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.
There are four registered locations King’s Mill Hospital in Sutton-in-Ashfield, Newark Hospital and Mansfield Community Hospital.
Newark Hospital provides a range of treatments, including consultant-led outpatient services, planned inpatient care, day-case surgery, endoscopy, diagnostic and therapy services, and a 24 hour Minor Injuries Unit & Urgent Care Centre. There were 47 beds across two medical wards. The day case surgery ward had facilities for up to 30 patients.
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 and the trust was subsequently placed into “Special Measures” by Monitor, the independent regulator of NHS foundation trusts. CQC undertook a first comprehensive inspection of the trust in Spring 2014. Although some improvements had been made CQC recommended a further period in special measures and gave an overall rating of ‘Requires Improvement.’
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 and we also spoke with staff individually.
Overall, this trust was rated as Inadequate. We made judgements about 13 services across the trust based on the five key questions that we ask.
At Newark hospital we rated the minor injuries unit, medical and outpatient and diagnostic imaging service as “Inadequate” and the surgical service as “Requires Improvement.”
Our key findings were as follows:
- Overall the hospital was clean, hygienic and well maintained but policies were not always followed on one of the wards.
- Improvements were needed to the safety of the minor injuries unit. Training on the care and treatment of children was needed. There were environmental risks for people who were at risk of self-harm.
- Medical staffing on the Minor Injuries Unit relied on locum medical staff. Nursing staffing levels were as planned within the surgical and outpatient service and staff felt they had the right number to meet patient’s needs. Beds had been reduced on one of the medical wards so that safe staffing levels could be maintained. Nurse staffing levels were as planned and there was an escalation process in place if levels fell short.
- Patient’s privacy was not always respected in the minor injuries unit. Doors/curtains were not always closed. Despite this we observed positive interactions between patients and staff.
- Patients attending the surgical service received individualised care. Care and treatment was evidence based and pain was well managed. The surgical service saw patients within national targets for treating people within 18 weeks of referral.
- In January 2015 the trust identified a significant number of patients, around 19,500 in total, where the outcome of their outpatient appointment was not recorded in the electronic system correctly, or they were overdue for review appointments. The trust’s initial response to the backlog of patients did not identify which patients needed review most urgently. There were delays in responding to the issue and in completing the work as planned.
- We were concerned about the trusts 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%.
- There were no specific audits that assessed the outcome of patients at Newark Hospital. It was not clear how the trust monitored the effectiveness of the service they were providing.
- There was a strategy for Newark Hospital but staff were frustrated by lack of pace to deliver this vision and felt there was poor leadership. We found little evidence of the progress made with implementing the vision and strategy. Morale amongst staff, particularly those in more junior levels was poor at Newark Hospital. Newark Hospital provided the trust with a range of opportunities to deliver new models of care but we saw little evidence that these opportunities were being taken forward.
There were areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure medicines are always safely managed in line with trust policies, current legislation and best practice guidance.
- Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance.
- Ensure staff understand the requirements of the Mental Capacity Act 2005 in relation to their role and responsibilities.
- Ensure all equipment, including emergency lifesaving equipment, is sufficient and safe for use in the minor injuries unit.
- Ensure safe care for patients with mental health conditions at the minor injuries unit and especially those who may self-harm or have suicidal intent.
- Ensure staff have the appropriate qualifications, competence, skills and experience to care for and treat children safely in the minor injuries unit.
- Ensure the inter-facility transfer protocol with East Midlands Ambulance Service is updated and is effective in providing safe and timely care for patients at the minor injuries unit.
- Ensure the ligature risk posed by the use of non-collapsible curtain rails in the minor injuries unit is addressed.
- Ensure there are effectively operated systems to assess, monitor and improve the quality and safety of the services provided in the minor injuries unit.
- 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 robust and effective governance links and oversight are established and maintained between outpatient services at Newark and Kings Mill Hospitals.
- Ensure the quality of the service provided by the specialist palliative care team is effectively monitored and reviewed 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 pacemaker devices removed from deceased patients are safely and promptly disposed of.
Professor Sir Mike Richards
Chief Inspector of Hospitals