All inspections: Sunderland Royal Hospital

Our rating of services improved. We rated it them as good because:

There were commendable examples of compassionate care; we saw staff go the extra mile several times and their care and support exceeded good care standards in some circumstances. There was a strong, visible person-centred culture. Discussions between staff and patients were carried out in a compassionate and supportive way; staff provided reassurance and information appropriate for the individual patient and their family.
Pathways of care were focussed on the individual patient and involved collaboration with other service providers to meet the needs of patients and to ensure continuity of care.
Patients with a learning disability, those living with dementia, and bariatric patients could access services appropriate for them and their needs were supported. Patients needing care and treatment for their mental health needs could access services in a joined-up way within the hospital.
Patients we spoke with all felt involved in their care and had been provided with information to help them make informed decisions about their care.
Patients were protected from abuse because staff had received training in safeguarding; there was a multi-disciplinary safeguarding team who provided comprehensive support to front line staff.
Patients, families, and staff were supported by the delirium and dementia outreach team (DDOT). The team supported patients with, or at risk of cognitive difficulties. There was support for carers and families in the form of information, education, and specialist advice. Therapeutic activities were provided for patients and the DDOT team visited wards across the trust to support cognitively frail in-patients who could not leave the acute areas. A follow up outpatient clinic was provided for patients who had experienced delirium.
The psychiatric liaison team supported patients with mental health needs who were cared for in all areas of the hospital. The team also provided training to staff in order to support their learning.
There were established multidisciplinary team (MDT) meetings for discussion of patients on specific pathways or with complex needs, this included attendance from nursing and medical staff, allied health professionals, and social workers.
There was collaborative working with the local authority to promote timely safe discharges from hospital.
There had been pharmacy initiatives which had been developed to support the needs of frail older people.
There was strong clinical leadership in the areas we inspected and a strong sense of teamwork within different groups of staff who worked cohesively together for the benefit of patients. Leaders were visible, approachable, and responsive and promoted cohesive working and a positive culture.
Staff generally felt that managers communicated well with them and kept them informed about the management of the wards and service changes.
Staff were encouraged to report incidents. We saw evidence from actions plans and root cause analysis that staff had identified and investigated serious incidents appropriately.
Local risk registers were in place which highlighted current risks and actions being taken to reduce the risk. Risks were discussed at governance meetings and we saw escalation of the risks to senior managers and clinical leads within the directorates.
Changes in practice were based on national guidelines and best practice and were audited to ensure they were embedded throughout the clinical areas.
There had been improvements in the recruitment of nursing and medical staff.
Wards, department and public areas were clean and tidy. Cleanliness scores were displayed in the clinical areas. All clinical equipment was clean and ready for use.

However;

Nurse staffing levels were consistently poor in some medical, elderly and surgical wards. There were unfilled shifts in acute areas; staff were moved from wards with higher levels of staffing to cover those working with less than safe levels. This impacted on the safety and quality of patient care.
Infection control procedures were not always followed in relation to hand hygiene, the use of personal protective equipment; staff were not always ‘bare below the elbow’. This posed a risk to patients.
Resuscitation and emergency equipment was not always checked regularly to ensure medicines and equipment was safe to use and within date.
There was inconsistent practice across wards regarding the management of medicines, for example drug fridge temperatures were not consistently recorded on some wards. Controlled drugs were not always checked as per the hospital policy.
Mandatory training was not always completed by medical or nursing staff in a timely manner and there was a need to improve compliance with mandatory training.
Some national audit results were poor and clinical areas were not meeting standards.
The trust was much worse than the England average for unplanned re-attendance rates in the emergency department.
Lessons learned after two never events in 2017 were not shared across all surgical areas after each of the events.
Some clinical policies and guidelines were past their review date. This meant staff did not always have the most up to date guidance to follow.

Sunderland Royal Hospital is one of two acute hospitals forming City Hospitals Sunderland NHS Foundation Trust. The trust provides acute hospital services to a population of around 350,000 people across the Tyne and Wear and Durham area. In total, the trust has 855 beds across two hospitals and employs around 4,923 staff. Sunderland Royal Hospital has 833 beds.

Sunderland Royal Hospital provides medical, surgical, critical care, maternity, children’s and young people’s services for people across the Tyne and Wear and Durham area. The hospital also provides accident and emergency (A&E) and outpatient services.

We inspected Sunderland Royal Hospital as part of the comprehensive inspection of City Hospitals Sunderland NHS Foundation Trust, which includes this hospital and Sunderland Eye Infirmary. We inspected Sunderland Royal Hospital on 17, 18 and 19 September and 2 October 2014.

We carried out this comprehensive inspection because the Care Quality Commission (CQC) had placed City Hospitals Sunderland NHS Foundation Trust in risk band 2 in the CQC’s Intelligent Monitoring system.

Overall, we rated Sunderland Royal Hospital as requires improvement. We rated it good for being effective, caring and well-led, but it requires improvement in providing safe and responsive care.

We rated A&E, surgical services, critical care, maternity, services for young people, end of life care and outpatient services as good, with medical care as requiring improvement.

Our key findings were as follows:

Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. Rates of Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) were within an acceptable range for the size of the trust.
Patients were able to access suitable nutrition and hydration, including special diets. Patients reported that, on the whole, they were content with the quality and quantity of food.
Processes were in place for implementing and monitoring the use of evidence-based guidelines and standards to meet patients’ care needs.
There was effective communication and collaboration between multidisciplinary teams.
There were staff shortages, particularly on the medical wards, mainly due to vacancies for nursing and medical staff. The trust was actively recruiting following a review of nursing establishments. In the meantime, bank and locum staff were being used to fill any deficits in staff numbers.
The trust had an overall elevated risk for the Hospital Standardised Mortality Ratio, which was higher than expected for weekend mortality as well as for weekday mortality. It was working with other trusts in the region and with NHS England to improve its mortality rates.

We saw several areas of outstanding practice, including:

Close collaborative working between the directorate of paediatrics and emergency medicine, which had developed a shared medical consultant staffing approach that included consultant staff qualified in paediatric emergency medicine.
The directorate of paediatrics had facilitated the inspection of the service by a team of young people.
The use of telehealth in maternity services. This system enabled women to monitor their blood glucose levels and blood pressure in their own homes, avoiding unnecessary visits to hospital.
The compassion shown to families if their family member died while on critical care. Nurses placed a locket of hair and the rings of the patient in a small silver bag, and handed a printed card to the family expressing sympathy from the staff on the critical care unit.

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

Importantly, the trust must:

Ensure that there are sufficient qualified, skilled and experienced nursing and medical staff, particularly on medical wards, including provision of staff out of hours, on bank holidays and at weekends.
Ensure that staff are suitably skilled and supported through the completion of mandatory training and appraisals, particularly in the A&E department.
Ensure that medicines are managed appropriately. Medicines were not always started promptly when a patient was admitted at the weekend, and controlled drugs incidents were not appropriately investigated and reported within the hospital.
Ensure that there is appropriate pharmacist support to ward and units, including with the reconciliation of medication.
Ensure that patients are placed on the most appropriate ward to meet their needs.
Ensure that the hospital fully complies with the four-hour wait standard in accident and emergency (A&E) and meets the standard that ambulance patients should be handed over within 15 minutes of arrival in the department.
Continue to review and reduce the mortality outliers for the Summary Hospital-level Mortality Indicator (SHMI) within the trust.
Ensure that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) orders are signed by the appropriate medical professionals, and that discussions with patients or family members are recorded.
Ensure that patient observation and monitoring charts for nutrition and hydration are fully and appropriately completed on medical wards.

However, we found that there was an area of poor practice that was a trust-wide issue resulting in a compliance action at trust level. This is reported in the trust provider report, which states:

The trust must:

Ensure that patient group directions (PGDs), which are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment, are updated and monitored in line with trust policy

In addition, the trust should:

Review the training of competency of staff who care for patients being discharged to the community with syringe drivers in place. This will ensure that patients are not taken off one piece of equipment before discharge and then connected to the other equipment used in the community.
Provide training on the grading of incidents and ensure that there are effective incident feedback mechanisms in place so that lessons can be learnt.
Review the arrangements over the storage and supply of surgical instruments to ensure that there is appropriate provision of equipment.
Review the storage and provision of linen in ward areas so that staff are assured that it is clean before use.
Review staffing in the specialist palliative care team in accordance with commissioning guidance.
Have in place assurance that training, supervision, appraisals and revalidation are monitored for the specialist palliative care team, who are employed by a different trust.
Collect and monitor information regarding patients dying in their preferred place of death.

Have mechanisms in place for reviewing and, if necessary, updating patient information, particularly in the outpatient department.
Introduce patient surveys specific to the outpatient department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The focus of this inspection was the accident and emergency department, care of the elderly and out patients. We undertook a visit over two days and visited accident and emergency, human resources, outpatients, and wards B21, E54, D43, F61 and E55. We also spent time with the Patient Advice and Liaison Service (PALS) and complaints teams. The inspection team included a compliance manager, three compliance inspectors, two specialist professional advisors and an expert by experience.

We found that patients' needs were assessed and their treatment plans were discussed with them and reflected relevant research and guidance. Patients told us they felt informed about what was happening to them regarding their care and discharge arrangements. People told us they were happy with the care and treatment they received.

We saw staff were recruited in a safe and effective way. The human resources department undertook checks to make sure people applying to work for the Trust had appropriate qualifications, skills and competencies prior to commencing employment.

The hospital was well-led and had a thorough system of checks to monitor the quality of the care provided at ward level. There was a clear route to ensure that any issues or risks were raised to the executive team and the senior management team.

There were significant changes being made to the complaints procedures and where there had been some delay in managing complaints in the past, the actions taken by the Trust to make it more responsive and inclusive for people who have raised concerns was impacting in a positive way.

The visit to Sunderland Royal Hospital began at 7am on the accident and emergency department. We visited the medical admissions unit, surgical admissions unit and wards E53, B26,C32,C31. We focused on the pathway people took from accident and emergency to the initial admission areas and to the ward appropriate for their condition.

Patients told us their privacy was maintained for example "they try their best but it's a shared ward", and 'they make sure that I am not embarrassed even when I need to use the toilet'. Others told us "the nurses are great, we have no problems and they have a nice manner.' Patients told us they 'felt safe', one said "Staff are nice" and another person who had frequent admissions told us 'I feel safe and nurses are kind. I have no complaints.'

Staff were positive about the support they received, their training and the resources available to carry out their role effectively. They gave us examples about how they talk to the patients about their treatment options and give support in line with the nursing and medical care plans.

The information we had for the outcomes we looked at, from external surveys and reports from other agencies was similar or better than other comparable services. People shared their views about the service by using the NHS Patient Choices website and the CQC 'Tell us your experience' facility on our website which were positive and negative in nature. We looked at the issues raised as part of this visit.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

As part of the review of City Hospitals Sunderland NHS Foundation Trust we carried out a visit to Sunderland Royal Hospital. The visit was carried out by four compliance inspectors, a regional intelligence and evidence officer and an expert by experience. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service. Experts by experience come from varied backgrounds.

We spent time on the out-patient departments, the medical admissions unit, and surgical and medical wards. We spoke with patients and their visitors about their experiences of the hospital and the service they had received. We also spoke with staff and observed how patients were cared for and how staff undertook their day to day duties.

Comments from patients' about their care and treatment included 'I'd give the nurses 10/10, they work hard and I'm well cared for' and 'they've looked after me properly'; they also told us 'the nurses will do anything you ask', that they 'felt safe on the ward' and that, 'everyone is lovely, very nice'. People also told us, 'it's been alright, fine' and one person said that it was, 'better than I expected' One person said "I couldn't fault the care' and when asked about how they were treated, one person said that staff were 'really nice and helpful' and another person said they were "very good.'

The majority told us that they enjoyed the food although one said that she had not liked all of the food available but 'generally there was always something to choose'. A person told us 'It's very good, nobody can complain about the food'; another said 'They try to give me what I like. I have to drink a lot, the staff remind me. The food is nice'.

We did receive some negative comments including one person who told us that they did not like being on the ward and that although some staff were 'okay' she said, 'I wish some staff were more friendly, they always seem too busy'. One person's relatives raised concern about trying to find out about their relatives care 'no one seemed able to tell us' and that they had been unable to speak to any one from the ward on the telephone which they said was very distressing. These comments were passed on to the hospital and action was taken to address peoples' individual concerns.

We asked people about the length of time they had to wait after using the buzzer to attract staff attention. One person said, 'They seem to take a long time to answer' but another person said they waited, 'a normal time, it depends which ones on duty but it's never very long'. Another person said, 'They don't come immediately but they do answer quickly.'

Archived: Sunderland Royal Hospital

All Inspections

17 April 2018

During a routine inspection

17-19 September and 2 October 2014

During a routine inspection

Professor Sir Mike Richards

10, 11 December 2013

During a routine inspection

13 November 2012

During a routine inspection

23 March 2012

During a themed inspection looking at Termination of Pregnancy Services

7, 20 November 2011

During a routine inspection