King's Mill Hospital

Sherwood Forest Hospitals NHS Foundation Trust was formed in 2001, and achieved foundation status in 2007. Sherwood Forest Hospitals is the main acute hospital trust for the local population, providing care for people across north and mid-Nottinghamshire, as well as parts of Derbyshire and Lincolnshire. The trust employs 4,300 members of staff working across the hospital sites.

King’s Mill Hospital in Sutton-in-Ashfield is the main acute hospital site. It provides over 550 inpatient beds (more than half in single-occupancy en-suite rooms), 13 operating theatres, and a 24 hour emergency department. Each year there are more than 45,000 inpatient admissions and 36,000 day case patients; 100,000 patients attend the emergency department, around 3,500 babies are delivered, and more than 390,000 people attend outpatient and therapy appointments in the King’s Treatment Centre.

In February 2013, the trust was identified as being one of the 14 healthcare providers in England which had higher than expected mortality rates. This led to the trust being reviewed by Professor Sir Bruce Keogh, NHS Medical Director for England. This review in July 2013 led to the trust being placed in special measures by Monitor, the independent regulator of NHS foundation trusts.

We inspected the trust in April 2014 and gave an overall rating of ‘Requires Improvement.’ We judged the provider was not meeting seven out of 16 essential standards of quality and safety.

We carried out an announced inspection visit from 16 to 19 June 2015 and three unannounced visits on 7, 9 and 30 June 2015. We held focus groups with a range of staff in the hospital, including nurses, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, physiotherapists, occupational therapists, pharmacists, domestic staff and porters. We also spoke with staff individually.

Overall, this trust was rated as inadequate. We identified significant concerns in safety and leadership of the trust. We found that effectiveness and responsiveness required improvement but the caring was good.

Our key findings were as follows:

• Staff were kind and caring and treated people with dignity and respect, but there were some instances where improvements were required. A greater emphasis was needed on providing care that was based on people’s individual needs rather than as tasks.
• Overall the hospital was clean, hygienic and well maintained. There had been 54 cases of clostridium difficile (c. diff) infections in 2014/2015. C diff is an infective bacteria that causes diarrhoea, and can make patients very ill. This was worse than the national average and above the trust’s target, which was a total of 48 cases per year. Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections MRSA rates for the hospital were low with one case recorded between 2014 and 2015. Routine screening of patients for MRSA was completed with further screening repeated after 21 days.
• Nursing and midwifery staffing had increased since 2013 and it had been a focus of the Executive Director of Nursing. Midwifery staffing levels were almost meeting the national recommended levels of 1:28. Planned nurse staffing levels were in accordance with national guidance of one registered nurse for every eight patients.
• There was an escalation process in place if staffing levels did not meet the planned levels, but staff didn’t always feel this resulted in a change. We saw some occasions where patients were not able to receive their assessed level of care due to shortages of healthcare assistant staff.
• In May 2015 there were 94.89 whole time equivalent (ETE) registered nurse vacancies. This was a high risk on the trusts risk register. A recruitment programme was ongoing and changes had been made to speed up the recruitment process. Oversees recruitment had taken place.
• There were medical staffing vacancies and there was a high use of locum medical staff.
• Patients pain was well managed and women in labour received a choice of pain relief. Patients at the end of life were given adequate pain relief and anticipatory prescribing was used to manage symptoms.
• Monitoring by the Care Quality Commission had identified areas where medical care was considered a statistical outlier when compared with other hospitals. The trust reported on their mortality indicators using the Summary Hospital- level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR). These indicate if more patients are dying than would be expected. The data for the trust was higher than would be expected and its overall level of HSMR was 120.67. This had been reported to the trust board and it was one of the trusts top three objectives for improvement.
• We were concerned about the hospitals performance in relation to the management of people with sepsis. There have been longstanding concerns about the management of patients with sepsis. This is a severe infection which spreads in the bloodstream. In 2010 and 2012 we raised mortality outlier alerts with the trust, when information showed there were a higher number of deaths than expected for patients with sepsis. The trust had identified a third mortality outlier for patients with sepsis in the period April 2014 to January 2015. Our analysis of the data from April 2014 to February 2015 found 88 deaths of patients with a diagnosis of “unspecified septicaemia” compared with an expected number of 58. The death rate for patients with this diagnosis was 32%, almost twice as much as the England rate of 17%.
• The trust participated in a range of national audits and outcomes varied. Outcomes for women in labour were good, although the trust was significantly higher for induced births. They did not understand the reason for this high rate.
• Like many trusts in England, their hospitals were busy. Bed occupancy rates were high and were consistently above 90% which was above the England average of 88%. It is generally accepted that when occupancy rates rise above 85%, this can affect the quality of care and the orderly running of the hospital. There were initiatives in place to reduce bed occupancy and improve the flow of patients through the hospital. Delayed discharges were a problem across the trust.
• The trust were not meeting the national targets set regarding patients access to treatment and they had failed to meet the 18 week target for access to treatment. The trust were however meeting the standard for patients being admitted, referred or discharged from the A&E department within four hours.
• There was a vision and strategy for the trust but staff were not able to articulate this to us. The priority for the organisation was to come out of special measures.
• Staff generally felt they were well supported at their ward or department level.

We saw several areas of outstanding practice including:

• There was some innovative work taking place at King’s Mill Hospital where the trust had developed a new changing facility for patients with complex disabilities. The facility offered a large changing area that would meet the needs of patients with profound disabilities.

• Staff went out of their way to meet the needs of their patients on the critical care unit. Some patients could be moved on their beds out of the critical care unit to an outdoor area. Staff told us they tried to do this when possible as patients appreciated being outside and away from the unit. Staff had been able to allow visiting by patients’ pet dogs in this way.

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

Importantly, the trust must:

• Ensure all staff receive training in safeguarding children and vulnerable adults. The training must be at an appropriate level for the role and responsibilities of individual staff.
• Ensure staff are appropriately trained to provide the care and support needed by patients at risk of self-harm.
• Ensure staff receive effective and appropriate guidance and training about the assessment and treatment of sepsis.
• Ensure staff understand the requirements of the Mental Capacity Act 2005 in relation to their role and responsibilities.
• Ensure all patients in the emergency department are able to summon help if they need it.
• Ensure all patients over the age of 75 have a cognitive assessment when arriving in the emergency department.
• Ensure learning from complaints is shared with staff in the emergency department which leads to improvement in care.
• Ensure the governance framework in the emergency department clearly identifies risks, responsibilities and actions required to manage those risks within a stated timeframe.
• Ensure systems and processes are effective in identifying where quality and safety are being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to outpatient appointment issues.
• Ensure any remedial actions taken to address outpatient appointment issues are regularly audited to give assurances improvement has taken place.
• Ensure patients in the critical care unit are routinely and properly assessed for delirium.
• Ensure the provision of level two critical care on Ward 43 includes nursing staffing levels in line with the ‘Core Standards for Intensive Care Units’ published by the Intensive Care Society and the commissioners expectations.
• Ensure patients requiring critical care at level two on Ward 43 are cared for by appropriately trained staff in line with the ‘Core Standards for Intensive Care Units’ published by the Intensive Care Society.
• Ensure staff delivering end of life care receive suitable training and development.
• Ensure all patients at the end of life receive care and treatment in line with current local and national guidance and evidence based best practice.
• Ensure the quality of the service provided by the specialist palliative care team is monitored to ensure the service is meeting the needs of patients throughout the trust.
• Ensure risks for end of life care services are specifically identified, and effectively monitored and reviewed with appropriate action taken.
• Ensure that the resuscitation trolleys and their equipment are checked, properly maintained and fit for purpose in all clinical areas in the children’s and young people’s service.
• Ensure that medication is monitored, in date and fit for purpose in all clinical areas of the children’s and young people’s service.
• Ensure emergency lifesaving equipment in the maternity service is checked regularly and consistently to ensure it is safe to use and properly maintained.
• Ensure staff have the appropriate competence and skills to provide the required care and treatment to women using the maternity and gynaecology service. Specifically, women who are acutely ill or who are recovering from a general or local anaesthetic.
• Ensure patients in the medical care wards receive person-centred care and treatment to meet their needs and reflect their personal preferences, including patients living with dementia and those with a learning disability.
• Ensure all staff working in the medical care service receive appropriate supervision, appraisal and training to enable them to fulfil the requirements of their role.
• Ensure patients in the medical wards are treated with dignity and respect at all times.
• Ensure sufficient provision of hand gel dispensers within the emergency department.
• Ensure adequate provision of defibrillators and cardiac monitoring equipment within the emergency department.

In addition the trust should:

• Ensure there are effective and consistent systems for learning from incidents to be shared across the trust at all locations.
• Ensure there are sufficient computers available for staff use in the ambulatory care area of the emergency department.
• Ensure there is appropriate signage and information in the emergency department and that this is available and accessible to all people using the service.
• Ensure the process for diagnosis of fractures and how learning is analysed and shared within the emergency department reduces the impact of missed diagnosis on patients.
• Improve the time taken for the transfer of patient care from ambulance staff to emergency department staff.
• Ensure clinical leadership in the emergency department is delivered at a consistently high standard 24 hours a day, seven days a week.
• Ensure patient records are available when patients attend outpatient and diagnostic imaging clinic appointments.
• Ensure patient records are available when patients attend outpatient and diagnostic imaging clinic appointments..
• Ensure systems and processes are operated effectively to minimise delays for patients in outpatient clinics.
• Ensure there is a review the hours of service provided by the specialist palliative care team to consider a face to face service available seven days a week.
• Ensure patient outcomes are regularly monitored and reviewed to ensure the end of life care service is meeting the needs of patients.
• Ensure that medical consultant staffing for the children’s and young people’s service is in line with Royal College of Paediatrics and Child Health (RCPCH) standards.
• Ensure acute paediatric clinical guidelines are reviewed and follow best practice guidance.
• Ensure that the paediatric allergy clinic meets the 18 week referral to treatment target.
• Ensure that all nursing and medical staff in the children’s and young people’s service receive a minimum of yearly appraisals.
• Ensure controlled drugs are checked twice a day on the maternity ward, in line with the trust’s policy.
• Ensure that staff in the maternity service follow the trust hand hygiene policy.
• Ensure that workforce requirements are analysed in terms of what women using the service need, rather than what midwives do.
• Ensure accurate data is collected regarding the use of steroid medication for pregnant women at risk of early labour.
• Ensure information and guidance about how to complain is available and accessible to patients and visitors in the maternity service.
• Ensure appropriate care and treatment pathways are developed for women using the pregnancy day care unit.
• Ensure that midwife visits to mothers with new-born babies are in line with current National Institute for Health and Care Excellence (NICE) guidance.
• Actively seek and record women’s views and preferences regarding one to one care and postnatal visits by midwives
• Ensure cardiotocograph documentation follows current local and national guidance.
• Consider appointing a designated bereavement midwife and a diabetic specialist midwife.
• Ensure all staff in the maternity and gynaecology service understand their role and responsibilities regarding the Deprivation of Liberty Safeguards.
• Provide a home from home environment for giving birth for women at low risk of complications.
• Ensure women attending the termination of pregnancy clinic are seen by a diploma level qualified counsellor.
• Ensure there is a designated consultant to take the lead for fetal medicine and the pregnancy day care unit.
• Ensure there are sufficient operating theatre facilities and time dedicated for planned caesarean section operations.
• Review the protocols for how long women remain in hospital after giving birth and consider changes to improve access to the maternity service.
• Ensure staff in the maternity and gynaecology service understand and comply with the trust’s policy regarding interpreter and translation services.
• Ensure that all identified risks in the maternity service are regularly reviewed and added to the trust risk register where appropriate.
• Ensure maternity information leaflets are easily available in languages other than English.
• Consider the development of a maternity services liaison committee.
• Ensure systems are operated effectively to reduce delays in transfer from theatre recovery to the surgical wards.
• Review the use of theatres to improve flow and reduce delays between surgical cases.
• Ensure the delays in orthopaedic surgery caused by limited access to a skilled periprosthetic consultant are monitored and reviewed and appropriate measures put in place to mitigate risk.
• Ensure that staff practices on the medical care wards are in line with trust policy and current legislation regarding the prevention and control of infection.

Professor Sir Mike Richards

Chief Inspector of Hospitals