George Eliot NHS Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We reviewed assessing needs, delivering evidence-based care and treatment, how staff , teams and services work together, monitoring and improving outcomes and consent to care and treatment as part of the effective key question. We found effective remained good. Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. However, we found staff were not always following correct process when completing the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans with patients.

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.

Specialist support from staff such as dietitians and speech and language therapists was available for patients who needed it. Staff assessed patients’ nutritional and hydration needs daily and acted upon the findings. Staff provided hydration and nutrition through a regimen of intravenous fluids and specialist feeds. This was with the support of the dietitian service, which supported patients who were not able to eat and drink while they were critically ill.

Staff told us they assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Staff used the critical care pain observation tool to assess pain. We saw evidence in records of staff observing signs of pain in patients with a reduced consciousness level or reduced communication. If there were any signs of pain in these patients, this was acted upon. Patients’ pain scores were regularly assessed and documented. Records showed that pain relief was administered promptly and patients’ pain reassessed after administration to ensure their pain was adequately controlled at all times. Staff obtained daily lactate to screen for sepsis. A microbiologist attended doctors rounds if required and discussed laboratory results with consultants. On call microbiologist cover was available out of hours. Patients were referred to physiotherapists based on their clinical need. Physiotherapists had a multi-disciplinary team (MDT) meeting for patients who had been in-patients for 4 days or more. The MDT used this meeting as an opportunity to discuss patients with complex needs as a team, to share ideas and to review treatment progress. Staff undertook skin integrity checks and referred patients to tissue viability as required. We saw a patient who had acquired a pressure sore had been referred to tissue viability team and the team. All necessary steps had been taken to ensure the patient continued to receive safe care and treatment. Rounding charts were in place and these had been completed as recommended.

There were processes in place to ensure staff holistically assessed patient needs. This included but was not limited to the risks from malnutrition, pressure damage, ventilator associated pneumonia and moving and handling. Due to the risks associated with being sedated and ventilated for a duration, additional risk assessments were completed for any delirium or mental health concerns associated with this.

Staff told us the unit’s policies, protocols and care bundles were based on guidance from NICE, the intensive care society and the faculty of intensive care medicine. Staff demonstrated awareness of the policies and knew where to access them. Patients’ care and treatment was assessed and delivered in line with national and best-practice guidelines. We saw evidence that staff assessed patients regularly for delirium in a patient records. This was in line with NICE CG103 delirium: prevention, diagnosis and management. Delirium was monitored daily under a care bundle called ‘Dreams’. Staff told us the unit met best practice guidance by promoting and participating in a programme of organ donation, led nationally by NHS Blood and Transplant. In the NHS, the number of patients suitable for organ donation is limited for a number of reasons. The vast majority of suitable donors would be cared for in a critical care unit. There was an organ donation team working alongside the unit. They directly supported the organ donation programme and worked alongside the clinical lead. We saw staff from the team visiting the unit during our inspection.

There were processes in place to ensure staff delivered high quality care and treatment in line with in date policies, procedures and guidelines which were based on best practice and national guidance and policies. Staff assessed patients needs and planned and delivered care in line with National Institute for Health and Care Excellence (NICE) and the Guidelines for the Provision of Intensive Care Services (GPICS) which were developed by the Faculty of Intensive Care Medicine (FCIM). There were processes in place to ensure patients who were admitted to critical care were closely monitored for heir nutritional input. Dietitians were involved with patient care and followed the recommended best practice to ensure patients were nutritionally safe during their admissions. Patients who were admitted to critical care required close monitoring due to the impact that severe disease, illnesses or injuries can have on the body. Where patients were sedated and unable to take any food or nutritional supplements orally, other methods were usually in place to ensure they maintained their intake. There were processes in place to ensure all local policies and SOPs were in line with the national guidance and monitored the programme in place for auditing the outcomes for the service.

There were processes in place to gather data on the performance of the service in relation to how they implemented evidence-based care and treatment as well as other nationally recognised processes. The clinical support services regularly met to ensure all processes were in line with the most current guidance and that audits were being completed in accordance with the directorates audit programme. The report from February 2024 showed the service were compliant with their audit programme. All audits were at the expected stages of either complete or in the data collection stages. There were no overdue audits for the service.

Staff told us there was good teamwork and communication within the multidisciplinary team. We observed this on the unit and at the bedside during the inspection. The critical care outreach team (CCOT) were all nurse prescribers and advanced life support trained. Staff alerted the team where patients scored national early warning signs of 10 and above. The CCOT team was made up of external staff and not directly pulled from the critical care unit. They attended the medical handover twice a day at 9 am in the morning and 9 pm in the evening. Speech and language services were accessible on referral. Staff told us they held multi-disciplinary team safety huddles in the morning. We listened to these, and staff identified high risk patients and had a comprehensive discussion around their needs. Clinicians reported a good working relationship between the intensive care unit, anaesthetist at 2 neighbouring NHS trusts.

Physiotherapists were available every day and we saw evidence of physiotherapy assessments and therapy sessions in the 4 patient records we reviewed. We observed evidence of discharge planning during the multidisciplinary handover. Each profession handed over patient information verbally to the relevant professional prior to the patient leaving the unit. There was a dedicated critical care pharmacist to provide advice and support to clinical staff in the unit at the time of our inspection.

There were processes in place to ensure member of the multidisciplinary team (MDT) worked together to ensure the needs of the patients were met. Key governance meetings were attended by members of the MDT which demonstrated an effective and cohesive service. Minutes from various governance and quality meetings were attended by members of the MDT. Evidence provided identified there were regular MDT ward rounds for patients which looked at the whole patient and their needs, this included but was not limited to the daily microbiology ward rounds with the infection control doctors and microbiologists.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Staff told us clinicians carried out various audits such as gut hygiene audits, genomic trials, rib fracture trials, end of life care on the intensive care unit and lung protective ventilation in the intensive care unit. Staff from the service submitted data to the Intensive Care National Audit and Research Centre (ICNARC) an organisation reporting on performance and outcomes for intensive care patients nationally. The clinical audit team was a dedicated team which collated this information and disseminated a summary of clinical audit activity. They highlighted any areas of concern, provided updates on the national audit and facilitated learning.

There were processes in place within the service to monitor and improve outcomes for patients who used the service. There was evidence of audits being conducted which included patient reported outcomes. Information received after the assessment identified a programme of audits for the period of 2023/24. Ten audits were identified with 9 of them either completed or data collection in progress. Four audit outcomes were shared after the onsite assessment; however no action plans were shared. The service also participated in national audits including the Intensive Care National Audit and Research Centre (ICNARC) audit and an audit looking at lung protection. The service had also signed up to another national audit (National evaluation of the use of critical care echocardiography in shock) however the data provided after the assessment identified the service had not submitted the data in the timeframe identified. This identified concerns with how effective the service was at monitoring and improving and the oversight of projects in place to drive improvements. Clinical effectiveness and outcomes were regularly discussed at the clinical services governance meetings however the minutes of these meetings did not always identify what was discussed and therefore we were not assured the processed were always effective.

We requested data in relation to their performance with the Intensive Care National Audit and Research Centre (ICNARC) audit, however the service were only able to provide the overall case mix programme data which they had contributed to, no data for how their service compared to the national picture was provided. The service provided other local audit outcome information which demonstrated there were areas for the service to improve on. However, no additional action plans or other data to demonstrate how the improvements would be achieved was provided. We requested information on sepsis performance for the service. Information received after the assessment identified the service did not complete separate sepsis audits due to the continuous monitoring of patients and all patients are at a high risk of sepsis. The service was therefore satisfied that through continuous monitoring of the patient and input daily from microbiology, all aspects of the sepsis 6 indicators were covered. Despite this response, no data to support the successful monitoring and management of confirmed sepsis patients was provided. The service collected their own data on readmission rates which was part of their critical care dashboard. Data collected for March 2023 to February 2024 showed there were 441 admissions into the critical care unit with only 7 readmissions (1.59%) within 48 hours of discharge from the CCU.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Staff made sure patients consented to treatment based on all the information available. We observed staff obtain verbal consent from patients before carrying out an intervention. Where consent could not be obtained, staff delivered care in the patient’s best interest. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system they could all update.

Staff told us there was a hospital policy to ensure staff were meeting their responsibilities under the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff could describe the process for making an application for requesting a DoLS for patients and when these needed to be reviewed. Staff received and kept up to date with training in the MCA and DoLS. Information provided by the trust showed 100% of medical and non-medical staff had completed mental capacity act training. Staff mostly understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989 and 2004 and they knew who to contact for advice. We observed significant input in a patient with complex needs following a cardiac arrest. Staff followed a multi-disciplinary team approach and had contacted external agencies such as social services and the coroner. A brain stem death test was carried out and staff discussed and documented the potential withdrawal of treatment if the test did not go well. Staff involved relatives in the consent process. Staff told us the service used The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) to support conversations about care in a future emergency. It was designed to allow patients greater influence on what happens to them, and that their wishes are carried out appropriately, should they ever find themselves in an emergency where they are not able to express their wants and/or needs. We reviewed 2 ReSPECT care records had found these had been completed by a medical staff. There was no evidence that these had been discussed with a relative with power of attorney. Staff we spoke with told us this was usual practice.

There were processes in place to ensure staff supported staff to make informed decisions about their care and treatment. There were policies and processes which staff were aware of and followed to gain patient consent. Where patients lacked the capacity to make decisions about their care and treatment themselves, there were processes which were in line with national guidance and legislation to ensure consent was gained lawfully. Information in relation to the consent process was observed by staff whilst on site completing the assessment.