of information. However, at the time of the inspection the trust was unable to electronically record numbers of sepsis cases within the trust. Additionally, a number of concerns were raised by staff about the lack of access to computer terminals on the wards, as there was no mobile technology, especially in relation to prescribing on the NGH site. The trust recognised that access to mobile technology was an issue but commented that further security needed to be in place before this could be considered
There was an electronic prescribing system in approximately 50% of inpatient areas and there was a planned roll out for the rest of the trust which was due to be completed by November 2018. A suite of reports was available to provide information on the quality and safety of prescribing, for example delayed and omitted doses, medicines reconciliation and Venous Thromboembolism prophylaxis prescribing. The chief pharmacist told us their aim was to build a live dashboard in the future to drive further improvements.
The trust was also developing real time data through its IT system and e-whiteboards within ED and wards/services. The whiteboards could show at a glance where patients were across the organisation. They also held key clinical information about each patient and the information relating to the next stage of the patient's clinical pathway. For example, the ED dashboard included a daily by the hour prediction of patients within ED. This enabled staff to monitor and control staffing/patient flow in ED more effectively. All trust staff could see the ED dashboard to
20171116 900885 Post-inspection Evidence appendix template v3 Page 19 understand pressures within the department. The dashboard could also be seen on the acute medical unit to aid bed management.
From our ongoing monitoring of the trust it was evident that there were effective arrangements to ensure that data or notifications were submitted to external bodies as required. There were effective arrangements in place to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems.
Engagement
Leaders were visible and approachable. Staff told us they felt comfortable raising issues of concern to them. Almost all staff fed back positively about this, however, feedback from junior doctors told us they felt their concerns about working at Weston Park had not been heard. We raised this with the trust and following the inspection we were provided with a summary of actions taken to address the doctors’ concerns.
The executive team had acknowledged that engagement was an area for improvement and changes were being made. We saw the trust’s staff engagement 2017/18 action plan which incorporated the staff survey action plan. This plan was supported by directorate staff engagement plans which had been developed to address trust priorities and each directorate’s staff survey and staff FFT results. The trust has reviewed the results of the 2017 staff survey and agreed actions to address the areas that required improvement. The overall trust staff engagement score was 3.83 which was above average for combined acute and community trusts and above the NHS average of 3.78. It was indicated in 2018 board papers that the trust was asking each directorate to include at least two directorate specific actions identified from their staff survey results, staff friends and family testing or staff or patient feedback to address in their annual plan.
The trust had a membership of 28,000 which included all staff. There was a council of 33 governors, most of which were very active: they attended as observers to board committees, visited patient areas and provided feedback to the trust executive group. Board members actively engaged with the governors and members of the trust. The trust had changed the timing of the council of governors to immediately after the board meeting; this was because of feedback to create more opportunity for engagement between governors and board members.
Whilst we were told there were regular planned walk arounds and visits by the executive and non- executive directors to services throughout the trust there did not appear to be a mechanism to record these or ensure that feedback was provided to the departments they had visited.
Engagement of staff varied across the trust. Examples were given at the unannounced inspection of staff views being reflected in the planning and delivery of services. The executive acknowledged that engagement with those staff that had a protected equality characteristic could be improved and there were plans in place to progress this. At the time of the inspection information provided to us by the trust indicated that there were no staff networks; there had been one BME focus group where 200 people attended. Feedback from consultants indicated that whilst there were clinical forums within their directorates there was a lack of opportunities for trust-wide meetings with the consultant body.
We saw evidence that the pharmacy department regularly engaged with staff, and their views were reflected in the planning and delivery of services. There was a staff engagement strategy in
20171116 900885 Post-inspection Evidence appendix template v3 Page 20 place with representation from all grades of pharmacy staff from all locations in the trust. There were a number of positive and collaborative relationships with external partners; for example, local networks, the citywide pharmacy group and other trusts.
The GP Collaborative (Sheffield Out of Hours Service) engaged closely with other trust services/providers. The Friends and family test was provided for face to face patients. However, it was recognised by staff that this was not providing much useful data and it mostly related to their full experience, for example, at ED. We were told the GP collaborative was investigating other mechanisms to engage with patients.
People’s views and experiences were gathered and acted on to shape and improve the services. In developing the quality strategy 2017-2020 the trust had received responses from over 600 patients and 550 staff which had informed the content of the strategy.
There was a patient experience committee led by the deputy chief nurse. This committee brought together data and information from a number of sources such as complaints and all patient experience feedback, including FFT and other surveys. There was no specific patient experience or involvement strategy in place. However, there were a number of mechanisms in place to involve patients and the public in the development and improvement of services. There were examples of these identified within individual directorates which we inspected. It was less clear about how the trust engaged across all its communities, including those that were hard to reach. However, plans were in place to address this including a quality objective for 2018/19 to significantly increase the scale of patient engagement with those who may be harder to reach or seldom heard.
There were links to Healthwatch including within the regional integrated care partnership. There was a city-wide dementia care group which included the CCG, the Alzheimer’s society, mental health providers and governors
We were told that more work was required to provide 'parity of esteem' (valuing mental health equally with physical health) for people with mental health conditions: this had been identified by the trust and was on the risk register with actions in place to address this. This was evident from the inspection when we identified a number of concerns about the completion of Deprivation of Liberty Safeguards. Additionally, a nurse we spoke with told us that a patient had wanted to appeal against their detainment under the Mental Health Act; the patient had requested an independent mental health advocate which had been actioned. The nurse was unable to identify to us what action to take or how they would escalate this.
Between March 2017 and February 2018, the Friends and Family test returns had a response rate of 30.5% for the trust which was better than the national average with 25.1%.
The trust had a rating on NHS choices of 3.5 stars out of five and on Facebook it had 4.1 stars out of five.
The trust also ran a volunteer programme and had over 700 volunteers. This included a youth section of over 100 people. As well as providing a valuable service for patients and the public visiting the trust it also provided the opportunity for some volunteers to progress into jobs within the trust or elsewhere.
We spoke with a number of stakeholders prior to the inspection, such as the local clinical commissioning group, NHS England, NHS Improvement and Health Education England. There was mainly positive feedback about collaborative relationships with the trust and its external
20171116 900885 Post-inspection Evidence appendix template v3 Page 21 partners which helped to build a shared understanding of the needs of the local population, and to deliver services to meet those needs.
Learning, continuous improvement and innovation
There were well developed systems in place to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work. Leaders and staff we spoke with were proud to work for the trust and provided us with examples of continuous learning, improvements and innovations. The trust participated in appropriate research projects and recognised accreditation schemes. The trust was one of the top ten trusts nationally in the number of research studies supported and recruitment to studies.
The trust had a long history of quality improvement initiatives. There had been a service improvement team in place since 2011. The trust had been training staff in quality improvement methodology; a two day course and over 1,300 staff had completed this. We were provided with many examples of improvement projects delivered by staff within the trust. In addition, in 2016 the trust had launched “Give it a go week” which for 2018 occurred during the week commencing 18 June. During this week staff were encouraged to try out new initiatives, no matter how small, to improve patient care within the trust. The trust had also run “Listening into action” (Lia) since 2014. We were told that 177 Lia schemes had been completed and about 25% of staff had been involved in one of these schemes, for example, the neonatal staffing was changed to ensure that there were adequate staff available to support parents during the doctors’ ward rounds. In 2018 an organisational development directorate had been established. The trust had also set up a micro systems coaching academy and were now funded to run course for the rest of the UK. There were 228 coaches that had “graduated” through this process.
The trust had recently put in place a trust-wide quarterly quality matters newsletter to share learning. In addition, each directorate also has their own newsletter; the frequency of these varied from one month to quarterly.
The pharmacy department encouraged continuous improvement and innovation. Training had been delivered in service improvement methods, and there was a Quality Improvement programme in place for six workstreams. The trust had appointed a safer diabetes care pharmacy fellow, who undertook research in collaboration with a local university to improve insulin and prescribing safety in hospital. This had led to changes in trust policy, increases in pharmacy staffing to support insulin self-administration, and the development of e-learning to improve the management of acute diabetes complications.
Learning from deaths There was evidence of learning from internal and external reviews, including those related to mortality or the death of a person using the services. However, there did not appear to be a trust- wide system in place at the time of the inspection for shared learning across directorates such as the M&M leads meeting to share learning.
There was a “Learning from deaths” policy in place from April 2018 which included a structured judgement review (SJR) process. The trust had been involved in national pilot work on the development of the learning from deaths guidelines.
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The trust had also had a medical examiner (ME) role since 2009. The ME was a medical consultant who also worked in ED at the NGH. They reviewed all the deaths that occurred on the NGH site, which was about 80% of all the trust’s deaths. This initial review was usually within 24 hours. The review included contacting family members to see if care had been effective and if there was anything that could have been done better. The target was to review every death using SJR methodology within 72 hours. The review determined whether a more detailed SJR was required or immediate escalation to the medical director or chief nurse. The trust was in the process of creating remunerated part time posts for the doctors/senior nurses (approximately 20) who would be trained by the end of 2018 to perform the SJRs. The trust had also agreed to appoint one whole time equivalent ME to cover the whole trust which meant that all deaths would be reviewed. The trust was planning to have the SJRs on datix by autumn 2018 which would help develop consistency, auditing and quality assurance processes.
There was a clear process outlined in a flow chart as to how the trust managed it’s learning from deaths process. As well as the ME and the structured judgement reviewers there was a trust wide Mortality governance committee with terms of reference and mortality and morbidity (M&M) committees within each directorate.
We reviewed eight SJRs and found them to be well written with analysis and key learning points described.
The SHMI (the summary hospital-level mortality indicator which reports on mortality at trust level) had been ‘better than’ or ‘as expected’ since 2010. The HSMR (Hospital Standardised Mortality Ratio) was 104.4% which was within expected limits. The trust provided us with an example of how they had learnt from data which suggested that the trust was a mortality outlier from the national hip fracture data.
Learning from incidents There was evidence of learning from incidents. The majority of staff we spoke with at the unannounced inspection told us they received feedback and learning from incidents. A small number of junior doctors we spoke with told us there was a lack of shared learning from incidents. All serious incident investigation reports were signed off at a weekly meeting by either the MD or chief nurse. We were told that since incident reporting became all electronic the reporting had improved. Staff got automatic feedback once the incident was closed.
At the 2015 CQC inspection we found that learning from incidents within one directorate was not always cascaded, where relevant, to other areas of the trust. Since this inspection the trust had acted to address this. There was a monthly management board briefing which all clinical and nurse directors attended where incidents were discussed and shared. If there were trust-wide implications and actions required, then the action plan was assigned to an executive director to oversee. Serious incidents (SIs) were also reviewed at the patient safety and risk committee which brought directorate members together. This committee had been formed in February 2018 together with the occupational safety and risk committee to improve the process for managing and learning from incidents; these committees replaced the safety and risk management board. We reviewed nine serious incident files. Overall the incidents were effectively investigated, and the reviews focussed on the learning. However, whilst there were terms of reference for each investigation there was no evidence in at least three files that the patient or their family/carers had helped to set the terms of reference and in four files there was no evidence that there was a support plan in place if they needed one. The incidents we reviewed all had action plans in place but there was no evidence of completion of these. On reviewing notes at the unannounced
20171116 900885 Post-inspection Evidence appendix template v3 Page 23 inspection, we found an incident where a patient had required a second major operation, and this had not been reported as a serious incident; following discussion with the trust this was then declared as an SI.
We were told that any never events were managed through a central action plan. A new system had been brought in since February 2018 whereby SIs that required trust-wide learning had trust- wide action plans in place which were overseen by an executive lead. At the time of the inspection two examples of this were: deteriorating patients and outpatient follow up appointments.
Complaints process overview There was a complaints system in place. Most complainants were responded to in a considerate manner. The trust worked to a tiered response time process, usually 25 or 40 days; where the timescale was determined based on the complexity of the concerns raised (60 days for complex complaints). The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale.
Between February 2017 and January 2018, the trust took an average of 25 days to close complaints.The months of March 2017, October 2017 and January 2018 had the highest number of complaints reported throughout the time period.
The trust was asked to comment on their targets for responding to complaints and current performance against these targets between February 2017 and January 2018.
Current Question In days performance What is your internal target for responding to complaints? 3 working days 100%
25 working days What is your target for completing a complaint 85% 40 working days If you have a slightly longer target for complex complaints 60 working days 85% please indicate what that is here Number of complaints resolved without formal process 02/2017 – 1,695 from February 2017 to February 2018 01/2018 (Source: Routine Provider Information Request (RPIR) – P61 Complaints)
We reviewed eleven complaints, there was evidence nine of these had been responded to in line with the trust target. All the complaint responses were signed by the chief executive and contained information about PHSO and a complaints feedback survey. All the complaint responses we reviewed had evidence of clinical involvement and contained contact details for staff who would be willing to speak with and/or meet the complainant. In one of the complaint responses we could not clearly see answers to the specific questions raised in the complaint. Seven of the complaint responses we reviewed were written very compassionately, the other four were written from more of a factual perspective.
Number of complaints made to the trust The trust received 1,442 complaints from February 2017 to January 2018. A breakdown of complaints by core service is shown in the tables below.
Trust level
Number of % of Core Service complaints complaints
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Other 455 31.55% AC - Surgery 238 16.50% AC - Medical care (including older people's care) 225 15.60% AC - Outpatients 148 10.26% AC - Urgent and emergency services 128 8.88% AC - Maternity 85 5.89% AC - Diagnostics 72 5% CHS - Adults Community 38 2.64% (blank) 18 1.25% AC - End of life care 9 1.17% AC - Gynaecology 9 1.17% CHS - End of Life Care 6 0.42% CHS - Community Dental 4 0.28% AC - Critical care 2 0.14% CHS - Children, Young People and Families 2 0.14% AC - Services for children and young people 1 0.07% CHS - Urgent Care 1 0.07% Provider wide 1 0.07%
Northern General Hospital – Total number of complaints = 717
Number of % of Core Service complaints complaints Other 230 32.08% AC - Medical care (including older people's care) 127 17.71% AC - Surgery 124 17.29% AC - Urgent and emergency services 113 15.76% AC - Outpatients 50 6.97% AC - Diagnostics 34 4.74% CHS - Adults Community 14 1.95% (blank) 8 1.12% AC - End of life care 7 0.98% CHS - End of Life Care 4 0.56% AC - Maternity 2 0.28% CHS - Children, Young People and Families 2 0.28% AC - Critical care 1 0.14% AC - Services for children and young people 1 0.14%
Royal Hallamshire Hospital – Total number of complaints = 429
Number of % of Core Service complaints complaints Other 140 32.63% AC - Surgery 93 21.68% AC - Outpatients 71 16.55% AC - Medical care (including older people's care) 56 13.05% AC - Diagnostics 27 6.29% AC - Maternity 13 3.03%
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AC - Urgent and emergency services 12 2.80% AC - Gynaecology 5 1.17% (blank) 4 0.93% CHS - Adults Community 3 0.70% AC - End of life care 1 0.23% Provider wide 1 0.23% CHS - Urgent Care 1 0.23% AC - Critical care 1 0.23% CHS - End of Life Care 1 0.23%
Weston Park Hospital – Total number of complaints = 49
Number of % of Core Service complaints complaints AC - Medical care (including older people's care) 21 42.86% Other 11 22.45% AC - Diagnostics 6 12.24% AC - Outpatients 5 10.20% AC - Surgery 3 6.12% AC - End of life care 1 2.04% AC - Maternity 1 2.04% AC - Urgent and emergency services 1 2.04% Services for children and young people 1 0.5% (Source: Routine Provider Information Request (RPIR) – P61 Complaints)
Compliments From February 2017 to January 2018, the trust received a total of 551 compliments. A breakdown for acute sites by core service is shown below. In addition, many others were received by wards but not recorded centrally.
Trust level Number of % of Core Service compliments compliments Critical care 266 48.28% Surgery 100 18.15% Medical care (including older people's care) 79 14.34% Diagnostics 65 11.80% Urgent and emergency services 33 5.99% Other 8 1.45%
The services with the most compliments at the trust were critical care with 266 compliments (48.28% of all compliments) and surgery with 100 compliments (18.15% of compliments).
Site Level Site Number of % of Compliments compliments Northern General Hospital 279 50.64% Royal Hallamshire Hospital 131 23.77% Community Site 90 16.33% Jessop (Woman’s) 21 3.81%
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Weston Park Hospital 12 2.18% Charles Clifford Dental 12 2.18% Rotherham Satellites 6 1.09% At site level, 50.6% of all compliments (279) were about Northern General Hospital. Rotherham Satellites had the lowest number of compliments with six. (Source: Routine Provider Information Request (RPIR) – P61 Compliments)
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Northern General Hospital
Urgent and emergency care
Facts and data about this service
Sheffield Teaching Hospitals NHS Foundation Trust’s Acute and Emergency Medicine Directorate is the primary centre for adult emergency care in Sheffield. The trust has around 16,000 employees providing unscheduled care for an average of 350 patients per day and has in excess of 100,000 attendances per year to the ED department.
Comprising of five hospitals on two sites across the city the Royal Hallamshire Hospital and the Northern General Hospitals are two of the UK's largest acute hospitals. The trust has one of the three major trauma centres for the Yorkshire and Humber region and it has partnerships with the University of Sheffield, Sheffield Hallam University, and other health and social care providers. (Source: Routine Provider Information Request (RPIR) Acute context)
Details of emergency departments and other urgent and emergency care services • Northern General Hospital: Accident and emergency • Royal Hallamshire Hospital: Minor injuries unit (Source: Routine Provider Information Request (RPIR) P2 – Sites)
Activity and patient throughput
Total number of urgent and emergency care attendances at Sheffield Teaching Hospitals NHS Foundation Trust compared to all acute trusts in England, April 2016 to March 2017
From April 2016 to March 2017 there were 190,600 attendances at the trust’s urgent and emergency care services as indicated in the chart above. (Source: NHS England)
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Urgent and Emergency Care attendances resulting in an admission
The percentage of A&E attendances at this trust that resulted in an admission increased by 4% from 2015/16 to 2016/17 and both rates were lower than the England averages. (Source: NHS England)
Urgent and emergency care attendances by disposal method, January to December 2017
* Admitted to hospital includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment (Source: Hospital Episode Statistics)
Is the service safe?
Mandatory training
The trust set a target of 90% for completion of mandatory training.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for nursing staff in urgent and emergency care is shown below:
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Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Resuscitation: Neonatal Life Support - Level 2c (1 Yearly) 4 4 100% 90% Yes Conflict Resolution - Level 1 (3 Yearly) 27 27 100% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 24 24 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 9 9 100% 90% Yes Moving & Handling - Level 2b (1 Yearly) 28 29 97% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 40 42 97% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 35 37 96% 90% Yes Information Governance - Level 1 (1 Yearly) 27 29 94% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 51 55 93% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 43 49 81% 90% No
Nursing and midwifery staff exceeded the trusts 90% planned level for nine out of 10 modules. Infection prevention and control – level 2 failed to meet the plan with 81%.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for medical and dental staff in urgent and emergency care is shown below:
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Equality & Diversity: General Awareness - Level 1 (3 Yearly) 1 1 100% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 13 13 100% 90% Yes Conflict Resolution - Level 1 (3 Yearly) 1 1 100% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 1 1 100% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 1 1 100% 90% Yes Information Governance - Level 1 (1 Yearly) 13 13 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 13 13 100% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 12 13 92% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 12 13 92% 90% Yes
Medical and dental staff exceeded the trusts 90% plan for all nine mandatory training modules. (Source: Routine Provider Information Request (RPIR) P40 –Mandatory and Statutory Training)
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• The trust provided mandatory training compliance at the time of our inspection. The overall completion rate for the emergency department as at 31 May 2018 was 78.1%, as against a 90% planned completion rate. We spoke with 13 staff about mandatory training who each confirmed their mandatory training was up to date. • Mandatory training was undertaken in a face-to-face setting. A senior nurse consultant was the training lead for the department. Some staff told us they felt well supported to be able to complete training. However, some other staff we spoke with felt they had limited time to access training. Areas covered in training were often reinforced through ‘breakfast club’ teaching sessions and supporting guidance was available through the department’s intranet share point. • Adult basic life support (resuscitation) training had been completed by 91.5% of staff and was refreshed annually. Conflict resolution training was provided for emergency department nursing staff to enable them to address potentially challenging situations and this was repeated three yearly. • We reviewed nine mandatory training evaluation forms completed in 2018 which demonstrated that meaningful feedback was obtained from staff following their attendance at training.
Safeguarding • Of the 14 staff we spoke with, each was conversant with the safeguarding referral processes for both adults and children (although it was not the department’s policy to see children under 16 years) and several members of staff stated they received regular updates from the safeguarding teams at breakfast club teaching sessions. • Most of the nursing staff we spoke with, including each emergency nurse practitioner, had received level 3 safeguarding training in the previous 12 months. Also, plans were in place for all nursing staff to undertake level 3 safeguarding as part of their mandatory training. • We spoke with the safeguarding lead, a senior sister in the emergency department. The safeguarding lead supported patients presenting with complex safeguarding needs, for example involving their mental health, domestic violence, learning difficulties, and female genital mutilation (FGM). • Very few children presented in the department as a local specialist children’s hospital was located nearby. However, if there were any suspected safeguarding concerns regarding minors they were admitted overnight until a full investigation would be undertaken the next day when all members of the multidisciplinary team were available. On some occasions, children who were accompanying parents who were injured or otherwise unwell may present and give rise to a safeguarding concern, and a paediatric liaison nurse was attached to the emergency department, engaged by the local specialist children’s hospital. The paediatric liaison nurse was able to access computer record systems in both hospitals and to contact the relevant agencies, including social services, school nursing and health visiting services. A multidisciplinary safeguarding team met quarterly. • Themes to focus on were decided at monthly meetings and included child sexual exploitation, domestic violence, persons under 18 years with mental health crisis. A scheme to support victims of domestic violence, ‘More about domestic violence’ had been
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in place, supported by an independent domestic violence advisor (IDVA) although we found the role had been terminated. Innovative schemes were in situ which enabled contact details to be shared discreetly for domestic violence support agencies. • For paediatric safeguarding concerns which did arise, we found staff were aware of referral processes and had access to paediatric liaison and a child protection information system which had recently commenced in line with national requirements from NHS improvement to all required areas including the emergency department. • . The emergency department was highly commended for its work on the ‘pathway for vulnerable young people’ in partnership with the local community youth service. • Referrals to the paediatric liaison service, and young people aged 16 and 17 who attended the emergency department with mental health needs, were the subjects of audits undertaken in 2017, and actions arising from these audits were completed during May 2018.
Safeguarding training completion rates The trust planned for 90% for completion of safeguarding training. A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for nursing staff in urgent and emergency care is shown below:
Staff Eligible Met trained staff Completion Trust (Yes/N Name of course (YTD) (YTD) rate Target o) Safeguarding Children & Young People - Level 3 (3 Yearly) 25 25 100% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 12 12 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 4 4 100% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 19 24 77% 90% No
Nursing and midwifery staff achieved 100% completion for three out of four safeguarding courses; they failed to meet the trusts 90% plan for safeguarding adult’s level 2 with 77%.
A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for medical and dental staff in urgent and emergency care is shown below:
Staff Eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 10 10 100% 90% Yes Safeguarding Children & Young People - Level 3 (3 Yearly) 12 13 92% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 12 13 92% 90% Yes Medical and dental staff exceeded the trusts 90% completion plan for all three safeguarding modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
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Cleanliness, infection control and hygiene • We observed that the emergency department appeared visibly clean, including the initial assessment unit, patient cubicles and toilet areas. Disposable curtains were in date. Domestic staff followed a cleaning schedule and care staff were responsible for cleaning equipment and trolleys. Cubicles available for patients who required isolation had personal protective equipment (gloves and aprons) available. We observed a basin flushing checklist in the sluice area which aimed to reduce the risk of Legionnaire’s Disease. • However, we also observed several instances when standards of hygiene were not maintained. We observed poor handwashing in frequency and technique. Equipment was not being cleaned between patients, particularly in the pit stop area and very little equipment cleaning was observed in the whole department. We discussed our concerns with the trust during the inspection and we were assured that immediate action was taken to address this issue. • Although blood pressure cuffs and other equipment were cleaned in the morning, we observed they were not cleaned after each patient. One member of staff in the department told us that cleaning does not get done. We observed (twice) nursing staff taking blood with no cleaning of equipment between patients. In four instances we observed, staff used either poor or non-existent hand washing techniques. The walk-in triage area did not have cleaning wipes available. On resuscitation bays thee and eight, we observed that no cleaning solution was available. We observed that some surfaces in the department were dirty. We discussed our concerns with the trust during the inspection and we were assured that immediate action was taken to address this issue. • We were informed that the emergency department achieved infection prevention and control accreditation in November 2017. The infection prevention and control accreditation certificate on display we observed was out of date. We were subsequently shown evidence of the current accreditation certificate. • Cleaning staff were employed by the hospital and external cleaning contractors were not used. Staff informed us there were usually six members of domestic staff in the department each day, who worked in designated areas. Domestic staff followed specified cleaning schedules which included cleaning floors unless there was a spillage of body fluids. In this instance nursing staff cleaned the floor. We were informed domestic staff were not permitted to clean desks for reasons of data protection. Desks were cleaned by housekeeping staff between 7am and 10pm. Domestic staff received weekly feedback following visits from the domestic supervisor.
• We were informed that infection control audits were undertaken monthly. Following our inspection, we requested and received evidence of environmental and hand hygiene compliance for the previous 12 months. Hand hygiene audits had been completed monthly at NGH A&E from August – December 2017, with no records for 2018 until June. Compliance varied from 86% to 100% though it was not stated how many staff had been observed on each occasion Environment and equipment • Since our previous inspection in 2015 the initial assessment unit at Northern General Hospital had been upgraded and a new helipad had been opened in June 2016 adjacent to the emergency department front door and resuscitation area. The medical assessment
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centre had recently been relocated to a clinical area adjacent to the main emergency department. • The GP collaborative was also located adjacent to the emergency department which supported the streaming service 24 hours a day, seven days per week, and operated the GP out of hour’s service. A relocated mental health assessment room had been opened for patients with mental health needs to be cared for in a safe environment, with a second room available for mental health patients. An eight bedded psychiatric decision unit was in place. • In the main entrance of the department the waiting area provided seating for patients waiting to be seen. The seats faced the reception area, so patients were visible from the reception desk, and there was clear signage directing patients to other areas, including GP assessment. The reception area had recently been refurbished and we were informed that the waiting area was due to be refurbished shortly. • Doors to two triage rooms and the minor’s area accessed directly from the waiting area. A third triage room was available. Ambulance patients arrived through a separate entrance and were taken either to an ambulance delivery (‘pit-stop’) area or to the resuscitation room. • The major’s area was split into red and blue bays. The resuscitation room had eight bays, four of which were mainly used for trauma. There was capacity to split the bays to provide extra space, if needed. The red major’s bay had 17 cubicles and the blue bay had 10. A clinical decision unit with 11 beds comprised the fourth area. A relative’s room was in process of being redecorated and refurbished. There was direct access to the recently refurbished x-ray department. • There were no designated waiting or assessment areas for children as they usually attended the emergency department at the local children’s hospital nearby. However, there was dedicated paediatric equipment in the resuscitation room, and a protocol in place for ambulance transfer to the children’s hospital when necessary. • We checked the equipment in each area of the department. The main equipment store in the department was fully stocked with all items in-date and undamaged. Bloods trolleys were stocked and checked by a technician responsible to undertake this. Each area within the department had a consumables trolley that was taken away at the close of the day and switched for a stocked and checked trolley. We checked the stocks and dates of items for trolleys located in each area of the department and found these were fully stocked and in date, with one exception. Although the children’s resus trolley checklist record showed items were checked on the date as our inspection, we found the trolley contained three out of date items, which we discussed with nursing staff who took immediate action. • We checked clinical equipment in draw storage and found it was well labelled and clean. When we checked two infusion pumps on charge we found one of the pumps was out of date for its service. We raised this with nursing staff who immediately arranged for the item to be serviced. • We observed a mental health assessment room within the emergency department and this met the quality standards for liaison psychiatry services. The emergency department also used a second room within the clinical decision unit, which the senior sister told us was used for individuals on a section 136 that needed urgent emergency treatment. This room did not have a viewing panel in the door and a sink and cupboard were in the room, but we
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were told the patient would not be unsupervised as the police remained in the room for the safety of the patient and others and the door remained open. The patient would then be transferred to the local section 136 suite when medically fit to do so.
Assessing and responding to patient risk
Emergency Department Survey 2016 The trust’s scored worse than other trusts for two questions and about the same as other trusts three Emergency Department Survey questions relevant to safety.
Question Score RAG Q5. Once you arrived at the hospital, how long 8.3 About the same as other did you wait with the ambulance crew before trusts your care was handed over to the emergency department staff? Q8. How long did you wait before you first 5.0 Worse than other trusts spoke to a nurse or doctor? Q9. Sometimes, people will first talk to a nurse 5.7 About the same as other or doctor and be examined later. From the trusts time you arrived, how long did you wait before being examined by a doctor or nurse? Q33. In your opinion, how clean was the 8.5 About the same as other emergency department? trusts Q34. While you were in the emergency 9.1 Worse than other trusts department, did you feel threatened by other patients or visitors? (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
Median time from arrival to initial assessment (emergency ambulance cases only) The median time from arrival to initial assessment was similar to the England median from April 2017 to March 2018.
The trust median time from arrival to initial assessment varied slightly across the 12 month period, from April to August 2017 the trusts performance was one minute faster than the England average, from October onwards the trusts performance showed a trend of decline; February 2018 the median time to initial assessment was 14 minutes compared to the England average of nine minutes.
Ambulance – Time to initial assessment from April 2017 to March 2018 at Sheffield Teaching Hospitals NHS Foundation Trust
(Source: Source: NHS Digital - A&E quality indicators)
Percentage of ambulance journeys with turnaround times over 30 minutes for this trust
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Northern General Hospital From April 2017 to March 2018 there was an upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Northern General Hospital.
Ambulance: Number of journeys with turnaround times over 30 minutes - Northern General Hospital
Ambulance: Percentage of journeys with turnaround times over 30 minutes - Northern General Hospital
(Source: National Ambulance Information Group)
Number of black breaches for this trust A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff.
From February 2017 to January 2018 the trust reported 218 “black breaches”. The highest numbers of black breaches were reported in February 2017 (85) and January 2018 (43). The trust reported much lower numbers of black breaches between April and July 2017 with only two being reported in May 2017. Following our inspection, the trust reported 13 black breaches in April 2018 and 12 black breaches in May 2018.
Number of black breaches 100 85 80 60 43 40 24 27 16 20 8 8 2 5 0
(Source: Routine Provider Information Request (RPIR) AC11 – Black Breaches)
• Our previous inspection report stated that the emergency department should continue to
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take action to ensure the department achieved the recognised standard of 15-minute arrival by ambulance to handover to emergency department. At this inspection we found that an ambulance handover nurse had been introduced and ambulance handover times were monitored daily against the 15 minute standard. Staff told us that this could be breached when several ambulances arrived at the same time. • NHS England’s quality dashboard for June 2018 showed that for May 2018, the latest month for which comparative data was available at inspection, 11.1 % of ambulance handover delays were for more than 60 minutes, which was worse than other trusts in the South Yorkshire area. • At our previous inspection we issued a requirement notice for the department to ensure that at initial assessment in the ‘pit stop’ area in the emergency department the patient’s vital signs were taken and recorded consistently. At this inspection we observed that although some action had been taken to address the previous inconsistency in taking and recording patients’ vital signs, we found that new observations were only being undertaken for medical patients. • The Sheffield Hospitals Early Warning Score (SHEWS) system was used to provide early warning of deteriorating patients, however, as observations were not always carried out on arrival and were not routinely completed on assessment, unless clinically indicated the use of SHEWS was of limited value within the department. The trust had taken other action to support consistent practice which included a statement of purpose for vital signs which had been agreed and distributed to staff. • At our previous inspection we issued a requirement notice for the department to ensure that robust escalation processes were implemented in the emergency department. At this inspection we found that a statement of purpose for escalation had been introduced which supported monitoring arrangements to capture escalation at times of increased activity. • At our previous inspection we issued a requirement notice for the department to ensure that patients in the clinical decisions unit had timely clinical reviews. At this inspection we found that the skill mix for the clinical decision unit had been reviewed and staffing of the unit increased. A statement of purpose for the unit had been prepared, agreed by clinical governance in September 2017 and shared with staff. An audit of the acuity of patients in the clinical decision unit was planned. • The relocation of the helipad close to the department provided rapid access to resuscitation and CT facilities to diagnose and treat major trauma patients and was supported by services in other departments imaging, vascular services, trauma and orthopaedics, and anaesthetics. • A revised front door process for arriving patients had been introduced, with assessment supported by medical input. The emergency department had implemented a revised initial assessment procedure in which patients were managed using symptom-based pathways to support appropriate observations. The ‘front-door’ approach supported timely diagnostics, decision-making and prompt treatment for the patient. • We found that at triage the department used a locally developed early warning scale to determine patient acuity. The computer system supporting triage applied the early warning scale to suggest the outcome for the patient, for example a score of three or more was identified as possible sepsis. Observations such as blood pressure and heart rate were not routinely taken or recorded, unless clinically indicated. This was in line with the nature of
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the injuries presented by patients. Where observations were required, they were documented appropriately. • Robust clinical deterioration pathways were in place, with a well-equipped resuscitation area with access to fluids, airway management tools, defibrillation and ECG monitoring. A separate radiography department, located in the next room provided imaging, as required. • Due to the nature of the work carried out by the department, patients were not routinely escorted to the radiography department. However, if escort care was required a health care assistant was available. • The department had adopted the ‘react to red’ skin campaign and placed an emphasis on checking the patient’s pressure areas on admission. This meant that where the condition of the patient’s skin on admission was reportable as a pressure sore prompt action was taken. • The GP centre undertook screening and streaming of patients supported by a computer system which assisted in streaming patients to the appropriate area of the department. Reception staff had received additional training to assist with the initial screening of patients and of signposting patients to external agencies. • The department was implementing the ‘Fit to sit’ initiative, for patients who were well enough to sit in chairs rather than wait on trolleys. The department had implemented a falls risk assessment to identify patients at risk and to develop individual plans for each patient to reduce the incidence of falls. Each patient and their falls risk were discussed at daily multidisciplinary safety huddles. • The department was also implementing a deteriorating patient education programme to support staff in escalating patients identified as at risk. Consultant medical staff we spoke with confirmed that patients identified in daily board round meetings may be escalated to the site matron, the bed manager, or to the trust executive on call. • We observed a patient admitted for trauma care during the inspection. • From November 2017 a mental health liaison team was based within the main emergency department at Northern General Hospital. The team was available between 8am and 10pm for the acute medical unit and on call out of hours. The team also covered Royal Hallamshire Hospital for urgent cases. • Emergency department staff informed us that close working with the community teams provided input prior to admission to facilitate a positive hospital admission. In terms of mental health related issues if the patient was known to services, informed staff they were suicidal, or had self-harmed further consideration was given regarding their needs. Staff told us they spoke with the nurse in charge regarding use of an assessment room instead of the waiting area or to ensure they were a priority for assessment. The senior sister told us that they made a patient as comfortable and safe as possible. If the patient wanted to stand outside and wait, required a quiet or lower stimulus environment or required reassurance and support then they would provide this. The police would remain with any patient brought in via a Section 136 and security staff could be used for patients displaying aggressive or challenging behaviour. • A mental health assessment proforma was completed during assessment, which included the capacity of the patient, a risk assessment to determine the need for supervision or regular observation and if mental health team involvement was required.
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Nurse staffing
The trust reported the following nurse staffing numbers for urgent and emergency care in March and December 2017. The service had fill rates of over 95% in March 2017 and in December 2017 the trust had 100% establishment. Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Urgent & emergency 115.5 121.6 95.0% 130.6 129.8 100.6% care (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
The trust provided updated information on the numbers of nursing staff deployed in the emergency department as part of our inspection:
Area of A&E staff deployed Establishment Actual April 2018 Vacancy A&E Group ancillary 29.0 27.2 1.8 Enhanced nurse practitioners 19.4 23.4 -4.0 A&E department nursing 148.8 140.0 8.8
For emergency department nursing, the trust informed us all vacancies were fully recruited and start dates arranged.
The following nurse staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
Vacancy rates From January to December 2017, the trust reported a vacancy rate for nursing staff in urgent and emergency care of -0.3%. This indicated a slight over establishment. The trust does not have a planned vacancy rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017 reported a turnover rate of 17.9% for nursing staff in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017, the trust reported a sickness rate for nursing staff in urgent and emergency care of 3.5% which was lower than the trust planned level of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage From January to December 2017, the trust reported 2,886 shifts filled by bank staff (47%) and 103 shifts filled by agency staff (2%) in urgent and emergency care. There were 3,093 shifts not filled by bank or agency staff (51%).
A breakdown of bank and agency usage by staff type is shown below:
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Bank/ agency Total Bank 2,886 (47%) Agency 103 (2%) Not filled 3,093 (51%) (Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
• Our previous inspection report stated that the emergency department should implement plans to increase nurse staffing in the emergency department to ensure there were appropriate staffing levels at all times. At this inspection we found that actual nurse staffing levels coincided with planned level, following the department’s involvement in the national safer nursing acuity initiative and subsequently, recruitment of nursing staff to attain planned establishment. This followed a £1.2m investment in additional staffing approved by the trust board in February 2016 which had meant increased nursing and support staff had increased by 25% since our previous inspection. • At our inspection the department provided the numbers of nursing staff in post as compared with establishment and nurse staffing rotas for the four weeks prior to our inspection. A centralised rota team had commenced the production of rotas since the previous inspection. This information confirmed the position the department had achieved in relation to its staffing numbers. • We were informed the department had discontinued the use of agency staff at the weekend, which had resulted in substantial cost savings in May 2018. • However, when we spoke with consultant staff we found they continued to make the case for the deployment of additional nursing staff in the department. Senior staff told us that a review of acuity in the department had commenced to support the optimal deployment of staff in the department. • We observed in the department that although a shift was reported to be understaffed by one qualified nurse and one non-qualified member of health care staff, the department overall appeared to be adequately staffed, with members of staff allocated to each clinical area. • We spoke with the bed manager about the predictive tool used to identify the department’s busiest times in relation to staffing need. The tool supported staff flexibility so that when patient demand required, staff could be redeployed to the busiest area, for example, from minor injuries to majors.
Medical staffing
The trust reported the following medical staffing numbers for urgent and emergency care in March and December 2017. The fill rate in December 2017 had increased by more than 15% from March 2017 and was over 100% establishment.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Urgent & emergency 45.0 52.6 85.7% 53.5 51.8 103.2% care
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(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
The trust provided updated information on the numbers of medical staff deployed in the emergency department as part of our inspection:
Area of A&E staff deployed Establishment Actual April 2018 Vacancy A&E medical 58.2 55.7 2.5 The following medical staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
Vacancy rates From January to December 2017, the trust reported a vacancy rate for medical and dental staff in urgent and emergency care of 4%. The trust does not have a planned vacancy rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017 reported a turnover rate of 22.9% for medical and dental staff in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017, the trust reported a sickness rate for medical and dental staff in urgent and emergency care of 1.4% which was lower than the trust planned level of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and locum staff usage The trust did not provide the total shifts available for middle grade doctors, so we were unable to calculate bank and locum usage overall or for this staff type as a proportion of the total shifts including permanent staff.
From January to December 2017, the trust reported 1,307 shifts filled by bank staff and 191 shifts filled by locum staff in urgent and emergency care at the trust. There were 708 shifts not filled by bank or agency staff.
A breakdown of bank and agency usage by staff type is shown below:
Bank/ agency Total Bank 1,307 (59%) Agency 191 (9%) Not filled 708 (32%) (Source: Routine Provider Information Request (RPIR) P21 Medical Locums)
Staffing skill mix As of December 2017, the proportion of consultant staff reported to be working in urgent and emergency care at the trust was the same as the England average and the proportion of junior (foundation year 1-2) staff was higher.
Staffing skill mix for the 52 whole time equivalent staff working in Urgent and Emergency Care at Sheffield Teaching Hospitals NHS Foundation Trust. This England Trust average Consultant 30% 29%
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Middle career^ 1% 14% Registrar group~ 39% 33% Junior* 29% 23%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)
• At our inspection the department provided the numbers of medical staff in post as compared with establishment and medical staffing rotas for the four weeks prior to our inspection. This information confirmed the position the department had achieved in relation to its staffing numbers. • Also, since our previous inspection, we were informed consultant and other medical staff undertook board rounds in the departments at three times during the day to support handover. We did not observe these during our inspection. • Following our previous inspection, we reported that the department should continue to review the provision of 24-hour consultant medical cover within the emergency department as part of being a major trauma centre. At this inspection we found that the number of consultants on duty in the emergency department varied between two and five and the consultants finished at 12 midnight. From May 2018 major trauma consultants were deployed across the hospital between 8am and 6pm Monday to Friday. • We spoke with the clinical consultant lead for major trauma. When a trauma event occurred out of hours the consultant on call needed to travel to the hospital which meant that the hospital did not usually meet the five-minute standard for the trauma team to be in place to respond to the trauma call. Although we were informed that the trust was reviewing the requirements for the major trauma centre to include consultant staff 24 hours and seven days per week, we remained concerned that the major trauma standards were being breached and this had not been resolved in a timely way following our previous inspection. • A medical workforce plan was in place which reflected sickness absence. The department maintained a rota for middle grade staff to support integration between middle grade and consultant staff. There were 14.2 WTE consultants in emergency medicine (excluding paediatrics) providing cover from 8am until 12 midnight 7 days per week and an on-call rota for trauma. Also, two additional middle grade staff were deployed in the department between 12 midnight and 8am. • We were informed that an internal locum bank was used when additional medical staff were needed (mainly at weekends) but agency medical staff were used only rarely in the emergency department. A resourcing meeting for the department was held weekly attended by rota coordinators to review gaps in staffing and to assess risks. Advance
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nurse practitioners staff (Grade 8 and above) were considered as part of the medical rota.
Records • Since the previous inspection the emergency department had achieved full compliance for its implementation of the ambulance service’s electronic patient record. As well as the electronic version, the department maintained paper records for use in the department. • At this inspection we reviewed a sample of 25 patient records in the emergency department. Our sample included ten records from the Royal Hallamshire minor injuries unit. The records were generally completed satisfactorily. However, we found that of the 25 records in our review, 11 of these did not have the patient’s allergy status recorded. We discussed our concerns with the trust during the inspection and we were assured that immediate action was taken to address this issue.
Medicines • Following our previous inspection we reported a number of discrepancies we had identified with the management of medicines in the department. At this inspection we reviewed the administration and storage of medicines and observed care in the emergency department. • A pharmacist was allocated to the emergency department and medicines cupboards were situated in each area of the department. A senior member of nursing staff acted as the principal link for pharmacy and provided a focus for the department on prescribing and the management of medicines. Advanced and emergency nurse practitioners supported the management of medicines in the department and in most instances were non-medical prescribers. • The medicines store room was air conditioned, clean and of the medicines items we checked all, with one exception, were in date. We spoke with a member of pharmacy staff involved in checking the medicines stocks. We were informed that pharmacy restocked medicines twice weekly. Imminent expiry dates were marked and medicines found open in the store were disposed of. Pharmacy maintained a list of medicines for the main store which for each item, indicated the earliest expiry date. Staff we spoke with informed us that medicines stocks were well maintained and they were not aware of medicines items ever being out of stock. • In the emergency department, in three instances we observed, where medicines bottles were open, the bottle was not identified with an ‘opened on’ date. Five members of staff we spoke with were not aware that the opened bottle required identifying with an ‘opened on’ date. Staff were also unaware of how long the medicine remained usable after opening. We were unable to locate evidence of the monitoring record for stored medicines items. We discussed our concerns with the trust during the inspection and we were assured that immediate action was taken to address this issue. • We found that oxygen charts were not being completed nor prescriber signatures completed, although a section in the patient notes related to oxygen. For 10 patients who were receiving oxygen therapy, none of these patients had been prescribed oxygen. One of these patients was on the ‘Shortness of breath pathway’. We discussed our concerns with the trust during the inspection and we were assured that immediate action was taken to address this issue.
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Incidents
Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From May 2017 to April 2018, there were no incidents which were classified as never events for urgent and emergency care at the trust. (Source: NHS Improvement - STEIS (01/05/2017 - 01/04/2018))
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported four serious incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS England from May 2017 to April 2018. Of these, the most common types of incident reported was/were: • Treatment delay meeting SI criteria with four (75% of total incidents)
(Source: NHS Improvement - STEIS (01/05/2017 - 01/04/2018))
• At our previous inspection we found there was a backlog of incidents awaiting investigation. At this inspection there were just four incidents awaiting investigation. Senior managers we spoke with explained how the department and within the wider hospital, incident reporting and investigation had been developed since our previous inspection. • The emergency department recorded reported incidents in an electronic system widely used in the NHS. We spoke with the consultant lead for audit and investigation that had been in the role since December 2016. We also spoke with 10 staff who were each aware of the incident reporting process and told us they were confident that incidents were dealt with appropriately. • Following a local review within the department, incidents were reported to a serious incident group which met weekly to review progress with the investigation of serious incidents. The serious incident group oversaw the investigation of incidents and approved the investigation report. • Lessons were learned following the investigation of incidents and learning was shared with staff. Learning from a significant incident selected each week was presented as a case review with associated learning points and shared with staff by email and staff notice boards. Themes from the investigation of incidents were featured in the emergency 20171116 900885 Post-inspection Evidence appendix template v3 Page 44
department governance newsletter and these were discussed at the emergency department clinical governance meeting. Medical and nursing staff spoke positively about the follow up they received from the investigation of incidents. • The serious incident group escalated the outcomes from the investigation of incidents to the executive team and a directorate action plan was implemented. Learning was shared at the patient safety and risk committee, the medicines safety committee and the healthcare governance committee among other forums. For investigations with implications across the trust an executive director had oversight of the corporate action plan.
• The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Duty of candour was reflected in the investigation of incidents and was included in the emergency department governance executive agenda. • Staff induction included themes from incidents and lessons learned. Incidents were also simulated to support learning for medical and nursing staff.
Safety thermometer
The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 12 new pressure ulcers, one falls with harm and six new catheter urinary tract infections from April 2017 to April 2018 within urgent and emergency care.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total pressure ulcers (12)
2 Total falls (1)
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3 Total CUTIs (6)
(Source: Safety thermometer - Safety Thermometer)
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Is the service effective?
Evidence-based care and treatment • Our previous inspection report stated that the emergency department should review guidance in the emergency department to ensure it reflected current evidence-based guidelines. At this inspection we found a review of guidance was in progress. The department shared with us the guidelines that had been updated. Medical and nursing leads were nominated for specific subject areas. • The emergency department followed recognised evidence-based care and treatment guidelines which were based on National Institute for Health and Clinical Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines. Clinical guidelines were set against national evidence and referenced. Guidelines were accessed by staff through the shared electronic information system. • We were informed that the department was involved in several research studies which supported the development of guidelines. For example, the use of blood products in the emergency department. The nominated lead for sepsis shared the updated guidance and pathways for sepsis-related topics which had resulted in revised clinical guidance for the management of sepsis and an updated sepsis screening tool from February 2018. • Revised clinical guidance was linked to training plans for the emergency department. Training and supporting literature was being revised for consistency and review of existing guidelines.
Nutrition and hydration Emergency Department Survey 2016 In the CQC Emergency Department Survey, the trust scored 6.9 for the question “Were you able to get suitable food or drinks when you were in the emergency department?” This was about the same as other trusts. (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
• The 12 patients we spoke with had been served drinks as needed. Six of these patients had been offered food and/or drinks, two had only arrived in the department a short time prior, and two had not been offered food or drink. However, when staff were approached they attended to the patients immediately. Relatives we spoke with also confirmed that food and drink had been offered to the patients they were accompanying. • Although drinks and snacks were available in the waiting room vending machines, one vending machine in the patient waiting area was out of order. We observed that drinks but not snacks included healthier options. We did not observe any information which promoted healthy eating or a healthy lifestyle choice. • We saw that each area of the emergency department had in place care support and housekeeping staff who worked with nursing staff to support patients’ nutrition and hydration needs.
Pain relief
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Emergency Department Survey 2016 In the CQC Emergency Department Survey, the trust scored 5.8 for the question “How many minutes after you requested pain relief medication did it take before you got it?” This was about the same as other trusts. The trust scored 7.0 for the question “Do you think the hospital staff did everything they could to help control your pain?” This was about the same as other trusts. (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
• A pain score assessment was required in triage and the department had recently completed a pain audit which compared the use of RCEM guidelines on pain management in the department. The audit showed that the number of patients who attended the department who had pain relief offered increased between September 2017 and February 2018 from 18.2% to 46.5%. The audit also showed that the documentation of pain management increased significantly during this period. • We observed the arrival of patients in the department and their progress through the care pathway, pain relief was administered appropriately and this was documented. We spoke with 10 patients and each of them had been asked if they were in any pain. Only three required pain relief and it was administered in a timely manner. Two had been asked if their pain had improved following pain relief. Relatives also confirmed that patients had been given pain relief within what they felt was an acceptable time.
Patient outcomes
RCEM Audit: Moderate and Acute Severe Asthma 2016/17 In the 2016/17 Moderate and Acute Severe Asthma report, the trust performed between the median and upper quartiles for one standard: STANDARD 8b: the patient’s inhaler TYPE was satisfactory for 16% of patients The trust’s performance was in the median quartile for five standards and in the lower quartile for six further standards that applied to the hospital. (Source: Royal College of Emergency Medicine)
RCEM Audit: Consultant sign-off 2016/17 In the 2016/17 Consultant sign-off audit, the trust performed between the median and upper quartiles for one of the three standards that applied to the hospital: • STANDARD 1: Consultant* reviewed - Atraumatic chest pain in patients aged 30 years and over for 18% of patients (Source: Royal College of Emergency Medicine)
RCEM Audit: Severe sepsis and septic shock 2016/17 Comparing this provider to other trusts on the 2016/17 Severe Sepsis and Septic Shock Audit, the trust was in the median to upper UK quartile for three of 13 standards: STANDARD 3: O2 was initiated to maintain SaO2>94% STANDARD 3a: 50% within one hour of arrival; for 29% of patients; STANDARD 3b: 100% within four hours of arrival; for 37% of patients. STANDARD 4: Serum Lactate measured within four hours of arrival: STANDARD 4a: 50% within one hour of arrival; for 29% of patients;
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STANDARD 4b: 100% within four hours of arrival; for 61% of patients. STANDARD 5: Blood Cultures obtained: STANDARD 5a: 50% within one hour of arrival; for 45% of patients; STANDARD 5b: 100% within four hours of arrival; for 71% of patients. (Source: Royal College of Emergency Medicine)
RCEM Audit: Procedural sedation in adults 2015/16 In the 2015/16 Procedural sedation in adult’s audit, which concluded in 2017, the audit concluded that sedation was safe if/when performed by a fully trained and competent clinician. It is paramount to fully consent the patient, and keep adequate documentation. Based on the latest sedation audit results, the NGH ED procedural sedation practice was below the standards and needed to be improved and monitored. (Source: Royal College of Emergency Medicine)
RCEM Audit: Fractured Neck of Femur - 2017 In the 2017 Fractured Neck of Femur audit, which reported in December in 2017, the audit concluded the audit results were extremely disappointing revealing sub-optimal patient care. The training provided to the triage nurses, the establishment of the initial assessment process and the neck of femur checklist have been implemented to help improve the care for this group of patients. A re-audit was planned for November 2018. (Source: Royal College of Emergency Medicine)
Unplanned re-attendance rate within 7 days From April 2017 and March 2018, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the England average but consistently better than the national standard of 5%.
Unplanned re-attendance rate within seven days - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS Digital - A&E quality)
• Although the emergency department participated in the national RCEM audits to benchmark its practice against the standards and other emergency departments, the
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consultant audit lead acknowledged that results of these audits previously demonstrated mainly poor outcomes for the emergency department. Action plans from these audits were in progress. Results from audit were linked to the department’s education and training programme. • The department participated in the trauma audit and research network. Outcome reports for the major trauma centre were presented in a major trauma centre dashboard which was prepared quarterly. The major trauma dashboard measures provided for the department to benchmark its performance particularly with five neighbouring major trauma centres for specific clinical measures and to track progress or deterioration in performance. Trauma outcomes were positive and were influenced by several factors including consultant led trauma teams, increased trauma training for nurses, and the new helipad which meant that secondary ambulance transfer of patients was no longer required. • Senior medical and nursing staff told us that the programme of local audits was being reviewed. A group had been set up to review outcomes for sepsis patients which included the patient’s experience of their stay in hospital. Sepsis outcomes showed a considerable improvement. The severe sepsis audit was undertaken by microbiology staff. Door to antibiotic time had improved but more work needed to be done. • The department had recently completed a pain audit which compared the use of RCEM guidelines on pain management in the department. The audit showed that the number of patients who attended the department who had pain relief offered increased between September 2017 and February 2018 from 18.2% to 46.5%. The audit also showed that the documentation of pain management increased significantly during this period. • An audit of outcomes for patients with fractured neck of femur and of pressure care was planned. Recognition and management of patients presenting with fractured neck of femur was improving, and the introduction of guidelines for administering fascia iliaca (FI) nerve blocks was introduced in May 2018. • Clinical governance monitoring reports were prepared which reflected key performance indicators and patient outcomes. The department regularly monitored its performance against a range of clinical indicators through a performance dashboard. • Neurosurgery was based at the Royal Hallamshire Hospital, which meant timely intervention was required by neurosurgeons. We found that guidelines for patients who required urgent referral to the neurology assessment unit for immediate specialist assessment were reviewed in August 2017.
Competent staff
Appraisal rates This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
From April 2017 to December 2017, 74% of staff within urgent and emergency care at the trust had received an appraisal compared to the trust’s planned level of 90%.
A split by staff group can be seen in the table below:
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Target Appraisals Eligible Appraisal Staff group met completed staff rate (Yes/no)
NHS infrastructure support 1 1 100% Yes Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T) 1 0 0% No Qualified nursing & health visiting staff (Qualified nurses) 94 70 74% No Support to doctors and nursing staff 91 68 75% No Support to ST&T staff 6 5 83% No Qualified Healthcare Scientists 1 0 0% No Medical & Dental staff - Hospital 1 0 0% No Medical and dental staff and nursing and midwifery staff failed to meet the trusts 90% target for appraisal completion. (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
• At our inspection senior managers provided evidence of the most up-to-date appraisal rates by staff group which showed a 12-month % rate of compliance of 77.7% as at 31 May 2018 for acute and emergency medicine. The training lead told us that personal development reviews included interaction to support the staff member’s development and an action log was completed and signed within two weeks of the appraisal. A planned career progression plan was available for all staff. Planned training opportunities within the emergency department included the multi-disciplinary team. • A structured induction programme was in place for new staff. All nursing staff new to the department received a four week induction, when they were not counted as part of the staff rota. The staff induction booklet included “top ten tips” for staff commencing work in acute and emergency medicine. Staff we spoke with who had recently joined the department told us they felt well supported, which included preceptorship and mentorship. When staff felt ready (usually after at least six months) they attended an initial assessment training day to enable them to work in the triage area. • We spoke with the emergency department’s training lead and training team staff about their role in leading and supporting clinical education training in the department. A training needs analysis and skills audits was in process of completion. In addition to planning and delivering mandatory training learning was supported with clinical teaching sessions taking place in clinical areas. Acute simulation of medical emergencies included trauma simulation which was delivered with multidisciplinary teams. A sepsis study day was in development. The clinical education programme was externally endorsed. • The department had supplemented the emergency and advanced nurse practitioners with training to support the development of these roles within the trust. The development of the advanced nurse practitioner role within the emergency department was supported and supervised by nurse consultant and emergency medical staff. Nurse practitioners received annual sepsis training. • Staff were enabled to become instructors, for example for the trauma nursing core course, to participate in a range of local and national training, and to have access to international secondments. Senior managers saw the emergency department’s function as including support for teaching and research, for example, through medical and nurse consultant staff allied to a local university. The emergency department received positive feedback 20171116 900885 Post-inspection Evidence appendix template v3 Page 51
following a recent external inspection of junior doctor induction and training, where the induction programme was seen as comprehensive and efficient. Breakfast briefings which included external speakers took place in the department each morning between 7am and 8.30am. Improved availability of training for trauma nursing staff and support for advanced life support training were further examples cited to us. For example, breakfast briefings included “Trauma of the week”. • Where poor performance was identified, the staff member was supported by being made supernumerary and having a more experienced staff member allocated to work with them before other routes were considered to address performance. • Some staff were trained to provide paediatric life support, although there was a local children’s hospital nearby with emergency department facilities, so that a child could be treated if this eventuality arose.
Multidisciplinary working • We found there was effective collaborative working both within the emergency department and with external partners. A commissioning agreement was in place with a neighbouring mental health trust to provide support for patients experiencing ill mental health within the department. Senior emergency department staff held frequent meetings with medical and nursing staff from the mental health trust to support joint working arrangements. Since November 2017, the mental health trust had maintained a presence in the department 24 hours a day, seven days a week. • The department liaised effectively with the police in supporting integrated inter-agency working. The department had a dedicated police liaison officer. We spoke with specialist staff from the mental health trust in the department who were engaged with staff from the police service undergoing a two week placement as part of their police training. • The inter-agency team were also working jointly to develop an interagency approach to other issues identified as impacting the department, including knife crime, gang violence, substance abuse and radicalization. The department worked with the police to develop tools to deter knife crime, mainly in young people. A multi-agency task and finish group had been set up to support a whole system approach to reduce the impact of knife crime on the public, patients and their families and in turn on the emergency department. Staff were briefed on these and a range of other subjects at daily breakfast briefings. • Arrangements with the local NHS ambulance service, the police service and the local authority operated effectively. The emergency department had effective arrangements in place with these and other external partners and participated in public health campaigns including police initiatives to reduce knife crime and gun crime. Senior staff in the department also liaised with the police service in contributing to a crisis care concordat and a multidisciplinary suicide prevention group had recently been formed. • The emergency department staff had developed positive interagency working with psychiatric liaison and the substance misuse service that attended the emergency department daily and picked up referrals for patients with drug and alcohol issues. • Senior medical staff told us a number of consultants who worked in the emergency department also worked across the trust, which supported liaison between departments and improved referrals to specialities. Trauma was identified as an area where medical
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staff considered there was scope to improve further the links with the wider trust. • The major trauma clinical lead attended major trauma meetings monthly which included members of the local trauma network representing Barnsley, Doncaster, Rotherham and Chesterfield. • The emergency department liaised closely with the local NHS children’s hospital as to the admission of children requiring urgent and emergency care. Staff were exchanged on a planned basis between the emergency departments of the two trusts to support staff experience of working with paediatric patients. • Links with community services for patients were through the front door response team which provided access to nursing care, physiotherapists, occupational therapists, for example for fall prevention assessments. Advice and support for patients following discharged from hospital meant they were able to return home sooner. • Medical and nursing staff worked well together. For example, following a pre-alert we observed the trauma team during a patient assessment. Members of the trauma team from each speciality arrived quickly and were given information about the patient’s condition from the pre-alert information. Each team member clearly identified themselves with the use of a name label. Equipment was prepared before the patient arrived. We observed staff as they discussed plans with each other and within the wider team. Multidisciplinary working was calm and well structured. • The ambulance service liaised closely with the Royal Hallamshire Hospital minor injuries unit to coordinate the admission and discharge of patients. Ambulance crew we spoke with told us they spoke directly with the nurse practitioner on duty in the unit after transporting a patient and before leaving the hospital. For patients with ill mental health, nurse practitioners liaised with the mental health team in the main emergency department for advice and to arrange to transfer patients, who were transported by ambulance.
Seven-day services • The emergency department was open 24 hours a day, seven days a week. • Consultant medical staff were on duty in the department seven days a week from 8am until 12 midnight. Consultants provided on-call cover from midnight to 8am and two additional middle grade staff were deployed in the department between 12 midnight and 8am. At this inspection the trust was reviewing the requirements for the major trauma centre to include consultant staff 24 hours and seven days per week. Although we were informed that the trust was reviewing the requirements for the major trauma centre to include consultant staff 24 hours and seven days per week, we remained concerned that the major trauma standards were being breached. • The mental health liaison team provided cover within the department 24 hours a day, seven days a week. • Radiology services were available within the department 24 hours a day, seven days a week. Diagnostic services were available 24 hours a day, seven days a week.
Health promotion
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• The department identified patients that required extra support during initial assessment. Staff worked with external agencies to provide services which were appropriate for the patient’s needs. The local mental health trust maintained a 24-hour presence in the department and signposted patients to relevant services where appropriate. • Referral pathways were in place for patients requiring the alcohol support service and we observed posters in the department with information about the service. Specialist support was available for patients who were victims of gang violence and patients under 17 years were referred to the community youth team for additional support. The community youth team provided support for young people to promote better health and lifestyle choices. • During our inspection we did not observe examples of other health promotion materials on display or information available within the department in areas which were accessible to patients.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Mental Capacity Act and Deprivation of Liberty training completion Data relating to mental capacity is included in the safeguarding adults’ level 2 training module. (Source: Routine Provider Information Request (RPIR) P40 –Mandatory and Statutory Training) • The Mental Capacity Act and deprivation of liberty safeguards were part of annual mandatory training for nursing staff and the department had achieved 80% compliance. We spoke with 13 members of staff about Mental Capacity Act and deprivation of liberty training and each confirmed they had completed mandatory training covering these areas. • Mental capacity assessments were included in the electronic patient record which meant these were completed for each patient. Staff were each able to explain mental capacity assessment, the circumstances in which it was required, and the procedure staff would follow in the department. Staff we spoke with were also aware of how they would access support from the on-site mental health team in the department. • Staff felt supported through updates received, for example, at the breakfast club sessions, and guidance was available on the intranet. Staff we spoke with told us they would escalate any issues or concerns about the deprivation of liberty safeguards if they were unsure. • We were informed that medical staff received safe and well training with the police to raise awareness. • We were informed that patients were given as much information as possible to help them make decisions. We observed a notice board with information for patients and carers about the Mental Capacity Act and deprivation of liberty safeguards in the waiting room of the clinical decisions unit. • Staff we spoke with said verbal consent was obtained from patients prior to treatment. Consent would not usually be documented unless a patient refused. Capacity was assessed as part of the front door mental health assessment, which in turn informed the continued assessment, management, support and treatment required for the patient. • Clinical educators joined the two weekly huddles and breakfast clubs. The senior sister informed us that they received emails and posts giving up to date information regarding the Mental Health Act and Mental Capacity Act. Staff were due to attend a three-day
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training course regarding mental health detention.
Is the service caring?
Compassionate care
Friends and Family test performance The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was generally better than the England average from March 2017 to December 2017. The trust slightly fell lower than the England average in January and February 2018.
A&E Friends and Family Test Performance - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS England Friends and Family Test)
• Our previous inspection report stated that the emergency department should review the experience of patients to ensure privacy and dignity was maintained in the emergency department, particularly during busy periods. At this inspection we found that the department had largely addressed the issues we had highlighted as to maintaining privacy and dignity in delivering patient care. This was confirmed by our observations of care in the department. Patients and their relatives we spoke with were positive about their experience in the department. • We observed staff engaged in the care and treatment of patients in various areas of the department including triage, in the red, blue and green areas, and in resus. Staff were polite and caring of the patients’ needs. Privacy was maintained when nursing staff entered the cubicle to administer care and treatment for the patient. • We observed that in the initial assessment area, support staff offered items of clothing and other essentials to patients who had arrived unexpectedly in the department. We observed as patients arrived by ambulance and a member of nursing staff took handover. Nursing staff subsequently took the patient’s observations behind closed curtains. In the blue area we observed care as it was administered to five patients. We observed very positive, compassionate interactions between staff and patients. We observed a further three patients where medical and nursing staff maintained the patient’s privacy and dignity by
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ensuring they had privacy to change into examination gowns. • We observed medical and nursing staff as the multidisciplinary trauma team were engaged in caring for a trauma patient in the resuscitation area. We observed very effective communication between staff as they prepared for the arrival of the trauma patient. Each member of the team wore identification of their role within the trauma team. After the patient arrived by ambulance, staff spoke in low voices as the ambulance crew gave handover information to the trauma team. Each of the team worked during the handover to stabilise the patient, and to move them safely onto the trolley. Nursing staff closed curtains and spoke in a lowered voice to maintain the patient’s dignity and to preserve confidentiality. • However, when all cubicles were in use we observed that one patient on a trolley, and a second patient sitting on a chair, were treated in the centre of the department. We saw that blankets were used to maintain the patient’s dignity. • We observed staff interactions with three patients who had presented requiring mental health support, and each member of staff appeared calm, friendly and non-judgmental. One patient who had attended the department previously told us that staff were always friendly and treated them with respect and dignity.
Emotional support • We observed that medical and nursing staff clearly understood the emotional impact of the patients’ care and treatment potentially had on the patient’s and their relative’s overall wellbeing. We observed two instances of staff working with patients who were distressed, to provide reassurance and putting them at ease. • The front door response team worked alongside emergency department staff to support patients being discharged, including patients who were to receive end of life care at home. Patients were offered comfort boxes to provide emotional support during their discharge. Ambulance and GP staff contributed to the support. We were informed that the palliative care team provided regular information and training to support emergency department staff in this role. • Patients were advised about how to access other support services and this advice was offered as early in the patient pathway as appropriate. Patients may be directed to other services from reception, where this was appropriate. Emotional support provided by staff included the carers, family and dependants of patients attending the emergency department. • The emergency department supported patients who become distressed, liaised with psychiatry about their medicine, and collected this from the onsite pharmacy when necessary. Mental health assessment rooms were available and when patients were risk assessed they were allocated to a bay close to a nursing station to ensure observation, in a locked area such as the clinical decision unit or if low risk or with family they may be placed in the seating area. Housekeepers were increased if additional support was required due to deterioration in mental health or detention under the Mental Health Act. • Two relatives’ rooms within the department were available for family members, for example if their relative was being cared for in the resuscitation room. The relatives’ rooms were in process of being refurbished. Special memory boxes were available to provide 20171116 900885 Post-inspection Evidence appendix template v3 Page 56
comfort to bereaved relatives. We were informed that a pastor service for the emergency department was available at certain key times in the week.
Understanding and involvement of patients and those close to them • We observed staff in areas of the department as they explained to patients what they needed to do with an explanation of why this was. In the red area, four groups of relatives we spoke with each felt they were kept up to date and were happy with the explanation of nursing care. Relatives told us that staff had been proactive in keeping them updated as to what was happening next and when their patient was likely to be moved. In the resuscitation area we observed as nursing staff explained what they were doing or going to do so the patient was able to engage with them and ask questions if they wanted to. We observed as a patient asked about their self-care needs and staff discussed their plan of care. • We spoke with 10 patients who each spoke highly of how staff communicated with them and offered advice that enabled them to understand their care and treatment. Patients felt staff were non-judgmental and gave the patients the time they needed to explain or to answer questions. • We spoke with two patients who had waited longer than they expected to see a doctor, but nursing staff had checked on them and explained the reasons for delays. One patient had been in the department for 12 hours before being admitted to the ward, as they had recurrent episodes of becoming acutely unwell and required monitoring. We spoke with the patient and their family several times and they felt everything possible had been done for them. • We observed staff interactions with three patients who had presented requiring mental health support, and each patient felt they had been well informed. Five patients had friends or relatives accompanying them who each told us that they had been well involved by staff. Emergency Department Survey 2016 The results of the CQC Emergency Department Survey 2016 showed that the trust scored similar to other trusts in 23 out of the 24 questions relevant to caring and better in one question.
Question Trust 2016 2016 RAG 3.2 About the Q10. Were you told how long you would have to wait to be same as examined? other trusts 8.6 About the Q12. Did you have enough time to discuss your health or same as medical problem with the doctor or nurse? other trusts Q13. While you were in the emergency department, did a doctor 8.3 About the or nurse explain your condition and treatment in a way you could same as understand? other trusts 9.0 About the Q14. Did the doctors and nurses listen to what you had to say? same as other trusts 8.8 About the Q16. Did you have confidence and trust in the doctors and same as nurses examining and treating you? other trusts Q17. Did doctors or nurses talk to each other about you as if you 9.2 About the
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Question Trust 2016 2016 RAG weren't there? same as other trusts 7.7 About the Q18. If your family or someone else close to you wanted to talk same as to a doctor, did they have enough opportunity to do so? other trusts 8.7 About the Q19. While you were in the emergency department, how much same as information about your condition or treatment was given to you? other trusts 7.7 About the Q21. If you needed attention, were you able to get a member of same as medical or nursing staff to help you? other trusts Q22. Sometimes in a hospital, a member of staff will say one 8.9 About the thing and another will say something quite different. Did this same as happen to you in the emergency department? other trusts 8.2 About the Q23. Were you involved as much as you wanted to be in same as decisions about your care and treatment? other trusts 9.0 About the Q44. Overall, did you feel you were treated with respect and same as dignity while you were in the emergency department? other trusts 7.6 About the Q15. If you had any anxieties or fears about your condition or same as treatment, did a doctor or nurse discuss them with you? other trusts Q24. If you were feeling distressed while you were in the 6.1 About the emergency department, did a member of staff help to reassure same as you? other trusts 8.3 About the Q26. Did a member of staff explain why you needed these same as test(s) in a way you could understand? other trusts 8.5 About the Q27. Before you left the emergency department, did you get the same as results of your tests? other trusts 8.8 About the Q28. Did a member of staff explain the results of the tests in a same as way you could understand? other trusts Q38. Did a member of staff explain the purpose of the 8.9 About the medications you were to take at home in a way you could same as understand? other trusts 6.1 About the Q39. Did a member of staff tell you about medication side effects same as to watch out for? other trusts 5.8 About the Q40. Did a member of staff tell you when you could resume your same as usual activities, such as when to go back to work or drive a car? other trusts 4.7 About the Q41. Did hospital staff take your family or home situation into same as account when you were leaving the emergency department? other trusts Q42. Did a member of staff tell you about what danger signals 6.4 About the regarding your illness or treatment to watch for after you went same as home? other trusts Q43. Did hospital staff tell you who to contact if you were worried 8.2 Better than about your condition or treatment after you left the emergency other trusts department? Q45. Overall... (please circle a number) 7.9 About the
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Question Trust 2016 2016 RAG same as other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
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Is the service responsive?
Service delivery to meet the needs of local people • Following our previous inspection, we reported on a number of planned changes for the emergency department which were expected to impact positively on service delivery. At this inspection we found that the initial assessment unit had been upgraded and a new helipad had been opened adjacent to the emergency department front door and resuscitation area. The GP collaborative had been relocated adjacent to the main emergency department (directly beneath the helipad), which supported the streaming service 24 hours a day, seven days per week, and the GP out of hours service. The medical assessment centre had been relocated to a clinical area adjacent to the main emergency department. • The mental health assessment room had been relocated. Coverage of the emergency department by mental health liaison specialists was extended from December 2017 and provided a 24 hour, seven days a week service. A secure mental health room opened in November 2017. • Public consultation to support the local services review was in progress at the time of our inspection. The department was also involved in contributing to the planning and development of urgent and emergency care services for the South Yorkshire and Bassetlaw accountable care system. The accountable care system supported more co- ordinated care arrangements between hospitals, GPs, mental health, social care and community services and helped to relieve the pressures of growing patient demand on the emergency department.
Meeting people’s individual needs • The department coordinated services and made them accessible to patients with different needs, including patients with protected characteristics under the Equality Act and those in vulnerable circumstances. Reasonable adjustments were made so that patients with a disability could access services on an equal basis to others. For example, the department was accessible for patients with limited mobility and those who used a wheelchair. • The department coordinated services and made them responsive to patients with complex needs. Patients were supported during referral; transfer between services and at discharge. The department addressed the information and communication needs of patients with a disability or sensory loss. A hearing loop was installed in the reception area. Emergency department staff had access to a translation line and an interpreting service for patients where English was not their first language. • The mental health liaison team provided cover within the department 24 hours a day, seven days a week. The service informed us it received 20 or more referrals daily. Patients below the age of 16 were referred to the local children’s hospital. Child and adolescent mental health services for patients aged 16 to 18 years was under review at the time of our inspection. • The psychiatric liaison team was working with commissioners to reduce the number of patients who frequently presented in the emergency department. A cohort of patients were assessed to establish if they were experiencing an underlying mental health issue and support was provided based on individual need.
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• A dementia friendly frailty assessment unit had recently been opened, adjacent to the department. In triage, ambulance crew informed nursing staff of any dementia or mental health needs. Staff in emergency medicine completed a dementia update as part of mandatory training and we reviewed the mandatory training evaluation form for nine members of staff who attended this training in 2018. • A member of nursing staff acted as dementia lead for the department. The dementia lead ran a ‘dementia club’ and had introduced crafts such as painting and distraction aids to the department. Patients with dementia were supported with memory and communication aids, for example arts and crafts boxes and ‘twiddle muffs’ which were made available to patients for distraction therapy. The dementia boxes were available for patients to take home when they were discharged as they were for single use. The department planned multidisciplinary focus groups to identify further innovations to support care for patients with dementia. • Patients with a learning disability or with dementia were identified in their electronic patient record so that appropriate support could be accessed. Emergency department staff informed us that patients with a known learning disability were flagged on the IT recording system. The senior sister informed us that close working with the community teams provided input prior to admission to facilitate a positive hospital admission. Emergency Department Survey 2016 The trust scored about the same as other trusts for all three Emergency Department Survey questions relevant to the responsive domain.
Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your 6.9 About the same as condition with the receptionist? other trusts Q11. Overall, how long did your visit to the emergency 6.3 About the same as department last? other trusts Q20. Were you given enough privacy when being examined or 8.8 About the same as treated? other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
Access and flow
Median time from arrival to treatment (all patients) The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust did not meet the standard for the entire reporting period from April 2017 to March 2018.
The trust’s performance saw improvements between April and July 2017 and from September 2017 to March 2018 there was an upward trend of improvement.
Median time from arrival to treatment from April 2017 to March 2018 at Sheffield Teaching Hospitals NHS Foundation Trust
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(Source: Source: NHS Digital - A&E quality indicators)
Percentage of patients admitted, transferred or discharged within four hours (all emergency department types) The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.
The trust did not meet the standard between April 2017 and March 2018.
Performance against this metric was at its lowest of 79% in February 2017, the trust improvement to exceed the England average from April to August 2017. From April 2017 onwards, the trust generally followed the trend of the England average.
Four hour target performance - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS England - A&E waiting times)
Percentage of patients waiting between four and 12 hours from the decision to admit until being admitted From April 2017 to March 2018 the trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was generally worse than the England average. Performance against this metric showed a trend of decline primarily between September up to March 2018. The trusts performance was better than the England average between June and August 2017.
Percentage of patients waiting more than four hours from the decision to admit until being admitted - Sheffield Teaching Hospitals NHS Foundation Trust
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(Source: NHS England - A&E waiting times)
Number of patients waiting more than 12 hours from the decision to admit until being admitted Over the 12 months from April 2017 to March 2018, an average of 507 patients per month waited over four hours from decision to admit until being admitted. One patient waited more than 12 hours during the reporting period. Month Number of patients waiting Number of patients waiting more than four hours to more than 12 hours to admission admission Apr-17 298 0 May-17 323 0 Jun-17 158 0 Jul-17 170 0 Aug-17 291 0 Sep-17 333 0 Oct-17 541 0 Nov-17 536 0 Dec-17 737 0 Jan-18 842 0 Feb-18 980 0 Mar-18 878 1 (Source: NHS England - A&E waiting times)
Percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment From April 2017 to March 2018 the monthly median percentage of patients leaving the trust’s urgent and emergency care services before being seen for treatment was better than the England average. Percentage of patient that left the trust without being seen - Sheffield Teaching Hospitals NHS Foundation Trust
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(Source: Source: NHS Digital - A&E quality indicators)
Median total time in A&E per patient (all patients) From April 2017 to March 2018 the trust’s monthly median total time in A&E for all patients was consistently higher than the England average. Median total time in A&E per patient - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS Digital - A&E quality indicators)
• For the most recent complete month prior to our inspection (May 2018) the emergency department daily attendance averaged 341 patients, which included 9 children. • For walk-in and ambulance patients on arrival at the front door of the emergency department immediate assessment was nurse led but supported by medical input. The ‘front-door’ approach supported timely diagnostics, decision-making and prompt treatment for the patient. The revised front door arrangement was implemented from November 2017. We observed the care of patients in the pit stop area. Patients arriving by ambulance were seen and investigations carried out prior to their being assessed by an emergency doctor. An electronic white board was in the area with arrival and disposal times to support the smooth flow of patients.
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• If there were delays in the department and ambulance handover times were increased, a senior nurse would undertake a rapid assessment and handover process, to enable more efficient turnaround times for ambulance crews. • Patients could be referred directly to the GP collaborative and we observed that this was well signposted within the department. The collaborative had operated the GP streaming service 24 hours a day, 7 days a week since October 2017. Initial screening of patients was supported by a computer system which assisted in streaming patients to the appropriate area of the department. Reception staff had received additional training to assist with the initial screening of patients and of signposting patients to external agencies. We were informed that joint protocols were in place with regular meetings to monitor and improve the service. Approximately 30 patients per day were referred. Consultant medical staff we spoke with told us there was potential to work more closely with general practice. • The department operated a ‘green stream’ or minor’s area which saw patients who had walked into the waiting room. About one in three arriving patients were seen in this area, including patients who were directed to the GP streaming service. • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in accident and emergency. At our previous inspection we issued two requirement notices. Firstly, for the department to ensure that patients did not wait longer than the recommended standard for assessment and treatment in the emergency department. Secondly, and related to this, to monitor performance information to ensure 95% of patients were admitted, transferred or discharged within four hours of arrival in the emergency department. At this inspection we found that the department had achieved up to 90% of patients being admitted, transferred or discharged within the four-hour standard. Although overall its performance was variable, it generally followed the trend of the England average. • Compliance with the 4-hour standard deteriorated between November 2017 and April 2018, reflecting winter pressures and an increase in the number of patients attending the department. Consultant medical staff we spoke with confirmed the service experienced severe winter pressures which gave rise to patient flow issues with difficulties in transferring patients from the department. NHS England’s quality dashboard for June 2018 showed that for May 2018, the latest month for which comparative data was available at inspection, 88.8% of patients were seen within four hours of arrival, which was worse than other trusts in the South Yorkshire area. During the week of our inspection the emergency department achieved compliance levels between 89.85 and 93.6% against the four-hour standard. This data included attendance data for the minor injuries unit and urgent care eye clinic at the Royal Hallamshire hospital. • Senior managers had devised an operational plan “Action 95” for the emergency department which examined the patient pathway through the department based on a maximum stay of four hours. A lead staff member was identified for each target area and the delivery of actions within the target area was monitored. An integrated performance scorecard was prepared daily which reported on accident and emergency waiting times. • At this inspection we found a number of other measures were being taken to improve patients flow. Our observation of the emergency department showed patient flow was effective. We observed in the emergency department’s patient waiting area that the information screen showed a patient waiting time of 3 hours 30 minutes (at 10:08am). We spoke to a selection of patients and people in the emergency department waiting room, to
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ask how long they had been waiting, whether they had been triaged, and to gain general impressions and comments. Patients we spoke with told us they were happy with their waiting times. • We observed the bed management meeting which was arranged three times daily, usually at 8am, 1pm and 5pm. The meeting was attended by the bed and patient flow manager and patient flow matrons from within the hospital and across the trust. The meeting reviewed information on attendances, patients waiting, breaches of the four-hour standard, and current and projected beds available in the hospital, including the Royal Hallamshire Hospital. • The clinical decision unit was located adjacent to the department and formed part of the department. Patients could be admitted directly from the emergency department or through a primary care or clinic referral. The unit provided ambulatory pathways for identified conditions including chest pain. Standard operating procedures were in place. • We visited the acute medical unit which was located adjacently to the emergency department and provided 56 beds. Patients were admitted from the emergency department. Since our previous inspection the two previously separate acute medical units had been integrated which we were informed had a positive impact on patient flow. The unit assessed patients and prepared a decision plan for patient care within 48 hours of arrival. We observed that the unit had gained a certificate of excellence. • The acute medical unit held regular service improvement meetings. Improvements achieved included the introduction of a senior sister operating between the acute medical unit and the emergency department and selective movement of patients to the medical assessment centre. The centre relocated to its present location in May 2018 to support improved flow for medical patients from the emergency department. The medical assessment centre was open seven days between 1pm and 8pm. A ‘blood room’ service in the medical assessment centre reduced time to assessment for GP patients. • The front door response team operated between the emergency department and the frailty unit to identify patients who could be supported in the frailty assessment area. The unit undertook falls assessments and supported discharges from the emergency department with appropriate support arrangement for patients being discharged.
Learning from complaints and concerns
Summary of complaints From January to December 2017, there were 128 complaints about urgent and emergency care. The trust took an average of 41 working days to complete these. The trust worked to a tiered response time process where the timescale was determined based on the complexity of the concerns raised, usually 25 or 40 days. The trust planned to respond to 90% of complaints within the agreed timescale. For 2017/18 the trust closed 93% of complaints within the agreed timescale. • The majority of complaints related to Northern General Hospital (113) • Emergency services had 28 complaints. • September 2017 had the highest number of complaints (19) • 72 complaints related to medical staff. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
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• The department provided an update of its complaints information for the period from January to March 2018. We reviewed a summary of the investigation of six complaints and saw evidence of shared learning from each of these which was shared with clinical governance and used to prepare clinical case examples for feedback to staff to embed learning. The clinical cases reflected identified themes and identified learning points with evidence of action taken which was shared with staff. The department also prepared guidance on one page which could be displayed and shared in the department for some learning themes, for example where this related to diagnosis of less common conditions. • The patient experience committee reviewed complaints and feedback information which the department received. We were informed the committee commissioned ‘deep dive’ reviews into identified areas of concern and shared learning from the investigation of complaints and identified good practice. • We saw information which was available for patients about how to make a complaint.
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Is the service well-led?
Leadership • A deputy medical director with responsibility for emergency care and patient flow was appointed in 2016. At our inspection we found there had been a recent change in leadership of the department with the appointment of a nurse director and matron for the emergency department. The care group leadership team included the nurse director, an operations director and clinical director which formed a clinical delivery leadership triumvirate. • The nurse director told us they led by example and regularly worked clinical shifts to support staff. Medical and nursing staff we spoke with were positive about the functioning of the leadership triumvirate for the emergency department and of the role of the nurse director. • An emergency department consultant was the clinical lead for major trauma and a lead consultant for trauma was identified daily. A nurse consultant was training lead for the emergency department. A senior nurse (band 6 or above) led and managed each separate clinical area of the department. • We spoke with ten staff in the department and each commented that recent changes in the leadership structure had been positive. Staff we spoke with felt valued listened to and supported. Each member of staff said that managers in the department were visible and approachable. Staff could refer themselves or be referred for support. Staff we spoke with told us they appreciated the changes being implemented by their managers and enjoyed being well supported by them.
Vision and strategy • A clear vision and operational plan was in place for the continued development of the emergency department. The directorate strategy and plan were linked to the trust’s corporate strategy. The vision for the department was linked to the aims of the trust’s ‘making a difference’ corporate strategy for 2017 to 2020. • The current three-year strategy for the care group for acute and emergency medicine was prepared in 2017. The strategy included a review of projected activity and performance with an evaluation of key risks. It included an analysis of planned operational performance and resource requirements to achieve the vision and key objectives for the department. • The current vision and strategy for the emergency department was encapsulated in a one- page document ‘The AEM Way’ prepared in January 2018 which identified lead members of staff for each work stream ongoing within the department. An ‘excellent emergency care’ and other work streams met monthly to review achievement against objectives.
Culture • The emergency department’s culture was clearly positive, which a visitor could sense, and which staff told us about. Staff we spoke with felt valued and appeared happy and enthusiastic. They spoke positively about working in the department. We spoke with 10 staff and each felt the culture in the department had improved and was more open and
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positive. Staff felt listened to by senior staff and regular meetings to facilitate discussion and raise any issues took place. Staff who had previously felt isolated now felt much more included within the team. • Medical staff we spoke with described the department as having a ‘caring, give-it-a-go and can-do’ culture. Medical and nursing staff we spoke with felt the culture of the department was still evolving following recent changes and the significant number of new staff joining the department. • Directors wanted to promote a positive culture which empowered staff and improved standards. The department directors praised the staff in the department and felt proud of their hard work. They stated that the staff were each enthusiastic and dedicated to their work. Directors were pleased with progress achieved so far in developing a positive culture but also acknowledged further progress was needed. External facilitators had been engaged in development work which had impacted positively on the culture in the department. • A pastor service for the emergency department was available for staff at key times in the week.
Governance • At our previous inspection we issued a requirement notice for the department to ensure arrangements for governance within the emergency department operate effectively. At this inspection we found the department had made a number of changes to strengthen the arrangements for governance linked to the ‘ward to board’ governance of the trust. • Governance arrangements had been strengthened with the appointment of the nurse director who with the clinical director had oversight of governance. The nurse director was the accountable lead for governance. At the time of our inspection triumvirate meetings were held bi-weekly. A medical governance lead and audit lead for emergency medicine was in place for the department and was supported by the care group governance coordinator. The department recognised there was more to do to develop audit. • The executive care group meeting for acute and emergency medicine met bi-monthly. The executive meeting was chaired by the operations director and attended by the other members of the triumvirate and senior clinical managers. We reviewed the minutes of the meetings held in February, April and June 2018. Governance items reviewed included operational performance, risks and the Action 95 plan. Actions arising from the meeting were assigned to identified staff members and were reviewed and progressed at the next meeting. The emergency department governance executive reported into the acute and emergency medicine executive. • Clinical governance arrangements had been strengthened with the clinical director having overall responsibility for clinical governance. Three clinical lead consultants were in place and the audit lead for the emergency department. Audits were managed by the audit consultant in liaison with the clinical effectiveness unit. The audit programme for the year was agreed by the governance team. A departmental governance newsletter was prepared monthly. Learning from a clinical governance case was selected each week and presented in newsletter format with associated learning points and shared with staff by email and staff notice boards.
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• A clinical governance meeting for the emergency department was held monthly chaired by the consultant lead. We reviewed the minutes of the meetings held in February, March and April 2018. The agenda included a review of audits in progress. Actions arising from the meeting were assigned to identified staff members and were reviewed and progressed at the next meeting. • Monthly governance meetings for major trauma were attended by the department’s clinical lead consultant for major trauma. Each patient death was subject to medical review. To support governance for major trauma, the trauma lead also attended quarterly governance meetings of the local trauma network attended by medical lead from each local hospital. • Regular staff meetings were held which supported governance arrangements for the emergency department. Emergency department consultants’ meetings were held regularly to support clinical governance. We reviewed the minutes of the meetings held in December 2017, March 2018 and April 2018. We also reviewed notes and action points arising from meetings attended by other groups of staff including care practitioners, sisters and administrative staff in the emergency department.
Management of risk, issues and performance • At our previous inspection we issued a requirement notice for the trust to ensure divisional risk registers reflected issues in the emergency department and demonstrated evidence of actions and reviews. At this inspection we found that new risks were added monthly to the risk register. Risks scoring three and below were managed locally within the department. Risks scoring four and above were recorded in the incident management system. Risk assessment was undertaken to confirm the level of risk and to identify actions to mitigate the risk. • The management of risk was part of ward to board governance processes. Risks were reviewed by the directorate governance team who decided whether risk validation group approval was required. High level risks were validated by the risk validation group. The risk validation group prepared a monthly report to the trust executive which highlighted key risks. Highest level risks were assigned to an executive director and included in a trust level risk assurance report. The patient safety and risk committee also received key risk reports. • We reviewed the risk register for the emergency department. The current risks rated at the extreme risk level were the major trauma centre requirement for consultant cover in the resuscitation area, and the management of severe sepsis and septic shock within the emergency department. Outcomes from audits were risk assessed and included in the risk register. Risks were reviewed according to the level of risk, with higher risks being reviewed more frequently. We saw evidence that the risks had been recently reviewed and escalated. However, one of the members of consultant staff we spoke said they were unaware of what was included in the emergency department risk register. Also, we did not see evidence that the trust board were appropriately sighted on the risks that were classed as ‘extreme’ by the emergency department. • Dashboard information was shared daily with the emergency department senior team, clinical operations and medical and nursing staff in the department. An integrated performance report was prepared weekly incorporating a quality dashboard and daily and weekly performance scorecard for the emergency department. We reviewed examples of
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the emergency department quality dashboard presented at governance meetings to support the review of incidents, complaints, trends and associated risks.
Managing information • Information was used to monitor and manage the operational performance of the department, and to measure improvement. Service performance measures were monitored and reported. • In October 2017 the emergency department had implemented the emergency care data set, the national data set for urgent and emergency care which replaced the previous commissioning data set for emergency departments. The emergency care data set supported electronic linking to triage and patient report forms. It also enabled the department to compare data more effectively with other emergency departments. • We found that staff had access to appropriate clinical and management guidance to support their work, accessed through the trust intranet. • The emergency department’s submission of data and notifications to external bodies was in place. We received assurance from senior managers as to the integrity of the emergency department’s data management systems compliance with data security standards. • Despite the electronic patient records we found that paper notes continued to be used in the department. The paper notes were scanned into the electronic data management system as the patient was discharged.
Engagement
Friends and Family test performance The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was generally better than the England average from March 2017 to December 2017. The trust slightly fell lower than the England average in January and February 2018. A&E Friends and Family Test Performance - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS England Friends and Family Test)
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• For the friends and family test, paper and electronic responses were available to patients. A monthly report of the friends and family test results included ‘soundbites’ from patients. The randomly selected sample of five we listened to was very positive. The weekly improvement meeting started with an analysis of the friends and family test results. The main themes identified were waiting times, communication and attitude of staff. • We did not observe signage or information displayed about the friends and family test or how to provide feedback about patient experience within several areas of the emergency department. When we asked staff about the friends and family feedback leaflets they didn’t seem to know much about how feedback was collected from patients and their families. There were no signs or leaflets left out for patients to complete. In the reception area a friends and family box was affixed to the wall but there were no friends and family cards for patients to complete. We asked a member of reception staff if they had any and they then put the cards on the counter for patients to complete. The department also received thank you cards and messages which staff were informed about when it was a personal compliment. Patient user groups included groups for patients with mental ill health. The patient experience committee reviewed feedback received, including the friends and family test results. The committee requested monthly exception reports where results were not as expected. Senior managers we spoke with informed us that the capture of patient feedback was an area for development. We were informed that recent staff survey results reflected an improved level of engagement with staff. Medical and nursing staff we spoke with told us that engagement with staff and feedback to staff following engagement had improved. Staff consultation took place through a variety of forums including a multidisciplinary improvement forum and new ideas were progressed through an improvement group. Survey monkeys were used to take particular ideas forward. For example, the recent move of the green steam to another area at weekends. A “You said we did” board was used to feed back the results of staff engagement. • We reviewed the acute and emergency medicine directorate staff engagement action plan as at 31 May 2018. Progress with actions which addressed issues identified from consultation and other sources were monitored. A member of staff was assigned for each action and a planned date for completion and a red-amber-green rating were assigned following review. • Surveys with staff included stress surveys, consultation about shift patterns and hours and staff engagement workshops. A fortnightly breakfast club format was used to support engagement with nursing staff. Learning and reflection and ‘moments of excellence’ were highlighted at daily handovers.
Learning, continuous improvement and innovation • The emergency department had implemented a range of innovative schemes which supported continuous improvement. A service improvement lead for acute and emergency medicine co-ordinated the programme of improvement through an improvement group. From October 2017 a perfect pathways meeting had been held fortnightly. An example of initiatives implemented from this included deploying a senior sister to operate between the emergency department and the acute medical unit to support patient flow. • Senior managers told us about the excellent emergency care workstream which had
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supported a range of improvements in emergency care pathways. A multidisciplinary improvement forum progressed new ideas and supported their implementation. For example, the recent move of the green steam to another area at weekends. • Supporting competency through training and development was a key focus for the department. The quality and emphasis placed on education and support for staff development was enhanced by members of staff with senior and leading roles remained clinically active. A nurse consultant lead was in place for education and training. Preceptorship supported new staff.
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Medical care (including older people’s care)
Facts and data about this service
Medical services at this trust are spread across six different care groups or business units: The Emergency care group includes diabetes and endocrinology, respiratory and gastroenterology services. Combined Community and Acute Care includes integrated geriatric and stroke medicine, therapeutics and palliative care. Head & Neck includes neurosciences incorporating the hyper- acute stroke unit. The Musculoskeletal care group incorporates pain services and rheumatology. Specialised Cancer, Medicine and Rehabilitation includes communicable diseases and specialised medicine, spinal injuries rehabilitation and specialised cancer services. South Yorkshire Regional Services includes cardiac and renal services. The care groups above also provide other non- medical services not listed here. Specialties based at NGH include - acute medicine, respiratory medicine, cardiology, diabetes and endocrinology, gastroenterology and renal services. The geriatric and stroke medicine directorate is mainly on the NGH site, although there are strong links with the neurology hyper-acute stroke service and the stroke unit based at the Royal Hallamshire Hospital. Northern General Hospital has 30 wards providing services across multiple specialities within medical care. The trust had 131,594 medical admissions from October 2016 and September 2017. Emergency admissions accounted for 39,600 (30%), 7,784 (5.9%) were elective, and the remaining 84,210 (63.9%) were day case. Admissions for the top three medical specialties were: • Gastroenterology: 25,856 • Clinical oncology 17,559 • Medical oncology: 12,176 (Source: Hospital Episode Statistics) Northern General Hospital was last inspected by CQC in December 2015. During this inspection we visited several medical wards including Firth 5 and 6, Chesterman 1 and 2, Robert Hadfield 1,2,3, and 4, Brearley 5,6, and 7, Cardiac Catheter Suite, Huntsman 1 and 5. We spoke with 17 patients and carers and more than 50 staff.
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Is the service safe?
Mandatory training
The service had systems and processes in place to ensure that staff could access mandatory training and staff we spoke with confirmed they had enough time to complete mandatory training.
Mandatory training completion was monitored centrally with any staff not on track being flagged to their line manager for individual follow-up. The trust provided of e-learning which supported staff in completing their training. Planning for training for staff was done throughout the year to encourage good compliance.
With reference to the tables below, we spoke with staff about the compliance rates with mandatory training shown regarding nursing staff. Although some mandatory training had not met the target for completion we saw evidence of plans to ensure 100% compliance.
Staff assured us that the compliance figures would improve as the year progressed as the staff who were still to do the training were booked in to complete it and so patient safety was not at risk.
Most of the staff we spoke with told us they were up to date with their mandatory training.
We saw evidence of a computer-based system called PALMS which alerted when their mandatory training was due. All the staff we spoke with told us they thought the alert system worked well.
We saw evidence that junior doctors were sent a weekly email reminder on a Friday which summarised the work rota for the forthcoming week and included the training schedule and relevant reminders for outstanding mandatory training.
Individual doctors could check their mandatory training schedule on PALMS.
Managers were copied into the reminder e mails to monitor mandatory training attendance rates for the staff they supervised.
Managers we spoke with told us until 2015 / 2016 dementia had been part of mandatory training. However, the Trust had needed to streamline mandatory training topics and it was no longer included.
The Nurse Directors had agreed dementia should be included in job specific essential training (JSET) and at the time of the inspection the Trust were evaluating different packages to deliver this.
Mandatory training completion rates The trust set a target of 90% for completion of mandatory training. The table below indicates the compliance with training as of April 17 to February 18 for nursing staff in medical care is shown below:
Northern General Hospital: Nursing and midwifery staff
Staff Eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Resuscitation: Paediatric Basic Life Support - Level 2b (1 Yearly) 40 41 99% 90% Yes 20171116 900885 Post-inspection Evidence appendix template v3 Page 75
Equality & Diversity: General Awareness - Level 1 (3 Yearly) 557 624 94% 90% Yes Fire Safety Training - Level 1b (2 Yearly) 5 6 90% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 456 517 90% 90% Yes Moving & Handling - Level 2b (1 Yearly) 366 402 90% 90% Yes Conflict Resolution - Level 1 (3 Yearly) 56 63 88% 90% No Moving & Handling - Level 2a (3 Yearly) 149 158 88% 90% No Information Governance - Level 1 (1 Yearly) 504 574 86% 90% No Infection Prevention and Control - Level 2 (1 Yearly) 475 566 86% 90% No Health, Safety & Welfare - Level 1 (3 Yearly) 525 598 86% 90% No Fire Safety Training - Level 1a (1 Yearly) 513 586 83% 90% No
Nursing and midwifery staff exceeded the trust target of 90% for five out of 11 mandatory training modules. The other six training areas were all above 83%.
Medical & dental staff Staff Eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Fire Safety Training - Level 1b (2 Yearly) 13 13 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 200 208 98% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 99 103 96% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 112 120 91% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 106 115 91% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 206 229 90% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 67 72 86% 90% No Information Governance - Level 1 (1 Yearly) 86 107 85% 90% No Fire Safety Training - Level 1a (1 Yearly) 97 108 82% 90% No Medical staff exceeded the trust target of 90% for six out of 11 mandatory training modules. The other five training areas were all above 82%.
Safeguarding
The trust had systems and processes in place to protect children and adults from neglect or abuse. Most staff we spoke with had undertaken safeguarding training to ensure that safeguarding
20171116 900885 Post-inspection Evidence appendix template v3 Page 76 was everyone’s business. The staff we spoke with who had not had safeguarding training told us they were booked in to receive it.
Staff we spoke with understood their responsibilities in identifying and reporting any safeguarding concerns. Staff we spoke with gave appropriate examples of when they had made safeguarding referrals.
Staff had access to safeguarding advice and support from link nurses on the ward, from the trust’s intranet, and the trust’s central safeguarding team. There was a policy addressing female genital mutilation with resources on the trust’s safeguarding patient’s intranet site. This supported staff to make appropriate reports and referrals and offer support.
We saw that the trust had policies for safeguarding adults and children. However, the children’s policy was out of date. However, the chief nurse was aware of the out of date policy and action was being taken to address this and ensure it was compliant with current national guidance.
Staff had access to safeguarding advice and support from link nurses on the ward, from the trust’s intranet, and the trust’s central safeguarding team.
In the last year, trust wide, medicine had made 156 adult safeguarding referrals and 54 child safeguarding referrals.
At the last inspection we found that staff compliance with safeguarding training did not meet the trust’s target. The tables below show that the position at this inspection was similar. However, the trust’s target of 90% compliance was almost achieved; the lowest being 80%.
Safeguarding training completion rates A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for nursing staff in medical care is shown below:
Northern General Hospital: Nursing and midwifery staff
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Safeguarding Children & Young People - Level 2 (3 Yearly) 350 385 88% 90% No Safeguarding Children & Young People - Level 3 (3 Yearly) 54 56 85% 90% No Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 347 397 84% 90% No Safeguarding Children & Young People - Level 1 (3 Yearly) 332 368 80% 90% No Nursing and midwifery staff did not exceed the trust target of 90% for any of the four safeguarding training modules.
Medical and dental staff Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Safeguarding Children & Young People - Level 1 (3 Yearly) 191 204 94% 90% Yes
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Safeguarding Children & Young People - Level 2 (3 Yearly) 39 41 90% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 193 212 85% 90% No Medical and dental staff exceeded the trust target of 90% for two of the three safeguarding training modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene
All the wards we visited were visibly clean and well maintained. Daily cleaning record checks were up to date.
Infection control audits were carried out once a month and covered the environment cleanliness, medical equipment, nursing staff and estates environment.
All ward audit results were submitted annually to accredit each ward. Results from the audits were submitted electronically to the central infection prevention control team and reports generated with action plans. The wards had a link nurse to assist staff in infection control. We saw audits for a selection of the wards we visited and all had achieved their target compliance score.
The IPC audit results for eight of the wards we visited showed all had been accredited within the last six months as having achieved the IPC audit targets.
Staff told us patients were subject to universal screening when they were admitted. They were swabbed for clostridium difficile toxin (C.diff), methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and methicillin susceptible staphylococcus aureus (MSSA). The results were returned within 48 hours.
In the period 1 June 2017 to 31 May 2018 the 14 wards we visited had between them; 32 cases of clostridium difficile toxin (C.diff), two cases of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia, six cases of (MRSA) non- bacteraemia and 20 cases of methicillin susceptible staphylococcus aureus (MSSA).
We reviewed the infection, prevention and control audits for 1 December 2017 to 15 June 2018 for the wards we visited. The audits included the following areas; aseptic technique, ward cleanliness, commode cleanliness including sear raiser, dress code, hand hygiene, handling and disposal of linen, peripheral intravenous cannula insertion, urinary catheter and cleaning and decontamination of equipment. All the wards achieved the audit target.
Hand washing facilities were available throughout the wards and we observed hand gel dispensers at the entrance to each ward, each bay and side room.
We observed staff complying with bare below the elbows policy, correct hand washing technique and use of hand gels in most areas we visited.
During the last inspection some staff were observed not always washing or gelling their hands when they should. During this inspection while visiting AMU ward Firth 5 a health care assistant was observed not using gloves or washing their hands in between patient contact. Two junior doctors were observed not to wash their hands or use hand gel before or after patient contact. A
20171116 900885 Post-inspection Evidence appendix template v3 Page 78 nurse and a consultant on the same ward were observed to wash their hands in between patient contacts.
If patients were flagged as an infection risk on the patient record system a barrier nurse was allocated to care for the patient. There were eight isolation rooms available within the hospital if required for infectious patients. If the patient was identified as requiring negative pressure, rooms were available at the Royal Hallamshire Hospital.
Negative room pressure is an isolation technique used in hospitals and medical centres to prevent cross-contaminations from room to room. It includes a ventilation system that generates negative pressure to allow air to flow into the isolation room but not escape from the room, as air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air from escaping the room. This technique is used to isolate patients with airborne contagious diseases.
Each ward we visited had an infection, prevention and control link nurse who could provide advice and assist in the audit process.
During the last inspection some domestic staff were observed on Hadfield 1 cleaning bed spaces and sinks in several bays without changing gloves or cloths between areas. During this inspection domestics on Hadfield 2 and 3 and Brealey 5 were observed changing aprons, gloves and cloths and disposing of them while cleaning bed spaces and sinks.
Staff we spoke with could explain the importance of use of personal protective equipment (PPE) and correct disposal of waste. Staff were observed using PPE including face protection.
Appropriate containers for segregating and disposing of clinical were available and in use across all the wards we visited. We observed that used linen, PPE and waste was disposed of correctly.
We saw sharps were disposed of safely and correctly on the wards we visited.
Patients we spoke with told us that the wards were clean and hygiene standards of the staff were good. They commented that they saw domestics wearing appropriate PPE when cleaning.
Environment and equipment
All the wards we visited were visibly clean and well maintained.
During the inspection AMU wards Firth 5 and Firth 6 were visited. Firth 6 was undergoing building work so the doors to the ward which were usually on a door release lock system were open when we visited.
The resuscitation trolleys were checked; all the equipment including oxygen and suction was checked and found to be in date and in order. There was evidence of the checks being recorded on an audit sheet for each trolley.
Staff we spoke with told us resuscitation trolleys were checked every 24 hours and after use and any used or out of dates items replaced.
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The resuscitation defibrillator on each ward had recently been updated and the device automatically tested itself when switched on.
Other equipment such as commodes, hoists and mobile computers were visibly clean and labelled ready for use.
Electrical equipment which we saw that required portable appliance testing (PAT) were in date at the time of the inspection.
We found there were some dementia friendly clocks on the wards, however there was an absence of appropriate signage and colour contrast on the ward environments.
We observed that patients who were living with dementia were supported by one to one nursing and cohorted to enhance their safe care.
The ward managers and the Dementia lead told us that the trust was aware of which wards were dementia compliant and which were not and had an action plan to bring the non-compliant wards into compliance.
Assessing and responding to patient risk
Staff used a series of tools and meetings to support them in assessing and responding to patient risk.
Staff used an adapted version of the national early warning score called the Sheffield hospitals early warning score (SHEWS) to assess the clinical condition of patients. This assessment tool enabled staff to identify if a patient’s clinical condition was changing for the worse and whether escalation and intervention was required to keep the patient safe.
The trust sepsis pathway complied with NICE guidelines. There was a link nurse for sepsis. The sepsis pathway was embedded in medicine care and staff used stickers to identify sepsis risks.
We saw notes of staff handovers and saw that staff at all levels and grades took part fully in handovers of patient care from one shift to the next. We saw staff used a situation, background, action and result (SBAR) framework to transfer patients between teams. This appeared to work well.
Following the handover from night to morning staff the ward took part in a safety huddle at which key messages and learning were delivered in addition to discussing the potential falls risks and pressure ulcer risks of individual patients. Further, patient assurance on safety was enhanced by use of the electronic whiteboard at the nurses’ station. With patient consent, this displayed names of patients with icons showing which patients were at a risk of falls or needed pressure ulcer care.
Regarding pressure ulcer care, the trust had a tissue viability team who led on a specific programme of work to address pressure ulcers. There were also pressure ulcer champions identified on each ward to link with the team. Staff told us they used nursing care turn sheets, notes outside doors showing time for turning, and a once weekly multi-disciplinary team meeting to review patients at risk.
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We reviewed five sets of records and found there was sufficient and regular information recorded for staff to assess patients’ conditions. Records reviewed showed that patients were risk assessed on admission to the ward; these assessments included falls, nutrition, hydration, pressure ulcers and dementia. Charts were completed to inform staff if any further intervention was necessary. Staff told us that completion of charts was audited weekly and fed back to staff individually or at the safety huddle.
The proportion of patients who received a venous thromboembolism (VTE) risk assessment was above the national target of 95%.
Medical outliers were managed using a “Take list” from Lorenzo. This was a real time automatically updated and accurate source of patient information which was added afterward rounds or safety huddles. This had been in operation for the last six months. The patient information meant that there was clarity always as to where patients were and who was responsible for them. The information could be scanned at ward level, so staff had the whole picture. This had been in operation since January 2018.
Doctors were observed printing off lists of patients who they were responsible for, so they could ensure any patient handover information or actions agreed at the safety huddles were not missed.
Nurse staffing
The trust used a nationally recognised safer nursing tool and professional judgement, together with an electronic rostering system, to plan staffing levels based on patient needs. This was used alongside a daily staffing meeting where gaps in staffing were reviewed and filled where possible. Staff reported that this system worked well and kept patients safe.
A review of the staffing on the wards we visited showed that between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on nightshift was below 75% on Robert Hadfield 3 and 4, and Brearley 6. Also, between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on dayshift was below 75% on Brearley 5 and 6. Following the inspection the trust told us that the data for the Frailty unit (Huntsman 1) had been inputted incorrectly and the fill rate should be 85% for RN nights. No evidence was provided as part of factual accuracy to corroborate this.
The trust`s Monthly Staffing Report for March 2018 was reviewed. It was noted that four of the wards we visited had been flagged and identified as having a variance of greater than 15% against either their day or night staffing for registered nurses / midwives or care staff during January 2018.
The variance only applied to the average fill rate for registered nurses as the average fill rate for care staff was within the 15% variance. The board had been provided with reassurance as to the steps being taken to address the problem which included use of bank and agency staff, monitoring and management of sickness through HR and the recruitment of 8.0 WTE.
During inspection we reviewed the staffing on Ward Brealey 4, where non-invasive ventilation (NIV) patients are nursed. The British Thoracic Society recommended enhanced staffing levels of one nurse to two NIV patients.
Staffing and patient numbers on Brearley 4 at midnight on each day between April and June 2018 were reviewed. On 15 days there were no NIV patients on the ward; on the other 76 days the staff to NIV patient ratio exceeded the recommendations of the British Thoracic Society. This meant
20171116 900885 Post-inspection Evidence appendix template v3 Page 81 that the staffing to patient ratio was better than what was recommended by the British Thoracic Society. On this ward the steps taken to improve the staffing levels had worked.
Staff we spoke with told us if there were any staffing concerns they would be managed through the daily Trust wide nurse staffing meeting and through the nurse staffing escalation policy.
Matrons were available for staff to escalate staffing issues to and out of hours a duty matron held a bleep, so they could be contacted for this purpose. We saw evidence of a clear policy of escalation to follow. The trust’s executive group received a monthly safer staffing report and all staffing levels were reviewed on a rolling six-month basis.
At the last inspection we noted issues with nurse staffing in terms of lack of registered nurses, staff feeling stretched and unable to take breaks. At this inspection staff reported that nurse staffing was much better than the last time we inspected. On all wards we visited actual staffing numbers matched planned staffing. Staff spoken with did not report any issues with staffing cover and confirmed that they were able to take breaks.
Staff and Ward managers on the wards we visited that were carrying nursing vacancies told us about recent recruitment activity that had succeeded in securing new starters. Staff spoke positively about this.
The trust reported the following nurse staffing numbers for medical care in March and December 2017. The service had fill rates of over 90% in both time periods.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 1,495.4 1,629.4 91.8% 1,547.6 1,710.2 90.5%
(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
Vacancy rates From January to December 2017 the trust reported a vacancy rate of 9.5% for nursing staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017, the trust reported a turnover rate of 7.95% for nursing staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017 the trust reported a sickness rate of 4.2% for nursing staff in medical care which is slightly higher than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage From January to December 2017, the trust reported 41,414 shifts of the requested shifts were filled by bank and agency staff (63%). This meant that 37% remained unfilled. A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 35,475 (54%) 20171116 900885 Post-inspection Evidence appendix template v3 Page 82
Agency 5,939 (9%) Not filled 24,740 (37%) (Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
Medical staffing The trust reported the following medical & dental staffing numbers for medical care services in March and December 2017. The service had fill rates of over 90% in both time periods.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 679.3 691.0 98.3% 706.6 693.7 101.9% (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
Vacancy rates From January to December 2017 the trust reported a vacancy rate of 1.4% for medical and dental staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017, the trust reported a turnover rate of 26.3% for medical and dental staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017 the trust reported a sickness rate of 1.2% for medical and dental staff in medical care which is lower than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Medical agency and locum staff usage From January to December 2017, the trust reported that 9,503 of the shifts requested were filled by bank and agency staff (96%). A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 5,042 (51%) Agency 4,461 (45%) Not filled 441 (4%) (Source: Routine Provider Information Request (RPIR) P21 Medical Locum
Staffing skill mix In December 2017, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) was lower.
Staffing skill mix for the 497 whole time equivalent staff working in medicine at Sheffield Teaching Hospitals NHS Foundation Trust This England Trust average Consultant 45% 42% Middle career^ 3% 7% Registrar group~ 33% 29% Junior* 19% 22%
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^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (Star) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital - Workforce statistics (01/10/2017 - 31/10/2017)
All medical staff we spoke with reported good access to senior opinions and they felt confident to ask for help and advice. Junior doctors on the wards we spoke with described good support from consultants and middle grade doctors.
The medical staff we spoke with told us that the medical staffing cover on the wards was sufficient to meet the needs of the patients as follows; the staffing on Brearley Ward 5 was two registrars per ward which had 28 beds. Three junior doctors per day would cover the ward with one doctor who was on the General Practice Vocational Training Scheme, one doctor who was doing Core Medical Training, one doctor in the second foundation year post qualification F2 and one doctor in the first year post qualification F1.
The consultants on Brealey 5 Ward were linked with Firth 2 Ward Vascular Surgery and Firth 3 General Surgery.
The ward cover was on site from 9am-5pm weekdays. After 5pm the cover was on call with the hospital nightshift team.
The Acute Medicine Consultant rota cover was 8am-6.30pm with a second consultant working 3pm-10pm and then being on call from home overnight.
On Saturday and Sunday consultant cover is from 8am – 5pm then covering on call from home.
Junior Doctor cover on MAU was 8am-8pm and 8pm-8am on a rota basis.
Handovers occurred at 8.15am on AMU and midday or sometimes 11am on the other wards. This process was supported by a 2pm ward safety huddle meeting.
A midday handover was observed on Brealey 5. The handover was consultant led. Present were junior doctors, senior nurses and the discharge coordinator. Each patient was discussed and a care plan agreed. All the information was recorded on the electronic patient white board and in the patients’ notes.
Handovers on the Medical Assessment Unit (MAU) occurred at 8.15am each day including Saturdays and Sundays. A safety huddle took place at 2pm to coincide with doctors starting their shift.
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Records
During the last inspection gaps had been identified in patient records regarding a nutritional assessment not being recorded and incomplete documentation of care plans / care needs in the records checked. At this inspection the five patient records that were reviewed had nutritional assessment and care plan / care needs recorded. All were legible, detailed, signed, and safely stored in locked trolleys and could only be opened using a key code.
During the last inspection there were concerns about the availably and accessibility of patient care plans. During this inspection the patient records we reviewed all had care plans. Staff we spoke with told us patient care plans were accessible and kept with the patients’ notes.
We saw evidence of care planning on the IT system, with consideration regarding communication for patients with a learning disability documented but no specific section for learning disabilities.
The patient records we reviewed showed screening was recorded, and assessments were completed, such as for falls or nutrition, and fluid charts for patients were up to date and patient’s fluids were replenished on a regular basis. All rounding information was captured on the records we saw.
Information relating to patient discharge was printed off in hard copy for the patient to keep while the electronic version of the discharge summary was accessible by community staff and GPs.
Medicines
The trust had an up to date medicines management policy which staff had access to on the trust’s intranet.
During the last inspection there were a small number of records where the antibiotic review or stop date was not recorded. During this inspection five records were checked; all recorded antibiotic review or stop date.
At the last inspection the doors to medicine rooms on the frailty unit, Huntsman 2, Brearley 1, and Brearley 5 were unlocked meaning that access to fluids was not restricted to authorised staff.
During this inspection we checked the storage of medicines, fluids and gases on the wards we visited and found that medicines, fluids and gases were stored securely in appropriately locked rooms and fridges were checked and stocks were in date.
We observed drugs trolleys used on the wards we visited we locked when not in use.
The storage and administration of controlled drugs, which require specific controls, was checked in all clinical areas. We found controlled drugs were appropriately stored with access restricted to authorised staff. Records showed the administration of controlled drugs were subject to a second check. After administration, the stock balance was confirmed to be correct and the balance recorded.
The drugs fridges were locked and there was a process in place to record daily fridge temperatures. All fridge temperatures were checked and recorded daily we saw evidence of this. There was evidence the fridge temperature audits were carried regularly. There were no gaps in
20171116 900885 Post-inspection Evidence appendix template v3 Page 85 recording. Staff we spoke with understood their responsibilities for raising concerns if the fridge temperature went out of range.
Patient records which were reviewed showed patients were receiving medicines promptly and any allergies were clearly recorded. We saw that oxygen was prescribed and logged correctly.
The trust’s clinical pharmacy team provided support around medicines reconciliation, checking of patients' own medication for continued use, prescription validation, discharge planning, counselling, assessment and provision of compliance aids, medicines information and participated in multidisciplinary ward rounds.
The trust ran a series of annual medicine audits including on medicine reconciliation, turnaround times for take home medicines, and safe and secure storage of medicines. For instance, the controlled drug audit showed that 97% of clinical areas completed a controlled drug checklist every three months. Another audit showed that 95% of areas with proximity card readers locked intravenous fluids away when not in use.
Incidents
The trust had a clear policy for the reporting of incidents, near misses and adverse events. Staff were encouraged to report incidents using the trust’s electronic reporting system. The staff we spoke with could describe the process of incident reporting and understood their responsibilities to report safety incidents including near misses.
There were no never events reported at Northern General Hospital over the last year.
The service held bimonthly morbidity and mortality meetings. The lead for patients with a learning disability told us every death of a patient with learning disability went through a medical examiner within the trust to identify any trends and cause of death. The information from the meeting was used at the weekly Junior Doctors weekly teaching sessions held 12.30pm to 1.30pm every Tuesday.
We reviewed two root cause analysis reports (RCA) from serious incidents and found actions plans and lessons learnt were identified. Actions included providing feedback to staff.
The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.
Staff we spoke with understood the importance of being open and honest with patients. E-learning training was available to staff about duty of candour and there was information on the trust’s intranet which staff could access. The trust’s incident reporting system had mandatory fields to complete and if duty of candour applied a lead was assigned to ensure all requirements were met which included the need to be open and honest with patients, relatives and carers if they had made a mistake or a patient had suffered harm. This process was overseen by the trust’s patient safety and risk committee. Trust wide in the last year medicine had applied the duty of candour 61 times.
Falls incidents were investigated by senior nursing staff and were presented during a falls meeting to look at the root causes and identify areas for learning which could be shared with all staff.
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Patients at risk of falls were discussed during handovers and during safety huddle meetings. We observed performance information in relation to falls reduction displayed on notices boards in the wards we visited.
Never Events Never Events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each Never Event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a Never Event.
From May 2017 to April 2018, the trust reported no incidents classified as never events for medicine. (Source: NHS Improvement - STEIS (01/05/2017 – 30/04/2018)
During the inspection staff on the Cardiac Catheter Suite told us of a never event which had occurred after the reporting period May 2017 to April 2018. They explained fully what had occurred, what investigation had been carried out and what remedial action had been undertaken including applying the duty of candour principles with the patient who staff had met with on three occasions.
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from May 2017 to April 2018.
These incidents were classified as; • Medication incident meeting SI criteria with one (50% of total incidents). • Treatment delay meeting SI criteria with one (50% of total incidents). (Source: Strategic Executive Information System (STEIS))
The trust had a process for approving serious incidents which met the criteria to ensure that only incidents that were serious incidents were logged as such. In March 2018, 66% of incidents were approved within 35 days, which was below the trust’s internal target of 95%. The trust had plans in place to improve the turnaround times for approval of incidents. For instance, in March 2018 two new safety and risk committees were created to support a more focussed discussion on key issues, including meeting the 35-day target. This was in addition to the supply of monthly performance reports to support the medicine directorates in monitoring their own performance and developing improvement plans.
All lessons learned from serious incidents were presented to the trust’s safety and risk committee.
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Safety thermometer
The Safety Thermometer is a national tool used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month, a suggested date for data collection is given but wards could change this.
Data from the Patient Safety Thermometer showed that the trust reported 174 new pressure ulcers, 21 falls with harm and 25 new urinary tract infections in patients with a catheter from April 2017 to April 2018 for medical services.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total Pressure ulcers (174)
2 Total Falls (21)
3 Total CUTIs (25)
1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only Source: Safety thermometer - Safety Thermometer
During the last inspection some wards had displayed their safety thermometer information for patients and visitors to see, but some did not.
Staff told us that while the safety thermometer was used the results were not displayed to the public to see. The matron validated the results and undertook a detailed analysis of any concerns so that lessons could be shared and learning embedded.
For example, the safety thermometer dashboard for ward Brearley 2, within the respiratory medicine speciality, showed that since May 2017 there had been: one fall with harm in November
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2017, two catheter related urinary tract infections, one in June 2017 the other in May 2018 and three pressure ulcers, two in March and one in May 2018.
The trust created a safety thermometer newsletter that summarised the results for each care group in an easy to use format. The trust was looking at automating the data collection process.
Major incident awareness and training
The trust had recently taken part in a table top exercise to test their business continuity plan and capacity following a mass casualty scenario. The exercise had been debriefed and improvements to the individual role action cards carried out as they had been considered too complex.
The Trust was going to take part in another multi-agency exercise in the autumn to further test their ability to deal with mass casualties.
The trust had set up an Ebola Service and Viral Haemorrhagic Fever category 4 facility. The trust was prepared to respond as surge capacity space. This meant the Trust had the capacity to treat patients who were admitted with a category 4 infection if there had been a sudden increase in admissions across the country. The work was led by a consultant who was a member of a national emergency planning committee for category 4 infection. A category 4 infection causes severe human disease and may be a serious hazard to employees; it is likely to be spread to the community, and there is no effective prophylaxis or treatment available, for example, Rabies and Ebola Virus.
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Is the service effective?
Evidence-based care and treatment
We saw evidence the service had systems and processes in place to monitor patient outcomes including, service evaluations, and participation in local and national audits, all with a view to providing effective patient outcomes.
During the inspection we saw evidence clinicians used a Friday Ward Round and Weekend Plan to assess patients and review their care. The form was used on the medical wards during the Friday ward rounds was used to identify patients that would be in hospital over the weekend.
The forms identified patient risk, their diagnoses, SHEWS and escalation plan. The form was coloured green, so the form would be visible in the patients notes.
The trust had systems and processes in place to ensure that care was given according to published national guidance such as that issued by National Institute for Health and Care Excellence (NICE). All staff we spoke with told us they could access guidelines, policies and procedures relevant to their role on the trust`s intranet site.
We saw evidence the Trust had a corporate policy which detailed the procedure for implementing NICE guidance. Staff were alerted to changes to guidelines by the trust’s clinical effectiveness unit who contacted the appropriate clinicians to examine if any changes were required. An audit information management system tracked implementation and guidance. If a change was required, the directorate concerned would submit an implementation plan which would then be monitored until completion.
During inspection we reviewed some trust guidelines on the intranet and saw the accompanying policies and guidelines were in date.
We saw evidence the Trust had a clinical guideline document for the management of sepsis. Staff we spoke with told us the guidelines were aimed to improve outcomes for patients presenting with sepsis or developing sepsis by providing evidence-based recommendations for practice. It was intended for the use of both medical and nursing staff. The document had a review date of August 2019.
We saw evidence the vascular service ran an audit on Hickman line infections. At the point of inspection, they were auditing whether a cover over the line when showering patients reduced the incidence of infections.
Some nursing staff we spoke to were unsure about when a patient may require a capacity assessment they told us medical staff carried out all capacity assessments and nurses completed deprivation of liberty safeguard applications which were faxed or emailed them to the legal department.
On inspection, the trust provided us with a list of patients deprived of their liberty. In nine patient records, over four different wards, we saw the completed deprivation of liberty safeguards application however, there were only two of the nine patient records that contained a completed mental capacity assessment. In three records, we saw evidence in the progress notes that an assessment of capacity had been completed however; this was not documented on the mental capacity assessment form.
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On one ward, nursing staff had shown us that a deprivation of liberty safeguards application had been completed by nursing staff for a patient and given to the ward sister in handover. No capacity assessment had been undertaken. On another ward, two further patients were identified by the nursing staff as being deprived of their liberty, as they wanted to leave the ward and were unable to, however no application had been made. The ward sister and matron confirmed this had not been completed due to lack of qualified nurses to complete the relevant paperwork.
We saw no evidence of any best interest decision making in any of the nine patient records.
During the inspection, we visited four different wards to look at the patient records of those who had been identified as having a learning disability. In the four patient files, we saw no capacity assessments or best interest decision making.
On one ward, a patient had been sectioned under the Mental Health Act the day before our visit. The nursing staff had followed the detention under the Mental Health Act action card and the ward matron explained she had contacted medical records for the relevant detention document pack, which contained all relevant forms, and leaflets including advocacy and a patient information leaflet explained patient rights. The patient had responded to the nurse that they wanted to appeal against their section and requested an independent mental health advocate, but the nurse was unable to identify to us how they would escalate this should the patient have to remain on the medical ward.
Nutrition and hydration
We saw evidence on the wards we visited of use of a hydration and nutrition assurance toolkit to help staff assess and audit how their ward was performing in relation to patient nutrition and hydration. The trust ran an annual nutrition and hydration awareness week to advertise good practice in patient care.
Staff we spoke with told us patients had a nutrition and hydration assessment completed on admission which was recorded in their admission record which also included risk factors.
We saw evidence staff used a malnutrition universal scoring tool (MUST) when a patient was admitted. The results had been recorded in the patient records we reviewed.
Any patients at risk of malnutrition were given food supplements.
We spoke to five patients all of whom told us there was a wide choice of food and they always had enough to eat and drink. Food options available including special diets such as gluten free, diabetic and soft diets.
Food was also available to meet patients cultural and religious beliefs. Relatives were allowed to bring in their own food for patients to eat.
Staff on the wards we visited told us they had access to a dietician for specialist advice.
We saw drinks were available within reach of the patients on the wards we visited, and staff assisted patients to eat if required.
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We saw the social eating project was championed on wards specialising in the care of older people at the Northern General Hospital. The staff encouraged patients to eat together and socialise in a dining room area rather than eating alone. Staff told us the project was already showing many benefits to the patients taking part, both mentally and physically.
Pain relief
Staff we spoke with told us patients had a pain assessment done which was recorded in their admission record. We saw evidence of this in the patient records we reviewed.
We observed staff during the two-hourly comfort round asking patients about their level of pain and if they felt they need additional relief.
Patients we spoke with told us they received pain medication when they needed it.
Staff told us they had access to specialist pain advice from the trusts pain team, palliative care team or the MacMillan team if they felt a patient’s pain medication was not being effective.
We saw evidence in the patients notes that as part of the SHEWS observation chart and intentional rounding (a structured approach whereby nurses conduct checks on patients at set times to assess and manage their fundamental care needs), staff regularly asked patients about their pain levels and recorded the scores.
There were charts with pictorial representations of pain which staff used for patients with learning disabilities or communication difficulties to indicate their levels of pain.
Staff told us they would also use other indications of a patient being in pain such as a raised heart rate, raised blood pressure, change in mood, not moving or displaying obvious signs of discomfort when moving.
Patient outcomes
Relative risk of readmission From January 2017 to December 2017, patients at Northern General Hospital had a higher than expected risk of readmission for elective admissions and a higher than expected risk of readmission for non-elective admissions when compared to the England average.
Patients in gastroenterology and cardiology had a lower than expected risk of readmission for elective admissions.
Patients in nephrology had a higher than expected risk of readmission for elective admissions.
Patients in respiratory and geriatric medicine had a higher than expected risk of readmission for non-elective admissions.
Patients in general medicine had a lower than expected risk of readmission for non-elective admissions.
Elective Re-Admissions - Northern General Hospital
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Note: Ratio of observed to expected elective readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
Non-Elective Admissions - Northern General Hospital
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
Heart Failure Audit
In-hospital Care Scores Results for Northern General Hospital in the 2015 Heart Failure Audit were higher than the England and Wales average for two of the four of the standards relating to in-hospital care, Cardiology in patient was more than two times lower than the England average;
17.2% Cardiology inpatient (%) 45.7%
Input from consultant cardiologist 57.8% (%) 56.9% Northern General Hospital England and Wales 90.9% Input from specialist (%) 79.0%
99.0% Received echo (%) 90.1%
Discharge Scores Results for Northern General Hospital were worse than the England and Wales average for eight out of nine standards relating to discharge:
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ACEI on discharge (%) 49.9% 61.1% ACEI/ ARB on discharge (%) 58.6% 73.7% Beta blocker on discharge (%) 67.9% 80.4% MRA on discharge (%) 43.7% 45.4% Received discharge planning (%) 94.0% 87.3% Referral to HF nurse follow up (%) 30.6% 54.8% Referral to HF nurse follow up (LVSD only) 33.3% 70.8% Referral to cardiology follow-up) 15.4% 47.2% Referral to cardiac rehabilitation (%) 1.9% 12.1% Northern General Hospital England and Wales
(Source: NICOR - Heart Failure Audit (01/04/2014 - 31/03/2015))
National Diabetes Inpatient Audit The National Diabetes Inpatient Audit (NaDIA) measures the quality of diabetes care provided to people with diabetes while they are admitted to hospital whatever the cause and aims to support quality improvement.
The audit attributes a quartile to each metric which represents how each value compares to the England distribution for that audit year; quartile 1 means that the result is in the lowest 25 per cent, whereas quartile 4 means that the result is in the highest 25 per cent for that audit year.
The 2016 National Diabetes Inpatient Audit identified 207 in patients with diabetes at Northern General Hospital, 82.9% of which reported that they were satisfied or very satisfied with the overall care of their diabetes while in hospital, which places this site in quartile one. The trust’s performance was lower than the England average of 83.6% by 0.7%. (Source: NHS Digital)
Lung Cancer Audit 2017 The trust participated in the 2017 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 54%, which did not meet the audit minimum standard of 90%. The 2015 figure was 80%.
The proportion of patients with histologically confirmed Non-Small Cell Lung Cancer (NSCLC) receiving surgery was 26.2%; this is not significantly different from the national level. The 2015 figure was 0%.
The proportion of fit patients with advanced (NSCLC) receiving chemotherapy was 58%; this is not significantly different from the national level. The 2015 figure was 0%.
The proportion of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy was 85%; this is significantly better than the national level. The 2015 figure was 0%.
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The one-year relative survival rate for the trust in 2016 was 41.1%; this is not significantly different from the national level. (Source: National Lung Cancer Audit)
The National Lung Cancer Audit looks at the care delivered during referral, diagnosis, treatment and outcomes for people diagnosed with lung cancer and mesothelioma. The audit aims to measure: the number of lung cancer cases within the UK; the range of treatments used; regional variations in treatments; variations in outcomes.
We asked the trust why the proportion of patients seen by a Cancer Nurse Specialist was 54% and what they were doing to achieve the 90% target. The trust told us that, lung cancer nurse specialists were reporting that they see the majority of patients with a diagnosis of lung cancer at the pre-diagnosis stage. But this data is not captured by the audit. The trust told us they would be changing their recording process and so the measure will improve going forward.
National Audit of Inpatient Falls 2017 In the 2017 audit, the crude proportion of patients who had a vision assessment (if applicable) was 7%. This did not meet the national aspirational standard of 100%. The crude proportion of patients who had a lying and standing blood pressure assessment (if applicable) was 13%. This did not meet the national aspirational standard of 100%. The crude proportion of patients assessed for the presence or absence of delirium (if applicable) was 31%. This did not meet the national aspirational standard of 100%. The crude proportion of patients with a call bell in reach (if applicable) was 47%. This did not meet the national aspirational standard of 100%. (Source: Royal College of Physicians)
The trust accepted that the audits showed that more work needed to be done to improve falls prevention within the trust.
The Trust had carried out an Inpatient Falls Audit November 2017.
The aims of the audit were to; improve inpatient falls prevention through audit and quality improvement and identify changes achieved locally since 2015.
The objectives of the audit were to measure compliance against NICE clinical guidance in respect of falls in older people, assessing risk and prevention and other relevant guidance of delirium, injury prevention, and medication optimisation.
The audit identified seven areas that needed to be improved in falls prevention in the Trust. The results were discussed at the Strategic Falls Group and a 15-point action plan developed.
During the inspection the action plan was reviewed, and seven actions were seen to be completed. The outstanding actions had timescales for completion. Competent staff
Appraisal rates This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
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From April to December 2017, 84% of staff within medical care had received an appraisal, compared to the trust’s target of 90%.
A split by staff group can be seen in the graph below:
Appraisals Eligible Appraisal Target met Staff group completed staff rate (Yes/no) NHS infrastructure support 39 33 85% No Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T) 337 296 88% No Qualified Allied Health Professionals (Qualified AHPs) 198 186 94% Yes Qualified nursing & health visiting staff (Qualified nurses) 908 741 82% No Support to doctors and nursing staff 973 799 82% No Support to ST&T staff 104 84 81% No Qualified Healthcare Scientists 38 33 87% No Medical & Dental staff - Hospital 6 5 83% No (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
Although the appraisal rate was below the trust`s 90% target the rate across staff groups was above 80%. Staff we spoke with confirmed that there was a system in place to ensure staff received an annual appraisal. Most of the staff we spoke with told us they had received an appraisal in the last 12 months.
Senior staff told us they received reports from human resources and could track individuals to ensure the appraisal was booked and done. Senior staff told us staff who had not yet had an appraisal were booked to receive one. We saw evidence of this on the trusts intranet system.
The trust ensured that staff were competent in their roles by ensuring staff received an annual appraisal, or through sharing information, by email, at team meetings, in a newsletter, and by offering staff additional training.
Senior staff told us they received reports from human resources and could track individuals to ensure the appraisal was booked and done. Staff who had not yet done an appraisal were booked to receive one.
We saw evidence of regional teaching for registrars which occurred monthly and was protected time for them to attend. The attendance rate was 70%
We observed teaching and learning taking place during ward rounds. Junior doctors confirmed this occurred on a regular basis.
The nursing and therapy staff on the Frailty Unit were working towards a new healthcare professional role where they would share a core range of skills through training, in partnership with Sheffield Hallam University, and competency-based development which would enable them to facilitate the effective assessment, treatment and flow of patients through the unit.
New staff were inducted and trained by the trust. For example, in one speciality we spoke with staff confirmed that they had received a three-day local induction followed by a six-month preceptorship and then a period of two weeks after that not being counted in staff numbers.
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For students, staff told us there was a clear training pathway and students who had trained on the wards reported a positive experience.
All wards visited had link nurses for various areas including infection control, safeguarding, learning disability and dementia to support staff in maintaining competence in these areas.
Some services had developed teams of nurses who could validate the safety thermometer data to ensure that the data submitted was robust.
Many services had trained care support workers to extend their skills in say, cannulation. The endoscopy service was training nurse endoscopists using a health education England programme.
The services visited had access to practice development nurses who helped oversee a rolling programme of additional competency training, in areas covering intravenous drug administration, veno-puncture, catheterisation, administration of stem cells and electrocardiography recording. The course consisted of a structured theory section followed by a practical assessment.
Consultants were trained in delivering bad news and had job specific end of life training.
Staff in the vascular speciality were encouraged and supported to do the pulmonary association medical education programme. Staff told us three quarters of the staff complement had done the course.
Multidisciplinary working
To ensure effective services were delivered to patients, we saw different teams and health professionals working with staff at the service.
The Frailty Unit was staffed by an integrated team of medical staff, nurses, therapists, Advanced Clinical Practitioners (ACP), assistant practitioners (trainees), clinical support workers and administration staff who worked together to provide patient care.
We could see from a handover sheet we examined from night to morning staff there was open, structured, and detailed communication between staff of different grades and roles.
The service had a trust nutrition steering group to provide strategic direction around nutrition and hydration for patients. This was made up of a multi-disciplinary staff group such as a pharmacist, dietitian, caterers, speech and language therapists and gastroenterologists.
We observed ward rounds attended by members of the MDT. For patients with a learning disability, links were made with the Sheffield Health and Social Care Learning Disability team where appropriate. The Transfer of Care team took the lead on discharging patients with complex needs and work closely with the Sheffield Continuing Health Care team and the Local Authority regarding discharge planning back to their place of residence.
Many of the services drew patients in from out of the immediate area and where this had occurred we saw evidence the consultants shared information in relation to the patient with the consultant from the referring hospital which would be followed by a multi-disciplinary team meeting to discuss the patients’ clinical needs and discharge.
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We saw evidence of weekly MDT meetings on the wards attended by doctors, occupational therapists, physiotherapists, dietitians and speech and language therapists and staff from the patient care team who specialised in complex discharges.
The Trust had representation on several groups and forums which supported the care of people with a learning disability, for example;
• Learning Disability Partnership Board • Hospital Passport Review • Mental Health and Learning Disability Delivery Board • Involvement with multi-service reviews.
The Trust were involved in Active Recovery which was a citywide inter-disciplinary service that operated between 8am until 2am 365 days a year, with the option of 24hr wrap-around care being provided for limited periods of time.
All referrals to the service were received through a Single point of Access (SPA). This responsive service was based at the NGH; however, it was a Community service and the patients were treated in their own homes.
The Core business of Active Recovery was; • To avoid unnecessary hospital admission. • Facilitate earlier discharge from hospital. • Prevent avoidable admission to long term care. • Provide time limited recovery and support in a patient’s own home.
We saw evidence the Trust used discharge to assess and complex discharge to assess which was a process which enabled clinically complex patients to transfer home safely from hospital, in a timely and efficient manner. This involved an Active Recovery generic assessor performing an assessment of a person’s clinical need and functional ability on the day of discharge in their usual home environment. The trust reported it had been identified that a number of patients spent longer in hospital once they were medically fit for discharge (MFFD) whilst waiting for a decision about their discharge route. Generally, those patients’ medical/clinical needs or social circumstances were more complex or uncertain, making a decision about the discharge route harder. During this time staff told us the patients could decondition increasing the likelihood of them being discharged to a residential or nursing care bed.
Managers we spoke with told us Discharge to Assess was a concept that had given the service the ability to offer timely patient centred specialist assessment in the correct environment maximising the opportunity to return home with the knowledge that concerns and doubts would be assessed appropriately and managed according to need. Managers told us the aim was to reduce complexity and uncertainty which were two factors that could lead to stresses in the acute environment.
Active Recovery also assisted in the rapid implementation of clinically appropriate support, equipment, assistive technology and referral on to other experts if required i.e. SALT, Mental Health Services and social care if needed.
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Managers we spoke with told us the programme also provided time limited support to enable the patient to return to their previous functional ability or maximise their potential through re-ablement, in their own home.
Many of the identified patients were frail and had dementia or delirium. Active Recovery used recognised tools to inform their assessment or to refer them on for mental health support. There were Occupational Therapists with mental health expertise within Active Recovery and specialist Community Mental Health Teams including the Dementia Rapid Response team which could be accessed if required.
The patient’s own GP would be informed of the outcome of the assessment and included in the plan of care.
The Trust also had access to intermediate Care (IC) beds. The beds were located across the city and offered rehabilitation for patients where it was agreed that the patient was not ready to go home but would benefit from further rehabilitation beds delivered multidisciplinary rehabilitation including input from Geriatricians, GPs, therapists, nursing staff and mental health.
Seven-day services
All medical specialties at Sheffield Teaching Hospitals Foundation Trust (STHFT) had a 24-hour, 7 day a week emergency service. There were separate specialities for geriatric and stroke medicine, diabetes and endocrinology, gastroenterology, respiratory medicine, acute medicine, neurology, haematology, infectious diseases and acutely unwell patients were admitted under the appropriate speciality team.
The front door response team and discharge teams provided seven-day cover to AMU and the medical wards.
There was seven-day therapy and pharmacy provision for the AMU and frailty admission unit.
Medical patients had access to seven-day diagnostic and imaging tests.
A dispensing service was available 24/7: the dispensary was open 8am - 8pm Monday to Friday and 9am - 5pm weekends and Bank Holidays with a resident pharmacist onsite outside these hours, providing advice with medicines information as well. Aseptic services were available 9am - 5pm Monday to Friday and 9am - 4pm weekends and Bank Holidays. Clinical services were available 9am - 5.30pm Monday to Friday to all areas.
Access to information
During the last inspection there had been some issues with the new electronic patient record system, which was exacerbated by administrator vacancies in some areas. The patient record system did not connect to the electronic whiteboard system, which meant that information needed to be specially uploaded or input on to a second system. During this inspection we observed the electronic whiteboard system on all the wards we visited was working without any problems.
Medical and Nursing staff we spoke with told us they felt the electronic patient record system worked well and gave them easy access to patient information.
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Health promotion
The trust had link workers who provided advice for dementia and end of life patients and their families or carers.
There was an alcohol liaison nurse who supported patients who were alcohol dependant with personal advice or information leaflets.
There was advice displayed in the wards in relation to smoking cessation.
In order to address the cause of pressure ulcers and to encourage better patient mental health the wards we visited adopted a pyjama paralysis programme which involved encouraging patients to get out of bed, get washed and dressed.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Mental Capacity Act and Deprivation of Liberty training completion Data relating to mental capacity is included in the safeguarding adults level 2 training section. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Staff we spoke with demonstrated an awareness and understanding of consent, the Mental Capacity Act, Deprivation of Liberty Standards(DoLS), dementia and care of patients with learning disabilities.
Staff could explain how to gain both written and verbal consent from patients and their representatives including the additional steps to take if the patient did not consent to treatment.
Two Deprivation of Liberty Standards applications for patients on Ward Brearley 5 were reviewed and the dates for standard authorisation or urgent extensions were absent. This was immediately pointed out to the matron, so this could be rectified.
Patients we spoke with told us doctors and nurses always explained what they wished to do, confirmed understanding and asked their permission before undertaking personal care or treatment.
Staff we spoke with told us they received training in the Mental Capacity Act and Deprivation of Liberty Standards(DoLS) as part of the safeguarding adults level 2 training.
Staff we spoke with told us there were clear protocols for sedation of patients and this was covered in the SHEWS assessment.
The Trust had an up to date sedation policy which set standards for Sheffield Teaching Hospitals Foundation Trust for safe use of sedation as a means of facilitating medical procedures and to act as an aid to clinicians involved in providing treatment or investigation to patients in which sedation is used.
The Mental Health liaison team were on duty 8pm- 12 midnight to provide advice and support for staff who spoke positively about the service. Staff told us the Crisis Team had a more limited response time.
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Is the service caring?
Compassionate care
During the inspection we spoke with 17 patients and five relatives.
We observed staff on all the wards we visited treating patients with kindness and respect.
During the inspection all the staff we spoke with could explain how personal, cultural, social and religious needs of people were taken account of during their care.
Staff explained during the patient booking in process any personal, cultural, social and religious needs were recorded on the patient record form. This information was also shared with other staff during shift change overs and during safety huddles.
Staff told us they would always speak with family members to confirm the information provided by the patient or to add information which may have been missed.
Five sets of patient notes were reviewed all contained relevant personal information which had been taken account of in the patients care.
We saw evidence that there was a wide range of food available for patients to take account of dietary needs either religious, cultural, medical or through personal choice. Staff told us relatives were encouraged to bring food in for their relatives.
Any food brought in by relatives was stored in a fridge, labelled and dated when brought in to prevent it going to the wrong patient or being kept too long and going out of date.
There was evidence individual dietary information was displayed on a white board behind the patient’s bed and ward collective patient dietary information was displayed on a white board in the kitchen for domestic staff to read.
We observed a caring and inclusive manner displayed by doctors during two ward rounds. Patient privacy and dignity was maintained by doctors and nurses closing curtains and doors to side rooms.
Patients and relatives told us doctors and nurses introduced themselves by name and answered any question they had about their care. This was observed during the ward rounds we saw.
We observed staff interacting with patients who had dementia in an understanding non- judgemental way. Two staff were observed holding a patient one each side helping them to exercise on the ward by walking up and down a corridor. The two staff offered encouragement and praise. Another member of staff was observed walking a patient back from the toilet. The patient was concerned and anxious about conversations they could over hear. The member of staff explained in calm way that what was being talked about was not in relation to them and this calmed them down.
A patient on Brearley 5 told us they “loved every minute” of being in the hospital and enjoyed interacting with the staff who were kind, giving them confidence to walk around.
The relatives of a patient living with dementia on Brearley 5 said that staff were kind and caring and they felt involved and well-informed about their relative’s care.
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One patient on AMU told us they had communication difficulties and staff were understanding and explained everything slowly and clearly, so they could understand.
We saw evidence patients were encouraged to be independent. Hadfield 5 ward displayed posters and had leaflets called “End PJ Paralysis” which encouraged staff to help patients get dressed and out of bed.
We observed staff carrying out regular comfort rounds where patients were asked about their comfort and if they were in pain. Staff told us they aimed to carry out the comfort rounds every two hours. We saw comfort rounds were recorded in the patient notes we reviewed.
Other needs such as providing drinks, helping a patient to the toilet or adjusting their position in bed were also observed.
Staff told us taking account of patient needs was not limited to the comfort rounds and all staff including support workers and domestics also listened to what patients told them and reported it to nursing staff. While visiting Brearley 5 a support worker was observed informing a nurse an elderly patient they had been speaking to had told them they were in pain. The nurse immediately attended to the patient.
The inpatient score for friends and family in March 2018 was 97% which was above the trust’s internal target of 95%.
As part of the trust’s electronic clinical assurance toolkit there was a section on privacy and dignity which was monitored by the matron to ensure it had been completed.
Friends and Family test performance The Friends and Family Test response rate for medicine at the trust was 31% which was better than the England average of 25% from April 2017 and March 2018. All three sites also achieved a better response rate than the England average.
Friends and family Test – Response rate between 01/04/2017 to 31/03/2018 by site.
(Source: NHS England Friends and Family Test)
Emotional support
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Staff we spoke with understood the impact a person’s care, treatment and condition could have on the wellbeing of the patient and those close to them. Staff told us about local support services which were available for patients, relatives and carers which included an organisation providing alternative therapies such as massage and raki and several cancer support organisations which provided a wide range services including counselling and a solicitor service free of charge.
Staff told us that if there were to be a discussion about private matters such as a prognosis which potentially could upset patients or relatives side rooms would be used to maintain privacy.
Staff we spoke with told us a care worker had sat for four hours with an end of life patient who was distressed while a family member travelled to the hospital to be with them.
There was evidence of clinical nurse specialists available to provide patients and relatives with a range of services and support including cancer care, tissue viability, learning disability and infection, prevention and control issues.
The hospital had a multi faith chaplaincy service available for patients and relatives.
We saw evidence in the patients notes we reviewed on the wards we visited of patients physical and psychological needs being regularly assessed and addressed.
There was evidence in the patients notes we reviewed and through speaking to patients, relatives and staff, that patients had their level of pain regularly assessed and were subject to a malnutrition universal screening tool assessment(MUST) when they were booked on to the ward.
Personal patient needs including hydration, personal hygiene and anxiety were addressed during the booking in process, during the comfort rounds by all staff and by doctors during ward rounds.
Understanding and involvement of patients and those close to them
All the patients and relatives we spoke with told us they had been kept well informed and had been involved in decisions about patient care.
Visiting times were flexible so that relatives could support their loved ones. The service sometimes funded carers to enable the carers to be with the patient 24/7.
Patients told us staff communicated with them in a way that they could understand and any questions they had were answered. Additional Information was made available to them including advocacy services and support within the community when discharged.
Staff we spoke with told us of the various methods used to communicate with patients who could not speak or when English was not their first language.
Staff told us they would give patients note pads and a pen to write down their responses to questions or make requests. Staff could access language line which provided translation services either over the phone or face to face.
Staff told us of patient who had throat surgery and could not speak so they obtained a throat microphone for them to use to communicate.
Staff used charts with pictures on for patients to indicate levels of pain.
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We were told of a dying patient who wished to return to their country of birth to die. Family members had been interpreting and were opposed to the patient’s wishes. Staff were concerned that what they were being told by the relatives was not what the patient was saying. Staff had an interpreter attend and speak to the patient in private and face to face. The wishes of the patient were confirmed, and they did go back to their country of birth to die.
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Is the service responsive?
Service delivery to meet the needs of local people
The trust had systems and processes in place to ensure that the needs of local people were considered when planning the service delivery.
The trust had created an operational plan for 2018/19. This was developed in partnership with the two commissioners the trust worked with. The operational plan required the specialities to create an activity plan, productivity and efficiency plans together with an annual business plan. The plans had been signed off by the local leadership team and monitored by the trust’s programme management office and business planning team.
Staff told us that there were a number of service improvement projects across the trust to focus on patient pathways such as the "Why not home? Why not today?" programme. For example, the trust was trialling a single point of access team for discharges and a transfer of care team. At the point of our inspection, the results were being evaluated.
A new Frailty Assessment Unit with 28 beds and two ambulatory areas with capacity for 12 patients opened in December 2017. This was a dedicated unit that had expertise to assess frail elderly patients and transfer them into the most appropriate setting to meet their needs. There was a dedicated Frailty Unit consultant who was driving innovations in front door assessment processes, including rapid multidisciplinary outpatient reviews and chair-based assessment areas to deliver comprehensive geriatric assessment and enable same day discharge.
Furthermore, we saw the consultant input had increased so that there were two consultants on the unit each day, including weekends, with a total of 14 hours consultant time a day every weekend.
The Geriatricians on the Frailty Unit were available to provide specialist advice to GPs considering potential admissions through the Single Point of Access. The quality impact was that the patients’ needs were known before they arrived, and the relevant tests/ interventions could be planned.
The Frailty Unit had increased the number of patients with 0+1 day length of stay discharged direct from the unit from 16.5% to 22.0%.
The average length of stay in Geriatrics had reduced from 14 days to 12.4 days.
The Geriatric Wards worked collaboratively with Primary Care and the Virtual Ward pilot to flag patients on discharge who would benefit from support at home to reduce the risk of re-admission. It was also supporting the development of the ‘OK to Stay’ care plan roll out to reach all geriatric medicine patients with one or more readmissions.
The partnership between geriatrics and surgery had enabled elderly patients to be assessed and discharged home faster. It has resulted in a reduction in length of stay by 2.5 days on average and a significant increase in the proportion of patients returning to their usual place of residence, up to 92% from 72%.
There was a dedicated pleural procedure room adjacent to the acute respiratory ward, ensuring timely access for patients to pleural interventions which was supported by appropriately trained staff.
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Nursing staff on the wards we spoke with were aware of the psychiatric liaison team and how to obtain out of hours support. Medical records we reviewed held detention document packs, which contained all relevant forms and leaflets and were available 24 hours a day, seven days a week for staff to access.
Average length of stay From February 2017 to January 2018 the average length of stay for medical elective patients at Northern General Hospital was 9.9 days, which is higher than England average of 5.8 days. For medical non-elective patients, the average length of stay was 7.5 days, which is higher than England average of 6.4 days. Average length of stay for elective specialties: • Average length of stay for elective patients in cardiology is higher than the England average. • Average length of stay for elective patients in nephrology and spinal injuries are lower than the England average.
Average length of stay for non-elective specialties: • Average length of stay for non-elective patients in general medicine is lower than the England average. • Average length of stay for non-elective patients in respiratory and geriatric medicine are higher than the England average.
Elective Average Length of Stay - Northern General Hospital
Note: Top three specialties for specific trust based on count of activity.
Non-Elective Average Length of Stay - Northern General Hospital
Note: Top three specialties for specific site based on count of activity. (Source: Hospital Episode Statistics)
Meeting people’s individual needs
We saw evidence of an early patient streaming system for acute admissions. The system was in place to route patients to the specialist service they required quickly. The specialisms were; Diabetes, Respiratory, Gastroenterology, Frailty and Acute Medicine. There was also Cardiology, 20171116 900885 Post-inspection Evidence appendix template v3 Page 106
Renal and Neurology on call as the numbers of patients requiring those specialities were lower than the others. The streaming system was in place seven days a week, 24 hours per day.
The Acute Respiratory team accepting patients from the streaming system had a consultant on duty 8am-2pm and another working 2pm-7pm.
The Acute Diabetic team which accepted patients from the streaming system had six endocrinologists and 9-10 diabetic consultants working on a 1:9 consultant to patient ratio. Consultant cover was provided between 8am-6pm.
We spoke with the clinical lead for patients with learning difficulties they told us patients with learning difficulties were usually on the Sheffield Case Register which enabled information to be transferred to a flagging system on Lorenzo when they were booked to attend a hospital appointment.
However, approximately 20% of people with learning difficulties were not on the Sheffield Case Register because they did not access care services or did not want to be on the register. That category of patient or those living outside the Sheffield area had their needs identified by hospital staff on admission.
The trust has an algorithm for staff to follow which helped identify patients with learning difficulties when they are admitted if they were not on the Sheffield case register. Once the patient was identified as having learning difficulties hospital staff would ask about needs/adjustments or consult families where possible to confirm them.
All patients had an individualised care plan and on admission nurses were prompted by the electronic care plan to ask the person/carer/relative whether they had a ‘hospital passport’ or any individualised communication tool. This was used to enhance individualised care. Hospital Passports were an initiative developed by national MENCAP and endorsed by organisations represented on the Learning Disability Partnership Board. Reasonable adjustments were also made where necessary to ensure that care was individualised e.g. longer outpatient appointments, funding and supporting carers.
In relation to patients with dementia each patient had an individualised medical and nursing plan which included common issues which affected older people and those with impaired cognition including mobility, continence, delirium assessment and falls management.
A review of the Dementia Assessment and Referral data collection, England - Quarter 4 2017-18 covering January to March showed the number of patients who had a diagnostic assessment was1028, the number of positive cases was1028, which meant 100% of the patients identified that required a diagnostic assessment received one.
The nursing plans were electronic and used activity focused care plans to model of nursing care. This model of nursing care was based on activities of daily living and aimed to maximise independence. Since development of the model there had been greater emphasis on dementia and delirium in acute hospitals and the Trust had therefore added a specific section on cognition.
Staff told us the aim of the MDT management was to maximise an individual’s ability to live as independently as possible and live how they choose. There was evidence in patient notes of subsequent discharge planning and care support identified on an individual patient basis.
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On the wards we saw use a patient passport (All About Me) to enhance patient centred care. This was completed by carers or the patient and was similar to ‘This is me’. Whilst this was available to be used and received good feedback the Trust were encouraging more use of the passport.
The 2016 National Audit for Dementia showed that nationally 48% of patients used this booklet. The most recent audit data from the Northern General Hospital showed the use was currently 40%. The Trust were continuing to promote this on the wards we visited with the staff.
If the patient’s attendance at hospital was for an elective procedure or an arranged visit they would bring with them their learning difficulties passport. It was flagged on the booking in system if a patient had a passport.
The clinical lead for patients with learning difficulties gave us examples where the trust had met individual patient needs.
A patient with learning difficulties and challenging behaviour did not want to sit in the hospital waiting room and was worried about appointment being late. The patient was allowed to wait in the garden until their appointment was due. They attended the appointment on time.
Another patient did not like being in hospitals and it was identified that if they were delayed even for a short time they would ask to leave. A few days before the patient appointment was due staff did a “dry run” with the patients’ carers from the hospital entrance, through the corridor and into the room where the patient would be treated so they knew exactly the route to prevent delays. The patient attended the appointment without any problems.
The clinical lead for patients with learning difficulties told us the trust had funded patient’s individual carers 24/7 whilst in hospital, purchased an inflatable cot bed and trialled lanyards so carers were identifiable to staff.
We saw evidence the accessible information standard in relation to the communication needs of patients was addressed during the booking in process and the information was recorded on Lorenzo which is the electronic patient record system.
The Trust reduced the amputation rate in people with diabetes by introducing a “Foot hot line” which took direct referrals from GPs and District Nurses, linking them directly to a Diabetes Consultant and providing patient assessment within 24hrs.
The Trust used the Sheffield retinal screening register to flag up admitted patients with diabetes which ensured that all patients with Type 1 diabetes were visited by the inpatient diabetes team. Blood glucose monitoring results could be viewed remotely, and staff were able to identify patients with hypoglycaemia and visit them on the ward without waiting for a referral.
The transition service for adolescents with diabetes had been revised after taking user feedback and now takes place in a purpose-built environment at the Northern General Hospital.
Access and flow
Referral to treatment (percentage within 18 weeks) - admitted performance
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From April 2017 to March 2018 the trusts referral to treatment time was similar to the England average. In the latest month November 2017, the trust’s performance showed 91% of patients were treated within 18 weeks compared to the England average of 88%.
The trend over time remained consistent.
(Source: NHS England)
Referral to treatment (percentage within 18 weeks) – by specialty
Four specialties were above the England average for admitted RTT (percentage within 18 weeks):
Specialty grouping Result England average Geriatric Medicine 100% 97.5% Rheumatology 97.9% 94.1% Thoracic Medicine 99.8% 93.1% (Source: NHS England)
Staff we spoke with told us Acute and Emergency Medicine had used winter funding to support an Emergency Department Streaming sister role. This role had reduced the time patients spent in the Emergency Department, had increased the use of the ambulatory seating in the Medical Assessment Centre (MAC) and had reduced the length of stay for these patients to a mean of 0.3 days. 61% of patients were being discharged directly from the MAC.
Further work was planned to develop the Streaming sister role into a permanent position. A similar approach had been adopted by the recently opened Sheffield Frailty Unit (SFU). SFU nursing teams maintained an overview of patients in the Emergency Department that required an SFU admission and where suitable, admitted the patients into the seated SFU assessment area rather than to a bed with a view to keeping the patients mobile and ultimately securing a same day or at least more rapid discharge.
Consultants and junior staff we spoke with who were covering Brearley 5 as well as Firth 2 and 3 dialled into the daily bed meetings to highlight any medical outliers on Firth 2 and 3. This provided clarity as to who was responsible for the outliers.
The number of patient night move per ward in the last year were as follows; • Firth 5 and 6 Amu 782 • Chesterman 1 Cardiology 376 • Chesterman 2 Day Ward 469 • Robert Hadfield 1Diabetes and Endocrinology 399 • Robert Hadfield 2 Diabetes and Endocrinology 324
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• Robert Hadfield 3 Gastroenterology 477 • Robert Hadfield 4 Gastroenterology 431 • Brearley 5 Geriatric Medicine 69 • Brearley 6 Geriatric Medicine 112 • Brearley 7 Geriatric Medicine 40 • Robert Hadfield 5 Geriatric Medicine 118 • Cardiac Catheter Suite Interventional Cardiology 77 • Brearley 4 Respiratory 245 • Huntsman 1 Frailty Unit 51 • Huntsman 5 Winter Surge 338
In terms of bed management, staff told us bed moves at night were very rare and if they took place it would be for a clinical reason, for example, because an emergency scan was needed. This was supported by the figures that the trust had supplied which showed for the last year Robert Hadfield 2 had two each month and Robert Hadfield 3 had three each month. Across medicine, in the period February 2018 to May 2018, 70% of medicine patients were not moved at all.
Over the last year, of the wards we visited, the wards for stroke and geriatric medicine had the highest percentage of delayed discharges of care compared to the whole patient cohort.
The number of discharged patients compared to the number of delayed discharges between February and May 2018 for the wards we visited showed the following;
• Chesterman 1- 3.8% • Robert Hadfield 1- 19.3% • Robert Hadfield 2-17% • Robert Hadfield 3 – 10% • Robert Hadfield 4- 7.5% • Robert Hadfield 5- 47% • Brearley 4- 11% • Brearley 5 – 44% • Brearley 6- 41% • Brearley 7- 41% • Huntsmen 5- 32%
The trust reported a delayed transfer of care (DTOC) rate of 5.8% which was higher than the national average of 4.2% and higher than the trust’s target rate of 3.5%. DTOC rates had been reducing between August and December 2017, however the trust had experienced increasing rates during January to March 2018 due to a challenging winter period with pressures in intermediate care, community services and limited availability of social care packages in the area (Source NHSI). The trust was actively monitoring DTOCs and reported them to its commissioners. The trust was involved in a cross-Sheffield health and social care task group which was looking to improve discharges. The trust told us it had adopted various methods to support responsive discharges. For example, the trust told us it was hoped that the roll out of electronic prescribing would streamline the requesting of “to take out” medicines which staff reported was a cause of delayed discharges.
Various specialist teams existed to support ward staff with discharges, such as the transfer of care team or the care home placement team. There were also services, such as the active recovery service which operated a discharge to assess model. This was supported by the single point of access which allowed access to information systems by social care and mental health services. 20171116 900885 Post-inspection Evidence appendix template v3 Page 110
Patient moves per admission During the last 12 months – During the previous 12 YR 1 months – YR2 (01/02/2017 to 31/01/2018) (01/02/2016 to 31/01/2017) Location site How How name Number many many (state the site of ward Number were %-share Number were %-share where the ward or moves of at of all of at of all unit is located) patients 'end patients patients 'end patients of of life'* life'* Sheffield Teaching 0 183,823 74% 178,145 74% Hospitals NHS 1 33,612 14% 33,570 14% Trust 2 19,035 8% 18,922 8% 3 6,908 3% 6,732 3%
4+ 3,972 2% 3,782 2%
Total 247,350 100% 241,151 100%
The trust reported that from February 2017 to January 2018, 98% of patients had appropriate ward moves and the remaining 2% were outlier ward stays (4+ moves). The previous year’s performance was the same. (Source: Trust Routine Provider Information Request (RPIR) P53 – Ward Moves)
Learning from complaints and concerns
Summary of complaints From January to December 2017 there were 225 complaints about medical care. The trust took an average of 27 working days to complete complaints. This was in line with their policy. The trust worked to a tiered response time process where the timescale was determined based on the complexity of the concerns raised. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints with in the agreed timescale.
The trust supplied us with data about the complaints received about the services; our analysis did not identify any specific themes or trends. The trust told us that complaints received were categorised on the trust’s complaints management system, to help the trust identify themes. The themes were monitored with an analysis featured in monthly, quarterly and annual patient experience reports. The main themes from the complaints were: • 56% of complaints relate to Northern General Hospital • 49% of complaints relate to inpatient services • 58% of complaints relate to medical staff • March 2017 and January 2018 had the highest number of complaints received both with 26. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
The service had a system in place to encourage complaints and compliments with a view to improving its service to patients.
Staff told us they would seek to resolve a concern informally, but complaints were dealt with formally if necessary. The governance arrangements in place ensured that lessons from
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The service advertised by notices displayed within the services how to complain and signposted patients or their carers or relatives to the trust’s help and advice service, for support in making a complaint.
The trust supplied us with data about the complaints received about the services, but we could not identify any themes or trends.
We discussed complaints with staff. All response times for complaints were met with support from the trust’s patient partnership team. Trust wide 92% of complaints met the agreed response timeframe.
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Is the service well-led?
Leadership
Medical services at this trust were spread across six different care groups or business units: The Emergency care group included diabetes and endocrinology, respiratory and gastroenterology services. Combined Community and Acute Care included integrated geriatric and stroke medicine, therapeutics and palliative care. Head & Neck includes neurosciences incorporating the hyper- acute stroke unit. The Musculoskeletal care group incorporated pain services and rheumatology. Specialised Cancer, Medicine and Rehabilitation included communicable diseases and specialised medicine, spinal injuries rehabilitation and specialised cancer services. South Yorkshire Regional Services included cardiac and renal services.
During inspection it was clear the leaders at Clinical Director, Operations Director and Nurse Director level had the skills, knowledge, experience and integrity to perform the role.
The executive director was responsible for the mental health strategy and the development of clear, measurable health outcomes.
There was evidence the Trust had a mental health strategy, which was under review during the inspection. The reviewing multidisciplinary team included the trust, clinical commissioning group, liaison psychiatry, police and other interested parties such as training, Mental Capacity Act and Mental Health Act lead, learning disabilities lead and department of psychological services.
At ward level there was clear leadership of the services.
The trust had a leadership offer that included access to accredited courses in leadership and access to coaching.
The team met regularly with the chief nurse, medical director, and deputy chief executive and through them had ready and easy access to the trust’s board.
Staff told us the team were approachable and visible and the team told us that they met regularly in different forums to discuss quality, finances and governance.
The leadership team derived support from a matron and band seven senior sisters at ward level with whom they met regularly.
Staff we spoke with described the leaders as visible and approachable as well as being supportive if staff wanted to try something new to improve the service.
Consultants on the care of the elderly wards were described as; approachable, supportive and very easy to get hold of for advice. Junior doctors on medical wards described their experience as “very positive”.
Leaders at all levels understood and could articulate the challenges the trust and their directorates faced in relation to quality and sustainability.
Vision and strategy
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There was a strategic business plan in place for all medical services.
The vision used by the service was the trust’s vision was to be recognised as the best provider of health care, clinical research and education in the UK and a strong contributor to the aspiration of Sheffield to be a vibrant and healthy city region. It was supported by the ‘PROUD’ values, (patients first, respectful, ownership, unity, and deliver).
Each directorate had a strategy and business plan which set out in detail how the directorate intended to contribute towards the trust’s vision and strategy.
Culture
All the staff we spoke with told us they were proud to work for the trust. They felt supported by their managers who were visible.
Staff told us there was good teamworking and they would be happy for friends or family to receive care in the trust.
Staff felt confident to report and concerns they had about patient safety and managers would take appropriate action.
There was evidence in staff appraisals and from what staff told us that learning and development was supported by managers.
In the 2017 staff survey 94% of all staff said they would recommend for family and friends to receive treatment at the trust.
Governance
The service had a clear governance framework with staff assigned specific roles that ensured quality performance and risks were known about and managed.
Staff told us each directorate had a quarterly clinical governance meeting. This was followed by a monthly directorate executive group meeting. We saw minutes for these meetings from a sample of specialities including: gastroenterology/hepatology; diabetes/endocrinology; respiratory; and integrated geriatric and stroke medicine. For the clinical governance meetings, the trust had introduced a standard template which looked at the five domains used by CQC and some of the services were starting to use this. On clinical governance meetings standing agenda items included: matters arising; safe, which looked at learning from a variety of sources such as incidents, serious incidents, claims, mortality and morbidity, medicines management; caring, which looked at things such as learning from friends and family; effectiveness, which looked at, for example, audits and NICE guidelines; responsiveness, which looked at such things as business continuity; and well-led, looking at for instance, the risk register and governance. The business meetings standard agenda items included: looking at delivering the best clinical outcomes, which looked at mandatory training, infection control, the risk register, complaints and incidents; providing patient centred services, which looked at the performance dashboard, staffing, and business cases; spending public money wisely, which looked at finance; employing caring and cared for staff, which looked at recruitment; and any other business 20171116 900885 Post-inspection Evidence appendix template v3 Page 114
Senior matrons met as a group and discussed governance issues including learning from incidents or complaints and staffing issues together with issues cascaded to them from the leadership team.
All staff in a leadership role also had access to directorate dashboards looking at performance, finance, governance and staff engagement.
Management of risk, issues and performance
The leadership team received information to support them in managing risk, identifying issues, and assessing performance.
We spoke with the leadership team about how they measured quality and performance. The team had access to various sources of information, such as dashboards (which captured a series of indicators ranging from infection rates, to waiting times, to staff metrics and patient experience), safety thermometer data, or complaints data.
This information was examined, discussed and action taken through the clinical governance meetings noted above. The leadership team also oversaw a structured annual programme of work supported by the trust which rolled on year to year. This was designed to engage with clinicians to identify workstreams and opportunities to improve quality. Once a workstream was agreed they were clinically led and supported by matrons, and finance and project managers.
We also discussed with the leadership team for each directorate the risk register. Risk registers were maintained at directorate level, with a brief description of the risk, control measures, an owner, risk level and a review date. For instance, Cardiothoracic speciality had five extreme, two high, eight moderate and four low. Diabetes and endocrinology had one extreme, and seven high. Emergency medicine had two high and three moderate. Gastroenterology/hepatology had one extreme, one high and four moderate. Integrated geriatric stroke medicine had one extreme, eight high, eight moderate, and 19 low. Respiratory medicine had two extreme, four high, and five moderate. One of the top risks was staffing. To address this the team said the trust was trying to recruit from overseas, and directorates were holding recruitment events. Some services were recruiting to administrative support to free up nurses to do nursing. The team explained this was a national issue and not just an issue that affected the specialist services. Another risk concerned the ageing estate. The team explained that this risk had been addressed through trust investment in refurbishing the ward environment. Another risk was the roll out of electronic prescribing. This had thrown up unforeseen information technology issues. Action taken included ensuring software experts were on hand to support wards with the roll out.
There was oversight of risks through committees such as: the elective care working group (ECWG), the waiting times performance overview group (WTPOG) and patient safety and risk committee. However, it was not clear from the minutes we reviewed how the leadership team escalated the risks marked as ‘extreme’ to the trust board. Managers we spoke with told us they felt the following were the top risks in the trust;
o Nurse staffing which is a recognised national issue. o Electronic prescribing. The trust is a pilot site and the first to introduce electronic prescribing on Lorenzo. There have been IT problems which were unforeseen and have delayed progress. The AMU is going live early next year.
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o Patient flow in elderly care. o Winter pressures particularly in respiratory medicine. o Shortage of consultant staffing in Accident and Emergency and the knock-on effects upon patient flow elsewhere in the hospital. o Increased pressures from the South Yorkshire bowel cancer screening programme due to a lack of staff trained to do the screening which was affecting the ability to hit performance targets.
The risks the managers discussed were on the trust risk register.
The trust had recently taken part in a table top exercise to test their business continuity plan and capacity following a mass casualty scenario. The exercise had been debriefed and improvements to the individual role action cards carried out as they had been considered too complex.
The Trust are going to take part in another multi-agency exercise in the autumn to further test their ability to deal with mass casualties.
Information management
From speaking with staff and reviewing information supplied in electronic format it was clear staff at all levels could access information in a digital format which could be interpreted and rapidly used to help improve the service.
The leadership team told us that they received information in electronic format and they found the information robust. For instance, the directorate received monthly performance reports to assist them in monitoring their performance and developing plans to improve. The team described how they could drill down through the data to fine tune it to site level and tumour site. Data was used to support the service’s plans.
To enhance the use and deployment of data, working jointly with the cancer alliance, the service had managed to recruit a data analyst who was able to draw data from multiple sources and run reports required by the service.
The trust told us its integrated performance report was assessed for data quality using a nationally recognised tool and a range of dashboards had been created to support directorates.
Engagement
Staff described feeling engaged with the services’ leads. They gave examples of how the services engaged with the public with a view to ensuring their views were used to help to shape the service.
Some services used an annual timeout for all medical staff at which staff could network and discuss ideas for improvement
On a weekly or monthly basis, there was a series of meetings to engage with staff, such as local service improvement meetings, senior sister meetings, and technology strategy group meetings. Staff meetings tended to take place every two weeks.
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According to the 2017 staff survey, trust wide the overall staff engagement score had increased from 3.82 in 2016 to 3.83 in 2017. The number of staff recommending the trust as a place to work was 68% and 81% as a place for care.
We learnt from staff that a new shift pattern was being trialled following a short survey of staff. We were told about this as an example of how staff were engaged.
All areas we visited had a dedicated staff area with noticeboards and a place for staff to go to have a break. We saw that bulletins were on the noticeboards along with other relevant staff messages.
A lot of close working took place with the local hospital charity with regular on-site meetings at which patient satisfaction was discussed.
The service had trialled a social media feed and this had proved popular and so there were plans to build a website for patients to use.
The trust run a series of annual themed surveys such as the carers survey which was running until July 2018. From responses to date there were 98% of carers stated that they ‘definitely’ or ‘to some extent’, had confidence and trust in the staff caring for the person they supported.
Patients or the public were engaged through ‘tell us what you think’ leaflets, online through the trust’s website, the friends and family test, and surveys, such as the carer’s survey. It was because of the carers’ survey that more flexible access to wards was brought in. The trust told us patients were closely consulted during the ward rebuild at the site.
The transition service for adolescents with diabetes had been revised after user feedback and now took place in a purpose-built environment at the Northern General Hospital.
Learning, continuous improvement and innovation
Prior to the inspection, and while on inspection, the specialities shared with us the following examples of learning, continuous improvement and innovation:
Managers we spoke told us they were involved in an accountable care partnership in Sheffield called “Why not home, why not today?”. The project was to work with partners to discharge patients quicker and provide more care at home. The trust recognised last year there were 12 different discharge routes they had reviewed this and reduced the discharge routes to three.
The trust was involved in a project which involved patients swallowing a capsule which contained a miniature camera which sent images of the stomach back to a screen which doctors can view.
The Neuroendocrine tumour service was awarded European Centre of Excellence status for its neuroendocrine tumour (NET) service.
Research findings led by the Trust across eight diabetes centres in England and Scotland had highlighted that education was key to the management of type 1 diabetes. The trust was named as a finalist in the BMJ’s 2018 ‘UK Research Paper of the Year’ award.
The diabetes team had continued to successfully secure major grants for key research in the field, including the award of a £3m National Institute for Health Research Health Technology
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Assessment (HTA) to study the effectiveness of pain control drugs in patients with chronic pain caused by diabetes. The grant award was one of the biggest ever given to a Trust research team.
The Trust are involved in an initiative with partners called the Big Room. The initiative had a track record of cross organisation innovation to improve care for older people and was the area from which Discharge to Assess was developed.
Currently, city wide staff from a wide variety of Sheffield’s teams which were involved in the care of older people were meeting in the Frailty Big Room. They had recently successfully designed a new discharge process for patients at risk of entering a care home, while in development it has been called ‘Complex Discharge to Assess’. The pilot had delivered an improved experience for 48 patients, 36 of whom had been able to stay in their own home. For the other 12 there was wide agreement that timely holistic assessment at home was the best way to decide if they needed to enter a care home.
Senior health and social care leaders had indicated they were so impressed by the outcomes that the new process would be incorporated into the city’s ‘Home to Assess’ pathway.
The Frailty Big Room was initially based at Sheffield Teaching Hospitals. However, as it had become a city-wide group it meets in alternative locations and is currently meeting weekly at a community intermediate care unit. This provided the opportunity for community staff to assess and redesign processes in their care pathway.
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Surgery
Facts and data about this service
Surgical services were managed through the trust’s directorate and group structures. The following groups had surgical services within them: OSCCA (Operating services, critical care and anaesthesia); South Yorkshire regional services group; Head and neck group; surgical services (general surgery, plastic and breast surgery and urology) and Musculo-skeletal care group.
The plastic and breast services provide plastic surgery, breast surgery, sarcoma surgery and burn care services within South Yorkshire with bases at the Northern General hospital and Royal Hallamshire hospital. Plastic and breast provides on-call provision to Sheffield Children’s hospital as well as consultant sessions for elective surgery and burn care. All trauma and elective hand work is undertaken at the Northern General hospital.
General surgery provides elective (cancer and benign) and non-elective general surgery services for patients within South Yorkshire, North Trent and nationwide. It is predominantly based at the Northern General hospital site, with elective services sub-divided into six specialties: • Colorectal surgery • General surgery • Obesity surgery • Endocrine surgery (outpatients only based at the Royal Hallamshire hospital) • Hepatopancreaticobiliary surgery • Upper gastrointestinal surgery Urology is based at the Royal Hallamshire hospital, with theatre lists on both sites. Urology provides a tertiary service in medical and surgical uro-oncology, reconstructive urology, spinal injuries, urology and endo-urology, as well as a specialised service in neuro-urology, and specialist andrological and male sexual dysfunction services. Urology provides state of the art therapy for complex and uncommon urological conditions. (Source: Routine Provider Information Request (RPIR) – Context acute tab)
Location site name Team/ward/satellite name Acute Pain Burns Unit Cardiac Theatres CCU Chesterman 3 Chesterman 4 Day surgery Firth 2 Firth 3 Northern General Hospital Firth 4 Firth 8 Firth 9 Hand Unit Huntsman 6 Huntsman 7 Operating Theatre Outreach Team Pre-Op Assessment Unit
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Podiatric Surgery Robert Hadfield 6 Surgical Assessment Unit Vickers 4 (Source: Routine Provider Information Request (RPIR) – “Sites-Acute” tab) The trust had 70,892 surgical admissions from January 2017 to December 2017. Emergency admissions accounted for 18,926 (27%), 37,705 (53%) were day case, and the remaining 14,261 (20%) were elective. (Source: Hospital Episode Statistics)
During this inspection we visited the operating theatres and recovery area, neuro day unit and in- patient unit, and the pre-assessment unit. We spoke with 18 patients and relatives and 51 members of staff. We observed staff delivering care and looked at patient records and prescription charts. We reviewed trust policies and performance information from, and about, the trust. We received comments from patients and members of the public who contacted us directly to tell us about their experiences.
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Is the service safe?
Mandatory training
The trust set a target of 90% for completion of mandatory training.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for medical/dental and nursing/midwifery staff in surgery is shown below:
Northern General Hospital medical and dental staff:
There were eight training courses eligible for medical and dental staff, the target was met for seven modules. Northern General hospital did not meet the fire safety training level 1a of which 20 staff were trained of a total of 22 eligible for the module.
Number of staff Number of Completion trained eligible rate Trust Met Name of course (YTD) staff (YTD) (YTD) Target (Yes/No) Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 10 10 100% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 7 7 100% 90% Yes Information Governance - Level 1 (1 Yearly) 14 14 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 10 10 100% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 27 28 98% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 28 29 98% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 27 29 92% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 20 22 65% 90% No Northern General Hospital nursing and midwifery staff:
There were nine training courses eligible for nursing and midwifery staff for Northern General hospital who met the 90% target for two modules. The lowest completion rate for surgery was 79% for health, safety and welfare - level 1 (3 yearly) of which 393 nursing and midwifery staff was trained of the 508 eligible for the module.
Last year the nursing and midwifery staff for surgery met the training completion rate, reaching 100% for the financial year April 2016 to March 2017.
Number of staff Number of Completion trained eligible rate Trust Met Name of course (YTD) staff (YTD) (YTD) Target (Yes/No)
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Resuscitation: Paediatric Basic Life Support - Level 2b (1 Yearly) 12 13 92% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 382 446 92% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 588 652 89% 90% No Information Governance - Level 1 (1 Yearly) 458 546 89% 90% No Equality & Diversity: General Awareness - Level 1 (3 Yearly) 509 553 88% 90% No Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 483 559 88% 90% No Moving & Handling - Level 2b (1 Yearly) 311 336 87% 90% No Moving & Handling - Level 2a (3 Yearly) 162 218 85% 90% No Health, Safety & Welfare - Level 1 (3 Yearly) 393 508 79% 90% No
(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Compliance rates for mandatory training were better than the last inspection of the trust. During our last inspection, information submitted by the trust showed that overall compliance with mandatory training in surgery was 83%. This was below the trust target of 90%
Mandatory training for staff was led by the clinical educators and included dementia, Deprivation of Liberty Safeguarding and Mental Capacity Act. Staff were allocated protected time on the rota to complete mandatory training and staff reported they felt training was a priority. Staff also attended a simulation day annually, arranged by the clinical educators to give staff hands on experiences in situations they may face in practice. For example, how to respond to a patient who is presenting with signs of sepsis.
We observed an education and training board in theatre which displayed information about upcoming training courses. The board also listed all staff and the dates when training had been completed. The staff we spoke to said they had completed their mandatory training and theatre management reported 90% completion rate for mandatory training. Firth 4 ward reported 94% completion rate for mandatory training for March 2018.
Safeguarding
All clinical staff were trained at safeguarding level 1 as a minimum. Senior clinical staff were expected to be trained in safeguarding level 2 and level 3. From the information the trust gave us, this was achieved or nearly achieved; however, medical and nursing staff training were below the trust target of 90% for safeguarding children and young people level 1.
Staff we spoke to were clear about what should be considered as a safeguarding issue and how to escalate safeguarding concerns. Staff we spoke to could demonstrate how to access the trust’s safeguarding policy and the safeguarding lead. We saw evidence of safeguarding consideration during the safety huddles we observed. Staff told us they received feedback following raising 20171116 900885 Post-inspection Evidence appendix template v3 Page 122 safeguarding concerns. Two members of staff on ward Vickers 4 advised they would raise safeguarding concerns with senior staff on the ward. One member of staff told us that social workers would be involved if patients had safeguarding concerns.
Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training.
A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for medical/dental and nursing/midwifery staff in surgery is shown below
Northern General Hospital medical and dental staff:
The medical and dental staff of Northern General hospital met the safeguarding training for one of the two eligible courses.
Eligible Staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 11 11 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 9 11 87% 90% No
Northern General Hospital nursing and midwifery staff:
The nursing and midwifery staff of Northern General hospital met the safeguarding training for three of the four eligible courses.
Eligible Staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children & Young People - Level 3 (3 Yearly) 36 38 95% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 199 220 90% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 516 582 90% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 487 552 88% 90% No Northern General hospital had a 91% safeguarding training completion rate for all staff up to February 2018. Last year the staff for this site within surgery met the training completion rate, reaching 100% for the financial year April 2016 to March 2017. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene
At this inspection, we found the wards and departments we visited visibly clean and tidy.
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The trust had an infection, prevention and control policy which directed staff to other policies and protocols for guidance about cleaning, decontamination and personal protective clothing.
The trust reported two cases of hospital acquired Methicillin resistant staphylococcus aureus MRSA from April 2017 to March 2018, this was higher than the nationally agreed threshold of zero cases. The trust reported 83 cases of Clostridium difficile (C.diff) in the same reporting period, this was lower than the nationally agreed threshold of 87 cases. This year one case of hospital acquired MRSA had been reported from April 2018 to June 2018 and 12 cases of hospital acquired C.diff. Following the inspection the trust the trust told us that there had been a change of definition which meant that no cases of MRSA were attributed to the trust between April to June 2018.
The trust had a policy to screen surgical patients for MRSA and Methicillin sensitive staphylococcus aureus (MSSA) as per best practice guidance. Elective patients were screened at pre- assessment.
The infection prevention and control team carried out surgical site infection surveillance data. The data we reviewed for January 2017 to December 2017 showed that five patients had reported an infection following primary hip replacement surgery, out of 389 operations performed, this equates to a rate of 1.3% which is worse than the national rate of 0.6%. Primary knee replacement surgery showed two patients had reported an infection following surgery, out of 498 operations performed, this equates to a rate of 0.4% which is better than the national rate of 0.5%. Data we reviewed for January to March 2018 showed a deterioration with 3 patients reporting infections for primary hip or knee replacement out of 225 operations carried out (1.1% primary hip and 1.5% primary knee).
During our inspection, we saw daily cleaning checklists, which were completed, dated and signed for between 25/05/2018 and 12/06/2018.
During the inspection, we observed that staff were compliant with hand hygiene policies, including ‘bare below the elbows’ and personal protective clothing policies. Handwashing advice was clearly displayed and facilities for hand hygiene were available. Hand hygiene compliance data was displayed on wards we visited. Staff had access to at the point of use alcohol gel. Patients reported they observed staff washing their hands and using alcohol gel. Taps for handwashing were non- touch.
We checked commodes in ward areas and found them to be visibly clean with labels indicating they were clean and ready for use. Mattress and commode cleaning guidance was displayed in utility rooms and information on the segregation of waste.
We saw processes for segregation of waste including clinical waste. Staff were able to segregate waste at the point of use. Sharps bins were used by staff to dispose of sharp instruments or equipment. Sharps bins in the areas visited were secure, dated signed and stored off the floor. This reflected best practice guidance outlined in Health Technical Memorandum HTM 07-01, safe management of healthcare waste.
Rooms were available for patients requiring isolation should these be required, at the time of the inspection no patients were being isolated.
Cleaning equipment was kept in a separate cupboard and different coloured mop buckets were available.
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Whilst on the ward we saw active cleaning taking place. Whilst one bay was empty cleaning staff were seen deep cleaning patients bed side tables. One nursing staff was observed cleaning a trolley used for medications or dressings before leaving it in the clean utility for future use
We inspected reusable equipment stored on the ward, we found bowls used for patient washing were still wet and stacked up inside each other preventing these items from drying.
It is recommended that water outlets such as bathroom and shower facilities should be regularly run to ensure effective management and control of pseudomonas aeruginosa and Legionella. During the inspection, staff we spoke with said that this was carried out daily and records were stored to provide assurance. Records we reviewed on Vickers 4 showed that, although staff were recording flushing off the water system, they were recording this information at 7am daily, even though the flushing was carried out throughout the day and records we reviewed showed that three days in May 2018 hadn’t been completed.
On inspection we found storerooms were used for mixed purposes, for example food was stored with clean utility. In the same cupboard we also found a phlebotomy trolley with blood still on it stored with clean equipment such as dressings and dried food. We also found that single use cleaning equipment was open and out of date. We highlighted the unsuitable storage of the phlebotomy trolley to the nurse in charge on the ward during the visit and this was moved to an alternative cupboard.
During our inspection, on Vickers 4 ward there was three different fridges on the ward, one for medication, one for patient and staff food and a further fridge for nutritional supplements. Fridge temperatures were only checked on two of these. The fridge containing nutritional supplements did not have any record of fridge temperatures being taken. The fridge did have a digital temperature display on the door, but no daily records were kept.
Environment and equipment
During our last inspection there was limited space for safe storage of equipment and resuscitation equipment was not checked daily. Whilst on this inspection, we saw resuscitation equipment was reviewed regularly, checked and tested consistently in line with trust policy. Equipment was tidy and ready for use. Trolleys we inspected were locked, appropriately stocked and equipment was in date. Resuscitation trolleys were easily located on main corridors in ward areas and theatre and in theatre recovery. Best practice is for resuscitation trolleys to be checked daily (Royal Collage of Anaesthetics – Resuscitation – Raising the Standard). We inspected resuscitation equipment in each of these areas and were assured that daily checks had been undertaken. We saw checklists signed and dated appropriately. The trolleys were secured with tamper proof seals.
Anaesthetic equipment appeared clean and tidy, checks complied with ‘The Association of Anaesthetists of Great Britain and Ireland’ (AAGBI) guidelines. We reviewed the difficult intubation trolley and noted from visual observation it was tagged and equipment was easily identifiable in each drawer as per best practice requirements.
We checked nurses’ stations, patient toilets and washing basins which were all clean and uncluttered. We observed sluice rooms to be clean and tidy. Utility stores were clean, tidy and
20171116 900885 Post-inspection Evidence appendix template v3 Page 125 equipment clearly labelled in drawers. We saw chemicals stored appropriately with instructions for usage.
Staff we spoke with said they rotated stocks of equipment however, on Vickers 4 ward we checked several items within the clean utility storage areas and found that there was no evidence of stock rotation with newer products at the front of storage cabinets. We also identified some stock was out of date. We informed the nurse in charge of this at the time of inspection. All instruments arrive on the ward pre packed; no instruments are sterilised on the ward.
Wards reported having sufficient equipment to meet the needs of their patients, for example moving and handling equipment. Firth 8 had its own supply of bariatric equipment, however, other wards reported that they obtained equipment from the store room if required.
We checked seven pieces of equipment across surgical areas and theatre including infusion pumps and anaesthetic machines. All equipment we reviewed had in date electrical safety testing within the last year. Dates equipment needed retesting were clearly visible on the equipment. All of the equipment we checked was labelled with an ‘I am clean stickers’ which showed the date the cleaning had been completed.
On Vickers 4 ward we saw that one room that was being used as a single patient room had no window and the patient’s bathroom had no sign to identify this was a bathroom. The sister on the ward reported that the room had previously been a storage cupboard but had been changed to a patient room to meet the needs of the ward.
Assessing and responding to patient risk
The trust had adapted the national early warning score system (NEWS), a tool for identifying deteriorating patients, into the Sheffield early warning score system (SHEWS). The SHEWS was a paper-based system and the documentation we reviewed across all ward areas showed accurate completion of SHEWS scores. We saw evidence of raised SHEWS scores being escalated appropriately. The medical records included the use of a yellow sticker system which was signed by the doctor at review. Staff we spoke with were confident that, out of hours, they could contact the outreach team for support if they recognised a patient deterioration.
The trust had a sticker system in place for identifying a deteriorating patient. An audit of this system between March and May 2018, identified 91.6% compliance by the surgical department with 100% of these patients having the minimum hourly observation commenced. The data indicated that 100% of SHEWS scores were recorded with each set of observation and 96.3%of the SHEWS scores were accurate for the patient. All patient records showed evidence of a patient care management plan. Patients were initially assessed on admission, including assessment of mental health and fall risk.
Whilst on inspection we observed a safety huddle on the renal ward. The huddles were attended by members of staff covering different sections of the ward. The meetings discussed safety issues with the patients and specifically looked at, pressure areas and falls risks. The ward displayed the number of days without any falls or new pressure sores on the ward, this was updated for everyone to see following the safety huddle. Whilst we were on inspection the board reported 140 days without a hospital acquired pressure ulcer and 38 days without a fall.
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We reviewed three sets of medical notes where the World Health Organisation (WHO) safety checklist had been completed appropriately prior to surgery.
We saw clinical areas that had information boards displaying information regarding sepsis. These showed the percentage of patients per directorate that had red flag sepsis. Staff said that they stored one vial of antibiotic in the control drug cupboard for timely treatment of sepsis according to best practice.
We saw health and safety checklists which were completed for April 2018 and May 2018.
Nurse staffing
During our last inspection, there was issues with staff being moved to other wards to cover shifts. Our previous report stated that the trust should try to reduce the movement of staff to clinical areas outside of their speciality. On this inspection, staff reported that they are still moved to other specialist areas to meet the demand. However, the trust told us they only move staff when it is required to maintain safe staffing levels; and this was carried out following an agreed risk assessment process within the Nursing and Midwifery Staffing Escalation Policy.
At this inspection, we reviewed staffing fill rates for March 2018 and saw that for surgical services there was 7.22% of actual vacancies for registered nurse shifts for both days and nights.
Ward Firth 8: 79.1% registered nurse (RN) shifts days and 125.4% Clinical support worker (CSW) shifts. Night shifts showed 78% RN shifts and 170.4% CSW shifts.
Ward Firth 9: 78.6% registered nurse (RN) shifts days and 116.3% Clinical support worker (CSW) shifts. Night shifts showed 80.1% RN shifts and 172.6% CSW shifts.
We reviewed duty rotas over the last three months, data showed that all areas were staffed below established levels on a small number of occasions, however the number of agency and bank staff used to achieve the planned staffing levels was high. For example, we reviewed 63 shifts on ward Vickers 4, on four occasions registered nurse shifts were below established levels, and 43 shifts had bank and agency registered nurse allocated over this same period.
In March 2018, surgical services used 1.94 WTE of a bank/agency registered nurse and 9.9 WTE of care staff and a combined overtime total of 2.45 WTE. The trust report sickness levels continue to be managed appropriately, supported by human resource colleagues
The trust has reported their staffing numbers below for December 2017. There were 125.29 less nursing staff in place than the trust planned to provide safe care within surgery.
Number in post Fill rate Staff group WTE Staff December 2017 Qualified Nursing and 816.3 691.01 85% Health Visiting Staff (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
The trust used a nationally recognised safer nursing tool and professional judgment, together with an electronic rostering system, to support staff in planning staffing levels having regard to patient needs. This was used alongside a daily staffing meeting to fill any gaps in staffing. Staff reported
20171116 900885 Post-inspection Evidence appendix template v3 Page 127 that this system worked well and kept patients safe. The matron was available for any escalation and out of hours a duty matron held a bleep for this purpose, who had a clear policy of escalation to follow. The trust’s executive group received a monthly safer staffing report and all staffing was reviewed on a rolling six-month basis.
Staff escalated staffing issues through the site management meetings twice a day, these meetings were used to review activity, manage staffing issues and monitor capacity and demand on each site.
The directorate used the SAFER (Senior review, All patients, Flow, Early discharge and Review) patient flow bundle, red2green initiatives and board rounds to improve safety and flow. The SAFER initiative involves five best practice safety elements to improve flow and discharge. The red2green campaign is a visual system to assist in the identification of wasted time in a patient’s journey, this approach identifies times patients spend in hospital without the day contributing to the patient’s discharge. The trust had recently employed a care navigator role to improve the patients journey and prevent or remove blockages in the patients discharge path.
Senior staff we spoke to said that retention of staff remained a challenge within the surgical division, despite overseas recruitment taking place.
Vacancy rates From January 2017 to December 2017, the trust reported a vacancy rate of 3.7% across surgery; for qualified nursing and health visiting staff the annual vacancy rate was 15%. This was above the trust target of 0%. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January 2017 to December 2017, the trust reported a turnover rate of 12.2% in surgery. Qualified nursing and health visiting staff (qualified nurses) has an annual turnover rate of 8.1% • Northern General Hospital has a turnover rate of 6.4% (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January 2017 to December 2017, the trust reported a sickness rate of 4.1% in surgery. Qualified nursing and health visiting staff (qualified nurses) has a sickness rate of 4%. Northern General Hospital has a sickness rate of 4.2%. This was slightly higher than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage Electronic rostering was used with a safer nursing care tool to identify any gaps in staffing. The matron had oversight of this and attended the bed meeting to review staffing. Staff on the wards reported they felt staffing levels were appropriate for the patient numbers they cared for. During our inspection we saw that planned and actual staffing levels were achieved.
Operating theatres staffing met the ‘Association for Perioperative Practice (AfPP) staffing recommendations. Theatres and ward staff reported they rarely used any agency nursing. They had their own bank staff or staff doing additional shifts to cover any gaps. We spoke with a senior nurse on the ward who said their registered nursing staff liked to do overtime and they were normally able to fill any nursing gaps with their own staff.
During our last inspection, there was concerns raised with staff being moved to other wards to cover shifts. On this inspection, staff reported that they were still moved to other specialist areas to
20171116 900885 Post-inspection Evidence appendix template v3 Page 128 meet the demand. However, the trust told us they only move staff when it is required to maintain safe staffing levels; and this was carried out following an agreed risk assessment process within the Nursing and Midwifery Staffing Escalation Policy.
One staff member told us that two of the three senior staff on the ward did not work late shifts and were only available every other weekend.
From January 2017 to December 2017, Northern General hospital reported they used bank staff a total of 1,342 times and agency nursing staff a total of 370 times and there were 4,236 shifts unfilled from 57,727 total shifts for qualified nursing staff. The bank and agency usage rate for this site was 10%. (Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
Medical staffing
At this inspection, for all surgical specialities a consultant was present on site. Surgical services had systems and processes in place to provide medical staffing levels so that patients were kept safe.
The services we visited had a daily consultant review. The rota for each service on the site ensured 24/7 consultant cover and where this consisted of on call cover, staff reported a timely response.
The trust has reported their staffing numbers below for December 2017.
Number in post Fill rate Staff group WTE Staff December 2017 Medical and dental - 377.09 369.27 98% Hospital (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
Vacancy rates
From January 2017 to December 2017, the trust reported a vacancy rate of 3.7% across surgery; for medical and dental staff, the annual vacancy rate was 3%. This was above the trust target of 0%. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January 2017 to December 2017, the trust reported a turnover rate of 12.24% in surgery. Medical and dental staff within surgery has an annual turnover rate of 25.76% • Northern General Hospital has a turnover rate of 22.8% (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January 2017 to December 2017, the trust reported a sickness rate of 4.1% in surgery. Medical and dental staff within surgery had an annual rate of 1.2%. Northern General Hospital has a sickness rate of 1%. This was below the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and locum staff usage
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We are unable to calculate the bank and agency usage rate as the trust did not provide the total number of shifts. The trust informed us their total shifts between January 2017 to December 2017 was 4,789 however the bank, locum and unfilled shifts total to this figure. From January 2017 to December 2017, the trust reported that they used bank staff a total of 2,780 times and locum staff a total of 1,990 times with 19 shifts unfilled. (Source: Routine Provider Information Request (RPIR) P21 Medical Locums)
We reviewed medical staffing and spoke with consultants, middle grade and junior doctors. Medical cover was available on-site 24 hours a day. Consultants were available 24 hours and were on site between 8am and 6pm. On-call cover was provided at evenings and weekends. On the theatre admission unit there was a consultant between the hours of 8.30am and 4pm
The on-call consultants were supported by on site registrars and foundation level doctors supported the wards. Junior doctors reported always having support and access to senior colleagues when required.
The ward was covered by several different consultants. Each week one consultant would be on call for the week to cover the patients on the ward.
In the medical notes we observed a weekend plan sticker which clearly communicated plans of care. It included diagnosis, co-morbidities, treatment to date and ongoing plans for example if blood tests were required.
The patients we spoke with reported visibility of doctors and being reviewed at weekends.
Theatre staff reported a shortage of middle grade doctors, consultants informed us that they would often had to cover their work due to staffing issues.
Staffing skill mix For December 2017, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was the same.
Staffing skill mix, whole time equivalent staff working at Sheffield Teaching Hospitals NHS Foundation Trust
This England Trust average Consultant 54% 49% Middle career^ 4% 11% Registrar Group~ 30% 29% Junior* 13% 11%
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~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)
Records
During our last inspection, we were concerned about record storage; however, whilst on this inspection we saw patients’ records were all stored in areas that were secure and in locked trolleys. We did not see any patients notes left unattended.
Paper records were available for each patient that attended the wards and departments; the trust used electronic patient management to record key information about the patient’s hospital stay. Electronic whiteboards were used on all wards we visited, which recorded key information about patient risks and treatment including flags for living with dementia, patient acuity and discharge plans. The boards ensured that staff had easy access to key information, such as reviews by other members of the multi-disciplinary team and patient acuity.
Staff we spoke with said they could access records out of hours without any issues.
We reviewed 13 sets of medical records during the inspection, all records showed staff used black ink, legible handwriting and documentation occurred at the time of review or administration of treatment. Out of the 13 records, seven sets had incomplete charts in them including fluid charts. Not all pages were appropriately labelled, and many entries were not initialled. Records within each folder were not stored chronologically.
We saw that patient records held individualised plans of care; for example, pressure area prevention and falls care plans, these were stored electronically.
We reviewed five sets of electronic nursing records, only one record viewed had been completed. Individualised care plans were completed as required. The electronic records also provided option to refer on for specialist care if required, for example safeguarding or tissue viability.
Medicines
On our last inspection, we found oxygen was not always prescribed as per trust policy. Whilst on this inspection, we reviewed three patients who were receiving oxygen therapy. Staff told us a new paper oxygen chart had been introduced since our last inspection. In addition, the electronic prescribing and administration system (EPMA) reminded staff to check the oxygen chart during the medicines round. In two cases we found oxygen was appropriately prescribed, including target blood oxygen levels. One patient was receiving oxygen, but no prescription had been written and there were no target oxygen levels set.
During our inspection, we reviewed the medication element of 10 patient clinical records and spoke with three patients. In general, medicines, including intravenous fluids, were stored securely and access was restricted to authorised staff. However, on Firth 4 we found the door propped open, an unlocked drug fridge and a drug bag on the floor with a patients’ medication in. On Huntsman 7 and Firth 9 we found the doors to the treatment rooms, which contained medicines and intravenous fluids, did not have a lock. This meant there was a risk that unauthorised persons could access medicines and fluids.
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Controlled drugs were appropriately stored with access restricted to authorised staff. They were audited daily, and we found no discrepancies in the controlled drug registers. We reviewed the controlled drugs records on surgical wards and in theatres and found accurate records and checks were completed in line with trust policy.
On Vickers 4, we reviewed the storage of medication in fridges and found there were five medications in the fridge that were prescribed to patients who were no longer on the ward.
Pharmacists checked (reconciled) patients’ medicines on admission to hospital and we saw this occurred in a timely manner. Where discrepancies were identified, pharmacists made an entry in the medical notes to alert the prescriber and ensured these were followed-up.
Patients we spoke with told us they had received their medicines, including pain relief, in a timely manner. Doctors explained the plan of treatment and provided verbal information on any new medicines which were prescribed.
The trust had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of antimicrobial resistance. For example, the local antimicrobial formulary was available to all staff via the trust intranet. Staff had also been provided with quick reference cards which summarised the treatment of common infections. We saw that when patients had been prescribed intravenous antibiotics, these were regularly reviewed and changed to oral alternatives in a timely manner. However, we found that prescribers did not always record an indication or stop date when prescribing antibiotics on EPMA.
We found that all patients we reviewed had been prescribed appropriate prophylaxis for Venous Thromboembolism (blood clots) where this was indicated. However, medical staff did not always complete the trust risk assessment form fully on admission to hospital.
Incidents
The trust reported four serious incidents in surgery over the past 6 months. Ward managers we spoke with said that if a serious incident occurred they would be involved in the root cause analysis process. We reviewed three serious incident reports; we found these to include contributing factors, identification of lessons learned and recommendations to prevent reoccurrence of the incident.
Our last report stated that the trust should introduce a robust process to share lessons learnt from incidents. All the staff we spoke with including medical staff were aware of how to report incidents and gave examples of what types of things they would report. During our last inspection, there was concerns staff did not get feedback following incidents. On this inspection, the ward staff reported getting feedback from incidents for example by emails from line managers with outcomes, learning and patient feedback. All staff we spoke to felt there was a good culture of incident reporting, including near misses. Staff we spoke to said that changes in practice had occurred because of incidents and said safety huddles had been developed to improve communication about patient risks
We saw wards that had a staff engagement noticeboard. This had information on incidents within the directorate. Recent incidents and learning points were detailed on the board for staff to learn from. The engagement board also included a section on the number of falls on the ward broken
20171116 900885 Post-inspection Evidence appendix template v3 Page 132 down by month. Learning points and actions taken to help reduce falls was also included; for example, the introduction of patient leaflets and non-slip socks.
Serious incidents were monitored through the trust’s serious incidents group which meet weekly. The serious incident group was attended by the Medical Director, Chief Nurse, Governance lead and Assistant Chief Executive.
Team meetings, a trust wide safety brief and safety huddles were also used for disseminating information. We observed a safety huddle on wards conducted by the nurse in charge. It was attended by various clinical staff. They discussed each patient, specifically any falls risks, plan of care and any concerns. They then discussed any other news including details of incidents and changes in practice. Staff reported that since the safety huddles were introduced there has been a reduction in pressure ulcers.
The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. We saw the duty of candour referenced in incident data. Staff we spoke with demonstrated an awareness of the duty and the importance of being open and honest when delivering care. We saw leaflets for patients in clinical areas with information regarding duty of candour. One patient we spoke with identified that there had been complications in theatre. The complications had been explained to the patient as soon as they woke from surgery
Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From May 2017 to April 2018, the trust reported two incidents classified as never events for surgery.
(Source: Strategic Executive Information System (STEIS))
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported nine serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from May 2017 to April 2018. Of these, the most common types of incident reported were: • Surgical/invasive procedure incident meeting SI criteria with three (33% of total incidents). • All other categories with two (22% of total incidents). • Medical equipment/ devices/disposables incident meeting SI criteria with one (11% of total incidents). 20171116 900885 Post-inspection Evidence appendix template v3 Page 133
• Pending review (a category must be selected before incident is closed) with one (11% of total incidents). • Sub-optimal care of the deteriorating patient meeting SI criteria with one (11% of total incidents). • Treatment delay meeting SI criteria with one (11% of total incidents).
(Source: Strategic Executive Information System (STEIS)
Safety thermometer
We did not see any Safety Thermometer information displayed in public ward areas. Senior staff reported they received email prompts to remind them to complete the safety thermometer. We were informed the trust was working with commissioners to improve application of the safety thermometer in practice. We reviewed the last two months of Safety Thermometers which was completed and submitted appropriately.
The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 84 new pressure ulcers, 26 falls with harm and nine new catheter urinary tract infections from April 2017 to April 2018 for surgery.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total Pressure ulcers (84)
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Total Falls (26)
3 Total CUTIs (9)
1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only (Source: NHS Digital)
Is the service effective?
Evidence-based care and treatment
Trust policies were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE). These were easily accessed on the trust’s intranet under clinical policies. All staff were aware of guidance and how to access it.
New guidance was monitored through clinical governance meetings and we saw evidence of this in the clinical governance report we reviewed. During our inspection, surgeons informed us that they had a monthly audit meeting where any issues and changes in practice were discussed.
We reviewed policies and found them to be in date and with version control and author identified. Staff stated that policies are up dated regularly and that paper copies of the latest versions can be found in the staff room. Care pathways were used for specific conditions for example the sepsis pathway had a link to the Royal College of Physicians acute toolkit, screening tool and care protocols.
The surgical directorate participated in several national audits including the national joint registry and the Nephrectomy audit. From this good practice and areas for development were identified.
A geriatrician working across the surgery department had implemented an older person pathway which had reduced the average hospital stay for older people from 20 to 15.5 days. This pathway had also reduced the readmission rate and staff felt it had improved the impact on patient care. This pathway was short listed for a hospital service journal award. The department had developed and implemented guidance for anaesthetic management of hip fractures.
Nutrition and hydration
At this inspection, we saw that food and fluid charts were not always completed accurately. Staff did not total the daily intake and output on fluid balance charts we reviewed. For the two fluid 20171116 900885 Post-inspection Evidence appendix template v3 Page 135 balance charts we reviewed, we noted that they were not fully completed, and the daily intake and output was not recorded.
During this inspection, we spoke with seven patients and five of these said the food was good. All said they were given enough food and all water jugs we saw had water in them. We saw a drink round taking place in the mornings where patient was offered a choice of hot or cold beverages. One patient we spoke to said that, as he was at the end of the ward, he was the last person to be offered a meal and the food from the trolley would be cold. The staff on the ward would ensure the food was re heated in a microwave to ensure that he was able to eat it hot.
The Malnutrition Universal Screening Tool (MUST) was used to assess and identify patients at risk of malnutrition and weight loss. Five sets of electronic MUST documentations were reviewed and all five had MUST scores completed. There was evidence that this was reviewed weekly. To highlight those at-risk MUST scores were also displayed next to the patients’ name on the white board in the treatment room. One patient that was identified as having an increased MUST score of over two did not appear to have any monitoring of food intake in place.
We did not see that patients were provided with different colour lids, trays or plates to help to identify them as needing support at mealtimes. We also did not see that equipment was available to help patients living with dementia to eat, for example coloured plates or cutlery.
Patients were offered breakfast and ward managers chose whether their ward had sandwiches or a hot meal at the other mealtimes.
We saw policies and observed clear explanations regarding fasting times at pre-assessment which were in line with best practice. There was a fasting policy and intravenous fluids would be commenced on an individual basis as required if patients were nil by mouth. Staff described the use of mouth care for patients who were unable to eat or drink.
Patients requiring a texture modified diet or thickened fluids were reviewed by speech therapy and a sign with recommendations was placed over the patient’s bed. Nutrition and hydration requirements for patients were also highlighted each day at the safety huddle. Staff told us there was a nutrition team on site. The ward identified those that needed extra support with their nutrition and hydration through the use of a ‘Red Tray’ system. Those at risk of malnutrition or needing additional support were offered fluids in red beakers and red lids were available for water jugs. There was a list of patients needing extra support in the kitchen allowing the house keeper to provide the right beakers and jugs for patients.
Staff told us how they encourage patients to have meals in the dining room, on firth 4 ward the housekeeper had set up a “bistro” at meal times where the tables had tablecloths, metal cutlery and flowers.
The wards identified where there was an additional nutrition need for patients. The house keeper and wider ward team had worked on a ‘snack attack’ project which had introduced an extra afternoon snack to all patients on the ward. The success of the pilot was shown on displays on the ward and highlighted that, over a short period, patient’s weights had increased. On the gastric surgery ward, all patients were assessed and if they would benefit, then smaller meals were offered. Staff called this project “little and often”. Little and often were bags that contained a selection of small high calories snacks.
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Pain relief
As part of the SHEWS observational chart and intentional rounding, staff regularly asked patients about their pain level and recorded scores. We spoke with eight patients on the ward, all patients we spoke with said that staff offered them pain relief at regular intervals and that additional pain relief was given as it had been prescribed. One patient reported that it had taken some time to get the pain sorted but this was now under control.
We saw evidence of pain scores in the documentation we reviewed. We reviewed four medicine charts and saw that patients had been prescribed and administered medicines, and that staff used pain scores to identify the patients level of pain and administer the correct level of pain relief.
Staff had access to an acute pain team and staff said they made referrals to this team as and when appropriate.
Patient outcomes
During our last inspection, we advised that the trust should review data collection methods and introduce a system to collect patient outcomes by speciality within care groups. The service had systems and processes in place to monitor patient outcomes including, service evaluations, and participation in local and national audits, all with a view to providing effective patient outcomes.
We saw evidence of a number of national audits, some of which are summarised below.
Relative risk of readmission During our last inspection we found higher than the England average standardised relative readmission rates (2014) for elective and non-elective surgical patients for trauma and orthopaedics, colorectal and hepatobiliary and pancreatic surgery. From January 2017 to December 2017, all patients at Northern General Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Colorectal surgery patients at Northern General Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Hepatobiliary and pancreatic surgery patients at Northern General Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Trauma and orthopaedics patients at Northern General Hospital had a higher expected risk of readmission for elective admissions when compared to the England average.
All patients at Northern General Hospital had a higher expected risk of readmission for non- elective admissions when compared to the England average. • General surgery patients at Northern General Hospital had a higher expected risk of readmission for non-elective admissions when compared to the England average. • Colorectal surgery patients at Northern General Hospital had a higher expected risk of readmission for non-elective admissions when compared to the England average. • Trauma and orthopaedics patients at Northern General Hospital had a higher expected risk of readmission for non-elective admissions when compared to the England average.
Elective Admissions - Northern General Hospital
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Note: Ratio of observed to expected elective readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity
Non-Elective Admissions - Northern General Hospital
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity (Source: HES - Readmissions (01/01/2017 - 31/12/2017))
Hip Fracture Audit In the 2017 Hip Fracture Audit, the risk-adjusted 30-day mortality rate was 8.3% which was within the expected range. The 2016 figure was 10%.
72.8% of patients had surgery on the day of or day after admission, which falls in the middle 50% when compared to all sites that participated in the audit. The 2016 figure was 74.4%.
The perioperative medical assessment rate was 91.8%, which falls in the middle 50% of all sites that participated in the audit. The 2016 figure was 91.8%.
96.3% of patients were documented as not developing a pressure ulcer which put the hospital in the middle 50% of all sites that participated in the audit. The 2016 figure was 96.5%.
The length of stay was 22.9 days, which falls in the middle 50% of all sites that participated in the audit. The 2016 figure was 22.2 days. (Source: National Hip Fracture Database 2017)
Bowel Cancer Audit In the 2016 Bowel Cancer Audit, 69.4% of patients undergoing a major resection had a post- operative length of stay greater than five days. This was worse than the national aggregate. The 2015 figure was 72.4%.
The risk-adjusted 90-day post-operative mortality rate was 4.8% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 4.7%.
The risk-adjusted 2-year post-operative mortality rate was 17.6% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 19.8%.
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The risk-adjusted 30-day unplanned readmission rate was 5.4% which was within the expected range when compared to other hospitals that participated in the audit. This was not reported in the 2015 report.
The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection was 53.9% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 53.2%. (Source: National Bowel Cancer Audit)
National Vascular Registry In the 2016 National Vascular Registry (NVR) audit, the trust achieved a risk-adjusted post- operative in-hospital mortality rate of 1.6% for Abdominal Aortic Aneurysms, indicating that the trust within the expected range. The 2015 figure was 1%.
Within Carotid Endarterectomy, the median time from symptom to surgery was 18 days, worse than the national standard of 14 days.
The 30-day risk-adjusted mortality and stroke rate was within expected range at 2.6%. The 2015 figure was 2.7%. (Source: National Vascular Registry)
National Oesophago-Gastric Cancer National Audit In the 2016 Oesophago-Gastric Cancer National Audit (OGCNCA), the age and sex adjusted proportion of patients diagnosed after an emergency admission was 13.2%. Patients diagnosed after an emergency admission are significantly less likely to be managed with curative intent. The audit recommends that overall rates over 15% could warrant investigation. The 2015 figure was 12.5%. (Source: National Oesophago-Gastric Cancer Audit 2016)
National Emergency Laparotomy Audit In the 2017 National Emergency Laparotomy Audit (NELA), Northern General Hospital achieved an amber rating for the crude proportion of cases with pre-operative documentation of risk of death. This was based on 129 cases.
The Northern General Hospital achieved an amber rating for the crude proportion of cases with access to theatres within clinically appropriate time frames. This was based on 63 cases.
The Northern General Hospital achieved an amber rating for the crude proportion of high-risk cases with a consultant surgeon and anaesthetist present in the theatre. This was based on 63 cases.
The Northern General Hospital achieved a green rating for the crude proportion of highest-risk cases admitted to critical care post-operatively. This was based on 35 cases.
The risk-adjusted 30-day mortality for the Northern General Hospital was within expectations, based on 129 cases. (Source: National Emergency Laparotomy Audit)
Patient Reported Outcome Measures In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations: • Groin hernias
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• Varicose veins • Hip replacements • Knee replacements
Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left.
In 2015/16 performance on groin hernias was worse than the England average.
• For Varicose veins, performance was better than the England average. • For hip replacements, performance was better than the England average. • For Knee replacements was better than the England average. (Source: NHS Digital)
The wards used enhanced recovery programmes which are evidence-based programmes designed to help people to recover more quickly following major surgery. The aims of these programmes are to ensure patients are as healthy as possible prior to receiving treatments, receive the best possible care during their operation and recovery. These include getting patients walking, eating and drinking earlier. Patients have one to one support whilst in recovery.
Competent staff Appraisal rates During our last inspection, information submitted by the trust showed between 72% and 100% of staff had completed their appraisal. Whilst on this inspection, management in theatres reported 100% of appraisals was completed and in date.
From April 2017 to December 2017, 85% of staff within surgery at the trust had received an appraisal compared to a trust target of 90%.
Individuals Staff who have Completion Target Met Staffing group required received an (%) (%) (Yes/No) (YTD) appraisal (YTD) Qualified Allied Health Professionals (Qualified Yes AHPs) 25 25 100% 90%
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Support to ST&T staff 16 16 100% 90% Yes Qualified Healthcare Yes Scientists 14 14 100% 90% Support to doctors and No nursing staff 309 266 86% 90% Qualified nursing & health visiting staff No (Qualified nurses) 369 309 84% 90% NHS infrastructure No support 24 20 83% 90% Other Qualified Scientific, Therapeutic & Technical No staff (Other qualified ST&T) 87 68 78% 90% Medical & Dental staff – No Hospital 3 2 67% 90%
Qualified nursing & health visiting staff (qualified nurses) and medical and dental staff both did not meet the 90% appraisal rate within surgery.
• Northern General Hospital had an 85% appraisal completion rate. (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
All new staff, both medical and nursing, attended a corporate induction when starting at the trust. A competency booklet was used to evidence learning. Newly qualified nursing staff underwent a six months preceptorship programme. All new starters, students and visitors wear a yellow hat in theatre so that they are clearly identifiable. We spoke with theatre staff who reported a very good induction and that they were initially supported by being allocated a mentor.
There was an induction pack for bank staff and students and we saw from the off-duty it was highlighted that this must be completed on a staff member’s first shift.
In addition to mandatory training there was role specific training on areas such as blood transfusion and conflict resolution. Staff reported they were encouraged to develop and attend additional training for example three members of staff had recently been seconded to undertake a cardiac surgical assistant course and staff reported there was an annual developmental study day for Band 5 which included topics such as leadership.
Ward staff reported a matrix was used to ensure a good mix of skills on the rota.
On the wards there were identified link nurses, for example, for colorectal surgery and continence. There was access to a range of specialist nurses including sepsis, respiratory, breast care and diabetes; they could be contacted by phone or electronic referral.
The junior doctors we spoke with reported they were offered lots of learning opportunities both formal and informal, protected teaching was given each Tuesday.
The trust supported nursing staff through the revalidation process. We saw information boards about the revalidation process. Revalidation is the new process that all nurses and midwives in the UK will need to follow from April 2016 to maintain their registration with the Nursing and Midwifery Council (NMC) and allow them to continue practising.
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Multidisciplinary working
Staff reported to us, and we observed good multidisciplinary team working; for example, on ward rounds between nursing and medical staff. We also saw evidence of this in the patient records we reviewed.
Daily multidisciplinary safety huddles took place each morning to discuss patient care and identify risks as well as to share other information. Physiotherapy and occupational therapy staff were aligned to ward areas which helped with continuity of care. Domestic staff attended ward rounds on a monthly basis to discuss any issues with clinical staff.
The theatre manager reported they were trying to build stronger links with ward staff. The theatre and ward staff communicated daily to ensure the safe transfer of patients and ward staff were invited to access any training provided in theatre.
We saw evidence of multidisciplinary working on the ward with a number of therapists on the ward throughout the day including physiotherapists, occupational therapists and Speech and Language therapists.
Seven-day services
Daily consultant ward rounds took place. We saw evidence of reviews at weekends and the patients we spoke with confirmed this. Staff provided examples of patients requiring emergency surgery or transfer to the intensive care unit out of hours and reported no concerns or delays with regards to this.
Consultants were available on-call out of hours and attended to see patients at weekends.
Physiotherapists and occupational therapists provided treatment Monday to Friday. There was a weekend and on call service out of hours. A pharmacist visited the unit Monday to Friday; the pharmacy was open seven days a week with a 24 hour on call service.
Health promotion
Health promotion information was available on all wards we visited. This included display boards and information leaflets. We saw information on smoking cessation, healthy eating, drugs, alcohol and housing needs.
Support was available to support patients with smoking cessation. We saw from notes this was discussed with patients as appropriate. There were procedures in place to support patients withdrawing from drugs or alcohol and the pharmacist would advise and support in such situations.
On admission, assessments for individual health needs would take place and support would be provided as appropriate.
As appropriate the multidisciplinary team provided health and self-care advice to patients to enable them to manage their own conditions.
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Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion Staff we spoke with demonstrated an understanding of consent, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards. We observed staff obtained verbal consent from patients before carrying out an intervention.
All the patients we spoke to informed us staff explained their care and treatment to them and sought consent prior to delivering the care.
The trust reported that from April 2017 to February 2018, Mental Capacity Act (MCA) training was completed within the safeguarding vulnerable adults - level 2 (3 yearly) module. This has been completed by 88% of staff in within surgery. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Is the service caring?
Compassionate care
The patients and relatives we spoke with were all positive about the care they had received. We spoke with seven patients who all said they were pleased with the care they had received on the ward. One patient’s family said, ‘it’s the best ward they had been on and they have been on a few’. One patient said the care they received was ‘smashing and they couldn’t get better if they paid’. Patients we spoke with said that staff answered buzzers quickly and during the inspection we did not hear buzzers ringing for long periods of time. All patients felt that they were kept involved in their care. During the inspection, we observed interactions between staff and patients; these were consistently done in a kind and compassionate way.
The majority of patients knew the names of the nurses and doctors caring for them. We saw information boards displaying thank you cards from previous patients and welcome to our ward.
However, we did see that two patients were having care and treatment with the door or curtains left open. One patient next to the nurses’ station was left without appropriate clothing on for a short period of time and medical devices were left alarming and only turned off when mentioned.
Friends and Family test performance The friends and family test information was displayed in ward areas including follow up “You said, we did.”
The Friends and Family Test response rate for surgery at Sheffield Teaching Hospitals NHS Foundation Trust was 29% which was similar compared the England average of 29% from April 2017 to March 2018.
A breakdown of response rate by site can be viewed below.
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Friends and family test response rate at Sheffield Teaching Hospitals NHS Foundation Trust, by site.
(Source: NHS England Friends and Family Test)
Emotional support
There was a bereavement service, and multi faith chaplaincy services were available on site and staff could access these for patients.
Staff we spoke with felt able to provide support to relatives and visitors as well as to patients and felt this was an important part of their role. We observed theatre staff welcome patients into the anaesthetic room and provide assurance to patients in recovery.
Specialist nurses were also available to provide advice and support for patients.
Understanding and involvement of patients and those close to them
Patients and their families said to us they were involved in discussions about their care and treatment, those nearing discharge were also kept up to date with plans around discharge.
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Patients said staff kept them informed of what was happening and that they had been given explanations from medical staff; we saw this whilst observing ward rounds.
Staff showed a good awareness of patients with complex needs and gave examples of when they provided support for them and their families.
During our inspection we also saw a book for patients who have communication difficulties such as dementia or non-English speakers.
During safety huddles we saw from discussions that conversations with family and the individual patients had taken place.
We saw information displayed about various mental health conditions including delirium, dementia and depression.
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Is the service responsive?
Service delivery to meet the needs of local people
The trust engaged with internal and external stakeholders, patients, governors, members, partners and staff to plan services. Local clinical commissioning groups and the NHS England commissioned services within the trust. Some specialist services were provided regionally and nationally.
Staff created a room within the theatre department with a seating area, tea and coffee and a screened off area with a bed. Staff told us this has been used when consultants required somewhere private to talk to relatives and when there had been distressed and grieving relatives in the department.
The surgical directorate provided elective (planned) and non-elective (acute) surgical treatments for patients.
The directorate had improved collaborative working with commissioners and had commissioners on key groups within the directorate to plan and deliver services.
The day surgery unit had designated areas for those waiting for surgery and post-operative patients. The service was nurse led with clear discharge guidelines. All elective patients were followed up in a dressing clinic.
There was a specialist dementia lead nurse employed by the trust. The staff we spoke with felt confident in caring for patients who may need additional support.
Average length of stay
Trust Level – elective patients
From February 2017 to January 2018, the average length of stay for all elective patients at the trust was 4.3 days, which is higher compared to the England average of 3.9 days.
• For trauma and orthopaedics elective patients at the trust was 4.0 days, which is as expected compared to the England average of 3.9 days. • For neurosurgery elective patients at the trust was 3.2 days, which is lower compared to the England average of 5.0 days. • For urology elective patients at the trust was 3.5 days, which is higher compared to the England average of 2.5 days.
Elective Average Length of Stay – Trust Level
Note: Top three specialties for specific trust based on count of activity.
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Trust Level – non-elective patients
The average length of stay for all non-elective patients at the trust was 4.9 days, which is as expected compared to the England average of 4.9 days.
• The average length of stay for general surgery non-elective patients at the trust was 3.6 days, which is as expected compared to the England average of 3.8 days. • The average length of stay for trauma and orthopaedics non-elective patients at the trust was 9.5 days, which is higher compared to the England average of 8.7 days. • The average length of stay for colorectal surgery non-elective patients at the trust was 3.4 days, which is lower compared to the England average of 4.4 days.
Non-Elective Average Length of Stay – Trust Level
Note: Top three specialties for specific trust based on count of activity.
Northern General Hospital - elective patients
From February 2017 to January 2018 the average length of stay for all elective patients at Northern General Hospital was 5.9 days, which is higher compared to the England average of 3.9 days.
• The average length of stay for trauma and orthopaedics elective patients at Northern General Hospital was 4.9 days, which is higher compared to the England average of 3.9 days. • The average length of stay for colorectal surgery elective patients at Northern General Hospital was 7.5 days, which is as expected compared to the England average of 7.1 days. • The average length of stay for cardiac surgery elective patients at Northern General Hospital was 9.7 days, which is as expected compared to the England average of 9.0 days.
Elective Average Length of Stay - Northern General Hospital
Note: Top three specialties for specific trust based on count of activity.
Northern General Hospital - non-elective patients
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The average length of stay for all non-elective patients at Northern General Hospital was 5.6 days, which is as expected compared to the England average of 4.9 days.
• The average length of stay for general surgery non-elective patients at Northern General Hospital was 3.6 days, which is as expected compared to the England average of 3.8 days. • The average length of stay for trauma and orthopaedics non-elective patients at Northern General Hospital was 9.4 days, which is higher compared to the England average of 8.7 days. • The average length of stay for colorectal surgery non-elective patients at Northern General Hospital was 3.4 days, which is lower compared to the England average of 4.4 days.
Non-Elective Average Length of Stay - Northern General Hospital
Note: Top three specialties for specific trust based on count of activity. (Source: Hospital Episode Statistics)
Meeting people’s individual needs
We saw a range of patient information leaflets, including memory loss, confusion and dementia, and orthopaedic therapy service inpatient guide. Staff we spoke with said that these leaflets had improved patients’ understanding and expectations of their stay.
During our inspection, we did not see that the wards we visited were dementia friendly. On Vickers 4 we discussed this with staff who showed awareness of the limitations and had developed an action plan to improve this. The trust identified environmental issues in relation to dementia using the Kings fund assessment tool for Vickers 4.
However, there were dementia friendly dolls and stimulation hand muffs available.
The wards were accessible for people who used a wheelchair or walking aids. Disabled toilets and showering facilities were available in the ward areas we visited.
Assessments took place on admission or during pre-assessment to identify individual patients’ needs. This information was used to inform care planning. From speaking with staff and reviewing records we were assured that staff were aware and responsive to the needs of different people. Different food choices were available and chaplaincy for different religions and faiths.
Staff felt they were proactive in planning for the needs of bariatric patients. This was identified at pre- assessment, so all necessary equipment could be obtained in advance of the procedure to avoid any delays.
Wards had extended visiting hours of 8am-8pm, staff we spoke with felt this had had a positive impact on patients
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The medical team on the ward told us about a pathway that had been developed along with specialist nurses that ensured hip fracture patients once on the ward receive intravenous bone health medication.
The directorate had improved collaborative working with commissioners and had commissioners on key groups within the directorate to plan and deliver services.
Access and flow
Patients accessed the service either as a planned admission, through the emergency department or from GP referrals.
The department held bed meeting twice daily to review capacity and demand. These were attended by the appropriate professionals. Staff reported that waiting for home care packages often delayed discharge. There was a short-term intervention team to improve access and flow.
The department used a fractured neck of femur pathway to improve flow for patients from the emergency department to recovery. Staff reported that this was a positive change.
Within the surgical assessment unit, there was a bay for patient assessment, which was to prevent patients staying overnight.
Referral to treatment (percentage within 18 weeks) - admitted performance From April 2017 to March 2018 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently better than the England average and shows a stable trend from April 2017 where 86% of this group of patients were treated within 18 weeks versus the England average of 69% whereas in March 2018, 88% of this group of patients were treated within 18 weeks versus the England average of 68%.
(Source: NHS England)
Referral to treatment (percentage within 18 weeks) – by specialty A breakdown of referral to treatment rates for surgery across the trust and broken down by specialty is below. Of these, four of specialties were above the England average and one was below the England average. Specialty grouping Result England average Cardiothoracic surgery (NGH) 76% 82% Ophthalmology (mainly RHH) 85% 71% Neurosurgery (mainly RHH) 96% 71% General surgery (both) 87% 73% Trauma and orthopaedics (mainly NGH) 85% 62%
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Cancelled operations A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice
Over the two years, the percentage of cancelled operations at the trust showed a downward trend and was generally lower than the England average. In the period for January 2016 to March 2016, this trust cancelled 400 surgeries. Of the 400 cancellations 3% were not treated within 28 days whereas in the time period of July 2017 to September 2017, this trust cancelled 258 surgeries. Of the 258 cancellations 1% were not treated within 28 days. The Trust informed us that they chose not to follow the national guidance to routinely cancel elective procedures due to winter pressures.
Percentage of patients whose operation was cancelled and were not treated within 28 days - Sheffield Teaching Hospitals NHS Foundation Trust
The above graph shows the trust cancellation rates significantly lower than the England average.
Cancelled Operations as a percentage of elective admissions - Sheffield Teaching Hospitals NHS Foundation Trust
Over the two years, the percentage of cancelled operations at the trust showed an upward trend and was generally lower than the England average. Cancelled operations as a percentage of elective admissions only includes short notice cancellations. (Source: NHS England)
At the 2015 inspection, we saw a decrease in cancelled operation. During this inspection, we reviewed cancellations for clinical and non-clinical reasons. We saw that within surgical services between March 2018 and May 2018, an average of 312 patients or 5% a month had surgery cancelled.
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We reviewed theatre performance and utilisation data provided by the trust between March 2018 to May 2018. The trust reported an average touch time of 83.9%.
Senior staff monitored cancelled operations and completed a root cause analysis for patients that were not treated within 28 days. Clinical directorates held a weekly patient tracking list meeting.
Staff informed us that common reasons for cancellations were lack of theatre time or lack of appropriate equipment or if a patient became unwell. Staff reported cancellations occurred approximately two-three times per week. The theatre department had daily team huddles where staff tried to rearrange cancelled operations.
Surgical services had access to ambulatory care. Ambulatory care is used to assess and treat patients quickly, it helps to avoid unnecessary admissions and improves patient flow and experience. The directorate had also opened a surgical admissions lounge which enabled patients requiring surgery to be admitted to the lounge, go to theatre and then return to an appropriate bed on the ward.
Staff informed us that when an operation was cancelled an incident report would be completed. We attended a patient flow meeting, where we saw good discussion of patients due for admission, outlier patients, perceived risks patients awaiting transfers to other wards or hospitals had waited.
Learning from complaints and concerns From February 2017 to January 2018, there were 238 complaints about surgical care. The trust took an average of 28 working days to complete. The trust worked to a tiered response time process where the timescale was determined based on the complexity of the concerns raised. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale. Northern General Hospital: There were 124 complaints. There are no clear themes identified from our review of complaints. The Trust told us that upon receipt, themes were identified from every complaint entered into the complaints management system, Datix. These themes were monitored with an analysis featured in monthly, quarterly and annual patient experience reports. (Source: Routine Provider Information Request (RPIR) P61 – Complaints)
Staff said they always attempted to resolve specific issues at the time they arose and encouraged patients to speak out if they had concerns as early as possible.
Complaints were discussed at ward meeting with lessons learnt, staff gave us examples. Complaint meetings were held monthly and quarterly to look at key themes. All staff we spoke to felt they received timely feedback regarding complaints.
Is the service well-led?
Leadership
The senior management team within general surgery had oversight of the directorate, they were supported by an operational director and nurse director. During our inspection, there was a high level of staff engagement. Staff we spoke with said the senior management team were supportive but not visible on the wards and departments. However, staff within theatres were more positive
20171116 900885 Post-inspection Evidence appendix template v3 Page 151 around the visibility of senior management. Staff we spoke with also said that executive team were not visible, and they had not seen them visit their areas. However, staff told us the Nurse Director held drop in clinics for staff to attend on a rolling basis.
Junior medical staff said that they felt supported by senior colleagues. There was a clear leadership structure, which staff could explain Some senior staff we spoke with said that staff had been seconded into many of the nursing leadership posts such as ward manager and deputy nurse director.
Ward managers we spoke with described positive, supportive relationships with the senior leadership team and matrons. We found the ward managers on the wards we visited knowledgeable and professional. They appeared visible and approachable for the staff they supported. Junior medical staff we spoke with said they felt supported by senior colleagues.
Vision and strategy
The trust had a mission statement and staff we spoke with were able to articulate this statement. Staff were aware of the trust vision and values. We saw information displayed in the areas we visited.
Surgical services had a strategic plan this strategy referenced national reports recommendations, the values and linked into the making it better 2017-2020 strategy of the trust.
Culture
Staff we talked with said they felt valued by their patients, ward leaders and the trust. They said that morale was good within the wards and departments. They also said they were proud of the feedback they received from patients.
The senior management team were proud of staff working within the directorate and their resilience during ‘winter pressures’. Staff felt supported by their managers and colleagues at ward level.
Staff we spoke with wanted to provide effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams. Staff informed us they felt morale had increased and the team were approachable and encouraging. Volunteers in the department also said that they felt included and part of the team.
It was apparent that senior leaders, department managers and shift leads were proud of their staff and praised them in their work. They told us that staff often went above and beyond to provide care to patients when extreme pressures had been placed on the hospital.
In theatres staff told us that they have introduced surgeon of the week, which has had a positive impact on all staff. Nursing staff reported a positive culture and good working relationships between staff groups.
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Governance
There was a clear governance structure with clear lines of responsibility and accountability.
The leadership team reported directly to the executive board, and systems were in place to allow information from them to be shared at ward level. Within theatre the cascading of information to teams was via the band six team leaders from monthly meetings with their manager.
We reviewed the clinical governance report for the surgical directorate. Patient safety, quality and experience outcomes were RAG rated within the document to highlight good practice and areas for improvement.
We reviewed monthly clinical governance meeting minutes and action logs and noted they were not particularly well attended. There were ongoing actions in relation to staff appraisals and training compliance.
There were monthly mortality and morbidity meetings and clinical incident review group meetings. Feedback from medical staff was that the governance framework was clearer and speciality meetings were well established.
Management of risk, issues and performance
The surgical directorate risk register included risks from all the clinical services. The senior leadership team reviewed risks at divisional governance meetings and the directorate risk register fed into the overarching register for all acute services.
Incidents and sharing of information took place in all areas via daily safety huddles.
The service was engaged in national clinical audit programmes and there were local audits to monitor performance in areas such as cystectomy audit, bowel cancer audit and nephrectomy audit
The trust provided the audits of surgical safety checklist over the past 3 months. The trust had achieved or nearly achieving targets set. The areas that the surgical department did not achieve the targets set was checking patients for MRSA, checking patients for difficult intubation and aspiration risk- 95.8% and if all of the team paused for the ‘Time-out’. The trust set targets of 100% and had achieved 94% or above.
There was a surgical site meeting held every quarter attended by ward and theatre management, infection control lead and microbiologist. All root causes analyses were discussed. During our inspection we saw evidence of minutes and action plans.
The trust had a business continuity plan. This document detailed how the trust would respond to an incident or event, which disrupted services.
The directorate had a risk register which highlighted current risks and documented mitigating actions to reduce the risks. Data we reviewed showed that there were currently 103 risks with 11 currently rated as extreme risks, 57 rated as high risks, 31 medium risks and four low risks following identification of mitigating actions. These risks were reviewed at the governance meetings but in the minutes, we saw the minutes of the meeting and evidence of discussion and escalation of these risks to executive boards.
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We discussed with senior staff within the directorate about their highest risks, they identified staffing, performance, capacity, finance and pressure area management these risks were identified on the risk register.
Information management
During our inspection, we observed that staff could access information relating to polices and guidance electronically. The system was easy to navigate. Staff received training on information governance and were aware of the importance of managing confidential patient information.
Information provided by the trust, showed that 100% of medical and dental staff and 89% of nursing staff had completed information governance training. Compliance for medical staff rates were better than the trust’s target level of training of 90%, with nursing staff rates being similar.
We did not have any concerns during the inspection about the security of patient records.
Computers were available on surgical wards. During the inspection, all computers were locked securely when not in use.
Engagement
Staff we spoke with said they had changed practice in relation to feedback from patients. They provided an example of lowering noise levels at night and buying soft closing bins, ear plugs for patients and reminding staff to be quieter.
We saw thank you cards and letters displayed in the entrance to ward areas.
Staff felt positive about the future and felt involved in decision making about changes in practice. Staff told us they felt valued for the work they had done.
Learning, continuous improvement and innovation
Senior managers and team leaders spoke about driving improvement and encouraging innovation. Team leaders felt they were supported in trying new ideas or ways of working.
During the inspection we saw a new initiative was launched; “give it a go week” this prompted staff to think about and implement improvement.
Staff reported to us that due to issues with delayed discharge due to waiting for care packages, there was a campaign “Why not home? Why not today?”.
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End of life care
Facts and data about this service
The trust provides end of life care at Northern General Hospital. End of life care encompasses all care given to patients who are approaching the end of their life and following death. It may be given on any ward or within any service in a trust. It includes aspects of essential nursing care, specialist palliative care, and bereavement support and mortuary services. There is an inpatient specialist 18 bedded Macmillan palliative care unit which provides care to patients with life limiting conditions that includes those who are in the last weeks to days of life. The remaining inpatient beds are supported by the hospital palliative care team (medical and nursing) who provide a seven-day service to support all healthcare professionals to deliver end of life care. There is an out of hours on call provision 24/7 that can provide specialist registrar/consultant delivered face to face advice and support as required. The palliative care team work alongside learning and development to support education and training to all staff. (Source: Routine Provider Information Request (RPIR) – Context Acute)
The chaplaincy department offer services to patients, relatives and staff 24 hours a day, seven days a week operating on an on-call basis out of hours. The mortuary and bereavement services department were open Monday to Friday 8am to 5pm and operated an on-call out of hours service.
The trust had 2,619 deaths from February 2017 to January 2018. (Source: Hospital Episode Statistics)
This report predominantly focuses on the inspection of the services provided by the specialist palliative care medical, nursing and administration team, the mortuary staff and the chaplaincy and the bereavement team.
We inspected the whole core service and looked at all five key questions. In order to make our judgements, we spoke with two patients and 29 staff from different disciplines. We observed daily practice and viewed eight sets of records of patients at this hospital. Before and after our inspection, we reviewed performance information about the trust and reviewed information provided to us by the trust.
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Is the service safe? Mandatory training At our previous inspection in 2015, we found only two of 12 mandatory training topics were above the trust plan of 90%. Overall compliance was 79%. At this inspection, information provided by the trust showed overall compliance had improved to 93% which was better than the trust plan. However, we saw low compliance in some areas for example 80% of the administration staff in the specialist palliative care team were non-compliant with information governance training, medical staff were not meeting the compliance rate for infection prevention and control at 63% and the teams’ overall compliance with Mental Capacity Act and Deprivation of Liberty Safeguards training was 67%. Staff we spoke with told us they were up to date with training and they were supported to complete their training. Newly appointed staff completed end of life care training as part of their introductory training ‘prepare to care’. This included recognition of death and dying, case study scenarios for symptom control and good communication with patients and their relatives. The trust had recently rolled out an end of life care e-learning training module available on the trust e-learning portal. Staff involved in end of life care, including porters involved in the movement of deceased patients completed this training; however, it had not yet been made mandatory on the training system. We were told this would become a job specific training requirement for all relevant staff.
Safeguarding We spoke with specialist palliative care nurses who were able to clearly define their responsibilities in relation to safeguarding patients. They were able to share examples of when they had needed to submit safeguarding concerns for patients in their care. From April 2017 to April 2018 the Macmillan palliative care unit raised two safeguarding concerns; however, we were unable to establish any further information around these concerns.
Safeguarding Safeguarding Safeguarding Safeguarding Safeguarding Children & Young Children & Young Children & Young Vulnerable Adults Vulnerable Adults People People People Level 1 (3 Yearly) Level 2 (3 Yearly) Level 1 (3 Yearly) Level 2 (3 Yearly) Level 3 (3 Yearly)
Macmillan Palliative Care Unit 100.00% 95.20% 100.00% 100.00% 100.00%
Hospital Support Team 100.00% 100.00%
(Source: Data request DR051 – Safeguarding Compliance)
Information received from the trust showed the specialist palliative care team were 100% compliant with safeguarding vulnerable adults level two and safeguarding children and young people level one. We asked the trust why the team completed level one training and were told the training had been identified through a training needs analysis, as an appropriate level of training for this staff group. All patients seen by the specialist team would be under the care of medical and nursing staff who would have completed a higher level of training. The chaplaincy team were 100% compliant with level one safeguarding vulnerable adults and level one safeguarding children and young people training.
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The mortuary staff were 80% compliant with level one safeguarding vulnerable adults and level one safeguarding children and young people training. The trust told us this was due to long term sickness within the team.
Cleanliness, infection control and hygiene All areas we visited, that were providing care at the end of life, appeared clean and well maintained. This included ward areas, the mortuary and the bereavement team offices. Within the mortuary, there was clear separation of clean, transitional and dirty zones. Personal protective equipment (PPE) such as gloves and aprons were available, and this was stored appropriately, in a cupboard away from the post mortem room. At the last inspection in 2015 we identified that no one appeared to be responsible for cleaning the concealment trolley used to transport deceased patients to the mortuary. At this inspection we were told that porters cleaned the concealment trolley after patients had been transported to the mortuary and they completed this in line with infection prevention and control protocols. All deceased patients were transported to the mortuary in colour coded body bags. There was a process in place to identify patients with communicable diseases such as HIV; these patients would be placed in a white body bag. All other patients were placed in a black body bag. The Macmillan palliative care unit conducted regular audits to monitor compliance with a wide range of infection control protocols. Aseptic non-touch technique audit results showed 100% compliance in the last two quarterly audits:
(Source: data request DR053 EoL IPC audits) The cleanliness audit showed compliance against the 95% plan. However, the audit was scheduled to take place monthly and data submitted in June 2018 showed that audits had not been completed since March 2018:
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(Source: data request DR053 EoL IPC audits) Commodes were audited for cleanliness and the results showed 100% compliance over 10 months; however, the audits had not been completed monthly, with January and April missing. Reasons for non-compliance in May were clearly documented:
(Source: data request DR053 EoL IPC audits) Hand hygiene audits were scheduled to take place monthly. The data submitted in June 2018 showed that audits were 100% compliant; however, they were not always completed monthly. Records submitted showed that data only reflected six months’ worth of audits; December, January, March, April and May were missing from the records:
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(Source: data request DR053 EoL IPC audits) The service audited the cleaning and decontamination of equipment which showed 100% compliance over two reporting quarters:
(Source: data request DR053 EoL IPC audits) The service had an annual infection prevention and control review, in May 2018 the result was 83% which is marginally below the trusts target of 85%.
(Source: data request DR053 EoL IPC audits) The service also audited and monitored other key infection and prevention control measures such as the prescribing of antibiotics, dress code, handling and disposal of linen, urinary catheter
20171116 900885 Post-inspection Evidence appendix template v3 Page 159 insertion, urinary catheter (ongoing), reducing the risk of clostridium difficile, IPC link worker attendance at study days and standard precautions. We observed that staff adhered to the infection control policy and used personal protective equipment (PPE), such as plastic aprons and gloves, when delivering personal care to patients. We observed medical and nursing staff following the trust policy for hand washing and ‘bare below the elbows’ guidance in clinical areas. We saw that the sluice was clean and tidy. We checked six commodes and saw these had been cleaned and had ‘I’m clean’ labels in place to visually identify that they had been cleaned. There was hand gel available outside rooms and at key entrance/exit points throughout the unit with clear signage so that staff, visitors and patients used it appropriately. We saw that there were yellow sharps bins for the disposal of contaminated needles throughout the palliative care unit. These were easily accessed by staff. Colour coded plastic bags were used to separate clinical, domestic and offensive waste. Bags were easily available in various points throughout the unit and there was signage to explain what the colours meant in terms of waste segregation. Information provided by the trust showed 83% overall compliance with infection prevention and control training for the specialist palliative care team. Medical staff were 63% compliant which is below the trust plan however nursing staff were 95% compliant which is better than the trust plan of 90%.
Environment and equipment The 18-bedded unit was split in to four three bedded bays and six single rooms. Bays were organised in to single sex accommodation. Every bay area and single room had access to a landscaped garden at the rear of the unit and the doors to the garden were alarmed. At the last inspection in 2015 we found that underfloor heating installed throughout the palliative care unit had made the medicines room very warm. Staff had reported this as a risk because the high temperatures could affect the drugs fridge. Work had been due to take place to isolate the heating for that area of the building. When we returned we found that the underfloor heating had been removed in this area and an air conditioning unit added which enabled the temperature of the room to be controlled. The room was cool, and we checked fridge temperatures and found them to be within the acceptable range. We checked consumables and equipment in the clean utility/medicines room and found everything was within the documented expiry date. Staff told us that they had a member of staff who helped to rotate and manage consumable stock in this room which had helped to improve stock management processes. Electrical items we inspected had been PAT tested appropriately. The trust had a safe and robust medical device process to ensure reusable equipment was proactively managed throughout its life cycle. The trust used a single type of syringe driver. These met the national recommendations issued in 2011 by the national patient safety agency (NPSA/2010/RRR019 safer ambulatory syringe drivers). Registered nurses we spoke with told us they received training on the use of the syringe drivers at the start of their employment; they then completed a competency booklet and attended refresher training as part of their mandatory training. Staff reported they were supported with this training by the clinical educator. Information provided by the trust indicated overall compliance of 66% for staff at this hospital who were compliant with this training which is significantly lower than the trust plan. 20171116 900885 Post-inspection Evidence appendix template v3 Page 160
We saw the compliance rates varied from 0% on wards Brearley 3 and Robert Hadfield to 100% on wards Brearley 1 and Brearley 2. On the Macmillan palliative care unit 65% of staff were compliant with syringe driver training. Staff in the mortuary told us that the mortuary had been designed and built to comply with Health Building Note (HBN) 20 Facilities for mortuary and post-mortem room services. The mortuary had facilities available for bereaved relatives and carers. This included a pleasantly decorated waiting room, multi-cultural facilities and disabled toilet facilities. The mortuary had an enclosed drive in facility for undertakers. This area had a system in place to remove exhaust fumes which meant staff were not subject to toxic fumes. The mortuary had male and female staff changing rooms and showers available for staff. The Human Tissue Authority (HTA) is a regulator set up in 2005 created by parliament; they are an executive agency of the Department of Health. The HTA regulate organisations that remove, store and use human tissue for research, medical treatment, post-mortem examination, education and training, and display in public. The HTA had inspected the mortuary services for the hospital in May 2018, the final audit report had not been produced at the time of our inspection. However, the HTA had provided the trust with initial feedback, this included one major shortfall and related to a policy document which was out of date for review. Staff at the mortuary showed us evidence that the policy had been updated and an email from the HTA advising that they were satisfied with the actions taken. This meant that at the time of our inspection the services provided by the hospital met the required standards for premises facilities and equipment. The fridges in the mortuary had an electronic automated alarm system to alert staff if the temperature of any individual fridge rose above 12 degrees centigrade. Staff were available 24 hours per day in case of emergencies. The mortuary had 120 fridges and five freezers for longer term storage. To support the trust during the winter pressures a temporary storage facility, with 28 additional spaces had been put in place. The room where the fridges and freezers were located was also cooled; this meant that bodies could be stored outside of a fridge space if necessary. We were told this occurred if a bariatric patient was brought to the mortuary at a time when there was not enough staff on duty to safely move the patient. In these cases, the patient could remain on their hospital bed until sufficient resource was available. A porter showed us the route that would be taken when transferring a deceased patient to the mortuary. Part of this journey was external to the hospital buildings, visible to the public and adjacent to a local bus route. This was highlighted as a concern by staff at the trust and the HTA. Senior pathology staff told us that a business case was being prepared to change the layout of the mortuary which would enable the creation of an internal entrance.
Assessing and responding to patient risk The specialist palliative care team were available to provide help and support to care for any end of life care patient across all wards. At our previous inspection in 2015 we found once it was clinically indicated that someone was nearing the end of life and had increased needs, nurses could refer to the guidelines on the intranet. This process however, was reliant on the individual general ward nurses skills and experience; there were no ‘triggers’ or formal pathways to support the decision making. At this
20171116 900885 Post-inspection Evidence appendix template v3 Page 161 inspection we found that the palliative care team had introduced a comprehensive end of life intranet site and clear ‘guidance for the care of the person who may be in the last hours to days of life’; they had also introduced rapid discharge home to die pathways for patients from general wards and the emergency department. The trust used an adapted version of the national early warning score called SHEWS to monitor for deterioration of a patient. We spoke to staff on general wards and the Macmillan palliative care unit about pressure relieving mattresses. Staff knew how to request and access pressure relieving mattresses to nurse end of life patients on, however they told us that there was sometimes a delay in receiving the mattresses. Delays reported ranged from two days to one week.
Nurse staffing The trust reviewed staffing twice per year, in January and June, using an acuity tool. Staffing on the unit was planned around the acuity and the dependency of the patients admitted to the unit. The unit operated on the following numbers based on 18 beds: Planned staffing 13 June 2018 Morning Afternoon Night Registered Nurse - 5 Registered Nurse - 4 Registered Nurse - 2 Healthcare Assistant - 2 Healthcare Assistant - 2 Healthcare Assistant - 2
Actual staffing 13 June 2018 Morning Afternoon Night Registered Nurse - 4 Registered Nurse - 4 Registered Nurse - 2 Healthcare Assistant - 2 Healthcare Assistant - 2 Healthcare Assistant - 2
The planned and actual staffing levels were clearly displayed on the unit. Staff we spoke to felt staffing levels were appropriate for the unit. However, at peak times of the year, for example during winter, staff could be moved off the unit to cover elsewhere. Staffing numbers were never allowed to drop to unsafe levels and staff moves were agreed based on patient numbers in the unit and their acuity. The unit had a senior charge nurse (ward manager) who worked Monday to Friday. Their role was split in to 40% managerial and 60% clinical, which translated in to two managerial days where they were not counted in the actual numbers and three clinical days where they were counted in the actual numbers. To support the ward manager there were two senior sisters and a matron. Overall staffing rates At this hospital there were 4.4 wte specialist palliative care nurses in the hospital support team. In addition, four of the registered nurses on the Macmillan palliative care unit held an accredited palliative care qualification. This meets the commissioning recommendations for specialist palliative care of one wte palliative care nurse per 250 hospital beds.
Vacancy rates
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The trust told us the vacancy rate for the specialist palliative care team was 8.9%. The trust did not provide an aspirational vacancy rate. At the time of our inspection there were no vacancies in the hospital support team. There was a 0.8 wte vacancy on the Macmillan palliative care unit. However, information provided by the trust indicated this vacancy had been recruited to and a new starter was due in post in September 2018.
Turnover rates The trust told us the turnover rate for the specialist palliative care team was 4.8%. This is better than the trust aspirational rate of 15%. Following our inspection, we received updated information which indicated the turnover rate for the Macmillan palliative care unit was 4.1%. The turnover rate in the hospital support team trust wide was 8.3%.
Sickness rates The trust told us the specialist palliative care team had a sickness rate of 5.4% which is worse than the trust aspirational rate of 4%. Following our inspection, the trust provided information which showed the sickness rate for the Macmillan palliative care unit was 6% and the sickness rate for the hospital support team was 3.6%.
Bank and agency staff usage We requested data on the use of bank and agency staff usage within the specialist palliative care nursing team. The trust told us there had been no requests for bank or agency staff to cover specialist palliative care nurses in the last twelve months. The Macmillan palliative care unit at Northern General hospital reported a bank and agency usage rate of 53% from May 2017 to April 2018, there were 573 shifts available of which 302 were covered by bank staff, two covered by agency staff, leaving 242 shifts uncovered. (Source: data request DR061 EoL nurse staffing)
Medical staffing The trust provides acute and community services to a population of 640,000. Commissioning guidance for specialist palliative care recommends the minimum requirements for this population size are two whole time equivalent (wte) consultants in palliative medicine and two wte additional supporting doctors (e.g. trainee/specialty doctor) The trust met this recommendation as they employed 6.7wte specialist palliative care consultants and seven wte registrars. There was a 24 hour on call rota for palliative medicine during the week and at the weekend. On call was covered by a specialist registrar (First call) and then the consultant if further advice was needed. The on-call rota operated from 5pm until 9am Monday to Friday and 9am until 9pm at weekends. The process for contacting the palliative doctors out of hours was for a doctor from the ward to call the specialist registrar. If required, the specialist registrar would contact the consultant on call for further advice. If physical assessment was required, the specialist registrar would attend the ward and if urgent attention was required the consultant would attend. Vacancy rates The trust reported that there were no medical staffing vacancies for end of life care medical staff. 20171116 900885 Post-inspection Evidence appendix template v3 Page 163
Turnover rates The trust told us there was a 12.5% turnover rate for medical staff within end of life care services. This is lower than the trusts aspirational rate of 15%.
Sickness rates The sickness rate for medical staff within end of life care services was 5%. This was worse than the trusts aspirational rate of 4%.
Bank and locum staff usage The trust did not report bank and locum use in hours or shifts. They reported there had been no agency consultant cover. Bank consultant costs, in the twelve months from May 2017 to May 2018, were reported as £18,729.77 and £26,340.00 for junior medical staff. The total spend was £45,069.77.
Records We looked at the care records of eight patients. Two patients were under the care of the specialist palliative care team and six patients were on the Macmillan palliative care unit. We saw that where appropriate a ceiling of care was documented. A ceiling of care is the documentation of discussions around care that should be given to the patient and provides information about limitations to interventions which are likely to be futile, burdensome, or contrary to the patient’s wishes given their terminal diagnosis. We saw that the specialist palliative care nurses completed a holistic review of each patient including their physical, spiritual and psychological needs. We saw that the team completed regular reviews and that their documentation was clear, legible and completed in line with the Nursing and Midwifery Council (NMC) standards for record keeping. We did not have any concerns about the security of patients’ medical or nursing records.
Medicines Medicines at the palliative care until were stored appropriately in a locked room. Controlled drugs were kept in a locked cupboard and the controlled drugs book was completed appropriately. We reviewed an error that had been crossed out and initialled appropriately, in line with policy and best practice. Medications had been transposed correctly and page numbers correlated with what was recorded in the book. We observed nurses preparing a controlled drug for administration to a patient, checking the preparation, reconciling the stock and recording this appropriately in the controlled drugs book. Medicines that required refrigeration were kept in a fridge in the locked room. Fridge temperatures were monitored and recorded appropriately. We reviewed electronic prescription records for five patients receiving end of life care. Anticipatory medications had been prescribed appropriately and syringe driver checks were documented in the patients’ records.
Incidents Staff from the palliative care team told us that they were able to report incidents via the trust electronic reporting system.
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We saw evidence of trust wide incidents reported on NRLS between 1 June 2017 and the 31 May 2018 relating to patients receiving palliative care. There were 194 incidents reported in relation to palliative medicine, all rated low or no harm. Staff advised the inspection team that they received shared learning from incidents across the trust through trusts alerts and bulletins. Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2017 to April 2018, the trust reported no incidents classified as never events within end of life care. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, no serious incidents (SIs) occurred in end of life care at the trust which met the reporting criteria set by NHS England from May 2017 to April 2018. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Safety thermometer The Macmillan palliative care unit displayed their safety thermometer results clearly on site. Below is a breakdown of the safety thermometer results over a 12-month period from May 2017 to May 2018.
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Is the service effective? Evidence-based care and treatment Policies used by the service were available for staff to access on the trust intranet. These included a range of pathways and guidance which reflected national evidence based best practice and guidelines, for example, ‘guidance for the care of the person who may be in the last hours to days of life’ which reflected ‘Five priorities for care of the dying person’ and rapid discharge pathways for general wards and the emergency department. The Gold Standard Framework accreditation is an independently validated marker of excellence for palliative and end of life care. We asked the trust about gold standards accreditation and were told Sheffield Teaching Hospital NHS Foundation Trust does not have the Gold Standards Framework accreditation. No further information was provided by the trust. At the previous inspection in 2015 we found there was variable compliance with national standards for completion of DNACPR forms. At this inspection we found the trust had completed an annual DNACPR audit which not only looked at the completion of the forms, but the discussions conducted with the patient and the timings for decision making. The audit had improved significantly, results from the previous audit placed compliance at 44%, following the most recent audit compliance was at 78%. The audit found that the average time taken to make the decision to implement a DNACPR was nine weeks before the patient died. However, the median time was identified as one week and three days. This had flagged the need to further understand the timing of the DNACPR decision. An action plan had been developed and a re-audit date for December 2018 had been set to measure the impact of the actions. The trust used a Sheffield version of the national early warning score (SHEWS) based on NICE guidelines, to monitor for deterioration of a patient. The clinical fellow in palliative care had designed and circulated questionnaires for medical staff, nursing staff and other multi-disciplinary team (MDT) staff across the trust to benchmark understanding and confidence in relation to palliative care and to better inform the palliative care team of the needs of the medical, nursing and MDT staff population.
Nutrition and hydration In the records we reviewed a malnutrition universal score tool (MUST) was completed and had scores recorded to identify patients who were at risk. Staff were able to access support from dieticians when required. Matrons conducted audits on swallowing assessments and the completion of nutrition and hydration tools. Patients received nutritional assessments and had MUST scores recorded There was a main waiting area in the reception of the palliative care unit where a vending machine was available for staff, patients and visitors which provided a range of snacks. On the main ward area next to the quiet room, there was a tea and coffee machine for patients and relatives. Patients had regular mealtimes, breakfast was served flexibly as the patient woke, lunch was served at 12.30pm and dinner served at 5.30pm. Meal times were displayed at the entrance to the ward, so relatives and visitors were aware of these timings. Staff told us there was a separate fridge in the kitchen, so the unit could store food brought in for patients by their visitors. If a patient wanted a specific meal these requests could be accommodated by staff. For example, if a patient coming to the end of their life requested a pizza
20171116 900885 Post-inspection Evidence appendix template v3 Page 166 or fast food meal, this could be ordered and accommodated so that the patient received the food they wanted to enjoy at that time. We spoke to one patient who told us they had difficulty eating and drinking and staff had addressed these issues and were supporting the patient to eat and drink. The Macmillan palliative care unit had trained volunteers who could assist patients to eat if they required extra support.
Pain relief Patient records showed that pain relief was being prescribed to patients appropriately. We saw pain assessment was part of the Sheffield Early Warning Score (SHEWS) chart. We saw patients’ pain levels were assessed regularly and when pain relief was administered this was evaluated for efficacy. Ward staff told us if a patient was struggling with pain control, the specialist palliative care team could assist and advise on alternative pain relief. There had been no pain audits specific to end of life care carried out in the last 12 months. However, in the 2016/17 end of life care satisfaction survey 84% (222) responders felt the patient’s pain was controlled. One patient on the Macmillan palliative care unit told us that when they had pain they did not have to worry about it as they knew staff would come quickly when asked and the pain relief offered helped a lot.
Patient outcomes In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. The mortuary team told us that they were involved in the trusts learning from deaths procedures as it had been highlighted that the review of medical notes had caused delays in deceased patients being released from the mortuary to the chosen undertakers. The Trust’s end of life project steering group audited the Macmillan palliative care unit e- whiteboard handover process on the 31 August 2017. The team identified that handover was a potential time for errors to occur. The team conducted an audit using The Royal College of Physicians and the Academy of Medical Colleges guidance on handover. Outcomes included utilising the multi-disciplinary team on the Macmillan palliative care unit to develop a standard operating process (SOP) for the whiteboard e-handover. Professionals involved in the development of the SOP then provided training to all staff that used the whiteboard e-handover, including healthcare assistants who may potentially only read the handover and not input data. This ensured that all staff involved in patient handover understood the process and the new SOP was introduced on the 7 August 2017. Key successes Key concerns Key actions following the audit Appropriate team members at Summary of symptoms / Development of SOP for the handover. Good information in problems should be clearer and Macmillan palliative care unit e- the medical notes about improved documentation required whiteboard, development of an advance care planning. for care needs and advanced agreed handover process, care planning. discussion with e-whiteboard
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system designers to see if additional fields can be added.
(Source: Universal PIR 2018.03.06) An electronic patient record system was in use which included an end of life care section. This allowed staff to record a patient’s preferred place of care and death. This also included a section to record whether preferred place of death was achieved and if not why not. However, the trust had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. However, we did see establishing patient’s preferred place of care was a priority and this was clearly documented in patients care records. End of life care Audit: Dying in Hospital The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed better than the England average for two of the five agreed clinical indicators: • Metric 1: Is there documented evidence within the last episode of care that it was recognised that the patient would probably die in the coming hours or days? % YES - 86% compared to the national aggregate of 83% • Metric 2: Proportion of patients for whom there was there documented evidence within the last episode of care that health professional recognition that the patient would probably die in the coming hours or days (imminent death) had been discussed with a nominated person(s) important to the patient? - 80% compared to the national aggregate of 79%
The trust answered yes to three of the eight organisational indicators: • Metric 7: Did your trust seek bereaved relatives’ or friends’ views during the last 2 financial years (from 1 April 2013 to 31 March 2015)? • Metric 9: Was there face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to Sunday? • Metric 10: Does your trust have one or more end of life care facilitators as of 1 May 2015? (Source: Royal College of Physicians)
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The trust had detailed actions needed to improve their audit outcomes in the next audit. We reviewed the actions identified and the trust had achieved many of the identified actions, including the introduction of a personalised care plan, sign off to recruit a lead nurse role, end of life e- learning and sign off to recruit a full-time facilitator role. The medical director chaired the end of life project steering group and provided representation from the trust’s executive team.
Competent staff We spoke with two specialist palliative care nurses at the hospital who told us that all members of the team had completed a post graduate study in palliative care. This included studying to degree or masters level in palliative care. In addition, all the specialist nurses were non-medical prescribers. We spoke with the end of life care facilitator who told us they worked 15 hours per week. We were told about the educational opportunities that were offered to all staff working across the trust. This included some planned training on the recognition of death and dying, care in the last hours and days of life, symptom control and holistic care of dying patients. The trust had more than 100 end of life care champions across general wards and was using the Yorkshire and Humber learning outcomes for end of life care as baseline competencies for the champions. In addition, the specialist palliative care team had provided training to the chaplaincy volunteers and were looking to roll this training out for the end of life care volunteers. The trust provided end of life care training twice a year for approximately 120 junior medical staff. Advanced care planning (ACP) was included as part of this training. ACP is the term used to describe the conversation between people, their families and carers and those looking after them about their future wishes and priorities for care. Nursing staff from the specialist palliative care team told us that they received clinical supervision once a month from a clinical psychologist which was internally provided and funded by the trust.
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Some members of the team also accessed external support from a psychotherapist. Staff we spoke with told us that this supported them to cope with their emotions related to the role they provided. We were told that the weekly multidisciplinary team meeting also provided informal supervision because this included a whole team review of the entire caseload. We were told that the team worked together to ensure that support was provided where needed. The team members also described an informal process of peer review being undertaken when they reviewed patients on a weekend who had been under the care of another team member.
Appraisal rates The trust set a compliance rate of 90% for staff having an annual appraisal. At the time of our inspection the chaplaincy team met this, being 90% compliant. Nursing staff were 87% compliant which is marginally below the plan. However, the mortuary staff were 67% compliant which is significantly worse than the trust plan. The trust did not provide data for the specialist palliative care team medical staff.
Multidisciplinary working The specialist palliative care team held a multidisciplinary meeting each Monday. At this meeting a full review of all patients on the team’s caseload took place. Any patient referrals received over the weekend were ‘shared’ between the team members. On a Friday a handover of all patients needing review over the weekend took place. The specialist palliative care team reported that they had developed positive team working with all wards caring for patients at the end of their life. They described part of their role as ensuring that general ward teams were empowered to effectively care for these patients. The acute palliative care consultant attended the frailty team huddles twice a week which helped to identify patients who were suitable for the service.
Seven-day services There was a 24 hour on call rota for palliative medicine during the week and at the weekend. On call was covered by a specialist registrar (First call) and then the consultant if further advice was needed. The on-call rota operated from 5pm until 9am Monday to Friday and 9am until 9pm at weekends. The specialist palliative care team nurses had been providing a seven-day service since 2012. Staff working in the mortuary were available Monday to Friday from 8am until 5pm. An on-call system was in place out of hours and at weekends for any concerns or for family viewings. Chaplaincy services were available 24 hours a day, seven days a week. The chaplaincy service had a chaplain on call rota and a chaplain worked across site on an on-call basis out of hours.
Health promotion
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Due to the complex needs and terminal prognosis of the patients on the Macmillan palliative care unit, health promotion materials were not presented in the same way they would be to a patient in the general hospital population with a non-terminal prognosis. Patients were given leaflets from Macmillan cancer care. These included advices about diagnosis and treatment as well as maintaining a healthy lifestyle. For further information on health promotion on general ward areas, please see the Medical care (including older people’s care) evidence appendix.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Consent to treatment means that a person must give their permission before they receive any kind of treatment or care. An explanation about the treatment must be given first. The principle of consent is an important part of medical ethics and human rights law. Consent can be given verbally or in writing. The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. Where someone is judged not to have the capacity to make a specific decision (following a capacity assessment), that decision can be taken for them, but it must be in their best interests. The Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person's best interests. Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are the Deprivation of Liberty Safeguards (DoLs). DoLs can only be used if the person will be deprived of their liberty in a care home or hospital. We looked at the trust’s policies for consent and mental capacity act, including DoLs. We found that these were in date and contained appropriate references to legislation such as the mental capacity act, equality and diversity and the human rights act.
Mental Capacity Act (MCA) and Deprivation of Liberty safeguards (DoLs) training completion Information provided by the trust showed overall compliance for MCA and DoLs training was 67% for nurses, medical staff and chaplains in the end of life care team which was worse than the trust plan of 90%. We requested these figures for mortuary and bereavement staff, but these figures were not provided.
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Is the service caring? Compassionate care We observed patients being treated with privacy and dignity. We observed a number of interactions between staff, patients and relatives. Staff were polite, respectful and professional in their approach. We observed staff responding compassionately to patients’ pain, discomfort and emotional distress in a timely and appropriate way. Confidentiality was respected in staff discussions with people and those close to them. Staff spoke about patients with complex needs in a respectful way and demonstrated a non- judgemental attitude. We spoke to two patients on the Macmillan palliative care unit. One patient told us that when they struggled with symptoms of their illness, staff would come and sit with them and give them the confidence to cope. Another patient told us the care was “very good” and they felt communication was clear, but they did not always feel they had time to ask questions. However, the patient felt their needs were being addressed and the staff were supportive.
Emotional support There was support available for patients and staff from the chaplaincy service. The chaplains were available 24 hours a day. The bereavement team dealt with all aspects of care for the bereaved family. This included ensuring death certificates and cremation forms were completed appropriately and in a timely manner and families received help and support to contact the registrar’s office. Families were provided with a release form which they completed and gave to their chosen undertakers. The undertakers then provided this to the mortuary staff when collecting the patient. Part of a deceased patients journey to the mortuary was external to the trusts buildings. We were concerned patients were being transported through a public area which was adjacent to a bus route. Staff we spoke with told us a business case was being prepared to enable the creation of an internal entrance to address this. Staff on the Macmillan palliative care unit supported families emotionally. Staff told us at any one time they had at least 36 people to support on the unit, 18 patients and then one family member or visitor as a minimum. Patients regularly had more than one visitor and we observed that staff were visibly caring in the way they communicated. We observed staff offering emotional support to patients and visitors.
Understanding and involvement of patients and those close to them Patients told us staff explained their care and treatment to them in a way they could understand. We observed staff communicating in a way that people could understand and was appropriate and respectful. Patients and relatives told us they were kept informed of what was happening and understood what the plan of care was. The trust conducted an annual end of life survey. The key results below were from 297 respondents to the survey conducted from July 2016 to June 2017. There were 85% of respondents who rated the care given to their loved ones in the last days to hours of life as excellent or good, 6% felt care given was fair, 7% felt care given was poor and 2% of respondents did not know.
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(Source: P94 end of life survey report)
Is the service responsive? Service delivery to meet the needs of local people End of life services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. End of life services were delivered to meet
20171116 900885 Post-inspection Evidence appendix template v3 Page 173 the needs of the local population, to ensure patients received coordinated care that was accessible and responsive to people with complex needs. Within the city of Sheffield good partnership working was in place with the local hospice, clinical commissioning group, the citywide end of life care steering group, primary health care providers across the city and Sheffield City Council. The trust also worked collaboratively with other specialist palliative care providers in the surrounding area such as those in Rotherham, Doncaster and Barnsley. At a regional level, the trust was a member of the Yorkshire and Humber Regional End of Life Care Group. The acute and community teams worked closely to deliver responsive care to patients at the end of their life. For example, a consultant told us specialist teams would liaise with acute or community specialist palliative care team members to arrange the care for patients. There was a palliative care outpatient clinic at Northern General Hospital on Thursday and Friday each week. Clinics also took place at the trusts other acute hospital sites on Monday, Tuesday and Wednesday. This meant there was access to a clinic every week day. The trust employed 14 chaplains which met the NHS Chaplaincy Guidelines 2015 Promoting Excellence in Pastoral, Spiritual & Religious Care guidelines. In addition, there were also chaplaincy volunteers. The multi-faith chaplaincy department had a diverse range of chaplains to reflect the religious, cultural and spiritual needs of the local population. There were Muslim chaplains, Roman Catholic chaplains, generic Christian chaplains and an honorary Buddhist chaplain. The chaplaincy department also had faith contacts in the community they could utilise if required. The chaplains worked on a 24-hour basis over the whole trust. There was a chapel that provided a Sunday service, two Muslim prayer rooms and a multi-faith room located in Northern General Hospital. The Macmillan palliative care unit had a social worker based at the unit who staff could refer patients to.
Meeting people’s individual needs
There was a main waiting area in reception of the Macmillan palliative care unit that was comfortably furnished and well decorated. There was a vending machine available for staff, patients and visitors which provided a range of snacks.
The unit had a quiet room that families could use whilst visiting. The room was tastefully decorated with comfortable seating. The room displayed a moving poem a patient had written for staff at the unit.
Staff told us that they would move dying patients from a bay in to a single room so that they could ensure patients privacy and dignity was maintained and so relatives could stay with the patient overnight and have more room.
All specialist palliative care nurses were non-medical prescribers, this meant that any medicines that were required to treat patients’ symptoms could be prescribed in a timely manner and there were no delays in care and treatment being provided.
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The trust had two Muslim chaplains who supported patients and were also available to provide support to staff when caring for Muslim patients and their families.
Two of multi-faith hospital chaplains had recently facilitated a session for the end of life care champions study day around meeting religious, spiritual and cultural needs.
The multi-faith chaplaincy department had a returning patients list which was checked daily. Any patient that had previously used the chaplaincy department would be identified and the chaplains would go out to see the returning patient without the need of a referral. This provided an excellent responsive service to patients who could then be seen without delay, which was important for patients nearing the end of their lives.
Staff we spoke with were focused and knowledgeable about supporting patients and their families from different cultural and ethnic backgrounds. They told us that they could access translation and interpretation services. They explained that this was essential when dealing with sensitive information. We were given an example of when the team had suspected that a family was withholding information from a patient whose first language was not English and how they managed this sensitive issue and supported the patients and the family.
We saw posters on the wall of the Macmillan palliative care unit advertising that the trust could provide leaflets and information in languages other than English. There were posters that also gave the option of requesting information in large print or easy read formats if required.
One of the specialist palliative care nurses was the teams’ lead for learning disabilities. Staff were aware of, and gave good examples of, caring for patients and family members with learning disabilities.
The emergency department had volunteers called ED pastors. The chaplaincy department felt that the presence of the ED pastors had helped to widen chaplaincy access and enabled them to reach more end of life patients arriving in the emergency department.
The Macmillan palliative care unit utilised volunteers for an innovative project called ‘oral history in palliative care’. The project was coordinated by the University of Sheffield. The oral history project involved the recording of unique life experiences. It captured voices and memories and people were involved in the process of producing their own life histories. The oral history project complemented the palliative care services offered at the unit by offering time to reflect, record identity and make a family record in the teller’s voice. These memories and life stories could be about anything the patient wished to talk about, which placed the patient at the centre of the experience. Participants received an audio CD soon after their interview and recordings were securely archived. With consent, interviews were available for palliative care research. Interviews were carried out by volunteer oral history interviewers, who were trained and supported in the practical, emotional and ethical complexities of the work. We spoke to a volunteer who told us when a patient passed away; their family could still listen to their voice on the CD and re-live special memories. Where patients could not verbalise their story, the oral history volunteers would work with the patient to write a letter with their memories that could be passed on to a loved one when they passed away.
The unit had an art therapy project and the artwork created by patients from the unit was due to be exhibited at the Millennium Gallery in Sheffield. The walls of the palliative care until had patients’ artwork displayed which provided a personalised feel.
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The unit had open visiting hours and could accommodate visits from children and pets, with prior arrangement by the ward manager. There was accommodation available for relatives to stay with their loved one when they were approaching the end of their life.
The family of a young patient had donated an electronic gaming system to the unit which were available for all patients to use.
The ward clerk at the Macmillan palliative care unit helped to organise letter writing and the creation of memory boxes for patients approaching the end of their life. Letters written were in the patient’s words and the unit could use charitable funds to purchase small gifts, that the patient requested, to be placed in memory box and left to the patient’s family.
Every bay area and single room in the Macmillan palliative care unit had access to a landscaped garden at the rear of the unit. Staff told us that patients could eat their meals outside when the weather allowed, and they could spend time with their friends and family in the garden when they visited. Patients could also use the garden for celebrations or quiet times, such as reading.
The unit worked with a local cancer charity that regularly attended the unit to support patients and relatives to talk about their thoughts and feelings in a safe and non-judgemental environment. Charity staff also offered complementary therapy treatments for patients, relatives and staff.
Staff on the Macmillan palliative care unit regularly organised and facilitated personalised events for patients, examples included: afternoon tea parties, DVD and pizza nights, pamper nights, weddings, Easter egg hunts, Christmas dinner for a family where the patient was unable to go home to celebrate, graduations, christenings and blessings, pet visits, ‘spa’ treatments and family celebrations. We were inundated with examples of events that had been arranged, sometimes at very short notice for patients. Staff reiterated that they would try and accommodate any request to meet the individual needs of the patient approaching the end of their life.
The Macmillan palliative care unit had a separate entrance/exit for ambulances to collect patients that had passed away. The exit was operational 24 hours a day and was away from other patients in the unit. There was a room near the exit with a spare hospital bed, where families could stay with their loved ones whilst waiting for them to be transferred to the mortuary. Staff told us that families could spend time with their loved ones in this area after death and nurses could perform last offices here after the family had departed and prior to deceased patients being collected. The area was curtained off and through a staff only door to protect the privacy and dignity of the deceased and their family.
Staff in the mortuary were aware of the multi-cultural needs of deceased patients and their families. Resources to support different cultures were kept in the relatives’ waiting room.
The wards worked with the mortuary to facilitate the rapid release of deceased patients, so their faith needs could be met. The mortuary staff had an out of hours on call service to enable families to visit their loved ones after death.
Access and flow
We spoke with members of the specialist palliative care team who advised that referrals to the team were sent via a fax to the administrator for the service. These were then forwarded to the
20171116 900885 Post-inspection Evidence appendix template v3 Page 176 coordinator. From Monday to Friday one of the team acted as the coordinator. On Saturdays and Sundays one specialist nurse was on duty and they received all referrals. The trust standard was that the palliative care team would review patients within 24 hours of receipt of a referral. In some cases, verbal advice was given to the referring ward for example on Saturdays and Sundays, when only one specialist nurse was on duty.
The specialist palliative care nurses reviewed and triaged all referrals in to the team. Where necessary patients could be referred for a review by a palliative care consultant.
Information provided by the trust showed response times for the specialist palliative care hospital support team from June 2017 to June 2018. This showed that trust wide 2192 (80.5%) patients were seen on the same day as they were referred and 249 (9.1%) were seen within 24 hours. Less than 1% patients waited more than 2 days.
Staff from the acute team referred patients to the community team when their acute episode of care was completed. They were also able to refer patients for admission from a general ward to the hospital’s Macmillan palliative care unit when longer term specialist care was required.
The Macmillan palliative care unit team met every morning, Monday to Friday for a multidisciplinary referral meeting. Patients’ referrals were discussed, and decisions were made based on the complexity of the patient and their individual needs. Staff told us that patients admitted to the unit were complex palliative cases, requiring high dependency and high acuity care for multifaceted physical, mental or emotional issues. Patients were not always admitted for physical health reasons; staff placed emphasis on a holistic approach to patients and their mental and emotional health alongside their physical condition. We reviewed the care records of a patient with complex mental and emotional needs at the Royal Hallamshire hospital and saw evidence of their referral and agreement to admit to the Macmillan palliative care unit at Northern General Hospital the following day.
Northern General Hospital had an innovative ‘front door response team’ based in the accident and emergency department. Their remit was to turn around end of life patients who wished to die at home to avoid unnecessary admittance to hospital. They told us end of life patients would sometimes attend the A&E department when they were struggling with pain relief and symptoms of their illness. These patients did not want to be admitted to hospital and wanted to return home to continue their planned palliative care package, however prior to the front door response team, these patients may have been admitted and lost their package of care at home, lengthening their stay until the care package could be reinstated which may have resulted in the patient not achieving their preferred place of death. The trust reported that the intervention of the front door response team had resulted in 20 admission avoidances for end of life patients. There were separate comprehensive ‘emergency department discharge to die’ pathways depending on whether the patient presented out of hours (8pm – 8am and weekends) or in general hours (8am to 8pm, Monday to Friday). There was also a checklist within the discharge to die pathway to ensure everything the patient needed was in place on discharge.
Checklist for discharge to die from Emergency Department The front door response team had access to ‘comfort boxes’ that contained essential items for patients to take home to die. This meant that patients and their families had access to essential items without delay.
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The front door response team liaised with the intensive home nursing team and community nursing teams to ensure that there was support in place for the patient at home and anticipatory medications and syringe drivers could be accessed 24 hours a day and sent home with the patient. The front door response team provided an excellent rapid approach to the treatment of patients that could otherwise be admitted to hospital, lose their home care packages and be unable to be discharged home to die until these packages were reinstated.
At Northern General Hospital they had recently appointed an ‘acute’ palliative care consultant. Their remit was to outreach predominantly in to the accident and emergency department, the frailty unit and the acute medical unit to try and widen the access of the palliative care team to patients who were suitable for the service but may not be identified and referred to the team until later in their hospital stay. The acute palliative care consultant attended the frailty team huddles twice a week which helped to identify patients who were suitable for the service. This was an excellent pro-active approach and ensured that patients were identified early on in their hospital stay and their care could be planned around their wishes, for example their identified preferred place of care and their preferred place of death.
The trust reported 304 delays for fast track discharges between June 2017 and May 2018, of these 259 were for this hospital and 22 were from the Macmillan palliative care unit. The trust did not provide data which gave details about the reasons for the delay or the length of the delays.
The trust reported the below figures for referrals for the central campus, covering Northern General Hospital and the Macmillan Palliative Care Unit:
Northern General Hospital
1,564 referrals were received by the team 6,070 contacts were made by the team. 41% of referrals had a non-cancer diagnosis, this mirrors last year’s numbers Of the 1,592 discharges in the year, 36.9% (586) died on a ward at NGH, 26.1% went home, 15% transferred to a hospice/palliative care unit & 3.2% were discharged to a care home. Average length of time on the caseload was 5.6 days, a decrease from 6.8 days in the previous year. The longest time on the caseload was 113 days. The hospital support team was involved in 25.9% (586) of the total deaths at Northern General Hospital (2265)
(Source: Data request DR184 percentages of patients receiving end of life treatment)
Learning from complaints and concerns
Staff told us complaints or concerns received on the ward would be actioned by the ward manager. This could involve a courtesy call to the patient or family to further ascertain what the issues were and how they could work to resolve them.
The specialist palliative care nurses we spoke with told us that they work with relevant teams on the acute wards when complaints are received that relate to care at the end of a patient’s life. In addition, they explained that if a family member or carer were to raise a concern with them they
20171116 900885 Post-inspection Evidence appendix template v3 Page 178 would report this to the nurse in charge of the relevant ward, so the concerns could be addressed in a timely manner.
The specialist palliative care nurses also explained meetings were offered to all families and carers following bereavement. This meant if family members had concerns they were addressed promptly and the family were supported following the loss of their loved one.
The trust had appointed a medical examiner to review all deaths at the Northern General Hospital site. The medical examiner called families to try and ascertain whether there were any concerns around the patient’s death, therefore concerns and complaints could be pro-actively picked up early on and dealt with rapidly.
The medical examiner role had been successful in the pilot at Northern General Hospital and the trust had decided to appoint a medical examiner to the Royal Hallamshire and Weston Park site to roll out the service across the trust.
Staff told us this had improved the service provided to families after a patient’s death and had helped to clarify concerns before they became complaints.
The trust complaints process was also detailed on the trust website, offering patients the option to submit complaints via the patient services team, an anonymous feedback form and the option to submit a complaint directly to the chief executive. This provided several routes for complaints to be submitted and reflected the transparent culture we observed at the trust.
The electronic reporting system used by the trust was not able to provide information regarding complaints related to end of life care. Therefore, a process was in place to screen complaints relating to end of life care and identify learning points.
The trust provided information which explained that complaints and lessons learned were incorporated within staff training programmes. For example, within the training days for end of life care champions. This training covered the management of complaints about end of life care and included the review a letter of complaint and the trust’s response.
The trust also completed thematic analysis of complaints. From 01 January 2016 to 31st December 2017, the thematic review highlighted communication and ward care around death as areas to focus on. These issues were being addressed through the end of life care strategy group. The vision was to further progress this by triangulating the medical examiner reviews, complaints and structured judgment reviews, facilitated by the learning from deaths guidance.
A service review had been registered with the clinical effectiveness department in preparation to undertake a comprehensive review of complaints relating to care in the last days of life or the death of a patient.
The Macmillan palliative care unit used an electronic reporting system to record complaints and compliments. This allowed the management team to flag any trends and share learning with the staff.
We observed that information was displayed clearly on the walls of the palliative care unit, detailing how to raise a concern or complaint and providing the contact details for the team that handled complaints.
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This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
From February 2017 to January 2018 there were nine complaints about end of life care. The trust took an average of 42 days to close these complaints. The trust worked to a tiered response time process where the timescale is determined based on the complexity of the concerns raised and in agreement with complainants. This is usually 25/40 days but can be up to 60 days for more complex cases. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale
Seven complaints related to Northern General hospital; all seven complaints related to inpatient areas with six of the seven also relating to medical staff. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
Is the service well-led? Leadership The service had managers at all levels with the right skills and abilities to run a service providing high quality sustainable care. There was a clear management structure at directorate and departmental levels. The managers knew about the quality issues, priorities and challenges in the department. The nursing and medical team was established with experienced staff that provided clinical and professional leadership. Staff told us that they were well supported in their roles and had a clear understanding of their responsibilities. They said leaders were visible and approachable. The therapeutics and palliative care directorate sat within the combined community and acute care, care group which covered integrated community care, primary care and interface services, integrated geriatric and stroke medicine and therapeutics and palliative care. A triumvirate of a clinical director, an operations director and a nurse director led the directorate of therapeutics and palliative care. The clinical director was supported by an operations director who managed the aspects of planning and performance within the directorate. The nurse director led on all aspects of the patient experience and worked closely with the operations director to make sure the correct resources were available to be able to deliver high standards of patient care. The Macmillan palliative care unit had a matron and senior charge nurse (ward manager) who provided local leadership. The matron provided strategic and managerial support for the Macmillan palliative care unit and the hospital support team. The matron reported in to the integrated pathway manager (lead specialist nurse in palliative care) who also had direct management responsibility of the intensive home nursing service and bereavement services. The matron supported the senior charge nurse (ward manager) in the management of the palliative care unit. The clinical director provided leadership to the clinical lead for palliative care and the head of chaplaincy. This structure provided direct nursing, pastoral and medical leadership. The trust had two clinical leads for end of life care, including a palliative care consultant and an intensive care consultant. The managers at different levels of the directorate knew about the quality issues, priorities and challenges the directorate faced and worked collaboratively across all sites to try and deliver solutions and pilot new ways of working. We observed that managers were proactive, and their positivity and motivation was inspiring. 20171116 900885 Post-inspection Evidence appendix template v3 Page 180
There was a clear commitment and focus by leaders to predict and respond to patient demand and flow, and this was supported by the other departments in the hospital, particularly around the management of end of life patients on general wards, the chaplaincy service and care after death in the mortuary. The mortuary team told us that the executive team was very responsive when funding was required. We were told that when funding was requested for additional storage facilities to manage winter pressures this was immediately approved, and the system was installed and available for use within 48 hours.
Vision and strategy At the last inspection in 2015 we found the trust did not have a strategy for the care of patients at the end of life. The absence of a strategy had resulted in staff not knowing the vision for end of life care across the trust. At this inspection we found the trust had a clear strategy and vision for end of life services and staff were aware of the strategy and where they could find it. The trust had held consultation focus groups with a diverse range of staff to help shape the end of life care strategy. This had resulted in the strategy being developed in partnership with staff, patients and carers and disseminated across the organisation. Areas highlighted as requiring improvement at the 2015 inspection had been addressed. These included: completion, approval and dissemination of the end of life care strategy; updating and the dissemination of ‘guidance for the care of the person who may be in the last hours to days of life’; development and approval of the individualised care plan for the last days of life; completion and rollout of the electronic end of life care nursing care plan; the establishment of an end of life care education and training subgroup of the end of life care project steering group, and appointment of a leadership fellow and two clinical leads in end of life care. (Source: https://www.sth.nhs.uk/patients/end-of-life-care)
Culture We found the culture of the Macmillan palliative care unit open and inclusive for staff and patients. Staff that we spoke with felt that they were valued and respected by their peers and leaders. We asked staff about the morale of the department and they all said that morale was good, and they worked collaboratively as a team. Staff told us that the executive team were visible and approachable, and they were proud to work at the trust. Staff within the mortuary had a positive team working culture. We spoke with three members of the team who all told us they felt valued by the trust. Senior members of the team provided an on-call system to support staff caring for deceased patients outside normal working hours. We asked if they were paid for this service and were told that it was an informal system however they were happy with this and said that 99% of the time any questions could be dealt with via a telephone call. The trust promoted the culture that care of the dying is everyone’s responsibility and provided the skills and tools to enable staff to consistently and compassionately undertake this. We spoke to staff on general wards where end of life care patients were being nursed. They told us that they felt end of life care was everyone’s responsibility and the hospital support palliative care team were accessible, effective and worked collaboratively with staff on the wards, whether in person or remotely. We found that staff on general wards had been supported to provide high quality
20171116 900885 Post-inspection Evidence appendix template v3 Page 181 palliative care to patients on their ward, which demonstrated the ‘upskilling’ culture of the specialist palliative care team. Staff felt supported in their work and there were opportunities to develop their skills and competencies, which was encouraged by senior staff. For example, some staff were undertaking masters level study in specialist palliative care modules. Staff we spoke with wanted to provide high quality, effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams.
Governance The department had governance, risk management and quality measures to improve patient care, safety and outcomes. However, whilst the trust had implemented recording of patients preferred place of care and death, they had not completed any audits. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. There was an end of life project steering group that was chaired by the medical director with representation from staff across all levels and a diverse range of departments in the trust. The governance system supported the strategy and provided continuing assurance up to board level, with the clear focus on providing a quality service. The trust had recently approved a business case to recruit a band eight lead nurse who, when appointed, would be the governance lead for end of life care and take over the project group responsibilities to continue to roll out the priorities identified by the group.
Management of risk, issues and performance The specialist palliative care team met monthly with the senior team for the service. We were told that risks, issues and performance were discussed at this forum. Staff gave us examples of the risks and issues raised, for example, not having use of laptops to access information and enable more effective working. The meeting was also used to share updates from strategic meetings. A member of the team was completing an audit of compliance in completing the syringe driver check sheet. This was in response to recognition that four hourly checks of the syringes were not consistently completed across all the general wards. Following completion of the audit the findings and an action plan would be shared with all general wards. Staff in the mortuary told us that their only risk was capacity however they had business continuity contingencies in place, for example, they had purchased an additional storage unit to manage winter pressures and were able to move deceased patients across site to the Royal Hallamshire mortuary if they were nearing full capacity. A business plan had been created to enable internal access to the hospitals mortuary. We were told that this had been identified as a concern however this was not detailed on the risk register. The end of life project steering group met officially on a bi-monthly basis. However key members of the group met on a weekly basis to ensure projects were progressing as per project plans. The trust had a process to share national patient safety alerts issued by Medicines and Healthcare Products Regulatory Agency (MHRA). Alerts were received by the patient and healthcare governance department. They were then logged on the trusts electronic incident reporting system and emailed to the patient safety manager. The patient safety manager would then disseminate 20171116 900885 Post-inspection Evidence appendix template v3 Page 182 the alert to the relevant staff including risk leads, who would action and cascade as appropriate. The cascade would incorporate all relevant staff and would include end of life care staff where appropriate. Deadlines for completion of actions were logged on trusts electronic incident reporting system which would then generate automated reminders. On completion of actions, the alert was closed on trusts electronic incident reporting system and a response sent to the Medicines and Healthcare Products Regulatory Agency (MHRA). There was a risk register with six recorded risks for end of life care and care after death. Three risks were rated as high risk, two as moderate and one as low risk. The risks had clear review dates documented. Staff in the mortuary told us their only risk was capacity however they had business continuity contingencies in place, for example they had purchased an additional storage unit to manage winter pressures.
Information management The trust had created a comprehensive end of life resource site on the staff intranet. The intranet site had been created by a clinical fellow in the palliative care team and based on the ‘three clicks’ rule. This meant that staff could access the information, guidance or pathway they needed with no more than three mouse clicks. The Macmillan palliative care unit used electronic care planning records for patients. These were comprehensive and secure. We reviewed a sample of policies and guidelines available to staff and found they were in date and had recently been reviewed and updated. • DNACPR policy ratified 1 May 2018. • Mental Capacity Act 2005 and Deprivation of Liberty policy ratified 1 March 2017 (due for review 1 November 2020) • T34 syringe pump protocol ratified 25 October 2017 (due for review 1 October 2020) • Care after death policy ratified 3 January 2018 (due for review 1 August 2020)
Staff in the specialist palliative care team did not meet the trust compliance rate for information governance. Overall compliance for information governance training for the specialist palliative care team was 83%. Nursing staff were 97% compliant which was better than the trust plan. Medical staff were 87% compliant, which is marginally worse. However, administration staff were 20% compliant which is significantly worse than the trusts expected compliance.
Engagement The trust had developed an end of life care project team. Members of team included the trust medical director, the integrated pathways manager, medical and nursing staff from the acute and community specialist palliative care team and a patient governor. The end of life care facilitator told us that they worked closely with other specialist nurses to ensure that they were able to care for patients cohesively at the end of their life. The specialist palliative care team had completed a service review in May 2018. Part of this had included asking for feedback from the general wards about the support they needed from the
20171116 900885 Post-inspection Evidence appendix template v3 Page 183 team. Once the feedback results were available, the team would be planning to include the suggestions within their day to day workload. The development of the end of life strategy, new guidance, care plans and training has been the result of co-production and engagement across staff, patients and carers. We were told the end of life care guidelines had been recently reviewed and updated. This had involved input from other disciplines including oncologists and anaesthetists. A staff engagement session was held during Dying Matters week, in May 2018, encouraging staff to consider what is important for patients to address at the end of life, but also their own wishes for the future. Prior to the launch of the trust strategy for end of life care, the end of life project working group (PWG) held consultation events that allowed all members of staff and patient representatives to share good practice but also highlight areas that required improvement and the tools or skills needed. Part of the role of the medical examiner included liaising with the family of deceased patients to discuss the cause of death, clarify any queries and detect any family concerns, allowing for escalation and signposting as appropriate.
Learning, continuous improvement and innovation
At Northern General Hospital they had recently appointed an ‘acute’ palliative care consultant. Their remit was to outreach predominantly in to the accident and emergency department, the frailty unit and the acute medical unit to try and widen the access of the palliative care team to patients who were suitable for the service but may not be identified and referred to the team until later in their hospital stay.
A treatment options form was being piloted in the renal department by a renal palliative care consultant. The end of life project steering group had also done work around heart failure and working with colleagues in cardiology to promote advanced care planning for patients nearing the final 12 months of their lives.
The specialist palliative care team had developed a section on the trust’s intranet to support staff in caring for patients at the end of their lives. This had been launched in April 2018. We looked at the information available and found this to be an effective but simple to use resource for all staff.
We were told that the specialist palliative care team were instrumental in identifying educational needs for staff. The end of life care facilitator told us that the trust had more than 100 end of life care champions (link nurses) working in general wards across the hospitals. Study days were held for the end of life care champions, the champions would then disseminate the learning to their own teams.
Initiatives such as sharing with staff five key points in five minutes, for example on respiratory secretions or patient’s spiritual needs, were being introduced into the safety huddles on the wards across the hospitals. These were also being added to the trust’s website.
The specialist palliative care team had developed the DNACPR policy through the end of life care working group. This had included the development of an information leaflet for patients, families and carers. We looked at this leaflet and saw it contained effective but easy to follow information
20171116 900885 Post-inspection Evidence appendix template v3 Page 184 about decision making around DNACPR. The leaflet also included information about advanced care planning, advanced decisions to refuse treatment and lasting power of attorney decision making.
The e-whiteboard handover audit had been nominated for a national patient safety award.
Staff in the mortuary told us it had been identified that they were operating on a potential single point of failure due to only having one electric fuse board for all the facilities. This was improved by having a second fuse board fitted which would ensure in the event of one fuse board failing a back-up system was available.
There were excellent responsive pathways in place for rapid discharge home to die from general ward areas and the emergency department. In the emergency department this pathway was supported by the front door response team who provided a bespoke service to end of life patients in A&E.
One of the hospital chaplains had been awarded the top Khadija Award at the Al Nisa Awards. These awards are a celebration of the contribution and achievements of Muslim women in the county. The chaplain was recognised for their innovative multi-faith work in developing understanding and co-operation between hospital teams and the community in their role as a Muslim Chaplain. In March 2017 Sheffield Teaching Hospitals was awarded £80,000 by Arts Council England and £35,000 from Sheffield Hospitals Charity to fund Arts sessions for patients. The funds were being used to provide a three-year programme of creative art workshops for a range of different patient groups, including palliative and end of life patients, across the Trust.
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Royal Hallamshire Hospital
Urgent and emergency care
Facts and data about this service
Sheffield Teaching Hospitals NHS Foundation Trust’s Acute and Emergency Medicine Directorate is the primary centre for adult emergency care in Sheffield. The trust has around 16,000 employees providing unscheduled care for an average of 350 patients per day and has more than 100,000 attendances per year to the ED department.
The Minor Injury service is used by an average of 70 patients per day.
Comprising of five hospitals on two sites across the city the Royal Hallamshire Hospital and the Northern General Hospitals are two of the UK's largest acute hospitals. The trust has one of the three major trauma centres for the Yorkshire and Humber region and it has partnerships with the University of Sheffield, Sheffield Hallam University, and other health and social care providers. (Source: Routine Provider Information Request (RPIR) Acute context)
Details of emergency departments and other urgent and emergency care services • Northern General Hospital: Accident and emergency • Royal Hallamshire Hospital: Minor injuries unit (Source: Routine Provider Information Request (RPIR) P2 – Sites)
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Is the service safe?
Mandatory training • The trust set a target of 90% for completion of mandatory training. The trust provided mandatory training compliance at the time of our inspection. The overall completion rate for the emergency department as at 31 May 2018 was 78.1%, as against a 90% planned completion rate. We spoke with 13 staff about mandatory training who each confirmed their mandatory training was up to date. • Mandatory training was undertaken in a face-to-face setting. A senior nurse consultant was the training lead for the department. Some staff told us they felt well supported to be able to complete training. However, some other staff we spoke with felt they had limited time to access training. Areas covered in training were often reinforced through ‘breakfast club’ teaching sessions and supporting guidance was available through the department’s intranet share point. • Adult basic life support (resuscitation) training had been completed by 91.5% of staff and was refreshed annually. Conflict resolution training was provided for emergency department nursing staff to enable them to address potentially challenging situations and this was repeated three yearly. • We reviewed nine mandatory training evaluation forms completed in 2018 which demonstrated that meaningful feedback was obtained from staff following their attendance at training. • At the Royal Hallamshire minor injuries unit, access to mandatory training had improved through the provision of computers in staff rest areas to access e-learning. • Specific data for the unit was not available. However, staff we spoke with had completed all mandatory training and felt well supported to do so. This included information governance, fire safety and moving and handling. Time was given for staff to complete training and staff were reminded verbally by the nurse consultant if mandatory training was not up to date. A breakdown of compliance for mandatory courses from April 2017 to February 2018 for nursing staff in urgent and emergency care is shown below:
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Resuscitation: Neonatal Life Support - Level 2c (1 Yearly) 4 4 100% 90% Yes Conflict Resolution - Level 1 (3 Yearly) 27 27 100% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 24 24 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 9 9 100% 90% Yes Moving & Handling - Level 2b (1 Yearly) 28 29 97% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 40 42 97% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 35 37 96% 90% Yes
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Information Governance - Level 1 (1 Yearly) 27 29 94% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 51 55 93% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 43 49 81% 90% No
Nursing and midwifery staff exceeded the trusts 90% planned level for nine out of 10 modules. Infection prevention and control – level 2 failed to meet the plan with 81%.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for medical and dental staff in urgent and emergency care is shown below:
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Equality & Diversity: General Awareness - Level 1 (3 Yearly) 1 1 100% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 13 13 100% 90% Yes Conflict Resolution - Level 1 (3 Yearly) 1 1 100% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 1 1 100% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 1 1 100% 90% Yes Information Governance - Level 1 (1 Yearly) 13 13 100% 90% Yes Moving & Handling - Level 2a (3 Yearly) 13 13 100% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 12 13 92% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 12 13 92% 90% Yes
Medical and dental staff exceeded the trusts 90% plan for all nine mandatory training modules. (Source: Routine Provider Information Request (RPIR) P40 –Mandatory and Statutory Training)
Safeguarding • Of the 14 staff we spoke with, each was conversant with the safeguarding referral processes for both adults and children (although it was not the department’s policy to see children under 16 years) and several members of staff stated they received regular updates from the safeguarding teams at breakfast club teaching sessions. • Most of the nursing staff we spoke with, including each emergency nurse practitioner, had received level 3 safeguarding training in the previous 12 months. Also, plans were in place for all nursing staff to undertake level 3 safeguarding as part of their mandatory training. • We spoke with the safeguarding lead, a senior sister in the emergency department. The safeguarding lead supported patients presenting with complex safeguarding needs, for example involving their mental health, domestic violence, learning difficulties, and female genital mutilation (FGM).
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• Very few children presented in the department as a local specialist children’s hospital was located nearby. Due to the nature of the Minor Injuries Unit it is unlikely that safeguarding issues would be as frequent as in the main department at the Northern General site, however, there is access to the same specialist safeguarding services as utilised at the Royal Hallamshire site • Themes to focus on were decided at monthly meetings and included child sexual exploitation, domestic violence, persons under 18 years with mental health crisis. Innovative schemes were in situ which enabled contact details to be shared discreetly for domestic violence support agencies. • For paediatric safeguarding concerns which did arise, we found staff were aware of referral processes and had access to paediatric liaison and a child protection information service which had recently commenced. The Child protection information system was implemented in line with national requirements from NHS improvement to all required areas including the emergency department. • For the Royal Hallamshire Hospital minor injuries unit, safeguarding arrangements were in place for adults, children and domestic violence victims. A link nurse for safeguarding issues was available. • Staff we spoke with were aware of the trusts safeguarding policy. They knew how to make referrals, types of incidents that they would refer to the safeguarding team and how to recognise safeguarding concerns. Staff were able to describe examples of safeguarding concerns they had had and had acted on including actions taken and outcomes where appropriate. The examples included the support of victims of domestic violence. • Staff had received the required training in safeguarding and emergency nurse practitioners were trained to level 2 as a minimum in line with their mandatory training plan. • Safeguarding links within the department were excellent, with a number of specific pathways reflective of the needs of patients, for example, in substance misuse. • Staff were aware of domestic violence risks and information was provided in several locations offering victims support. The unit also had everyday items, which were given to patients at risk of domestic violence.
Safeguarding training completion rates The trust planned for 90% for completion of safeguarding training.
A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for nursing staff in urgent and emergency care is shown below:
Staff Eligible Met trained staff Completion Trust (Yes/N Name of course (YTD) (YTD) rate Target o) Safeguarding Children & Young People - Level 3 (3 Yearly) 25 25 100% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 12 12 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 4 4 100% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 19 24 77% 90% No
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Nursing and midwifery staff achieved 100% completion for three out of four safeguarding courses; they failed to meet the trusts 90% plan for safeguarding adult’s level 2 with 77%.
A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for medical and dental staff in urgent and emergency care is shown below:
Staff Eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 10 10 100% 90% Yes Safeguarding Children & Young People - Level 3 (3 Yearly) 12 13 92% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 12 13 92% 90% Yes Medical and dental staff exceeded the trusts 90% completion plan for all three safeguarding modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene • We observed that the minor injury department appeared visibly clean, including the patient cubicles and toilet areas. Domestic staff followed a cleaning schedule and care staff were responsible for cleaning equipment and trolleys. •
• At the Royal Hallamshire Hospital minor injuries unit there were no incidences of methicillin-resistant staphylococcus aureus or clostridium difficile recorded. • The hospital had an infection control accreditation programme that set standards for infection prevention and control practice. The aim was to optimise and assess infection prevention and control practices in clinical teams throughout the hospital to reduce infection rates. The unit had received infection control accreditation. Weekly and monthly audits were carried out as part of this accreditation. We observed the most recent accreditation certificate prior to it being displayed within the unit. • We observed staff adhering to trust policy and national standards for infection prevention and control. Cleaning was carried out regularly by nursing staff as well as domestic staff. A cleaning log was implemented and documented daily. Patient assessment areas were cleaned after each patient use. The cleaning records were completed regularly and fully. Hand basins were appropriately sited; soap and alcohol gel dispensers were working and well stocked. Paper towels were available for drying hands. Sharps bins were available and were not over filled. • Where appropriate within the Minor Injuries unit there is facility to utilise an examination area which can be utilised as an isolation room for infectious patients, however due to the nature of the department and the injuries it treated meant that this rarely occurred.
Environment and equipment • The minor injuries unit was comprised of a waiting area, a small reception area, four examination rooms and adjacent x-ray facilities. The design, maintenance and use of
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facilities were appropriate. The unit reception area faced the waiting area and reception staff could observe members of the public from their desk. There was a seat for patients booking in and the reception was away from the seating area to make booking in as confidential as possible. Patient assessment areas in the unit were well equipped and privacy was managed as effectively as possible with curtains to the front only. The plaster room was clean, well-stocked and tidy. This room was also used for the treatment of deteriorating or seriously ill patients. • The defibrillator in the unit was checked daily. Airway management equipment was available, well maintained and fully equipped along with other resuscitation equipment. The unit had access to its own ultrasound machine, allowing rapid access to diagnostic information. Bedside IT equipment was in place in the unit for electronically ordering diagnostic tests and completing prescriptions. • At the Royal Hallamshire Hospital minor injuries unit, cubicles were well organised and items on the resus trolley were in date and tagged to identify them. Equipment observed was in good condition and portable appliance testing was up to date. When we checked consumables stocks and equipment we identified several out of date items in storage. We discussed this with nursing staff, so they could take immediate action. • Equipment maintenance assurance records indicated that 89% of devices were assessed prior to one month before due date. • The PLACE inspection awarded Royal Hallamshire Hospital 90.2% for condition, appearance and maintenance.
Assessing and responding to patient risk
Emergency Department Survey 2016 This survey only applied to the NGH location Median time from arrival to initial assessment (emergency ambulance cases only) The median time from arrival to initial assessment was similar to the England median from April 2017 to March 2018.
The trust median time from arrival to initial assessment varied slightly across the 12-month period, from April to August 2017 the trusts performance was one minute faster than the England average, from October onwards the trusts performance showed a trend of decline; February 2018 the median time to initial assessment was 14 minutes compared to the England average of nine minutes.
Ambulance – Time to initial assessment from April 2017 to March 2018 at Sheffield Teaching Hospitals NHS Foundation Trust
(Source: Source: NHS Digital - A&E quality indicators)
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Percentage of ambulance journeys with turnaround times over 30 minutes for this trust: Royal Hallamshire Hospital
From April 2017 to March 2018 there was a stable trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Royall Hallamshire Hospital.
Ambulance: Number of journeys with turnaround times over 30 minutes - Royal Hallamshire Hospital
Ambulance: Percentage of journeys with turnaround times over 30 minutes - Royal Hallamshire Hospital
(Source: National Ambulance Information Group)
• At the Royal Hallamshire Hospital minor injuries unit, patients were seen on a first come first served basis unless concerns were raised by the reception staff to nursing staff as having more urgent needs or identified by nurse practitioners through the electronic patient record system. Patients were not triaged. • If unit reception staff noticed a patient in the waiting area who appeared to be deteriorating they called a nurse. If a patient was brought to the unit by ambulance, the ambulance crew were required to phone ahead and speak to the sister in charge. It was only with the sister’s agreement that the patient was transported to the unit. • Emergency care practitioner staff told us they relied on reception staff to identify patients to them who may be high risk or unwell and in need of urgent care. This was recognised by the nursing staff as a potential risk as a deteriorating patient may not be identified. • Most patients arrived at the unit by their own transport. When a patient arrived by ambulance a member of nursing staff attended the ambulance to assess the patient and speak with the ambulance crew. This enabled them to assess whether the patient was suitable for treatment in the minor injuries unit or whether they needed to attend the main emergency department. • When waiting times increased, nurse practitioners carried out a rapid triage in the waiting area to ensure risk was managed whilst waiting was minimised. Deteriorating patients were managed in the unit’s resuscitation room. This area was equipped with a trolley, defibrillator and airway management equipment. • If a patient presented with a serious condition nursing staff liaised with the main 20171116 900885 Post-inspection Evidence appendix template v3 Page 192
emergency department and the patient was transferred by ambulance. Nursing staff also call ahead to ensure the emergency department were aware of the patient being sent to them. • Although children were not routinely seen in the unit, nurse practitioners assessed children that did present and referred them either to the children’s hospital or called the ambulance service as appropriate.
Nurse staffing
The trust reported the following nurse staffing numbers for urgent and emergency care in March and December 2017. The service had fill rates of over 95% in March 2017 and in December 2017 the trust had 100% establishment.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Urgent & emergency 115.5 121.6 95.0% 130.6 129.8 100.6% care (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
The following nurse staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
Vacancy rates From January to December 2017, the trust reported a vacancy rate for nursing staff in urgent and emergency care of -0.3%. This indicated a slight over establishment. The trust does not have a planned vacancy rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017 reported a turnover rate of 17.9% for nursing staff in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017, the trust reported a sickness rate for nursing staff in urgent and emergency care of 3.5% which was lower than the trust planned level of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage From January to December 2017, the trust reported 2,886 shifts filled by bank staff (47%) and 103 shifts filled by agency staff (2%) in urgent and emergency care. There were 3,093 shifts not filled by bank or agency staff (51%).
A breakdown of bank and agency usage by staff type is shown below:
Bank/ agency Total Bank 2,886 (47%) Agency 103 (2%) Not filled 3,093 (51%)
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(Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
• At the Royal Hallamshire Hospital minor injuries unit, an emergency department nurse consultant led the unit. The department required a minimum of two nurse practitioners to be on duty. This was managed through a rota system combined with the rota system used at the main emergency department. Where this did not occur, for example due to short notice sickness, a nurse practitioner was transferred from the main emergency department or bank staff were used to ensure a full complement of staff was available. • A minimum of two emergency nurse practitioners were on duty for a 12-hour shift. Planned and actual staff numbers always matched. This was reflected in rotas observed on in the department. • There was no formal handover procedure in place. However, a communications book was used for staff to alert the next shift coming on duty of any issues or concerns. Staff we spoke with told us that communication between staff was excellent. • In addition to the nurse practitioners on duty, the unit was on some occasions also staffed by health care assistants for part of the day and advanced nurse practitioners in training. The member of reception staff was also based in the unit. We were informed the unit did not use agency staff. The unit did use bank staff that were familiar with the unit. • For the Royal Hallamshire Hospital minor injuries unit, consultant and medical registrar staff were on call to provide support. If medical cover was required, the nurse practitioner on duty contacted the main emergency department. Nurse practitioner staff may also contact the speciality areas at the Royal Hallamshire hospital. If children attended the minor injuries unit, they were referred to the local children’s hospital emergency department.
Records • At this inspection we reviewed ten records from the Royal Hallamshire minor injuries unit. The records were generally completed satisfactorily. • At the Royal Hallamshire Hospital minor injuries unit patient documentation was duplicated as the unit had recently introduced electronic record keeping. Standard emergency department patient assessment documents were used in the unit and then the information was entered onto the computer system manually. This increased the risk of information not being entered fully or accurately, however staff felt this approach was best as it allowed staff to note take during patient assessment and to check the information whilst inputting it to the computer system. • We reviewed patient records and found that areas of documentation were being left blank by nurse practitioners where they considered the information to be not relevant due to the level of injury or how the patient presented to the minor injury unit. However, the type of patients attending minor injuries did not routinely require significant documentation and this was reflected in the patient notes observed. Information relating to assessment and treatment was recorded adequately in line with trust and professional standards. • Hand written patient records were observed as being legible, and reflective of history, assessment, diagnosis and treatment plans were recorded.
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Medicines • At the Royal Hallamshire Hospital minor injuries unit, appropriate arrangements for managing medicines were in place including obtaining, prescribing (where appropriate), recording, handling, dispensing, safe administration and disposal. Drugs were kept in locked cupboards and records were kept relating to their administration and disposal. Drugs that we checked were in date and the packaging was intact. • Emergency nurse practitioners on duty were also nurse prescribers. We observed nursing staff administering medications to patients on five occasions. Appropriate checks were made each time for patient identification and allergy status, and checks were also completed against the prescription. We observed that one practitioner checked with another colleague before administering medicines. • The unit used the same prescribing system as the main emergency department. Staff administered medication either using patient group directives or with prescribing rights where the nurse practitioner was suitably qualified. These were checked by the nurse consultant to ensure they were up to date. A senior charge nurse had a pharmacy link role. • Staff accessed clinical areas with swipe cards and pin codes and medicine cupboards were locked using a key. The crash trolley was clip locked and sealed. The trolley was checked once monthly unless it was used in which case it was restocked. The trolley was stored in a room rather than an open area. Equipment stored with the crash trolley was checked daily. • Medication requiring refrigeration was kept in a locked fridge and temperatures were checked daily. Fridge temperatures were recorded to ensure temperatures were maintained within safe ranges. However, we found there were 13 missing entries between January and June 2018. Storage of some anaesthetic medicine items was not locked. • Medical gases were available in appropriate quantities. Oxygen supplies in store and on the crash trolley were in order but we did not find evidence that prescribed oxygen was recorded. • A supply of commonly used medicines was kept in the department, however, where appropriate patients were given prescriptions to take to either the hospital pharmacy or a community pharmacy. Controlled drugs were not used within the department. • Annual and quarterly checks were in place for medicines management, which provided assurances on the robustness of the medicines management process. Evidence was provided of ongoing audit, but figures were not yet available.
Incidents
Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2017 to April 2018, there were no incidents which were classified as never events for urgent and emergency care services at the trust. (Source: NHS Improvement - STEIS (01/05/2017 - 01/04/2018))
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In accordance with the Serious Incident Framework 2015, the trust reported four serious incidents (SIs) in urgent and emergency care trust-wide which met the reporting criteria set by NHS England from May 2017 to April 2018. All of these were at NGH.
Of these, the most common types of incident reported was/were:
• Treatment delay meeting SI criteria with four (75% of total incidents)
(Source: NHS Improvement - STEIS (01/05/2017 - 01/04/2018))
• At our previous inspection we found there was a backlog of incidents awaiting investigation. At this inspection there were just four incidents awaiting investigation. Senior managers we spoke with explained how the urgent and emergency services and within the wider trust, incident reporting and investigation had been developed since our previous inspection. • For the Royal Hallamshire Hospital minor injuries unit, members of staff we spoke with understood the process and importance of incident reporting as well as their responsibilities. Staff were aware of the type of potential incidents to report, such as drug errors, assaults and clinical errors. Lessons were learnt from the incidents. • Staff used an electronic reporting system for formal reporting, but also stated that concerns would be raised with a senior member of staff to deal with incidents as soon as possible. • Incidents were dealt with quickly and appropriately. The trust provided documents stating that all incidents were reported and that this was used to create reports (including trend and theme information). • Patients using the unit were informed when things had gone wrong, the circumstances were explained, and apologies given. Patients were kept aware of changes that may occur because of mistakes. Staff were able to explain Duty of Candour and give examples of practice, such as apologising for delays in care. All staff were keen to be open, honest and to accept ownership of mistakes. • Mortality and morbidity meetings were carried out for the whole emergency care directorate. Findings were shared and applied within the minor injuries unit, as required.
Safety thermometer
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The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 12 new pressure ulcers, one falls with harm and six new catheter urinary tract infections from April 2017 to April 2018 within urgent and emergency care.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total pressure ulcers (12)
2 Total falls (1)
3 Total CUTIs (6)
(Source: Safety thermometer - Safety Thermometer)
Safety performance figures across the emergency care directorate were identified as being comparable to other NHS trusts. However, this figure included the emergency care directorate, not only the minor injuries unit.
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Is the service effective?
Evidence-based care and treatment • Our previous inspection report stated that the emergency department should review guidance in the emergency department to ensure it reflected current evidence-based guidelines. At this inspection we found a review of guidance was in progress. The department shared with us the guidelines that had been updated. Medical and nursing leads were nominated for specific subject areas. • At the Royal Hallamshire Hospital minor injuries unit, nurse practitioners and prescribers followed clinical guidance as used in the main emergency department. Staff gave examples of National Institute for Health and Clinical Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines which they used, for example the Ottawa foot ankle and knee rules. The unit was trialling wood cast for fractures jointly with a local university. • Clinical governance meetings were used as an approach to monitor outcomes and ensure use of evidence-based care and treatment. • We observed evidence based clinical guidance on the trust intranet. We also observed staff using NICE guidelines to assist with decision making. There was access by telephone to medical colleagues either within the Royal Hallamshire hospital or in the main emergency department as required. • The unit met the minimum requirements for units that see the less seriously ill or injured as outlined in the College of Emergency Medicine document “unscheduled care facilities”.
Nutrition and hydration • For the Royal Hallamshire Hospital minor injuries unit there was provision for drinking water within the unit. There was no provision for food; however, the nature of the service offered meant patients visiting the unit could use a selection of vending machines, the hospital canteen or shops as required.
Pain relief • For the Royal Hallamshire Hospital minor injuries unit, we observed four patient assessments and spoke with one patient as they were leaving the department. Each patient had been asked if they had any pain, and pain relief had been administered when requested, in a timely manner. Pain scores were documented, where appropriate along with any pain relief given, allergies and consent to treatment where appropriate. • Each patient we spoke with stated they had either received timely pain relief or had been offered it and had declined.
Patient outcomes
Unplanned re-attendance rate within seven days - Sheffield Teaching Hospitals NHS Foundation Trust
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(Source: NHS Digital - A&E quality)
• For the Royal Hallamshire Hospital minor injuries unit our previous inspection report stated that although the unit worked closely with the main emergency department, audits specific to the minor injuries unit should be completed to review effectiveness and to monitor improvements to services and treatment offered in this location. At this inspection we found local audits are undertaken in MIU. These include annual documentation audits incorporating a random sample. All non-medical prescribers in MIU complete a three- yearly peer review of prescribing. • Neurosurgery was based at the Royal Hallamshire Hospital, which meant timely intervention was required by neurosurgeons. We found that guidelines for patients who required urgent referral to the neurology assessment unit for immediate specialist assessment were reviewed in August 2017. • We were informed the unit was periodically involved in the trial of new products rather than the main emergency department because the monitoring of patient outcomes was more straightforward. A recent example was air cast boots. • An electronic clinical assurance toolkit has been developed and was implemented in RHH. The department had also recruited, as planned, a number of senior sisters and a governance team to support audit activity and compliance within the department. • At the Royal Hallamshire Hospital minor injuries unit, patients were each reviewed by a nurse practitioner prior to discharge. Where x-rays had been taken, they were reviewed by a consultant post discharge at the main emergency department through the electronic patient record system. An ongoing audit was in progress for missed fractures, and an audit of unplanned returns was due to be completed for the unit.
Competent staff
Appraisal rates This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
From April 2017 to December 2017, 74% of staff within urgent and emergency care at the trust had received an appraisal compared to the trust’s planned level of 90%. 20171116 900885 Post-inspection Evidence appendix template v3 Page 199
A split by staff group can be seen in the table below:
Target Appraisals Eligible Appraisal Staff group met completed staff rate (Yes/no)
NHS infrastructure support 1 1 100% Yes Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T) 1 0 0% No Qualified nursing & health visiting staff (Qualified nurses) 94 70 74% No Support to doctors and nursing staff 91 68 75% No Support to ST&T staff 6 5 83% No Qualified Healthcare Scientists 1 0 0% No Medical & Dental staff - Hospital 1 0 0% No Medical and dental staff and nursing and midwifery staff failed to meet the trusts 90% target for appraisal completion. (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
• At our inspection senior managers provided evidence of the most up-to-date appraisal rates by staff group which showed a 12-month % rate of compliance of 77.7% as at 31 May 2018 for acute and emergency medicine. The training lead told us that personal development reviews included interaction to support the staff member’s development and an action log was completed and signed within two weeks of the appraisal. A planned career progression plan was available for all staff. Planned training opportunities within the emergency department included the multi-disciplinary team. • A structured induction programme was in place for new staff. All nursing staff new to the department received a four-week induction, when they were not counted as part of the staff rota. The staff induction booklet included “top ten tips” for staff commencing work in acute and emergency medicine. Staff we spoke with who had recently joined the department told us they felt well supported, which included preceptorship and mentorship. When staff felt ready (usually after at least six months) they attended an initial assessment training day to enable them to work in the triage area. • We spoke with the emergency department’s training lead and training team staff about their role in leading and supporting clinical education training in the department. The Emergency Medicine directorate became a separate directorate from January 2018 and a training needs analysis and skills audits was in process of completion. In addition to planning and delivering mandatory training learning was supported with clinical teaching sessions taking place in clinical areas. Acute simulation of medical emergencies included trauma simulation which was delivered with multidisciplinary teams. A sepsis study day was in development. The clinical education programme was externally endorsed. • The department had supplemented the emergency and advanced nurse practitioners with training to support the development of these roles within the trust. The development of the advanced nurse practitioner role within the emergency department was supported and supervised by nurse consultant and emergency medical staff. Nurse practitioners received annual sepsis training. • Staff were enabled to become instructors, for example for the trauma nursing core course, to participate in a range of local and national training, and to have access to international
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secondments. Senior managers saw the emergency department’s function as including support for teaching and research, for example, through medical and nurse consultant staff allied to a local university. The emergency department received positive feedback following a recent external inspection of junior doctor induction and training, where the induction programme was seen as comprehensive and efficient. Breakfast briefings which included external speakers took place in the department each morning between 7am and 8.30am. Improved availability of training for trauma nursing staff and support for advanced life support training were further examples cited to us. For example, breakfast briefings included “Trauma of the week”. • Where poor performance was identified, the staff member was supported by being allocated supernumerary and having a more experienced staff member allocated to work with them before other routes were considered to address performance. • Some staff were trained to provide paediatric life support, although there was a local children’s hospital nearby with emergency department facilities, so that a child could be treated if this eventuality arose. • For the minor injuries unit at Royal Hallamshire Hospital, Staff had the qualifications, skills, knowledge and experience to carry out their roles. Each member of staff we spoke with were qualified as emergency nurse practitioners as well as being experienced nurses. They had completed non-medical prescriber’s courses and were undertaking further training to ensure they were constantly developing and there was a total of 17 staff trained to this level within the department. • Staff we spoke with had each received an appraisal in the last 12 months. Learning needs were identified in annual appraisals, one to one meetings and development meetings. • Each member of staff we spoke with was satisfied with the quality, availability, support and appropriateness of training they received. Staff we spoke with said support from the head of the unit was excellent and they had developed links with a local university through the nurse consultant who was the professional lead for advanced practice nurses for the trust. One member of staff stated that the support for training opportunities was part of the reason they chose to work for this trust. • Staff received job specific training prior to commencing the role and were expected to meet minimum education standards. Emergency and advanced nurse practitioners received regular training to maintain competence. • All staff rotated between the minor injuries unit and the main emergency department to support consistency in competence. Staff also worked routinely as emergency department senior nurses as part of their normal rota to ensure they maintained these skills. We were shown an example of a rota with shifts across both sites for nurse practitioner and senior nurse roles. • Education and training was considered a high priority within the department, and staff were encouraged and given time to complete training in areas of interest relevant to the role such as mentorship training. When staff were in training, they were directly supervised by qualified staff. • Emergency nurse practitioners who worked in the unit contributed to external teaching activity which supported their own role in the unit. The involvement of nurse practitioners in leading clinics and with teaching and research supported the development of innovative practice for the department. Fortnightly focus sessions were used to highlight areas of
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training need and to introduce new equipment or training opportunities. • Poor or variable staff performance was managed through one to one meetings with the nurse consultant, annual appraisals or through the creation of ongoing development plans. There was capacity to provide support for staff that needed it.
Multidisciplinary working • The ambulance service liaised closely with the Royal Hallamshire Hospital minor injuries unit to coordinate the admission and discharge of patients. Ambulance crew we spoke with told us they spoke directly with the nurse practitioner on duty in the unit after transporting a patient and before leaving the hospital. For patients with ill mental health, nurse practitioners liaised with the mental health team in the main emergency department for advice and to arrange to transfer patients, who were transported by ambulance. • In the Royal Hallamshire minor injuries unit, staff contacted staff in the main emergency department if they required further advice or needed to refer a patient for further treatment. Medical staff from the main department worked alongside emergency nurse practitioners in the unit when waiting times were increased. Other examples of multidisciplinary working we observed included onsite therapists and radiographers. • Staff we spoke with told us they maintained informal relationships with staff from other departments based at the Royal Hallamshire hospital. Referrals were made to other services and staff stated that this was a smooth process and that other specialities accepted referrals without challenge. Where appropriate, there was an established process to admit patients requiring further treatment or care. • We observed evidence of external multidisciplinary working. For example, ambulance paramedic staff told us they contacted the unit to ensure patients could be treated within the unit before bringing them. GP surgeries contacted the unit for advice as to whether to refer patients to the unit or the main emergency department. • The department had excellent links with social services and safeguarding teams and were involved in a project identifying young people at risk of drug abuse or gang violence. • Patients with acute psychiatric or mental health needs were not routinely seen at the unit. Where psychiatric support was required, patients were advised to attend the main emergency department as there was no service available at the Royal Hallamshire hospital beyond initial assessment. Transfer to the main department was facilitated if required.
Seven-day services • The Royal Hallamshire Hospital minor injuries unit was open from 8am to 8pm for 364 days per year. It was closed on Christmas Day. • X-ray facilities were available throughout the opening times of the unit and results were shared electronically. The unit kept common medicines on site to dispense when the pharmacy was closed. Information was available for local pharmacies, including late opening pharmacies. • Blood tests were taken on site and staff told us turnaround was one to one and a half
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hours. We did not see blood samples being taken during our inspection.
Health promotion • At the Royal Hallamshire Hospital minor injuries unit, nursing staff told us that if a patient requested support or guidance to other services for health promotion they were signposted to the appropriate contact for the service. For example, a patient admitted for stiches to a head wound had enquired about their diabetes care and was signposted to their own GP. We observed information leaflets available for patients and staff giving aftercare and treatment advice to patients prior to discharge.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Mental Capacity Act and Deprivation of Liberty training completion Data relating to mental capacity is included in the safeguarding adults’ level 2 training module. (Source: Routine Provider Information Request (RPIR) P40 –Mandatory and Statutory Training)
• The Mental Capacity Act and deprivation of liberty safeguards were part of annual mandatory training for nursing staff and the department had achieved 80% compliance. We spoke with 13 members of staff about Mental Capacity Act and deprivation of liberty training and each confirmed they had completed mandatory training covering these areas. • In the Royal Hallamshire Hospital minor injuries unit, we found that staff understood how and when to obtain consent. We observed staff as they obtained informed consent prior to assessment and treatment and documented this appropriately. Assessment and treatment was explained to the patient. • Emergency nurse practitioners told us they relied on implied consent for patients attending the unit. If a patient declined treatment, this was documented as ‘patient declined to consent to treatment’. We were informed that some nursing staff documented whether a patient consented but not normally. • Staff we spoke with were aware of the rights of patients and their role in protecting the rights of patients in relation to the Mental Health Act. The requirements of legislation and guidance relating to mental capacity were understood by the staff we spoke with. Staff were able to explain assessment and treatment in several ways and stated that where they felt a patient lacked capacity they would act in the best interests of the patient and make safeguarding or GP referrals, as appropriate. • Where concerns regarding cognitive function were raised, a patient would be referred to the main emergency department for further assessment and treatment. • The nature of the patients treated routinely at the minor injury unit meant that staff did not need to restrain or deprive liberty. However, as staff worked across both sites, they were aware of policy and had completed mandatory training as required by their roles.
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Is the service caring?
Compassionate care
Friends and Family test performance The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was generally better than the England average from March 2017 to December 2017. The trust slightly fell lower than the England average in January and February 2018. A&E Friends and Family Test Performance - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS England Friends and Family Test)
• For the Royal Hallamshire Hospital minor injuries unit, respondents to the NHS website rated the unit highly, with an average rating of 4 out of 5 stars. We observed staff interacting with patients and family members in a considerate and respectful manner, acting in a friendly, approachable and professional way. We observed patients being treated with dignity and compassion. Privacy was respected as staff closed doors and curtains when patients were being assessed or treated. Staff were friendly and respectful in their approach. We spoke with four patients in the unit who each spoke very positively about the care they received. Staff showed respect and were aware of the need to protect confidentiality. • The unit reception area faced the waiting area and reception staff could observe members of the public from their desk. There was a seat for patients booking in and the reception was away from the seating area to make booking in as confidential as possible. However, we observed the lack of privacy at the unit reception area which meant it was difficult to maintain patient confidentiality. For patient assessment areas in the unit privacy was managed as effectively as possible with curtains to the front only. • Due to the layout of the unit, it could be difficult fully to maintain privacy and confidentiality. Cubicles were curtain fronted so did not block sound, the reception area was on an open corridor and the waiting area was small and open to passers-by. However, privacy and dignity was maintained, as much as possible, within the department. We observed that the curtains were drawn when patients were being assessed and treated. When speaking with patients, staff used suitable volumes to avoid being over heard by other patients.
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• Staff we spoke with told us that they always challenged disrespectful, discriminatory or abusive behaviours. The trust had a zero tolerance policy towards violence and aggression.
Emotional support
At the Royal Hallamshire Hospital minor injuries unit we observed staff working with patients who were distressed, to provide reassurance. Staff understood the impact relatively minor injuries may have on people’s physical and emotional wellbeing. They offered emotional support in the department and referred patients to GP’s and social services, when required.
Understanding and involvement of patients and those close to them
Emergency Department Survey 2016 This survey was only undertaken at the NGH location. • At the Royal Hallamshire Hospital minor injuries unit, we observed staff communicating effectively with patients, to ensure that care, treatment and conditions were understood. Staff gave a clear explanation to the patient about their condition. Staff checked that patients had fully understood their care and treatment by asking whether they had any further questions at the end of a treatment. • Staff gave patients advice about the services available and how to access them. Where a patient required further advice or support after treatment they were advised to contact their GP as long-term care was beyond the scope of the minor injury service. Patients were encouraged to manage their own health care and wellbeing and self-care advice was given on discharge.
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Is the service responsive?
Service delivery to meet the needs of local people • The minor injuries unit within the Royal Hallamshire Hospital was located in an area with a high student population. The service worked closely with student groups to provide injury care without the need to travel to the north of the city. Close links with the university ensured facilities were well advertised and used appropriately. • The local service review included investigating the closure of the unit. Subsequently public consultation indicated this was unacceptable to members of the public, particularly those located on the south side of the city of Sheffield. Arrangements for further consultation were in progress at the time of our inspection. • Staff stated that they understood the cultural needs of the diverse population of Sheffield and went to great lengths to meet those needs, including liaising with members of staff from those communities to establish cultural, social and religious needs.
Meeting people’s individual needs • At the Royal Hallamshire Hospital minor injuries unit we found services were delivered in a way that accommodated the specific needs of patients. Where a patient was living with dementia or learning disability, they were prioritised to minimise distress and anxiety. Patients who were profoundly deaf were communicated with by text messages, or pad and pen to ask questions. • Respect was shown to patients of different faiths or cultures and staff had investigated how to best meet the needs of the multicultural population of Sheffield, for example through the use of chaperones. The department had access to an interpreter's service by telephone. • Staff we spoke with stated that they provided non-discriminatory care and decision- making. We were told by staff that the unit had a reputation within the community for providing a service for patients with learning disabilities or dementia as it was often quieter, and patients could be seen and treated more quickly than by attending the main department. One member of staff had undertaken additional dementia studies to provide a higher standard of care for patients with dementia. Link workers were also available. • We discussed the care of patients with a learning disability with nursing staff. We were informed that patients usually arrived at the unit with a carer to support them and this made communication more effective. We observed the care of a patient with a learning disability. The patient was asked if they had a learning disability and was supported appropriately with their care and treatment. The unit did not use communication cards or picture boards. • Patients with mobility needs or disabilities were treated, where possible, in the most comfortable position for them. Due to the nature of the work carried out by the minor injury unit, hoisting equipment was not used. Bariatric equipment was available on the hospital site.
Emergency Department Survey 2016
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The trust scored about the same as other trusts for all three Emergency Department Survey questions relevant to the responsive domain. Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your 6.9 About the same as condition with the receptionist? other trusts Q11. Overall, how long did your visit to the emergency 6.3 About the same as department last? other trusts Q20. Were you given enough privacy when being examined or 8.8 About the same as treated? other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016)
Access and flow • The Royal Hallamshire Hospital minor injuries unit was located on the ground floor, near to main doors and was easily accessible. The time of entry was recorded on arrival and we observed that there was minimal waiting for patients to see the receptionist. In order to minimise waiting times, patients were assessed whilst other patients were having diagnostic tests, such as an x-ray. • Our previous inspection report stated that the unit should improve the monitoring of time to be seen and total time in department. At this inspection we found that performance monitoring reports were available from the electronic system and the department had completed the action. • For the most recent complete month prior to our inspection (May 2018) daily attendance at the minor injuries unit averaged 59 patients, which included one to two children. • During the week of our inspection the unit achieved 100% compliance with the four-hour standard. During our inspection visit to the unit the average waiting time for treatment was 90 minutes. • Patients were advised of likely waiting times when the unit was busy. Waiting times were reported by staff to be consistently less than two hours and patients we spoke with confirmed that waiting times were minimal. There was no length of waiting time displayed in the unit waiting area. • We were informed that if waiting times increased in the unit, doctors from the main department assisted to improve patient flow. The unit was also staffed by health care assistants and trainee advanced nurse practitioners to assist emergency nurse practitioners and reduce waiting times for treatment and care by carrying out procedures and treatments on behalf of emergency nurse practitioners. Staff reported that they stayed late to see patients in the department if required, but that patients arriving near to closing time were advised to attend the main emergency department.
Learning from complaints and concerns
Summary of complaints
From January to December 2017, there were 128 complaints about urgent and emergency care. The trust took an average of 30 working days to complete. The trust works to a tiered response time process where the timescale is determined based on the complexity of the concerns raised.
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The Trust target is to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints with in the agreed timescale.
• The majority of complaints related to Northern General Hospital (113) • Emergency services had 28 complaints. • September 2017 had the highest number of complaints (19) • 72 complaints related to medical staff.
(Source: Routine Provider Information Request (RPIR) P61 Complaints) • At the Royal Hallamshire Hospital minor injuries unit we found complaints and concerns were monitored and followed up appropriately. Complaints were handled effectively and confidentially. Staff attempted to deal with complaints at the time, apologising, explaining reasons for any failings and developing plans to rectify problems as best as possible. Staff said this level of complaint management minimised the number of complaints made formally, but that patients and their relatives were not discouraged or prevented from making formal complaints. • Staff we spoke with told us they provided advice and support in making a complaint where appropriate and we were provided with an example of this. We observed that information leaflets and posters about making a complaint were available in the unit. • Following the investigation of a complaint, information and changes to practice, if required, were shared with individual staff. If the issue had a wider impact then information was shared in team meetings, in the governance newsletter and by email. We saw examples of changes made as a result of complaints, which included the introduction of health care assistants to improve caring and reduce waiting times.
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Is the service well-led?
Leadership • A deputy medical director with responsibility for emergency care and patient flow was appointed in 2016. At our inspection we found there had been a recent change in leadership of the department with the appointment of a nurse director and matron for the Urgent and Emergency Care Directorate. The care group leadership team included the nurse director, an operations director and clinical director which formed a clinical delivery leadership triumvirate. • The nurse director told us they led by example and regularly worked clinical shifts to support staff. Medical and nursing staff we spoke with were positive about the functioning of the leadership triumvirate for the emergency department and of the role of the nurse director. • The Royal Hallamshire Hospital minor injuries unit was nurse led. We found the nurse consultant provided leadership and was the first point of call for nurse practitioners in the unit. • Staff in the unit we spoke with felt well supported by their managers. Staff stated that the nurse consultant was a regular part of the clinical team and well respected. Staff told us the arrangement with the nurse consultant and nurse director providing oversight of the unit worked well. Managers were accessible and supportive.
Vision and strategy • A clear vision and operational plan was in place for the continued development of the emergency department. The directorate’s strategy and plan was linked to the trust’s corporate strategy. The vision for the department was linked to the aims of the trust’s ‘making a difference’ corporate strategy for 2017 to 2020. • The Royal Hallamshire Hospital minor injuries unit shared the wider vision and strategy of the emergency department, which was encapsulated in a one-page document ‘The AEM Way’ prepared in January 2018 and was in line with the trust’s three-year strategy. Each member of staff we spoke with was aware of the aims and values for the main department and the wider trust and the role they played in achieving this. As staff in the unit also worked in the main emergency department they were aware of the vision and strategy for the emergency directorate.
Culture • The emergency department’s culture was clearly positive, which a visitor could sense, and which staff told us about. Staff we spoke with felt valued and appeared happy and enthusiastic. They spoke positively about working in the department. We spoke with 10 staff and each felt the culture in the department had improved and was more open and positive. Staff felt listened to by senior staff and regular meetings to facilitate discussion and raise any issues took place. Staff who had previously felt isolated now felt much more included within the team. • At the Royal Hallamshire Hospital minor injuries unit staff told us they felt valued; everyone who worked in the unit was passionate about it. Staff were proud of the reputation of the 20171116 900885 Post-inspection Evidence appendix template v3 Page 209
unit and stated that they felt a professional responsibility to patients and their colleagues to maintain high standards. Staff we spoke with told us teamwork was open and transparent and the unit was a happy and busy place to work. The emergency nurse practitioner team engaged as a family and they each felt valued and appreciated. • The safety and wellbeing of staff was important to the staff and management of the unit. Staff we spoke with told us there was a positive culture towards whistleblowing and sharing information. Support plans were in place and we observed well-being posters for staff in the unit. Security carried out regular patrols of the area and could be called by staff in an urgent situation. However, staff also felt more could be mentioned about staff wellbeing, and it could be promoted more.
Governance • At our previous inspection we issued a requirement notice for the department to ensure arrangements for governance within the emergency department operate effectively. At this inspection we found the department had made a number of changes to strengthen the arrangements for governance linked to the ‘ward to board’ governance of the trust. • Governance arrangements had been strengthened with the appointment of the nurse director who with the clinical director had oversight of governance. The nurse director was the accountable lead for governance. At the time of our inspection triumvirate meetings were held bi-weekly. A medical governance lead and audit lead for emergency medicine was in place for the department and was supported by the care group governance coordinator. The department recognised there was more to do to develop audit. • The executive care group meeting for acute and emergency medicine met bi-monthly. The executive meeting was chaired by the operations director and attended by the other members of the triumvirate and senior clinical managers. We reviewed the minutes of the meetings held in February, April and June 2018. Governance items reviewed included operational performance, risks and the Action 95 plan. Actions arising from the meeting were assigned to identified staff members and were reviewed and progressed at the next meeting. The emergency department governance executive reported into the acute and emergency medicine executive. • Clinical governance arrangements had been strengthened with the clinical director having overall responsibility for clinical governance. Three clinical lead consultants were in place and the audit lead for the emergency department. Audits were managed by the audit consultant in liaison with the clinical effectiveness unit. The audit programme for the year was agreed by the governance team. A departmental governance newsletter was prepared monthly. Learning from a clinical governance case was selected each week and presented in newsletter format with associated learning points and shared with staff by email and staff notice boards. • A clinical governance meeting for the emergency department was held monthly chaired by the consultant lead. We reviewed the minutes of the meetings held in February, March and April 2018. The agenda included a review of audits in progress. Actions arising from the meeting were assigned to identified staff members and were reviewed and progressed at the next meeting. • Monthly governance meetings for major trauma were attended by the department’s clinical lead consultant for major trauma. Each patient death was subject to medical review. To
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support governance for major trauma, the trauma lead also attended quarterly governance meetings of the local trauma network attended by medical lead from each local hospital. • Regular staff meetings were held which supported governance arrangements for the emergency department. Emergency department consultants’ meetings were held regularly to support clinical governance. We reviewed the minutes of the meetings held in December 2017, March 2018 and April 2018. We also reviewed notes and action points arising from meetings attended by other groups of staff including care practitioners, sisters and administrative staff in the emergency department. • The governance lead for the emergency department was the same for the Royal Hallamshire Hospital minor injuries unit and similar governance processes applied to the unit. Staff in the minor injuries unit were clear about their roles and responsibilities in relation to governance of the unit. At this inspection we found local audits are undertaken in MIU. These include annual documentation audits incorporating a random sample. All non-medical prescribers in MIU complete a three-yearly peer review of prescribing. • Management of risk, issues and performance • At our previous inspection we issued a requirement notice for the trust to ensure divisional risk registers reflected issues in the emergency department and demonstrated evidence of actions and reviews. At this inspection we found that new risks were added monthly to the risk register. Risks scoring three and below were managed locally within the department. Risks scoring four and above were recorded in the incident management system. Risk assessment was undertaken to confirm the level of risk and to identify actions to mitigate the risk. • The management of risk was part of ward to board governance processes. Risks were reviewed by the directorate governance team who decided whether risk validation group approval was required. High level risks were validated by the risk validation group. The risk validation group prepared a monthly report to the trust executive which highlighted key risks. Highest level risks were assigned to an executive director and included in a trust level risk assurance report. The patient safety and risk committee also received key risk reports. • We reviewed the risk register for the emergency department. The current risks rated at the extreme risk level were the major trauma centre requirement for consultant cover in the resuscitation area, and the management of severe sepsis and septic shock within the emergency department. Outcomes from audits were risk assessed and included in the risk register. Risks were reviewed according to the level of risk, with higher risks being reviewed more frequently. We saw evidence that the risks had been recently reviewed and escalated. However, one of the members of consultant staff we spoke said they were unaware of what was included in the emergency department risk register. Also, we did not see evidence that the trust board were appropriately sighted on the risks that were classed as ‘extreme’ by the emergency department. • Dashboard information was shared daily with the emergency department senior team, clinical operations and medical and nursing staff in the department. An integrated performance report was prepared weekly incorporating a quality dashboard and daily and weekly performance scorecard for the emergency department. We reviewed examples of the emergency department quality dashboard presented at governance meetings to
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support the review of incidents, complaints, trends and associated risks. • The Royal Hallamshire Hospital minor injuries unit used the emergency department risk register and followed the risk processes used in the main department. We saw that the risk register reflected risks specific to the unit, for example, delays with ambulance transport for patients being transferred between sites and being discharged. • Staff in the unit were clear about their roles and responsibilities in relation to risk management. We discussed items on the risk register. These reflected the concerns of staff and were identified as areas that the hospital was working to resolve, such as increased recruitment and working with partner organisations regarding transfer of patients.
Managing information • Information was used to monitor and manage the operational performance of the department, and to measure improvement. Service performance measures were monitored and reported. • In October 2017 the emergency department had implemented the emergency care data set, the national data set for urgent and emergency care which replaced the previous commissioning data set for emergency departments. The emergency care data set supported electronic linking to triage and patient report forms. It also enabled the department to compare data more effectively with other emergency departments. • We found that staff had access to appropriate clinical and management guidance to support their work, accessed through the trust intranet. • The emergency department’s submission of data and notifications to external bodies was in place. We received assurance from senior managers as to the integrity of the emergency department’s data management systems compliance with data security standards. • Despite the electronic patient records we found that paper notes continued to be used in the department. The paper notes were scanned into the electronic data management system as the patient was discharged. • At the Royal Hallamshire Hospital minor injuries unit the electronic document management system ensured immediate access to notes. Staff were able to access patient details and previous attendance details as required. Staff spoke positively about their ability to access information and provided assurance that patient information was dealt with confidentially and sensitively. The introduction of the electronic patient record system allowed notes to be shared with appropriate services also using the system, including the main emergency department and outpatient departments. • On discharge from the unit, patients were made aware of plans of any follow up care needed and appropriate referrals were made to ensure continuity of care. Where required, medication was dispensed, or prescription requests given to ensure medication could be obtained. Letters were generated by the electronic patient record system to send to GP's to advise of attendance. • At the Royal Hallamshire Hospital minor injuries unit we observed confidential notes left on a photocopier and on desks. We found a computer access card was left on a computer and uniforms with name badges in a non-secure stock room. We spoke with staff about 20171116 900885 Post-inspection Evidence appendix template v3 Page 212
these issues during the inspection and received assurance that immediate action was taken. Engagement
Friends and Family test performance
The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was generally better than the England average from March 2017 to December 2017. The trust slightly fell lower than the England average in January and February 2018.
A&E Friends and Family Test Performance - Sheffield Teaching Hospitals NHS Foundation Trust
(Source: NHS England Friends and Family Test) • For the friends and family test, paper and electronic responses were available to patients. A monthly report of the friends and family test results included ‘soundbites’ from patients. The randomly selected sample of five we listened to was very positive. The weekly improvement meeting started with an analysis of the friends and family test results. The main themes identified were waiting times, communication and attitude of staff. • We did not observe signage or information displayed about the friends and family test or how to provide feedback about patient experience within several areas of the emergency department. When we asked staff about the friends and family feedback leaflets they didn’t seem to know much about how feedback was collected from patients and their families. There were no signs or leaflets left out for patients to complete. In the reception area a friends and family box was affixed to the wall but there were no friends and family cards for patients to complete. We asked a member of reception staff if they had any and they then put the cards on the counter for patients to complete. The department also received thank you cards and messages which staff were informed about when it was a personal compliment. Patient user groups included groups for patients with mental ill health. The patient experience committee reviewed feedback received, including the friends and family test results. The committee requested monthly exception reports where results were not as expected. Senior managers we spoke with informed us that the capture of patient feedback was an area for development. We were informed that recent staff survey results reflected an improved level of
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engagement with staff. Medical and nursing staff we spoke with told us that engagement with staff and feedback to staff following engagement had improved. Staff consultation took place through a variety of forums including a multidisciplinary improvement forum and new ideas were progressed through an improvement group. Survey monkeys were used to take particular ideas forward. For example, the recent move of the green steam to another area at weekends. A “You said we did” board was used to feed back the results of staff engagement. • We reviewed the acute and emergency medicine directorate staff engagement action plan as at 31 May 2018. Progress with actions which addressed issues identified from consultation and other sources were monitored. A member of staff was assigned for each action and a planned date for completion and a red-amber-green rating were assigned following review. • Surveys with staff included stress surveys, consultation about shift patterns and hours and staff engagement workshops. A fortnightly breakfast club format was used to support engagement with nursing staff. Learning and reflection and ‘moments of excellence’ were highlighted at daily handovers. • At the Royal Hallamshire Hospital minor injuries unit we did not observe signage about the friends and family test. We also did not observe staff asking patients to provide feedback or informing them of methods to use. We were informed that patient feedback about the unit was received through text messages and feedback could be given through the trust website although staff we spoke with felt responses could be improved for patients who did not use a mobile device. We observed that feedback from patients was received through thank you cards which were displayed in the staff room. • Staff at the Royal Hallamshire Hospital minor injuries unit told us that they felt staff views were listened to and they felt involved in the development and provision of services in the unit. A staff forum met every two months and ideas were shared and often put into practice, for example changes to rotas or handover processes. Staff stated that the management team had often asked staff for opinions or ideas before implementing changes. • Staff we spoke with felt stakeholders listened to the public and public opinion. The department was involved in public consultation as to the services provided in Sheffield which included the minor injuries unit within the Royal Hallamshire Hospital. Staff we spoke with told us the consultations could have been more widely publicised.
Learning, continuous improvement and innovation • Supporting competency through training and development was a key focus for the department. The quality and emphasis placed on education and support for staff development was enhanced by members of staff with senior and leading roles remained clinically active. A nurse consultant lead was in place for education and training. Preceptorship supported new staff. • The Royal Hallamshire Hospital minor injuries unit had trialled and implemented new and innovative schemes to support continuous improvement and to promote sustainability. The unit leadership and nurse practitioners provided a focus on staff education and development. Each member of staff we spoke with was undertaking further training beyond that required for their role. This was supported encouraged by the nurse
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consultant who staff said provided a focus on engaging in quality initiatives to improve patient care.
Medical care (including older people’s care)
Facts and data about this service
Medical services at this trust are spread across six different care groups or business units. The Emergency care group includes diabetes and endocrinology, respiratory and gastroenterology services. Combined Community and Acute Care includes integrated geriatric and stroke medicine, therapeutics and palliative care. Head & Neck includes neurosciences incorporating the hyper- acute stroke unit. The Musculoskeletal care group incorporates pain services and rheumatology. Specialised Cancer, Medicine and Rehabilitation includes communicable diseases and specialised medicine, spinal injuries rehabilitation and specialised cancer services. South Yorkshire Regional Services includes cardiac and renal services. The care groups above also provide other non- medical services not listed here.
Royal Hallamshire Hospital has 14 wards providing services across multiple specialities within medical care including infectious diseases, rheumatology, dermatology, haematology, stroke medicine, gastroenterology, respiratory medicine, diabetes and endocrine, and neurology.
(Acute PIR – Full 2018 03 05 Documents – Context)
The trust had 131,594 medical admissions from October 2016 and September 2017. Emergency admissions accounted for 39,600 (30%), 7,784 (5.9%) were elective, and the remaining 84,210 (63.9%) were day case. Admissions for the top three medical specialties were:
• Gastroenterology: 25,856 • Clinical oncology 17,559 • Medical oncology: 12,176 (Source: Hospital Episode Statistics)
Is the service safe?
Mandatory training
The service had systems and processes in place to ensure that staff could access mandatory training and staff we spoke with confirmed they had enough time to complete mandatory training.
Mandatory training completion was monitored centrally with any staff not on track being flagged to their line manager for individual follow-up. The trust provided lots of e-learning which supported staff in completing their training. Planning for training of staff was done throughout the year to encourage good compliance.
With reference to the tables below, we spoke with staff about the compliance rates with mandatory training shown regarding staff. Staff assured us that the compliance figures would improve as the year progressed and so patient safety was not at risk.
Mandatory training completion rates
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The trust set a target of 90% for completion of mandatory training.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for nursing staff in medical care is shown below:
Royal Hallamshire Hospital: Nursing and midwifery staff
Staff Eligible trained staff Completio Trust Met Name of course (YTD) (YTD) n rate Target (Yes/No) Conflict Resolution - Level 1 (3 Yearly) 55 55 100% 90% Yes Resuscitation: Paediatric Basic Life Support - Level 2b (1 Yearly) 4 4 100% 90% Yes Fire Safety Training - Level 1b (2 Yearly) 1 1 100% 90% Yes Moving & Handling - Level 2b (1 Yearly) 148 158 95% 90% Yes Moving & Handling - Level 2a (3 Yearly) 207 218 93% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 333 365 92% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 363 389 92% 90% Yes Information Governance - Level 1 (1 Yearly) 338 366 91% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 305 333 86% 90% No Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 237 261 85% 90% No Fire Safety Training - Level 1a (1 Yearly) 272 301 83% 90% No
Nursing and midwifery staff exceeded the trust target of 90% for eight out of 11 mandatory training modules. The other three areas were all above 83% compliance.
Medical and dental staff
Staff Eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Resuscitation: Paediatric Basic Life Support - Level 2b (1 Yearly) 15 15 100% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 4 4 100% 90% Yes Fire Safety Training - Level 1b (2 Yearly) 27 31 95% 90% Yes Information Governance - Level 1 (1 Yearly) 90 97 94% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 75 86 94% 90% Yes Moving & Handling - Level 2a (3 Yearly) 83 91 93% 90% Yes 20171116 900885 Post-inspection Evidence appendix template v3 Page 216
Infection Prevention and Control - Level 2 (1 Yearly) 82 99 91% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 78 98 89% 90% No Fire Safety Training - Level 1a (1 Yearly) 115 133 83% 90% No Equality & Diversity: General Awareness - Level 1 (3 Yearly) 124 147 82% 90% No
Medical and dental staff met or exceeded the trust 90% completion target for seven out of 10 modules. The other three subjects were 82% or above. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Safeguarding
The trust had systems and processes in place to protect children and adults from neglect or abuse. Staff we spoke with had undertaken safeguarding training so that safeguarding was everyone’s business.
We saw that the trust had policies for safeguarding adults and children. However, the children’s policy was out of date. However, the chief nurse was aware of the out of date policy and action was being taken to address this and ensure it was compliant with current national guidance.
In the last year, trust wide, medicine had made 156 adult safeguarding referrals and 54 child safeguarding referrals.
Staff we spoke with understood their responsibilities in identifying and reporting any safeguarding concerns.
Staff had access to safeguarding advice and support from link nurses on the ward, from the trust’s intranet, and the trust’s central safeguarding team. In particular, there was a policy addressing female genital mutilation with resources on the trust’s safeguarding patients intranet site. This supported staff to make appropriate reports and referrals and offer support.
Safeguarding training completion rates A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for nursing staff in medical care is shown below:
Royal Hallamshire Hospital: Nursing and midwifery staff
Staff Eligible Met trained staff Completio Trust (Yes/ Name of course (YTD) (YTD) n rate Target No) Safeguarding Children & Young People - Level 3 (3 Yearly) 135 142 97% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 109 114 93% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 231 251 92% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 321 349 91% 90% Yes
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Nursing and midwifery staff exceeded the trust target of 90% for all four safeguarding training modules.
Medical and dental staff Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Safeguarding Children & Young People - Level 3 (3 Yearly) 4 4 100% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 17 17 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 63 64 99% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 73 83 94% 90% Yes
Medical and dental staff exceeded the trust target of 90% for all four safeguarding training modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene
We found that the environment was visibly clean, and that systems and processes were in place to control infection and promote hygiene.
All patients were swabbed for methicillin resistant staphylococcus aureus (MRSA) when they were admitted to the ward. A patient was placed in an isolation room on the ward if they came from abroad or from a hospital that was known to have had an outbreak. The MRSA test was re-run for patients who stayed for longer than a month.
In the period 1 June 2017 to 31 May 2018, of the wards we visited, wards E1, E2, L1, L2, P3, P4 and Q2 had, respectively but between them, nine cases of clostridium difficile (C.diff), zero cases of MRSA, and eight cases of methicillin susceptible staphylococcus aureus (MSSA).
When infections occurred, the trust had a system of investigation, including a post infection review, following which an action plan was produced. Staff described how they would send samples to the laboratory to check for infection and inform the nurse in charge and the trust’s infection team and notify colleagues at handover.
We saw posters displayed around the ward about infection prevention and handwashing.
Hand washing facilities and antibacterial gel dispensers were available at the entrance of the wards and on corridors or at the end of beds. Services had access to isolation rooms for infectious patients and signs were placed on the doors to alert people to an infection risk.
We observed staff using personal protective equipment when required, and they adhered to ‘bare below the elbow’ guidance. Staff were seen using personal protective equipment (PPE) and handwashing before and after patient contact.
To support staff in maintaining levels of infection control, wards benefited from dedicated housekeepers and a central trust domestic team. Staff cleaned equipment after use and a sticker
20171116 900885 Post-inspection Evidence appendix template v3 Page 218 was used to indicate equipment that had been cleaned. Housekeepers kept the sluice area clean and tidy and ensured commodes were cleaned and ready for use.
Infection prevention control audits were done regularly, and results submitted electronically to the central infection prevention control team and reports generated with action plans. The wards had a link nurse for infection control. We saw audits for a selection of the wards we visited, and all had achieved their target compliance score.
Waste was separated and disposed of in appropriate colour coded bins.
Environment and equipment
We found the ward environment was a mixture of wards that had been refurbished and those awaiting refurbishment, but all the wards seen were clutter free, wheelchair accessible, and with enough equipment for staff to carry out their role.
For instance, the gastroenterological service’s environment was due to be refurbished in the future. Some improvements had been made in the meantime. For example, because of patient feedback about the room temperature being too cold, secondary glazing was fitted. Another example was the neurological service where a business case for the hyper acute stroke unit (HASU) reconfiguration had been developed and had been signed off by commissioners. The trust told us further work was required before this change could be implemented. In contrast, the haematology service had modern refurbished facilities. For instance, ward O1 had 17 newly refurbished side rooms; three of which had specialised air filtration systems installed to prevent infection.
Staff told us that the trust was aware of which wards had an environment which was dementia compliant and which were not and had an action plan to bring the non-compliant wards into compliance.
We found no gaps in checking of resuscitation trolleys. We found the environment was uncluttered, with storage space, and wide corridors. Sharps bins were used and stored properly.
Staff had access to equipment they needed and told us that if bariatric equipment was needed this could be ordered. In particular, staff had access to computers to view electronic patient records. Equipment we saw had been electrical safety checked. The trust had a medical device policy that ensured equipment was logged, planned maintenance provided and meetings held to address any gaps.
To park, patients had access to a multi-storey car park on the site.
Assessing and responding to patient risk
Within the medicine service staff used a series of tools and meetings to support them in assessing and responding to risks posed to patient safety.
Staff used an adapted version of the national early warning score (SHEWS) to assess the health and wellbeing of patients. These assessment tools enabled staff to identify if the clinical condition of a patient was changing for the worse and required early intervention and or escalation to keep the patient safe. On the records we looked at we found that screening was recorded for the
20171116 900885 Post-inspection Evidence appendix template v3 Page 219 venous thrombo-embolism check, and assessments were completed, such as for SHEWS, body maps for pressure ulcers and all care checking information was captured on the records we saw.
The trust sepsis pathway complied with NICE guidelines. There was a link nurse for sepsis. The sepsis pathway was embedded in medicine care and staff used stickers to identify sepsis risks.
The proportion of patients who received a venous thromboembolism (VTE) risk assessment was above the national target of 95%.
We saw notes of staff handovers and observed a morning handover and saw staff at all levels and grades took part fully in handovers of patient care from one shift to the next. We saw staff used a situation, background, action and result (SBAR) framework to transfer patients between teams. This appeared to work well.
Services made use of safety huddles to discuss patients at risk of falls and took mitigating actions such as, review of risk assessments, one to one nursing, and placement in visible rooms. For challenging patients, perhaps those with mental health issues, staff would undertake daily reviews and the matron would be briefed and the team would work with the link nurse on the ward.
At the nurses’ station, further patient assurance on safety was enhanced by use of an electronic whiteboard. With patient consent, this displayed names of patients with icons showing which patients were at risk of falls or needed pressure ulcer care.
With regard to pressure ulcer care, the trust had a tissue viability lead whose team led on rolling out a programme to address pressure ulcers which had led to pressure ulcer champions being identified on the wards. For instance, staff told us they used nursing care turn sheets, notes outside doors showing time for turning, and a once weekly multi-disciplinary team meeting to look at patients at risk.
We reviewed five sets of records and found there was information recorded for staff to assess the condition of a patient. Records reviewed showed that patients were risk assessed on admission to the ward for things like falls, nutrition, hydration, pressure ulcers and dementia. Charts were completed to inform staff if any further intervention was necessary. Staff told us that completion of charts was audited weekly and fed back to staff individually or at the safety huddle.
Medical outliers were managed using a “Take list” from Lorenzo. This was a real time automatically updated and accurate source of patient information which was added after ward rounds or safety huddles. This had been in operation for the last six months. The patient information meant that there was clarity at all times as to where patients were and who was responsible for them. The information could be scanned at ward level, so staff had the whole picture.
Nurse staffing
Medical services had systems and processes in place to provide the required nurse staffing levels so that patients were kept safe.
To support staff in planning staffing levels based on patient needs, the trust used a nationally recognised safer nursing tool and professional judgment, together with an electronic rostering
20171116 900885 Post-inspection Evidence appendix template v3 Page 220 system. This was used alongside a daily staffing meeting to fill any gaps in staffing. Staff reported that this system worked well and kept patients safe. The matron was available for any escalation and out of hours a duty matron held a bleep for this purpose and followed a clear policy of escalation. The trust’s executive group received a monthly safer staffing report and all staffing was reviewed on a rolling six monthly basis.
Specialities we visited, such as endocrinology or haematology, reported that they were able to match planned nursing levels to actual nursing using the above processes. In the areas we visited where this was challenging, such as the neurological service, staff reported the gap of, say, one nurse, would be filled using a regular bank staff member who was usually an existing staff member doing overtime. Staff spoken with did not report any issues with staffing cover and confirmed that they were able to take breaks.
The service had a hyper acute stoke unit (HASU) that consisted of six beds. The nurse staffing for the HASU was one staff nurse and two support workers for each shift, (early, late, night) plus, on every shift, a HASU nurse. Also, although not included in the numbers, there were two stroke nurse specialists on duty in the early shift, with one on the late and night shift. The trust told us that from July 2018 the stroke nurse specialists would be included in the numbers. Data supplied for April to June 2018 showed no gaps in the rota.
The stroke nurse practitioners on HASU were not supernumerary and they were ward based. During the night there are always three staff nurses on shift, including a stroke nurse practitioner. This enabled the stroke nurse practitioner to leave the ward if a patient presented at the hospital to attend the neurological assessment unit and direct to scan if needed. Having three staff nurses on shift ensured that the ward was safely staffed.
Many of the specialities we spoke with had been successful in recruiting more nursing staff and some specialities undertook exit interviews with staff to try and find out why staff wanted to leave.
A review of the staffing on the wards we visited showed that between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on nightshift was below 75% on L2 Neurology on dayshift and nightshift. Following the inspection, the trust told us that the data for the L2 Neurology had been inputted incorrectly and the fill rate should be for RN days 87.5% and 95.7% for RN nights. No evidence was provided as part of factual accuracy to corroborate this
The trust reported the following nurse staffing numbers for medical care in March and December 2017. The service had fill rates of over 90% in both time periods.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 1,495.4 1,629.4 91.8% 1,547.6 1,710.2 90.5% (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
Vacancy rates From January to December 2017 the trust reported a vacancy rate of 9.5% for nursing staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates
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From January to December 2017, the trust reported a turnover rate of 7.95% for nursing staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017 the trust reported a sickness rate of 4.2% for nursing staff in medical care which is slightly higher than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage From January to December 2017, the trust reported 41,414 shifts filled by bank and agency staff (63%). This meant that 37% of vacant shifts were left unfilled.
A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 35,475 (54%) Agency 5,939 (9%) Not filled 24,740 (37%) (Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
Medical staffing
Medical services had systems and processes in place to provide medical staffing levels so that patients were kept safe.
The services we visited had a daily consultant review. The rota for each service on the site ensured 24/7 consultant cover and where this consisted of on call cover, all consultants were able to attend site within 30 minutes if necessary.
None of the services we visited reported any issues with medical cover.
The trust reported the following medical & dental staffing numbers for medical care in March and December 2017. The service had fill rates of over 90% in both time periods.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 679.3 691.0 98.3% 706.6 693.7 101.9% (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
Vacancy rates From January to December 2017 the trust reported a vacancy rate of 1.4% for medical and dental staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017, the trust reported a turnover rate of 26.3% for medical and dental staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates
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From January to December 2017 the trust reported a sickness rate of 1.2% for medical and dental staff in medical care which is lower than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Medical agency and locum staff usage From January to December 2017, the trust reported that 9,503 shifts were filled by bank and agency staff which was 96% of those requested. A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 5,042 (51%) Agency 4,461 (45%) Not filled 441 (4%) (Source: Routine Provider Information Request (RPIR) P21 Medical Locum
Staffing skill mix
In December 2017, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) was lower.
Staffing skill mix for the 497 whole time equivalent staff working in medicine at Sheffield Teaching Hospitals NHS Foundation Trust This England Trust average Consultant 45% 42% Middle career^ 3% 7% Registrar group~ 33% 29% Junior* 19% 22%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 Source: NHS Digital - Workforce statistics (01/10/2017 - 31/10/2017)
Records
We reviewed five sets of records and found them to be legible, detailed, signed, and safely stored in locked trolleys when not in use.
Patient records, apart from the admission record which was electronic, were paper records. At the last inspection we reported that there were issues with staff having access to computers. At this inspection we found staff had no issues with access to computers and they used a swipe card to view these electronic records.
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On the records we looked at we found that screening was recorded for the venous thrombo- embolism check, and assessments were completed, such as for SHEWS, body maps for pressure ulcers and all care checking information was captured on the records we saw.
Staff told us that records were audited regularly, and items reviewed included controlled drugs, use of the malnutrition universal screening tool (MUST), SHEW scoring, and cannula charts. Results of the audits were fed back to nursing staff. For instance, we saw an inpatient record audit dated June 2017 which included in the actions feeding back to nursing staff.
Information relating to discharge was printed off in hard copy for the patient to keep while the electronic version of the discharge summary was accessible by community staff and GPs.
The trust was in the process of rolling out electronic patient records on a phased basis.
We found completion of deprivation of liberty safeguards documentation was not timely on some wards, but detained patients seen had all relevant paperwork completed including suicide risk assessments.
Medicines
We checked the storage of medicines, fluids and gases on the wards we visited. We found that medicines, fluids and gases were stored securely in appropriately locked rooms and fridges were checked and stocks were in date.
The trust had an up to date medicines management policy which staff had access to on the trust’s intranet. The trust ran a series of annual medicine audits including ones on medicine reconciliation, turnaround times for take home medicines, and safe and secure storage of medicines. For instance, the controlled drug audit showed that 97% of clinical areas completed a controlled drug checklist every three months. Another audit showed that 95% of areas with proximity card readers, which are a security feature that locks the door unless you swipe the reader with a card that works, locked intravenous fluids away when not in use. Electronic prescribing was being rolled out across all ward areas.
We checked the storage and administration of controlled drugs, which require specific controls, in all clinical areas. We found controlled drugs were appropriately stored with access restricted to authorised staff. Records showed the administration of controlled drugs were subject to a second check. After administration, the stock balance was confirmed to be correct and the balance recorded. A random check of the records showed no gaps in checking.
Drugs trolleys we saw were all locked with an electronic keypad which was being used by staff.
At the last inspection we found that fridge temperature monitoring was incomplete. At this inspection we found medicines that required refrigeration were stored appropriately in fridges. The drugs fridges were locked and there was a process in place to record daily fridge temperatures. All fridge temperatures were checked and recorded daily. There were no gaps in recording. Staff we spoke with understood their responsibilities for raising concerns if the fridge temperature went out of range.
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Also, at the last inspection, we found that intravenous fluids were not securely stored in all the clinical areas visited and some stock was out of date. However, at this inspection this was not the case.
Patient records seen showed patients were receiving medicines promptly and any allergies were clearly recorded.
The trust’s clinical pharmacy team provided support around medicines reconciliation, checking of patients' own medication for continued use, prescription validation, discharge planning, counselling, assessment and provision of compliance aids, medicines information and participated in multidisciplinary ward rounds.
Incidents
The trust had a clear policy for the reporting of incidents, near misses and adverse events. Staff were encouraged to report incidents using the trust’s electronic reporting system. The staff we spoke with could describe the process of incident reporting and understood their responsibilities to report safety incidents including near misses.
As can be seen in the table below the medical services at this site reported no never events over the last year.
Staff we spoke with said feedback from incidents was shared in many ways including; handover, safety huddles, and staff meetings.
The trust had a process for ensuring that deaths were reviewed within 24 hours using the structured judgment review method with any learning presented to departmental mortality and morbidity meetings. The trust’s standardised mortality ratio was within the ‘as expected’ range.
The lead for patients with a learning disability told us every death of a patient with learning disability goes through a medical examiner within the trust to identify any trends and cause of death.
We reviewed two root cause analysis reports (RCA) from serious incidents and found actions plans and lessons learnt were identified. Actions included providing feedback to staff.
The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.
Staff we spoke with understood the importance of being open and honest with patients. E-learning training was available to staff about duty of candour and there was information on the trust’s intranet which staff could access. The trust’s incident reporting system had mandatory fields to complete and if duty of candour applied a lead was assigned to ensure all requirements were met. This process was overseen by the trust’s patient safety and risk committee.
Trust wide from May 2017 to April 2018, medical services had incidents where the duty of candour had been applied 61 times.
Never Events
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Never Events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each Never Event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a Never Event. From May 2017 to April 2018, the trust reported no incidents classified as never events for medicine. (Source: NHS Improvement - STEIS 01/05/2017 – 30/04/2018)
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from May 2017 to April 2018.
These incidents were classified as; • Medication incident meeting SI criteria with one (50% of total incidents). • Treatment delay meeting SI criteria with one (50% of total incidents). (Source: Strategic Executive Information System (STEIS))
The trust had a process for approving serious incidents to ensure that only incidents that were serious incidents were logged as such. In March 2018, 66% of incidents were approved within 35 days, which was below the trust’s internal target of 95%. The trust had plans in place to improve the turnaround times for approval of incidents. For instance, in March 2018 two new safety and risk committees were created to support a more focussed discussion on key issues, including meeting the 35-day target. This was in addition to the supply of monthly performance reports to support the medicine directorates in monitoring their own performance and developing improvement plans.
All lessons learned from serious incidents were presented to the trust’s safety and risk committee.
Safety thermometer
The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
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Data from the Patient Safety Thermometer showed that the trust reported 174 new pressure ulcers, 21 falls with harm and 25 new urinary tract infections in patients with a catheter from April 2017 to April 2018 for medical services.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total Pressure ulcers (174)
2 Total Falls (21)
3 Total CUTIs (25)
1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only Source: Safety thermometer - Safety Thermometer
Staff told us that while the safety thermometer was used the results were not displayed to the public to see. The matron validated the results and undertook a detailed analysis of any concerns so that lessons could be shared and learning embedded.
For example, the safety thermometer dashboard for ward L2, within the neurology speciality, showed that since May 2017 there had been: no falls with harm; one catheter related urinary tract infection in August 2017; and pressure ulcers remained at one a month, apart from in October 2017 (4), with five months having no pressure ulcers.
The trust created a safety thermometer newsletter that summarised the results for each care group in an easy to use format. The trust was looking at automating the data collection process.
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Is the service effective?
Evidence-based care and treatment
The trust had systems and processes in place to ensure that care was given by the service according to published national guidance such as that issued by National Institute for Health and Care Excellence (NICE). All staff we spoke with could access, via the trust’s intranet, guidelines, policies and procedures relevant to their role.
The trust had a corporate policy which detailed the procedure for implementing NICE guidance. Staff were alerted to changes to guidelines by the trust’s clinical effectiveness unit who contacted the appropriate clinicians to examine any change required. An audit information management system tracked implementation and guidance. If a change were required, the directorate concerned would submit an implementation plan which would then be monitored until completion.
Our review of guidelines on the intranet showed that there were lots of guidelines which staff confirmed were well used. The policies and guidelines we saw were in date. For instance, the guideline for the management of sepsis had a review date of August 2019.
Nutrition and hydration
We found that the services had systems and processes in place to effectively support staff to meet the nutrition and hydration needs of patients and visitors. The trust ran an annual nutrition and hydration awareness week to advertise good practice in patient care.
On admission each patient had a nutritional assessment and staff described how dietitian services could be accessed for complex cases. Where necessary, food charts were used to monitor intake of food.
The medicine service at the site offered patients a full range of meals to meet any needs arising from religion, culture, allergies or personal choice. Staff told us they could go out of menu where necessary and provided snacks outside of mealtimes. Pictures could be used to assist patients in choosing food. Visitors could access snack machines. Patients could also use the canteen on D floor and the coffee shops on A and B floor.
Staff described how they tried to encourage patients to be independent when eating but would help where needed, with patients requiring help being noted on handover sheets or by using a red mat system. Some specialities had volunteers to help feed patients.
When we spoke with patients they described food that was of high quality.
Water jugs were in reach and replenished regularly. Fluids were monitored where necessary.
Pain relief
We found that the service had systems and processes in place to effectively support staff to meet the pain relief needs of patients.
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In the patient records we saw there were pain assessment charts to support staff in monitoring pain relief for patients. In addition, staff described, when using care rounding documents, they would use their own experience to help them assess pain and use objective markers such as a raised heart rate or blood pressure and document their findings. For patients who could not verbalise their pain staff could use pictures and a recognised scoring system.
Pain relief was discussed at handover and any issues noted in addition to analgesics being reviewed on ward rounds.
Staff told us that they had access 24/7 to the trust’s palliative care team who could supply expert advice on pain and its management.
Patients we spoke with had no issues with how their pain was being managed.
Patient outcomes
The service had systems and processes in place to monitor patient outcomes including, service evaluations, and participation in local and national audits, all with a view to providing effective patient outcomes.
We saw evidence of a number of local audits, some of which are summarised below. The endocrinology service was in the process of auditing pain in patients undergoing the double balloon procedure. This audit was started because the service wanted to see if reported pain was less when using a new procedure which drew on some of the benefits of a general anaesthetic. Interim results showed 0/10 pain scores using the new procedure. Another audit was looking at small bowel preparation. This was because of data which showed that patient satisfaction with the prior preparation (and therefore effectiveness of the cleaning of the small bowel) was poor. Poor patient experience often led to having to repeat the process which caused delay and added cost. The service was trialling a new preparation and while initial feedback was positive the audit results were going to be reviewed before a change was made.
In the neurology services they were looking at how to improve recording of venous thrombo- embolism results by the out of hour’s service. This had come to light following an examination of the safety thermometer data. The service also ran an antibiotic audit, and this revealed more work was needed on the 72-hour review by doctors. The service created an action plan which involved speaking with staff to make sure they did the review within 72 hours.
In the haematology service, they were in the process of undertaking a mask audit, to see what the psychological effect of staff wearing masks could have on patients, balanced against the reduced infection rates wearing masks could have. Staff told us junior doctors were also undertaking antibiotic timeliness audits. The service, as part of the trust’s ‘give it a go week’ initiative, was due to introduce an oral assessment chart for the mouths of their patients who were particularly susceptible to mucus which made eating challenging. Results were due to be examined in various forums including the consultants meeting and the governance meeting.
The vascular service ran an audit on Hickman line infections. At the point of inspection, they were auditing whether a cover over the line when showering patients reduced the incidence of infections.
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Many services used a hydration and nutrition assurance toolkit to help them assess and audit how their ward was doing with nutrition and hydration. The trust ran an annual nutrition and hydration awareness week to advertise good practice in patient care.
The endoscopy service at the site was fully accredited by the joint advisory group for endoscopy services.
Relative risk of readmission From January 2017 to December 2017, patients at Royal Hallamshire Hospital had a higher than expected risk of readmission for elective admissions and a similar to expected risk of readmission for non-elective admissions when compared to the England average.
• Patients in clinical haematology and gastroenterology had a higher than expected risk of readmission for elective admissions • Patients in respiratory medicine had a lower than expected risk of readmission for elective admissions • Patients in neurology had a higher than expected risk of readmission for non-elective admissions • Patients in clinical haematology and infectious diseases had a lower than expected risk of readmission for non-elective admissions
Elective Admissions - Royal Hallamshire Hospital
Note: Ratio of observed to expected elective readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
Non-Elective Admissions - Royal Hallamshire Hospital
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
Sentinel Stroke National Audit Programme (SSNAP) Royal Hallamshire Hospital takes part in the quarterly Sentinel Stroke National Audit programme. On a scale of A-E, where A is best, the trust achieved an overall SSNAP level of grade C in latest three audits, for the time periods April – July 2017, December 2016 – March 2017 and August –
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November 2016. This was an improvement from the previous three quarters where the trust achieved an overall SSNAP level D.
Royal Hallamshire Hospital
(Source: Royal College of Physicians London, SSNAP audit)
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The trust told us that the latest score for the above audit rated the stroke service at B moving from C.
National Audit of Inpatient Falls 2017 The RHH did not participate in this audit.
Competent staff
Appraisal rates From April to December 2017, 84% of staff within medical care had received an appraisal, compared to the trust’s target of 90%. A split by staff group can be seen in the graph below: Appraisals Eligible Appraisal Target met Staff group completed staff rate (Yes/no) NHS infrastructure support 39 33 85% No Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T) 337 296 88% No Qualified Allied Health Professionals (Qualified AHPs) 198 186 94% Yes Qualified nursing & health visiting staff (Qualified nurses) 908 741 82% No Support to doctors and nursing staff 973 799 82% No Support to ST&T staff 104 84 81% No Qualified Healthcare Scientists 38 33 87% No Medical & Dental staff - Hospital 6 5 83% No (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
The service ensured that staff were competent in their roles by ensuring staff received an annual appraisal, or through sharing information, by email, at team meetings, in a newsletter, and by offering staff additional training.
Staff we spoke with confirmed that there was a system in place to ensure staff received an annual appraisal. Some services, like the endocrinology and vascular service, were at 100% compliance. Others, such as haematology, were at 80%. Senior staff told us they received reports from human resources and could track individuals to ensure the appraisal was booked and done. Staff who had not yet done an appraisal were booked to receive one.
New staff were inducted and trained by the trust. For example, in one speciality we spoke with staff confirmed that they had received a three-day local induction followed by a six-month preceptorship and then a period of two weeks after that not being counted in staff numbers.
For students, staff told us there was a clear training pathway and students who had trained on the wards reported a positive experience.
All wards visited had link nurses for various areas including infection control, safeguarding, learning disability and dementia to support staff in maintaining competence in these areas.
Some services had developed teams of nurses who could validate the safety thermometer data to ensure that the data submitted was robust.
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Many services had trained care support workers to extend their skills in say, cannulation. The endoscopy service was training nurse endoscopists using a Health Education England programme.
The services visited had access to practice development nurses who helped oversee a rolling programme of additional competency training, in areas covering intravenous drug administration, veno-puncture, catheterisation, administration of stem cells and electrocardiography recording. The course consisted of a structured theory section followed by a practical assessment. For instance, in the haematology service they had run a bone marrow transplant study day. This was used to educate staff about the whole process, the patient journey, and the protocols in place. In addition, there was training on equipment such as infusion devices, syringe drivers, airvo humidifiers, and bladder scanners.
Consultants were trained in delivering bad news and had job specific end of life training.
Staff in the vascular speciality were encouraged and supported to do the pulmonary association medical education programme. Staff told us three quarters of the staff complement had done the course.
Multidisciplinary working (MDT)
To ensure effective services were delivered to patients, we saw different teams and health professionals working with staff at the service.
We could see from the handover sheets we examined that at a handover from night to morning staff there was open, structured, and this detailed communication between staff of different grades and roles.
The services had a trust-wide nutrition steering group to provide strategic direction around nutrition and hydration for patients. This was made up of a multi-disciplinary staff group such as a pharmacist, dietitian, caterers, speech and language therapists and gastroenterologists.
For complex patients, wards used a multi-disciplinary team to look at the discharge. For example, in the neurological service, for patients with Huntingdon’s disease, the consultant and speech and language therapy team worked together to plan the discharge.
Many of the services drew patients in from out of area and where this occurred, for instance in haematology, the consultants would discuss the patient with the consultant from the referring hospital and then a multi-disciplinary team meeting would occur to discuss patients. This meeting would be attended by nurses, doctors, pharmacists, microbiologists, histopathologists and the bone marrow transplant team.
Many specialities held a weekly MDT meeting on the ward that was attended by doctors, occupational therapists, physiotherapists, dietitians and speech and language therapists plus staff from the patient care team who specialised in complex discharges.
We saw evidence of the Yorkshire Ambulance Service have an acute stroke pathway which outlined that Sheffield’s HASU was based at RHH. The protocol ensured that patients were brought directly from home to the RHH stroke service, and if in the thrombolysis timeframe direct to scan, so bypassing A& E which ensured they were transferred in a timely way.
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Seven-day services
The medical services ensured there was a seven-day consultant rota providing cover and no services we visited reported issues with seven-day access to diagnostic services.
While there was 24/7 consultant cover, some services were not physically open seven days a week. For example, endocrinology at this site was not provided seven days a week because it operated Monday to Friday during which time there was 24/7 consultant cover. Staff told us the service sometimes ran a Saturday list for patients with suspected cancer, but this was only as an outpatient clinic. Cover was provided at an adjacent trust hospital for patients requiring endocrinology services on a Saturday. Nurses for the site were on call to help support that service.
A dispensing service was available 24/7: the dispensary was open 8am - 8pm Monday to Friday and 9am - 5pm weekends and Bank Holidays with a resident pharmacist onsite outside these hours, with medicines information as well.
Aseptic services were available 9am - 5pm Monday to Friday and 9am - 4pm weekends and Bank Holidays. Clinical services were available 9am - 5.30pm Monday to Friday to all areas.
Health promotion
The services had various initiatives running to promote healthy lifestyles, including pyjama paralysis and smoking cessation.
In order to address the cause of pressure ulcers and to encourage better patient mental health the wards we visited adopted the national End PJ Paralysis campaign which involved encouraging patients to get out of bed, get washed and dressed to prevent deconditioning.
Staff described to us how they tried to support patients to give up smoking by offering patches and leaflets on smoking cessation. As part of the admission process patients were asked about their smoking and drinking habits and were then given advice.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff knew the importance of gaining consent to treatment and had received training in consent, mental capacity and deprivation of liberty safeguards.
We saw that the trust had an up to date policy dealing with consent and mental capacity.
Staff spoken with knew about mental capacity and where to access more help, say, to assist them in completing a best interest decision or a deprivation of liberty application. We saw that the trust’s intranet was a valuable resource in this regard.
In nine records we looked at, while deprivation of liberty safeguarding applications were made, only two records contained a completed mental capacity assessment, while in three other records the assessment was elsewhere in the records and we could not find evidence of a best interest decision having been recorded. The trust told us that its internal auditors had been commissioned to look at this.
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The mental health liaison team were on duty 8pm- 12 midnight to provide advice and support for staff. Staff told us the crisis team had a more limited response time.
Mental Capacity Act and Deprivation of Liberty training completion Data relating to mental capacity is included in the safeguarding adults level 2 training section. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Is the service caring?
Compassionate care
We found that patients received compassionate care from staff which supported their privacy and dignity.
Several interactions we observed between staff, both nursing and medical, demonstrated how staff maintained confidentiality and supported patient dignity and provided compassionate care. For instance, we saw a patient being given support to exercise safely. We saw staff helping patients up from a chair to use the toilet. All staff seen spoke with patients in a kind and compassionate way, encouraging the patients.
Friends and Family test performance The Friends and Family Test response rate for medicine at the trust was 31% which was better than the England average of 25% from April 2017 and March 2018. All three sites also achieved a better response rate than the England average. The inpatient score for recommending the services to friends and family in March 2018 was 97% which was above the trust’s internal target of 95%.
Friends and family Test – Response rate between 01/04/2017 to 31/03/2018 by site.
(Source: NHS England Friends and Family Test)
As part of the trust’s electronic clinical assurance toolkit there was a section on privacy and dignity compliance with which was monitored by the matron.
Patients spoke positively about the quality of the care with comments including: “absolutely brilliant” and “they can’t do enough for you.” Patients said that nurses were responsive to call bells and kept them informed with their care.
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Emotional support
We found that staff offered a range of emotional support to patients.
Staff told us that they often found evidence of potential cancers. They gave the example of supporting these patients emotionally by using a private room and a nurse who had links into psychological support services.
Some of the services were looking to send staff on an external course about breaking bad news.
Staff also told us they signposted patients to other agencies for emotional support. For example, in the vascular service staff could signpost patients to the pulmonal hypertension association support network and a 24-hour helpline. Staff explained that they would also try and assist patients to access their local psychological support services.
On some wards staff had access to counselling rooms which were used when it was necessary to have what could be emotionally challenging discussions.
Some services had specialist nurses, for instance, in motor neurone, who supported the emotional needs of patients by being there, answering questions, and by working with other teams in the trust to get the patient home as soon as possible. One thing the motor neurone service did was to carry out all investigations on the same day to reduce the emotional impact on the patient.
Staff had access to chaplaincy services for those patients with a faith or none.
Understanding and involvement of patients and those close to them
We found the staff services tried to understand patients, involve them and those close to them.
Staff told us that relatives of patients with learning disability could stay inside rooms which were quiet because the patients did not like loud noises.
Visiting times were flexible so that relatives could support their loved ones. The service sometimes funded carers to enable the carers to be with the patient 24/7.
Other services, such as the haematology service, had psychology services specifically for its patients in addition to offering complementary therapies.
One service invited a patient in for a pre-visit to the ward and to plan their admission, worked closely with the patient’s carer.
Staff members displayed understanding and a non-judgemental attitude towards patients who had mental health needs, learning disabilities and dementia. We observed a volunteer spending time with a patient with learning disabilities, on one ward, who appeared to be occupied and content.
Nursing staff on some wards told us that they could accommodate carers or family members who wanted or needed to stay with the patient and they had a bed available for this.
Nursing staff we spoke to on one ward told us that they considered the communication needs of a patient with learning disabilities, they asked closed questions and paid attention to non-verbal body language to establish if the patient required additional support.
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Staff have access to communication aids to help patients become partners in their care and treatment. The wards use hospital passports to support patients with a learning disability, wards also used different documents, which were situated above the patients’ bed. On some wards this was a traffic light which indicated to all hospital staff that this patient may require additional support or have communication difficulties and on one ward they had an ‘About me’ A4 sheet indicating the food and drink the patient likes and what makes them happy and unhappy. The wards use the ‘All about me’ document for patients with dementia.
The trust had a carers strategy in place to support and give carers rights. It was piloting the use of yellow lanyards for carers of patients with learning disabilities which identified them as a carer and gave them rights in terms of car park passes and unrestricted visiting times.
Is the service responsive?
Service delivery to meet the needs of local people
The trust had systems and processes in place to ensure that the needs of local people were taken into account when planning the service delivery.
The trust had an operational plan for 2018/19. This was developed in partnership with the two commissioners it worked with. This required the specialities to create an activity plan and productivity and efficiency plans together with an annual business plan, all with support from a central trust team. The plans were signed off by the local leadership team and monitored by the trust’s programme management office and business planning team.
Staff told us that there were a number of service improvement projects across the trust to focus on patient pathways such as the "Why not home? Why not today?" programme. For example, the trust was trialling a single point of access team for discharges and a transfer of care team. At the point of our inspection, the results were being evaluated.
We found no mixed sex accommodation breaches.
As shown below the service had average lengths of stay for both elective and non-elective procedures lower than the England average.
Average length of stay
From February 2017 to January 2018 the average length of stay for medical elective patients at Royal Hallamshire Hospital was 4.6 days, which is lower than England average of 5.8 days. For medical non-elective patients, the average length of stay was 8.3 days, which is higher than England average of 6.4 days.
Average length of stay for elective specialties • Average length of stay for elective patients in gastroenterology and neurology are lower than the England average.
Average length of stay for non-elective specialties: • Average length of stay for non-elective patients in neurology is higher than the England average.
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• Average length of stay for non-elective patients in infectious diseases and clinical haematology higher than the England average.
Elective Average Length of Stay - Royal Hallamshire Hospital
Note: Top three specialties for specific site based on count of activity.
Non-Elective Average Length of Stay - Royal Hallamshire Hospital
Note: Top three specialties for specific site based on count of activity. (Source: Hospital Episode Statistics)
Meeting people’s individual needs
We saw that staff cared for patients as individuals and strived to meet their individual needs.
All wards had link nurses to champion care for people living with dementia or those with a learning disability. Staff had access to e-learning for dementia and learning disability
Staff told us that patients with a learning disability were flagged on the electronic patient record and the system could also tell staff whether the patient had a passport detailing their preferences and needs. Staff told us that adjustments could be made such as offering appointments on particular days of the week. The trust had a library of easy read resources for learning disability patients.
On the neurology wards we saw that the trust had employed two learning disability nurses who provided, amongst other things, responsive outpatient support.
Staff told us that they could access language interpretation services and leaflets could be produced in different languages. The trust’s website was set up so that a different language could be selected.
Access and flow
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The services had systems and processes in place to monitor access and flow and to ensure that they were responsive to the needs of patients.
An example of this was the endocrinology service which had developed admission criteria to support it with its access and flow. This meant that patients at this site had to be self-caring or require minimal assistance; more complex patients would be admitted at an adjacent trust hospital.
Staff at the service said the process for transfer from other hospitals was robust. For example, the trust on this site ran a national small bowel centre which took referrals from outlying areas. A consultant was able to review imaging and bloods on a shared system and if a referral was required a clerk would book the patient in. Staff told us the system worked really well.
Some services used flow nurses to manage admissions onto the ward. These nurses booked tests before the patient arrived so that when the patient arrived everything was ready Other services had trained up care support workers to assist with investigations and tests, again to increase efficiency.
Staff told us that where services occupied a single floor of the hospital flow was managed by running the service as a floor rather than as separate wards. This supported efficient staff utilisation taking into account the acuity, dependency and number of patients.
The haematology service used an ambulatory care pathway run from ward O2 for patients who were on complex medicine regimes or who had received a transplant or chemotherapy treatment. This supported patients to be as independent as possible, eliminating some stays at hospital, and freed up hospital beds. Staff also described how they worked with the bone marrow team to plan admissions so that they were distributed throughout the month to ensure adequate staffing was available.
In the vascular speciality they modified the clinic sizes so that patients were not waiting excessive periods of time. While the service did try and offer time slots many patients were late and so this did not work. The trust told us the stroke pathway had been redesigned with an offsite stroke assessment and rehabilitation centre that was integrated with community stroke services, which promoted care closer to home.
The trust reported that, as shown below, from February 2017 to January 2018, 98% of patients had appropriate ward moves and the remaining 2% were outlier ward stays (4+ moves). The previous year’s performance was the same.
Patient moves per admission During the last 12 months – During the previous 12 YR 1 months – YR2 (01/02/2017 to 31/01/2018) (01/02/2016 to 31/01/2017) Location site How How name Number many many (state the site of ward Number were %-share Number were %-share where the ward or moves of at of all of at of all unit is located) patients 'end patients patients 'end patients of of life'* life'* 0 183,823 74% 178,145 74% 1 33,612 14% 33,570 14%
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Sheffield Teaching 2 19,035 8% 18,922 8% Hospitals NHS 3 6,908 3% 6,732 3% Trust 4+ 3,972 2% 3,782 2%
Total 247,350 100% 241,151 100%
(Source: Trust Routine Provider Information Request (RPIR) P53 – Ward Moves)
Data supplied by the trust showed that moves at night for the last year for the wards we visited were: clinical investigations unit (0), P3 (38), P4 (15), E1 (72), L1 (109), L2 (303), M2 (40), Q1 (26), and Q2 (78).
Staff within the endocrinology service told us, when patient numbers were low, patients were moved to other wards so that staff could be utilised on other wards. This had been incident reported. Staff told us they tried to manage patient expectations around being moved and there were no complaints about this. In contrast, other services, such as haematology, only moved patients for clinical reasons. For instance, if a patient following treatment became unwell and had to be admitted as an emergency because of the risk of sepsis, if the wards were full, then a bed would have to be made available. Ward moves were low for haematology because their patient cohort required specialist equipment and rooms with specialised air filtration systems.
Over the last year, of the wards we visited, the wards for stroke and geriatric medicine had the highest percentage of delayed discharges of care compared to the whole patient cohort. For instance, ward Q1 had 54% and ward Q2 had 30%. Other wards we visited had percentages that ranged from 2% to 6%.
The trust reported a delayed transfer of care (DTOC) trust-wide rate of 5.8% which was higher than the national average of 4.2% and higher than the trust’s target rate of 3.5%. DTOC rates had been reducing between August and December 2017, however the trust had experienced increasing rates during January to March 2018 due to a challenging winter period with pressures in intermediate care, community services and limited availability of social care packages in the area (Source NHSI). The trust actively monitored DTOCs and reported them to its commissioners. The trust was involved in a cross-Sheffield health and social care task group which was looking to improve discharges. The trust told us it had adopted various methods to support responsive discharges. For example, the trust told us it was planned that the roll out of electronic prescribing would streamline the requesting of ‘to take out’ medicines which staff reported was a cause of delayed discharges. Various specialist teams existed to support ward staff with discharges, such as the transfer of care team or the care home placement team. There were also services, such as the active recovery service, which operated a discharge to assess model. This was supported by the single point of access which allowed access to information systems by social care and mental health services.
Referral to treatment (percentage within 18 weeks) - admitted performance
From April 2017 to March 2018 the trust’s referral to treatment time was similar to the England average. In the latest month November 2017, the trust’s performance showed 91% of patients were treated within 18 weeks compared to the England average of 88%.
The trend over time remained consistent.
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(Source: NHS England)
Referral to treatment (percentage within 18 weeks) – by specialty
Four specialties were above the England average for admitted RTT (percentage within 18 weeks):
Specialty grouping Result England average Geriatric Medicine 100% 97.5% Neurology 97.4% 91.5% Rheumatology 97.9% 94.1% Thoracic Medicine 99.8% 93.1% (Source: NHS England)
Learning from complaints and concerns
The services had a system in place to encourage complaints and compliments with a view to improving services for patients.
Staff told us they would seek to resolve a concern informally first, but complaints were dealt with formally if necessary. The governance arrangements in place ensured that lessons from complaints were shared amongst staff. The patient services team ran workshops for staff on resolving issues.
We saw notices displayed within the services showing how to complain and signposted patients or their carers or relatives to the trust’s help and advice service, for support in making a complaint.
We discussed complaints with staff. All response times for complaints were met with support from the trust’s patient partnership team.
Staff learnt from complaints and tried to improve the service as a result. For example, in the endocrinology service a complaint about the room being too cold was addressed by installation of secondary glazing. Another example concerned feedback from carers about purchasing a piece of equipment for a patient with learning difficulties and because of the feedback, following a risk assessment, the equipment was purchased.
Summary of complaints
From January to December 2017 there were 225 complaints about medical care, the trust took an average of 38 days to complete complaints. This is in line with their policy which states complaints should be completed within 25 or 40 days for more complex cases. The trust worked to a tiered response time process where the timescale was determined based on the complexity of the
20171116 900885 Post-inspection Evidence appendix template v3 Page 241 concerns raised. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale.
The main themes from the complaints were:
• 56% of complaints relate to Northern General Hospital • 49% of complaints relate to inpatient services • 58% of complaints relate to medical staff • March 2017 and January 2018 had the highest number of complaints received both with 26. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
The trust supplied us with data about the complaints received about the services, but we could not identify any themes or trends.
Is the service well-led?
Leadership
The various specialist services we visited sat within defined directorates detailed earlier which were led by a local senior leadership team being made up of a clinical director, operations director, and nurse director.
The trust invested in their leaders: this included access to accredited courses in leadership and access to coaching.
We met a selection of the above teams for a variety of the services we visited who were in the main experienced in commissioning, designing and running theirs services. It was evident from discussions that each team’s priority was on running a clinically safe service.
Each team met regularly with the chief nurse, medical director, and deputy chief executive and through them had ready and easy access to the trust’s board.
Staff told us their senior team was approachable and visible and each team told us that they met regularly in different forums to discuss quality, finances and governance.
At ward level the leadership teams derived support from a matron and band seven senior sisters with whom they met regularly.
Vision and strategy
The vision used by the services we visited was the trust’s vision, to be recognised as the best provider of health care, clinical research and education in the UK and a strong contributor to the aspiration of Sheffield to be a vibrant and healthy city region. It was supported by the ‘PROUD’ values, (patients first, respectful, ownership, unity, and deliver).
Each directorate had a strategy and business plan which set out in detail how the directorate intended to contribute towards the trust’s vision and strategy.
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Culture
We observed that the services we visited had a positive culture with staff that were proud to provide patient focussed care to patients.
Staff we spoke with described good teamwork and multi-disciplinary working with visible leaders who were happy to help and provide support.
In the 2017 staff survey, 94% of all staff said they would recommend for family and friends to receive treatment at the trust.
Staff had various forums in which they could express their views and be heard including one to ones, team meetings, and safety huddles.
Governance
The services had a clear governance framework with staff assigned specific roles that ensured quality performance and risks were known about and managed.
Staff told us each directorate had a quarterly clinical governance meeting. This was followed by a monthly directorate executive group meeting. We saw minutes for these meetings from a sample of specialities including: gastroenterology/hepatology; neurosciences; diabetes/endocrinology; respiratory; and integrated geriatric and stroke medicine. For the clinical governance meetings, the trust had introduced a standard template which looked at the five domains used by CQC and some of the services were starting to use this. On clinical governance meetings standing agenda items included: matters arising; safe, which looked at learning from a variety of sources such as incidents, serious incidents, claims, mortality and morbidity, medicines management; caring, which looked at things such as learning from friends and family; effectiveness, which looked at, for example, audits and NICE guidelines; responsiveness, which looked at such things as business continuity; and well-led, looking at for instance, the risk register and governance. The business meetings standard agenda items included: looking at delivering the best clinical outcomes, which looked at mandatory training, infection control, the risk register, complaints and incidents; providing patient centred services, which looked at the performance dashboard, staffing, and business cases; spending public money wisely, which looked at finance; employing caring and cared for staff, which looked at recruitment; and any other business.
Senior matrons met as a group and discussed governance issues including learning from incidents or complaints and staffing issues together with issues cascaded to them from the leadership team.
All staff in a leadership role also had access to directorate dashboards looking at performance, finance, governance and staff engagement.
Management of risk, issues and performance
The leadership team for each directorate received information to support them in managing risk, identifying issues, and assessing performance.
We spoke with members of the leadership team from each directorate about how they measured quality and performance. The team had access to various sources of information, such as dashboards (which captured a series of indicators ranging from infection rates, to waiting times, to
20171116 900885 Post-inspection Evidence appendix template v3 Page 243 staff metrics and patient experience), safety thermometer data, or complaints data. This information was examined, discussed and action taken through the clinical governance meetings noted above.
The leadership team for each directorate also oversaw a structured annual programme of work supported by the trust which rolled on year to year. This was designed to engage with clinicians to identify workstreams and opportunities to improve quality. Once a workstream was agreed they were clinically led and supported by matrons, finance and project managers.
We also discussed with the leadership team for each directorate the risk register. Risk registers were maintained at directorate level, with a brief description of the risk, control measures, an owner, risk level and a review date. For instance, Cardiothoracic speciality had five extreme, two high, eight moderate and four low. Diabetes and endocrinology had one extreme, and seven high. Emergency medicine had two high and three moderate. Gastroenterology/hepatology had one extreme, one high and four moderate. Integrated geriatric stroke medicine had one extreme, eight high, eight moderates, and 19 low. Respiratory medicine had two extreme, four high, and five moderate. One of the top risks was staffing. To address this the team said the trust was trying to recruit from overseas, and directorates were holding recruitment events. Some services were recruiting to administrative support to free up nurses to do nursing. The team explained this was a national issue and not just an issue that affected the specialist services. Another risk concerned the ageing estate. The team explained that this risk had been addressed through trust investment in refurbishing the ward environment. Another risk was the roll out of electronic prescribing. This had thrown up unforeseen information technology issues. Action taken included ensuring software experts were on hand to support wards with the roll out.
There was oversight of risks through committees such as: the elective care working group (ECWG), the waiting times performance overview group (WTPOG) and patient safety and risk committee. However, it was not clear from the minutes we reviewed how the leadership team escalated the risks marked as ‘extreme’ to the trust board.
Information management
From speaking with staff and reviewing information supplied in electronic format, it was clear that staff at all levels could access information in a digital format which could be interpreted and rapidly used to help improve the service.
The leadership team told us that they received information in electronic format and they found the information robust. For instance, each directorate received monthly performance reports to assist them in monitoring their performance and developing plans to improve. The team described how they were able to drill down through the data to fine tune it to site level. Data was used to support each specialities’ plans for the future.
Engagement
Staff described feeling engaged with the services’ leads. They gave examples of how the services engaged with the public with a view to ensuring their views were used to help to shape the service.
Some services used an annual timeout for all medical staff at which staff could network and discuss ideas for improvement
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On a weekly or monthly basis, the services held a series of meetings to engage with staff, such as local service improvement meetings, senior sister meetings, and technology strategy group meetings. Staff meetings tended to take place every two weeks.
According to the 2017 staff survey, trust wide, the overall staff engagement score had increased from 3.82 in 2016 to 3.83 in 2017. The number of staff recommending the trust as a place to work was 68% and 81% as a place for care.
The trust ran a series of annual themed surveys such as the carers survey which was running until July 2018. From responses to date there were 98% of carers who stated that they ‘definitely’ or ‘to some extent’, had confidence and trust in the staff caring for the person they supported.
Patients or the public were engaged through the ‘tell us what you think’ leaflets, online through the trust’s website, the friends and family test, and surveys, such as the carer’s survey. It was as a result of the carers’ survey that more flexible access to wards was brought in.
The trust told us patients were closely consulted during the ward rebuild at the site.
Some specialities made use of user groups, for instance, the endocrinology user group to gather feedback from patients to help improve the service.
Learning, continuous improvement and innovation
Prior to the inspection, and while on inspection, the specialities shared with us the following examples of learning, continuous improvement and innovation:
As a service gastroenterology had won more than ten national and international awards over the past two years. There was a Sheffield clinical research fellowship programme which had supported gastroenterology trainees for over 13 years.
The site was the home to one of the largest stem cell collection centres in the UK outside of London, which collected and redistributed stem cell donations across the country.
The haematology team at the site were involved in a number of treatment trials for various conditions including inflammatory bowel and auto-immune disease.
In respiratory, the site had the largest pulmonary hypertension unit in Europe active in research to improve patient outcomes.
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Surgery Facts and data about this service
Surgical services were managed through the trust’s directorate and group structures. The following groups had surgical services within them: OSCCA (Operating services, critical care and anaesthesia); South Yorkshire regional services group; Head and neck group; surgical services (general surgery, plastic and breast surgery and urology) and Musculo-skeletal care group.
The plastic and breast services provide plastic surgery, breast surgery, sarcoma surgery and burn care services within South Yorkshire with bases at the Northern General hospital and Royal Hallamshire hospital. Plastic and breast provides on-call provision to Sheffield Children’s hospital as well as consultant sessions for elective surgery and burn care. All trauma and elective hand work is undertaken at the Northern General hospital.
General surgery provides elective (cancer and benign) and non-elective general surgery services for patients within South Yorkshire, North Trent and nationwide. It is predominantly based at the Northern General hospital site, with elective services sub-divided into six specialties: • Colorectal surgery • General surgery • Obesity surgery • Endocrine surgery (currently based at the Royal Hallamshire hospital) • Hepatopancreaticobiliary surgery • Upper gastrointestinal surgery Urology is based at the Royal Hallamshire hospital, with theatre lists on both sites. Urology provides a tertiary service in medical and surgical uro-oncology, reconstructive urology, spinal injuries, urology and endo-urology, as well as a specialised service in neuro-urology, and specialist andrological and male sexual dysfunction services. Urology provides state of the art therapy for complex and uncommon urological conditions. (Source: Routine Provider Information Request (RPIR) – Context acute tab)
Location site name Team/ward/satellite name
Post anaesthetic care unit Surgical day unit Ward F1 Ward F2 Ward G1 Ward G2
Royal Hallamshire Hospital Ward H1 Ward H2 Ward I1 Ward N2 Clinical investigations unit Theatre admission unit
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(Source: Routine Provider Information Request (RPIR) – “Sites-Acute” tab)
The trust had 70,892 surgical admissions from January 2017 to December 2017. Emergency admissions accounted for 18,926 (27%), 37,705 (53%) were day case, and the remaining 14,261 (20%) were elective. (Source: Hospital Episode Statistics)
During this inspection we visited the operating theatres and recovery area, neuro day unit and in- patient unit and the pre-assessment unit. We spoke with 12 patients and relatives and 41 members of staff. We observed staff delivering care and looked at three medical notes, five paper records and four electronic notes. We reviewed trust policies and performance information from, and about, the trust. We received comments from patients and members of the public who contacted us directly to tell us about their experiences.
Is the service safe? Mandatory training
The trust set a target of 90% for completion of mandatory training. A breakdown of compliance for mandatory courses from April 2017 to February 2018 for medical/dental and nursing/midwifery staff in surgery is shown below:
Royal Hallamshire Hospital medical and dental staff:
There were eight training courses eligible for medical and dental staff of which this site did not meet the target for any of the modules. The lowest completion rate for surgery was 58% for resuscitation: adult basic life support (level 2a) of which 29 medical and dental staff was trained of the 38 eligible for the module.
Number of Average of staff Number of % trained eligible Completion Trust Met Name of course (YTD) staff (YTD) (YTD) Target (Yes/No) Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 17 19 87% 90% No Information Governance - Level 1 (1 Yearly) 39 41 79% 90% No Fire Safety Training - Level 1a (1 Yearly) 30 33 78% 90% No Health, Safety & Welfare - Level 1 (3 Yearly) 39 41 76% 90% No Moving & Handling - Level 2a (3 Yearly) 29 32 72% 90% No Infection Prevention and Control - Level 2 (1 Yearly) 36 41 70% 90% No Equality & Diversity: General Awareness - Level 1 (3 Yearly) 19 21 60% 90% No Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 29 38 58% 90% No
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Royal Hallamshire Hospital nursing and midwifery staff:
There were nine training courses eligible for nursing and midwifery staff of which this site met the target for five modules. The lowest completion rate for surgery was 87% for resuscitation: adult basic life support (level 2a) of which 234 nursing and midwifery staff was trained of the 263 eligible for the module.
Number of Average of staff Number of % trained eligible Completion Trust Met Name of course (YTD) staff (YTD) (YTD) Target (Yes/No) Conflict Resolution - Level 1 (3 Yearly) 7 7 100% 90% Yes Moving & Handling - Level 2b (1 Yearly) 246 258 94% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 299 320 93% 90% Yes Information Governance - Level 1 (1 Yearly) 262 289 91% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 293 315 90% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 196 217 89% 90% No Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 276 293 88% 90% No Fire Safety Training - Level 1a (1 Yearly) 277 296 87% 90% No Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 234 263 87% 90% No (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Compliance rates for mandatory training were slightly better than the last inspection of the trust. On the previous inspection, information submitted by the trust showed that overall compliance with mandatory training was 83%. This was below the trust target of 90%.
Mandatory training for staff was led by the clinical educators and included dementia, Deprivation of Liberty, safeguarding and Mental Capacity Act. Staff were allocated protected time on the rota to complete mandatory training and staff reported they felt training was a priority. Staff also attended a simulation day annually, arranged by the clinical educators, to give staff hands on experiences in situations they may face in practice. For example, how to respond to a patient who is presenting with signs of sepsis.
We observed an education and training board in theatre which displayed information about upcoming training courses including safeguarding. The board also listed all staff and the dates when training had been completed, it stated four staff members had not completed their mandatory training out of a total of 60 staff. On the wards we spoke to staff who said they had completed their mandatory training and P2 ward reported 100% mandatory training.
Safeguarding
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All clinical staff were trained at safeguarding level 1 as a minimum. Senior clinical staff were expected to be trained in safeguarding level 2 and level 3. From the information the trust gave us, this was achieved or nearly achieved.
Staff we spoke to were clear about what should be considered as a safeguarding issue and how to escalate safeguarding concerns. Staff we spoke to could demonstrate how to access the trust’s safeguarding policy and the safeguarding lead. We saw evidence of safeguarding consideration during the safety huddles we observed. Staff informed us they received feedback following raising safeguarding concerns.
Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for medical/dental and nursing/midwifery staff in surgery is shown below:
Last year the nursing and midwifery staff for surgery met the training completion rate, reaching 100% for the financial year April 2016 to March 2017.
Safeguarding Training Completion by module – Medical and Dental Staff Royal Hallamshire Hospital medical and dental staff:
The medical and dental staff of Royal Hallamshire hospital met the safeguarding training for two of the three eligible courses.
Eligible Staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children & Young People - Level 2 (3 Yearly) 34 34 100% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 42 43 98% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 34 39 87% 90% No
Safeguarding Training Completion by module – Nursing and Midwifery Staff Royal Hallamshire Hospital nursing and midwifery staff:
The nursing and midwifery staff of Royal Hallamshire hospital met the safeguarding training for two of the four eligible courses.
Eligible Staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children & Young People - Level 3 (3 Yearly) 2 2 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 293 315 90% 90% Yes
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Safeguarding Children & Young People - Level 2 (3 Yearly) 196 217 89% 90% No Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 276 293 88% 90% No (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene
At this inspection, we found the wards and departments we visited visibly clean and tidy. We reviewed Patient Led Assessments of the Care Environment (PLACE) reports for 2017 and noted 96% compliance for cleanliness which was slightly worse than the 98% England average.
The trust had an infection, prevention and control policy which directed staff to other policies and protocols for guidance about cleaning, decontamination and personal protective clothing. Cleaning checklists were displayed on the wall for cleaning of a room or bed space following the discharge of a patient. We saw checklists for flushing showers, all completed for June 2018.
The trust reported two cases of hospital acquired Methicillin resistant staphylococcus aureus MRSA from April 2017 to March 2018; this was higher than the nationally agreed threshold of zero cases. The trust reported 83 cases of Clostridium difficile (C.diff) in the same reporting period; this was better than the nationally agreed threshold of 87 cases. This year one case of hospital acquired MRSA had been reported from April 2018 to June 2018 and 12 cases of hospital acquired C.difficile. Following the inspection, the trust the trust told us that there had been a change of definition which meant that no cases of MRSA were attributed to the trust between April to June 2018.
The trust had a policy to screen surgical patients for MRSA and Methicillin sensitive staphylococcus aureus (MSSA) as per best practice guidance. Elective patients were screened at pre- assessment.
The infection prevention and control team carried out surgical site infection surveillance data. The data we reviewed for January 2017 to December 2017 showed that five patients had reported an infection following primary hip replacement surgery, out of 389 operations performed, this equates to a rate of 1.3% which is worse than the national rate of 0.6%. Primary knee replacement surgery showed two patients had reported an infection following surgery, out of 498 operations performed, this equates to a rate of 0.4% which is better than the national rate of 0.5%. Data we reviewed for January to March 2018 showed a deterioration with three patients reporting infections for primary hip or knee replacement out of 225 operations carried out (1.1% primary hip and 1.5% primary knee).
During our inspection, we saw weekly cleaning standard audits, which for May 2018 scored over 95% compliance. Ward staff told us they conducted monthly audits including the patient environment and infection, prevention and control.
During the inspection, we observed that staff were compliant with hand hygiene policies, including ‘bare below the elbows’ and personal protective clothing policies. Handwashing advice was clearly displayed and facilities for hand hygiene were available. Hand hygiene compliance data was displayed on wards we visited. Staff had access to, at the point use of, alcohol gel. Patients
20171116 900885 Post-inspection Evidence appendix template v3 Page 250 reported they observed staff washing their hands and using alcohol gel. Taps for handwashing were non- touch.
We inspected reusable equipment stored on the ward. We reviewed three pieces of reusable clinical equipment and found all of these items were clean but not labelled to say they had been cleaned. This meant staff would not know which equipment was ready for use.
We checked commodes in ward areas and found them to be visibly clean with labels indicating they were clean and ready for use. Mattress and commode cleaning guidance was displayed in utility rooms and information on the segregation of waste.
We saw processes for segregation of waste including clinical waste. Staff were able to segregate waste at the point of use. Sharps bins were used by staff to dispose of sharp instruments or equipment. Sharps bins in the areas visited were secure, dated signed and stored off the floor. This reflected best practice guidance outlined in Health Technical Memorandum HTM 07-01, safe management of healthcare waste.
Rooms were available for patients requiring isolation, for example, if they had an infection. During the inspection we saw that patients requiring isolation were isolated appropriately.
Cleaning equipment was kept in a separate cupboard and different coloured mop buckets were available. However, some cleaning solutions were in unlabelled bottles with no opened or made up date included.
Whilst on the ward we saw active cleaning taking place. Whilst one bay was empty, cleaning staff were seen deep cleaning patients’ bed side tables.
Environment and equipment
Resuscitation equipment we reviewed was regularly checked and tested consistently in line with trust policy. Equipment was tidy and ready for use. Trolleys we inspected were locked, appropriately stocked and equipment was in date. Resuscitation trolleys were easily located on main corridors in ward areas, theatre and in theatre recovery. Best practice is for resuscitation trolleys to be checked daily (Royal Collage of Anaesthetics – Resuscitation – Raising the Standard). We saw checklists signed and dated appropriately. On the surgical inpatient unit, a rota was used to indicate whose responsibility it was to check the trolley each day. The trolleys were secured with tamper proof seals.
Anaesthetic equipment appeared clean and tidy, checks complied with ‘The Association of Anaesthetists of Great Britain and Ireland’ (AAGBI) guidelines. We reviewed the difficult intubation trolley and noted from visual observation it was tagged and equipment was easily identifiable in each drawer as per best practice requirements. We saw records of daily checks and more in depth monthly checks from the end of January 2017 to the end of May 2018
We checked nurses’ stations, patient toilets and washing basins which were all clean and uncluttered. We observed sluice rooms to be clean and tidy. Utility stores were clean, tidy and equipment clearly labelled in drawers. We saw chemicals stored appropriately with instructions for usage. We checked four mattresses which were all clean with no tears however in the theatre admission unit, we saw carpet in some clinical areas.
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Staff we spoke with said that they had adequate stocks of equipment and we saw evidence of stock rotation. All items we reviewed, were in date and had been rotated in date order. All storage items were clearly labelled in theatre and kept on shelves off the floor. All instruments arrive on the ward pre packedand staff reported an on-call service was available if required.
Wards reported having sufficient equipment to meet the needs of their patients, for example moving and handling equipment. Bariatric equipment could be obtained from the equipment library if required.
We checked 18 pieces of equipment across surgical areas and theatre including infusion pumps and anaesthetic machines all had in date electrical safety testing within the last year. The date that the equipment needed retesting were clearly visible on the equipment. All the equipment we checked were labelled with an ‘I am clean stickers’ which showed the date the cleaning was done.
We reviewed Patient Led Assessments of the Care Environment (PLACE) reports for 2017 and noted 93% compliance for condition, appearance and maintenance similar to the 94% England average.
Assessing and responding to patient risk
The trust had adapted the national early warning score system (NEWS), a tool for identifying deteriorating patients, into the Sheffield early warning score system (SHEWS). The SHEWS was a paper-based system and the documentation we reviewed across all ward areas showed accurate completion of SHEWS scores. We saw evidence of raised SHEWS scores being escalated appropriately. The medical records included the use of a yellow sticker system which was signed by the doctor at review. Staff we spoke with were confident that, out of hours, they could contact the outreach team for support if they recognised a patient deterioration.
The trust had a sticker system in place for identifying a deteriorating patient. An audit of this system between March and May 2018, identified 96% compliance by the surgical department with 100% of these patients having the minimum hourly observation commenced. The data indicated that 94.3% of SHEWS scores were recorded with each set of observations and 100% of the SHEWS scores were accurate for the patient. All patient records showed evidence of a patient care management plan.
Patients were initially assessed on admission, including assessment of mental health and fall risk.
Whilst on inspection, staff told us about the introduction of safety huddles on the ward. The huddles were attended by members of staff covering different sections of the ward. The meetings discussed safety issues with the patients and specifically looked at pressure areas and falls risks. It was identified that one patient had been reviewed by a tissue viability nurse for their pressure area. Staff reported that since the safety huddles were introduced falls and new pressure sores had reduced.
We reviewed three sets of medical notes, all had the World Health Organisation (WHO) safety checklist completed appropriately prior to surgery.
We saw clinical areas that had information boards displaying information regarding sepsis. These showed the percentage of patients per directorate that had red flag sepsis. Staff told us that they
20171116 900885 Post-inspection Evidence appendix template v3 Page 252 stored one vial of antibiotic in the control drug cupboard for timely treatment of sepsis, according to best practice.
In the department we saw the clinical engagement board which displayed results from the most recent audits. The board reported that the last audit for medicine management showed 94% compliance across the surgical department. The audit for waste management was 94% compliance and records keeping in patient notes was 95.13% for staff compliance.
On the theatre admission unit, we saw clinic activity and protected appointment time. Staff stated that they will always try to accommodate patients referred directly from out-patients clinic.
Nurse staffing
During our last inspection, there was issues with staff being moved to other wards to cover shifts. Our previous report stated that the trust should try to reduce the movement of staff to clinical areas outside of their speciality. On this inspection, staff reported that they are still moved to other specialist areas to meet the demand. Staff said that they are moved to support other areas during winter pressures.
At this inspection, we reviewed staffing fill rates for March 2018 and saw that for surgical services there was 7.22% of actual vacancies for registered nurse shifts for both days and nights.
Ward H2: 90.8% registered nurse (RN) shifts days and 105.6% Clinical support worker (CSW) shifts. Night shifts showed 100% RN shifts and 110.5% CSW shifts. Ward F2: 98.2% RN shifts days and 103% CSW shifts. Night shifts showed 100% RN shifts and 98.9% CSW shifts.
The trust reported their staffing numbers below for December 2017. There were 125.29 less nursing staff in place than the trust planned to provide safe care within surgery.
Number in post Fill rate Staff group WTE Staff December 2017 Qualified Nursing and 816.3 691.01 85% Health Visiting Staff (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
In March 2018, surgical services used 1.94 WTE of a bank/agency registered nurse and 9.9 WTE of care staff and a combined overtime total of 2.45 WTE. The trust report sickness levels continue to be managed appropriately, supported by human resource colleagues
We reviewed duty rotas over the last three months. Data showed that all areas were staffed below established levels on a small number of occasions.
For example, we reviewed 63 nursing shifts on ward H2, on 23 occasions registered nurse shifts were below established levels, however in the same time period 24 shifts had bank registered nurse allocated. However there remained 33 shift that had been offered to bank that were unfilled.
We did see that the trust had assistant practitioners (band four nurses), Band four nurses are not registered nurses, but have had additional training.
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The trust used a nationally recognised safer nursing tool and professional judgment, together with an electronic rostering system, to support staff in planning staffing levels having regard to patient needs. This was used alongside a daily staffing meeting to fill any gaps in staffing. Staff reported that this system worked well and kept patients safe. The matron was available for any escalation and out of hours a duty matron held a bleep for this purpose, who had a clear policy of escalation to follow. The trust’s executive group received a monthly safer staffing report and all staffing was reviewed on a rolling six-month basis.
Staff escalated staffing issues through the site management meetings twice a day. These meetings were used to review activity, manage staffing issues and monitor capacity and demand on each site. During inspection, staff informed us that, attached to the e-roster was a skill set requirement for each shift to ensure there was an appropriate skill mix on duty at all times.
The directorate used the SAFER (Senior review, All patients, Flow, Early discharge and Review) patient flow bundle, red2green initiatives and board rounds to improve safety and flow. The SAFER initiative involves five best practice safety elements to improve flow and discharge. The red2green campaign is a visual system to assist in the identification of wasted time in a patient’s journey, this approach identifies times patients spend in hospital without the day contributing to the patient’s discharge. The trust had recently employed a care navigator role to improve the patients’ journey and prevent or remove blockages in the patient’s discharge path.
The trust reported 85% rate of retention for medical staff. Senior staff we spoke with said that retention of staff remained a challenge within the surgical division, despite overseas recruitment taking place.
Vacancy rates From January 2017 to December 2017, the trust reported a vacancy rate of 3.7% across surgery; for qualified nursing and health visiting staff the annual vacancy rate was 15%. This was above the trust target of 0%. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January 2017 to December 2017, the trust reported a turnover rate of 12.2% in surgery. Qualified nursing and health visiting staff (qualified nurses) has an annual turnover rate of 8.1%. Royal Hallamshire Hospital has a turnover rate of 10.5% (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January 2017 to December 2017, the trust reported a sickness rate of 4.1% in surgery. Qualified nursing and health visiting staff (qualified nurses) has a sickness rate of 4%. Royal Hallamshire Hospital has a sickness rate of 4%. This was slightly higher than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage Electronic rostering was used with a safer nursing care tool to identify any gaps in staffing. The matron had oversight of this and attended the afternoon bed meeting to review staffing. However, if the hospital was in escalation they would attend all three of the daily bed meetings. Staff on the wards reported they felt staffing levels were appropriate for the patient numbers they cared for. During our inspection we saw that planned and actual staffing levels were achieved.
Operating theatres staffing met the ‘Association for Perioperative Practice (AfPP) staffing recommendations. Theatres and ward staff reported they rarely used any agency nursing. They 20171116 900885 Post-inspection Evidence appendix template v3 Page 254 had their own bank staff or staff doing additional shifts to cover any gaps. We spoke with a senior nurse on the ward who said their registered nursing staff liked to do overtime and they were normally able to fill any nursing gaps with their own staff.
Ward handovers took place three times a day; informal handovers also took place as required throughout the day. In addition to this, safety huddles took place in each area. These highlighted any patient safety issues.
Medical staffing
At this inspection, for all surgical specialities a consultant was present on site. Surgical services had systems and processes in place to provide medical staffing levels so that patients were kept safe.
The services we visited had a daily consultant review. The rota for each service on the site ensured 24/7 consultant cover and where this consisted of on call cover, staff reported a timely response.
The trust has reported their staffing numbers below for December 2017.
Number in post Fill rate Staff group WTE Staff December 2017 Medical and dental – 377.09 369.27 98% Hospital (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)
Vacancy rates From January 2017 to December 2017, the trust reported a vacancy rate of 3.7% across surgery; for medical and dental staff, the annual vacancy rate was 3%. This was above the trust target of 0%. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January 2017 to December 2017, the trust reported a turnover rate of 12.24% in surgery. Medical and dental staff within surgery has an annual turnover rate of 25.76%. Royal Hallamshire Hospital has a turnover rate of 26.8% (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January 2017 to December 2017, the trust reported a sickness rate of 4.1% in surgery. Medical and dental staff within surgery had an annual rate of 1.2%. Royal Hallamshire Hospital had a sickness rate of 1.5%. This was slightly higher than the trust target of 3.5%.
(Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and locum staff usage
We are unable to calculate the bank and agency usage rate as the trust did not provide the total number of shifts. The trust informed us their total shifts between January 2017 to December 2017 was 4,789 however the bank, locum and unfilled shifts total to this figure.
From January 2017 to December 2017, the trust reported that they used bank staff a total of 20171116 900885 Post-inspection Evidence appendix template v3 Page 255
2,780 times and locum staff a total of 1,990 times with 19 shifts unfilled.
(Source: Routine Provider Information Request (RPIR) P21 Medical Locums)
We reviewed medical staffing and spoke with consultants, middle grade and junior doctors. Medical cover was available on-site 24 hours a day. Consultants were available 24 hours and were on site between 8am and 6pm. On-call cover was provided at evenings and weekends. On the theatre admission unit, there was a consultant between the hours of 8.30am and 4pm
The on-call consultants were supported by on site registrars and foundation level doctors supported the wards. Junior doctors reported always having support and access to senior colleagues when required.
The ward was covered by several different consultants. Each week one consultant would be on call for the week to cover the patients on the ward. A ward round by the consultant or their registrar would take place every day at 7am. During the day the ward had junior doctor (F1/F2) cover. In addition to this, consultants would review their patients on the ward, as required.
In the medical notes, we observed a weekend plan sticker which clearly communicated plans of care. It included diagnosis, co-morbidities, treatment to date and ongoing plans, for example if blood tests were required.
The patients we spoke with reported good visibility of doctors and being reviewed at weekends. Staff reported enough medical cover.
Staffing skill mix For December 2017, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was the same. Staffing skill mix, whole time equivalent staff working at Sheffield Teaching Hospitals NHS Foundation Trust
This England Trust average Consultant 54% 49% Middle career^ 4% 11% Registrar Group~ 30% 29% Junior* 13% 11%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)
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Records
During our last inspection, we were concerned about record storage; however, whilst on this inspection we saw patients’ records were all stored in areas that were secure and in locked trolleys. We did not see any patients’ notes left unattended.
Paper records were available for each patient that attended the wards and departments; the trust used electronic patient management to record key information about the patient’s hospital stay. Electronic whiteboards were used on all wards we visited, which recorded key information about patient risks and treatment including flags for living with dementia, patient acuity and discharge plans. The boards ensured that staff had easy access to key information, such as reviews by other members of the multi-disciplinary team and patient acuity.
Staff we spoke with said that they could access records out of hours with ease.
We reviewed five sets of paper medical records during the inspection. Staff used black ink, legible handwriting and documentation occurred at the time of review or administration of treatment. We saw that patient records held individualised plans of care; for example, pressure area prevention and falls care plans, which were stored electronically. However, one set of notes did not have patient identifiers on each page and a different set of notes had a number of loose pages inserted at the front.
We saw that patient records held individualised records of care for example; spinal and neuro observations charts.
We reviewed four sets of paper nursing care records, which all had incomplete charts in them including fluid charts. Not all pages were appropriately labelled, and many entries were not initialled. Records within each folder were not stored chronologically.
We reviewed four sets of electronic nursing records, three out of four records viewed had been completed. Individualised care plans were completed as required. The electronic records also provided an option to refer on for specialist care if required, for example safeguarding or tissue viability.
Medicines
During our last inspection, we found oxygen was not always prescribed in line with trust policy. Whilst on this inspection, we reviewed four patients who were receiving oxygen therapy and found this was appropriately prescribed, including target blood oxygen levels. Staff stated that a new paper oxygen chart had been introduced since our last inspection to improve the prescribing and monitoring of oxygen.
In general, medicines, including intravenous fluids, were stored securely and access was restricted to authorised staff. However, on ward I1 we found the treatment room, which contained medicines and intravenous fluids, did not have a door. On ward F2 staff had propped open doors to two treatment rooms. This meant there was a risk that unauthorised persons could access medicines and fluids. The trust is in the process of rolling out swipe security access to all doors where intravenous medications and fluids are stored, I1 and F2 are part of that planned programme which is nearing completion.
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Pharmacists checked (reconciled) patients’ medicines on admission to hospital, and we saw this generally occurred in a timely manner and any discrepancies were followed up appropriately.
Patients we spoke with informed us they had received their medicines, including pain relief, in a timely manner. Doctors explained the plan of treatment and provided verbal information on any new medicines which were prescribed.
The trust had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of antimicrobial resistance. For example, the local antimicrobial formulary was available to all staff via the trust intranet. Staff had also been provided with quick reference cards which summarised the treatment of common infections. We saw that prescribers recorded indications and stop or review dates on the paper medicines charts. When patients had been prescribed intravenous antibiotics, these were regularly reviewed and changed to oral alternatives in a timely manner.
We found that all patients we reviewed had been prescribed appropriate prophylaxis for Venous Thromboembolism (blood clots) where this was indicated. However, medical staff did not always complete the trust risk assessment form fully on admission to hospital.
Controlled drugs were appropriately stored with access restricted to authorised staff. They were audited daily, and we found no discrepancies in the controlled drug registers. We reviewed the controlled drugs records on surgical wards and in theatres and found accurate records and checks were completed in line with trust policy.
We observed oxygen cylinders were stored appropriately. Medication trolleys were locked and secured to the wall when not in use.
On ward N2, we saw that staff recorded medicines refrigerator temperatures daily. We also saw actions recorded if the temperatures were not within expected ranges. We did not see that staff recorded the room temperature of the room the fridge was located, this is not in accordance with guidance. Also, on N2, we saw the medicines fridge was not locked but was within a locked room. The information available showed temperatures to be within range however in a two-week period there were six days when records hadn’t been taken. The fridge also contained named patient medications for patients who were no longer on the ward.
We reviewed 13 medicine charts and we saw that allergies were documented, some medicines charts had medicines that were pre-printed prescriptions such as oxygen. All medicine charts we reviewed showed that staff had prescribed and administered medicines as per best practice guidance.
Incidents
The trust reported four serious incidents in surgery over the past 6 months. During our inspection we found one occurrence that the trust should have reported as a serious incident but had not, after we highlighted our concerns the trust reviewed the occurrence and registered the occurrence as a serious incident. Ward managers we spoke with said that if a serious incident occurred they would be involved in the root cause analysis process. We reviewed three serious incident reports; we found these to include contributing factors, identification of lessons learned and recommendations to prevent reoccurrence of the incident.
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Our last report stated that the trust should introduce a robust process to share lessons learnt from incidents. All the staff we spoke with including medical staff were aware of how to report incidents and gave examples of what types of things they would report. During our last inspection, there was concerns staff did not get feedback following incidents. On this inspection, the ward staff reported getting feedback from incidents for example by emails from line managers with outcomes, learning and patient feedback. All staff we spoke to felt there was a good culture of incident reporting, including near misses. Staff we spoke to said that changes in practice had occurred because of incidents and said safety huddles had been developed to improve communication about patient risks
We saw wards that had a staff engagement noticeboard. This had information on incidents within the directorate. Recent incidents and learning points were detailed on the board for staff to learn from. The engagement board also included a section on the number of falls on the ward broken down by month. Learning points and actions taken to help reduce falls was also included; for example, the introduction of patient leaflets and non-slip socks.
Serious incidents were monitored through the trust’s serious incidents group which meet weekly. The serious incident group was attended by the Medical Director, Chief Nurse, Governance lead and Chief Executive.
Team meetings, a trust wide safety brief and safety huddles were also used for disseminating information. We observed a safety huddle on wards conducted by the nurse in charge. It was attended by various clinical staff. They discussed each patient, specifically any falls risks, plan of care and any concerns. They then discussed any other news including details of incidents and changes in practice. Staff reported that since the safety huddles were introduced there has been a reduction in pressure ulcers.
The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. We saw the duty of candour referenced in incident data. Staff we spoke with demonstrated an awareness of the duty and the importance of being open and honest when delivering care. We saw leaflets for patients in clinical areas with information regarding duty of candour. One patient we spoke with identified that there had been complications in theatre. The complications had been explained to the patient as soon as they woke from surgery
Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From May 2017 to April 2018, the trust reported two incidents classified as never events for surgery.
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(Source: Strategic Executive Information System (STEIS))
During our inspection, we discussed never events with staff. Four staff members stated that they were not aware of the two never events that occurred in the trust over the identified 12-month time period. However, they could recall one that occurred over a year ago which was a wrong site surgery.
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported nine serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from May 2017 to April 2018. Of these, the most common types of incident reported were • Surgical/invasive procedure incident meeting SI criteria with three (33% of total incidents). • All other categories with two (22% of total incidents). • Medical equipment/ devices/disposables incident meeting SI criteria with one (11% of total incidents). • Pending review (a category must be selected before incident is closed) with one (11% of total incidents). • Sub-optimal care of the deteriorating patient meeting SI criteria with one (11% of total incidents). • Treatment delay meeting SI criteria with one (11% of total incidents).
Royal Hallamshire Hospital reported four incidents, three of which were reported as surgical/invasive procedure incident meeting SI criteria type of incident. (Source: Strategic Executive Information System (STEIS)
Safety thermometer
We saw safety thermometer information displayed in some ward areas. Senior staff reported that they received email prompts to remind them to complete the Safety Thermometer. We were
20171116 900885 Post-inspection Evidence appendix template v3 Page 260 informed that the trust was working with commissioners to improve how the safety thermometer was applied in practice.
The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 84 new pressure ulcers, 26 falls with harm and nine new catheter urinary tract infections from April 2017 to April 2018 for surgery.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Sheffield Teaching Hospitals NHS Foundation Trust
1 Total Pressure ulcers (84)
2 Total Falls (26)
3 Total CUTIs (9)
1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only (Source: NHS Digital)
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Is the service effective?
Evidence-based care and treatment
Trust policies were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE). These were easily accessed on the trust’s intranet under clinical policies. All staff were aware of guidance and how to access it.
New guidance was monitored through clinical governance meetings and we saw evidence of this in the clinical governance report we reviewed. During our inspection, surgeons informed us that they had a monthly audit meeting where any issues and changes in practice were discussed.
We reviewed policies and found them to be in date and with version control and author identified. Care pathways were used for specific conditions, for example the sepsis pathway had a link to the Royal College of Physicians acute toolkit, screening tool and care protocols.
The surgical directorate participated in a number of national audits including the national joint registry and the Nephrectomy audit. From this good practice and areas for development were identified.
The department had developed and implemented guidance for anaesthetic management of hip fractures.
The surgical department has above average national performance with respect to national Referral to Treatment targets. Regularly in the top three organisations with performance around 95% against the 92% target for incomplete pathways.
The surgical department reported first ever use of a new cutting-edge heart treatment known as aortic valve neocuspidisation in adults in the UK. The replacement valve is created using a piece of tissue harvested from the covering of the patient’s own heart or from readymade Bovine pericardium. Once created, the valve – which acts like a natural valve and is much bigger and therefore much better for the heart than an artificial valve is sewn into place using millimetre- precision measurements.
Nutrition and hydration
During this inspection, we spoke with 14 patients and all of these said the food was good. All said they were given enough food and all water jugs we saw had water in them. We saw drinks round taking place in the mornings where patients were offered hot drinks as well as juice. A variety of food choices were available to patients. Staff said that, if there was a delay in getting elective patients a bed on the ward, they could be provided with diet and fluids in recovery.
The Malnutrition Universal Screening Tool (MUST) was used to assess and identify patients at risk of malnutrition and weight loss. We found these recorded and reassessed in the notes we reviewed. If required patients could be referred to the dietician for additional advice and support. We reviewed four sets of electronic MUST documentations and all four had MUST scores completed. We saw boards with information about MUST tools. We reviewed four fluid charts and found that these were all completed accurately and totalled on a daily basis to identify a patient’s fluid input and output. 20171116 900885 Post-inspection Evidence appendix template v3 Page 262
On ward N2, we saw patients requiring a texture modified diet or thickened fluids were reviewed by speech therapy and a sign with recommendations was placed over the patient’s bed. The ward identified those that needed extra support with their nutrition and hydration through the use of a ‘Red Tray’ system. Those at risk of malnutrition or needing additional support were offered fluids in red beakers and red lids were available for water jugs. There was a list of patients needing extra support in the kitchen allowing the house keeper to provide the right beakers and jugs for patients.
However, on other wards we visited, we did not see that patients were provided with different colour lids, trays or plates to help to identify them as needing support at mealtimes. We also did not see that equipment was available to help patients living with dementia to eat, for example coloured plates or cutlery.
Patients requiring additional nutrition could request a cooked breakfast and we saw two patients on ward H2 that had accessed this.
Patients were offered breakfast and ward managers chose whether their ward had sandwiches or a hot meal at the other mealtimes. For example, one ward we visited had chosen sandwiches for lunch and a hot evening meal.
We saw policies and observed clear explanations regarding fasting times at pre-assessment which were in line with best practice. There was a fasting policy and intravenous fluids would be commenced on an individual basis as required if patients were nil by mouth. Staff described the use of mouth care for patients who were unable to eat or drink.
Pain relief
As part of the SHEWS observational chart and intentional rounding, staff regularly asked patients about their pain level and recorded the scores. We spoke with five patients on the ward, all patients we spoke with said that staff offered them pain relief at regular intervals and that additional pain relief was given as it had been prescribed.
We saw evidence of pain scores in the documentation we reviewed. One patient informed us they were ‘provided with pain relief immediately’.
We reviewed four medicine charts and saw that patients had been prescribed and administered medicines, and that staff used pain scores to identify the patients level of pain and administer the correct level of pain relief.
During the inspection, we heard a conversation where a member of staff was assessing a patient’s pain level and deciding on a medicine to administer, this was done in a clear, supportive way and the decision to administer medicines was taken in partnership with the patient.
Staff had access to an acute pain team and staff told us they made referrals to this team as and when appropriate.
Patient outcomes
During our last inspection, we advised that the trust should review data collection methods and introduce a system to collect patient outcomes by speciality within care groups. The service had
20171116 900885 Post-inspection Evidence appendix template v3 Page 263 systems and processes in place to monitor patient outcomes including, service evaluations, and participation in local and national audits, all with a view to providing effective patient outcomes.
We saw evidence of a number of local audits, some of which are summarised below.
Relative risk of readmission From November 2016 to October 2017, all patients at Royal Hallamshire Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Urology patients at Royal Hallamshire Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Neurosurgery patients at Royal Hallamshire Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. • Ophthalmology patients at Royal Hallamshire Hospital had a higher expected risk of readmission for elective admissions when compared to the England average.
All patients at Royal Hallamshire Hospital had a higher expected risk of readmission for non- elective admissions when compared to the England average. • Urology patients at Royal Hallamshire Hospital had a higher expected risk of readmission for non-elective admissions when compared to the England average. • ENT patients at Royal Hallamshire Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. • Neurosurgery patients at Royal Hallamshire Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average.
Elective Admissions - Royal Hallamshire Hospital
Note: Ratio of observed to expected elective readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity
Non-Elective Admissions - Royal Hallamshire Hospital
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity (Source: HES - Readmissions (01/01/2017 - 31/12/2017))
Bowel Cancer Audit
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In the 2016 Bowel Cancer Audit, 69.4% of patients undergoing a major resection had a post- operative length of stay greater than five days. This was worse than the national aggregate. The 2015 figure was 72.4%.
The risk-adjusted 90-day post-operative mortality rate was 4.8% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 4.7%.
The risk-adjusted 2-year post-operative mortality rate was 17.6% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 19.8%.
The risk-adjusted 30-day unplanned readmission rate was 5.4% which was within the expected range when compared to other hospitals that participated in the audit. This was not reported in the 2015 report.
The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection was 53.9% which was within the expected range when compared to other hospitals that participated in the audit. The 2015 figure was 53.2%. (Source: National Bowel Cancer Audit)
National Oesophago-Gastric Cancer National Audit In the 2016 Oesophago-Gastric Cancer National Audit (OGCNCA), the age and sex adjusted proportion of patients diagnosed after an emergency admission was 13.2%. Patients diagnosed after an emergency admission are significantly less likely to be managed with curative intent. The audit recommends that overall rates over 15% could warrant investigation. The 2015 figure was 12.5%. (Source: National Oesophago-Gastric Cancer Audit 2016)
Patient Reported Outcome Measures In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations: • Groin hernias • Varicose veins • Hip replacements • Knee replacements
Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left.
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In 2015/16 performance on groin hernias was worse than the England average. • For Varicose veins, performance was better than the England average. • For hip replacements, performance was better than the England average. • For Knee replacements was better than the England average. (Source: NHS Digital)
The wards used enhanced recovery programmes which are evidence-based programmes designed to help people to recover more quickly following major surgery. The aims of these programmes are to ensure patients are as healthy as possible prior to receiving treatments and to receive the best possible care during their operation and recovery. These include getting patients walking, eating and drinking earlier.
Competent staff Appraisal rates From April 2017 to December 2017, 85% of staff within surgery at the trust had received an appraisal compared to a trust target of 90%. Five staff members reported to us that they were up to date with their appraisal and they received an email reminder when they are nearly out of date. On ward P2, management planned staff appraisals into the rota every month. For nursing staff, we saw evidence of 30 out of 31 appraisals were completed and in date.
Individuals Staff who have Completion Target Met Staffing group required received an (%) (%) (Yes/No) (YTD) appraisal (YTD) Qualified Allied Health Professionals (Qualified Yes AHPs) 25 25 100% 90% Support to ST&T staff 16 16 100% 90% Yes Qualified Healthcare Yes Scientists 14 14 100% 90% Support to doctors and No nursing staff 309 266 86% 90% Qualified nursing & health visiting staff No (Qualified nurses) 369 309 84% 90% NHS infrastructure No support 24 20 83% 90%
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Other Qualified Scientific, Therapeutic & Technical No staff (Other qualified ST&T) 87 68 78% 90% Medical & Dental staff – No Hospital 3 2 67% 90% Qualified nursing & health visiting staff (qualified nurses) and medical and dental staff both did not meet the 90% appraisal rate within surgery. • Royal Hallamshire Hospital had an 82% appraisal completion rate. (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
All new staff, both medical and nursing, attended a corporate induction when starting at the trust. A competency booklet was used to evidence learning. Newly qualified nursing staff underwent a six months preceptorship programme. We spoke with two new theatre staff who reported a very good induction and that they were initially supported by being allocated a mentor.
There was an induction pack for bank staff and students and we saw from the off-duty it was highlighted that this must be completed on a staff member’s first shift.
In addition to mandatory training there was role specific training on areas such as blood transfusion and conflict resolution. Staff reported they were encouraged to develop and attend additional training. In the theatre admission unit, we saw evidence of regular teaching sessions including safeguarding and female genital mutilation and, on the wards, we saw evidence of teaching sessions in biological medications, safeguarding and conflict resolution.
In theatre a skills matrix was used to identify learning needs and band six staff had responsibility/ specialism in particular areas. Staff reported that there was a full time clinical nurse educator for every surgical speciality.
On the wards there were identified link nurses, for example, for colorectal surgery and continence. There was access to a range of specialist nurses including respiratory, breast care and diabetes; they could be contacted by phone or electronic referral.
The junior doctors we spoke with reported they were offered lots of learning opportunities both formal and informal, protected teaching was given each Tuesday.
The trust supported nursing staff through the revalidation process. We saw information boards about the revalidation process. Revalidation is the new process that all nurses and midwives in the UK will need to follow from April 2016 to maintain their registration with the Nursing and Midwifery Council (NMC) and allow them to continue practising.
Multidisciplinary working
Staff reported to us, and we observed, good multidisciplinary team working; for example, on ward rounds between nursing and medical staff. We also saw evidence of this in the patient records we reviewed.
Daily multidisciplinary safety huddles took place each morning to discuss patient care and identify risks as well as to share other information. Physiotherapy and occupational therapy staff were
20171116 900885 Post-inspection Evidence appendix template v3 Page 267 aligned to ward areas which helped with continuity of care. Domestic staff attended safety huddles on a regular basis to discuss any issues with clinical staff.
The theatre manager report that they are trying to build stronger links with ward staff. The theatre and ward staff communicated daily to ensure the safe transfer of patients and ward staff were invited to access any training provided in theatre.
Seven-day services
Daily consultant ward rounds took place. We saw evidence of reviews at weekends and the patients we spoke with confirmed this. Staff provided examples of patients requiring emergency surgery or transfer to the intensive care unit out of hours and reported no concerns or delays with regards to this.
Consultants were available on-call out of hours and attended to see patients at weekends.
Physiotherapists and occupational therapists provided treatment Monday to Friday. There was a weekend and on call service out of hours. A pharmacist visited the unit Monday to Friday; the pharmacy was open seven days a week with a 24 hour on call service.
Health promotion
Health promotion information was available on all wards we visited. This included display boards and information leaflets. We saw information on smoking cessation, healthy eating, drugs, alcohol and housing needs. For example, on P2 inpatient unit there was a relative room with information leaflets, including healthy diets, the importance of keeping hydrated and self-help.
Support was available to support patients with smoking cessation. We saw from notes this was discussed with patients as appropriate. There were procedures in place to support patients withdrawing from drugs or alcohol and the pharmacist would advise and support in such situations.
On admission, assessments for individual health needs would take place and support would be provided as appropriate.
As appropriate, the multidisciplinary team provided health and self-care advice to patients to enable them to manage their own conditions.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion
Staff we spoke with demonstrated an understanding of consent, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards. We observed staff obtained verbal consent from patients before carrying out an intervention.
All the patients we spoke to informed us staff explained their care and treatment to them and sought consent prior to delivering the care.
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The trust reported that, from April 2017 to February 2018, Mental Capacity Act (MCA) training was completed within the safeguarding vulnerable adults - level 2 (3 yearly) module. This had been completed by 88% of staff in within surgery. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Is the service caring?
Compassionate care
The patients and relatives we spoke with were all positive about the care they had received. Patients described the staff as caring, one made the comment ‘no matter how busy they are, the staff are always polite and helpful’, another patient said the staff ‘are brilliant, they restore your faith in human nature, would recommend their care to anyone’. All patients felt that they were kept involved in their care.
During the inspection we observed interactions between staff and patients; these were consistently done in a kind and compassionate way. We observed patients having call bells within reach and were answered promptly. Feedback from patients confirmed that staff usually responded in a timely manner. We saw information boards displaying thank you cards from previous patients and welcome to our ward and information was displayed in relation to compassionate care in patient areas.
The majority of patients knew the names of the nurses and doctors caring for them.
On the theatre admission unit, we saw patients’ belongings stored in lockable containers for transportation.
Friends and Family test performance
The Friends and Family Test information was displayed in ward areas including follow up “You said, we did.”
The Friends and Family Test response rate for surgery at Sheffield Teaching Hospitals NHS Foundation Trust was 29% which was the same to the England average of 29% from April 2017 to March 2018.
A breakdown of response rate by site can be viewed below.
Friends and family test response rate at Sheffield Teaching Hospitals NHS Foundation Trust, by site.
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(Source: NHS England Friends and Family Test)
Emotional support
There was a bereavement service, and multi faith chaplaincy services were available on site and staff could access these for patients.
Staff we spoke with felt able to provide support to relatives and visitors as well as to patients and felt this was an important part of their role. We observed theatre staff welcome patients into the anaesthetic room and provide assurance to patients in recovery.
Specialist nurses were also available to provide advice and support for patients.
Understanding and involvement of patients and those close to them
Patients and their families told us they were involved in discussions about their care and treatment, those nearing discharge were also kept up to date with plans around discharge. Patients said staff kept them informed of what was happening and that they had been given explanations from medical staff; we saw this whilst observing ward rounds.
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Staff showed a good awareness of patients with complex needs and gave examples of when they provided support for them and their families. For example, ward P2 reported to us that they had a deaf-mute patient, the staff arranged a sign language interpreter who taught the staff signing skills. The staff also contacted the pain nurse who gave the ward a visual pain scale to ensure the patient could communicate if they were in pain.
During our inspection we also saw a book for patients who have communication difficulties such as dementia or non-English speakers.
During safety huddles we saw from discussions that conversations with family and the individual patients had taken place.
We saw information displayed about various mental health conditions including delirium, dementia and depression.
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Is the service responsive?
Service delivery to meet the needs of local people
The trust engaged with internal and external stakeholders, patients, governors, members, partners and staff to plan services. Local clinical commissioning groups and the NHS England commissioned services within the trust. Some specialist services were provided regionally and nationally.
The surgical directorate provided elective (planned) and non-elective (acute) surgical treatments for patients.
The directorate had improved collaborative working with commissioners and now had commissioners on key groups within the directorate to plan and deliver services.
The day surgery unit had designated areas for those waiting for surgery and post-operative patients. The service was nurse led with clear discharge guidelines. All elective patients were followed up in a dressing clinic.
The staff we spoke with felt confident in caring for patients who may need additional support.
Average length of stay
Royal Hallamshire Hospital - elective patients
From December 2016 to November 2017 the average length of stay for All elective patients at Royal Hallamshire Hospital was 3.3 days, which is lower than expected compared to the England average of 3.9 days.
Elective Average Length of Stay - Royal Hallamshire Hospital
Note: Top three specialties for specific trust based on count of activity.
Royal Hallamshire Hospital - non-elective patients
The average length of stay for all non-elective patients at Royal Hallamshire Hospital was 3.3 days, which is lower than expected compared to the England average of 5.0 days.
Non-Elective Average Length of Stay - Royal Hallamshire Hospital
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Note: Top three specialties for specific trust based on count of activity. (Source: Hospital Episode Statistics)
Meeting people’s individual needs
We saw a range of patient information leaflets, including memory loss, confusion and dementia, and orthopaedic therapy service inpatient guide. Staff we spoke with said these leaflets had improved patients understanding and expectations of their stay.
On inspection, staff on P2 ward informed us that they had a high number of patients where English was not their first language. The staff advised they used picture boards to communicate on a day to day basis. They could access interpreters via the phone or face to face if required.
The wards were accessible for people who used a wheelchair or walking aids. Disabled toilets and showering facilities were available in the ward areas we visited.
Assessments took place on admission or during pre-assessment to identify individual patient’s needs. This information was used to inform care planning. From speaking with staff and reviewing records we were assured that staff was aware and responsive to the needs of different people. Different food choices were available and chaplaincy for different religions and faiths.
Staff felt they were proactive in planning for the needs of bariatric patients. This was identified at pre-assessment, so all necessary equipment could be obtained in advance of the procedure to avoid any delays.
During our inspection, the wards we visited had very limited provisions in place for patients with additional needs such as those living with dementia. We did not see that patients were provided with different colour lids, trays or plates to help to identify them as needing support at mealtimes. We also did not see that equipment was available to help patients living with dementia to eat, for example coloured plates or cutlery. We did not see the use of coloured bathroom doors or toilet seats. However, on ward N2, we saw patients requiring a texture modified diet or thickened fluids were reviewed by speech therapy and a sign with recommendations was placed over the patient’s bed. The ward identified those that needed extra support with their nutrition and hydration through the use of a ‘Red Tray’ system. Those at risk of malnutrition or needing additional support were offered fluids in red beakers and red lids were available for water jugs. There was a list of patients needing extra support in the kitchen allowing the house keeper to provide the right beakers and jugs for patients.
One staff member said the ward received patients living with learning disabilities frequently. They had a ward-based link nurse and used the hospital passport with the patient.
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Access and flow
Patients accessed the service either as a planned admission, through the emergency department or from GP referrals.
The department held daily bed meetings to review capacity and demand, which were attended by the appropriate professionals. Staff reported that waiting for home care packages often delayed discharge. There was a short-term intervention team to improve access and flow.
The department used a fractured neck of femur pathway to improve flow for patients from the emergency department to recovery. Staff reported that this was a positive change.
Within the surgical assessment unit, there was a bay for patient assessment which was to prevent patients staying overnight.
Referral to treatment (percentage within 18 weeks) - admitted performance
From April 2017 to March 2018 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was consistently better than the England average and shows a stable trend from April 2017 where 86% of this group of patients were treated within 18 weeks versus the England average of 69% whereas in March 2018, 88% of this group of patients were treated within 18 weeks versus the England average of 68%.
(Source: NHS England)
The Trust informed us that they chose not to follow the national guidance to routinely cancel elective procedures due to winter pressures.
Referral to treatment (percentage within 18 weeks) – by specialty A breakdown of referral to treatment rates for surgery broken down by specialty is below. Of these, four of specialties were above the England average and one was below the England average. Specialty grouping Result England average Cardiothoracic surgery (NGH) 76% 82% Ophthalmology (mainly RHH) 85% 71% Neurosurgery (mainly RHH) 96% 71% General surgery (both) 87% 73% Trauma and orthopaedics (mainly NGH 85% 62%
Cancelled operations A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not
20171116 900885 Post-inspection Evidence appendix template v3 Page 274 been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice
Over the two years, the percentage of cancelled operations at the trust showed a downward trend and was generally lower than the England average. In the period for January 2016 to March 2016, this trust cancelled 400 surgeries. Of the 400 cancellations 3% weren’t treated within 28 days whereas in the time period of July 2017 to September 2017, this trust cancelled 258 surgeries. Of the 258 cancellations 1% weren’t treated within 28 days. The Trust informed us that they had chosen not to follow the national guidance to routinely cancel elective procedures due to winter pressures.
Percentage of patients whose operation was cancelled and were not treated within 28 days - Sheffield Teaching Hospitals NHS Foundation Trust
Cancelled Operations as a percentage of elective admissions - Sheffield Teaching Hospitals NHS Foundation Trust
Over the two years, the percentage of cancelled operations at the trust showed an upward trend and was generally lower than the England average. Cancelled operations as a percentage of elective admissions only includes short notice cancellations. (Source: NHS England)
At the 2015 inspection, we saw a decrease in cancelled operation. During this inspection, we reviewed cancellations for clinical and non-clinical reasons. We saw that within surgical services between March 2018 and May 2018, an average of 312 patients or 5% a month had surgery cancelled.
We reviewed theatre performance and utilisation data provided by the trust between March 2018 to May 2018. The trust reported an average touch time of 83.9%.
Senior staff monitored cancelled operations and completed a root cause analysis for patients that were not treated within 28 days. Clinical directorates held a weekly patient tracking list meeting.
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Staff informed us that common reasons for cancellations was due to a lack of theatre time or lack of appropriate equipment or if a patient became unwell. Staff reported cancellations occurred approximately two to three times per week. The theatre department had daily team huddles where staff tried to rearrange cancelled operations.
Surgical services had access to ambulatory care. Ambulatory care is used to assess and treat patients quickly, it helps to avoid unnecessary admissions and improves patient flow and experience. The directorate had also opened a surgical admissions lounge which enabled patients requiring surgery to be admitted to the lounge, go to theatre and then return to an appropriate bed on the ward.
We attended a patient flow meeting, where we saw good discussion of patients due for admission, outlier patients, perceived risks patients awaiting transfers to other wards or hospitals had waited.
Learning from complaints and concerns From February 2017 to January 2018, there were 238 complaints about surgical care. The trust took an average of 28 working days to complete. The trust works to a tiered response time process where the timescale is determined based on the complexity of the concerns raised. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale.
The Trust told us that upon receipt, all themes are identified from every complaint entered into the complaints management system, Datix. These themes are continually monitored with an analysis featured in all monthly, quarterly and annual patient experience reports. Royal Hallamshire Hospital: There were 93 complaints against this site for surgery. 72 complaints were reported against ‘all aspects of clinical treatment’ and complaints took an average of 39 days to be completed and investigated. (Source: Routine Provider Information Request (RPIR) P61 – Complaints)
Staff said that they always attempted to resolve specific issues at the time they were raised and encouraged patients to speak out if they had concerns as early as possible.
None of the patients we spoke with were aware of how to complain formally but many said they would speak to the ward sister.
Complaints are discussed at ward meeting with lessons learnt and staff gave us examples. One example was where a patient complained seeing a member of staff on their mobile phone at the nurses’ station, following this a reminder sent to all staff by email. Complaint meetings were held monthly and quarterly to look at key themes. All staff that we spoke to felt they received timely feedback regarding complaints.
Is the service well-led? Leadership
The senior management team within general surgery had oversight of the directorate, they were supported by a nurse director. During our inspection, there was a high level of staff engagement. Staff we spoke with said the senior management team were supportive but not visible on the wards and departments. However, staff within theatres were more positive around the visibility of
20171116 900885 Post-inspection Evidence appendix template v3 Page 276 senior management. Staff we spoke with also said that executive team were not visible, and they had not seen them visit their areas.
Junior medical staff said that they felt supported by senior colleagues. There was a clear leadership structure; which staff could explain. some senior staff we spoke with said that staff had been seconded into many of the nursing leadership posts such as ward manager, matron and assistant head of nursing.
Ward managers we spoke with described positive, supportive relationships with the senior leadership team and matrons
We found the ward managers on the wards we visited knowledgeable and professional. They appeared visible and approachable for the staff they supported.
Junior medical staff we spoke with said they felt supported by senior colleagues.
Vision and strategy
The trust had a mission statement, staff we spoke with were able to articulate this statement. Staff were aware of the trust vision and values. We saw information displayed in the areas we visited.
Surgical services had a strategic plan this strategy referenced national reports recommendations, the values and linked into the making it better 2017-2020 strategy of the trust.
Culture
Staff we talked with said they said they felt valued by their patients, ward leaders and the trust. They said that morale was good within the wards and departments. They also said that they were proud of the feedback they received from patients.
The senior management team were proud of staff working within the directorate and their resilience during ‘winter pressures’. Staff felt supported by their managers and colleagues at ward level.
Staff we spoke with wanted to provide effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams. Staff informed us they felt morale had increased and the team were approachable and encouraging. Volunteers in the department also said they felt included and part of the team.
It was apparent that senior leaders, department managers and shift leads were proud of their staff and praised them in their work. They told us staff often went above and beyond to provide care to patients when extreme pressures had been placed on the hospital.
In ward areas, we observed senior doctors asking junior doctors if they needed any support. Junior doctors reported feeling very supported able to ask for advice. Nursing staff reported a positive culture and good working relationships between staff groups.
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Governance
There was a clear governance structure with clear lines of responsibility and accountability.
The leadership team reported directly to the executive board, and systems were in place to allow information from them to be shared at ward level. Within theatre the cascading of information to teams was via the band six team leaders from monthly meetings with their manager.
We reviewed the clinical governance report for the surgical directorate. Patient safety, quality and experience outcomes were RAG rated within the document to highlight good practice and areas for improvement.
All specialities within the surgical department held monthly governance meetings. The trust provided evidence of meeting minutes. We reviewed monthly clinical governance meeting minutes and action logs and noted they were not particularly well attended. It was noted in the September 2017 minutes to ensure there was attendance from each area. There were ongoing actions in relation to staff appraisals and training compliance.
There were monthly mortality and morbidity meetings and clinical incident review group meetings. The trust provided evidence of meeting minutes. Feedback from medical staff was that the governance framework was clearer and speciality meetings were well established.
Management of risk, issues and performance
The surgical directorate risk register included risks from all of the clinical services. The senior leadership team reviewed risks at divisional governance meetings and the directorate risk register fed into the overarching register for all acute services.
Incidents and sharing of information took place in all areas via daily safety huddles.
The service was engaged in national clinical audit programmes and there were local audits to monitor performance in areas such as cystectomy audit, bowel cancer audit and nephrectomy audit
The trust provided the audits of surgical safety checklist over the past 3 months. The trust had achieved or nearly achieving targets set. The areas that the surgical department did not achieve the targets set was checking patients for MRSA, checking patients for difficult intubation and aspiration risk- 95.8% and if all of the team paused for the ‘Time-out’. The trust set targets of 100% but had achieved 94% or above.
There was a surgical site meeting held every quarter attended by ward and theatre management, infection control lead and microbiologist. All root causes analyses were discussed. During our inspection we saw evidence of minutes and action plans.
The trust had a business continuity plan. This document detailed how the trust would respond to an incident or event, which disrupted services.
The directorate had a risk register which highlighted current risks and documented mitigating actions to reduce the risks. Data we reviewed showed that there were currently 103 risks with 11 currently rated as extreme risks, 57 rated as high risks, 31 medium risks and four low risks
20171116 900885 Post-inspection Evidence appendix template v3 Page 278 following identification of mitigating actions. These risks were reviewed at the governance meetings but in the minutes, we saw the minutes of the meeting and evidence of discussion and escalation of these risks to executive boards.
We discussed with senior staff within the directorate about their highest risks, they identified staffing, performance, capacity, finance and pressure area management these risks were identified on the risk register.
Information management
During our inspection, we observed that staff could access information relating to polices and guidance electronically. The system was easy to navigate. Staff received training on information governance and were aware of the importance of managing confidential patient information.
Information provided by the trust, showed that 100% of medical and dental staff and 89% of nursing staff had completed information governance training. Medical staff rates were better than the trust’s target level of training of 90%, with nursing staff rates being similar.
We did not have any concerns during the inspection about the security of patient records.
Computers were available on surgical wards. During the inspection, all computers were locked securely when not in use.
Engagement
Staff we spoke with said they had changed practice in relation to feedback from patients. They provided an example of lowering noise levels at night and buying soft closing bins, ear plugs for patients and reminding staff to be quieter.
We saw thank you cards and letters displayed in the entrance to ward areas.
Staff felt positive about the future and felt involved in decision making about changes in practice. Staff told us they felt valued for the work they had done.
Learning, continuous improvement and innovation
Senior managers and team leaders spoke about driving improvement and encouraging innovation. Team leaders felt they were supported in trying new ideas or ways of working.
During the inspection we saw a new initiative was launched; “give it ago week” this prompted staff to think about and implement improvement, for example one ward decided that housekeepers would go to collect patient’s property following operations to reduce patient frustration of waiting for their property to arrive.
Staff reported to us that due to issues with delayed discharge due to waiting for care packages, there was a campaign “Why not home? Why not today?”.
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End of life care
Facts and data about this service
The trust provides end of life care at Royal Hallamshire Hospital. End of life care encompasses all care given to patients who are approaching the end of their life and following death. It may be given on any ward or within any service in a trust. It includes aspects of essential nursing care, specialist palliative care, and bereavement support and mortuary services. At Royal Hallamshire Hospital there are no dedicated end of life inpatient beds and end of life patients are accommodated on general wards. However, end of life patients in general inpatient beds are supported by the hospital palliative care team (medical and nursing) who provide a seven-day service to support all healthcare professionals to deliver end of life care. There is an out of hours on call provision over 24 hours, seven day a week that can provide specialist registrar/consultant delivered face to face advice and support as required. The palliative care team work alongside learning and development to support education and training to all staff. The trust had 2,619 deaths from February 2017 to January 2018. (Source: Hospital Episode Statistics)
The chaplaincy department offer services to patients, relatives and staff 24 hours a day, seven days a week operating on an on-call basis out of hours. The mortuary department was open Monday to Friday 8am to 5pm and operated an on-call out of hours service. This report predominantly focuses on the inspection of the services provided by the specialist palliative care medical, nursing and administration team, the mortuary staff and the chaplaincy and the bereavement team. We inspected the whole core service and looked at all five key questions. In order to make our judgements at the Royal Hallamshire Hospital, we spoke with six patients and carers and 13 staff from different disciplines. We observed daily practice and viewed four sets of records. Before and after our inspection, we reviewed performance information about the trust and reviewed information provided to us by the trust.
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Is the service safe? Mandatory training Overall mandatory training rates At our previous inspection in 2015, we found only two of 12 mandatory training topics were above the trust plan of 90%. Overall compliance was 79%. At this inspection, information provided by the trust showed overall compliance had improved to 93% which was better than the trust plan. However, compliance was lower than the trust plan of 90% for some subjects. For example, administration staff in the specialist team were 80% non- compliant with information governance, medical staff were 63% compliant with infection prevention and control training and the team overall were 67% compliant with Mental Capacity Act and Deprivation of Liberty Safeguards training. Medical device training for the use of syringe drivers was lower than the trust plan at 66% and on some wards, there were no staff were compliant with the training. Staff we spoke with told us they were up to date with training and they were supported to complete their training. Newly appointed clinical support workers completed ‘prepare to care’ which incorporated end of life care training as part of their introductory training. This included recognition of death and dying, case study scenarios for symptom control and good communication with patients and their relatives. The trust had recently rolled out an end of life care e-learning training module available on the trust e-learning portal. Staff involved in end of life care, including porters involved in the movement of deceased patients completed this training; however, it had not yet been made mandatory on the training system. We were told this would become a job specific training requirement for all relevant staff.
Safeguarding We spoke with ward staff who were able to clearly define their responsibilities in relation to safeguarding patients. They were able to share examples of when they had needed to submit safeguarding concerns for end of life patients in their care. Safeguarding training completion rates Information received from the trust showed the specialist palliative care team were 100% compliant with safeguarding vulnerable adults level two and safeguarding children and young people level one. We asked the trust why the team completed level one training and were told the training had been identified through a training needs analysis, as an appropriate level of training for this staff group. All patients seen by the team would be under the care of medical and nursing staff who would have completed a higher level of training. The chaplaincy team were 100% complaint with level one safeguarding vulnerable adults and level one safeguarding children and young people training. The mortuary staff were 80% compliant with level one safeguarding vulnerable adults and level one safeguarding children and young people training. The trust told us this was due to long term sickness within the team.
Cleanliness, infection control and hygiene
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Information provided by the trust showed 83% overall compliance with infection prevention and control training for the specialist care team. Medical staff were 63% compliant which is below the trust plan however nursing staff were 95% compliant which is better than the trust plan of 90%. All areas that we visited, that were providing care at the end of life, appeared clean and well maintained. This included ward areas, the mortuary and the bereavement team offices. Within the mortuary, there was clear separation of clean, transitional and dirty zones. Personal protective equipment (PPE), such as gloves and aprons, was available and this was stored appropriately, in a cupboard away from the post mortem room. The mortuary had two cleaners, one cleaner for upstairs and one cleaner for downstairs. Mortuary technicians were responsible for cleaning the post mortem room. At the last inspection in 2015 we identified that no one appeared to be responsible for cleaning the concealment trolley used to transport deceased patients to the mortuary. At this inspection we were told that porters cleaned the concealment trolley after patients had been transported to the mortuary and they completed this in line with infection prevention and control protocols. All deceased patients were transported to the mortuary in colour coded body bags. There was a process in place to identify patients with communicable diseases such as HIV; these patients would be placed in a white body bag. All other patients were placed in a black body bag.
Environment and equipment All wards we visited during our inspection appeared well maintained. The trust had a safe and robust medical device process to ensure reusable equipment was proactively managed throughout its life cycle. The trust used a single type of syringe driver. These met the national recommendations issued in 2011 by the national patient safety agency (NPSA/2010/RRR019 safer ambulatory syringe drivers). Registered nurses we spoke with told us they received training on the use of the syringe drivers at the start of their employment; they then completed a competency booklet and attended refresher training as part of their mandatory training. Staff reported they were supported with this training by the clinical educator. Information provided by the trust indicated compliance in syringe driver training was between 65% on wards E1 and E2 and 100% on ward M2. Overall compliance was 89% which is marginally below the trust plan of 90%. Staff in the mortuary told us that the mortuary had been designed and built to comply with Health Building Note (HBN) 20 Facilities for mortuary and post-mortem room services. The mortuary had facilities available for bereaved relatives and carers. This included a pleasantly decorated waiting room, a viewing room, multi-cultural facilities and disabled toilet facilities. The mortuary had male and female staff changing rooms and showers available for staff. The mortuary had CCTV in the fridge areas; however, this did not cover the post mortem room for privacy and dignity reasons. CCTV footage was recorded to a hard drive and access to this footage was strictly limited to named personnel only in the event of a serious incident. The Human Tissue Authority (HTA) is a regulator set up in 2005 created by parliament; they are an executive agency of the Department of Health. The HTA regulate organisations that remove, store and use human tissue for research, medical treatment, post-mortem examination, education and training, and display in public.
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The HTA had inspected the mortuary services for the hospital in May 2018, the final audit report had not been produced at the time of our inspection. However, the HTA had provided the trust with initial feedback, this included one major shortfall and related to a policy document which was out of date for review. Staff at the mortuary showed us evidence that the policy had been updated and an email from the HTA advising that they were satisfied with the actions taken. This meant that at the time of our inspection the services provided by the hospital met the required standards for premises facilities and equipment. The fridges in the mortuary had an electronic automated alarm system to alert staff if the temperature of any individual fridge rose above 12 degrees centigrade. Staff were available 24 hours per day in case of emergencies. The mortuary had 45 fridges which included five bariatric fridge spaces.
Assessing and responding to patient risk The specialist palliative care team were available to provide help and support to care for any end of life care patient across all wards. At our previous inspection in 2015 we found once it was clinically indicated that someone was nearing the end of life and had increased needs, general ward-based nurses could refer to the guidelines on the intranet. This process however, was reliant on the individual nurse’s skills and experience; there were no ‘triggers’ or formal pathways to support the decision making. At this inspection we found that the palliative care team had introduced a comprehensive an end of life intranet site and clear ‘guidance for the care of the person who may be in the last hours to days of life’; they had also introduced rapid discharge home to die pathways for patients from general wards and the emergency department. The trust used an adapted version of the national early warning score called SHEWS to monitor for deterioration of a patient.
Nurse staffing Overall staffing rates Information provided by the trust indicated there were 40 whole time equivalent registered nurses within the specialist palliative care team. Information received from the trust following our inspection showed that the trust employed 4.8 wte specialist palliative care nurses. This meets the commissioning guidance for the number of beds these staff covered.
Vacancy rates The trust told us the vacancy rate for the specialist palliative care team was 8.9%. The trust did not provide an aspirational vacancy rate. There were no vacancies in the team at the time of our inspection.
Turnover rates The trust told us the turnover rate for the specialist palliative care team was 4.8%. This is better than the trust aspirational rate of 15%. Following our inspection, information received from the trust indicated that the turnover rate within the specialist palliative care nurse team, turnover was 8.3% in the previous 12 months.
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Sickness rates The trust told us the specialist palliative care team had a sickness rate of 5.4% which is worse than the trust aspirational rate of 4%. Information received following our inspection showed that sickness rate for the specialist palliative care nurses trust wide was 3.6% which is better than the trust aspirational rate.
Bank and agency staff usage We requested data on the use of bank and agency staff usage within the specialist palliative care nursing team. The trust told us there had been no requests for bank or agency staff to cover specialist palliative care nurses in the last twelve months.
Medical staffing
The trust provides acute and community services to a population of 640,000. Commissioning guidance for specialist palliative care recommends the minimum requirements for this population size are two whole time equivalent (wte) consultants in palliative medicine and two wte additional supporting doctors (e.g. trainee/specialty doctor) The trust met this recommendation as they employed 6.7wte specialist palliative care consultants and seven wte registrars. There was a 24 hour on call rota for palliative medicine during the week and at the weekend. On call was covered by a specialist registrar (First call) and then the consultant if further advice was needed. The on-call rota operated from 5pm until 9am Monday to Friday and 9am until 9pm at weekends. The process for contacting the palliative doctors out of hours was for a doctor from the ward to call the specialist registrar. If required, the specialist registrar would contact the consultant on call for further advice. If physical assessment was required, the specialist registrar would attend the ward and if urgent attention was required the consultant would attend. Vacancy rates The trust reported that there were no medical staffing vacancies for end of life care medical staff.
Turnover rates The trust told us there was a 12.5% turnover rate for medical staff within end of life care services. This is lower than the trust aspirational rate of 15%.
Sickness rates The sickness rate for medical staff within end of life care services was 5%. This was worse than the trust aspirational rate of 4%.
Bank and locum staff usage The trust did not report bank and locum use in hours or shifts. They reported there had been no agency consultant cover. Bank consultant costs, in the twelve months from May 2017 to May 2018, were reported as £18,729.77 and £26,340.00 for junior medical staff. The total spend was £45,069.77.
Records We looked at the care records of four patients under the care of the specialist palliative care team and saw that where appropriate a ceiling of care was documented. A ceiling of care is the
20171116 900885 Post-inspection Evidence appendix template v3 Page 284 documentation of discussions around care that should be given to the patient and provides information about limitations to interventions which are likely to be futile, burdensome, or contrary to the patient’s wishes given their terminal diagnosis. We reviewed the care records of a patient with complex mental and emotional needs at the Royal Hallamshire hospital and saw evidence of their referral and agreement to admit to the Macmillan palliative care unit at Northern General Hospital the following day. We saw that the specialist palliative care nurses completed a holistic review of each patient including their physical, spiritual and psychological needs. We saw that the team completed regular reviews and that their documentation was clear, legible and completed in line with the Nursing and Midwifery Council (NMC) standards for record keeping. Overall compliance for information governance training for the specialist palliative care team was 83% which was below the trust plan of 90%. Nursing staff were 97% compliant which was better than the trust plan. Medical staff were 87% compliant, which is marginally worse than the plan; however, administration staff were 20% compliant which is significantly worse than the trust plan. We did not have any concerns about the security of patient’s medical or nursing records.
Medicines We reviewed prescription records for four patients receiving end of life care. Medications had been prescribed appropriately and syringe driver checks were documented in the patients’ records, where patients were on a syringe driver. For further information on the storage and handling of medications on general ward areas, please see the Medical care (including older people’s care) evidence appendix.
Incidents We saw evidence of trust wide incidents reported on NRLS between 1 June 2017 and the 31 May 2018 relating to patients receiving palliative care. There were 194 incidents reported in relation to palliative medicine, all rated low or no harm. Staff we spoke with told us they received shared learning from incidents across the trust through trusts alerts and bulletins. The mortuary had a policy for damage to deceased patients. If damage occurred to a deceased patient after death, the mortuary took photographs, and this was assessed as to whether it was reportable as a serious incident. Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2017 to April 2018, the trust reported no incidents classified as never events within end of life care. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Breakdown of serious incidents reported to STEIS
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In accordance with the Serious Incident Framework 2015, no serious incidents (SIs) occurred in end of life care at the trust which met the reporting criteria set by NHS England from May 2017 to April 2018. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Safety thermometer The safety thermometer at the Royal Hallamshire Hospital is reported on under the Medical care (including older people’s care) evidence appendix.
Is the service effective? Evidence-based care and treatment Policies used by the service were available for staff to access on the trust intranet. These included a range of pathways and guidance which reflected national evidence based best practice and guidelines, for example, ‘guidance for the care of the person who may be in the last hours to days of life’ which reflected ‘5 priorities for care of the dying person’ and rapid discharge pathways for general wards and the emergency department. The Gold Standard Framework accreditation is an independently validated marker of excellence for palliative and end of life care. We asked the trust about gold standards accreditation and were told Sheffield Teaching Hospital NHS Foundation Trust does not have the Gold Standards Framework accreditation. No further information was provided by the trust. At the previous inspection in 2015 we found there was variable compliance with national standards for completion of do not attempt cardio pulmonary resuscitation (DNACPR) forms. At this inspection we found the trust had completed an annual DNACPR audit which not only looked at the completion of the forms, but the discussions conducted with the patient and the timings for decision making. The audit found that the average time taken to make the decision to implement a DNACPR was 9 weeks before the patient died. The audit had improved significantly, results from the previous audit placed compliance at 4%, following the most recent audit compliance was at 78%. The trust used an adapted national early warning score system (SHEWS) based on NICE guidelines, to monitor for deterioration of a patient. The clinical fellow in palliative care had designed and circulated questionnaires for medical staff and nursing and multi-disciplinary team (MDT) staff across the trust to benchmark understanding and confidence in relation to palliative care and to better inform the palliative care team of the needs of the medical, nursing and MDT staff.
Nutrition and hydration The service ensured people's nutrition and hydration needs were identified, monitored and met, including where they had specific dietary requirements. We spoke to one patient who told us that they had struggled with eating and drinking due to the symptoms of their illness. The patient told nursing staff they would like a specific brand of soup and the staff on the ward ensured that the patient had the soup they requested the next day. The patient said staff were responsive to their nutritional needs and went above and beyond to meet specific needs.
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Matrons conducted audits on swallowing assessments and the completion of nutrition and hydration tools. Staff completed malnutrition risk assessments completed using a malnutrition universal scoring tool (MUST). MUST scores were recorded and patients were referred for specialist dietary support if assessed as at risk.
Pain relief Patient records showed that pain relief was being prescribed to patients appropriately. One patient told us that when they had been admitted to hospital their pain had been out of control. The patient now felt that due to the daily input from the specialist palliative care team, their pain was now manageable as their medication had been adjusted. Another patient told us that staff were responsive to their needs when they needed more pain relief. The trust used syringe drivers to help patients manage their pain. We observed that syringe drivers were used with a wide range of analgesia, tailored to the patient’s own pain relief needs. Some patients had been prescribed ketamine for pain relief and staff were open to exploring further pain relief options with patients who had severe pain and were not responding to ‘traditional’ analgesia. There had been no pain audits specific to end of life care carried out in the last 12 months. However, in the 2016/17 end of life care satisfaction survey 84% (222) responders felt the patient’s pain was controlled.
Patient outcomes End of life care Audit: Dying in Hospital The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed better than the England average for two of the five agreed clinical indicators: • Metric 1: Is there documented evidence within the last episode of care that it was recognised that the patient would probably die in the coming hours or days? % YES - 86% compared to the national aggregate of 83% • Metric 2: Proportion of patients for whom there was there documented evidence within the last episode of care that health professional recognition that the patient would probably die in the coming hours or days (imminent death) had been discussed with a nominated person(s) important to the patient? - 80% compared to the national aggregate of 79%
The trust answered yes to three of the eight organisational indicators:
• Metric 7: Did your trust seek bereaved relatives’ or friends’ views during the last 2 financial years (from 1 April 2013 to 31 March 2015)? • Metric 9: Was there face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to Sunday? • Metric 10: Does your trust have one or more end of life care facilitators as of 1 May 2015? (Source: Royal College of Physicians)
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An electronic patient record system was in use which included an end of life care section. This allowed staff to record a patient’s preferred place of care and death. This also included a section to record whether preferred place of death was achieved and if not why not. However, the trust had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. However, we did see that establishing patients’ preferred place of care was seen as a priority and this was clearly documented in patients’ care records. The trust had detailed actions needed to improve their audit outcomes in the next audit. We reviewed the actions identified and the trust had achieved many of the identified actions, including the introduction of a personalised care plan, sign off to recruit a lead nurse role, end of life e- learning and sign off to recruit a full-time facilitator role. The medical director chaired the end of life project steering group and provided representation from the executive board.
Competent staff We spoke with two specialist palliative care nurses who told us that all members of the team had completed post graduate study in palliative care. This included studying to degree or masters level in palliative care. In addition, all of the specialist nurses were non-medical prescribers. We spoke with the end of life care facilitator who told us they worked 15 hours per week. We were told about the educational opportunities that were offered to all staff working across the trust. This included some planned training on the recognition of death and dying, care in the last hours and days of life, symptom control and holistic care of dying patients. The trust had more than 100 end of life care champions and was using the Yorkshire and Humber learning outcomes for end of life care as a learning framework for the champions. In addition, the specialist palliative care team had provided training to the chaplaincy volunteers and were looking to roll this training out for the general end of life care volunteers. The trust provided end of life care training twice a year for approximately 120 junior medical staff. Advanced care planning was included as part of this training. Advanced care planning is the term used to describe the conversation between people, their families and carers and those looking after them about their future wishes and priorities for care. Nursing staff from the specialist palliative care team told that they received clinical supervision once a month from a clinical psychologist which was internally provided and funded by the trust. Some members of the team also accessed external support from a psychotherapist. Staff we spoke with told us that this helped to emotionally deal with the role they provided. We were told that the weekly multidisciplinary team meeting also provided informal supervision because this included a whole team review of the entire caseload. We were told that the team worked together to ensure that support was provided where needed. The team members also described an informal process of peer review being undertaken when they reviewed patients on a weekend who had been under the care of another team member.
Appraisal rates
The trust plan was for 90% of staff to have an annual appraisal. At the time of our inspection the chaplaincy team met this, being 90% compliant. Nursing staff were 87% compliant which is marginally worse than the compliance plan. However, the mortuary staff were 67% compliant
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Multidisciplinary working The specialist palliative care team reported that they had developed positive team working with all wards caring for patients at the end of their life. They described part of their role as ensuring that general ward teams were empowered to effectively care for these patients. We spoke to staff on a general ward who told us the palliative care team worked well with their ward team and were accessible and responsive. The specialist palliative care team held a multidisciplinary meeting each Thursday. We attended the specialist palliative care team multidisciplinary team meeting during our inspection. All the specialist nurses and the palliative care consultants attended this meeting. We heard that apologies had been received from the hospital chaplain but understood that they would usually be included in the meeting. We saw that a holistic review of each patient on the teams’ caseload was completed. In addition to this the team also discussed the care of patients who had recently died or been discharged from the service. Where appropriate the team considered the chaplaincy support for patients who they felt would benefit from this.
Seven-day services The specialist palliative care team nurses had been providing a seven-day service since 2012. Palliative care medical cover could be accessed seven days a week. There was a 24 hour on call rota for palliative medicine during the week and at the weekend Staff working in the mortuary were available Monday to Friday from 8am until 5pm. An on-call system was in place out of hours and at weekends for any concerns or for family viewings. Chaplaincy services were available 24 hours a day, seven days a week. The chaplaincy service had a chaplain on call rota and a chaplain worked across site on an on-call basis out of hours. Health promotion Patients were given leaflets from Macmillan cancer care which provided more information on their cancer diagnosis. For further information on health promotion on general ward areas, please see the Medical care (including older people’s care) evidence appendix.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Consent to treatment means that a person must give their permission before they receive any kind of treatment or care. An explanation about the treatment must be given first. The principle of consent is an important part of medical ethics and human rights law. Consent can be given verbally or in writing. The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over.
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Where someone is judged not to have the capacity to make a specific decision (following a capacity assessment), that decision can be taken for them, but it must be in their best interests. The Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person's best interests. Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are the Deprivation of Liberty Safeguards (DoLs). DoLs can only be used if the person will be deprived of their liberty in a care home or hospital. We looked at the trust’s policies for consent and mental capacity act, including DoLs. We found that these were in date and contained appropriate references to legislation such as the mental capacity act, equality and diversity and the human rights act. We looked at DNACPR forms completed for three patients and found these were completed in full, there was also documented evidence within the medical records that the decision to implement the DNACPR had been discussed with the patient and their families, where appropriate.
Mental Capacity Act and Deprivation of Liberty Safeguards training completion Information provided by the trust showed overall compliance for MCA and DoLs training was 67% for nurses, medical staff and chaplains in the end of life care team which was worse than the trust plan of 90%. We requested these figures for mortuary and bereavement staff, but these figures were not provided.
Is the service caring? Compassionate care We observed patients being treated with privacy and dignity. We observed a number of interactions between staff, patients and relatives. Staff were polite, respectful and professional in their approach. We observed staff responding compassionately to patients’ pain, discomfort and emotional distress in a timely and appropriate way. Confidentiality was respected in staff discussions with people and those close to them. Staff spoke about patients with complex needs in a respectful way and demonstrated a non- judgemental attitude. One patient told us that their situation had changed rapidly, and staff had taken time to talk to their family without overwhelming them.
Emotional support We witnessed the specialist palliative care team considering the emotional needs of patients during their weekly MDT meeting. There was support available for patients and staff from the chaplaincy service. The chaplains were available 24 hours a day. The bereavement team dealt with all aspects of care for the bereaved family. This included ensuring death certificates and cremation forms were completed appropriately and in a timely manner and families received help and support to contact the registrar’s office. Families were 20171116 900885 Post-inspection Evidence appendix template v3 Page 291 provided with a release form which they completed and gave to their chosen undertakers. The undertakers then provided this to the mortuary staff when collecting the patient. We spoke to a patient’s relative who told us that they had stayed with the patient for two nights. The relative told us that the ward team and the palliative care team had looked after and supported their needs, as well as the patient’s needs.
Understanding and involvement of patients and those close to them We saw that when conversations about care and treatment took place with patients and their families, these were clearly documented by the specialist palliative care team. We observed staff communicating in a way that people could understand and was appropriate and respectful. Patients and relatives told us they were kept informed of what was happening and understood what the plan of care was. The trust conducted an annual end of life survey. The key results below were from 297 respondents to the survey conducted from July 2016 to June 2017. 85% of respondents rated the care given to their loved ones in the last days to hours of life as excellent or good, 6% felt care given was fair, 7% felt care given was poor and 2% of respondents did not know.
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(Source: P94 end of life survey report)
Is the service responsive? Service delivery to meet the needs of local people End of life services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. End of life services were delivered to meet the needs of the local population, to ensure patients received coordinated care that was accessible and responsive to people with complex needs. Acute and community services at the trust worked in close partnership with a number of external providers and agencies to provide a responsive end of life care service to the local and wider population. Within the city of Sheffield good partnership working was in place with the local hospice, clinical commissioning group, the citywide end of life care steering group, primary health care providers across the city and Sheffield City Council. The trust also worked collaboratively with other specialist palliative care providers in the surrounding area such as those in Rotherham, Doncaster and Barnsley. At a regional level, the trust was a member of the Yorkshire and Humber Regional End of Life Care Group. There was a palliative care outpatient clinic at Royal Hallamshire Hospital on Monday and Wednesday each week. Clinics also took place at the trusts other acute hospital sites on Tuesday, Thursday and Friday. This meant there was access to a clinic every week day.
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The trust employed 14 chaplains which met the NHS Chaplaincy Guidelines 2015 Promoting Excellence in Pastoral, Spiritual & Religious Care guidelines. In addition, there were also chaplaincy volunteers. The multi-faith chaplaincy department had a diverse range of chaplains to reflect the religious, cultural and spiritual needs of the local population. There were Muslim chaplains, Roman Catholic chaplains, generic Christian chaplains and an honorary Buddhist chaplain. The chaplaincy department also had faith contacts in the community they could utilise if required. The chaplains worked on a 24-hour basis over the whole trust. There was a large chapel that incorporated a reflective contemplation area and a multi-faith room, there was also a Muslim prayer room located in Royal Hallamshire Hospital. However, the multi- faith room was small and did not offer sufficient room for disabled access. We found that the Muslim prayer room was difficult to locate, however there were detailed directions to the room displayed inside and outside of the chapel.
Meeting people’s individual needs All of the specialist palliative care nurses were non-medical prescribers, this meant that any medicines that were required to treat patients’ symptoms could be prescribed in a timely manner and there were no delays in care and treatment being provided. The trust had a Muslim chaplain who supported patients and was also available to provide support to staff when caring for Muslim patients and their families. The multi-faith chaplaincy department had a returning patients list which was checked daily. Any patient that had previously used the chaplaincy department would be identified and the chaplains would go out to see the returning patient without the need of a referral. This provided an outstanding responsive service to patients who could then be seen without delay, which was important for patients nearing the end of their lives. Staff in the mortuary were aware of the multi-cultural needs of deceased patients and their families. Resources to support different cultures were kept in a room adjacent to the viewing room and staff could provide families with these resources at their request. The wards worked with the mortuary to facilitate the rapid release of deceased patients, so their faith needs could be met. The mortuary staff had an out of hours on call service to enable families to visit their loved ones after death Mortuary staff told us they could accommodate special requests such as placing family members, partners and mothers and babies close to each other in the fridge. This was particularly poignant for mothers and babies that died in childbirth and they would be placed together in the fridge. Mortuary staff would also place items left with the deceased patient, such as teddy bears, with the patient in the viewing room when the family came for a viewing. Staff we spoke with told us that they could access translation services. They explained that this was essential when dealing with sensitive information. We were given an example of when the team had suspected that a family was withholding information from a patient whose first language was not English. Information was available in easy read and large print where patients requested this as an additional need.
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We reviewed the care records of a patient with complex mental and emotional needs at the Royal Hallamshire hospital and saw evidence of a referral to the psychiatric liaison team for assistance in managing the patient. One of the specialist palliative care nurses was the teams’ lead for learning disabilities. Staff were aware of, and gave good examples of, caring for patients and family members with learning disabilities. The mortuary returned deceased patients jewellery to their family in small jewellery pouches.
Access and flow We spoke with members of the specialist palliative care team who advised that referrals to the team were sent via a fax to the administrator for the service. These were then forwarded to the coordinator. From Monday to Friday one of the team acted as the coordinator. On Saturdays and Sundays one specialist nurse was on duty and they received all referrals. The trust standard was that the palliative care team would review patients within 24 hours of receipt of a referral. In some cases, verbal advice was given to the referring ward for example on Saturdays and Sundays, when only one specialist nurse was on duty. The table below provides the detail of response times for the Specialist palliative care hospital support team for a calendar year from 13 June 2017 to 12 June 2018. Where there is a response of 0, this indicates the patient was seen on the same day. 1 – seen the next day 2 – seen within 2 days of referral 3 – seen within 3 days of referral Whilst there are a very small number of responses greater than 3 days, this is because this was requested on referral. A total of 2,722 new patients were seen in this time scale but unfortunately the data is missing for 257 patients (9.44%) so could not be extracted for the report. The percentages do not add up to 100% as some have been rounded down.
Response times Northern General Grand Percentage (days) Central Campus Hospital Total of total 0 916 1276 2192 80.5% 1 21 228 249 9.1% 2 4 7 11 0.4% 3 4 5 9 0.33% 4* 1 1 0.04% 5* 1 1 0.04% 6* 1 1 0.04% 9* 1 1 0.04% Data missing 185 72 257 9.4% Grand Total 1130 1592 2722 99.89% *Future date was requested – e.g. elective admission
Please note that the missing data is due to the field not being completed by the clinician on the Infoflex Electronic Patient record. (Source: Data request DR089 referral to review by SPCT times) The specialist palliative care nurses reviewed and triaged all referrals in to the team. Where necessary patients could be referred for a review by a palliative care consultant.
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Staff from the acute team referred patients to the community team when their acute episode of care was completed. They were also able to refer patients for admission from a general ward to the hospital’s Macmillan palliative care unit when longer term specialist care was required. We reviewed the care records of a patient with complex mental and emotional needs at the Royal Hallamshire hospital and saw evidence of their referral and agreement to admit to the Macmillan palliative care unit at Northern General Hospital the following day. Staff told us that patients admitted to the unit were complex palliative cases, requiring high dependency and high acuity care for multifaceted physical, mental or emotional issues. Patients were not always admitted for physical health reasons; staff placed emphasis on a holistic approach to patients and their mental and emotional health alongside their physical condition. The trust reported delayed 35 fast track discharges between June 2017 and May 2018; we do not have the data to report on reasons for or the length of the delay. The trust reported the below figures for referrals for the central campus, covering Weston Park and Royal Hallamshire Hospitals:
Central Campus 1,097 referrals were received by the team. 7,110 contacts were made by the team. 17.4% of referrals had a non-cancer diagnosis, an increase from 13.7% in the previous year.
Of the 1,118 discharges in the year, 22.4% (240) died on a ward at Central Campus, 39.6% went home, 11.3% transferred to a hospice/palliative care unit & 1.35% was discharged to a care home.
The average length of time on the caseload was 7.8 days. The longest time on the caseload was 103 days.
The Hospital Support Team was involved in 60.1% (240) of the total number of deaths at CC (520) (88% of deaths at Weston Park Hospital)
(Source: Data request DR184 percentages of patients receiving end of life treatment)
Learning from complaints and concerns The specialist palliative care nurses we spoke with told us that they work with relevant teams on the acute wards when complaints are received that relate to care at the end of a patient’s life. In addition, they explained that if a family member or carer were to raise a concern with them they would report this to the nurse in charge of the relevant ward, so the concerns could be addressed in a timely manner. The specialist palliative care nurses also explained that meetings were offered to all families and carers following bereavement. This meant that if family members had concerns they were addressed promptly and the family were supported following the loss of their loved one. The trust had appointed a medical examiner to review all deaths at the Northern General Hospital site. The role of the independent medical examiner and the medical examiner’s office was to screen all deaths at Sheffield Teaching Hospitals. ( The role of the medical examiner and officers was to: • Expert review the death
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• Highlight cases to the coroner for further review/investigation • Identify deaths that fulfil the Learning from Deaths criteria for further Structured Judgement Review • Liaise with the medical staff that were caring for the patient • Clarify the cause of death to allow certification • Liaise with the family to discuss the cause of death, clarify any queries and detect any family concerns, allowing for escalation and signposting as appropriate • Liaise with the Bereavement Office and Mortuary The medical examiner role had been successful in the pilot at Northern General Hospital and the trust had decided to appoint a medical examiner to the Royal Hallamshire and Western Park site to roll out the service across the trust. The complaints process was also detailed on the trust website, offering patients the option to submit complaints via the patient services team, and anonymous feedback form and the option to submit a complaint directly to the chief executive. This provided several routes for complaints to be submitted and reflected the transparent culture we observed at the trust. The trust provided information which explained that complaints and lessons learned were incorporated within staff training programmes. For example, within the training days for end of life care champions. This training covered the management of complaints about end of life care and included the review a letter of complaint and the Trust’s response. The electronic reporting system used by the trust was not able to provide information regarding complaints related to end of life care. Therefore, a process was in place to screen complaints relating to end of life care and identify learning points. The trust also completed thematic analysis of complaints. From 01 January 2016 to 31 December 2017, the thematic review highlighted communication and ward care around death as areas to focus on. These issues were being addressed through the end of life care strategy group. The vision was to further progress this by triangulating the Medical Examiner reviews, complaints and structured judgment reviews, facilitated by the learning from deaths guidance. A service review had been registered with the clinical effectiveness department in preparation to undertake a comprehensive review of complaints relating to care in the last days of life or the death of a patient.
Summary of complaints
This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. From February 2017 to January 2018 there were nine complaints about end of life care. The trust took an average of 42 days to close these complaints. The trust worked to a tiered response time process, usually 25 or 40 days; where the timescale was determined based on the complexity of the concerns raised. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale. One complaint related to the Royal Hallamshire Hospital and related to communication between two trusts involved in the patient’s care. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
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Is the service well-led? Leadership The service had managers at all levels with the right skills and abilities to run a service providing high quality sustainable care. There was a clear management structure at directorate and departmental levels. The managers knew about the quality issues, priorities and challenges in the department. The leadership, management and governance of end of life services supported the delivery of high-quality and person-centred care, supported learning and innovation, and promoted an open and fair culture. The therapeutics and palliative care directorate sat within the combined community and acute care, care group which covered integrated community care, primary care and interface services, integrated geriatric and stroke medicine and therapeutics and palliative care. A triumvirate of a clinical director, an operations director and a nurse director led the directorate of therapeutics and palliative care. The clinical director was supported by an operations director who looked after aspects of planning and performance within the directorate. The nurse director looked after all aspects of the patient experience and worked closely with operations director to make sure the correct resources are available to be able to deliver high standards of patient care. There was a matron who provided strategic and managerial support for the Macmillan palliative care unit at Northern General Hospital and the hospital support team, who worked across all sites. The matron reported in to the integrated pathway manager (lead specialist nurse in palliative care) who also had direct management responsibility of the intensive home nursing service and bereavement services. The matron supported the senior charge nurse (ward manager) in the management of the palliative care unit. The clinical director provided leadership to the clinical lead for palliative care and the head of chaplaincy. This structure provided direct nursing, pastoral and medical leadership. The nursing and medical team was established with experienced staff that provided clinical and professional leadership. Staff told us that they were well supported in their roles and had a clear understanding of their responsibilities. They said leaders were visible and approachable. The managers at different levels of the directorate knew about the quality issues, priorities and challenges the directorate faced and worked collaboratively across all sites to try and deliver solutions and pilot new ways of working. We observed that managers were proactive, and their positivity and motivation was inspiring. There was a clear commitment and focus by leaders to predict and respond to patient demand and flow, and this was supported by the other departments in the hospital, particularly around the management of end of life patients on general wards, the chaplaincy service and care after death in the mortuary. The mortuary team told us that the executive team was very responsive when funding was required. We were told that when funding was requested for additional storage facilities to manage winter pressures this was immediately approved, and the system was installed and available for use within 48 hours.
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At the last inspection in 2015 we found the trust did not have a strategy for the care of patients at the end of life. The absence of a strategy had resulted in staff not knowing the vision for end of life care across the trust. At this inspection we found the trust had a clear strategy and vision for end of life services and staff were aware of the strategy and where they could find it. The trust had held consultation focus groups with a diverse range of staff to help shape the end of life care strategy. This had resulted in the strategy being developed in partnership with staff, patients and carers and disseminated across the organisation. Areas highlighted as requiring improvement at the 2015 inspection had been addressed. These included: completion, approval and dissemination of the end of life care strategy; updating and the dissemination of ‘guidance for the care of the person who may be in the last hours to days of life’; development and approval of the individualised care plan for the last days of life; completion and rollout of the electronic end of life care nursing care plan; the establishment of an end of life care education and training subgroup of the end of life care project steering group, and appointment of a leadership fellow and two clinical leads in end of life care. The trust had two clinical leads for end of life care, including a palliative care consultant and an intensive care consultant. At the last inspection we found there was limited monitoring of quality of care for end of life care. At this inspection we saw that quality of care was being measured for end of life care services and patients’ preferred place of care and death was now being recorded for monitoring purposes however this had not been audited at this hospital. This meant the trust did not have assurance that people were achieving their preferred place of care or death.
Culture We found the culture of the hospital was open and inclusive for staff and patients. Staff that we spoke to felt that they were valued and respected by their peers and leaders. We asked staff about the morale of the department and they all said that morale was good, and they worked collaboratively as a team. Staff told us that the executive team were visible and approachable, and they were proud to work at the trust. Staff within the mortuary had a positive team working culture. We spoke with members of the team who all told us they felt valued by the trust. Senior members of the team provided an on-call system to support staff caring for deceased patients outside normal working hours. We asked if they were paid for this service and were told that it was an informal system however they were happy with this and said that 99% of the time any questions could be dealt with via a telephone call. The trust promoted the culture that care of the dying is everyone’s responsibility and provided the skills and tools to enable staff to consistently and compassionately undertake this. We spoke to staff on general wards where end of life patients were being nursed. They told us that they felt end of life care was everyone’s responsibility and the hospital support palliative care team were accessible, effective and worked collaboratively with staff on the wards, whether in person or remotely. We found that staff on general wards had been supported to provide high quality palliative care to patients on their ward, which demonstrated the ‘upskilling’ culture of the specialist palliative care team. Staff felt supported in their work and there were opportunities to develop their skills and competencies, which was encouraged by senior staff. For example, some staff were undertaking masters level study in specialist palliative care modules.
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Staff we spoke with wanted to provide high quality, effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams.
Governance The department had governance, risk management and quality measures to improve patient care, safety and outcomes. However, whilst the trust had implemented recording of patients preferred place of care and death, they had not completed any audits. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. There was an end of life project steering group that was chaired by the medical director with representation from staff across all levels and a diverse range of departments in the trust. The medical director sat on the trust executive board, so provided executive representation to the end of life project steering group. The medical director acted as the official ‘project sponsor’. The governance system supported the strategy and provided continuing assurance up to board level, with the clear focus on providing a quality service. The trust had recently approved a business case to recruit a band eight lead nurse who, when appointed, would be the governance lead for end of life care and take over the project group responsibilities to continue to roll out the priorities identified by the group.
Management of risk, issues and performance The specialist palliative care team met monthly with the senior team for the service. We were told that risks, issues and performance were discussed at this forum. Staff gave examples of the risks and issues raised as being the team not having access to laptops to access information and enable more effective working. The meeting was also used to share updates from strategic meetings. A member of the team was completing an audit of compliance in completing the syringe driver check sheet, this was being completed as it was recognised that four hourly checks were not consistently completed across all of the general wards. Following completion of the audit the finding and an action plan would be shared with all general wards. Staff in the mortuary told us that their only risk was capacity however they had business continuity contingencies in place, for example they had purchased an additional storage unit to manage winter pressures. The trust had a process to share national patient safety alerts issued by Medicines and Healthcare Products Regulatory Agency (MHRA). Alerts were received by the patient and healthcare governance department. They were then logged on the trusts electronic reporting system and emailed to the patient safety manager. The patient safety manager would then disseminate the alert to the relevant staff including risk leads, who would action and cascade as appropriate. The cascade would incorporate all relevant staff and would include end of life care staff where appropriate. Deadlines for completion of actions were logged on the trusts electronic reporting system which would then generate automated reminders. On completion of actions, the alert was closed on the trusts electronic reporting system and a response sent to the Medicines and Healthcare Products Regulatory Agency (MHRA).
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There was a risk register that recorded six risks in relation to end of life care and care after death. Three risks related to histopathology and pathology were rated as high risk and did not directly affect the delivery of end of life care. Two risks were rated as moderate one of which covered the histology flammable store and one of which covered the organisation and running of training courses and educational sessions using cadaveric tissues by the mortuary. One risk was rated as low risk which was related to managing violence and aggression. The risks had clear review dates documented but the register we reviewed did not detail any mitigating actions.
Information management The trust had created a comprehensive end of life resource site on the staff intranet. The intranet site had been created by a clinical fellow in the palliative care team and based on the ‘three clicks’ rule. This meant that staff could access the information, guidance or pathway they needed with no more than three mouse clicks. We reviewed a sample of policies and guidelines available to staff and found they were in date and had recently been reviewed and updated. • DNACPR policy ratified 1 May 2018. • Mental Capacity Act 2005 and Deprivation of Liberty policy ratified 1 March 2017 (due for review 1 November 2020) • T34 syringe pump protocol ratified 25 October 2017 (due for review 1 October 2020) • Care after death policy ratified 3 January 2018 (due for review 1 August 2020)
Staff in the specialist palliative care team did not meet the trust plan for information governance mandatory training. Overall compliance for the specialist palliative care team was 83%. Nursing staff were 97% compliant which was better than the trust plan. Medical staff were 87% compliant, which is marginally worse than the trust plan. However, administration staff were 20% compliant which is significantly worse than the trust compliance plan.
Engagement The trust had developed an end of life care project team. Members of team included the trust medical director, the integrated pathways manager, medical and nursing staff from the acute and community specialist palliative care team and a patient governor. The trust conducted bereavement surveys and end of life surveys with families of recently deceased patients to try and gain feedback to improve the services provided. The trust asked patients to take part in the NHS Friends and Family Test (FFT), and end of life patients based on general wards would be counted within that wards results. The end of life care facilitator told us that they worked closely with other specialist nurses to ensure that they were able to care for patients cohesively at the end of their life. The specialist palliative care team had completed a service review in May 2018. Part of this had included asking for feedback from the general wards about the support they needed from the team. Once the feedback results were available, the team would be planning to include the suggestions within their day to day workload. The development of the end of life strategy, new guidance, care plans and training has been the result of co-production and engagement across staff, patients and carers.
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Learning, continuous improvement and innovation On the day of our inspection we were told that funding had been approved for a full-time band 8a lead end of life care nurse and a full-time end of life care facilitator. These roles would further enhance the continuous improvement of the end of life care project group and provide governance, training and leadership support. The trust had appointed another clinical leadership fellow for palliative care after the success of the initial post which was due to end in July 2018. This role would contribute to further innovation for the end of life project group. The treatment options form was being piloted in the renal department by a renal palliative care consultant. The treatment options form was part of the wider end of life toolkit, alongside the individualised plan of care. The trust recommended that the treatment options form be considered for patients in whom the appropriateness of escalation in therapy may need to be considered during their current admission or in any anticipated future admissions. Completion of the form was for the benefit of the patient and those looking after them to ensure appropriate interventions/measures were undertaken in a timely manner. The end of life project steering group had also done work around heart failure and working with colleagues in cardiology to promote advanced care planning for patients nearing the final 12 months of their lives. The specialist palliative care team had developed a section on the trusts intranet to support staff in caring for patients at the end of their lives. This had been launched in April 2018. We looked at the information available and found this to be an effective but simple to use resource for all staff. We were told that the specialist palliative care team were instrumental in identifying educational needs for staff. The end of life care facilitator told us that the trust had more than 100 end of life care champions (link nurses) working in general wards across the hospitals. This meant that end of life care was well embedded on general wards and the champions contributed to the culture of ensuring that care of the dying was everyone’s responsibility. Study days were held for the end of life care champions, the champions would then disseminate the learning to their own teams. Initiatives such as five key points in five minutes, for example on respiratory secretions or patients’ spiritual needs, were being introduced in to the safety huddles on the wards across the hospitals. These were also being added to the trusts website. The specialist palliative care team had developed the DNACPR policy through the end of life care working group. This had included the development of an information leaflet for patients, families and carers. We looked at this leaflet and saw it contained robust but easy to follow information about decision making around DNACPR. The leaflet also included information about advanced care planning, advanced decisions to refuse treatment and lasting power of attorney decision making. We were told that where appropriate the trust used materials from external agencies, for example from Macmillan cancer support. One of the hospital chaplains had been awarded the top Khadija Award at the Al Nisa Awards. These awards are a celebration of the contribution and achievements of Muslim women in the county. The chaplain was recognised for their innovative multi-faith work in developing understanding and co-operation between hospital teams and the community in their role as a Muslim Chaplain.
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In March 2017 Sheffield Teaching Hospitals was awarded £80,000 by Arts Council England and £35,000 from Sheffield Hospitals Charity to fund Arts sessions for patients. The funds were being used to provide a three-year programme of creative art workshops for a range of different patient groups, including palliative and end of life patients, across the Trust.
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Weston Park Hospital
Medical care (including older people’s care)
Facts and data about this service
Medical services at this trust are spread across six different care groups or business units: The Emergency care group includes diabetes and endocrinology, respiratory and gastroenterology services. Combined Community and Acute Care includes integrated geriatric and stroke medicine, therapeutics and palliative care. Head & Neck includes neurosciences incorporating the hyper- acute stroke unit. The Musculoskeletal care group incorporates pain services and rheumatology. Specialised Cancer, Medicine and Rehabilitation includes communicable diseases and specialised medicine, spinal injuries rehabilitation and specialised cancer services. South Yorkshire Regional Services includes cardiac and renal services. The care groups above also provide other non- medical services not listed here.
Weston Park Hospital is one of only four specialist cancer hospitals in the UK. Specialist non- surgical oncology services are provided for the local population of Sheffield and South Yorkshire, North Nottinghamshire and North Derbyshire and further afield. The medicine services at Weston Park sat within the specialist cancer services directorate and consisted of two oncology wards and one chemotherapy day case ward which included a teenage cancer unit. (Acute PIR – Full 2018 03 05 Documents – Context)
The trust had 131,594 medical admissions from October 2016 and September 2017. Emergency admissions accounted for 39,600 (30%), 7,784 (5.9%) were elective, and the remaining 84,210 (63.9%) were day case.
Admissions for the top three medical specialties were: • Gastroenterology: 25,856 • Clinical oncology 17,559 • Medical oncology: 12,176 (Source: Hospital Episode Statistics)
Is the service safe?
Mandatory training
The service had systems and processes in place to ensure that staff could access mandatory training and staff we spoke with confirmed they had enough time to complete mandatory training.
Mandatory training completion was monitored centrally with any staff not on track being flagged to their line manager for individual follow-up. The trust provided lots of e-learning which supported staff in completing their training. Planning for training for staff was done throughout the year to encourage good compliance.
With reference to the tables below, we spoke with staff about the compliance rates with mandatory training shown regarding nursing staff. Staff assured us that the compliance figures would improve as the year progressed and so patient safety was not at risk.
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Mandatory training completion rates The trust set a target of 90% for completion of mandatory training.
A breakdown of compliance for mandatory courses from April 2017 to February 2018 for nursing staff in medical care is shown below:
Nursing and midwifery staff
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Moving & Handling - Level 2a (3 Yearly) 5 5 100% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 71 74 99% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 75 77 96% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 76 80 96% 90% Yes Information Governance - Level 1 (1 Yearly) 40 42 95% 90% Yes Moving & Handling - Level 2b (1 Yearly) 55 62 91% 90% Yes Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 62 67 84% 90% No Infection Prevention and Control - Level 2 (1 Yearly) 71 77 83% 90% No
Nursing and midwifery staff exceeded the trust target of 90% for six out of eight mandatory training modules.
Medical & dental staff Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Resuscitation: Adult Basic Life Support - Level 2a (1 Yearly) 11 11 100% 90% Yes Resuscitation: Immediate Life Support - Level 3 (1 Yearly) 11 11 100% 90% Yes Infection Prevention and Control - Level 2 (1 Yearly) 27 27 100% 90% Yes Fire Safety Training - Level 1b (2 Yearly) 26 27 96% 90% Yes Fire Safety Training - Level 1a (1 Yearly) 26 27 96% 90% Yes Information Governance - Level 1 (1 Yearly) 26 27 96% 90% Yes Moving & Handling - Level 2a (3 Yearly) 26 27 96% 90% Yes Equality & Diversity: General Awareness - Level 1 (3 Yearly) 25 27 93% 90% Yes Health, Safety & Welfare - Level 1 (3 Yearly) 25 27 93% 90% Yes
Medical and dental staff met or exceeded the trust 90% completion target for all nine modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
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Safeguarding
The trust had systems and processes in place to protect children and adults from neglect or abuse. Staff we spoke with had undertaken safeguarding training so that safeguarding was everyone’s business.
We saw that the trust had policies for safeguarding adults and children. However, the children’s policy was out of date. However, the chief nurse was aware of the out of date policy and action was being taken to address this and ensure it was compliant with current national guidance.
In the last year, trust-wide, medicine had made 156 adult safeguarding referrals and 54 child safeguarding referrals.
At the last inspection we found that staff compliance with safeguarding training did not meet the trust’s target. The tables below show that the position at this inspection was vastly improved. Staff we spoke with understood their responsibilities in identifying and reporting any safeguarding concerns. For example, on the teenage cancer unit, staff told us if someone over 25 years old was on the unit then that person would be found another bed if a teenager needed to be admitted.
Staff had access to safeguarding advice and support from link nurses on the ward, from the trust’s intranet, and the trust’s central safeguarding team. In particular, there was a policy addressing female genital mutilation with resources on the trust’s safeguarding patients intranet site. This supported staff to make appropriate reports and referrals and offer support.
Safeguarding training completion rates This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.
A breakdown of compliance for safeguarding courses from April 2017 to February 2018 for nursing staff in medical care is shown below:
Nursing and midwifery staff
Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Safeguarding Children & Young People - Level 3 (3 Yearly) 17 17 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 32 32 100% 90% Yes Safeguarding Children & Young People - Level 2 (3 Yearly) 31 33 99% 90% Yes Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 14 17 81% 90% No
Nursing and midwifery staff exceeded the trust target of 90% for three of the four safeguarding training modules.
Medical and dental staff
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Staff Eligible Met trained staff Completion Trust (Yes/ Name of course (YTD) (YTD) rate Target No) Safeguarding Vulnerable Adults - Level 2 (3 Yearly) 11 11 100% 90% Yes Safeguarding Children & Young People - Level 1 (3 Yearly) 11 11 100% 90% Yes
Medical and dental staff exceeded the trust target of 90% for all safeguarding training modules. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
Cleanliness, infection control and hygiene
We found that the environment was visibly clean, and that systems and processes were in place to control infection and promote hygiene.
All patients were swabbed for methicillin resistant staphylococcus aureus (MRSA) when they were admitted to the ward. A patient was placed in an isolation room on the ward if they came from abroad or from a hospital that was known to have had an outbreak. To support staff in managing infections, one room over the two wards had specialised pressurising features. A yellow poster on the door alerted staff and visitors that a patient in the room was an infection risk. The MRSA test was re-run for patients who stayed for longer than a month.
In the period 01 June 2017 to 31 May 2018 ward two had two cases of clostridium difficile (C.diff) and ward 3 had one case of methicillin susceptible staphylococcus aureus (MSSA) but otherwise, in the same period, there were no cases of MRSA on either ward.
When infections occur, the trust had a robust system of investigation, including a post infection review, following which an action plan was produced.
At the last inspection we found that there was a lack of information displayed for patients about infection control. At this inspection we saw posters displayed around the ward about infection prevention and handwashing.
Hand washing facilities and antibacterial gel dispensers were available at the entrance of the wards and on corridors.
We observed staff using personal protective equipment when required, and they adhered to ‘bare below the elbow’ guidance. Staff were seen using personal protective equipment (PPE) and handwashing before and after patient contact. A hand hygiene audit for June 2018 scored 100% compliance.
To support staff in maintaining levels of infection control, wards benefited from dedicated housekeepers and a central trust domestic team. Staff cleaned equipment after use and a sticker was used to indicate equipment that had been cleaned. Housekeepers kept the sluice area clean and tidy and ensured commodes were cleaned and ready for use.
Infection prevention control audits were done regularly, and results submitted electronically to the central infection prevention control team and reports generated with action plans. The wards had a link nurse for infection control. We saw audits for a selection of the wards we visited, and all had achieved their target compliance score. 20171116 900885 Post-inspection Evidence appendix template v3 Page 307
Waste was separated and disposed of in appropriate colour coded bins.
Environment and equipment
We found the ward environment had benefited from a full rebuild and modernisation programme creating clutter free, wheelchair accessible facilities, with enough equipment for staff to carry out their role. Parking at the site was not ideal given the cohort of patients seen by the hospital.
In or around 2017 the trust completed a full rebuild and modernisation of the two adult inpatient wards at Weston Park giving 69 beds so increasing the size and providing enhanced clinical facilities to support an improved patient care experience. In particular, the teenage unit on ward three was very welcoming and made to look less like a clinical area.
To support people with dementia the ward environment had been designed to be dementia friendly, such as by using contrasting colours on walls, floors and doors, and clocks on the wards. There was an absence of appropriate signage on some doors. Patients identified with dementia were supported by one to one nursing and cohorted to enhance their safe care. Staff told us that following the inspection signage on the doors had been reinstated.
At the last inspection we found gaps in the checking of resuscitation trolleys but at this inspection we found no gaps in checking. Also, unlike the previous inspection, we found the emergency hypo boxes were all tamper proof. Further, where we found last time that the environment was cluttered, and sharps bins stored in unlocked rooms, at this inspection we found the environment was uncluttered, with ample storage space, and wide corridors. Sharps bins were used and stored properly. Lastly, at the last inspection we noted that CCTV was used on the brachytherapy suite, but it was unclear whether patients had consented to this. At this inspection we saw that patients were asked to sign a consent form.
Staff had access to equipment they needed and told us that if bariatric equipment was needed this could be ordered. Equipment seen had been electrical safety checked. The trust had a medical device policy that ensured equipment was logged, planned maintenance provided and meetings held to address any gaps.
Whilst space on the site was limited and there were no plans to create additional parking, several features made parking at the site frustrating, which was not ideal given the cohort of patients being treated at the site.
Patients or visitors arriving by car would either have to wait for a parking space or try and park at a nearby multi-storey car park and walk back to the site if they were able to do so. The parking meter only accepted change and payment had to be made immediately rather than when leaving.
On the positive side, the car park was staffed, so patients could access assistance and there was a change machine near the main reception on the ground floor. But there was no scope to pay any other way or pay on leaving.
Assessing and responding to patient risk
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Within the medicine service staff used a series of tools and meetings to support them in assessing and responding to risks posed to patient safety.
Staff used an adapted version of the national early warning score (SHEWS) to assess the health and wellbeing of patients. These assessment tools enabled staff to identify if a patient’s clinical condition was changing for the worse and required intervention to keep the patient safe.
The trust sepsis pathway complied with NICE guidelines. There was a link nurse for sepsis. The sepsis pathway was embedded in medicine care and staff used stickers to identify sepsis risks.
The proportion of patients who received a venous thromboembolism (VTE) risk assessment was above the national target of 95% although we saw no data about the second check.
We saw notes of staff handovers and saw staff at all levels and grades took part fully in handovers of patient care from one shift to the next. We saw staff used a situation, background, action and result (SBAR) framework to transfer patients between teams. This appeared to work well.
Following the handover from night to morning staff the ward took part in a safety huddle. Key messages and learning were delivered in addition to discussing falls risks and pressure ulcer risks posed by individual patients.
At the nurses’ station, further patient assurance on safety was enhanced by use of the electronic whiteboard. With patient consent, this displayed names of patients with icons showing which patients were at particular risk of falls or needed pressure ulcer care.
With regard to pressure ulcer care, the trust had a tissue viability lead whose team led on rolling out a programme to address pressure ulcers which led to pressure ulcer champions being identified on the ward. Staff told us they used nursing care turn sheets, notes outside doors showing time for turning, and a once weekly multi-disciplinary team meeting to look at patients at particular risk.
We reviewed two sets of records and found there was sufficient and regular information recorded for staff to assess the condition of the patient. Records reviewed showed that patients were risk assessed on admission to the ward for things like falls, nutrition, hydration, pressure ulcers and dementia and charts were completed to inform staff if any further intervention was necessary. Staff told us that completion of charts was audited weekly and fed back to staff individually or at the safety huddle.
Consultant oncologists were available out of hours for emergencies and if a patient’s condition gave rise for concern. All oncologists lived close to the site and could respond within 30 minutes. Patients were reviewed daily by a consultant and a daily on call consultant reviewed all admissions in the preceding 24 hours.
Medical outliers were managed using a “Take list” from Lorenzo. This was a real time automatically updated and accurate source of patient information which was added after ward- rounds or safety huddles. This had been in operation for the last six months. The patient information meant that there was clarity at all times as to where patients were and who was responsible for them. The information could be scanned at ward level, so staff had the whole picture.
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The trust’s clinical pharmacy team provided support around medicines reconciliation, checking of patients' own medication for continued use, prescription validation, discharge planning, counselling, assessment and provision of compliance aids, medicines information and participated in multidisciplinary ward rounds.
Nurse staffing
Medicine had systems and processes in place to support it in providing safe nurse staffing levels so that patients were kept safe.
The trust used a nationally recognised safer nursing tool and professional judgment, together with an electronic rostering system, to support staff in planning staffing levels having regard to patient needs. This was used alongside a daily staffing meeting to fill any gaps in staffing. Staff reported that this system worked well and kept patients safe. The matron was available for any escalation and out of hours a duty matron held a bleep for this purpose, who had a clear policy of escalation to follow. The trust’s executive group received a monthly safer staffing report and all staffing was reviewed on a rolling six-month basis.
At the last inspection we noted issues with nurse staffing in terms of lack of registered nurses, staff feeling stretched and unable to take breaks. At this inspection staff reported that nurse staffing was much better than the last time we inspected with all vacancies having been filled. Recent recruitment activity had succeeded in securing new starters with three posts on ward two and one post on ward three. On all wards we visited actual staffing numbers matched planned staffing. Staff spoken with did not report any issues with staffing cover and confirmed that they were able to take breaks.
For students, staff told us there was a clear training pathway and students who had trained on the wards reported a positive experience.
The trust reported the following nurse staffing numbers for medical care in March and December 2017. The service had fill rates of over 90% in both time periods.
A review of the staffing on the wards we visited showed that between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on ward 2 dayshift was 85.9% and for care staff 102.5%. The average fill rate on ward 3 dayshift for registered nurses/midwives was 90.5% and for care staff 114.3% on ward 3.
A review of the staffing on the wards we visited showed that between 1/6/18 – 30/6/18 the average fill rate for registered nurses/midwives on ward 2 nightshift was 96.6% and for care staff 129%. The average fill rate on ward 3 nightshift for registered nurses/midwives was 95.3% and for care staff 99% on ward 3.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 1,495.4 1,629.4 91.8% 1,547.6 1,710.2 90.5% (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
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Vacancy rates From January to December 2017 the trust reported a vacancy rate of 9.5% for nursing staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017, the trust reported a turnover rate of 7.95% for nursing staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017 the trust reported a sickness rate of 4.2% for nursing staff in medical care which is slightly higher than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Bank and agency staff usage From January to December 2017, the trust reported 41,414 shifts filled by bank and agency staff (63%). A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 35,475 (54%) Agency 5,939 (9%) Not filled 24,740 (37%) (Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)
Medical staffing Medicine had systems and processes in place to support it in providing medical staffing levels so that patients were kept safe. Medical cover was provided by a mixed team consisting of consultant oncologists, middle grade doctors and junior doctors.
Staff told us medicine employed 30 oncologists. A daily consultant on call reviewed all admissions over the preceding 24 hours and there was a daily consultant review. The rota ensured 24/7 consultant cover and all consultants were able to attend site within 30 minutes if necessary. From 12:30am all junior ward cover was provided by junior staff from the local hospital accompanied by security staff.
At present there were two doctor vacancies which were covered by long term locums. Senior staff told us these posts were about to be advertised again. However, staff told us trying to fill oncologist posts was a national issue.
Most staff spoken with reported good access to senior opinions and high confidence levels in calling for help. However, responses from junior doctors were mixed; some told us they felt isolated, not listened to or supported in a timely manner whilst working at WPH.
Much of the activity for consultants occurred outside the site owing to the large geographical area served by the hospital and the clinics oncologists had to cover in order to support patients referred from regional hospitals. Some junior doctors told us that securing physical presence of oncologists on site was challenging because of this.
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We raised this with the leadership team who were aware of the issue; the l team assured us that plans were being worked up to address the concerns, such as a consultant of the week.
The trust reported the following medical and dental staffing numbers for medical care in March and December 2017. The service had fill rates of over 90% in both time periods.
Actual Planned Fill rate Actual Planned Fill rate Core staff staff staff staff Service (Mar 2017) (Mar 2017) (Mar 2017) (Dec 2017) (Dec 2017) (Dec 2017) Medical care 679.3 691.0 98.3% 706.6 693.7 101.9% (Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual)
The following medical and dental staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template
Vacancy rates From January to December 2017 the trust reported a vacancy rate of 1.4% for medical and dental staff in medical care. The trust did not provide a vacancy target rate. (Source: Routine Provider Information Request (RPIR) P17 Vacancies)
Turnover rates From January to December 2017, the trust reported a turnover rate of 26.3% for medical and dental staff in medical care; this was lower than the trusts annual target of 15%. (Source: Routine Provider Information Request (RPIR) P18 Turnover)
Sickness rates From January to December 2017 the trust reported a sickness rate of 1.2% for medical and dental staff in medical care which is lower than the trust target of 4%. (Source: Routine Provider Information Request (RPIR) P19 Sickness)
Medical agency and locum staff usage From January to December 2017, the trust reported 9,503 shifts filled by bank and agency staff (96%)
A breakdown of bank and agency usage is shown below:
Bank/ agency Total Bank 5,042 (51%) Agency 4,461 (45%) Not filled 441 (4%) (Source: Routine Provider Information Request (RPIR) P21 Medical Locum
Staffing skill mix
In December 2017, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) was lower.
Staffing skill mix for the 497 whole time equivalent staff working in medicine at Sheffield Teaching Hospitals NHS Foundation Trust This England Trust average Consultant 45% 42% Middle career^ 3% 7% 20171116 900885 Post-inspection Evidence appendix template v3 Page 312
Registrar group~ 33% 29% Junior* 19% 22%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 Source: NHS Digital - Workforce statistics (01/10/2017 - 31/10/2017)
Records
We reviewed two sets of records and found them to be legible, detailed, signed, and safely stored in locked trolleys.
At the last inspection medicine at Weston Park was in the process of introducing electronic patient records and we said this was causing access issues for agency staff. At this inspection, staff told us, apart from the admission record which was electronic, they had reverted to paper records. This was because the previous system was used as an archiving system and the trust decided to put a stop to the project and re-introduce electronic records at a date in the future. As a result, none of the issues reported last time we inspected were an issue because staff had access to records which were stored securely in locked trolleys.
We looked at patient records. We found that screening was recorded, and assessments were completed, such as for falls or nutrition, and fluid charts for patients were up to date and patients’ fluids were replenished on a regular basis. All care checking information was captured on the records we saw.
Staff told us that records are audited weekly and items reviewed include controlled drugs, use of the malnutrition universal screening tool (MUST), SHEW scoring, and cannula charts. Results were plotted on a graph and fed back to nursing staff. For instance, we saw an inpatient record audit dated June 2017 which included in the actions feeding back to nursing staff.
Information relating to discharge was printed off in hard copy for the patient to keep while the electronic version of the discharge summary was accessible by community staff and GPs.
Medicines
We checked the storage of medicines, fluids and gases on the wards we visited and found that medicines, fluids and gases were stored securely in appropriately locked rooms and fridges were checked and stocks were in date.
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The trust had an up to date medicines management policy which staff had access to on the trust’s intranet. The trust ran a series of annual medicine audits including on medicine reconciliation, turnaround times for take home medicines, and safe and secure storage of medicines. For instance, the controlled drug audit showed that 97% of clinical areas completed a controlled drug checklist every three months. Another audit showed that 95% of areas with proximity card readers locked intravenous fluids away when not in use. Electronic prescribing was being rolled out across all ward areas.
We checked the storage and administration of controlled drugs, which require specific controls, in all clinical areas. We found controlled drugs were appropriately stored with access restricted to authorised staff. Records showed the administration of controlled drugs were subject to a second check. After administration, the stock balance was confirmed to be correct and the balance recorded. A random check of the records showed no gaps in checks.
Drugs trolleys seen were all locked with an electronic keypad which was being used by staff.
At the last inspection we found that fridge temperature monitoring was incomplete. At this inspection we found medicines that required refrigeration were stored appropriately in fridges. The drugs fridges were locked and there was a process in place to record daily fridge temperatures. All fridge temperatures were checked and recorded daily. There were no gaps in recording. Staff we spoke with understood their responsibilities for raising concerns if the fridge temperature went out of range.
Also, at the last inspection, we found that intravenous fluids were not securely stored in all the clinical areas visited and some stock was out of date. However, at this inspection this was not the case.
Patient records seen showed patients were receiving medicines promptly and any allergies were clearly recorded. For one patient record we saw where oxygen was being used we saw that oxygen was prescribed and logged correctly.
The trust’s clinical pharmacy team provided support around medicines reconciliation, checking of patients' own medication for continued use, prescription validation, discharge planning, counselling, assessment and provision of compliance aids, medicines information and participated in multidisciplinary ward rounds.
Incidents
The trust had a clear policy for the reporting of incidents, near misses and adverse events. Staff were encouraged to report incidents using the trusts electronic reporting system. The staff we spoke with could describe the process of incident reporting and understood their responsibilities to report safety incidents including near misses.
As can be seen in the table below the medicine service at Weston Park reported no never events over the last year.
Staff told us any chemotherapy near misses, drug labelling issues, prescribing issues or chemotherapy delivery issues were reported and investigated and feedback was given through
20171116 900885 Post-inspection Evidence appendix template v3 Page 314 regular team meetings. Staff we spoke with said feedback from incidents was shared in many ways including; handover, safety huddles, and staff meetings.
The service held bimonthly chemotherapy morbidity and mortality meetings. The lead for patients with a learning disability told us every death of a patient with learning disability goes through a medical examiner within the trust to identify any trends and cause of death. The trust’s standardised mortality ratio was within the ‘as expected’ range.
We reviewed two root cause analysis reports (RCA) from serious incidents and found actions plans and lessons learnt were identified. Actions included providing feedback to staff.
The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.
Staff we spoke with understood the importance of being open and honest with patients. E-learning training was available to staff about duty of candour and there was information on the trust’s intranet which staff could access. The trust’s incident reporting system had mandatory fields to complete and if duty of candour applied a lead was assigned to ensure all requirements were met. This was overseen by the patient safety and risk committee.
Trust wide in the last year, medicine had applied the duty of candour 61 times.
Never Events Never Events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each Never Event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a Never Event. From May 2017 to April 2018, the trust reported no incidents classified as never events for medicine. Source: NHS Improvement - STEIS (01/05/2017 – 30/04/2018)
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from May 2017 to April 2018.
These incidents were classified as; • Medication incident meeting SI criteria with one (50% of total incidents). • Treatment delay meeting SI criteria with one (50% of total incidents). (Source: Strategic Executive Information System (STEIS))
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The trust had a process for approving serious incidents to ensure that only incidents that were serious incidents were logged as such. In March 2018 66% of incidents were approved within 35 days, which was below the internal trust target of 95%. The trust had plans in place to improve the turnaround times for approval of incidents. For instance, in March 2018 two new safety and risk committees were created to support a more focussed discussion on key issues, including meeting the 35-day target. This was in addition to the supply of monthly performance reports to support the directorate in monitoring their own performance and developing improvement plans.
All lessons learned from serious incidents were presented to the trust’s safety and risk committee.
Safety thermometer
The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported 174 new pressure ulcers, 21 falls with harm and 25 new urinary tract infections in patients with a catheter from April 2017 to April 2018 for medical services.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Sheffield Teaching Hospitals NHS Foundation Trust
Total Pressure ulcers (174)
Total Falls (21)
3 Total CUTIs (25)
1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only
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(Source: Safety thermometer - Safety Thermometer)
Staff told us that while the safety thermometer is used the results were not displayed for the public to see. The matron validated the results and undertook a detailed analysis of any concerns so that lessons could be shared and learning embedded.
The safety thermometer dashboard for ward two at the site showed that since January 2018 there had been no falls with harm, or catheter related urinary tract infections. All pressure ulcers remained at one a month apart from in September 2017 (3), November 2017 (4), December, January and February 2018 (2) and April 2018 (3).
The trust created a safety thermometer newsletter that summarised the results for each care group in an easy to use format. The trust was looking at automating the data collection process.
Is the service effective?
Evidence-based care and treatment
The trust had systems and processes in place to ensure that care was given by the service according to published national guidance such as that issued by National Institute for Health and Care Excellence (NICE). All staff we spoke with could access, on the trust’s intranet, guidelines, policies and procedures relevant to their role.
The trust had a corporate policy which detailed the procedure for implementing NICE guidance. Staff were alerted to changes to guidelines by the trust’s clinical effectiveness unit who contacted the appropriate clinicians to examine any change required. An audit information management system tracked implementation and guidance. If a change was required, the directorate had to submit an implementation plan which was then monitored until completion.
We spoke with the clinical lead responsible for ensuring that clinical guidelines were updated in accordance with NICE guidelines and had an author and a review date. Our review of guidelines on the intranet showed that there were lots of guidelines which staff confirmed were well used. Policies and guidelines seen were in date. For instance, the guideline for the management of sepsis had a review date of August 2019.
Staff told us about the development of chemotherapy handbooks. This allowed staff to check compliance of individual treatments or prescriptions so as to provide staff with a robust set of clinical protocols for treatment. The handbooks were reviewed and approved by site specialist groups.
Nutrition and hydration
We found that the service had systems and processes in place to effectively support them to meet the nutrition and hydration needs of patients and visitors. The trust ran an annual nutrition and hydration awareness week to advertise good practice in patient care.
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The medicine service at Weston Park offered patients a full range of meals to meet any needs arising from religion, culture, allergies or personal choice. Staff told us they could go out of menu where necessary and provided snacks outside of mealtimes. Pictures could be used to assist patients in choosing food. Visitors could access snack machines in the main reception.
On admission each patient had a nutritional assessment and staff described how dietitian services could be accessed for complex cases. Where necessary, food charts were used to monitor intake of food.
Staff described how they tried to encourage patients to be independent when eating but would help where needed, with patients requiring help being noted on handover sheets. Occupational therapists provided support with adapted crockery.
When we spoke with patients they described food that was hot, good and that they could get what they wanted.
Water jugs were in reach and replenished regularly. Fluids were monitored where necessary and one patient described how their fluid intake was recorded and how staff stayed with them to encourage them to drink enough fluid.
Staff told us that since the wards moved to open visiting times there was no longer any protected meal times, but this did not appear to be an issue with patients we spoke with.
The trust ran an annual nutrition and hydration awareness week to advertise good practice in patient care.
Pain relief
We found that the service had systems and processes in place to effectively support them to meet the pain relief needs of patients.
In the patient records we reviewed, there were pain assessment charts to support staff in monitoring pain relief for patients. In addition, staff described how, when using care rounding documents, they would use their own experience to help them assess pain and use objective markers such as a raised heart rate or blood pressure and document their findings. For patients who could not verbalise their pain staff could use pictures and a recognised scoring system.
Pain relief was discussed at handover and any issues noted in addition to analgesics being reviewed on ward rounds.
Staff told us that they had access 24/7 to the trust’s palliative care team who could supply expert advice on pain and its management.
Patients we spoke with had no issues with how their pain was being managed.
Patient outcomes
The service had systems and processes in place to monitor patient outcomes including, service evaluations, and participation in local and national audits, all with a view to providing effective patient outcomes.
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At the last inspection we noted that, with regard to the telephone advice service, doctors were not recording the calls. At this inspection we found that the service had taken several actions to effectively improve patient outcomes with regard to the telephone service. This arose from a service evaluation and a review of complaints about not being able to get through to the telephone service. First, staff told us the service was actively looking for a different telephone service with a view to calls being recorded and also to permit calls to come directly to the service’s switchboard. Secondly, the service was piloting an electronic triage tool. This helped staff structure the call and document decisions made. Lastly, the service had succeeded in recruiting an additional two dedicated staff nurses to take calls under the supervision of an advanced nurse practitioner. The benefit of this on patient outcomes was that more calls could be taken plus the advanced nurse practitioner could be freed up to see more patients.
In terms of the estate, the rebuild of the wards and the impact on patient outcomes has been noted above. However, the service recognised that the lack of a sky bridge connecting the site to the adjacent hospital was creating poor patient outcomes. For instance, patients requiring a CT scan over the weekend had to be taken by an ambulance in order to receive a CT scan. However, staff told us a sky bridge would be completed early in 2019. This would mean patients requiring a CT scan would no longer need to wait for an ambulance because they could be wheeled across the sky bridge. Also, doctors who needed to attend the site would not need to wait for a security escort because they too could use the sky bridge instead.
Staff told us they conducted audits to see if patient outcomes could be improved. For instance, staff told us about a recent sepsis audit they carried out looking at whether the service was meeting the required standards. At the time of inspection, the results of the audit were being compiled.
Relative risk of readmission From January 2017 to December 2017, patients at Weston Park Hospital had a higher than expected risk of readmission for elective admissions and a similar to expected risk of readmission for non-elective admissions when compared to the England average.
• Patients in clinical oncology (previously radiotherapy) and medical oncology had a higher than expected risk of readmission for elective admissions
• Patients in clinical oncology (previously radiotherapy) and gynaecological oncology had a similar to expected risk of readmission for non-elective admissions
• Patients in medical oncology had a lower than expected risk of readmission for non-elective admissions
Elective Admissions - Weston Park Hospital
Note: Ratio of observed to expected elective readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
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Non-Elective Admissions - Weston Park Hospital
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity.
A service evaluation looked at delays in starting treatment on the elective pathway. The review highlighted issues around preparation of medicines and related issues such as transport. In order to address this, and to allow staff to focus on ironing out any delays or obstacles to timely treatment, the service was in the process of recruiting two advanced clinical practitioners to focus on the elective pathway. The staff recruited would also be able to support the wider team by prescribing. This was a new initiative, but it was hoped the service would see delays in elective treatment reducing.
Lung Cancer Audit 2017 The Weston Park hospital did not participate in the 2017 Lung Cancer audit.
National Audit of Inpatient Falls 2017
The above audit did not include patients at the site.
Competent staff
Appraisal rates From April to December 2017, 84% of staff within medical care had received an appraisal, compared to the trust’s target of 90%. A split by staff group can be seen in the graph below:
Appraisals Eligible Appraisal Target met Staff group completed staff rate (Yes/no) NHS infrastructure support 39 33 85% No Other Qualified Scientific, Therapeutic & Technical staff (Other qualified ST&T) 337 296 88% No Qualified Allied Health Professionals (Qualified AHPs) 198 186 94% Yes Qualified nursing & health visiting staff (Qualified nurses) 908 741 82% No Support to doctors and nursing staff 973 799 82% No Support to ST&T staff 104 84 81% No Qualified Healthcare Scientists 38 33 87% No Medical & Dental staff - Hospital 6 5 83% No (Source: Routine Provider Information Request (RPIR) P43 Appraisals)
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The service ensured that staff were competent in their roles by ensuring staff received an annual appraisal, or through sharing information by email or at team meetings or in a newsletter, and by offering staff additional training.
Staff told us the figures for nursing staff appraisal showed compliance was at 89% with a target of 90%. Staff we spoke with confirmed that they had received an annual appraisal or were booked to receive one. Senior staff told us they receive reports from human resources and can track individuals to ensure the appraisal is booked and done.
All wards visited had link nurses for various areas including infection control, safeguarding, learning disability and dementia.
The service had a practice development nurse who helped oversee a rolling programme of additional competency training in areas covering intravenous drug administration, veno-puncture, catheterisation, and electrocardiography recording. The course consisted of a structured theory section followed a practical assessment. In addition, there was training on equipment such as infusion devices, syringe drivers, airvo humidifiers, and bladder scanners.
Staff told us they recently undertook a simulated cardiac arrest on ward 3 with observers using a real bleep. Learning from this was still being collated at the time of our inspection.
Staff were given opportunities to progress. For instance, the service had trained ten advanced nurse practitioners with a view to them operating at an advanced nursing practice level. On the day case unit staff rotated every two months between the three areas of outpatients, clinical research and day case.
Junior doctors received regular training every Thursday afternoon and also attended clinic days.
Multidisciplinary (MDT) working
To ensure effective services were delivered to patients, we saw different teams and health professionals working with staff at the service.
We could see from the handover sheets we reviewed that at a handover from night to morning staff there was open, structured, and detailed communication between nurses.
A weekly MDT meeting took place on the ward that was attended by doctors, occupational therapists, physiotherapists, dietitians and speech and language therapists plus staff from the patient care team who specialised in complex discharges.
Junior doctors working on the wards reported that consultant and middle grade doctors were supportive and accessible and that handovers took place seven days a week without fail.
We saw in records that we reviewed that staff had worked with the trust’s palliative care team.
Staff provided verbal handovers to district nurse teams in addition to completing a detailed handover document for use by community staff and GPs.
Seven-day services
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Apart from the day case unit, which was open Monday to Friday only (and outside of these hours patients could use the telephone service 24/7), there was consultant cover 24/7 every day of the week but for diagnostic procedures, such as scans, this was only available Monday to Friday, although access could be arranged over the weekend at the adjacent trust hospital. Staff told us when the sky bridge was operational the service would see an improvement in meeting seven-day service standards.
A dispensing service was available 24/7: the dispensary was open 8am - 8pm Monday to Friday and 9am - 5pm weekends and Bank Holidays with a resident pharmacist onsite outside these hours, providing advice with medicines information as well. Aseptic services were available 9am - 5pm Monday to Friday and 9am - 4pm weekends and Bank Holidays. Clinical services were available 9am - 5.30pm Monday to Friday to all areas.
Health promotion
The service had various initiatives running to promote healthy lifestyles, including pyjama paralysis and smoking cessation.
In order to address the cause of pressure ulcers and to encourage better patient mental health the wards we visited adopted the national End PJ Paralysis campaign which involved encouraging patients to get out of bed, get washed and dressed to prevent deconditioning.
Staff described to us how they tried to support patients to give up smoking by offering patches and leaflets on smoking cessation. As part of the admission process patients were asked about their smoking habits.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff knew the importance of gaining consent to treatment and had received training in consent, mental capacity and deprivation of liberty safeguards.
We saw that the trust had an up to date policy dealing with consent and mental capacity.
Staff spoken with knew about mental capacity and where to access more help, say, to assist them in completing a best interest decision or a deprivation of liberty application. We saw that the trust’s intranet was a valuable resource in this regard.
Our review of patient records showed no issues with regard to consent were present.
The mental health liaison team were on duty 8pm- 12 midnight to provide advice and support for staff. Staff told us the crisis team had a more limited response time.
Mental Capacity Act and Deprivation of Liberty training completion Data relating to mental capacity is included in the safeguarding adults level 2 training section. (Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)
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Is the service caring?
Compassionate care Friends and Family test performance The Friends and Family Test response rate for medicine at the trust was 31% which was better than the England average of 25% from April 2017 and March 2018. All three sites also achieved a better response rate than the England average. Friends and family Test – Response rate between 01/04/2017 to 31/03/2018 by site.
(Source: NHS England Friends and Family Test)
We found that patients received compassionate care from staff which supported their privacy and dignity.
Several interactions we observed between staff, both nursing and medical, demonstrated how staff maintained confidentiality and supported patient dignity and provided compassionate care. This was shown by how staff answered questions, pulled curtains round when interacting with patients, offered a chaperone or answered call bells quickly.
Patients we spoke with told us how staff were in their bays regularly and no requests were ignored, describing staff as attentive, taking time to answer questions and explain medications. Patients remarked on how rooms were clean and calm, and the chairs provided were comfortable. One patient said, “very caring, the place is so clean” while another said, “I cannot fault the service”.
The inpatient score for friends and family in March 2018 was 97% which was above the trust’s internal target of 95%.
As part of the trust’s electronic clinical assurance toolkit there was a section on privacy and dignity which was monitored by the matron.
Emotional support
We found that staff offered a range of emotional support to patients at what was a challenging stage in their lives.
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Staff described to us how they took time to try and understand an individual’s needs, and took time during meals to support patients, or when bathing patients, would chat to them. Staff were ready to raise any disrespectful behaviour towards patients to their supervisor.
The environment had two counselling rooms which were used when it was necessary to have what could be an emotionally challenging discussion. Single rooms were available for patients who were on an end of life pathway.
A range of leaflets offering support or information about cancer were available which staff could hand out to support patients’ emotional need for more information. Staff told us they had done training on breaking bad news.
Staff told us how a staff member stayed with a patient for many hours providing emotional support and comfort while waiting for the patient’s relative to arrive.
The service could refer patients to a local cancer charity for support which offered counselling or alternative therapies such as massage or raki. For those patients anxious about their property and affairs the charity could arrange access to a lawyer.
Staff had access to chaplaincy services for those patients with a faith or none.
Understanding and involvement of patients and those close to them
We found the service tried to understand patients, involve them and those close to them.
Staff told us that relatives could stay in ‘put me up beds’ and visiting times were flexible so that relatives could support their loved ones. Comfortable chairs were also supplied for relatives to use.
The service sometimes funded carers to enable the carers to be with the patient 24/7.
Staff described how they worked closely with a relative who wanted to take an active part in caring for their loved one who was on an end of life pathway. Staff involved the relative in safe aspects of bathing and signposted them to cancer support and counselling services.
Is the service responsive?
Service delivery to meet the needs of local people
The trust had systems and processes in place to ensure that the needs of local people were taken into account when planning the service delivery.
The trust had created an operating plan for 2018/19. This was developed in partnership with the two commissioners it worked with. This required the service to create an activity plan and productivity and efficiency plans together with an annual business plan, all with support from a central trust team. The plans were signed off by the local leadership team and monitored by the trust’s programme management office and business planning team.
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Some examples of the steps the service had taken to meet the needs of local people are shown below.
Staff told us that there were a number of service improvement projects across the trust to focus on patient pathways such as the ‘Why not home? Why not today?’ programme. For example, the trust was trialling a single point of access team for discharges and a transfer of care team. At the point of our inspection, the results were being evaluated.
We found no mixed sex accommodation breaches.
To drive consistency in service provision for local people, the service ensured that it taught the nurses, say in Rotherham or Doncaster, so that wherever a patient was within the region, they received the same service from highly trained staff.
As noted above under ‘patient outcomes’, the service had made changes to the telephone call service in order to improve the service for local people to make it more responsive.
One topic the service was currently looking at for local people concerned new drugs approved by NICE. Staff described how a task and finish group had been created to look at how the service could manage and respond to the demands this would place on the service. Initial investigations suggested that some nurses would need to be trained to do pre-treatment assessments and work would need to be done to examine the impact on the number of chairs in the day case unit. Demand on the telephone advice service had already been addressed by the changes noted above.
The trust told us about a number of other specialised services they had designed to respond to the needs of local people. For instance, cancer survivorship and late effects clinics which were created to help people surviving from cancer with the side effects arising from the powerful treatments they had received. Further, the service ensured that all oral anticancer therapy was delivered to a patient’s home or designated boots pharmacy within the local area. Lastly, palliative care services were available seven days a week for inpatients at the service.
As shown below the service had average lengths of stay for both elective and non-elective procedures lower than the England average.
Average length of stay From February 2017 to January 2018 the average length of stay for medical elective patients at Weston Park Hospital was 3.7 days, which is lower than England average of 5.8 days. For medical non-elective patients, the average length of stay was 4.3 days, which is lower than England average of 6.4 days. Average length of stay for elective specialties: • Average length of stay for elective patients in medical and clinical oncology (previously radiotherapy) are lower than the England average.
Average length of stay for non-elective specialties: • Average length of stay for non-elective patients in medical and clinical oncology (previously radiotherapy) and neurology are lower than the England average.
Elective Average Length of Stay - Weston Park Hospital
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Non-Elective Average Length of Stay - Weston Park Hospital
Note: Top three specialties for specific site based on count of activity.
Meeting people’s individual needs
The service treated its patients as individuals and strived to meet their individual needs.
All wards had link nurses to champion care for people living with dementia or those with a learning disability. Staff had access to e-learning for dementia and learning disability
Staff told us that patients with a learning disability could be flagged on the electronic patient record and the system could also tell staff whether the patient had a passport. Staff told us that adjustments could be made such as offering appointments on particular days of the week. The trust had a library of easy read resources for learning disability patients.
Staff told us that they could access language interpretation services and leaflets could be produced in different languages. The trust’s website was set up so that a different language could be selected.
Access and flow
The service had systems and processes in place to monitor access and flow through the service to ensure that it remained responsive to the needs of patients in its care.
Over the last six years staff told us the plan to improve access and flow involved reducing planned inpatient stays, by moving inpatient chemotherapy to a day case setting where possible, leading to an improved patient experience because patients could be in their home.
Staff told us they had looked at the inpatient chemotherapy pathway with a view to improving how they managed elective inpatients on the ward. The aim was to make sure the treatment was as efficient as possible in order to free up beds for non-elective patients. Part of the work the service had done involved getting elective patients into the service in a more managed way with a view to
20171116 900885 Post-inspection Evidence appendix template v3 Page 326 shortening the patients’ pathways. This was achieved by using dedicated staff in the day case unit to manage the elective list.
In order to improve access and flow on the day case unit, staff told us how they had developed pathways, say for blood transfusions, which supported staff in checking that everything had been done so that when the patient came in to the ward everything was ready and done.
Another refinement to improve access and flow concerned starting hydration with patients before the chemotherapy treatment started. Staff told us this had knocked four hours off the waiting time for patients.
Staff told us building would start on the sky bridge between the site and the adjacent trust hospital. In terms of access and flow staff described how, when the bridge was open, it would provide improved access to pharmacy, laboratories, imaging and critical care and staff. The trust told us that further estate improvement was planned including a new expanded pharmacy aseptic facility to support demand management for chemotherapy to meet predicted demand.
In terms of bed management, staff told us bed moves at night were very rare and if they took place it would be for a clinical reason, say, because an emergency scan was needed. This was supported by the figures that the trust had supplied which showed for the last year ward two had two each month and ward 3 had 3 each month. Across medicine as a whole, in the period February 2018 to May 2018, 70% of medicine patients were not moved at all.
The trust reported that from February 2017 to January 2018, 98% of patients had appropriate ward moves and the remaining 2% were outlier ward stays (4+ moves). The previous year’s performance was the same.
Patient moves per admission During the last 12 months – During the previous 12 YR 1 months – YR2 (01/02/2017 to 31/01/2018) (01/02/2016 to 31/01/2017) Location site How How name Number many many (state the site of ward Number were %-share Number were %-share where the ward or moves of at of all of at of all unit is located) patients 'end patients patients 'end patients of of life'* life'* Sheffield Teaching 0 183,823 74% 178,145 74% Hospitals NHS 1 33,612 14% 33,570 14% Trust 2 19,035 8% 18,922 8% 3 6,908 3% 6,732 3%
4+ 3,972 2% 3,782 2%
Total 247,350 100% 241,151 100%
(Source: Trust Routine Provider Information Request (RPIR) P53 – Ward Moves)
We discussed with staff what issues delayed discharges. Data supplied by the trust showed that wards two and three over the last year had 12 delayed discharges. Staff told us it was transport to the adjacent trust hospital. The trust was aware of this and it was partly why a “sky bridge” was to be built. Staff told us this issue would disappear when the sky bridge was open. Another issue was take home medicines. However, staff told us this would improve because the advanced care
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The trust reported a delayed transfer of care (DTOC) trust-wide rate of 5.8% which was higher than the national average of 4.2% and higher than the trust’s target rate of 3.5%. DTOC rates had been reducing between August and December 2017, however the trust had experienced increasing rates during January to March 2018 due to a challenging winter period with pressures in intermediate care, community services and limited availability of social care packages in the area (Source NHSI). Following the inspection, the trust provided information about DTOC rates at Weston Park; the level of delayed discharges was significantly lower than the Trust rate. In 2017/18 there were 162 patients with a delayed discharge in Medical Oncology, Clinical Oncology & Choriocarcinoma with a total of 218 medically fit for discharge days. There were trust-wide 4550 discharges over the same period.
The trust was actively monitoring DTOCs and reported them to its commissioners. The trust was involved in a cross-Sheffield health and social care task group which was looking to improve discharges. The trust told us it had adopted various methods to support responsive discharges. For example, the trust told us it was planned that the roll out of electronic prescribing would streamline the requesting of to take out medicines which staff reported was a cause of delayed discharges. Various specialist teams existed to support ward staff with discharges, such as the transfer of care team or the care home placement team. There were also services, such as the active recovery service, which operated a discharge to assess model. This was supported by the single point of access which allowed access to information systems by social care and mental health services.
As at February 2018, the cancer waiting time standards were achieved apart from the 62 days from referral to treatment (GP referral) (in quarter three it was 84% (threshold 85%). The trust had processes in place to reduce or extinguish standard breaches. For example, cancer waiting times (CWT) performance was circulated throughout the organisation on a weekly basis for information and action. All patients on a GP 62-day pathway without a decision to treat and a pathway of 62 days in length were escalated to teams for clinical review on a weekly basis. The work to address any drop-in target compliance was overseen by the cancer executive who worked with clinical and managerial teams to ensure continued performance. The service engaged with the local cancer alliance about pathway improvement work. In addition, there was a waiting times performance overview group who worked with the elective care working group to look at the standards and see what needed to be done to support compliance with the standards.
As shown below the trust’s referral to treatment performance was similar to the England average.
Referral to treatment (percentage within 18 weeks) - admitted performance From April 2017 to March 2018 the trusts referral to treatment time was similar to the England average. In the latest month November 2017, the trust’s performance showed 91% of patients were treated within 18 weeks compared to the England average of 88%.
The trend over time remained consistent.
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(Source: NHS England)
Referral to treatment (percentage within 18 weeks) – by specialty Four specialties were above the England average for admitted RTT (percentage within 18 weeks):
Specialty grouping Result England average Geriatric Medicine 100% 97.5% Neurology 97.4% 91.5% Rheumatology 97.9% 94.1% Thoracic Medicine 99.8% 93.1% (Source: NHS England)
Learning from complaints and concerns
Summary of complaints From January to December 2017 there were 225 complaints about medical care, the trust took an average of 38 days to complete complaints. This is in line with their policy which states complaints should be completed within 25 or 40 days for more complex cases. The trust worked to a tiered response time process where the timescale is determined based on the complexity of the concerns raised and in agreement with complainants. This is usually 25/40 days but can be up to 60 days for more complex cases. The Trust target is to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints with in the agreed timescale. The trust told us that themes were identified from complaint categories entered into the complaints management system. The themes were monitored with an analysis featured in monthly, quarterly and annual patient experience report The main themes from the complaints were: • 56% of complaints relate to Northern General Hospital • 49% of complaints relate to inpatient services • 58% of complaints relate to medical staff • March 2017 and January 2018 had the highest number of complaints received both with 26. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
The service had a system in place to encourage complaints and compliments with a view to improving its service to patients.
Staff told us they would seek to resolve a concern informally, but complaints were dealt with formally if necessary. The governance arrangements in place ensured that lessons from complaints were shared amongst staff. Staff told us the patient services team ran workshops for staff on resolving issues.
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The service advertised by notices displayed within the unit how to complain and signposted patients or their carers or relatives to the trust’s help and advice service for support in making a complaint.
The trust supplied us with data about the complaints received about the service, but we could not identify any themes or trends.
We discussed complaints with staff and were told that there were three open complaints. All response times for complaints were met with support from the trust’s patient partnership team. Trust wide 92% of complaints met the agreed response timeframe.
Staff told us they had responded to feedback about the telephone advice service by making the changes described above so that it could improve the responsiveness of the telephone service.
Is the service well-led?
Leadership
The service sat within the specialised cancer, medicine and rehabilitation directorate and was led by a team of four people being a clinical director, operations director, nurse director and programme director, who together formed the leadership team.
The trust had a leadership offer that included access to accredited courses in leadership and access to coaching.
We met the above team who together had decades of experience in commissioning, designing and running a specialised cancer service. The team’s focus was on running a clinically safe service.
The team met regularly with the chief nurse, medical director, and deputy chief executive and through them had ready and easy access to the trust’s board. The programme director met regularly with the cancer network partners to discuss and plan how better to lead on cancer services in the region.
Staff told us the team were approachable and visible and the team told us that they met regularly in different forums to discuss quality, finances and governance.
The leadership team derived support from a matron and band seven senior sisters at ward level with whom they met regularly.
Vision and strategy
The vision used by the service was the trust’s vision, to be recognised as the best provider of health care, clinical research and education in the UK and a strong contributor to the aspiration of Sheffield to be a vibrant and healthy city region. It was supported by the ‘PROUD’ values, (patients first, respectful, ownership, unity, and deliver).
Staff told us that they had established a programme board which existed to drive improvement within the specialised cancer services. Staff described how the programme board was tasked to
20171116 900885 Post-inspection Evidence appendix template v3 Page 330 look at how best to deliver cancer services for the region. Staff had been engaged in the discussions and work has been done on process mapping services and redesigning teams.
Staff at the service worked in partnership with the cancer alliance with a view to developing a strategy for chemotherapy across the region and had a cancer services strategy.
Culture
The service had a positive culture with staff that were proud to provide patient focussed care to patients.
Staff we spoke with described good teamwork and multi-disciplinary working with visible leaders who were happy to help and provide support.
In the 2017 staff survey, 94% of all staff said they would recommend for family and friends to receive treatment.
Staff had various forums in which they could express their views and be heard including one to ones, team meetings, and safety huddles. Staff had a dedicated staff room, and this was used to communicate key messages to staff.
Governance
The service had a clear governance framework with staff assigned specific roles that ensured quality performance and risks were known about and managed.
Staff told us they had a clinical governance meeting quarterly. We saw minutes for these meetings for September 2017, December 2017 and March 2018. Standing agenda items included: matters arising; feedback from weekly governance catch up meetings; risk; patient experience; infection control; shared learning; and any other business. However, we could not see evidence that the clinical director was present at any of the meetings and neither was it noted that they had sent apologies for their absence. The clinical leads for Specialised Cancer Services for chemotherapy and radiotherapy were at some of these meetings. While staff also had access to dashboards looking at performance, finance and governance and staff engagement, it was not possible to tell from the minutes we were given whether these dashboards were being used.
The leadership team told us that they had monthly business meetings, and this appeared to be the approach taken by other specialities who provided us with their minutes. The trust supplied us with monthly business meeting minutes for April, May, and June 2018. The Clinical Director attended one of these meetings and apologised for not attending the other two meetings. The meetings appeared to follow a standard agenda looking at, amongst other things, performance reports, finance, and the human resources dashboard.
The minutes from the meetings showed that risk was discussed but what was discussed was not reflected in the risk register. For instance, in the minutes of the March 2018 governance meeting, it was recorded all the risks on the register were out of date, but nothing was recorded as to what actions the leadership team were going to take to address this.
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Managers told us about other risks when we met them, but these were not on the risk register.
It was not possible from the minutes of the governance meetings or the risk register to identify how the risks were escalated to the Board. One of the risks, for example, was identified as being extreme but it was not clear what the trust were doing to mitigate that risk.
Chemotherapy morbidity and mortality meetings were held bimonthly.
Management of risk, issues and performance
The leadership team received information to support them in managing risk, identifying issues, and assessing performance. However, a comparison of the risk register with the minutes discussing risks suggested that the process for overseeing risks, tracking actions to hold individuals to account, and the updating of the risk register needed to be more well-led.
We spoke with the leadership team about how they measured quality and performance. The team had access to various sources of information, such as dashboards (which captured a series of indicators ranging from infection rates, to waiting times, to staff metrics and patient experience), safety thermometer data, or complaints data. While the minutes we reviewed showed this information was examined and discussed it was not clear from the minutes what action had been taken or how the dashboards were being used.
The trust also oversaw a structured annual programme of work supported by the medical care groups which rolled on year to year. This was designed to engage with clinicians to identify workstreams and opportunities to improve quality. Once a workstream was agreed they were clinically led and supported by matrons, and finance and project managers.
We also discussed with the leadership team the risk register. Risk registers were maintained at directorate level, with a brief description of the risk, control measures, an owner, risk level and a review date. The trust sent us a copy of the specialised cancer, medicine and rehabilitation directorate’s risk register. This showed the directorate had one extreme and three high risks.
At the last inspection we found that not all the items on the risk register were discussed, despite some being past their review date in June 2015. At this inspection, it was not apparent from reading the minutes what up to date actions were being taken to manage the risks. In fact, the minutes of the March meeting simply recorded that most of the risks were out of date but there was no indication about what the leadership team were doing about this. Discussion of risks in earlier minutes seen recorded either nothing about the individual risks on the register or recorded a revised review date, which was not reflected on the risk register. On one risk there was an action, but it was not clear how the leadership team could be aware whether the action had been done because the next or subsequent meeting did not record anything about it.
A comparison of the risks shown on the register with the discussion of risk in the minutes did not reveal a risk about ward staffing which was mentioned in the minutes but not on the register. However, when we spoke with the leadership team they did inform us that one of the top risks was medical staffing, which was discussed in the minutes we saw. The team explained this was a national issue and not just an issue that affected the services. To tackle this the team said over the last few years they had successfully appointed eight consultants. This had left two vacancies which were being filled by long term locums but even then, those posts were going out to advert.
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The team was realistic that the national picture was unlikely to get better and so they had already started to increase the skills mix of the team by appointing fifteen advanced nurse practitioners (ANPs). Another risk concerned the ageing estate which we highlighted at our last inspection. The team explained that this risk had been addressed by trust investment in the ward environment (which we saw) and agreed further investment, such as with regard to the sky bridge and related building works. Other risks were rising demand for telephone advice and new drug treatments. The team had addressed both risks in the ways described above earlier in this report. Also, these last two risks were not recorded on the risk register the trust sent to us or discussed in the minutes we were sent.
There was oversight of risks through committees such as: the elective care working group (ECWG), the waiting times performance overview group (WTPOG) and patient safety and risk committee. However, it was not clear from the minutes we reviewed how the leadership team escalated the risks marked as ‘extreme’ to the trust board. For all the reasons above it appeared that while the leadership team discussed risks, the process for overseeing risks, tracking actions to hold individuals to account, and the updating of the risk register needed to be more well-led.
Information management
We saw from speaking with staff and reviewing information supplied in electronic format, that staff at all levels could access information in a digital format which could be interpreted and rapidly used to help improve the service.
The leadership team told us that they received information in electronic format and they found the information robust. For instance, the directorate received monthly performance reports to assist them in monitoring their performance and developing plans to improve. The team described how they were able to drill down through the data to fine tune it to site level and tumour site. Data was used to support the service’s plans for the future.
To enhance the use and deployment of data, working jointly with the cancer alliance, the service had managed to recruit a data analyst who was able to draw data from multiple sources and run reports required by the service.
The trust told us its integrated performance report was assessed for data quality using a nationally recognised tool and a range of dashboards had been created to support directorates.
Engagement
Staff described feeling engaged by the service and explained how the service engaged with the public with a view to ensuring their views were used to help to shape the service.
The service ran an annual cancer meeting for staff from a range of disciplines. This gave staff the opportunity to network with colleagues, listen to presentations, hear about patient feedback and share experiences.
On a weekly or monthly basis, the service held a series of meetings to engage with staff, such as local service improvement meetings, senior sister meetings, and technology strategy group meetings. Staff meetings tended to take place every two weeks.
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According to the 2017 staff survey, the overall staff engagement score had increased from 3.82 in 2016 to 3.83 in 2017. The number of staff recommending the trust as a place to work was 68% and 81% as a place for care.
We learnt from staff that a new shift pattern was being trialled following a short survey of staff. We were told about this as an example of how staff were engaged.
All areas we visited had a dedicated staff area with noticeboards and a place for staff to go to have a break. We saw that bulletins were on the noticeboards along with other relevant staff messages.
A lot of close working took place with the local hospital charity with regular on-site meetings at which patient satisfaction was discussed.
The service had trialled a social media feed and this had proved popular and so there were plans to build a website for patients to use.
The trust run a series of annual themed surveys such as the carers survey which was running until July 2018. 98% of carers stated that they ‘definitely’ or ‘to some extent’, had confidence and trust in the staff caring for the person they support.
Patients or the public were engaged through ‘tell us what you think’ leaflets, online through the trust’s website, the friends and family test, and surveys, such as the carer’s survey. It was as a result of the survey that more flexible access to wards was brought in. The trust told us patients were closely consulted during the ward rebuild at the site.
For research there was a patient focus group.
Learning, continuous improvement and innovation
Prior to the inspection, and while on inspection, the service shared with us the following examples of learning, continuous improvement and innovation:
The service recognised that its current network model needed revision and so it was working with the cancer alliance programme to look at a revised chemotherapy network model.
The senior team were proud of the work they had done to increase the skills mix of the wider team by recruiting and training up advanced nurse practitioners.
In terms of research, the service had attracted an oncology professor which meant that there was more scope to have researchers working alongside doctors.
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End of life care
Facts and data about this service
The trust provides end of life care across all wards at Weston Park, Royal Hallamshire and Northern General Hospital. End of life care encompasses all care given to patients who are approaching the end of their life and following death. It may be given on any ward or within any service in a trust. It includes aspects of essential nursing care, specialist palliative care, bereavement support and mortuary services. Inpatient beds are supported by the hospital palliative care team (medical and nursing) who provide a seven-day service to support all healthcare professionals to deliver end of life care. There is an out of hours on call provision 24 hours a day that can provide face to face advice and support as required from a specialist registrar or consultant. The palliative care team work alongside learning and development to support education and training to all staff. (Source: Routine Provider Information Request (RPIR) – Context Acute)
The trust had 2,619 deaths from February 2017 to January 2018. (Source: Hospital Episode Statistics)
The chaplaincy department offer services to patients, relatives and staff 24 hours a day, seven days a week, operating on an on-call basis out of hours. The mortuary and bereavement services department are based on the Royal Hallamshire hospital site, which was adjacent to Weston Park Hospital. The mortuary is open Monday to Friday 8am to 5pm and operates an on-call out of hour’s service. This report predominantly focuses on the inspection of the services provided by the specialist palliative care medical, nursing and administration team, the mortuary staff and the chaplaincy and the bereavement team. We inspected the whole core service and looked at all five key questions. To help us make our judgements, we spoke with 12 patients and their family and friends. We observed practice, staff interactions with patients and viewed seven sets of care records. We spoke with 14 staff members including consultants, junior medical staff, registered and non-registered nursing staff and therapists at the hospital. We also interviewed the senior team for the service. Before and after our inspection, we reviewed performance information about the trust and reviewed information provided to us by the trust.
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Is the service safe? Mandatory training At our previous inspection in 2015, we found only two of 12 mandatory training topics were above the trust plan of 90%. Overall compliance was 79%. At this inspection, information provided by the trust showed overall compliance had improved to 93% which was better than the trust plan. However, staff mandatory training compliance was lower than the trust plan of 90% for some subjects. For example, 80% of administration staff in the specialist team were non-compliant with information governance, medical staff were 63% compliant with infection prevention and control training and overall the team were 67% compliant with Mental Capacity Act and Deprivation of Liberty Safeguards training. Medical device training for the use of syringe drivers was lower than the trust plan at 66%. Staff we spoke with told us they were up to date with training and they were supported to complete their training. Newly appointed clinical support workers completed ‘prepare to care’ which incorporated end of life care training as part of their introductory training. This included recognition of death and dying, case study scenarios for symptom control and good communication with patients and their relatives. The trust had recently rolled out an end of life care e-learning training module available on the trust e-learning portal. Staff involved in end of life care, including porters involved in the movement of deceased patients completed this training; however, it had not yet been made mandatory on the training system. We were told this would become a job specific training requirement for all relevant staff.
Safeguarding Information received from the trust showed the specialist palliative care team were 100% compliant with safeguarding vulnerable adults level two and safeguarding children and young people level one. We asked the trust why the team completed level one training and were told the training had been identified through a training needs analysis, as an appropriate level of training for this staff group. All patients seen by the team would be under the care of medical and nursing staff who would have completed a higher level of training. The chaplaincy team were 100% complaint with level one safeguarding vulnerable adults and level one safeguarding children and young people training. The mortuary staff were 80% compliant with level one safeguarding vulnerable adults and level one safeguarding children and young people training. The trust told us this was due to long term sickness within the team. Staff told us they understood safeguarding processes and gave good examples about patients being admitted from care homes, or their own home with pressure damage being a safeguarding concern they would raise. Staff also told us the trust safeguarding team were accessible and supportive when they needed help and support with safeguarding concerns. Staff told us they were able to access information and advice was available on the trusts intranet.
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Cleanliness, infection control and hygiene All areas we visited, providing care at the end of life, appeared clean and well maintained. Patients we spoke with told us staff washed their hands and used hand gel before commencing treatment. We observed staff adhered to the infection control policy and used personal protective equipment (PPE), such as plastic aprons and gloves, when delivering personal care to patients. We observed medical and nursing staff following the trust policy for hand washing and ‘bare below the elbows’ guidance in clinical areas. Hand sanitiser gel was available throughout the wards and staff utilised this before entering patient bay areas. Information provided by the trust showed 83% overall compliance with infection prevention and control training for the specialist palliative care team. Medical staff were 63% compliant which is below the trust plan however nursing staff were 95% compliant which is better than the trust plan of 90%.
Environment and equipment At our previous inspection in 2015, we found some areas of the wards and public areas needed updating. There was a refurbishment programme which had commenced. The service had a schedule for this work to be done over the next 18 months. At this inspection the wards had been refurbished. Staff spoke positively about the changes to the ward environments and how they felt the changes had benefitted patients, their families and staff. A patient we spoke with also told us they thought the facilities were very good. Another patient told us a problem with the sliding door to the bathroom had been attended to quickly by the facilities team. The trust had a safe and robust medical device process to ensure reusable equipment was proactively managed throughout its life cycle. The trust used a single type of syringe driver. These met the national recommendations issued in 2011 by the national patient safety agency (NPSA/2010/RRR019 safer ambulatory syringe drivers). Registered nurses we spoke with told us they received training on the use of the syringe drivers at the start of their employment; they then completed a competency booklet and attended refresher training as part of their mandatory training. Staff reported they were supported with this training by the clinical educator. Information provided by the trust indicated 99% of staff at this hospital were compliant with this training. Two registered nurses told us they had no issues obtaining syringe drivers, the wards each had their own supply and additional drivers were available from a central store. However, when a patient was discharged with a syringe driver staff told us it was sometimes difficult to obtain them back from the community. We spoke with a staff member who told us patients sometimes had to wait up to ten days for a specialist mattress to support pressure area care. We were told an external company provided these and the hospital received a delivery every one to two weeks. In patients’ notes we saw pressure damage risk assessments were completed and actions to minimise risk were implemented including turn charts. However, we found pressure damage accounted for the majority of incidents reported for patients receiving care at the end of their life.
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There was no mortuary at this hospital site. This was located at the Royal Hallamshire Hospital which was adjacent to this site. Deceased patients were transferred to the mortuary by an external ambulance company. Staff we spoke with did not raise any concerns about the service provided.
Assessing and responding to patient risk The specialist palliative care team were available to provide help and support to care for any end of life care patient across all wards. At our previous inspection in 2015 we found once it was clinically indicated that someone was nearing the end of life and had increased needs, nurses could refer to the guidelines on the intranet. This process however, was reliant on the individual nurse’s skills and experience; there were no ‘triggers’ or formal pathways to support the decision making. At this inspection the palliative care team had introduced a comprehensive end of life intranet site and clear guidance for the care of the person who may be in the last hours to days of life. They had also introduced rapid discharge pathways for patients from general wards. We looked at the medical, nursing and allied health professional care records of six patients who had been identified as being in their last year of life. We saw risk assessments were completed for all patients. These included risks of pressure damage, malnutrition, moving and handling and falls. Where appropriate we saw some patients had care pathways in place, for example we saw spinal cord compression care pathways in the records of two patients who had been admitted with this condition. We did not always see individualised care plans in place and we could not always find evidence the trust palliative care guidelines had been referred to when planning care. We discussed this with a senior member of staff who told us the guidelines should be referenced within the patients care records. However, it was acknowledged by staff there was limited documented evidence to support this. The trust used a Sheffield Early Warning Score (SHEWS) which was adapted from a nationally recognised tool to enable staff to recognise and respond to a deteriorating patient. We saw these forms completed in the care records we reviewed. The specialist palliative care nurses completed a holistic review of each patient including their physical, spiritual and psychological needs. Following this a plan of care was clearly documented for the ward staff to follow. Where necessary the specialist nurses referred patients for a medical review or to other specialist teams for example to respiratory or breast specialist nurses. Patients in the last days of their life were identified at the daily handover. Staff would then check the patient’s notes for DNACPR forms, advanced care planning and to ensure a patient’s wishes were actioned. Patients at the end of their life were identified using a discreet symbol of the electronic whiteboard system. Staff told us medical and nursing staff understood the symbol. The national NHS patient safety team, part of NHS Improvement and formally the National Patient Safety Agency (NPSA), manage and operate the National Reporting and Learning System (NRLS). This team identify risks and issues that might not be recognised locally and could merit national action. We asked how the trust managed national alerts. The trust provided a copy of their Management of the central alert system (CAS) and the onward distribution and action of safety alerts policy which showed the trust had a robust electronic procedure in place.
Nurse staffing
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Overall staffing rates Information provided by the trust indicated there were 40 whole time equivalent registered nurses within the specialist palliative care team. Information received from the trust following our inspection showed that the trust employed 4.8 wte specialist palliative care nurses. This meets the commissioning guidance for the number of beds these staff covered.
Vacancy rates The trust told us the vacancy rate for the specialist palliative care team was 8.9% in the last 12 months. The trust did not provide an aspirational vacancy rate. There were no vacancies in the team at the time of our inspection.
Turnover rates The trust told us the turnover rate for the specialist palliative care team was 4.8%. This is better than the trust aspirational rate of 15%. Following our inspection, information received from the trust indicated that the turnover rate within the specialist palliative care nurse team, turnover was 8.3% in the previous 12 months.
Sickness rates The trust told us the specialist palliative care team had a sickness rate of 5.4% which is worse than the trust aspirational rate of 4%. Information received following our inspection showed that sickness rate for the specialist palliative care nurses trust wide was 3.6% which is better than the trust aspirational rate.
Bank and agency staff usage We requested data on the use of bank and agency staff usage within the specialist palliative care nursing team. The trust told us there had been no requests for bank or agency staff to cover specialist palliative care nurses in the last twelve months.
Medical staffing The trust provides acute and community services to a population of 640,000. Commissioning guidance for specialist palliative care recommends the minimum requirements for this population size are two whole time equivalent (wte) consultants in palliative medicine and two wte additional supporting doctors (e.g. trainee/specialty doctor) The trust met this recommendation as they employed 6.7wte specialist palliative care consultants and seven wte registrars. There was a 24 hour on call rota for palliative medicine during the week and at the weekend. On call was covered by a specialist registrar (First call) and then the consultant if further advice was needed. The on-call rota operated from 5pm until 9am Monday to Friday and 9am until 9pm at weekends. The process for contacting the palliative doctors out of hours was for a doctor from the ward to call the specialist registrar. If required, the specialist registrar would contact the consultant on call for further advice. If physical assessment was required, the specialist registrar would attend the ward and if urgent attention was required the consultant would attend.
Vacancy rates The trust reported that there were no medical staffing vacancies for end of life care medical staff.
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Turnover rates The trust told us there was a 12.5% turnover rate for medical staff within end of life care services. This is lower than the trust aspirational rate of 15%.
Sickness rates The sickness rate for medical staff within end of life care services was 5%. This was worse than the trust aspirational rate of 4%.
Bank and locum staff usage The trust did not report bank and locum use in hours or shifts. They reported there had been no agency consultant cover. Bank consultant costs, in the twelve months from May 2017 to May 2018, were reported as £18,729.77 and £26,340.00 for junior medical staff. The total spend was £45,069.77.
Records We did not have any concerns about the security of patient’s medical or nursing records. Records were held in a locked cabinet and were secure, but easily accessible to staff. Overall compliance for information governance training for the specialist palliative care team was 83% which was below the trust plan of 90%. Nursing staff were 97% compliant which was better than the trust plan. Medical staff were 87% compliant, which is marginally worse than the trust plan, however administration staff were 20% compliant which is significantly worse than the trust plan. Ward 3 audited records on a weekly basis to ensure patients preferred place of care and preferred place of death was documented in the patient notes. The audit looked at 10 sets of patient notes and covered a wide range of areas including MUST scores, SHEWS scores, cannula care, fluid balance charts, waterlow scores and nursing care guidelines as well as the patient’s preferred place of care and death. We looked at the care records of six patients under the care of the specialist palliative care team and saw where appropriate a ceiling of care was documented. A ceiling of care is the documentation of discussions around care that should be given to the patient and provides information about limitations to interventions which are likely to be futile, burdensome, or contrary to the patient’s wishes given their terminal diagnosis. The specialist palliative care team completed regular reviews and their documentation was clear, legible, dated, timed and signed in line with the Nursing and Midwifery Council (NMC) standards for record keeping.
Medicines We reviewed the medicines administration charts in the patient’s notes we reviewed and found medicines were prescribed appropriately. Where appropriate these included anticipatory and as required medicines to enable staff to administer medicines to support symptom control in a timely manner. All patients had pain relief prescribed. Staff told us the specialist palliative care nurses were nurse prescribers and were very responsive at prescribing anticipatory medicines for end of life patients. One registered nurse told us the specialist team were always available to give advice when they had any difficulties achieving symptom control for end of life care patients.
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Incidents We looked at the trust wide incidents reported on the National Reporting and Learning System between 1 June 2017 and the 31 May 2018 relating to patients receiving palliative care. There were 194 incidents reported in relation to palliative medicine, all rated low or no harm. Staff we spoke to told us they reported incidents in relation to end of life patients. One example given was pressure sores. Staff told us there was an education board where key messages around pressure care could be displayed and pressure care incidents were discussed at the safety huddle. Turn charts were used to demonstrate pressure area care. Patients receiving care at the end of life who had pressure damage were referred to the tissue viability nurse if the damage was category three or above. The ward had guidelines on how to locally manage category two pressure damage. Medical photographers took photographs of pressure areas which were uploaded on to the patient’s electronic patient record system for tissue viability review and feedback. Staff told us pressure damage was actioned and investigated immediately. Investigation outcomes were displayed in the staffroom and shared at team meetings. Staff we spoke with told us they received shared learning from incidents across the trust through trusts alerts and bulletins. Never Events Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From May 2017 to April 2018, the trust reported no incidents classified as never events within end of life care. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, no serious incidents (SIs) occurred in end of life care at the trust which met the reporting criteria set by NHS England from May 2017 to April 2018. (Source: NHS Improvement - STEIS (01/05/2017 - 30/04/2018))
Safety thermometer The safety thermometer at the Royal Hallamshire Hospital is reported on under the Medical care (including older people’s care) evidence appendix.
Is the service effective? Evidence-based care and treatment Policies used by the service were available for staff to access on the trust intranet. These included a range of pathways and guidance which reflected national evidence based best practice and guidelines, for example, ‘guidance for the care of the person who may be in the last hours to days of life’ which reflected ‘Five priorities for care of the dying person’ and rapid discharge pathways for general wards and the emergency department.
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The Gold Standard Framework accreditation is an independently validated marker of excellence for palliative and end of life care. We asked the trust about gold standards accreditation and were told Sheffield Teaching Hospital NHS Foundation Trust does not have the Gold Standards Framework accreditation. No further information was provided by the trust. Following the withdrawal of the Liverpool End of Life Care Pathway in 2014, the trust had developed guidelines for end of life care. A pathway was not used but the guidelines were designed to support staff to develop an individualised plan of care for patients receiving care at the end of their life. At our previous inspection in 2015, the guidance was still in draft form. This was not in use at the hospital and it was unclear which guidelines staff were following. At this inspection, we saw guidelines had been introduced, these had also been reviewed and updated in April 2018 and were available on the trust’s intranet. We saw the guidelines contained appropriate references to national best practice guidance such the National Institute for Health & Clinical Excellence (NICE). Staff on the wards at the hospital were aware of the guidelines. However, when we spoke with staff, on both wards, about the guidelines they showed us folders which had printed copies of the 2016 guidelines. This meant staff might not be accessing the most up to date guidance and as we found in 2015, it was unclear which guidelines staff were using. The trust used an adapted version of the national early warning score (SHEWS) based on NICE guidelines, to monitor for deterioration of a patient.
Nutrition and hydration In the records we reviewed a malnutrition universal score tool (MUST) was completed and had scores recorded to identify patients who were at risk. Staff were able to access support from dieticians when required. Patients told us they enjoyed the food. Two patients said they found it ‘very good’. We saw patients had drinks to hand or were supported with diet and fluids when they needed assistance. Matrons conducted audits on swallowing assessments and the completion of nutrition and hydration tools.
Pain relief We saw pain assessment was part of the Sheffield Early Warning Score (SHEWS) chart. We saw patients’ pain levels were assessed regularly and when pain relief was administered this was evaluated for efficacy. We spoke to a patient who told us staff were responsive when they needed pain relief. The patient told us they had been admitted to hospital due to issues around pain control, but they felt staff on the ward had now got this under control. Another patient said the specialist nurses had reviewed all their medicines and made changes which had greatly improved their pain. Ward staff told us if a patient was struggling with pain control, the specialist palliative care team could assist and advise on alternative pain relief.
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We observed an interaction between a palliative care consultant and a patient who was experiencing difficulties in achieving appropriate pain relief. We saw alternative medicines were discussed with the patient and the use of a non-medicinal heat pack was also implemented. There had been no pain audits specific to end of life care carried out in the last 12 months. However, in the 2016/17 end of life care satisfaction survey 84% (222) responders felt the patient’s pain was controlled.
Patient outcomes End of life care Audit: Dying in Hospital The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed better than the England average for two of the five agreed clinical indicators: • Metric 1: Is there documented evidence within the last episode of care that it was recognised that the patient would probably die in the coming hours or days? % YES - 86% compared to the national aggregate of 83% • Metric 2: Proportion of patients for whom there was there documented evidence within the last episode of care that health professional recognition that the patient would probably die in the coming hours or days (imminent death) had been discussed with a nominated person(s) important to the patient? - 80% compared to the national aggregate of 79%
The trust answered yes to three of the eight organisational indicators: • Metric 7: Did your trust seek bereaved relatives’ or friends’ views during the last 2 financial years (from 1 April 2013 to 31 March 2015)? • Metric 9: Was there face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to Sunday? • Metric 10: Does your trust have one or more end of life care facilitators as of 1 May 2015? (Source: Royal College of Physicians)
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The trust had created an action plan to improve their audit outcomes in the next audit. We reviewed this and found the trust had achieved many of the identified actions, including the introduction of a personalised care plan, sign off to recruit a lead nurse role, end of life e-learning and sign off to recruit a full-time facilitator role. The medical director chaired the end of life project steering group and provided representation from the executive board. At our inspection in 2015, we found the trust did not a have system in place to monitor whether patients died in their preferred place of care. At this inspection, we saw an electronic patient record system which included an end of life care section. This allowed staff to record a patient’s preferred place of care and death. This also included a section to record whether preferred place of death was achieved and if not why not. However, despite this being highlighted in 2015 as a concern, the trust had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. However, we did see establishing patient’s preferred place of care was a priority and this was clearly documented in patients care records. In December 2016, the Care Quality Commission (CQC) published its review on the way NHS trusts review and investigate the deaths of patients in England: Learning, candour and accountability. The CQC found none of the trusts they contacted were able to demonstrate best practice across every aspect of identifying, reviewing and investigating deaths and ensuring learning is implemented In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. The trust had implemented its learning from deaths policy in April 2018. We reviewed this policy and saw it included references to national guidance. The trust had employed an independent Medical Examiner since 2009. This role included screening all deaths at the trust. At the time of our inspection this was being undertaken at the
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Northern General campus, with an agreed plan to expand the service to cover the Central Campus in the near future. Funding for the Medical Examiner and Officers had been extended and the role updated to include identifying deaths that fulfil the Learning from Deaths criteria for further Structured Judgement Review. In addition, this team also: • Provided an independent expert review of the death. • Highlighted cases to the coroner for further review/investigation. • Liaised with the medical staff that were caring for the patient. • Clarified the cause of death to allow certification. • Liaised with the family to discuss the cause of death, clarify any queries and detect any family concerns, allowing for escalation and signposting as appropriate. • Liaised with the Bereavement Office and Mortuary.
Competent staff Members of the specialist palliative care team held end of life care education and training meetings to determine and plan the training needs of staff working in the trust.
Ward staff told us the specialist palliative care team worked with junior doctors to build their confidence and support them with palliative care. One health care assistant we spoke with told us they had attended a training course on ‘The care needs of a dying person’. This member of staff also told us they were supported by other staff to provide last offices to deceased patients. This included shadowing until they felt competent to undertake this care. We spoke with the end of life care facilitator who told about the educational opportunities offered to all staff working across the trust. These included planned training on the recognition of death and dying, care in the last hours and days of life, symptom control and holistic care of dying patients. The trust had more than 100 end of life care champions across general wards and was using the Yorkshire and Humber learning outcomes for end of life care as baseline competencies for the champions. The specialist palliative care team had provided training to the chaplaincy volunteers and were intending to roll this training out for the end of life care volunteers. The trust provided end of life care training twice a year for approximately 120 junior medical staff. Advanced care planning (ACP) was included as part of this training. ACP is the term used to describe the conversation between people, their families and carers and those looking after them about their future wishes and priorities for care. A ward manager we spoke with told us how the specialist team provided supportive training whilst performing their day to day role. We were given examples of how nurses on the hospital’s general wards had learned from the team by observing them performing their role. Nursing staff from the specialist palliative care team told us they received clinical supervision once a month from a clinical psychologist which was internally provided and funded by the trust. Some members of the team also accessed external support from a psychotherapist. We were told this provided emotional support for the role they provided.
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We were told the weekly multidisciplinary team meeting also provided informal supervision because this included a whole team review of the entire caseload. We were told the team worked well together to ensure support was provided where needed. The team members also described an informal process of peer review being undertaken when they reviewed patients on a weekend who had been under the care of another team member. A consultant oncologist told us they completed end of life care and communication skills training. This member of staff was also on the committee of the local hospice and had 20 years’ experience of identifying patients needing end of life care. The end of life care pathways coordinator gave talks at the trust’s post graduate medical education (PGME) group every six months to update medical staff on changes to practice and pathways, updated policies, protocols and guidelines. We spoke with specialist palliative care nurses at the hospital who told us all members of the team had completed post graduate study in palliative care. This included studying to degree or masters level in palliative care and oncology. In addition, all specialist nurses were non-medical prescribers. Staff in the mortuary had completed role specific post graduate qualifications including the diploma in Mortuary Technology and Hygiene or certificate in Mortuary Technology and Hygiene. Chaplaincy team members had also completed post graduate academic studies including post graduate diploma in theology, ministry and mission, master’s in theology and religious studies and master’s in health and social care chaplaincy.
Appraisal rates The trust plan was for 90% of staff to have an annual appraisal. At the time of our inspection the chaplaincy team met this, being 90% compliant. Nursing staff were 87% compliant which is marginally below the plan. However, the mortuary staff were 67% compliant which is significantly worse than the trust plan. The trust did not provide data for the specialist palliative care team medical staff.
Multidisciplinary working The specialist palliative care team reported they had developed positive team working with all wards caring for patients at the end of their life. They described part of their role as ensuring general ward teams were empowered to effectively care for these patients. We attended the specialist palliative care team multidisciplinary team meeting during our inspection. All specialist nurses and the palliative care consultants attended this meeting. We heard that apologies had been received from the hospital chaplain but understood they would usually be included in the meeting. We saw that a holistic review of each patient on the team’s caseload was completed. The team also discussed the care of patients who had recently died or been discharged from the service. Where appropriate the team considered chaplaincy support for patients who they felt would benefit from this. We spoke with an oncologist at this hospital who told us the specialist palliative care team were available seven days each week and all teams worked together to care for patients receiving care at the end of their life.
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Staff on the general wards told us all members of the multidisciplinary team worked together to facilitate fast track discharges to enable patients at the end of their life to be cared for in their preferred place of care. This included the specialist palliative care team in the acute and the community settings, the transfer of care team and staff on general wards including medical, nursing and therapy staff. A senior nurse told us the local ambulance trust was responsive when their support was needed to facilitate fast track discharges. We spoke with an occupational therapist who told us 90% of their workload involved the assessment and treatment of palliative care patients. They explained they would be involved in fast track discharges including those outside the city. For local patients the therapists liaised with the integrated community therapy team to facilitate safe discharges for patients at the end of their life. Staff we spoke with told us they were able to access support from specialist teams where necessary, for example the breast, lung and tissue viability nurses, dieticians and speech and language therapists. Some patients we spoke with told us other specialists had also been involved in their care, for example patients told us they had been seen by the lung clinical nurse specialist and the breast cancer nurse. A consultant we spoke with explained all teams worked closely to be responsive to end of life care patients’ wishes. For example, the trust had a team called the best supportive care team who would liaise with the patient’s oncologist and palliative care consultant and if needed arrange an MDT meeting. The group would then meet with the patient to determine their wishes and facilitate fast track discharge and advanced care plans if these were required.
Seven-day services The specialist palliative care nurses had been providing a seven-day service since 2012. Therapists based at the hospital were available six days each week, there was no cover provided on Sundays. Physiotherapists were available on a Sunday to see emergencies through an on-call system Staff working in the mortuary were available Monday to Friday from 8am until 5pm. An on-call system was in place out of hours and at weekends for any concerns or for family viewings.
Health promotion Due to the complex needs and terminal prognosis of the patients receiving end of life care, health promotion materials were not presented in the same way they would be to a patient in the general hospital population with a non-terminal prognosis. Patients were given information leaflets from Macmillan cancer care. These included advice about diagnosis and treatment as well as maintaining a healthy lifestyle. For further information on health promotion on general ward areas, please see the Medical care (including older people’s care) evidence appendix.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Consent to treatment means a person must give their permission before they receive any kind of treatment or care. An explanation about the treatment must be given first. The principle of consent
20171116 900885 Post-inspection Evidence appendix template v3 Page 347 is an important part of medical ethics and human rights law. Consent can be given verbally or in writing. Patients told us staff always asked for permission before providing care and treatment. We witnessed this during our inspection. We saw consent to care and treatment and also consent to share records in the medical, nursing and therapy notes we reviewed. The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. Where someone is judged not to have the capacity to make a specific decision (following a capacity assessment), that decision can be taken for them, but it must be in their best interests. The Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person's best interests. Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are the Deprivation of Liberty Safeguards (DoLs). DoLs can only be used if the person will be deprived of their liberty in a care home or hospital. We did not review any records of patients who lacked capacity to consent at this inspection. At our inspection in 2015, we found the trusts DoLs Policy was out of date. At this inspection we looked at the trust’s policies for consent and mental capacity act, including DoLs. We found these were in date and contained appropriate references to legislation such as the Mental Capacity Act, equality and diversity and the Human Rights Act. A senior nurse was able to describe their responsibilities in relation to patients who were at risk of a deprivation of their liberty and how to apply for an urgent authorisation. Staff told us they had previously had patients with a DoLs on the ward. They felt the trust process was easy to follow and they could access support if necessary from the duty matron or safeguarding team. In 2015, we looked at nine do not attempt cardiopulmonary resuscitation (DNACPR) forms; four of them (44%) were either incomplete or gave us concern. At this inspection we found the trust had completed an annual DNACPR audit which not only looked at the completion of the forms, but also the discussions conducted with the patient and the timings for decision making. The audit results had shown significant improvement. Following the most recent audit compliance was at 78%. The audit found the average time taken to make the decision to implement a DNACPR was nine weeks before the patient died. However, the median time was identified as one week and three days. This had flagged the need to further understand the timing of the DNACPR decision. An action plan had been developed and a re-audit date for December 2018 had been set to measure the impact of the actions. We reviewed ten DNACPR forms at this hospital and found these were completed in full, there was also documented evidence within the medical records that the decision to implement the DNACPR had been discussed with the patient and their families, where appropriate.
Mental Capacity Act (MCA) and Deprivation of Liberty safeguards (DoLs) training completion Information provided by the trust showed overall compliance for MCA and DoLs training was 67% for nurses, medical staff and chaplains in the end of life care team which was worse than the trust
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Is the service caring? Compassionate care We spoke to six patients and six relatives, friends and carers. Patients told us staff were caring, compassionate, polite and respectful. Staff always introduced themselves and explained who they were and what they were doing. A patient told us staff were discreet and confidential in their communication, they drew the curtains around before treatment commenced to maintain privacy and dignity. Another patient told us the hospital was ‘fantastic’ and their needs were always dealt with quickly, call bells were answered quickly and if needed they received pain relief straight away. A further patient told us they saw a lot of new faces, but they were all ‘ever so friendly’. The specialist palliative care nurse had seen the patient on the day of our inspection. The patient told us the specialist palliative care nurses were ‘very good’ and if the patient did not understand what they were saying; the nurses would rephrase the plan of treatment, so the patient did understand. Another patient under the care of the specialist palliative care team told us they were ‘so pleased with the care received’ and the nurse specialists were ‘excellent and needed to be commended’. This patient’s family member told us all staff were ‘very supportive’. We saw a board with thank you cards from families of patients. One family had raised funds for the hospital in lieu of flowers at their loved one’s funeral. One card thanked staff for treating a patient with care, compassion, dignity and respect. Patients were encouraged to sit out of bed and to get dressed in their own day clothes. We observed consistently positive interactions between patients and staff.
Emotional support We witnessed the specialist palliative care team considering the emotional needs of patients during their weekly MDT meeting. One patient we spoke to had been offered emotional support but had not taken it up. They told us they would ask a nurse how to access support if they changed their minds. Staff told us they could refer end of life patients to psychology if they were struggling with their diagnosis and mental health. Ward staff undertook training on breaking bad news. We observed a sensitive and emotionally supportive discussion between a palliative care consultant and a patient with a newly diagnosed terminal condition. A local cancer charity regularly attended the ward to support patients and relatives to talk about their thoughts and feelings in a safe and non-judgemental environment. The charity staff also offered complementary therapy treatments for patients.
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Relatives collected death certificates from the bereavement office at the Royal Hallamshire Hospital. Staff told us relatives regularly came to see and thank ward staff after their appointment at the bereavement office.
Understanding and involvement of patients and those close to them We saw when conversations about care and treatment took place with patients and their families that these were clearly documented by the specialist palliative care team. We spoke with a patient who told us they had been told ‘what was going on’ and this had been communicated in a way they understood. A relative of this patient told us they could call the hospital at any time for an update. Another patient told us doctors always explained things clearly. We spoke to two relatives who felt communication to families from medical staff was frustrating and could be improved. The relatives had been unable to organise a meeting with a member of medical staff to try and understand more about their relative’s diagnosis. They had been able to speak to nursing staff on the ward but felt medical staff were not as accessible. Staff on ward 3 encouraged families to be involved in aspects of patient care, for example mouth care. Staff told us they explained how important mouth care was and showed families how to do this. Relatives were supported by the same nurses they had seen previously, where possible, to ensure continuity of care for relatives as well as patients. The trust conducted an annual end of life survey. The key results below were from 297 respondents to the survey conducted from July 2016 to June 2017. There were 85% of respondents who rated the care given to their loved ones in the last days to hours of life as excellent or good, 6% felt care given was fair, 7% felt care given was poor and 2% of respondents did not know.
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Is the service responsive?
Service delivery to meet the needs of local people End of life services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. End of life services were delivered to meet the needs of the local population, to ensure patients received coordinated care that was accessible and responsive to people with complex needs. Acute and community services at the trust worked in close partnership with a number of external providers and agencies to provide a responsive end of life care service to the local and wider population. Within the city of Sheffield good partnership working was in place with the local hospice, clinical commissioning group, the citywide end of life care steering group, primary health care providers across the city and Sheffield City Council. The trust also worked collaboratively with other specialist palliative care providers in the surrounding area such as those in Rotherham, Doncaster and Barnsley. At a regional level, the trust was a member of the Yorkshire and Humber Regional End of Life Care Group. Sheffield did not have a single designated electronic palliative care co-ordination system (EPaCCS). These systems enable the recording and sharing of people's care preferences and key details. However, information provided by the trust showed that staff from different teams were able to access and share information relating to palliative care patients across primary and secondary care. In addition, the trust and the local hospice had used a shared electronic system since 2007. Both these systems allowed staff to access data about the care needs and preferences of patients. A consultant we spoke with told us they were able to arrange urgent tests or arrange emergency admissions for end of life care patients who were identified as deteriorating when attending outpatient clinics. There was a palliative care outpatient clinic at Weston Park each Tuesday. Clinics also took place at the trusts other acute sites on Monday, Wednesday, Thursday and Friday. This meant there was access to a clinic every week day. The acute and community teams worked closely to deliver responsive care to patients at the end of their life. For example, a consultant told us specialist teams would liaise with acute or community specialist palliative care team members to arrange the care for patients. The trust employed 14 chaplains which met the NHS Chaplaincy Guidelines 2015 Promoting Excellence in Pastoral, Spiritual & Religious Care guidelines. In addition, there were also chaplaincy volunteers. The multi-faith chaplaincy department had a diverse range of chaplains to reflect the religious, cultural and spiritual needs of the local population. There were Muslim chaplains, Roman Catholic chaplains, generic Christian chaplains and an honorary Buddhist chaplain. The chaplaincy department also had faith contacts in the community they could utilise if required. The chaplains provided trust wide 24-hour cover. There was a small chapel on the first floor of the hospital. The chapel had multi-faith resources available; however, there was no separate multi-faith room or Muslim prayer room. Multi-faith rooms and Muslim prayer rooms were available across the site at the Royal Hallamshire Hospital. 20171116 900885 Post-inspection Evidence appendix template v3 Page 352
Meeting people’s individual needs Wards had flexible visiting hours between 8am and 8pm and could accommodate requests to visit patients out of hours. Children could visit with prior arrangement with the ward manager. The trust offered free parking to relatives of end of life care patients and tea and coffee was also available free of charge. Staff were able to identify and document any patient wishes, such as advance care planning decisions, preferred place of care and death, on the end of life nursing care plan on the electronic patient record system. An individualised plan of care of last days of life was being piloted on some wards during our inspection. This document had prompts to remind staff to explore previous advance care plans with the patient and their family. It also included a section for documenting preferred place of death. We asked the trust for data relating to the percentage of patients achieving their preferred place of care, but this was not currently being audited at the trust. One nurse told us they always ‘try their upmost’ to facilitate fast track discharges but when it was not possible to get patients home they strived to keep the patient and their family together. Funding had been made available to provide beds for family members; we were told this had made a huge difference for patients’ relatives who had been recognised by staff as suffering with sleep deprivation during patients’ last days of life. Staff from a local charity, dedicated to improving the quality of life for people living with cancer, supported the trust in caring for patients at the end of their life. This included a number of alternative therapies including aromatherapy, homeopathy, acupuncture, reiki, art therapy and counselling. Staff gave us an example of an end of life patient who wished to see their puppy. The ward had risk assessed this and accommodated the patient in a side room, so their wish could be fulfilled. Staff gave other exceptional examples of fulfilling patients’ last wishes on the ward. For example, providing a specific fast food meal a patient requested, special toiletries if patients asked for them and changes to room facilities to accommodate complex requests. Two of multi-faith hospital chaplains had recently facilitated a session at the end of life care champions study day around meeting religious, spiritual and cultural needs. Ward staff told us the chaplaincy service was responsive. The multi-faith chaplaincy department had a returning patients list which was checked daily. Any patient who had previously used the chaplaincy department would be identified and the chaplains would go out to see the patient without a referral. This provided an excellent responsive service to patients who could then be seen without delay, which was important for patients nearing the end of their lives. The ward could facilitate requests to wash and prepare deceased patients in line with specific religious, spiritual or cultural beliefs. The trust had a Muslim chaplain who supported patients and was also available to provide support to staff when caring for Muslim patients and their families. Staff in the mortuary were aware of the multi-cultural needs of deceased patients and their families. Resources to support different cultures were kept in the relative’s waiting room.
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The wards worked with the mortuary to facilitate the rapid release of deceased patients, so their faith needs could be met. The mortuary staff had an out of hours on call service to enable families to visit their loved ones after death. Staff told us they could access information in different languages for patients whose first language was not English. They could also access interpreter services on the phone and face to face. All specialist palliative care nurses were non-medical prescribers, this meant any medicines that were required to treat patient’s symptoms could be prescribed in a timely manner and there were no delays in care and treatment being provided. Staff we spoke with told us they could access translation and interpretation services. They explained this was essential when dealing with sensitive information. In 2015, we found the ward environments were not designed to meet the needs of patients with dementia or a learning disability. At this inspection we felt all appropriate initiatives had not been considered as part of the refurbishment. Following our inspection, we received information from the trust that stated senior members of staff had carried out a review of the wards at Weston Park Hospital using the King’s fund dementia friendly environment toolkit. The trust advised there were some elements of the guidance that had not been implemented fully after careful consideration and justification of the clinical issues and patient experience for all patients and not those with dementia. However, a further review was being planned to explore any additional areas where further improvements could be made, and several signposting issues had been already been identified and rectified including ward 3 signage on toilet doors. The use of crockery in different colours had also been discussed at the nurse director operational meetings to ensure a trust-wide plan was put in place for all dementia patients. Patients with dementia were highlighted using a symbol on the electronic patient system; this meant staff could see at a glance those patients who may need additional support. One of the specialist palliative care nurses was the teams’ lead for learning disabilities. We saw the trusts ‘All about me’ document which could be utilised by staff caring for patients with dementia to ensure the person’s individualised needs were met. This document was referenced in the trust’s guidance for the care of the person who may be in the last hours to days of life.
Access and flow Information provided by the trust showed 1097 referrals were received by the specialist palliative care team on the central campus between June 2017 and May 2018; this information was not split by site and therefore covered the Royal Hallamshire Hospital and Weston Park hospital. There were 7110 contacts made by the team. Of these referrals 17.4% had a non-cancer diagnosis, an increase from 13.7% in the previous year. There were 1118 discharges between June 2017 and May 2018, 22.4% (240) of patients died on a ward at the hospitals, 39.6% went home, 11.3% transferred to a hospice or the palliative care unit at Northern General Hospital and 1.4% were discharged to a care home. We spoke to ward staff who told us the specialist palliative care team visited the wards at the hospital every day therefore patients were usually seen within 24 hours of being referred. We were told the team were very responsive to referrals, including urgent referrals for patients who deteriorated rapidly. In the case of a rapidly deteriorating patient, the ward staff could contact the specialist palliative care team by telephone without a paper referral and they could then submit a retrospective paper referral.
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We spoke with members of the specialist palliative care team who advised referrals to the team were sent via a fax to the administrator for the service. These were then forwarded to the coordinator. From Monday to Friday one of the team acted as the coordinator. On Saturdays and Sundays one specialist nurse was on duty and they received all referrals. The trust standard was for the palliative care team to review patients within 24 hours of receipt of a referral. In some cases, verbal advice was given to the referring ward for example on Saturdays and Sundays, when only one specialist nurse was on duty. Information provided by the trust showed response times for the specialist palliative care hospital support team from June 2017 to June 2018. This showed that trust wide 2192 (80.5%) patients were seen on the same day as they were referred and 249 (9.1%) were seen within 24 hours. Less than 1% patients waited more than 2 days. The ward had a good working relationship with the local hospice. Ward staff liaised with the hospice to facilitate fast track discharges to the hospice. The ward could facilitate fast track discharges home to die, however staff told us this process could sometimes be delayed if specialist care needed to be organised at home for discharge. Where families could support their loved one on discharge without the immediate input from intensive home nursing or community nursing, then patients could be discharged home rapidly. The transfer of care team supported the transfer of patients from hospital and lead on the discharge planning of patients on the fast track pathway. The transfer of care team covered each speciality and each ward had a transfer of care nurse linked to the ward, they worked closely with the multi-disciplinary team based on the wards. The team also liaised with patients, relatives and carers regarding preferred place of death on discharge and facilitated this by working closely with the Sheffield continuing health care team. Rapid discharges home to die procedures had been developed and were in use. Flow charts were available for rapid discharge from the general wards (both in and out of hours), as well as checklists to aid staff. The trust had a community intensive home nursing service (IHNS) who were able to provide one-to-one care for patients who were believed to be in the last few weeks of life, to enable them to die at home. The acute team worked cohesively with the IHNS and could arrange for them to provide care before continuing healthcare funding was approved to ensure a prompt and responsive approach. Information provided by the trust showed there had been minimal numbers of delayed discharges (10) from June 2017 and May 2018 at this hospital. This showed that the trust had robust processes in place to ensure that’s patients were discharged in a timely manner. Deceased patients were transported from Weston Park Hospital to the mortuary at the Royal Hallamshire Hospital by a private funeral director. Porters transferred deceased patients to the back lift and screened off the route to protect the privacy and dignity of the deceased patient. The undertaker collected the patient from the side entrance and transferred into a private ambulance to the mortuary. The specialist palliative care nurses reviewed and triaged all referrals to the team. Where necessary patients could be referred for a review by a palliative care consultant. Staff from the acute team referred patients to the community team when their acute episode of care was completed.
Learning from complaints and concerns
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Summary of complaints From February 2017 to January 2018 there were nine complaints about end of life care. The trust took an average of 42 days to close these complaints. (Source: Routine Provider Information Request (RPIR) P61 Complaints)
The trust worked to a tiered response time process where the timescale is determined based on the complexity of the concerns raised and in agreement with complainants. This is usually 25/40 days but can be up to 60 days for more complex cases. The Trust target is to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints with in the agreed timescale.
“The trust told us that themes were identified from complaint categories entered into the complaints management system. The themes were monitored with an analysis featured in monthly, quarterly and annual patient experience report.
Staff told us complaints or concerns received on the ward would be actioned by the ward manager. This could involve a courtesy call to the patient or family to further ascertain what the issues were and how they could work to resolve them. The specialist palliative care nurses we spoke with told us they work with relevant teams on the acute wards when complaints are received that relate to care at the end of a patient’s life. In addition, they explained that if a family member or carer were to raise a concern with them they would report this to the nurse in charge of the relevant ward, so the concerns could be addressed in a timely manner. The specialist palliative care nurses also explained meetings were offered to all families and carers following bereavement. This meant if family members had concerns they were addressed promptly and the family were supported following the loss of their loved one. The trust had appointed a medical examiner to review all deaths at the Northern General Hospital site. The medical examiner called families to try and ascertain whether there were any concerns around the patient’s death, therefore concerns and complaints could be pro-actively picked up early on and dealt with rapidly. The medical examiner role had been successful in the pilot at Northern General Hospital and the trust had decided to appoint a medical examiner to the Royal Hallamshire and Weston Park site to roll out the service across the trust. The trust complaints process was also detailed on the trust website, offering patients the option to submit complaints via the patient services team, an anonymous feedback form and the option to submit a complaint directly to the chief executive. This provided several routes for complaints to be submitted and reflected the transparent culture we observed at the trust. The trust provided information which explained that complaints and lessons learned were incorporated within staff training programmes. For example, within the training days for end of life care champions. This training covered the management of complaints about end of life care and included the review a letter of complaint and the trust’s response. The electronic reporting system used by the trust was not able to provide information regarding complaints related to end of life care. Therefore, a process was in place to screen complaints relating to end of life care and identify learning points. The trust also completed thematic analysis of complaints. From 01 January 2016 to 31st December 2017, the thematic review highlighted communication and ward care around death as
20171116 900885 Post-inspection Evidence appendix template v3 Page 356 areas to focus on. These issues were being addressed through the end of life care strategy group. The vision was to further progress this by triangulating the medical examiner reviews, complaints and structured judgment reviews, facilitated by the learning from deaths guidance. A service review had been registered with the clinical effectiveness department in preparation to undertake a comprehensive review of complaints relating to care in the last days of life or the death of a patient. A patient we spoke with told us they would feel confident to raise a concern.
Is the service well-led? Leadership The service had managers at all levels with the right skills and abilities to run a service providing high quality sustainable care. There was a clear management structure at directorate and departmental levels. The managers knew about the quality issues, priorities and challenges in the department. The therapeutics and palliative care directorate sat within the combined community and acute care, care group which covered integrated community care, primary care and interface services, integrated geriatric and stroke medicine and therapeutics and palliative care. A triumvirate of a clinical director, an operations director and a nurse director led the directorate of therapeutics and palliative care. The clinical director was supported by an operations director who lead on aspects of planning and performance within the directorate. The nurse director lead on all aspects of the patient experience and worked closely with operations director to make sure the correct resources were available to be able to deliver high standards of patient care. There was a matron who provided strategic and managerial support for the Macmillan palliative care unit at Northern General Hospital and the hospital support team, who worked across all sites. The matron reported to the integrated pathway manager (lead specialist nurse in palliative care) who also had direct management responsibility of the intensive home nursing service and bereavement services. The clinical director provided leadership to the clinical lead for palliative care and the head of chaplaincy. This structure provided direct nursing, pastoral and medical leadership. The nursing and medical team was established with experienced staff who provided clinical and professional leadership. Staff told us they were well supported in their roles and had a clear understanding of their responsibilities. They said leaders were visible and approachable. The trust had two medical leads for end of life care, including a palliative care consultant and an intensive care consultant. The managers at different levels of the directorate knew about the quality issues, priorities and challenges the directorate faced and worked collaboratively across all sites to try and deliver solutions and pilot new ways of working. We observed that managers were proactive, and their positivity and motivation was inspiring. The board representative for End of Life Care was the trust’s medical director. There was not a specific nominated non-executive director (NED) for End of Life care however developments in end of life care were reported to the chair of the healthcare governance committee who was responsible for the oversight of the end of life care agenda.
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There was a clear commitment and focus by leaders to predict and respond to patient demand and flow, and this was supported by the other departments in the hospital, particularly around the management of end of life patients on general wards, the chaplaincy service and care after death in the mortuary. The mortuary team told us the executive team was very responsive when funding was required. We were told when funding was requested for additional storage facilities to manage winter pressures this was immediately approved, and the system was installed and available for use within 48 hours.
Vision and strategy At our inspection in 2015 there was no strategy for end of life care. We told the trust they must ensure they implement strategy for the care of patients at the end of life because the absence of a strategy had resulted in staff not knowing the vision for end of life care. Within the five-year plan, there was no written strategy with timescales to determine how different parts of the plan were to be achieved and there was limited monitoring of quality of care for end of life care. At this inspection we saw an end of life care strategy had been implemented. The trust had held consultation focus groups with a diverse range of people to help shape the strategy. This had resulted in the strategy being developed in partnership with staff, patients and carers and disseminated across the organisation. At the last inspection we found there was limited monitoring of quality of care for end of life care. At this inspection we saw that quality of care was being measured for end of life care services and patients’ preferred place of care and death was being recorded for monitoring purposes. Areas highlighted as requiring improvement at the 2015 inspection had been addressed. These included: completion, approval and dissemination of the end of life care strategy; updating and the dissemination of ‘guidance for the care of the person who may be in the last hours to days of life’; development and approval of the individualised care plan for the last days of life; completion and rollout of the electronic end of life care nursing care plan; the establishment of an end of life care education and training subgroup of the end of life care project steering group, and appointment of a leadership fellow and two clinical leads in end of life care. A senior nurse we spoke with told us the end of life care strategy was discussed at the senior sisters’ meeting when it was being developed and information was then disseminated to staff at team meetings. Ward staff were aware of the end of life care strategy. A consultant oncologist told us the strategy had been shared and reviewed by the consultant medical committee. An occupational therapist told the therapy teams had been involved in the development of the strategy. Staff in the mortuary told us they had been consulted and involved in the development of the service strategy.
Culture We found the culture of the hospital was open and inclusive for staff and patients. Staff we spoke with felt they were valued and respected by their peers and leaders. We asked staff about the
20171116 900885 Post-inspection Evidence appendix template v3 Page 358 morale and they all said morale was good and they worked collaboratively as a team. Staff told us the executive team were visible and approachable and they were proud to work at the trust. Staff within the mortuary had a positive team working culture. We spoke with members of the team who all told us they felt valued by the trust. Senior members of the team provided an on-call system to support staff caring for deceased patients outside normal working hours. We asked if they were paid for this service and were told it was an informal system however they were happy with this and said 99% of the time any questions could be dealt with via a telephone call. The trust promoted the culture that care of the dying is everyone’s responsibility and provided the skills and tools to enable staff to consistently and compassionately undertake this. We spoke to staff on general wards where end of life patients were being nursed. They told us they felt end of life care was everyone’s responsibility and the hospital’s palliative care team were accessible, effective and worked collaboratively with staff on the wards, whether in person or remotely. We found staff on general wards had been supported to provide high quality palliative care to patients on their ward, which demonstrated the ‘upskilling’ culture of the specialist palliative care team. Staff felt supported in their work and there were opportunities to develop their skills and competencies, which was encouraged by senior staff. For example, some staff were undertaking masters level study in specialist palliative care modules. Staff we spoke with wanted to provide high quality, effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams. One registered nurse told us the trust was the best they had ever worked in, they felt listened to and supported.
Governance The service had governance, risk management and quality measures to improve patient care, safety and outcomes. However, whilst the trust had implemented recording of patients preferred place of care and death, they had not completed any audits. Therefore, whilst a system was now in place the trust was still not measuring patient outcomes for this. There was an end of life project steering group that was chaired by the medical director with representation from staff across all levels and departments in the trust. The governance system supported the strategy and provided continuing assurance up to board level, with the clear focus on providing a quality service. The trust had recently approved a business case to recruit a band eight lead nurse who, when appointed, would be the governance lead for end of life care and take over the project group responsibilities to continue to roll out the priorities identified by the group. The trust had a medical device management group (MDMG) which met monthly to review governance arrangements for medical devices as well as managing planned replacement of capital and high-volume revenue devices.
Management of risk, issues and performance The specialist palliative care team met monthly with the senior team for the directorate. We were told risks, issues and performance were discussed at this forum. Staff gave examples of the risks and issues raised, such as the team not having access to laptops to retrieve information and
20171116 900885 Post-inspection Evidence appendix template v3 Page 359 enable more effective working. The meeting was also used to share updates from strategic meetings. A member of the team was completing an audit of compliance in completing the syringe driver check sheet. This was being completed as it was recognised that four hourly checks were not consistently completed across all general wards. Following completion of the audit the findings and an action plan would be shared with all general wards. The trust had a process to share national patient safety alerts issued by Medicines and Healthcare Products Regulatory Agency (MHRA). Alerts were received by the patient and healthcare governance department. They were then logged on the trusts electronic reporting system and emailed to the patient safety manager. The patient safety manager would then disseminate the alert to the relevant staff including risk leads, who would action and cascade as appropriate. The cascade would incorporate all relevant staff and would include end of life care staff where appropriate. Deadlines for completion of actions were logged on the trusts electronic reporting system which then generated automated reminders. On completion of actions, the alert was closed on the trusts electronic reporting system and a response sent to the Medicines and Healthcare Products Regulatory Agency (MHRA). There was a risk register with six recorded risks for end of life care and care after death. Three risks were rated as high risk, two as moderate and one as low risk. The risks had clear review dates documented. Staff in the mortuary told us their only risk was capacity however they had business continuity contingencies in place, for example they had purchased an additional storage unit to manage winter pressures. We saw the trust had a major incident plan and local escalation policies in place, to support staff and provide assurance regarding emergency preparedness, response and resilience (EPRR). However, the major incident plan was out of date as this had been due for review in December 2017.
Information management The trust had created a comprehensive end of life resource site on the staff intranet. The intranet site had been created by a clinical fellow in the palliative care team and based on a ‘three clicks’ rule. This meant staff could access the information, guidance or pathway they needed with no more than three mouse clicks. We reviewed a sample of policies and guidelines available to staff and found they were in date and had recently been reviewed and updated. • DNACPR policy ratified 1 May 2018. • Mental Capacity Act 2005 and Deprivation of Liberty policy ratified 1 March 2017 (due for review 1 November 2020) • T34 syringe pump protocol ratified 25 October 2017 (due for review 1 October 2020) • Care after death policy ratified 3 January 2018 (due for review 1 August 2020) The end of life care guidelines had been reviewed and updated in 2018, however on two wards the copies we were shown were out of date. This meant staff might not access the most up to date documents.
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Staff in the specialist palliative care team did not meet the trust plan for compliance with information governance training. Overall compliance for information governance training for the specialist palliative care team was 83%. Nursing staff were 97% compliant which was better than the trust plan. Medical staff were 87% compliant, which is marginally worse than the trust plan. However, administration staff were 20% compliant which is significantly worse than the trusts expected compliance rate.
Engagement The trust had developed an end of life care project team. Members of team included the trust’s medical director, the integrated pathways manager, medical and nursing staff from the acute and community specialist palliative care team and a patient governor. The end of life care facilitator told us they worked closely with other specialist nurses to ensure they were able to care for patients cohesively at the end of their life. The specialist palliative care team had completed a service review in May 2018. Part of this had included asking for feedback from the general wards about the support they needed from the team. Once the feedback results were available, the team would be planning to include the suggestions within their day to day workload. The development of the end of life strategy, new guidance, care plans and training has been the result of co-production and engagement across staff, patients and carers. We were told the end of life care guidelines had been recently reviewed and updated. This had involved input from other disciplines including oncologists and anaesthetists. A staff engagement session was held at Weston Park Hospital during Dying Matters week, in May 2018, encouraging staff to consider what is important for patients to address at the end of life, but also their own wishes for the future. Prior to the launch of the trust strategy for end of life care, the end of life project working group (PWG) held consultation events that allowed all members of staff and patient representatives to share good practice but also highlight areas that required improvement and the tools or skills needed.
Learning, continuous improvement and innovation On the day of our inspection we were told funding had been approved for a full-time band 8a lead end of life care nurse and a full-time end of life care facilitator. The trust had appointed another clinical leadership fellow for palliative care after the success of the initial post which was due to end in July 2018. A clinical fellow in palliative care had designed and circulated questionnaires for medical staff and nursing and MDT staff across the trust to benchmark understanding and confidence in relation to palliative care and to better inform the palliative care team of the needs of the medical, nursing and MDT staff. The treatment options form was being piloted in the renal department by a renal palliative care consultant. The end of life project steering group had also done work around heart failure and working with colleagues in cardiology to promote advanced care planning for patients nearing the final 12 months of their lives.
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The specialist palliative care team had developed a section on the trust’s intranet to support staff in caring for patients at the end of their lives. This had been launched in April 2018. We looked at the information available and found this to be an effective but simple to use resource for all staff. We were told the specialist palliative care team were instrumental in identifying educational needs for staff. The end of life care facilitator told us the trust had more than 100 end of life care champions (link nurses) working in general wards across the hospitals. Study days were held for the end of life care champions, the champions would then disseminate the learning to their own teams. We heard the specialist palliative care team provided informal training when they visited wards to review referred patients. Staff told us they found this beneficial. Initiatives such as five key points in five minutes, for example, on respiratory secretions or patient’s spiritual needs, were being introduced in to the safety huddles on the wards across the hospitals. These were also being added to the trusts website. The specialist palliative care team had developed the DNACPR policy through the end of life care working group. This had included the development of an information leaflet for patients, families and carers. We looked at this leaflet and saw it contained robust but easy to follow information about decision making around DNACPR. The leaflet also included information about advanced care planning, advanced decisions to refuse treatment and lasting power of attorney decision making. We were told where appropriate the trust used materials from external agencies, for example from Macmillan cancer support. We spoke with a consultant who told us they had plans to improve the service utilising charitable funds. This included improving outpatient services and purchasing a magnetic resonance linear accelerator (MR Linac) combining two technologies – an MR scanner and linear accelerator. This enabled precise location of tumours, and for clinicians to tailor the shape of X-ray beams and accurately deliver doses of radiation to moving tumours. The Trust was piloting ‘Schwartz Rounds’ which were to support staff resilience and to enhance existing psychological and pastoral support such as the Trust’s Employee Psychological Support Service and Chaplaincy. One of the hospital chaplains had been awarded the top Khadija Award at the Al Nisa Awards. These awards are a celebration of the contribution and achievements of Muslim women in the county. The chaplain was recognised for their innovative multi-faith work in developing understanding and co-operation between hospital teams and the community in their role as a Muslim Chaplain. In March 2017 Sheffield Teaching Hospitals was awarded £80,000 by Arts Council England and £35,000 from Sheffield Hospitals Charity to fund Arts sessions for patients. The funds were being used to provide a three-year programme of creative art workshops for a range of different patient groups, including palliative and end of life patients, across the Trust.
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Community health services
Community end of life care
Facts and data about this service
All community services provided by this trust are involved in the care of people who are in or near to the last year of life. This is predominantly led by integrated care teams.
This report predominantly focuses on the intensive home nursing service (IHNS). The IHNS is provided by community clinical support workers under the leadership of registered nurses. This service enhances care provided by other services, for example district nurses, general practitioners and local hospice staff, to enable people to die in their own home if this is their preferred place.
Patients needing care at the end of their life could be referred from any health care professional to the service.
End of life care in the community was last inspected in December 2015 as part of our comprehensive inspection programme. During the 2015 inspection, we inspected and rated all five key questions. Overall, we rated community end of life care as good. We rated safe, effective, caring, and responsive as good. We rated well led as requires improvement.
This inspection was a short notice announced inspection. We re-inspected all domains and key questions.
During the inspection, we spoke with 11 members of staff, including all grades of nursing staff and community support workers, administrative staff and the leadership team. Due to the sensitive nature of the service, we were unable to observe care being provided however during our inspection we spoke with two people whose family members had been cared for by the IHNS. Following our inspection, we spoke with three relatives of patients who had been cared for by staff from the IHNS. Is the service safe? Mandatory training
At our inspection in 2015, mandatory training rates were 64% overall for community staff who provided care for people at the end of life.
The trust set a compliance rate of 90% for completion of mandatory training. At this inspection, we were provided with an overall compliance figure for mandatory training for the service. This was 93%, in June 2018, which was better than the trust plan
Staff we spoke with told us they were up to date with training and that they were supported to complete their training. The team leadership team told us staff were paid for attending training if this was not included within their contracted hours.
We spoke with a member of staff who coordinated training within the service; they told us staff attended all of their mandatory training over two days. In addition, training was also provided 20171116 900885 Post-inspection Evidence appendix template v3 Page 363 specific to the role, for example fire safety training, tailored to caring for patients in their home, was delivered by the trust fire safety officer.
Newly appointed clinical support workers completed ‘prepare to care’ which incorporated end of life care training as part of their introductory mandatory training. This included recognition of death and dying, case study scenarios for symptom control and good communication with patients and their relatives. Safeguarding
At our inspection in 2015, 44% of nursing staff in the community had completed safeguarding adults training; this was below the trust plan of 90%.
At this inspection the trust provided information which showed the IHNS had exceeded the trust plan for all safeguarding modules. In May 2018 they were 100% compliant with safeguarding vulnerable adults level one training, 98.5% complaint with safeguarding vulnerable adults level two training and 91% complaint with safeguarding children and young people level two training.
Staff we spoke with told us they understood safeguarding processes and were able to give good examples about safeguarding concerns they would raise. For example, they told us about a situation when they felt the children, of a patient they were caring for, were being neglected.
Staff told us they were able to access information and advice was available on the trusts intranet and the trust safeguarding team were accessible and supportive when they needed help and support with safeguarding concerns.
A band six nurse from the service who was responsible for staff education told us they provided staff with educational sessions on the boundaries of their roles, in terms of their involvement, the support available, what to report and record and the recognition of accidental and non-accidental injuries. Some of the educational session had also been designed around local safeguarding series case reviews.
Cleanliness, infection control and hygiene
The service held a supply of personal protective equipment (PPE), such as plastic aprons and gloves, for staff to use when delivering personal care to patients.
The band five registered nurses completed monthly spot check audits on infection prevention and control initiatives compliance; this included checking that staff were adhering to trust dress code, bare below the elbow, waste management policies, standard precautions and hand hygiene. We looked at the results of these audits and found the IHNS had scored 95% to 100% for all aspects from August 2017 to July 2018.
In a patient and relative survey completed in 2017, 90% of responders said that staff performed hand hygiene before personal care was given, 8% said they didn’t know.
Environment and equipment
The trust had a safe and robust medical device process to ensure reusable equipment was proactively managed throughout its life cycle. 20171116 900885 Post-inspection Evidence appendix template v3 Page 364
At our inspection in 2015, 89% of syringe pumps were serviced within a month of the due date. This was marginally worse than the trust plan of 90%.
The trust used a single type of syringe driver. These met the national recommendations issued in 2011 by the national patient safety agency (NPSA/2010/RRR019 safer ambulatory syringe drivers).
The community clinical support workers completed competency training for the syringe drivers and had standard operating procedures to adhere to in the event of an issue arising with the driver. The staff we spoke with defined their role and responsibilities regarding the use of the syringe drivers.
Assessing and responding to patient risk
We were told all patients had a moving and handling risk assessment completed prior to the community clinical support workers providing care.
We spoke with staff from the community nursing teams who told us staff from the IHNS would escalate any concerns about patients at the end of their life for review and reassessment by the community nursing team or their GP.
We were told that handovers took place at the beginning and end of each shift. This included a face to face handover between the staff working in the patients’ homes and also a telephone voicemail handover from the night shift worker to an answerphone in the team base. These messages were then checked by the band five staff when they came on duty at 8am.
The national NHS patient safety team, part of NHS Improvement and formally the National Patient Safety Agency (NPSA), manage and operate the National Reporting and Learning System (NRLS). This team identify risks and issues that might not be recognised locally and could merit national action. We asked how the trust managed national alerts. The trust provided a copy of their Management of the central alert system (CAS) and the onward distribution and action of safety alerts policy which showed the trust had a robust electronic procedure in place
Nurse staffing The intensive home support team included: • A part-time band seven lead registered nurse (0.6 whole time equivalent (wte)) • Two part-time (job share) band six registered nurses (1.4 wte). • Three band five registered nurses (2.7wte). • 62 band two community clinical support workers (50 wte). • Three part-time administration and clerical staff (2.2 wte).
The band six staff were responsible for the day to day management and educational needs of the band five and band two staff. This included any sickness and performance related concerns.
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The band five staff supplemented the care prescribed by the trusts’ community nursing teams and oversaw the work of the band two staff ensuring that safe effective care was being provided to people in their own homes. In addition, they received and triaged telephone referrals in to the service Monday to Friday and then completed an initial assessment to determine the level of input required. When necessary the band five staff nurses reassessed needs to increase or decrease the package of care in line with the patient’s needs.
The band six and band five registered nurses provided a five-day service from 8am to 5pm Monday to Friday.
The clinical support workers were rostered to provide care 24 hours per day for the service users on the teams’ caseload. In addition, one clinical support worker was based with the community nursing team from 4:45pm until 10pm and a second was on duty from 10pm until 7am to provide responsive support as required out of hours, for example, these staff members could be directed to provide care in to a patient’s home who otherwise might have needed admitting to hospital.
Vacancy rates Vacancies within the IHNS were as follows: • 0.3 wte band seven. • There were no band five or band six registered nurse vacancies. • 10.7 wte band two community support workers. • 0.15 wte band three administration.
Turnover rates Information received from the trust indicated there had been a 0% turnover in the IHNS in the previous 12 months for registered nurses and administrators. This is lower than the trusts aspirational rate of 15%.
There had been a 16.1% turnover of band two community clinical support workers, which is slightly worse than the trust aspirational rate.
Sickness rates Information provided by the trust following our inspection showed the sickness rate for the IHNS was 7%, which is significantly worse than the trust aspirational sickness level of 4%.
Nursing – Bank and Agency Qualified nurses Information provided by the trust showed that 216 hours of agency were used in IHNS from 31 May 2017 to 1 June 2018. However, this was not for end of life care but to support admissions avoidance and early facilitated discharge.
Medical staffing No medical staff were employed as part of the IHNS in community.
Records The IHNS used paper records in the patient’s home. Community nursing notes were also available in the patients’ homes for reference. Due to the sensitive nature of the service we did not accompany any staff on home visits therefore we were unable to assess the quality of the paper notes. However, we saw the results of a record keeping audit which had been completed in September 2017. This showed overall compliance against 17 standards as 82%. The audit showed 100% compliance against nine standards, three standards scored 70-80% and five scored between 0 and 67%. We saw that an action plan had been created to address the concerns. Two of the three identified actions were completed, and one was ongoing. 20171116 900885 Post-inspection Evidence appendix template v3 Page 366
Medicines The IHNS did not prescribe or hold any stock or medicines. The community clinical support workers were competency assessed to administer patients’ own prescribed medicines in the homes of the patients they were caring for. However, this was usually a task undertaken by the patients’ families for oral medicines or the community nurses if patients were receiving medicines via a syringe driver. Anticipatory prescribing is designed to ensure that there is a supply of drugs in the patient's home, combined with the apparatus needed to administer them, with the intention that they are available to an attending clinician for use after an appropriate clinical assessment. Staff told us they had no concerns about the availability of anticipatory medicines in patient’s homes. Staff were able to access medicines out of hours as pre-emptive medicine packs were stored in the GP Collaborative at Northern General Hospital. The members of the team we spoke with confirmed they had received training and were able to detail their responsibilities in relation to the administration of medicines and when they would need to refer to a senior member of staff or another service. For example, they would call a district nurse or the patients GP if a patient needed a review of their anticipatory medicines or if regular medicines appeared to be less effective or the patient was suffering from any disease progression related symptoms.
Incident reporting, learning and improvement We looked at the trust wide incidents reported on the National Reporting and Learning System (NRLS) between 1 June 2017 and the 31 May 2018 relating to patients receiving palliative care. There were 194 incidents reported in relation to palliative medicine, all rated low or no harm. Incident reporting training was included as part of staffs’ induction. Additional support and lessons learned were covered in monthly educational sessions held within the service. We were told staff were encouraged to report near misses to improve the quality of care provided by the service. The community clinical support workers we spoke with were able to detail their responsibilities in relation to reporting incidents and gave good examples of when they would report an incident. They also confirmed they received feedback after reporting an incident. Trusts are required to report serious incidents to Strategic Executive Information System (STEIS). These include ‘never events’ (serious patient safety incidents that are wholly preventable). In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in community services for end of life care, which met the reporting criteria, set by NHS England between March 2017 and February 2018.
Is the service effective? Evidence-based care and treatment Policies used by the service were available for staff to access on the trust intranet. These included a range of pathways and guidance which reflected national evidence based best practice and guidelines, for example, ‘guidance for the care of the person who may be in the last hours to days
20171116 900885 Post-inspection Evidence appendix template v3 Page 367 of life’ which reflected ‘Five priorities for care of the dying person’ and rapid discharge pathways for general wards and the emergency department. Following the withdrawal of the Liverpool End of Life Care Pathway in 2014, the trust had developed guidelines for end of life care. A pathway was not used but the guidelines were designed to support staff to develop an individualised plan of care for patients receiving care at the end of their life. At our previous inspection in 2015, the guidance was still in draft form. At this inspection, we saw guidelines had been introduced, these had also been reviewed and updated in April 2018 and were available on the trust’s intranet. We saw the guidelines contained appropriate references to national best practice guidance such the National Institute for Health & Clinical Excellence (NICE). The Gold Standard Framework accreditation is an independently validated marker of excellence for palliative and end of life care. We asked the trust about gold standards accreditation and were told Sheffield Teaching Hospital NHS Foundation Trust does not have the Gold Standards Framework accreditation. No further information was provided by the trust.
Nutrition and hydration The community clinical support workers we spoke with talked to us about the importance of supporting patients and their families with nutrition and hydration. In addition, they told us about the importance of ensuring that good oral hygiene and mouth care was maintained for patients who were at the end of their life. One member of staff told us about a family member who felt guilty for eating when their loved one was dying and how they encouraged them by telling them they needed to eat to maintain their strength.
Pain relief The community clinical support workers supported patients by administering medications including pain relief. They were able to tell us about examples when they had called for a district nurse of GP review, when they felt a patient needed their pain relief reviewed. Information provided by the trust indicated no pain audits had been completed in the past 12 months by community teams for patients receiving end of life care.
Patient outcomes At our inspection in 2015, we found the trust did not a have system in place to monitor whether patients died in their preferred place of care. We told the trust they should develop a system for monitoring whether patients died in their preferred place of care.
An electronic patient record system was in use which included an end of life care section. This allowed staff to record a patient’s preferred place of care and death. This also included a section to record whether preferred place of death was achieved and if not why not. However, the trust had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring if patients achieved their wishes. However, we did see establishing patients’ preferred place of care was seen as a priority.
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The IHNS had completed an evaluation of the patient and family experience of the intensive home nursing service in 2017, to highlight any service improvement areas linked to quality of care and the patient carer experience. Community services had developed the ‘Ok to Stay’ plan which was used for patients with complex long-term conditions and palliative needs. This allowed patients and their families to record their individual preferences. The trust had evaluated the outcomes from this project and found since initiation of the plan almost 70% of patients had no further admissions to hospital.
Competent staff Information provided by the trust showed 100% of staff working in the IHNS had an up to date appraisal in July 2018. The community clinical support workers we spoke with told us they had an up to date appraisal. They said they found the appraisal process helpful in identifying their development needs. Band five staff we spoke with told us they completed the appraisals for the clinical support workers. The service used an electronic system that flagged when appraisals were due; an email was then sent to the support worker to ask them to make an appointment for their appraisal. Members of the specialist palliative care team held end of life care education and training meetings to determine and plan the training needs of staff working in the trust. We spoke with the end of life care facilitator who told about the educational opportunities offered to all staff working across the trust. These included planned training on the recognition of death and dying, care in the last hours and days of life, symptom control and holistic care of dying patients. The trust had more than 100 end of life care champions across all its services and was using the Yorkshire and Humber learning outcomes for end of life care as baseline competencies for the champions. The leadership team told us part of the band five registered nurse role in the IHNS was to work with clinical support workers to ensure quality, provide support and identify and training and education needs. The band five staff we spoke with confirmed this and band two staff told us they found this supportive. All newly recruited team members shadowed an established member of the team until they were deemed competent and felt confident to work alone. A band six registered nurse provided educational support and held monthly education sessions at the staff base. This team member was a qualified associate lecturer. Staff were required to attend a minimum of four sessions per year. These included one hour of training and one hour of peer support, review and clinical supervision. The sessions included end of life and palliative care education including ethical principles, as well as general topics such as information governance, record keeping, care planning, referral processes, duty of candour and whistle blowing. The community clinical support workers spoke positively about the training which also included competency-based training for the administration of medicines and care of medical devices, including syringe pumps, in patient’s homes. In addition to the above training, speakers were also invited to present at the educational sessions, we were told by staff this had included talks from the oxygen therapy nurse and the chronic obstructive pulmonary disease nurse.
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In a survey completed in 2017, 100% of patients and carers said they had confidence and trust in the staff caring for the patient.
Multidisciplinary working and coordinated care pathways Staff we spoke with told us they liaised with other teams to provide a robust service. This included the local hospice, community nursing teams, social care, local GP practices and the continuing health care (CHC) team as well as the trust’s acute teams including the palliative care inpatient unit at Northern General Hospital. The team were working with the continuing healthcare team to develop a pathway to support fast track discharges from the acute hospitals for patients whose preferred place of care was their own home and provide care on an interim basis until funding was approved for CHC. Out of hours access to support was through the community nursing team and a GP collaborative based at Northern General Hospital. A community clinical support worker, who could be directed to support patients also sat with this team from 4:45pm until 7am. We spoke with members of the community nursing team who described the positive relationship between the services. The community nurses said they relied on the IHNS to support patients and ensure their comfort in their preferred place of care. The community clinical support workers told us they worked closely with other community teams, they described themselves as being the ‘eyes and ears’ for the community nurses.
Consent, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLs)
Mental Capacity Act and Deprivation of Liberty training completion Consent to treatment means a person must give their permission before they receive any kind of treatment or care. An explanation about the treatment must be given first. The principle of consent is an important part of medical ethics and human rights law. Consent can be given verbally or in writing. The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. Where someone is judged not to have the capacity to make a specific decision (following a capacity assessment), that decision can be taken for them, but it must be in their best interests. The Mental Capacity Act allows restraint and restrictions to be used but only if they are in a person's best interests. Extra safeguards are needed if the restrictions and restraint used will deprive a person of their liberty. These are the Deprivation of Liberty Safeguards (DoLs). DoLs can only be used if the person will be deprived of their liberty in a care home or hospital. At our inspection in 2015, we found the trust’s DoLs Policy was out of date. At this inspection we looked at the trust’s policies for consent and mental capacity act, including DoLs. We found these were in date and contained appropriate references to legislation such as the Mental Capacity Act, equality and diversity and the Human Rights Act. The band six nurse who coordinated the training for staff told us staff attended MCA and DoLs training as part of their mandatory training, however these were also topics that were covered in the service educational sessions. The community clinical support workers we spoke with were aware of the policies and their responsibilities in relation to consent DoLs and the MCA.
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Staff within the IHNS were 92% compliant with MCA and DoLs training which was better than the trusts target.
Is the service caring? Compassionate care Due to the sensitive nature of the care the IHNS supported we were not able to witness them providing care, however we spoke with nine members of the team. We found they spoke about patients and their families in a respectful and caring way. The showed compassion and understanding about the sensitivity needed in the role and gave good examples of how they had supported patients and their families at the end of a patient’s life. The senior leadership team had arranged for us to speak to some relatives that had used the service recently. We contacted these relatives after our inspection by telephone. We spoke with one relative who told us the care of their relative had been ‘awesome’ and the team were amazing; they described them as ‘absolutely fantastic’ and said all of the staff were very friendly. We spoke with a community nurse who had personal experience of the team; they described them as fantastic and gave us an example of the staff going ‘above and beyond’. This related to one of the team going and picking up another family member, so they could be with the patient at the end of their life and this had meant another family member did not have to leave the patient’s bedside. In a survey completed by patients and relatives in 2017, 100% of those completing the survey said they were treated with dignity and respect and rated the care as good or very good.
Emotional support We spoke with one community clinical support worker who had joined the team after having the support of the team for a family member. This member of staff told us about the emotional support they had received during what was a very difficult time. They described the team input as being like ‘the cavalry arriving’. They explained that with the support of the IHNS they were able to be ‘a daughter’ rather than a ‘carer’. Training on breaking bad news was provided as part of the educational sessions held for the community clinical support workers. Another member of staff described trying to be like the families’ backbone to ‘support and keep them strong’. Staff told us team members needed a ‘caring soul’ and ‘life skills’ for the role. We felt the team members we met had these qualities. The staff we spoke with told us about times when they felt they had achieved good results in supporting families, this included telling us about the support they gave a young person who was caring for a parent, and how they had supported a Muslim family whilst caring for their relative during Ramadhan.
Understanding and involvement of patients and those close to them Staff described preparing people for the difficult time ahead, when caring for the families and patients at the end of their life. They told us every family was unique and they supported each person’s individual needs. One member of staff gave an example of how a family member felt
20171116 900885 Post-inspection Evidence appendix template v3 Page 371 guilty for eating when their loved one was dying and how they encouraged them by telling them they needed to eat to maintain their strength. One relative told us they had no other family and that the team had supported them as well as their family member. Another relative told us they would not have been able to meet their relatives’ wish to die at home, without the support of the IHNS. They told us they were physically and emotionally ‘worn out’ and the support they received helped them tremendously.
Is the service responsive? Planning and delivering services which meet people’s needs End of life services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care. End of life services were delivered to meet the needs of the local population, to ensure patients received coordinated care that was accessible and responsive to people with complex needs. Acute and community services at the trust worked in close partnership with a number of external providers and agencies to provide a responsive end of life care service to the local and wider population. Within the city of Sheffield good partnership working was in place with the local hospice, clinical commissioning group, the citywide end of life care steering group, primary health care providers across the city and Sheffield City Council. At a regional level, the trust was a member of the Yorkshire and Humber regional end of life care group. The acute and community teams worked closely to deliver responsive care to patients at the end of their life. For example, a consultant told us specialist teams would liaise with acute or community specialist palliative care team members to arrange the care for patients. The intensive home support team provided different levels of service to meet individual needs. This included a visiting service through to 24-hour care. • In the last three to seven days of life the service could provide 24-hour care. • A night care service was available seven nights each week for the last month of a person’s life. • A ‘respite’ night service was available for two nights each week for the last two to three months of life. • A variable intensity Palliative (VIP) care service was a non-time limited service which could support families and patients in the earlier stages of their disease progression. The VIP service was tailored to suit individual family’s needs. We were told this service could have a waiting list as the patients were those who were not at the end stage of their lives and not in crisis. • An additional member of staff was on duty from 4:45pm until 7am to provide a responsive out of hour’s service to help to support people to remain in their own homes. If a patient receiving overnight care died during the night, the clinical support worker would also join the team to provide any responsive support that was needed for the remainder of their shift. • In order to provide a responsive service some staff were employed on ‘flexi’ contracts. These were 20-hour contracts; staff provided their availability (five days each week
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including alternate weekends). They were then rostered based on availability to work three shifts. If the person they were caring for passed away or they worked additional hours, they then had a floating hour’s balance, positive or negative, which could be utilised depending on the needs of the service. This included providing support to the acute services if needed. The service had also received additional funding to provide support to the active recovery service. The active recovery service aimed to prevent unnecessary or avoidable admissions and to facilitate early supported discharge from hospital through the provision of home-based assessment of needs and subsequent care plan development and delivery. Many of the people accessing the service are in the last year of their lives. Other people experiencing an acute exacerbation of an existing condition may enter the last days of life whilst in the care of this service. The IHNS were able to support patients to remain in their own home by providing a responsive service to support patients in their own homes. The community clinical support workers we spoke with recognised they were caring for increasing numbers of non-cancer patients at the end of their lives and gave examples of caring for more patients with different comorbidities such as heart failure, Huntington’s disease, Parkinson’s disease, multiple sclerosis and chronic obstructive pulmonary disease. The trust employed 14 chaplains which met the NHS Chaplaincy Guidelines 2015 Promoting Excellence in Pastoral, Spiritual & Religious Care guidelines. In addition, there were also chaplaincy volunteers. The multi-faith chaplaincy department had a diverse range of chaplains to reflect the religious, cultural and spiritual needs of the local population. There were Muslim chaplains, Roman Catholic chaplains, generic Christian chaplains and an honorary Buddhist chaplain. The chaplaincy department also had faith contacts in the community they could utilise if required. The chaplains provided trust wide 24-hour cover.
Meeting the needs of people in vulnerable circumstances The Intensive home nursing service (IHNS) was established in the 1990s. The aim of the service was to provide care for people in the last weeks, days and hours of life. The intensive element of the service was able to provide one to one care for significant periods of time in order to enable people to be cared for in their own homes as a realistic alternative to admission. The service was delivered by nursing support workers who provided care delegated to them by the district nursing team caring for the patient. In April 2004, additional funding was received that enabled the launch of the VIP service. The focus of care for this part of the service was the support of informal carers and loved ones in the months before the death of the person. It was felt that the provision of a small number of hours of home-based respite each week would enable the carer to continue to care for their loved one. The time allocated was usually one half- day per week and this enabled the carer to address things such as shopping or going to the bank, as well as attending for hairdresser appointments or pursuing hobbies and activities. The clinical support workers aim was to enhance the care that was provided by other clinical teams. The plan of care for each patient was developed by a registered health care professional within the responsible team and the IHNS clinical support workers delivered the care elements within it that were delegated to them.
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Two of multi-faith hospital chaplains had recently facilitated a session at the end of life care champions study day around meeting religious, spiritual and cultural needs. Staff from the service attended this training. The trust had a Muslim chaplain who supported patients and was also available to provide support to staff when caring for Muslim patients and their families. Staff we spoke with told us they could access translation and interpretation services. However, because they were caring for people in their own homes there had been very few occasions when this was needed. We were told by a band six member of staff that the community clinical support workers were given advice and support regarding the needs of families in relation to interpretation and translation services and were able to request this if necessary. We spoke with eleven members of staff. All staff were able to tell us about situations where they had cared for people, patients and their family members, with a learning disability, living with dementia or who had spiritual or cultural needs. This included caring for a person with a learning disability whose mother was at the end of their life. Others gave positive examples about how they had supported people living with dementia. One relative told us how a member of staff had driven to collect another family member so that all of those present with the dying person did not need to leave the house. Staff gave us examples of when they had recognised the individual needs of different members of the family and told us how they had supported people in those circumstances. Staff told us how they had supported a Muslim family with their nutritional needs during Ramadhan. The community clinical support workers we spoke with recognised the importance of preventing admission to hospital wherever possible especially when the patient’s home was their preferred place of care. We were told staff usually worked from 7am until 3pm, 3pm to 10pm or a night shift from 10pm to 7am. However, if needed they flexed their shifts to meet the needs of each individual family and patient. We were told where appropriate the trust used materials from external agencies, for example information leaflets, including disease, pain control and financial advice leaflets from Macmillan cancer support.
Access to the right care at the right time We were told most referrals came from the patient’s own GP, community nursing teams and the local hospice. Referrals were received by the clerical team and passed to one of the band six registered nurses who would then arrange an assessment of the patient to determine the level of care needed. The service provided care 24 hours a day, seven days each week. Rapid discharges home to die procedures had been developed and were in use. Flow charts were available for support rapid discharge from the general wards (both in and out of hours), as well as checklists, to aid staff. The community intensive home nursing service was able to provide one-to-one care for patients who were believed to be in the last few weeks of life, to enable them to die at home. This could be arranged before continuing healthcare funding was approved to ensure a prompt and responsive approach.
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Information provided by the trust indicated the service responded to referrals based on the needs of patients. Approximately half of the staff worked on a flexible hours contract meaning that when clinical activity was high the service was able to work flexibly to meet demand. When maximum flexibility was needed, and capacity was stretched, the provision of care was prioritised according to individual need. Care could be prioritised for those individuals who were in the last hours to days of their life however priority was also based on the availability of other support available to those requiring care. For example, someone who was days to weeks away from death might still be prioritised if they lived alone or without access to any other care and if there was a risk of an avoidable and unwanted admission to a 24-hour care facility. When it was identified that demand was exceeding capacity an ‘unmet need’ form was completed and escalated to palliative care leadership. We were not able to make a judgement on how quickly the service was able to respond to an urgent referral for support, as this information was not collated by the trust. However, we saw that this was a bespoke service which enhanced and supported the care provided by other healthcare professionals. There were no national requirements for this type of service to be provided and no key performance indicators for this type of service. From 1 June 2017 to 31 May 2018 the service received 865 referrals for people requiring palliative and end of life care. The service provided 5,902 contacts were during the same 12-month period.
Learning from complaints and concerns From February 2017 to January 2018 there were six complaints about community end of life care. The trust took an average of 41 days to close these complaints. The trust works to a tiered response time process where the timescale is determined based on the complexity of the concerns raised and in agreement with complainants. This is usually 25/40 days but can be up to 60 days for more complex cases. The Trust target was to respond to 90% of complaints within the agreed timescale; during 2017/18 the Trust closed 93% of complaints within the agreed timescale. The trust complaints process was detailed on the trust website, offering patients the option to submit complaints via the patient services team, an anonymous feedback form and the option to submit a complaint directly to the chief executive. This provided several routes for complaints to be submitted and reflected the transparent culture we observed at the trust. The trust provided information which explained that complaints and lessons learned were incorporated within staff training programmes, for example within the training days for end of life care champions. This training covered the management of complaints about end of life care and included the review of a letter of complaint and the Trust’s response. The electronic reporting system used by the trust was not able to provide information regarding complaints related to end of life care. Therefore, a process was in place to screen complaints relating to end of life care and identify learning points. The trust also completed thematic analysis of complaints. From 01 January 2016 to 31st December 2017, the thematic review highlighted communication and ward care around death as areas to focus on. These issues were being addressed through the end of life care strategy group. The vision was to further progress this by triangulating the Medical Examiner reviews, complaints and structured judgment reviews, facilitated by the learning from deaths guidance. A service review had been registered with the clinical effectiveness department in preparation to undertake a comprehensive review of complaints relating to care in the last days of life or the death of a patient.
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Is the service well-led? Leadership The therapeutics and palliative care directorate sat within the combined community and acute care group. This group covered integrated community care, primary care and interface services, integrated geriatric and stroke medicine and therapeutics and palliative care. A triumvirate of a clinical director, an operations director and a nurse director led the directorate of therapeutics and palliative care. The clinical director was supported by an operations director who led on aspects of planning and performance within the directorate. The nurse director lead on all aspects of the patient experience and worked closely with the operations director to make sure the correct resources were available to be able to deliver high standards of patient care. There was a matron who worked across all sites and the community service, who provided strategic and managerial support to the intensive home nursing team. The matron reported in to the integrated pathway manager (lead specialist nurse in palliative care) who also had direct management responsibility of the intensive home nursing service and bereavement services. The nursing and medical team was established with experienced staff who provided clinical and professional leadership. Staff told us they were well supported in their roles and had a clear understanding of their responsibilities. They said leaders were visible and approachable. A community clinical support worker told us the leadership are always available for support and advice or if they were finding a situation difficult. The managers at different levels of the directorate knew about the quality issues, priorities and challenges the directorate faced and worked collaboratively across all sites to try and deliver solutions and pilot new ways of working. We observed that managers were proactive, and their positivity and motivation was inspiring. The leaders of the IHNS described the band two community clinical support workers as ‘the best anywhere’ and described them as being ‘something special’. The board representative for End of Life Care was the trust’s medical director. There was not a specific nominated non-executive director (NED) for End of Life care however developments in end of life care were reported to the chair of the healthcare governance committee (a NED) who was responsible for the oversight of the end of life care agenda. There was a clear commitment and focus by leaders to predict and respond to patient demand and flow.
Vision and strategy At our inspection in 2015 there was no strategy for end of life care. We told the trust they must ensure they developed and implemented a strategy for the care of patients at the end of life because the absence of a strategy had resulted in staff not knowing the vision for end of life care. Within the five-year plan, there was no written strategy with timescales to determine how different parts of the plan were to be achieved and there was limited monitoring of quality of care for end of life care. At this inspection we saw an end of life care strategy had been implemented. The trust had held consultation focus groups with a diverse range of staff to help shape the strategy. This had
20171116 900885 Post-inspection Evidence appendix template v3 Page 376 resulted in the strategy being developed in partnership with staff, patients and carers and disseminated across the organisation. At the last inspection we found there was limited monitoring of quality of care for end of life care. At this inspection we saw that quality of care was being measured for end of life care services and patients’ preferred place of care and death was being recorded for monitoring purposes. Areas highlighted as requiring improvement at the 2015 inspection had been addressed. These included: completion, approval and dissemination of the end of life care strategy; updating and the dissemination of ‘guidance for the care of the person who may be in the last hours to days of life’; development and approval of the individualised care plan for the last days of life; completion and rollout of the electronic end of life care nursing care plan; the establishment of an end of life care education and training subgroup of the end of life care project steering group, and appointment of a leadership fellow and two clinical leads in end of life care. Staff we spoke with were aware of and able to talk to us about the trust’s ‘PROUD’ values.
Culture Staff we spoke with felt they were valued and respected by their peers and leaders. We asked staff about the morale and they all said morale was good and they worked collaboratively as a team. The leadership team and staff we spoke with explained debrief support sessions were held following them caring for young people who were dying or those who had a traumatic death. It was recognised that the staff working within the service often felt bereaved following the death of a patient. Staff support was available from one of the band six staff working in the service who was a trained counsellor and psychotherapist. The trust promoted the culture that care of the dying is everyone’s responsibility and provided the skills and tools to enable staff to consistently and compassionately undertake this. Staff we spoke with wanted to provide high quality, effective care and treatment to patients and put patients at the centre of the experience. One member of staff described the culture as being very positive, with staff who want to go ‘above and beyond’. The community clinical support workers we spoke with told us they were really proud of the care they provided and of the service in general. One described it as ‘the best service ever’. Another said they felt proud when they put their uniform on and felt they made a difference.
Governance In 2015 staff we spoke with were unsure who provided leadership on end of life care for community services, they were less confident about senior managers understanding the role of community services in a trust which predominately provided acute hospital-based services. The governance arrangements were still being developed following re-organisation of the directorate structures. The trust board received divisional performance management reports but there were no measures for the community end of life service included in the reports. At this inspection we found the trust had developed the service and had governance, risk management and quality measures to improve patient care, safety and outcomes. There was an end of life project steering group that was chaired by the medical director with representation from staff across all levels and departments in the trust. The governance system supported the strategy
20171116 900885 Post-inspection Evidence appendix template v3 Page 377 and provided continuing assurance up to board level, with the clear focus on providing a quality service. The trust had implemented processes to record whether patients preferred place of death was achieved and if not why not. However, the trust had not completed any audits of this data. Therefore, whilst a system was now in place the trust was still not measuring if patients achieved their wishes. However, we found establishing patients’ preferred place of care was seen as a priority. The trust had recently approved a business case to recruit a band 8a lead nurse who, when appointed, would be the governance lead for end of life care and take over the project group responsibilities to continue to roll out the priorities identified by the group. Patients in their own homes had trust owned medical devices in use if medicines were being delivered by a syringe driver. The trust had a medical device management group (MDMG) which met monthly to review governance arrangements for medical devices as well as managing planned replacement of capital and high-volume revenue devices.
Management of risk, issues and performance The senior team for the service met monthly. We were told risks, issues and performance were discussed at this forum. The meeting was also used to share updates from strategic meetings. The trust had a process to share national patient safety alerts issued by Medicines and Healthcare Products Regulatory Agency (MHRA). Alerts were received by the patient and healthcare governance department. They were then logged on the trusts electronic reporting system and emailed to the patient safety manager. The patient safety manager would then disseminate the alert to the relevant staff including risk leads, who would action and cascade as appropriate. The cascade would incorporate all relevant staff and would include end of life care staff where appropriate. Deadlines for completion of actions were logged on the trusts electronic reporting system which then generated automated reminders. On completion of actions, the alert was closed on the trust’s electronic reporting system and a response sent to the Medicines and Healthcare Products Regulatory Agency (MHRA). There was a risk register with one recorded risk for the IHNS. The risk had a review date documented. We looked at the minutes from the palliative care and therapeutics directorate, operational business and governance meeting and saw risks, complaints and compliments, clinical effectiveness, audit and research, lessons learned and revised policies and changes to NICE guidance were discussed at these meetings. We saw the trust had a major incident plan and local escalation policies in place, in order to support staff and provide assurance regarding emergency preparedness, response and resilience (EPRR). However, the major incident plan was out of date as this had been due for review in December 2017. The IHNS leadership team told us staff safety was paramount and risk assessments were performed prior to staff working alone in a service user’s home. In addition, risks were also highlighted for specific cases, for example, if a staff member had a fear of dogs they would not be allocated to work in a patient’s home where there were dogs.
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Many of the community clinical support workers worked alone therefore the service had procedures for staff to follow. This included the evening and night team contacting each worker to ensure they had arrived at their place of work. All night workers finished at 7am and were therefore required to leave a message at the base to advise when they had arrived home following a night shift. These calls were then checked by the clerical workers at 8am, all staff were provided with a mobile telephone. If staff did not leave a message this was followed up by the service.
Information management The trust had created a comprehensive end of life resource site on the staff intranet. The intranet site had been created by a clinical fellow in the palliative care team and based on a ‘three clicks’ rule. This meant staff could access the information, guidance or pathway they needed with no more than three mouse clicks. We reviewed a sample of policies and guidelines available to staff and found they were in date and had recently been reviewed and updated. • DNACPR policy ratified 1 May 2018. • Mental Capacity Act 2005 and Deprivation of Liberty policy ratified 1 March 2017 (due for review 1 November 2020) • T34 syringe pump protocol ratified 25 October 2017 (due for review 1 October 2020) • Care after death policy ratified 3 January 2018 (due for review 1 August 2020) The end of life care guidelines had been reviewed and updated in 2018.
Engagement The trust had developed an end of life care project team. Members of team included the trust medical director, the integrated pathways manager, medical and nursing staff from the acute and community specialist palliative care team and a patient governor. The end of life care facilitator told us they worked closely with other specialist nurses to ensure they were able to care for patients cohesively at the end of their life. The development of the end of life strategy, new guidance, care plans and training has been the result of co-production and engagement across staff, patients and carers. We were told the end of life care guidelines had been recently reviewed and updated. This had involved input from other disciplines including oncologists and anaesthetists. Prior to the launch of the trust strategy for end of life care, the end of life project working group (PWG) held consultation events that allowed all members of staff and patient representatives to share good practice and to also highlight areas that required improvement and the tools or skills needed to do this. We learned the service had recruited family members of former patients. Staff we spoke with told us family members had been inspired by the service and therefore applied to work in the team. The IHN leadership team told us they had asked for staff feedback about their support and educational needs and although the response rates were low (25%) they had been able to identify themes to enable them to focus on the needs of the staff.
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The IHN leadership team had also engaged staff in shaping the future of the service, staff had been encouraged to suggest ideas for changes to the service, the service vision and also how the leadership team could support staff in their role. The leadership team for the IHNS recognised some of the community clinical support workers were not comfortable using IT systems therefore they used communication methods staff were comfortable with, for example paper-based information sharing and face to face meetings. In addition, it had been noted whilst there was good staff engagement scores for the division in the staff survey, the service leads needed to improve the scores for the band two staff. Despite this the members of the team we spoke with felt staff engagement and communication was positive, they spoke with us about the updates they received and how compliments were shared with them. The service had engaged patients and their families in a service review in 2017; an outcome from this was that families preferred the staff members to be consistent. Where possible this had been factored in to the rostering process. The service did not currently collate any formal feedback from bereaved relatives; however, they received thank you cards and compliments which were shared with the team.
Learning, continuous improvement and innovation The end of life care working group had developed a policy for subcutaneous fluids being given to patients in their own homes. This meant patients needing parenteral fluid therapy could now remain in their own homes. In addition, the community teams had worked closely to ensure end of life care guidelines were available on the electronic records systems. Funding had recently been approved for a full-time band 8a lead end of life care nurse and a full- time end of life care facilitator. The trust had appointed another clinical leadership fellow for palliative care after the success of the initial post which was due to end in July 2018. The end of life project steering group had also done work around heart failure and working with colleagues in cardiology to promote advanced care planning for patients nearing the final 12 months of their lives. The specialist palliative care team had developed a section on the trust’s intranet to support staff in caring for patients at the end of their lives. This had been launched in April 2018. We looked at the information available and found this to be an effective but simple to use resource for all staff. We were told the specialist palliative care team were instrumental in identifying educational needs for staff. The end of life care facilitator told us the trust had more than 100 end of life care champions (link nurses) working in general wards across the hospitals. Study days were held for the end of life care champions, the champions would then disseminate the learning to their own teams. A clinical fellow in palliative care had designed and circulated questionnaires for medical staff and nursing and MDT staff across the trust to benchmark understanding and confidence in relation to palliative care and to better inform the palliative care team of the needs of the medical, nursing and MDT staff. The specialist palliative care team had developed the DNACPR policy through the end of life care working group. This had included the development of an information leaflet for patients, families
20171116 900885 Post-inspection Evidence appendix template v3 Page 380 and carers. We looked at this leaflet and saw it contained robust but easy to follow information about decision making around DNACPR. The leaflet also included information about advanced care planning, advanced decisions to refuse treatment and lasting power of attorney decision making. The trust participated in ‘dying matters week’ in May 2018. Events were planned across the city and patients, relatives and visitors were encouraged to attend. These events included market stalls providing information for patients, visitors and staff to encourage them to talk about dying, death and bereavement and included a ‘before I die’ wall, which encouraged people to think about their own wish list. These events took place at the Northern General Hospital, Weston Park Hospital and Manor Clinic. Following a complaint relating to end of life care, a face to face meeting was held with the bereaved relatives and with permission the meeting was recorded, and extracts of the recording were then used in training sessions about optimising the discharge of people in the last days and weeks of life. The trust had updated the End of Life Care template on the electronic records system to ensure patients spiritual and emotional needs were addressed The trust end of Life eLearning pack had been launched and this included a bespoke community element. One of the hospital chaplains had been awarded the top Khadija Award at the Al Nisa Awards. These awards are a celebration of the contribution and achievements of Muslim women in the county. The chaplain was recognised for their innovative multi-faith work in developing understanding and co-operation between hospital teams and the community in their role as a Muslim Chaplain.
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