George Eliot NHS Hospital

The George Eliot Hospital is part of George Eliot Hospital NHS Trust. It is an acute hospital and provides accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’s services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

The George Eliot Hospital is a 352-bed district general hospital, based on the outskirts of Nuneaton. The hospital employs approximately 1,676 staff. It provides a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&E department, maternity and outpatient services.

We carried out this comprehensive inspection because the George Eliot NHS Trust had been flagged as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system due to being in special measures as a result of the trust inspection as part of the Keogh review.

The team of 31 included CQC inspectors and analysts, doctors, nurses, patients and public representatives, experts by experience and senior NHS managers. The inspection took place on 30 April and 1 May 2014 with an unannounced visit on 10 May between 4pm and 8pm.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing effective, caring and responsive care, but it required improvement for safety and well led care in some services

We rated medical, critical care, maternity, children and young people’s services, end of life care and outpatient services as ‘good’ and A&E and surgery services as ‘requires improvement’.

Our key findings were as follows:

• Staff were caring and compassionate and treated patients with dignity and respect.
• Staff followed good infection control practices except in A&E where poor practices were observed. The hospital was clean and well maintained and infection control rates in the hospital were within an acceptable range.
• Patients’ experiences of care were good and the NHS Friends and Family Test results were higher than the national average for most inpatient wards and A&E.
• A review of nurse staffing levels had been undertaken and staffing levels had been increased. Safe staffing levels were being monitored and maintained but there was a heavy reliance on nurse bank and agency staff in some areas. Staff recruitment was continuing.
• The trust had opened a new acute medical admissions unit (AMU), which, along with the ambulatory care unit (ACU), was intended to improve the flow of emergency patients through the hospital by speeding up their assessment, treatment and discharge.
• The hospital had worked to improve emergency care and had introduced the modified early warning system, care pathways and care bundles to standardise care for patients who were acutely ill. Seven-day services had been developed and mortality rates were now within the expected range.
• The number of pressure ulcers, falls and catheter related infections was higher than the England average. The hospital monitored harm-free care in all patient areas and had taken action that was reducing these avoidable harms.
• Incidents were reported but staff did not always receive feedback; nor were lessons learned widely shared. A&E and maternity services were under-reporting incidents. The trust was investing in a new electronic incident reporting system.
• Medicines were not always being safely stored and managed. This was particularly evident in the A&E department and the operating department. In both departments there were concerns relating to the storage and stock control of medicines, including controlled drugs, where legal requirements not been met.
• Radiology services had been without appropriate leadership for many years. The service had antiquated procedures and these were not responding well to increasing service demands and there were long waiting times for services.
• Discharge arrangements were improving and there was early supported discharge coordinated by a discharge team.
• Staff were positive about the changes in the trust and they felt that the culture was open, transparent, educative and innovative.

We saw several areas of outstanding practice including:

• The ambulatory care unit (ACU) opened in December 2013 and had a positive impact on preventing patient admissions. It was helping to meet the needs of patients in the community who required medical intervention without the need for admission to hospital.
• There were physician associates, who were staff trained to support medical staff with assessment, investigation and diagnosis.  One physician associates was trained to complete comprehensive assessments for frail elderly patients.
• The trust had developed initiatives to encourage people living with dementia to eat. They used coloured plates and adapted cutlery, and warmed plates to keep food warm.
• The trust had a ‘carer’s passport’, which was a scheme whereby named relatives could offer their help by coming onto the ward and providing care for their loved one, such as help with eating meals or personal care. The hospital offered named relatives free parking or 10% off meals bought at the hospital.
• Discharge booklets were introduced in all medical wards. These were kept by every patient’s bed and were completed by members of the multidisciplinary team (including intermediate care and social services) to record specific outcomes leading towards safe patient discharge.
• A nurse-led early discharge support team was provided for patients with chronic obstructive pulmonary disease. This included home visits and physiotherapy input. The team worked closely with the respiratory ward to ensure longer term management. A discharge bundle had been introduced that included follow-up within 72 hours.
• The Oasis Project identified patients during their pre-operative assessment who may be anxious about surgery. The project consisted of a team of volunteer therapists who had a professional qualification in relaxation. Therapists would talk through any anxieties at that time to provide reassurance to the patient and would make a note in the patient’s file to prompt action for when they were admitted for surgery
• The trust had produced a leaflet for relatives and friends inviting them to contact the critical care outreach team directly if they had concerns about their relative.
• The hospital had made significant strides in the recognition and management of sepsis and the delivery of the 'Sepsis Six' care bundle. They had a critical care outreach nurse seconded as a Sepsis Nurse who monitored compliance and had introduced a sepsis recognition tool, sepsis boxes for the wards and stickers to improve fluid balance completion.
• Picture screens were used on the intensive therapy unit (ITU) that depicted, for example, a soothing flower blossom scene. Staff and relatives commented that these were calming and relaxing and gave the patients lovely visual images.
• A special service called ‘Providing information and positive parenting support’ (PIPPs) was available to give information and positive parenting support to teenage mothers and others who were vulnerable. Midwives developed close relationships with the women and offered additional support, continuity of care and coordinated multi-agency cases conferences involving social services.
• Multidisciplinary networks in children’s and young people’s services were being developed to deliver care closer to their homes.
• The hospital used the AMBER care bundle, which is a national approach to support advanced care planning when doctors are uncertain whether a patient may recover or be in the final stages of life (months or days). Trained team members acted as champions to drive high-quality care at these times. They encouraged staff, patients and families to continue with treatment in the hope of a recovery, while talking openly about everyone’s wishes and putting plans in place should the person die.
• The end of life care team had rolled out care standards to ward areas using a strategy called ‘Transform’. Staff were trained to ensure that patients in the hospital had a good experience of end of life care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

• Medicines are managed at all times in line with legal requirements.
• There is effective leadership and governance arrangements in the A&E, operating department, maternity and radiology.

In addition the trust should ensure:

• Safety standards in the A&E department are improved to be in line with current national guidance.
• Parents and Children have information if they have to have long waiting times in the Rose Goodwin observation unit in A&E.
• Care pathways and care bundles continue to be embedded into everyday practice and monitored.
• It continues to reduce the avoidable harms of pressure ulcers, falls, and catheter urinary tract infections.
• People living with dementia continue to have consistent care and support in all areas of the trust.
• The Five Steps to Safer Surgery checklist is audited to ensure appropriate and consistent use.
• Patients being ‘checked in’ for theatre have their privacy and dignity maintained.
• Staffing levels continue to improve (especially in A&E and surgery), and patient care is appropriately delivered by trained, experienced and skilled staff.
• The use of linen drapes in theatres is avoided.
• That all staff use the incident reporting system to report incidents, and that learning from incidents is cascaded and shared.
• Do Not Attempt Cardio Pulmonary Resuscitation orders are appropriately completed so that there is timely documentation of the decision by the appropriate person, and this decision is reviewed if there is a change in a patient’s condition, and mental capacity is assessed.
• Radiology services improve so that patients do not experience delays and long waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

16 July 2014