We carried out a comprehensive and announced inspection of the Royal National Hospital for Rheumatic Diseases between 15 and 18 March 2016, as part of our comprehensive inspections programme of all acute NHS trusts.

The Royal National Hospital for Rheumatic Diseases is a registered location and provides medical, children’s and outpatient services. We did not inspect the children’s services as part of this inspection.

We rated the Royal National Hospital for Rheumatic Diseases (RNHRD) as requires improvement overall. There were improvements needed in safety, responsiveness and leadership in the medicine (including older people’s care) service, which was requires improvement overall. The outpatient service was rated as good.

Our key findings were as follows:

Safe:

• Patients admitted to the medical ward with complex needs did not have care plans in place to provide the staff with detailed information and guidance regarding their care and treatment needs.
• Patient monitoring records and charts were not fully or consistently completed.
• It was not clear that correct procedures had been consistently followed when staff identified safeguarding concerns in relation to patients admitted to the ward.
• Patients admitted to the ward were screened for infections prior to being admitted to the ward. However, the results from the screening test were not stored in the notes held on the ward but returned to medical records. This meant there was a risk that the promotion and control of infection on the ward would not be effective.
• Not all staff had completed their mandatory training.
• There was not a clear system in place to provide consultant cover for medical patients who were transferred from the Royal United Hospital (RUH).

However:

• Staff understood their responsibilities and were encouraged to report incidents and events which could potentially cause patients harm. Learning was taken from such incidents to reduce the risk of similar events reoccurring. Information had been provided to staff regarding Duty of Candour and staff were aware of the principles of the legislation.
• The safety thermometer information showed patients generally experienced harm free care on the ward
• The ward was hygienic and staff demonstrated a good understanding of the promotion and control of infection.
• Medicines were managed appropriately and stored securely.

Effective:

• Staff provided care and treatment in line with the trusts policies and procedures and national guidelines.
• Patients were offered support with their meals and additional snacks and drinks were available to patients at all times.
• Staff were encouraged to undertake role specific training to ensure they were competent and provided a high standard of care and treatment.
• Multi-disciplinary team working was effective and at times outstanding at the hospital.

However:

• Not all services were operational over seven days. Patients did not have routine access to therapy, x-ray and medical staff out of hours. There was no clear pathway for medical patients to be seen or reviewed by a consultant.
• Not all staff demonstrated a clear understanding of the Deprivation of Liberty Safeguards.

Caring:

• Feedback from patients and/or their representatives was consistently positive about the manner in which staff treated them.
• We observed staff were kind, compassionate and showed empathy to those they cared for and provided a service to.
• Patients were provided with sufficient information and support to help them understand their care and treatment plans and options available to them.

Responsive:

• At times the medical patients transferred from RUH did not always meet the criteria in place and their care needs were complex and impacted upon patients already on the ward. There was limited therapy support for these patients.
• The ward did not fully meet the care needs for patients who lived with dementia. However the admission criteria was clear that patients with dementia should not be transferred to the hospital but was not always followed.
• There was a delay in follow up appointments for patients.

However:

• Patients were provided with appointment dates promptly when assessed as requiring admission to the ward to take part in a pain management programme.
• Services were developed in response to patient need for example, the fibromyalgia service.
• The facilities and environment offered access to patients with disabilities.
• Patients knew how to make a complaint and complaints were responded to appropriately by the trust.

Well Led:

• The trust had acquired the RNHRD in February 2015. Governance systems had been put in to place and in some areas were working well, in others they had not fully embedded.
• There was limited monitoring and quality measurement of the care and treatment records maintained for patients on the ward. There were significant gaps in the care records which had not been identified or addressed.

However:

• There was a positive culture at the hospital and staff were proud of the service they delivered to patients
• There was clear local leadership in the hospital and staff were confident and able to approach the hospital manager for support and guidance when necessary.
• Not all staff saw their line manager regularly and sought support from other managers on site when needed.
• Staff meetings were held regularly to enable information to be shared and staff to be updated.

We saw several areas of outstanding practice including:

• The hospital had been passed the criteria to be recognised as a centre of excellence for lupus
• The hospital had received national recognition by the Health Service Journal as the best specialist place to work in 2015.
• Staff worked well as a multi-disciplinary team throughout the hospital. We saw outstanding team working during a multi-disciplinary team meeting we attended. The patient was at the centre of the meeting, with all professionals striving to promote the health and wellbeing of the patient.
• Patients could attend the RNHRD either as inpatients or staying nearby in self-contained flats, dependent on their care needs and independent living skills. The patients who stayed on the ward were provided with care from the nursing staff. The psychologists who led the pain management programmes provided nursing staff with informal training regarding the philosophy of the programme and how to support patients with their treatment.
• The Fibromyalgia service had been developed in response to patient need and was now being set up to become a franchised model to share the programme with other trusts.
• The Complex Regional Pain Syndrome (CRPS) service held a weekly multidisciplinary meeting. We attended this meeting during our inspection and found the content and style of the meeting to be outstanding.

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

Importantly, the trust must:

• The trust must ensure care records and documentation such as risk assessments, referrals to other professionals and clinicians, care plans and monitoring records such as food and fluid charts are in place. The records should be in sufficient detail and maintained appropriately to direct and inform staff on the action they must take to meet the care and treatment needs for patients.
• The trust must ensure that appropriate medical care is provided for patients transferred to the RNHRD from the medical wards at RUH.

In addition the trust should:

• The trust should ensure that staff have access to up to date information on the patient’s infection status in particular in relation to MRSA.
• The trust should ensure robust procedures are put in place for ensuring the promotion and control of infection regarding the routine steam cleaning of the ward and equipment.
• The trust should encourage all staff to complete incident reports themselves.
• Staff should have access to feedback following the reporting of incidents to ensure that learning takes place after an incident.
• The trust should ensure that records demonstrate the action taken when safeguarding concerns are identified.
• The trust should ensure that patients and visitors to the hospital can easily find their way to all departments.
• The trust should ensure that patients can access hand washing facilities in every toilet.
• The trust should ensure that fluids for intravenous infusion are not accessible to patients and visitors to the ward.
• The trust should ensure that the mandatory training is kept up to date for all staff.
• All equipment should be serviced, maintained and/or calibrated to ensure it was fit for purpose and ready to use.
• The trust should ensure all staff were confident and competent to use emergency equipment when necessary.
• All staff should be trained and competent to use emergency evacuation equipment.
• The trust should ensure that patient’s medical care and treatment needs can be met at the RNHRD before transfers are arranged. The transfer criteria should be complied with.

• The trust should look to reference the guidance by The Law Society in its policy relating to deprivation of Liberty, and ensure there is flexibility within the policy when applying the 72-hour rule.

• The trust should ensure governance systems continue to be embedded.

• The trust should ensure monitoring and quality measurement of the care and treatment records is in operation.

Professor Sir Mike Richards

Chief Inspector of Hospitals