Royal Hallamshire Hospital

⚠ In surgery and medicine, the trust had not identified and addressed environmental risks including risks presented through unsafe storage of equipment, cleaning supplies and medical gases. Equipment was not clearly identified as being clean or appropriately maintained and serviced.

⚠ Staff did not consistently undertake and record the required physical health monitoring after administering rapid tranquilisation to keep patients safe.

⚠ There continued to be inconsistencies in practice in relation to the Mental Capacity Act. In medicine, patients subject to the Deprivation of Liberty Safeguards did not always have a recorded capacity assessment and/or decision recorded in their best interest.

⚠ The trust had not made significant improvement in identifying and reporting serious incidents.

⚠ There remained a backlog of serious incidents requiring investigation.

⚠ There remained risks in services which had not been identified. In some instances we found leaders had not acted to reduce the impact of risks, and risks were not always reviewed in a timely manner.

⚠ The trust had not trained sufficient numbers of staff to ensure physical restraint was undertaken safely and appropriately. The trust continued to rely on untrained staff to restrain patients when needed.

⚠ Data showed that in the RCEM Audit on Mental Health (Adult) 2020/2021 that the emergency department did not meet the fundamental standards that all patients should have mental health triage on arrival to briefly gauge their risk of self-harm or suicide and risk of leaving the department before assessment or …

⚠ The trust provided IPC audits for the emergency department for 2021 and 2022. The trust scored 88% and 92% which was below the trust target of 95%. We found that they were completed inconsistently. Hand hygiene results were not available for February, July or August 2022.

⚠ However, during the inspection, we did find gaps in recorded of intentional rounding in patient's records.

⚠ Security staff were required to provide one to one observations of patients presenting with high risks of violence, aggression or absconding. In incidents reports we saw security staff were required to restrain patients. However, security staff had not had the training required to manage restraint safely in a healthcare setting.

⚠ We were not assured that this was a robust process, and when the department was busy and understaffed, the nurse and consultant in charge were not always able to stay at their station to support the IAU.

⚠ However, patients did not always receive treatment within agreed timeframes and national targets. The emergency department had seen an increase in attendances and waiting times for treatment, The trust did not meet national targets for admission to ward times.

⚠ The percentage of ambulance handovers completed within 15 minutes in June 2022 was 35.7% which had declined from 41.95% in June 2021. The percentage of ambulance handovers that took more than 30 minutes in June 2022 was 20.1%.

⚠ We also saw the department had long waits to see medical staff including up to 7 hours. This meant that the emergency department was under sustained pressure at times.

⚠ We identified ongoing issues with restraint training, the use of restrictive practices and data security.

⚠ We reviewed the risk register and not all the risks that they told us about were included on the register. We were not assured that all key areas that were identified at the last inspection were addressed.

⚠ We observed controlled drugs (diamorphine) in theatres that had been drawn up and left unattended in an unsecure area which any member of staff could access and we saw two examples of controlled drugs (fentanyl) not having two signatures prior to removal from storage which was not in accordance with …

⚠ Staff did not always follow infection control principles; we saw multiple examples of staff across all roles and grades and across all surgical wards not correctly wearing personal protective equipment (PPE).

⚠ The service did not clearly display information about how to raise a concern in patient areas. We saw no obviously displayed information on making complaints in any patient area that we visited.

⚠ Improvements had been made since our last inspection, but we saw that there have been multiple areas where compliance towards trust targets has not been met such as in infection prevention and control audits and safety checklists in theatres.

⚠ At the last inspection there were issues with the storage of oxygen bottles, and during this inspection we still saw oxygen bottles being stored inappropriately. There were examples of unsecured bottles on the wards and within storage areas, and this posed a safety risk to both staff and patients.

⚠ Staff did not always follow infection control principles; we saw multiple examples of staff across all roles and grades and across all surgical wards not correctly wearing personal protective equipment (PPE) in line with the trust’s requirements at the time of inspection.

⚠ The service did not clearly display information about how to raise a concern in patient areas. We saw no obviously displayed information on making complaints in any patient area that we visited.

⚠ Improvements had been made since our last inspection, but we saw that there have been multiple areas where compliance towards trust targets has not been met such as in infection prevention and control audits and safety checklists in theatres.

⚠ We reviewed two sets of patient notes where rapid tranquilisation had been administered and observed that there had been no recording of patients’ physical health observations post administration. This was not in line with the trust's policy for rapid tranquilisation which states that “Patient is reassessed at regular intervals or …

⚠ Security staff were required to provide one to one observations of patients presenting with high risks of violence, aggression or absconding. In incidents report we saw security staff were required to restrain patients. However, security staff had not had the training required to manage restraint safely in a healthcare setting. …

⚠ On ward L1 we observed on one ward that not all patients had access to call bells, as these had been damaged and were awaiting replacements. Whilst staff had been allocated to remain within patient bays, it was unclear as to how patients would attract the attention of staff should …

⚠ We observed three examples where patients had been subjected to a DOLS order but did not have corresponding capacity assessments and/or a decision recorded in the patients’ best interest.

⚠ At our last inspection we said the trust must ensure confidential records are stored securely in line with national guidance. At this inspection on wards we visited notes trollies were mostly left unlocked and unattended with patient notes stored underneath trollies, easily accessible to visitors. This was in breach of …

⚠ We identified ongoing issues in relation to the completion of mental capacity documentation, the use of restrictive interventions and training in relation to this, secureness of patient records, reporting of incidents.

⚠ Outcomes for patients were not always positive, consistent and did not always meet expectations, such as national standards. The trust provided a range of supporting action plans following their clinical audit programme, which identified areas in which the trust was not in line with national standards.

⚠ Staff did not always report serious incidents clearly and in line with trust policy. We reviewed NRLS between October 2021 and August 2022 and found that incident report times were variable and not always timely. Out of 24990, incidents there were 917 reported 90+ days after the incident occurred. 196 …

⚠ We reviewed two sets of patient notes where rapid tranquilisation had been administered and observed that there had been no recording of patients’ physical health observations post administration. This was not in line with the trust's policy for rapid tranquilisation which states that “Patient is reassessed at regular intervals or …

⚠ Security staff were required to provide one to one observations of patients presenting with high risks of violence, aggression or absconding. In incidents report we saw security staff were required to restrain patients. However, security staff had not had the training required to manage restraint safely in a healthcare setting. …

⚠ Only 30% (11/37) of observations had been completed at the correct frequency. Overall, only two sets of notes had a ‘Deteriorating Patient Sheet’ filed and neither were fully completed.

⚠ We observed three examples where patients had been subjected to a DOLS order but did not have corresponding capacity assessments and/or a decision recorded in the patients’ best interest.

⚠ At this inspection on wards we visited notes trollies were mostly left unlocked and unattended with patient notes stored underneath trollies, easily accessible to visitors. This was in breach of trust policy and General Data Protection Regulation (GDPR). Individual patient paper records were stored in folders outside of each bay, …

⚠ We identified ongoing issues in relation to the completion of mental capacity documentation, the use of restrictive interventions and training in relation to this, secureness of patient records, reporting of incidents.

⚠ Outcomes for patients were not always positive, consistent and did not always meet expectations, such as national standards. The trust provided a range of supporting action plans following their clinical audit programme, which identified areas in which the trust was not in line with national standards.

⚠ Staff did not always report serious incidents clearly and in line with trust policy. We reviewed NRLS between October 2021 and August 2022 and found that incident report times were variable and not always timely. Out of 24990, incidents there were 917 reported 90+ days after the incident occurred. 196 …

⚠ The average wait time for women being identified as requiring admission to labour ward to being admitted to the labour ward to commence induction was 1.47 days, however, we saw two occasions where women waited six days for their induction. This is not in line with national guidance.

⚠ In September 2022, we saw that the investigation procedures had been streamlined although there remained a backlog of incidents to review.

⚠ Managers were revising posters used to communicate learning as staff had fed back these were not the most effective method.

⚠ Midwifery staff were not fully compliant with all mandatory training, including safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards.

⚠ However, time-critical medications were not always prescribed or administered in a timely way. In the last audit of time critical medication completed in May 2022, 20% of critical medicines had not been prescribed and that 23% were not administered on time.

⚠ Audit of IPC procedures continued to be completed inconsistently and varied in meeting compliance targets across wards. Hand hygiene audits between January and August had only been consistently completed each month for the midwifery led labour ward and Rivelin ward. Hand hygiene audits were not completed consistently for Whirlow ward.

⚠ We reviewed four complaints; two complainants had not received an outcome to their complaint for over nine months and one had received repeated extension dates.

⚠ The service did not currently have a regular audit schedule in place to ensure consistent oversight of the safety of the service.

⚠ The service's risk register was not reflective of the current risks and areas of focus. The SLT were aware this was an area for improvement and that the current risk register was not an accurate reflection of the service. The risk register was a mix of corporate and directorate risk …

⚠ However, timeliness of reviews and implementation of change was variable, which delayed improved outcomes for women.

⚠ Out of 2,374 incidents there were 451 reported 90+ days after the incident occurred. This means that investigations and lessons learned remained untimely.

⚠ The trust acknowledged that in the absence of an end-to-end maternity IT system they were unable to provide robust evidence for all elements of the Saving Babies Lives care bundle.