George Eliot NHS Hospital

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• 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

We reviewed learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control and medicines optimisations for the safe key question. We found safe remained good. The service had enough skilled staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. However, we had concerns about the training compliance of staff in some key subjects including life support and safeguarding.

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.

Staff knew what incidents to report and how to report them. Staff gave examples of incidents they had reported, confirming this. Staff reported serious incidents clearly and in line with trust policy. From 1 December 2023 to September 2022, there had been 209 incidents reported across the clinical support services directorate with 161 classified as no harm, 44 as low harm and 4 incidents as moderate harm. Managers monitored mandatory training and alerted staff when they needed to update their training. The hospital set a target of 85% for completion of all mandatory training courses. The hospital data showed an overall 96.5% compliance for medical, nursing and non-clinical staff which was better than hospital target. Staff we spoke with confirmed their mandatory training was up to date. Staff were also provided with specific mandatory clinical skills training in critical care. However, further information demonstrated there were compliance issues with safeguarding level 3 training and immediate life support (ILS) which were below the expected trust target. Clinical staff completed training on recognising and responding to patients living with mental health needs, learning disabilities, autism and dementia.

There were processes in place for staff to follow when reporting incidents. Incidents were discussed as part of regular huddles and meetings, and where learning was required there were processes to follow for staff to ensure this was shared and embedded. Where serious incidents had occurred, staff formally undertook the duty of candour. Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is a regulation, which was introduced in November 2014. This regulation requires the organisation to be open and transparent with a patient when things go wrong in relation to their care and the patient suffers harm or could suffer harm, which falls into defined thresholds. The duty of candour regulation only applies to incidents where severe or moderate harm to a patient has occurred. We requested the reports for the last 3 incidents, however the evidence provided by the trust were minutes of a meeting where incidents were discussed and learning explored as the service had recorded any serious incidents recently. Evidence showed there were processes within the service to ensure staff met to discuss and learn from significant incidents. As the service were part of a directorate of other services, the process for learning from experiences crossed over many services. This enabled cross department learning. There were also processes in place to ensure all relevant safety alerts were shared within the department.

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.

Staff received mandatory training in the safeguarding of vulnerable adults and children as part of their induction, followed by yearly safeguarding refresher training. We reviewed safeguarding training compliance rates for the clinical support services directorate and compliance was at 95.4% with the trust target of 85%. Level two safeguarding compliance was 100% and safeguarding adults and children level 3 compliance was at 77% which was slightly below the trust’s target. Staff understood their responsibilities and knew how to identify potential abuse and report safeguarding concerns. Staff completed training on safeguarding through electronic learning and had a good understanding of their responsibilities in relation to the safeguarding of vulnerable adults. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff professional standards of practice and behaviour were underpinned by values of equality and diversity.

There were processes in place for staff to follow to ensure patients were safeguarded from the risk of harm and abuse. The trust had a process in place to identify where patients were at risk due to safeguarding concerns. The policies were in date and contained the most recent national guidance and legislation. The service had a process in place to monitor staff training to ensure they were in compliance with the trusts target. The service had systems in place for the identification and management of vulnerable adults and children at risk of abuse.

Staff made sure patients and those close to them understood their care and treatment. We observed staff spending time with patients, their families and carers when discussing their care. A relative told us staff were knowledgeable and provided good care. There was an organ donation staff to directly promote and support staff and relatives with the organ donation programme. They attended the unit during our inspection.

Patient assessments were carried out to manage risks in line with national guidance. Risk assessments were undertaken in areas such as venous thromboembolism (VTE), falls, malnutrition and pressure sores. These were assessed and documented in the patient’s records on admission and 24 hours later in line with best practice. Records included risk assessments for VTE, pressure areas and nutrition. Staff had completed all assessments in the 4 records we reviewed. Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The hospital used the National Early Warning Score 2 (NEWS2) for the detection and response of deteriorating patients. We checked NEWS documentation in all records we reviewed in the unit. We found NEWS to be consistently completed and when they deteriorated this was appropriately escalated. Visiting professionals to the unit (for example, physiotherapists or dieticians) were given an update on a patient’s condition and progress before giving any treatment. Data shared with us following our assessment showed 100% of staff had attended basic life support level 1 training, 91.7% of staff had attended adult basic life support level 2 training. However, staff did not meet the trust’s target of 85% with only 53.8% of staff being up-to-date on level 3 immediate life support training and 77.8% of staff being up-to-date on level 4 advanced life support training for role appropriate staff. On the intensive care unit, patients were closely monitored so staff could respond to any deterioration. Patients were cared for by levels of nursing staff recommended in the core standards for critical care. Patients who were classified as needing intensive care (level 3) were cared for by one nurse for each patient. Patients who needed high dependency type care (level 2) were cared for by one nurse for two patients.

There was a trust wide process in place which the service was aware of for managing and escalation of a deteriorating patient. This provided staff with the information they required to ensure the situation was managed well regardless of where the emergency occurred. The service completed risk assessments in line with trust policy which was patient centred and kept patients safe. Staff ensured the risk of ventilator associated pneumonia (VAP) was identified and mitigated for patients. VAP was a common risk for patients who were ventilated and required thorough risk assessments and actions put in place to meet the patient need. The service followed processes and policies in place to complete individual risk assessments for patients who were admitted. Where discussions with the patient couldn’t be held as they were sedated and ventilated, any required discussions about managing the risk of patients was completed with the patients next of kin. There was a process in place to support deteriorating patients on the wards or patients who had been stepped down from the critical care service. The critical care outreach team (CCOT) were available 24 hours each day and provided a service which was in line with national guidance.

The unit provided mixed sex accommodation for critically ill patients within the Department of Health guidance. To maintain patients’ privacy the bed spaces were separated by curtains. The service had a relatives’ room which was well equipped with seating, hot drinks, trust and charity information leaflets. Relatives used it as an overnight stay room as it had a sofa bed. Staff also used it to meet visitors in private. A waiting area equipped with chairs was available for visitors to sit. We observed visitors sitting in the area and taking turns to visit their relatives to avoid overcrowding during visiting times.

Staff told us the design, maintenance and use of facilities and premises kept patients, staff and visitors free from avoidable harm. The ICU was equipped to provide care for 8 ventilated patients with provision for 2 side rooms and a 6 bedded bay. The unit refurbishment plan was underway and scheduled to commence on the 22 April 2024 with plans to upgrade the air conditioning unit and replace windows. Staff told us they had enough equipment to keep patients safe. There were two resuscitation trolleys available in the department, along with a difficult airway trolley. This equipment was checked daily and documented as complete and ready for use. All basic, advanced airway, circulation and fluid items were in date.

The environment was spacious and well-lit. Corridors were free from obstruction to allow prompt access, ensuring people were kept safe. The unit complied with the national standards Health Building Notes 04-02 in terms of space and equipment required for intensive care facilities. The unit was secure, and access was by an intercom. Visitors were required to ring the bell to gain access to the unit. A transfer grab bag was available within the department; this was used for in hospital transfers to other wards or for diagnostics.

There was a process in place to ensure equipment and the environment were well maintained and safely met the needs of the patients admitted to the area. However, it was noted there were issues within the department where flooring was no longer considered safe having come away from 3 separate areas within the ward. We were therefore not assured the processes to ensure the department was safely maintained was effective.

Staff told us the unit had an establishment of 32.43 budgeted full time equivalent (FTE) nursing posts with an actual FTE of 30.74. The service had a band 7-unit manager and 10 band 6 nurses who supported in the running of the ward. It had 10 band 5 nurses, 4 band 3 healthcare support workers and a housekeeper. The nurse in charge was responsible for allocating breaks. Staff managed breaks by two nurses swapping to cover each other. Managers told us the service had low vacancy rates. Staffing data provided by the trust following our inspection showed, the nursing vacancy rate was 5.2% with the total vacancy rate for the department at 8.36%. A critical care unit recruitment plan was in place with external candidates recruited from across the UK. Senior staff managed sickness with support from the human resources and occupational health teams in line with trust policy. Staff told us 2 staff were off on long term sickness. The critical care unit fulfilled all medical staffing requirements of Core Standards for Intensive Care. There were 7 intensive care consultants and specialist registrar whole time equivalent (WTE). The service had no vacancies for medical staff. The consultants we spoke with confirmed they and their colleagues had no other clinical commitments whilst on call. They performed ward rounds twice daily and were able to come into the hospital within 30 minutes, meeting the Intensive Care Society Standards. Care in the ITU/HDU was led by a consultant in intensive care. A consultant was present on the unit from 8am to 9pm, 7 days a week. Staff told us that outside these hours a consultant was able to attend the unit within 30 minutes if required.

The service had enough nursing and support staff to keep patients safe, however the number of nurses and healthcare assistants did not always match planned numbers. Actual and planned nurse staffing was based on acuity. Nurses supported other areas of the hospital, such as the emergency department where there was reduced acuity. We reviewed the staffing rota for 2 weeks prior to our assessment and found gaps in night shifts for nursing staff. These gaps were covered by agency staff who were intensive care trained staff. On day 2 of our inspection, the service was over capacity with 6 staff to care for 5 level 3 patients and 3 level 2 patients during the day and 5 members of staff on the night shift. Staff managed risk as a level 2 patient was fit to be stepped down to the ward but could not be moved due to complex needs. Staff mitigated risk by a senior staff caring for both a stable level 3 patient and a level 2 patient likely to be stepped down to level 1. We saw the appropriate staffing levels were maintained throughout the inspection period. The enhanced care team provided cover when the department was under established. All nurses including the nurse in charge were counted in the numbers. For example, on day 1 and 2 of our inspection, nurses in charge were allocated level 3 patients. This did not leave them free to co-ordinate the shift and was not in line with the requirement of 1:1 care for level 3 patients. Senior staff told us the service had 8 beds and so was not funded to have an extra floating nurse.

There were processes in place to ensure there was enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. There was a Standard Operating Procedure (SOP) in place for staff to follow in times when the dependency and acuity of patients is greater than the number of staff on the unit. The service worked in line with the Guidelines for the Provision of Intensive Care Service (GPICS) standards 2022 and the SOP supported this approach. When times of escalation were required, there was a flow chart for staff to follow to ensure support was put in place and ensure patients remained safe. Managers had processes in place to ensure they managed the vacancies, turnover and sickness within the department. This information was reviewed and discussed regularly at governance meetings. There were processes in place to address vacancy issues with recruitment ongoing to ensure the service was staffed safely. There were processes in place to request agency and bank cover for shifts which required additional staffing resources. Managers monitored the usage and accompanied spend associated with this, although there were no limits or caps in place. New starters including those working under bank and agency received a local induction as part of the processes in place to ensure staff were safely inducted to the local area.

Staff told us the service generally performed well in hand hygiene audits. Hand hygiene and infection prevention and assurance audits carried out in the intensive therapy unit showed 100% compliance in the reporting period from December 2023 to February 2024. Staff told us screening for MRSA (Methicillin resistant Staphylococcus aureus), Clostridioides difficile (commonly known as C. difficile) was completed and appropriate measures taken if positive. Pseudomonas and Legionella had recently been isolated in some of the taps within the unit. The service used filters and flushed taps regularly as part of the domestic cleaning schedule to mitigate risk. No inpatient or staff had contracted the infection as a result of exposure.

At the time of our inspection, high standards of cleanliness were maintained cross the department, with reliable systems in place to prevent healthcare-associated infections. However, we found 3 areas in the critical care bay where the sealant to the flooring had come loose. There was a risk of microorganisms living in the cracks posing a risk of infection. This was not in line with Health Building Note (HBN 00-10) part A design for flooring. We raised this with leaders during our feedback session with the trust. The unit had two side rooms with facilities for respiratory isolation. Patients with transmissible respiratory infections were prioritised in these rooms. At the time of our assessment, both of these siderooms were in use and we observed staff ‘donning and doffing’ the appropriate personal protective equipment (PPE).

There were policies and processes in place for staff to follow to ensure the risk of infection was controlled well. The policy was in date and laid out for staff the expected standards required and the practices they were expected to complete. To ensure staff adhered to the processes and policies in place, they completed audits to assess the standards. Hand hygiene was an essential measure of infection prevention and control standards, adherence to the 5 moments for hand hygiene is a key measure in the prevention of transmitting infection. In addition to hand hygiene and standard audits, the service also completed high impact intervention (HII) audits in relation to catheter insertion, ongoing catheter care, peripheral cannula insertion and the on-going management of a peripheral catheter. There was also regular monitoring of uniform standards as well. The results of the audits showed the most recent audit results for the insertion of peripheral cannula, ongoing management of peripheral cannulas and the insertion of urinary catheters had improved from the previous months, however the results generally fluctuated for these. As a result of the fluctuating results, an action plan had been developed to continue the improvement. The service followed required processes to monitor healthcare associated infections due to the alert organisms including MRSA, Meticillin sensitive Staphylococcus aureus (MSSA), Escherichia coli (E. coli) bacteraemias and Clostridium difficile. Information provided showed between March 2023 and March 2024 there had been 2 Clostridium difficile infections, 2 E. coli bacteraemias and no MRSA or MSSA bacteraemias. In addition to these mandatory reportable HCAIs, the service also recorded the number of infections from multi-drug resistant (MDR) Pseudomonas. In the period of March 2023 and February 2024, the service recorded 1 infection.

Staff told us they followed systems and processes when safely prescribing, administering and recording medicines. Staff administered medicines safely by checking patient’s identification and allergies, providing appropriate support and recording administration. A pharmacist attended the intensive care unit daily and reviewed patients’ medicines. Staff told us the service had systems to ensure staff knew about safety alerts and incidents, so patients received their medicines safely. Staff were aware of their responsibilities in managing safety alerts. Information was shared and actions taken where necessary. Medicines incidents and near misses were reported and investigated on the unit. Learning following incidents was generally shared with staff. From 1 August to 31 October 2023 the clinical support services submitted a total of 15 medication related incidents for further investigation. These were for outpatients department and critical care. The deputy chief pharmacist, who also served as the trust’s medicines safety officer, consistently monitored all medication incidents directly related to the pharmacy department. These incidents were deliberated upon at the monthly pharmacy risk and governance group where any pertinent learning was shared.

We reviewed medicine charts of 4 patients and found that they accurately reflected the prescribed and administered medications for that patient. Medicine charts and patient records also clearly stated any patient allergies. The treatment room was swipe card operated. Only authorised people had access to the room. Staff monitored medication fridge temperatures in line with trust policy and national guidance. We found 6 gaps in fridge temperature checks in February 2024, 6 gaps in March 2024 and a gap in April 2024. Fridge temperatures we looked at were all in range between 2-8 degrees centigrade. The room and fridge temperature checks were undertaken by domestic staff and nursing staff had no oversight on temperature checks. We raised this with senior staff at the time of our inspection who said necessary steps will be taken to address the gaps.

There were processes in place to ensure staff prescribed, administered, recorded and stored medicines safely. The trust had a medicines policy in place which provided all relevant information which was in line with national best practice, professional standards and legislation. The policy was in date and had evidence of amendments being made when there were relevant updates which impacted the policy. The policy also covered another trust which was under the same executive leadership, but there were clearly identified areas which applied to the separate hospitals. Audits were conducted to ensure staff adhered to the processes, standard operating procedures (SOPs) and policies in place. Where areas of non-compliance were recorded, an action plan was put in place to ensure improvements were made. There was a trust wide antimicrobial policy in place and processes to ensure staff were compliant with this. Information showed the trust as a whole were not meeting the target for reducing the amount of antimicrobials being prescribed from the watch and reserve list. It was however noted there was no Antimicrobial Surveillance Group meetings being held and antimicrobial ward rounds were not routinely taking place. This highlights the processes which the trust have in place are not assured for the stewardship of antimicrobial use, which in turn means the service will not be engaged in stewardship of antimicrobials.