Our rating of services improved. We rated them as good.

A summary of this hospital appears in the overall summary above.

In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures.

We chose this hospital because they represented the variation in hospital care according to our new intelligent monitoring model. This looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations. Using this model, Sherwood Forest Hospitals Foundation Trust was considered to be a high risk trust.

We carried out an announced visit on 24 and 25 April 2014 and unannounced, out-of-hours visits on 29 April and 9 May 2014.

Our key findings were as follows:

• We saw poor record keeping in some areas, particularly relating to patients care.
• We found that staffing in some areas was below the levels that would be expected.
• Care plans should be improved to reflect patients needs.,
• Discharge planning should be improved.
• The WHO surgical checklist should be embedded in all practice.

We saw several areas of outstanding practice including:

• The Rotherham model for reducing smoking in teenage pregnancy has reduced  smoking rates.
• Pillow cards were left in Gynaecology during comfort rounds when a patient was asleep or not in their bed so they knew when the next round would be.
• There was good multidisciplinary working across the trust.

Importantly, the trust must:

• ensure that accurate record keeping is maintained with regard to people’s observations and hydration.
• ensure that accurate record keeping is maintained on drug administration charts so people receive the appropriate care and treatment for their needs.
• ensure that all staff have the competence to recognise when a person is deteriorating so appropriate care is provided.
• ensure that there are secure systems for storing medicines and that people are given medicines according to their prescription.
• ensure that all people have an effective and current care plan that meets their individual needs and provides appropriate guidance for staff to be able to meet their needs.
• ensure there is full medical support for all surgical specialties, in particular vascular services.
• ensure mandatory training and appraisals take place to ensure all staff are appropriately trained and have up-to-date knowledge.
• ensure actions taken and lessons learned are shared with staff at all levels
• ensure that staff mandatory training and appraisals are completed to meet trust targets

In addition the trust should:

• Equipment should all be portable appliance tested and serviced to ensure they are fit-for-purpose
• Midwifery staffing could be improved by completion of the directorate's on-going recruitment programme
• The trust should ensure that team briefings are completed before and after surgery, including fully embedding WHO surgical safety checklists
• Introduction and implementation of children and young people services specific pain management guidance and protocols.
• Nurse presence and inclusion at all 'Team Around the Child' ward rounds on paediatric ward, ward 25.
• Confirm and establish longer term nurse management structures on paediatric ward, ward 25, to provide staff with increased, visible managerial support.
• Increased receptionist staffing on paediatric ward, ward 25, including weekends.
• The trust should ensure that people with a dementia have an accurate and current care plan to provide staff with clear guidance to meet their needs.
• The trust should ensure there is an appropriate skill mix of nursing staff on duty so that people’s needs are recognised and met.
• The trust should plan to provide seven day a week and effective out of hours cover by doctors and consultants for all specialties.
• The trust should ensure that effective discharge planning occurs across all specialties for all people who are fit for discharge.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We inspected Kings Mill Hospital between June and July 2013 and found serious concerns over the way the trust assessed and monitored the quality of services.

At this visit we inspected Kings Mill Hospital in order to follow up on compliance with the Warning Notice served in June 2013.

We visited a range of wards and departments, spoke with patients, their relatives and visitors. We spoke with a range of staff including the Chief Executive and Chair, members of the executive team, doctors, nurses and support staff. We were assisted by a specialist advisor in trust governance and assurance. We worked with NHS England who had a team visiting the hospital undertaking an assurance review of actions taken to address issues from the Bruce Keogh Rapid Responsive Review, which took place in June 2013. We attended interviews and staff focus groups with the NHS England team and shared information before and during the inspection. We examined documents such as Board minutes, information about complaint monitoring and the Board Assurance Framework.

We found in the leadership team a commitment to improving the quality of care experienced by patients and a determination to address shortfalls identified in the past. New appointments to the Board and governors had taken place. Work was progressing on the development of the leadership team and governance members with their role in supporting good governance in the trust.

We found the trust had introduced a broad range of initiatives to improve the governance arrangements and to align these with the Board Assurance Framework.

We found a number of examples where new initiatives demonstrated better communication and reporting between the Board and the ward and back to the Board. Some initiatives had only been introduced a week or two before the inspection or were still in the planning stage. Therefore the trust was not in a position to assess whether these were effective, although early indications were positive.

We found improvements in the way the trust maintained its risk registers. The system was more robust and ensured accountability for actions. We were informed by the trust that they had dealt with the backlog in radiology reporting. A system had been introduced so that when necessary reports were dealt with through evening lists or assistance from external providers. The issues within the radiology department remain a significant risk due to the high number of vacancies unfilled and the trust is working with the Royal College of Radiology to find a solution.

We found a Nursing and Midwifery Strategy had been introduced and there was an increase in nursing staff on nights. Staffing levels were reviewed daily, with numbers on duty being displayed on ward notice boards. In October 2013 a paper had gone before the Trust Board proposing a £4million investment in nursing posts. We were informed following the inspection that this investment had been agreed at the December 2013 Trust Board meeting.A recruitment strategy had been developed including international recruitment and a return to nursing practice programme. Recruitment for medical staff remained a challenge. There had been an effort to increase middle grade and consultant support, but some doctors reported this had not kept pace with increasing patient numbers.

We found a commitment to improve the patient experience and embed the patient’s voice into the activities of the trust. Listening events with the general public and staff had taken place to improve patient, public and staff engagement. Plans were being developed on how to improve services by incorporating feedback from these events.

Staff were committed to improving the processes for feedback on patients’ experience and learning from incidents and complaints. The backlog of complaints had been cleared and improvements on information about complaints, including themes was being provided to the Board.

The director of nursing was developing a Patients’ Experience Strategy and better working was reported between the wards and the Patient Advice and Liaison Service (PALS) to ensure improvements followed from patient feedback.

We found information available throughout the hospital about how to complain and the PALS but most patients spoken with were not aware of the process or the services available. However, all patients spoken with stated staff had been supportive and they could raise any concerns with them. One patient said, “Staff asked me whether I would like to complete a ‘Friends and Family Test Form’. I was happy to do so as I have felt safe here.” Another patient said, “I would recommend this place to my family and friends, which several years ago I wouldn’t have been able to do.”

Many of the staff described the trust as, “Being on a journey’. The challenge for the trust is to complete work on planned initiatives, embed new arrangements across the trust and ensure improvements are sustained in the long term. This will require a commitment from the Trust Board, particularly in ensuring the pace of change is timely with a continuous review of effectiveness going forward.

We had been informed that some patients had received inaccurate information following an examination of breast tissue taken and tested at the Kings Mill hospital between 2004 and 2011. Although the results of testing had an effect on individual treatment plans, the patients concerned were not recalled by the hospital until October 2012.

Current breast care patients we spoke with reported that they were very satisfied with the care and support they had received from the breast care unit at the hospital. One patient explained that that they were, "more comfortable, because I know why I am here and what’s happening." Another patient told us,"The care here is spot on."

Patients on the wards we visited gave us positive comments about their care and treatment. One patient told us, "I have been happy with the treatment provided. I think the care is good and I trust the nurses with what they do."

We spoke with the relatives of patients and one said that the hospital was, "Very good, any problems we had were sorted straight away and I feel I can speak with the doctors and nurses openly."

We found that nursing care planning followed a standard format in the hospital, and core care plans were being used. Daily records were up to date and showed that patients were offered individual sessions with staff to discuss their progress. Each nursing entry commenced with "Consent gained prior to nursing ."

We could not assure people that the care, treatment and support they received when they used the diagnostic services met their needs and protected their rights. We asked the Royal College of Pathologists to investigate services in the histopathology department. This confirmed that people's care and welfare needs were being met with regard to diagnostic and screening procedures at the hospital. A summary of the findings is included in our report and their full report from the Royal College of Pathologists has been published separately.

We had been informed by Monitor (the independent body who authorise and regulate NHS foundation trusts) that they were concerned about the trust’s governance duties and its general duty to exercise its functions effectively, efficiently and economically.

We asked a ward manager if they were confident in the running of the trust. They answered, "More than I was. It’s all more organised now." They also told us of helpful weekly meetings with the head of nursing.

We spoke with non executive directors who were well informed and aware of their roles and responsibilities within the organisation. They were very supportive of the executive team and they assured us that quality of care would not be compromised by any financial decisions. They also told us, "All concerns need to get to the board quicker. At present some of the emphasis is lost."

We spoke with three patients who told us that before they received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

We spoke with four patients who told us they had no concerns about the security of their records and had not seen any incidents where personal information had not been kept confidential.

Patients told us that they understood the care and treatment choices available to them. They told us that their privacy and dignity was respected. They also told us that they felt listened to and their views were taken into account.

Patients told us that they had not been asked to sign any consent forms (for nursing care). This is in line with the Trust's policy which is based upon Department of Health guidance. They also told us that staff did ask permission before providing basic care and treatment such as toileting and bathing.

Patients told us that they were satisfied that the ward and their bed areas were kept very clean and tidy. All patients told us that they observed all staff use hand gels after they had provided them with treatment.

All patients told us that staff gave them their medicines in a timely manner. Patients also told us that their medicines were appropriately locked up and that staff always waited and supervised them to take their medication. A patient said, “I forgot to bring my anti depressants, when I told staff about this they quickly arranged for some more from the pharmacy, I was very impressed.”

All patients told us that staff across all different levels and job roles were competent and suitably skilled to do their job. A patient said, “I feel safe here and the staff are competent in what they do.”

All of the patients that we spoke with told us that staff had not told them how to make a complaint, nor had they been provided with any written information telling them how to make a complaint. A patient said, “I have not been told how to make a complaint, but if I had one I would speak to the nurses as they are very approachable.” Another patient said, “Staff have not told me how to make a complaint, but I have seen a complaints’ notice behind the nurses station, I have not had to make a complaint.”

Patients told us that their records were kept safe and that staff ensured their confidentiality was protected. A patient said, “I do feel that the records are kept safe and confidential, I have not seen any lying around."

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.