Northern General Hospital

We inspected the Northern General Hospital as part of the inspection of Sheffield Teaching Hospitals NHS Foundation Trust from 7 to 11 December 2015. We undertook an unannounced inspection on 23 December 2015. We carried out this inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

We did not inspect the GP out of hours collaborative as part of this inspection.

Overall, we rated Northern General Hospital as good. We rated safe, effective, caring and responsive as good. Well-led was rated as requires improvement.

We rated critical care and outpatients and diagnostics as outstanding. Medical care and surgery were rated as good. Emergency and urgent care and end of life care were rated as requires improvement.

Our key findings were as follows:

• We found the hospital was clean and staff adhered to infection control principles. The trust scored 99% for cleanliness in the patient-led assessments of care environments (PLACE) report for 2015.
• There was a trust infection control accreditation programme in place. This programme set standards for infection prevention and control practice. Most clinical areas had achieved accreditation; plans were in place where this was not the case.
• There had been four cases of MRSA reported by the trust between June 2014 and June 2015.
• There had been 33 cases of C.difficile between April 2015 and November 2015 at the Northern General Hospital. This was a rate in line with the England average per 10,000 bed days. The trust’s rate of C.difficile was below the trajectory target with 42 cases against a stretch target of 52 cases at the end of November 2015.
• The trust used the safer nursing care tool, professional judgement and nursing hours per patient day to determine appropriate levels of staffing. There were some areas where staffing fell below planned levels on a regular basis, particularly in the Emergency Department, although the trust was mitigating risks as far as possible. Recruitment to vacancies was in progress. Staff were able to use bank or agency staff, where available, to fill staffing shortfalls.
• The trust was committed to the development of advanced nurse practitioners to ensure patient care was maintained and the potential recruitment difficulties to junior doctor posts mitigated. This also allowed good advancement opportunities for nurses.
• Mortality indicators showed no evidence of risk.
• Patients were assessed for their nutritional needs. The trust had introduced HANAT (hydration and nutrition assurance toolkit) to encourage good nutrition and hydration best practice in the hospital environment.
• There was a well-established culture of continuous quality improvement. This was supported and assured by robust governance, risk management and quality monitoring. The trust used a Microsystems Coaching Academy which worked well to support small scale service improvements.
• The trust’s vision and values were embedded in practice. These informed performance reviews and staff felt they were meaningful.
• Clinical directorates had individual five year strategies that were linked to trust’s strategy, aims and objectives. The directorate strategies had consideration of the other clinical departments they worked with to deliver high quality care and the assistance required from corporate directorates and other partners.
• There were concerns regarding the emergency department at the Northern General Hospital this included the clinical decision unit. Specifically we had concerns regarding the quality of care of patients during times when the department was busy.
• There were concerns regarding the clinical decision unit specifically regarding the monitoring and escalation of deterioration patients in the seated area of this unit. We raised this with the trust at the time of inspection and a protocol was put in place.
• The introduction of a new IT system had resulted in the trust not being able to record performance targets in the emergency department.
• There were variable levels of compliance with mandatory training.
• There was variation in the quality and completeness of Do Not Attempt Resuscitation (DNACPR) forms.
• In medicine, there were concerns regarding the access to nursing guidelines that were held electronically and could not always be accessed by all nursing staff. Care needs were conveyed between nurses using verbal communication or handover sheets rather than referring to the nursing care plan.

We saw several areas of outstanding practice including:

• The patient care and experience delivered by staff in the Bev Stokes Day Surgery Unit, particularly in relation to patients living with learning disabilities and dementia, was outstanding.

• The duty floor anaesthetist role in theatre developed in Sheffield was going to be used by the Royal College of Anaesthetists as a beacon of good practice.
• A relative’s room had been developed within the operating theatre complex.
• On GICU /GHDU, there was the use of an electronic patient information system to ensure timely and accurate records, access to trust and local policies, procedures and guidelines The system ensured effective care was delivered and it was fully integrated and provided real-time information across teams and services.
• An advanced clinical pharmacy service which included a consultant pharmacist and pharmacy prescribers had been developed to improve the safety and efficacy of medicines used in critical care.
• The use of the Enhanced Recovery After Thoracic Surgery (ERAS) programme had resulted in marked improvements in the quality of care for patients on CICU.
• The laboratory team had introduced a ‘Patient Safety Zone’ project into the inpatient wards and in the community. The aim was to reduce labelling errors. Disturbance or distraction while taking blood samples has been identified as a major risk factor for errors. This initiative had been introduced to improve patient safety. Pathology staff showed us lots of publicity material, including branded biro pens.
• In laboratory medicine, we observed large screens above the bench dealing with urgent samples. It contained a full list of patients waiting for results in the emergency department. The same screens were on display in the emergency department. This meant laboratory staff could see exactly who was waiting in the emergency department and gave context and ‘humanity’ to the samples they were analysing. Urgent results for the emergency department samples were available in one hour because of the use of this management tool.
• Radiology provided an excellent service of ‘hot reporting’ for reporting x-rays for the emergency department patients; results were ready within 20 minutes.
• There were numerous examples where staff went out of their way to meet individual’s needs. Staff demonstrated acts of kindness and flexibility to ensure patients and families suffered as little distress as possible.
• A culture of innovation and improvement was evident throughout all levels of the organisation. For example, geriatric medicine had historically been part of acute medicine but was now combined with community services. It was hoped this would help improve integrated pathways for elderly patients between acute and community services and facilitate provision of services in the community to enable elderly patients to be cared for at home whenever possible.

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

Importantly, the trust must:

• The trust must ensure patients do not wait longer than the recommended standard for assessment and treatment in the emergency department.
• The trust must ensure that on initial assessment in the “pit stop area” in the emergency department patient’s vital signs are taken and recorded consistently.
• The trust must ensure that patients in the clinical decisions unit have timely clinical reviews.
• The trust must monitor performance information to ensure 95% of patients are admitted, transferred or discharged within four hours of arrival in the emergency department.
• The trust must ensure robust escalation processes are implemented in the emergency department.
• The trust must ensure arrangements for governance within the emergency department operate effectively.
• The trust must ensure the safe storage of intravenous fluids.
• The trust must ensure doctors follow policy and best practice guidance in relation to the prescription of oxygen therapy.
• The trust must ensure a strategy for end of life care is implemented.
• The trust must ensure that DNACPR records are fully completed.

In addition the trust should:

• The trust should ensure that staff have attended mandatory training in accordance with the trust target.
• The trust should improve the compliance rates for medical and nursing staff receiving an annual appraisal.
• The trust should implement plans to increase nurse staffing in the emergency department to ensure there are appropriate staffing levels at all times.
• The trust should continue to review the provision of 24 hour consultant medical cover within the emergency department as part of being a major trauma centre.
• The trust should review and implement standards of record keeping, risk assessments and the documentation of care given in the emergency department so staff have the complete information they require before carrying out care and treatment.
• The trust should continue to take action to ensure the emergency department achieve the recognised standard of 15-minute arrival by ambulance to handover to emergency department.
• The trust should review guidance in the emergency department to ensure it reflects current evidence-based guidelines.
• The trust should review the experience of patients to ensure privacy and dignity is maintained in the emergency department, particularly during busy periods.
• The trust should ensure staff follow policy and best practice guidance in relation to the administration of intravenous fluids.
• The trust should review the use of nursing care guidelines and ensure they are consistently available for all staff providing patient care, to enable accountability for care provided.
• The trust should try to reduce the movement of staff to clinical areas outside of their speciality.
• The trust should introduce a robust process to share lessons learnt from incidents and mortality and morbidity reviews across directorates and care groups.
• The trust should ensure it reviews the process for the appropriate testing of all medical equipment used for patient care in the critical care units.
• The trust should ensure that there are appropriate weaning plans in place for all patients with tracheostomies and that these are made in timely way.
• The trust should consider reviewing review data collection methods and the process for submitting ICNARC data for Cardiac Intensive Care, so that patient outcomes can be benchmarked with other similar services.
• The trust should consider reviewing the critical care services in line with the Core Standards for Intensive Care Units 2013 to address areas where they are not meeting these standards.
• The trust should consider reviewing the computer provision on CICU.
• The trust should consider the implementation of the electronic patient clinical information system on CICU so there is alignment with the other critical care units.
• The trust should consider a process for obtaining patient feedback following discharge from critical care.
• The trust should monitor preferred place of care for patients at the end of life.
• The trust should review implementation of NICE urinary incontinence in neurological disease for outpatients in the spinal injuries unit.
• The trust should review the fracture clinic environment to ensure meet the needs of patients.
• The trust should routinely collect waiting time information for patients waiting for appointments.
• The trust should develop standard procedures for completing interventional radiology non-surgical safety checklists for all staff to follow.
• The trust should consider undertaking regular audits of patient electronic records to ensure consistency in the completion of MRI safety checklist and pregnancy checks.
• The trust should continue to take action to reduce the number of medical outlier patients across the trust.
• The trust should continue to take action to reduce the number of bed moves patients experience during their hospital stay.
• The trust should monitor access to records in the outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals