The Rotherham NHS Foundation Trust

Updated 29 September 2021

The leadership of the trust had significantly improved since our last inspection in 2018 but this was not yet enough to make an impact on the rating. Staff including the trust chair, who we interviewed at the last inspection, were overall very positive about the changes in leadership. Members of the board articulated they felt much more enabled, supported, listened to and empowered to undertake their roles than previously.

The leadership team led by the new CEO and chair had identified that the trust needed to develop their own plans to improve the people of Rotherham’s experience of services and this was a message we heard consistently throughout our inspection.

The trust had recognised that there was a need, because of the changes within the healthcare system, the impact of COVID-19 and the changes in the trust itself over recent years, to update and refresh the vision and strategy and hoped to take this to board in September 2021. The CEO articulated a clear vision of what the trust wanted to achieve. A new strategy was being developed with input from the wider system and local staff about how this was going to be achieved.

It was recognised by the board there had been challenges regarding the trust's organisational culture over the last few years. To address this, targeted and focused work had been undertaken with the board and executive team, including input from facilitators to identify issues to establish open and honest strong working relationships.

The trust had made good progress in strengthening its operational financial management and governance arrangements but there was further work needed to understand the scale of any underlying deficit supported by a credible analysis of the key drivers.

Whilst the improvements in leadership and culture were evident since our previous inspection, the trust recognised more work needed to be done to embed service improvements and for these changes to be reflected in positive patient outcomes.

When inspecting the core services at the trust we saw that some of the changes that had happened at a senior level in the organisation had not yet become embedded at ward/department level. There continued to be a slow progress in some areas against our previous inspection findings particularly in urgent and emergency care and medicine. All divisions had a triumvirate management team in place, however, not all posts were fully recruited to support this. Additional posts had only very recently been recruited to, such as quality improvement matrons and the deputy director of quality assurance.

The trust promoted equality and diversity in daily work and mainly provided opportunities for career development. However, the trust currently had no formal staff networks.

The aim of the trust was to work within the system and create partnerships with the local community as well as accessing NHS support to establish the trust as a supportive, diverse and inclusive employer for all the Rotherham community.

A significant level work had been done within the trust to improve the governance. Several initiatives had been put in place to improve governance at the trust. Including 'Safe and Sound', 'Perfect Ward' and the employment of quality improvement matrons.

The arrangements for some areas of governance were very new and at the time of the inspection it was not possible to fully evidence their effectiveness and the impact these changes would have. In some core services not all staff were clear about their roles and accountabilities and processes were not always completed in a timely manner. However, plans had been put in place to create the conditions and structures for effective governance in the trust.

Medicines optimisation within the trust required further development. The trust medicines optimisation strategy was out of date and had not been reviewed or renewed from April 2020. The trust did not have a pharmacy business plan, workforce plan or strategy specific to the pharmacy team. Medicines reconciliation rates within 24 hours consistently fell below the national average. There was no seven-day clinical pharmacy service. Multidisciplinary attendance at key medicines committees was not always in place with two out of the last four meetings not meeting quoracy.

Work was underway to embed the medicines safety officer role into trust governance processes. The controlled drug accountable officer role required further embedding and oversight to ensure that governance arrangements highlighted and took action on areas of concern found during the core service inspection. This was still an issue when we revisited during our well-led inspection.

We raised our concerns during our inspection and following the inspection, the trust provided an action plan which aimed to review medicines management, oversight, audit and governance processes within the trust.

Leaders and teams identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. However, systems to manage performance effectively were not always implemented.

In interviews with members of the Executive and Senior Leaders team people were all clear about the trust's risks and articulated a coherent consistent narrative. These included mortality, medical and nursing staffing and Child Adolescent Mental Health (CAMH) services.

However, the performance dashboard used in core services were at a high level and did not focus on the detail of quality or highlight specific concerns about patient care. Also, we were not assured in all core services that senior leaders had enough oversight of performance targets which could have a negative impact on patients' care and experience of services.

Information and data overall were well managed across the trust. New systems had been developed to improve patient outcomes such as 'Perfect Ward', these were introduced in a phased way and learning taken at each stage to improve the system. However, we did see instances on wards and departments where patient information was not stored securely.

Leaders and staff actively and openly engaged with patients', staff, the public and local organisations to plan and manage services. They collaborated with partner organisations and operated a system approach to help improve services for patients'.

The trust provided evidence of continued engagement with patient groups despite the pandemic and acted on their feedback.

The trust were committed to continually learning and improving services. Quality improvement methods had been introduced and staff understood the skills needed to use them, but these improvements were not fully embedded in all areas at the time of the inspection.

Updated 18 March 2019

Updated 18 March 2019

Updated 14 July 2015

Staff did not always report patient safety incidents and did not always receive feedback about incident investigations, and there was inconsistent sharing and learning across the service in order to improve practice.

District nursing teams were under-staffed and taking on increasing workloads. Fast response, intermediate care and, community matrons supported the district nursing teams, and we saw that all staff were dedicated to providing a good service for patients. However, staffing shortfalls meant that nurses could not attend mandatory and other training. Although there were governance structures in place to monitor and manage risks associated with district nursing staffing levels, demands on the service had not been addressed.

Arrangements to minimise risks to patients were in place and we saw elements of good practice including clean clinic areas, good infection prevention and control practice, a good understanding of safeguarding procedures and, the use of independent and community nurse prescribers.

Care was delivered in line with the trust policies and procedures, national guidance and, NICE quality standards and access to care and treatment and, outcomes for people were positive.

People who received care were treated with compassion and respect. We saw staff worked hard to ensure people received a high standard of care. All the patients people we spoke with were consistently positive about the care they received.

During our inspection we met with some dedicated, innovative staff who demonstrated the values of the trust, were passionate about their jobs and, were proud of their work but felt ‘ignored’ by the acute trust. Staff morale was low and many staff felt de-valued.

Updated 18 March 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• At our last inspection we rated safe, effective, responsive and well led as requires improvement. Caring was rated as good.
• At this inspection we rated safe, effective and well led as requires improvement. Caring and responsive were rated as good.
• Practitioners in the 0-19 service were holding high caseloads. There was a risk that records were not contemporaneous as high workloads meant that some practitioners were not completing their records in a timely manner. These issues had also been identified at our last inspection.
• There was no oversight of safeguarding referrals and in the sexual health service there were no safeguarding alerts on the electronic patient record. This meant that children and young people’s records may not be complete and staff may not be immediately aware of a vulnerable child.
• The 0-19 service were failing to meet some of their performance targets. Antenatal contacts, six to eight week contacts and health screening at school entry were all below target. This had been a concern at our last inspection.
• There was a limited number of audits in place and there was no audit plan.
• There was no process in place for regular clinical supervision and staff had varying experiences of receiving clinical supervision. This had been identified at our last inspection.
• Looked after children were not receiving initial health needs assessments in a timely manner.
• There had been a slow pace of change since moving to a 0-19 team and changes were not fully embedded. Staff were still working as separate health visiting and school nursing teams. Several changes in the management team meant that changes had not been driven forward. The service was moving to skill mix teams and competencies were written for the different staff bands, however, at the time of our inspection these competencies were not yet in place.

However;

• The new service leads were aware of the challenges to the service and there was a work plan in place for 2018/2019. The work plan incorporated workstreams including audit and clinical supervision. The service was working closely with the clinical commissioning group and the local authority to plan and deliver services.
• Staff were kind and caring. Their focus was on supporting children, young people and their families. There was effective multidisciplinary working, both internally and externally.
• New services, such as the paediatric acute rapid response outreach team (PARROT) had been set up to support unwell children in the home and avoid hospital admissions.
• The service had a vision and strategy and there were governance systems in place.
• The service provided care based on evidence based guidance and staff had access to up to date policies and guidance.
• Learning from incidents and complaints were shared at staff meetings. Presentations from the meetings were shared with staff. Service leads were attempting to engage with staff to keep them up to date with service development.

Updated 14 July 2015

Updated 2 March 2017

We rated this core service as good for safe, effective, responsive and well led. We rated caring as outstanding. This was because safety performance data was good; patients were protected from avoidable harm and abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Managers shared the learning from incidents. Record keeping was good. The environments were fit for purpose and equipment was available. Medicines were stored, prescribed and administered safely.

Although we were concerned that consent to care and treatment, at the Oakwood Community Unit, was not obtained in line with legislation and guidance, including the Mental Capacity Act 2005 for patients who lacked capacity, we saw that patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Patients were prescribed and administered pain relief in a timely manner. Staff providing care were competent and skilled and there was evidence of strong multidisciplinary team working.

Friends and family test results were 100% positive for both units. Feedback we received from patients and their relatives and carers was consistently positive. We observed consistently caring, sensitive and compassionate staff. Patients and their families were supported psychologically and emotionally.

Services had been planned and developed in a way that met the needs of the local population and teams were highly responsive to the needs of the patients in their care. The introduction of an activities coordinator at Oakwood Community Unit had ‘transformed the service’. We saw that vulnerable patients including those living with dementia were supported.

All teams were aware of the trust vision and values and we saw robust strategic plans for both services. Governance, risk management and quality measurement processes were embedded in the teams. Staff we spoke with told us that senior staff were visible and supportive. We found that staff in all teams were consistently positive, friendly, helpful and approachable in all areas we visited. All staff were team focused. We saw examples of innovation, improvement and sustainability.

Updated 2 March 2017

Overall rating for this core service

We carried out this inspection because when we inspected the service in February 2015, we rated the service as requires improvement. We asked the provider to make improvements following that inspection.

At this inspection, we rated services for community end of life as requires improvement, because;

The use of the end of life individualised care plan for adults was not embedded into practice and not used by all the services that provided end of life care. Managers within the community nursing service had recently began to review the use of the document in April 2016 and evidence on inspection showed that the document was not fully completed. Audits for community end of life were not embedded and actions were required to improve the quality of care provided in the community. These included staff completing and discussing advanced care planning to reduce the need for patients to be admitted to hospital unnecessarily.

Staff had completed mental capacity training, however ‘do not attempt cardiopulmonary resuscitation (DNACPRs) were not completed appropriately for patients who lacked capacity and mental capacity forms and assessments were not completed. This was identified as a risk within the CQC comprehensive inspection in February 2015. Policies required to be reviewed in line with national guidance and the trust’s timescales; these included DNACPR policy and syringe driver policy.

The trust still needed to build on the work they had commenced for the end of life strategy. For example, they needed to improve advanced care planning and implementation and embedding the individualised end of life care plan. These areas were not included as risks on the risk register. Preferred place of care was not always recorded on the patient’s record which would identify where they wanted to be cared for within the last few days of life.

Ongoing communication was still required to aid integration of the acute and community services.

The trust had made some improvements from the CQC inspection in February 2015. These included staff reporting incidents and receiving feedback from the trust. Incidents were now shared across various methods. Safety huddles were held to discuss staffing levels and to look at the allocation of staff when required. Procedures were in place for patients whose visits required to be rearranged and patients who wanted visits would be seen. Staff could access patient’s electronic records and further software had been added to the laptops to use in areas with connectivity issues. The implementation of the care co-ordination centre allowed patients to access a professional at any time who would contact the appropriate team.

We also saw that anticipatory medication was provided to patients and staff could prescribe medication quickly for patient’s whose symptoms could not be controlled. Staff managed patient’s pain and nutritional needs and completed the appropriate assessments. Equipment was available for patients and staff would often pre-empt and ensure equipment was at the patient’s house incase it was required.

All community areas provided good links with GPs and the palliative care team to manage the patients. Some GP surgeries were on the same patient electronic system and could see the care records provided by the community services.

Staff provided compassionate and supportive care within the home and ward environment. Patients were encouraged to be involved in decision making about their end of life care needs. Staff communicated well and worked together to plan the care and treatment.

Senior staff in all community settings could complete fast track forms; this enabled care to be put in place quickly for patients whose condition was deteriorating and may have requested their preferred place of death at home.