The Royal National Orthopaedic Hospital NHS Trust comprises of the main hospital in Stanmore and an outpatients facility in Bolsover Street. It is the largest specialist orthopaedic hospital in the UK, with 220 beds, and is regarded as a leader in the field of orthopaedics, both in the UK and worldwide. As a national centre of excellence, the trust treats patients from across the country, many of whom have been referred by other hospital consultants for second opinions, or for treatment of complex or rare conditions.
The Royal National Orthopaedic Hospital NHS Trust has been selected as one of the first specialist trusts to be inspected under CQC’s revised inspection approach. It provides surgery, medical care for spinal and rehabilitation patients, outpatients, critical care and children and young people’s services.
The team of over 30 included CQC inspectors and analysts, doctors, nurses, Experts by Experience and senior NHS managers. The inspection took place on 7, 8 and 9 May 2014.
Overall, we rated this trust as ‘requires improvement’. We rated it ‘outstanding’ for providing caring and effective care but it required improvement for the services to be safe, responsive and well-led.
We rated medical care as ‘outstanding’ and surgery and critical care as ‘good’. However, the outpatient services and children and young people’s services ‘require improvement’.
Our key findings were as follows:
- The premises at the Stanmore location were not fit for purpose – it does not provide an adequate environment to care and treat patients.
- Bullying and harassment had been a theme of the culture for the last six years. More recently there had been a significant focus on culture, values and behaviours of all staff.
- Patients praised staff and the excellent care they received. The NHS Friends and Family Test results were consistently higher than the national average. The response rate was 73.1% compared to the national average of 24%.
- Staff were caring and compassionate and treated patients with dignity and respect.
- Staffing levels and the skill mix of staff met patients’ needs.
- Overall staff followed good infection control practices. The hospital was clean and well maintained. Infection control rates in the hospital were within a statistically acceptable range.
- The medical care for spinal injury patients and patients receiving rehabilitation was outstanding.
- Some patients had unnecessary waits at their outpatients appointments.
- The children and young people’s service was not responsive to their needs.
We saw several areas of outstanding practice including:
- Outstanding clinical outcomes for patients.
- The London Sarcoma Service (one of five National Centres) was rated as Excellent or Good by the majority of patients. The satisfaction scores were 3.5% higher than the England average for cancer services
- London Spinal Cord Injury Centre is one of eight centres in England. The pathway of care was described as “world class” by patients and in independent reviews.
- Innovative surgery was being carried out to improve patients’ quality of life. For example, limb lengthening for patients with skeletal malformation.
- The executive board demonstrated leadership and vision for the hospital.
- There were good staffing levels with the appropriate skills to care for patients.
- Effective multidisciplinary working putting the patient first.
- A hotel-based rehabilitation programme supporting patients to recover from surgery and have a normal daily life.
- A ward dedicated to providing wound care to patients with appropriately skilled staff.
- Some wards had started to use a drink container that attached to equipment and could be kept with patients at all times to ensure patients were kept hydrated, especially during rehabilitation sessions.
- The training for surgical trainees was excellent.
- The education for children and young people’s was well integrated into the service, and inclusive and innovative teaching methods meant that children and young people could continue to access learning throughout their hospital stays.
- The outpatients service environment at Bolsover Street was designed with the patient at the centre of service.
- Medical records were available in 99% of outpatients appointments.
- Some patients at outpatients were given pagers on arrival so they were free to wait in an area that suited them - children’s play areas, the café or different departments within the building - and not miss their appointments
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must ensure:
- The design and layout of the Stanmore location is suitable for all service users.
- To continue to significantly focus on culture, values and behaviours of all staff.
- Robust governance systems are in place for managing risk.
- Learning from incidents is widely shared.
- Outpatient clinic appointments start on time and patients do not experience avoidable delays.
- The World Health Organisation (WHO) surgical safety checklist is used and completed at each stage of surgery and radiology.
- The paediatric resuscitation equipment is checked regularly to assure it is ready for use if required.
- Staff that treat children and young people are up-to-date with the appropriate level of safeguarding training.
- The needs of children and young people are considered in scheduling operations.
In addition the trust should:
- Develop the services across seven days.
- Review its use of opioids prescribed for pain relief for older people.
- Consider the mechanisms in place for identifying if equipment including mechanical ventilators, cardiac monitors and mattresses used to prevent pressure ulcers are clear to all when testing is needed.
- Ensure all staff are aware of support mechanisms such as the employee assistance programme. The RCN recommends there should be formal support mechanism available due to the challenging and highly specialised nature of the service provided, particularly with children and young people.
- Consider carrying out formal proactive audits of cleanliness and infection control in the outpatients clinics.
Professor Sir Mike Richards
Chief Inspector of Hospitals