We carried out a focussed unannounced inspection of the Rotherham General Hospital. We visited the hospital on 17 July 2018 because we identified concerns in relation to: -

• The management of non-invasive ventilation (NIV) patients admitted to the Rotherham General Hospital
• The management of the deteriorating child in the urgent and emergency care centre at the Rotherham General Hospital

We did not rate the service because this was a focussed unannounced inspection looking at specific areas of concern. Therefore not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

We inspected the paediatric area in the urgent and emergency care centre and visited the medical wards to look at the management of acute non-invasive ventilation (NIV) patients. Non-invasive ventilation (NIV) is the use of airway support provided through a face (nasal) mask or a similar device.

For this inspection we only inspected the safe domain. The inspection was based on specific key lines of enquiry relating to assessing and managing risk, incidents, medicines management, patient records, environment and equipment, training and competency and medical and nurse staffing.

We requested further information following the inspection to provide assurance that immediate risks to patients were being addressed. We made a formal request for assurance using our powers under Section 31 of the Health and Social Act 2008. Section 31 allows the Care Quality Commission to take urgent enforcement action if it has reasonable cause to believe that, unless it acts any person will or may be exposed to the risk of harm.

The trust provided a detailed response including improvement actions taken or planned for completion by November 2018. This showed that sufficient actions had been planned to address the immediate risks to patient safety within the service.

In the Urgent and Emergency Care service (paediatric area), we found that:

• There was insufficient escalation and management of the deteriorating child, and a lack of oversight and governance of the risks to children within the paediatric (children’s) urgent and emergency care service.
• There were three serious incidents that highlighted a lack of clinical oversight, poor medicines management and delayed diagnosis and treatment of children in the urgent and emergency care services.
• There was no paediatric-specific training for staff or competency assessment in place for sepsis or diabetes / diabetic ketoacidosis(DKA). Staff did not routinely use Paediatric Early Warning Scores (PEWS) on all children attending the department.
• Patient records were not complete and contained errors and omissions. Daily resuscitation equipment checklist records were not always completed by staff.
• We asked the trust to provide further information following the inspection that immediate risks to patients attending the paediatric urgent and emergency department were being addressed.
• The trust provided a detailed response including improvement actions taken or planned for completion by October 2018. This showed that sufficient actions had been planned to address the immediate risks to patient safety within the service.
• A multi-disciplinary paediatric task and finish group was established following the inspection to oversee improvements and address the immediate risks to children.
• The information detailed a number of actions that had been implemented including the completion of a risk assessment, additional recruitment, improvements to staff rotas with consultant and middle grade doctor cover, implementation of staff training and increased monitoring. Further improvement actions were planned for completion by October 2018.

In the Medical Care service (acute NIV patients), we found that:

• There was insufficient management, oversight and governance of the risks to acute non-invasive ventilation (NIV) patients admitted at the hospital.
• Inspiring Change, a report published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2017 identified areas for improvement following a review of patients receiving acute non-invasive ventilation.
• The NIV services were not provided in line with British Thoracic Society (BTS) guidelines. Patients did not always receive care in specifically identified area(s) and nurse staffing levels were not always sufficient to meet the needs of these patients.
• In the patient records we reviewed we found that they contained errors and omissions and showed evidence of delayed escalation and delayed or missed observations.
• Patients did not always have a specialist consultant review within 14 hours of admission and patients did not have a daily consultant review thereafter.
• We asked the trust to provide further information following the inspection that immediate risks to non-invasive ventilation patients were being addressed.
• The trust provided a detailed response including improvement actions taken or planned for completion by November 2018. This showed that sufficient actions had been taken to address the immediate risks to patient receiving non-invasive ventilation at the hospital.
• The trust reported following the inspection that from August 2018 onwards all patients that commenced on NIV would receive ongoing care and treatment within the high dependency unit (HDU). This would allow NIV patients to receive care and treatment by appropriately trained and competent staff and achieve recommended staffing levels, in line with BTS guidelines.
• The NCEPOD recommendations and action plan were reviewed and updated and a further audit had commenced.
• Additional record audits and spot checks were taking place or planned to improve documentation compliance.
• The roles and responsibilities of the clinical lead for NIV were defined along with support functions. A multidisciplinary NIV task and finish group was also established following the inspection to oversee NIV patient safety.
• An additional middle grade registrar position had been added to rosters to support patient reviews at weekends.

Professor Ted Baker Chief Inspector of Hospitals

People told us what it was like to be a patient in The Rotherham NHS Foundation Trust Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We visited four wards during this inspection, the wards primarily provided care and treatment to older people.

We spent a period of time observing staff providing care to patients. This method of observation is called the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed six patients on one of the wards for a period of 45 minutes during lunchtime. We recorded their experiences at regular intervals. This included noting the patient’s mood, and how staff interacted with patients, other patients who used services, and the environment.

We saw patients were given the option to use cleansing wipes prior to the meal. Meals were well presented and patients were given the assistance they needed.

The patients with whom we spoke told us that they were treated with dignity and respect. They also confirmed that they were asked what name they wished to be called and their wishes were respected. One patient said “Nurses asked me what I liked to be called. They call me Mrs C this is what I want.”

Patients told us that they were involved in decisions about their care and treatment, and the nurses took time to explain how treatment was given. One patient said “They explain what, why and how about my treatment and keep me informed of progress.”

Patients told us that they were very satisfied with the meals provided while they were in hospital. Patients were provided with a wide choice of food and drink which they selected earlier in the morning. The food was described as “Delicious.” “Choice and variety of food is fantastic.” “It’s substantial when you think of the number and variety of people they cater for.”

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.

People told us that they were regularly consulted about their care and treatment. People said the consultants spoke to them on the wards and told them about the treatment and how long they may have to stay in hospital. They told us the staff always respected their dignity and ensured their privacy was maintained. People told us “Physiotherapists and Occupational Therapists helped them to get on their feet and made sure they were safe”.

People told us that they had given consent to the care and treatment they received, although some said they had been really poorly and could not remember much about their admission into the hospital.

People told us they were very well looked after and they rated their care as very good. They said they received help with personal care and the nurses were “like angels”. They said that everyone was working to assist them to go home, which included making plans to help them return home.

One person told us that the food was very good, with lots of choice. People said they could choose to have soup and a sandwich instead of a big meal. Another person told us the food is smashing, with lovely roast dinners. “We get lots of drinks including water and choices of tea and coffee”. “The food is nutritional and was always hot”.

Our rating of services stayed the same. We rated the hospital as requires improvement because we rated the domains of safe, effective, responsive and well-led as requires improvement, and we rated caring as good.