Our rating of services improved. We rated it them as good because:

• There were sufficient numbers of nursing staff with the right qualifications, skills, training and experience to provide the right care and treatment in all the areas we visited.
• Staff understood and fulfilled their responsibility to raise concerns and report incidents.
• We saw excellent multi-disciplinary working across the hospital that was respectful and professional. There was a team work culture.
• Staff were consistently kind, caring and respectful towards patients and their relatives. Feedback from patients confirmed that staff treated them with compassion.
• Staff in all areas clearly understood how to protect patients from abuse. We saw improved staff awareness and promotion of safeguarding displays around the hospital since our last inspection.
• Dementia and learning disability care had significantly improved since our last inspection.
• Concerns and complaints were taken seriously, investigated appropriately and lessons were learnt from the results, which were shared with staff.
• A positive culture was promoted by leaders at all levels and staff understood how they contributed to the trust values.
• We found local leadership to be knowledgeable about issues and priorities for the quality and sustainability for their services, and had a good understanding of the challenges they faced. We saw they were responding to address these challenges and this work was ongoing.
• Despite the suspension national referral to treatment target (RTT) reporting in June 2017, we saw honest and transparent action to address breaches during the previous 12 months. The trust took swift action and sought stakeholder support and was meeting the planned trajectory to meet the target.
• The ROCS team had a positive impact on length of stay for patients requiring long-term intravenous therapy. Patients who were assessed as not requiring a hospital bed received their intravenous therapy at home.
• The trust was in the process of quality improvement projects such as ‘perfecting pathways’ to improve patient care. These projects were encouraging staff to be innovative in their own departments to effect change and improvement.
• The trust’s research and development team was proactive in research trials and used advanced clinical technology to improve the outcomes for patients with bone tumours and soft tissue sarcomas. We saw examples of patients offered less invasive procedures based on innovative research findings.

However:

• We found in both medical care and outpatients that there was a lack of shared learning when things went wrong. Some staff were not aware of the term ‘never event’ despite the trust in 2016 having three surgical never events. Understanding of the term duty of candour varied across the trust despite the provision of training.
• The trust used several IT systems that did not interface with each other which meant that there was duplication of information and extra workload for staff. Not all staff had the required access for all systems and many staff we spoke with were frustrated with the different systems to record patient information which could cause delays.
• The trust faced data quality issues and was in the process of identifying and rectifying outdated databases to ensure robust and accurate data management.
• Staff were not knowledgeable or confident in providing care to patients detained under the Mental Health Act. There was a lack of supporting information, policies and guidance for staff to follow to ensure patients additional mental health needs were met.
• The Bone Infection Unit had the potential to be an outstanding service however, there was a lack of strategy, outcome monitoring and service evaluation and therefore could not demonstrate service effectiveness.
• The electronic staff record did not hold latest compliance data which meant local managers kept local records additionally to this causing extra work and therefore the system ineffective. Training data was not provided to us to demonstrate compliance rates for individual modules.
• Not all staff had access to additional education to support their roles for example specialist oncology training and mentorship training.
• Interpretation services to provide language support to patients who required it was not consistently used across all services.
• Patient records were not consistently secure within the outpatients department.
• Despite significant improvement work to address patient wait times in outpatients, we observed long patient waits, cancelled appointments and overbooked clinics. This was a concern in our previous inspection.

This inspection was completed by a pharmacy inspector. The purpose of the inspection was to follow up on the concerns raised at the inspection on the 11 December 2012 regarding the management of medicines. We found that the Trust had carried out the necessary improvements and we found procedures were in place to reduce the risk associated with the management of medicines.

The inspection was led by one of five CQC inspectors and included a pharmacy inspector. During our inspection we spoke with a total of eleven people who were using the service and four relatives. We looked at the care and treatment that people were receiving within: Theatres, the High Dependency Unit, Ward One and on Ward 11 (children's ward) and the discharge lounge. We spoke with staff who covered a range of different roles.

The majority of feedback we received was positive about the care and treatment people had received. One person told us, ‘’You hear such horrible stories about hospitals but I cannot fault them here.’’ We noted that in some instances care records did not always contain adequate information about people's care needs.

People told us they had given consent where it was applicable and that the information they were given was detailed and that staff explained everything to them. Parents of children receiving treatment advised that explanations about treatment were given to children by staff and that this had assisted in reducing anxieties of their children. There were usually enough qualified, skilled and experienced staff to meet people’s needs.

People said they would be happy to raise any concerns they had with staff.

We found that the systems for managing medicines were not sufficiently robust. Action was needed to ensure care and treatment was always planned or delivered in a way that ensured people's safety.

The focus of our site visit was in the theatre and recovery departments. This followed a number of serious incidents, including two never events that had occurred in the operating theatres. Never events are serious, largely preventable patient safety incidents that should not occur if the available controls and checks have been completed.

We visited most of the theatres and the recovery areas in the theatre department. We also spent time following patients from the wards into theatre and looked at the medicines arrangements for patients being discharged. During our time on site, we talked to staff and reviewed a range of trust records and records of care for people who use services. We were able to speak with four patients in the high dependency unit and the discharge lounge. During our visit to the theatre department and recovery areas, we were unable to speak with many patients as they were still sleepy following their surgery. We were able to speak with one patient who told us "They are fantastic", "They explain things very well", and "I can't praise them enough."

During this review, we had discussions with local health commissioners, who shared our concerns about the quality and safety of care. A separate visit to ward areas at the hospital was completed by commissioners. They reviewed two of the wards. Overall, they found that there were good standards of care in these areas.

We undertook this unannounced inspection on 20th July 2016 which was a focused inspection of the high dependency unit (HDU) specifically looking at paediatric care.

We last inspected The Royal Orthopaedic Hospital in July 2015 when we conducted a focused follow up inspection of HDU (as part of the critical care core service) and the outpatients department (OPD). This was because we identified concerns in 2014 with one of the five questions in each area rated as inadequate.

Following the focused inspection in July 2015, we saw improvements in HDU however; we rated the service as requires improvement. The ratings remained the same for HDU as in 2014; however, the issues identified were different and had an impact across the five domains.

There were significant concerns specifically the care of children at the trust including paediatric nursing and medical cover and the HDU environment. We therefore told the trust they must take action to improve both of these areas of concern. Other areas of concern that the trust were required to act upon included contribution of data to Intensive Care National Audit and Research Centre (ICNARC) or similar, to benchmark the service against other similar hospitals, to address the HDU toilet facilities so that they are single sex and can accommodate children and multi-disciplinary ward rounds and handovers should take place.

In view of the paediatric care concerns identified, during a meeting with a Deputy Chief Inspector, it was agreed that the trust commission a review by the Royal College of Paediatrics and Child Health (RCPCH) of their paediatric service. The trust accepted this and the review took place in March 2016 with the report following in June 2016.

The report described many recommendations with some serious concerns relating to non-compliance with national professional guidance. Of greatest concern were the continued absence of paediatrician support and the governance processes relating to activity involving children and young people.

Since the publication of the 2015 report, the trust has put a comprehensive action plan in place to address the issues identified. This action plan is ongoing with several actions outstanding.

The reason for this focused inspection was following receipt of the RCPCH report and action plan from the trust on 21st June 2016, which raised some concerns with us. Our concerns related to the action plan, to address all the areas of improvement required which were extensive. We decided we needed to visit on-site to better understand how the trust was going to address the recommendations and make timely improvements.

In view of the focused inspection with the aim to gain assurance of paediatric care in HDU only, we did not rate this service.

We spoke with 22 staff in total including nursing and medical staff, local and senior management. We visited HDU and the governance department but also spoke to nursing staff who worked on the children’s ward (ward 11).

Our key findings were as follows:

• The trust had made improvements with paediatric nursing cover with plans to increase provision in line with national guidance.

• Medical cover remained a concern as identified both CQC and the RCPCH; however, the escalation process for the deteriorating child had been strengthened.

• We found a printing error on the Paediatric Early Warning Score (PEWS) chart.Regular staff did not follow the printed advice so children were not at risk. However new or temporary staff may have used the form as printed and this could put children at risk.

• The trust did not have a fully realised children’s strategy to achieve the vision or a senior leader with paediatric experience. Plans were in place to address these.

• The main door into HDU was broken and had been an issue for some time. This was both a security risk and at times prevented staff from entering with their security passes.

• Governance processes around care of the child require improvement in particular, incident reporting and exposure at quality and safety meetings.

• We observed poor hand hygiene on HDU, with clinical staff entering the unit failing to wash their hands or use hand gel.

• The manager of HDU was new to post within the two weeks prior to our inspection.

• Staff were welcoming of the changes to paediatric care and felt improvements were necessary.

• Some improvements we saw since the July 2015 inspection related to medicines safety, and environmental plans for HDU.

The trust should:

• Act upon the recommendations of the RCPCH to develop and implement policies in a timely manner.

• Implement a fit for purpose PEWS chart immediately to detect the deteriorating child.

Please note the requirement notices served in the report published December 2015 still apply and the trust is still working on the action plan associated with them.

Professor Sir Mike Richards

Chief Inspector of Hospitals