Rotherham District General Hospital, Rotherham

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 113

• Of these how many have an ensuite toilet: 21

• Of these how many have an ensuite toilet and shower or bath: 43

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 Every bed has the potential to care for a specialist palliative care patient. No beds are specifically ring fenced.

• Does this hospital have a named private unit/service:

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Datix IR1 system We have a comprehensive web based reporting system for incidents, claims, complaints and risks. All staff have received appropriate training in this system to ensure all incidents are recorded, investigated and actioned in a timely manner

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Datix IR1 system We have a comprehensive web based reporting system for incidents, claims, complaints and risks. All staff have received appropriate training in this system to ensure all incidents are recorded, investigated and actioned in a timely manner

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: Datix IR1 system All never events are identified by a specific section on the web based Datix system with triggers to appropriate staff to initiate prompt investigation and action.

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 0

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 0

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 5743 All incidents graded 1-8 have a concise root cause analysis undertaken. Incidents graded 8 and above, SUIs, unexpected deaths, pressure ulcers, VTE and red incidents have a full RCA carried out.

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 100% All appropriate to PAR scoring system

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99%

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: Business Intelligence Strategy. A rolling programme of training on clinical indicators is provided by the service improvement team

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): Quality and Standards team.

• Is safety and quality data available on a central platform and actively disseminated to users: We have a comprehensive ward to board process that includes numerous clinical quality indicators. We also have regular monthly performance requirements for all mandatory and chosen clinical quality indicators for all areas.

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical and medical All elective patients are screened with the exception of day case endoscopy, daycase dental unless going through main theatres, opthalmlogy, minor dermatology day cases, procedures via x ray or medical physics as day cases, Obstetrics unless planned C Section.

• Are all oncology patients screened at the pre-op assessment clinic: YES

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Culture based in 24-48hrs Culture based for routine screening. Molecular in cases of emergency trauma for theatre on the same day with no results known.

• On admission, does topical suppression take place immediately:

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• Protocol for isolating patients with infections: Single rooms are used on a risk assessment basis, cohorting in bays takes place where necessary. This system works well, there has never been any wards closed.

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust prescribe probiotics to any patient groups as a prophylactic measure to reduce C.difficile infections:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea: All newly admitted patients presenting with diarrhoea are assessed by the Infection Control Team.

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit

• Number of beds in the unit: 28

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: North Trent Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 344

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 281

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week : Current provision is being delivered 7 days a week between the hours of 9 am to 9 pm. Plans are being completed to extend to 24 hour coverage by the Stroke Network

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment:

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? :

• What is the audited Percentage of all patients that attend the class prior to surgery: 100

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 90

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - audited figure was: 0

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: Unless clinically necessary

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress: All patients are given a help line number on discharge.

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: A multi-disciplinary specialist palliative care team

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: There is a 24 hour helpline for professionals

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital:

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme: The hospital participates in the national 2 yearly audit for the end of life care

Maternity Care

Maternity Sites

• Rotherham District General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2849

• How many babies were born in the unit during the year? (not including home births): 2938

• How many women had a home birth? (not including births at home by accident): 22

• Number of antenatal rooms: 1

• Total antenatal beds: 6

• Number of assessment area rooms (for monitoring and / or induction): 1

• Total assessment area beds: 2

• Number of delivery rooms: 14

• Total delivery beds: 14

• Number of postnatal rooms: 7

• Total postnatal beds: 22

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 1

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 14

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 32

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Not available

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 102.79 We have no vacant posts

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 102.79 we have no agency or bank staff

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call not on site

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site on call during night time hours

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups:

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 12

• Scan 2 available between: 20

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: The Rotherham NHS Foundation Trust