The Royal National Orthopaedic Hospital (Stanmore)

Updated 22 March 2019

The Royal National Orthopaedic Hospital NHS Trust (the RNOH) is a specialist orthopaedic hospital located in Greater London. It has two locations, one in Stanmore and another (an outpatient only facility) in Bolsover Street located two minutes away from Great Portland Street Tube station.

RNOH consider themselves to be the largest orthopaedic hospital in the United Kingdom (UK), and a leader in the field of orthopaedics both in the UK and world-wide.

The RNOH is a major teaching centre and around 20% of orthopaedic surgeons in the UK received training there.

Outpatient services are provided at both the Stanmore site and at the central London outpatient assessment centre in Bolsover Street. In addition to general orthopaedics, they have specialist clinics dealing with bone tumours, scoliosis, metabolic disease, rheumatology, urology, spinal injuries, specialist shoulder conditions and sports injuries.

Inpatient facilities are provided at the Stanmore location where they have 220 inpatient beds on 13 wards. The hospital has 10 operating theatres and three recovery areas of 14 beds in total with five dedicated to paediatrics. Patients requiring special monitoring after surgery are accommodated in either the high dependency unit, or intensive care unit, which had 12 beds.

In October 2016 RNOH commenced some redevelopment work in recognition of the fact that their estate was very old. In July 2018 they completed phase one of that work. This new building will provide new wards for adult surgery, a children’s ward and a private patients ward.

Updated 22 March 2019

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

We rated safe requires improvement and effective, responsive, caring and well led as good.

• Medicine went down to good from outstanding.
• We rated outpatients as good. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.
• Services for children and young people went up to good from requires improvement.
• Surgery remained at the same rating of good.

Updated 22 March 2019

Our rating of this service went down. We rated it as good because:

• Staff had improved systems to assess and respond to patient risk to ensure they reflected the highly complex needs of some individuals. These included the provision of on-call emergency teams, the use of electronic monitoring tools and improved staff training.
• Allied health professional therapists led rehabilitation programmes and had key roles in care and treatment planning and delivery. Rehabilitative care was evidence-based and teams worked to incorporate the latest knowledge and leading-edge research outcomes into care planning.
• Consultants and pharmacists had developed an active programme of prescription reduction for opioids and aimed to manage pain whilst reducing community-related dependence.
• Specialist services worked closely together to coordinate care as part of a well-established multidisciplinary approach to assessment and treatment for patients living with highly complex and often rare conditions.
• From May 2017 to April 2018, patients had a lower than expected risk of readmission for elective admissions and a lower than expected risk of readmission for non-elective admissions when compared to the national average.
• Staff actively sought out research opportunities that had the potential to lead to improved patient experience and outcomes. Clinical services were clearly research-focused and there was substantial support in place for staff to develop research that had potential to improve care for their patients and knowledge amongst clinical teams.
• Staff had completed extended training to help them communication with patients with a range of complex emotional needs. This included using evidence-based strategies to de-escalate challenging situations and to provide meaningful, effective support to patients experiencing depression and anxiety.
• Multidisciplinary teams planned extensive involvement exercises with patients and relatives to understand their expectations of care and rehabilitation. This was part of a broader approach to individualised communication that promoted self-confidence and empowerment amongst patients.
• A range of specialist clinical services worked across the hospital and provided individual care planning and reviews to patients with complex and often rare conditions. For example, the hospital was the UK’s only centre for treating Ehlers-Danlos syndrome and a specialist metabolic medicine team delivered research-based care for patients with rare bone diseases.
• Rehabilitation plans were established on a long-term basis and in most cases for life. Allied health professionals worked with patients to implement plans to patients to use at home based on facilities accessible to them.
• The trust had established a wide range of engagement opportunities and activities for staff, patients and their carers and relatives. This included forums, events and feedback exercises.

However, we also found areas for improvement:

• Staff described significant pressures resulting from a persistent shortage of nurses.
• Staff described aggression, verbal abuse and violence as a key daily concern when delivering care. Although senior teams had implemented a range of policies and improved training to address this, it remained a recurring theme amongst incidents.
• From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for admitted pathways for medicine was better than as the England average for seven months and worse for the remaining five months.

We last inspected medical care services in May 2014. We told the trust it must:

• Focus significantly on culture, values and behaviours of staff.
• Ensure learning from incidents is shared widely.

We told the trust it should:

• Consider the impact of opioid prescribing on older patients in relation to delirium and confusion.
• Develop the service across seven days.
• Ensure staff are aware of the employee assistance programme.

At this inspection we found the trust had addressed most issues. There had been testing and exploration of expanded seven-day working with some improvement in provision. There was a need for further improvement in the reporting of and learning from incidents

Updated 22 March 2019

Our rating of this service improved. We rated it as good because:

• There was good multidisciplinary working within children’s services. Records demonstrated input from a full clinical team including allied health professionals such as physiotherapists.
• The service delivered care in line with national clinical guidance. Staff had access to policies and procedures based on national guidance on the trust intranet.
• Equipment we checked were clean and had now been serviced and calibrated regularly.
• The service had 24-hour paediatric consultant cover seven days a week which met the Royal College of Paediatric and Child Health standards.
• There was now a dedicated children’s outpatient unit.
• There were two separate paediatric recovery areas which provided children and young people with a dedicated space away from adult patients after surgery. Since the last inspection the number of paediatric trained recovery nurses had been increased from two to three in the paediatric theatre recovery area.
• The service now had paediatric trained nurses in pre-assessment clinics.
• Consent was sought and clearly recorded in patients’ notes.
• Staff were passionate about their work and focused on delivering child-centred care. Feedback from patients and families was consistently positive.
• The play team used a model MRI scanner to show children what happened during an MRI scan to help alleviate any anxieties and fears. The use of the scanner had significantly reduced the number of children under the age of 12 requiring a general anaesthetic for a scan.
• The service had a service level agreement with a local mental health trust which provided support for children with pre-existing mental health conditions. There was a paediatric clinical psychology and child and adolescent psychiatrist who provided a range of services and clinics including bereavement counselling.
• The service had clinical nurse specialists who supported children in their transition from children’s to adult services.
• Referral to treatment times were consistently good at 94% compliance.
• The new facility for children’s inpatients which would be functional before the publication of this report had been designed with children, young people and their families in mind. Improvements included a dedicated playroom for younger children, age neutral designs, a connecting covered indoor corridor to theatres and facilities for parents and siblings including a baby feeding room and fully accessible toilets.
• Staff commented positively on changes that had been made since the change to the divisional structure. Staff said that the leadership used to be very clinician-led and that now nursing staff had a greater voice.

However:

• Mandatory training levels for medical staff remained low and it was not clear how the divisional leaders planned to monitor and increase completion rates. Mandatory training levels for paediatric immediate life support for both nursing and medical staff were particularly low.
• Staff were able to articulate escalation protocols for deteriorating patients and the use of paediatric early warning score (PEWS) which we saw in records we reviewed. However, staff were unable to show us the deteriorating child policy or pathway on the trust intranet. The trust later sent through a deteriorating child pathway which detailed the correct actions for staff to take in the case of a deteriorating child. The trust also took immediate steps during the inspection to ensure staff were familiar with the pathway by sharing it in the trust’s ‘message of the week’ system.
• There was a high level of nursing vacancies especially for band 5 and 6 paediatric nurses. However, the trust was taking measures to manage bed capacity to ensure that staffing levels were correct for the acuity and dependency of patients.
• Safeguarding supervision had still not yet been fully implemented in the service.
• Five of the seven records we reviewed did not contain pain reviews including review of pain for children using patient controlled analgesia.
• There was still limited provision for children with learning disabilities, autism, sensory and behavioural needs. There was no dedicated learning disability nurse or champion for children’s services. However, the trust was looking into implementing learning disabilities training for staff and appointing a learning disabilities nurse.
• The service used evidence based tools to screen for malnutrition. A nutrition initiatives re-audit in April 2017 showed that paediatric wards underperformed in the audit which assessed the recording of information on the malnutrition screening tool.
• The culture in children’s services still appeared unsettled. Some staff reported that pockets of bullying still remained and felt management did not always consult them when decisions were made.

Updated 15 August 2014

Patients received appropriate care and treatment in accordance with national guidelines. There were sufficient numbers of staff on duty, and enough equipment to meet patients’ needs. Systems were in place to monitor the quality and safety of patient care provided.

Staff were knowledgeable and compassionate. They were aware of the incident reporting systems and told us that they were encouraged by senior staff to report incidents and raise awareness of patient safety issues. Patients were fully informed and satisfied with the outcomes of their treatment. They told us that they were cared for in a supportive way, and found staff very friendly.

Updated 22 March 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

• The service had improved how it carried out environmental audits and were no longer solely reliant on the Patient Led Assessment of the Care Environment (PLACE). There were a range of cleanliness audits including hand hygiene and cleaning spot checks. There were hand gel dispensers throughout the department and staff observed hygiene protocols and policies.
• At the previous inspection the service had identified problems with the performance of the external cleaning provider. This had improved, we were told by staff and patients that the department was clean and we observed this to be the case.
• The service managed patient incidents effectively. Staff recognised incidents when they occurred and knew how to report them. Staff apologised to patients when things went wrong and gave them information and support. Staff we spoke with understood the Duty of Candour.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• Staff understood how to recognise and report abuse. There were clear safeguarding procedures in place.
• Staff could explain how they recognised and responded to deteriorating patients. There were measures in place for patient who became unwell in outpatients such as an on-call medical assessment team.
• The service’s environment and equipment were managed in a way that kept patients safe. There were clear exit routes and floors were clear of trip hazards. Equipment was available and tested regularly.
• The service’s practice was up to date with Royal College guidance and best practice set out by the National Institute for Health and Care Excellence (NICE).
• Each specialty monitored patient outcomes and used this information to improve care and treatment.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. There were a range of nurse led specialist clinics.
• Staff were able to access pain relief and there was a good multidisciplinary service provided to patients in the pain clinic.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Patient records showed that consent was gained from patients prior to procedures or treatment. Staff told us they had access to guidance on gaining consent.
• Staff cared for patients with compassion. Our observations of interactions in the department and feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment. Appointment times were longer than average so that patients had time to ask questions.
• Patients were provided with information leaflets to increase their understanding of care and involvement in the service. They told us that clinicians explained care and treatment clearly and took time to respond to their queries and concerns.
• Staff provided emotional support to patients to minimise their distress. There were private rooms available to have sensitive conversations.
• The service took account of the needs of patients and provided a range of clinics to meet the needs of patients from across a wide geographical area.
• Service managers were taking action to address clinical capacity and reduce late starting and late running clinics as well as the prevalence of patients missing their appointments.
• The service performed better than the national standard on many referral to treatment (RTT) measures. All specialties met the 18-week standard for non-complete pathways, the two-week standard for an urgent GP referral and the 31-day standard for receiving the first treatment after a decision to treat. Three specialties were above the England average of patients on non-admitted pathways seen within 18 weeks, with four below. We heard that these figures were improving.
• The service had taken action to improve instances of patients not attending their appointments, including a text messaging service.
• The outpatient department was fully accessible to patients with reduced mobility. There was support for bariatric patients, those living with dementia and with a learning disability. Signs in the department were clear and there was adequate space for patients to wait, this had improved since the last inspection.
• At the last inspection we found there were delays in sharing information with GPs following appointments. We heard from patients and service managers that this had improved and information was now shared more quickly.
• Managers of the service had the right competencies to lead the service and understood the challenges facing the department and how they planned to address them.
• There was a clear management structure and governance processes in the department and wider clinical division headed by a triumvirate. Managers understood their roles and those of their colleagues.
• There was a positive, supportive working culture in the department. Staff spoke well of each other and enjoyed being part of the team. There was a productive, helpful working environment between staff of different disciplines and levels of seniority.
• At the last inspection we found that waiting times were managed by individual specialties and overall departmental leadership was lacking. This had improved, and outpatient managers now had greater influence over access issues and took action to improve capacity.
• Managers had developed a clinical utilisation tool to maximise clinical capacity.

However:

• Reception staff did not receive customer service or conflict resolution training which might have supported them to perform their roles.
• Mandatory training rates did not meet the trust target in some areas such as fire safety and dementia awareness.
• There was a low staff appraisal rate so we were not assured that managers provide support to staff and monitor their work in the department.
• The service operated Monday to Friday only and did not provide weekend or out-of-hours clinics. However, the trust told us it had trialled weekend services but there had been limited demand for this service from patients.
• At the last inspection we had found that executive level managers were not visible in outpatients and this did not seem to have improved. Staff we spoke with did not know who senior managers were or recall seeing them in outpatients.

Updated 22 March 2019

Our rating of this service stayed the same. We rated it as good because:

• During our last inspection we found incident reporting was not encouraged across all surgical areas. During this inspection, we found this had improved and both ward staff and theatre staff were encouraged to report incidents and near misses.
• During this inspection we found medicines and controlled drugs were stored securely in the clinical areas and operating theatres. Fridge temperatures were appropriately recorded and monitored.
• Since the last inspection the department had embedded the use of the World Health Organisation (WHO) surgical checklist for interventional treatments undertaken in theatre and radiology.
• The trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns.
• We found the trust had implemented the national early warning score (NEWS) to effectively assess and escalate deteriorating patients. Staff had good knowledge of what to do in the event of a patient deteriorating.
• The service demonstrated effective internal and external multidisciplinary (MDT) working.
• People using the trust’s surgical services were treated with dignity and respect.
• Patients told us they felt listened to by health professionals, and felt informed and involved in their treatment and plans of care.
• The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served.
• There was good medical leadership within the department and a good culture for scrutinising surgical cases.

However,

• Not all staff were practicing appropriate infection prevention and control practice. We saw some staff did not wash their hands between patients and were not bare below the elbows. Hand hygiene performance was poor in some areas and we saw no action plans in place to address this.
• Although the trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated an understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns, compliance for safeguarding adults and children training was poor and below the trust target of 95%, for both nursing and medical staff.
• In theatres we found theatre doors were not fitted with smoke seals and corridors were used for the storage of flammable material. The storage area was cluttered and filled with boxes. In the event of a fire this could pose a significant risk for the safe evacuation of patients and staff. However, the storage area was not part of the fire evacuation route.
• Fire safety training had poor compliance across the department.
• During this inspection we found some surgical wards did not display the NHS safety thermometer information for staff or patients to view.
• During this inspection, staff told us about issues regarding allocation of theatre time for surgeries. Staff said managers did not consider the time in anaesthetics which could impact theatre flow.
• Senior leaders and managers of the surgical service had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions. However, we did find some risks the department had not mitigated. For example, the theatre doors not fitted with smoke seals.