Fitzwilliam Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse and managed safety incidents well. Managers made sure staff were competent. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team. The service had safe systems for appropriate and safe handling of medicines. However, staff did not fully follow their policy when reconciling patient’s medicines.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had up to date incident reporting processes for internal and external incidents and we reviewed evidence prior to our assessment that demonstrated the service understood its responsibility to submit statutory notifications. Governance processes showed leaders had oversight of incidents and promoted a positive reporting culture to share learning and manage risks.

Staff were encouraged to report incidents and received feedback from incidents they reported, describing an open culture of incident reporting based on learning and positive leadership support. Incidents were reviewed through the service governance processes and learning shared through safety bulletins, email, and team meetings. Staff had a good understanding of their role and responsibilities regarding duty of candour. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. Staff and leaders gave patients and families a full explanation and apology when things went wrong, and they had an opportunity to feedback in the incident investigation process.

Patients benefited from leaders promoting a positive incident reporting culture and managing risks. Feedback from patients reflected that they felt safe within the service and had the opportunity to raise concerns or incidents when they occurred. During our inspection we reviewed records the demonstrated patients and relatives participated in investigations and provide with outcomes including any learning from the incident and how this would be shared within the service.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Leaders and staff understood the importance of safeguarding in promoting and delivering harm free care. Staff knew how to recognise and repot abuse; they knew the services main safeguarding contacts and how to seek additional guidance if they identified any concerns. Staff and leaders gave good examples of when they had followed the services safeguarding processes, working alongside external agencies to promote patient and staff safety. Staff understood the services policies and processes for gaining patient consent and how to support people using the Mental Capacity Act (2005).

The service had up to date policies for the safeguarding of adults and children, staff and completed appropriate training and knew how to recognise and report abuse. Staff were trained in safeguarding level 3 for both adults and children and the service provided evidence showing compliance rates which met the corporate target levels. We reviewed evidence that showed how the process had worked following concerns raised. The documentation followed the corporate safeguarding policy. It was clear and concise, and concerns were escalated appropriately as detailed within the services safeguarding processes.

Patient feedback showed they felt safe within the service, they found staff caring, approachable and focused on their needs.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff we spoke with told us they had the right equipment to meet the needs of patients and during our on-site assessment we observed staff stored and maintained equipment appropriately. Staff were able to explain the process for reporting any faults or defects of equipment or the environment and told us that leaders were responsive in ensuring repairs were conducted.

Patients feedback showed they felt safe in the environment and that the services were appropriate to their needs.

The service had planned preventative schedules to maintain the environment and equipment. Equipment was visibly clean and maintained in line with the services and manufacturer’s guidance. The service was committed to sustainability and implemented various initiatives to improve energy efficiency, reduce energy costs to improve services for patients and staff. For example, installing electric vehicle charging stations, low energy lighting and improving power and plant management systems.

Since our last inspection, the service had made improvements in its physical environment to promote patient safety and improve the patient experience. The changes had improved the services ability to meet infection, prevention and control standards as well as provide patients and relatives with environments appropriate to their needs.

Patient feedback showed that they found staff to be helpful, caring, knowledgeable and efficient. Patients said there was good communication with staff and that they found staff to be skilled. People told us they were given information leaflets and advice specific to their surgical procedure.

Staff we spoke with were clear about their roles and accountabilities and had opportunities to meet, discuss and learn from the performance of the service. Managers held regular team meetings to discuss safety issues, learning from incidents, medicines updates, updates to policies and guidelines and risk management. Managers ensured new staff completed an induction and staff completed role specific training and competencies. Leaders of the service provided evidence there were low staff vacancies and turnover.

The service's appraisal rates as of the end of January 2024 for all eligible, regular permanent staff were good with 92% compliance. We reviewed the following staffing data for the time period of February 2023 to January 2024. The service reported a low rate of agency staffing for all roles at 9.6% and bank staffing for all roles at 10.2%. The service reported that between February 2023 to January 2024, sickness rates were low at an average of 3.4% across all staff groups.

Processes in place supported safe and effective staffing in the service. Managers arranged for a daily emergency response team huddle, which meant staff were clear in their roles for emergent situations. Policies and procedures were in place for staff seeking help with clinical problems. Managers ensured staff completed mandatory training specific for their roles. There was 100% compliance with consent training for eligible staff and 100% of staff completed an induction. Processes were in place to ensure staff followed safe surgical procedures checklists. There were arrangements for out of hours medical coverage and an anaesthetic rota. Leaders of the service ensured medical staff had appropriate checks under practicing privileges.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with told us they received their medicines, including pain relief, safely and in a timely manner. Staff gave them advice on their medicines at discharge.

Medicines, including controlled drugs, were stored securely and safely. Staff monitored room and refrigerator temperatures daily in areas where medicines were stored. We looked at nine medicines administration records and found that all had allergies and weight documented so that medicines could be prescribed safely.

There were robust processes in place to ensure patients received their medicines on discharge both during pharmacy opening hours and out of hours. However, on two separate records we saw that the prescribers’ signature was missing for two medicines. This had not been identified until the discharge process. Due to pharmacy staff shortages, staff were not fully completing the medicines reconciliation process (an accurate list of medicines is compiled and checked with what has been prescribed whilst the patient is in hospital) according to their policy. Following our inspection, the hospital provided us with an action plan and a comprehensive risk assessment. Medicines audits were completed regularly, actions identified were communicated with the ward and followed up by senior staff.

Staff completed medicines management training and annual assessments were completed to ensure they remained competent. Staff followed national practice to check patients had the correct medicines at pre-operative assessment clinics and when they were admitted to the service. Staff followed robust processes to investigate when incidents occurred. Leaders ensured lessons were learned and cascaded learning to staff.