George Eliot Hospital NHS Trust

George Eliot Hospital NHS Trust provides a range of hospital and community-based services to 300,000 people in North Warwickshire, South West Leicestershire and North Coventry, employing around 1,917 staff. The hub of the trust is the George Eliot Hospital, a 352-bed district general hospital, based on the outskirts of Nuneaton.

The trust has six locations registered with the Care Quality Commission, including the George Eliot Hospital. The other locations are the Camphill GP Led Health Centre, Satis House, Leicester Road (APMS Practice), The Chaucers (APMS Practice) and the Leicester Urgent Care Centre.

During this inspection we inspected the George Eliot Hospital. This hospital is an acute hospital providing accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’ 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.

We carried out this comprehensive inspection because George Eliot Hospital NHS Trust had been flagged as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was one of 11 trusts placed into special measures in July 2013, after Sir Bruce Keogh’s review into hospitals with higher than average mortality rates. There were concerns about the role of the leadership team in driving improvements in the quality of care and treatment, the pace of quality improvement, the number of unnecessary bed moves for patients, the level of clinical staff out of hours and at the weekend, the quality of medical handovers, the use of nationally recognised pathways of care, the need to improve incident reporting, and the need to reduce the prevalence of pressure ulcers and to clarify the grading of pressure ulcers.

The announced inspection took place between 30 April and 1 May 2014, with an unannounced visit on 10 May between 4pm and 8pm.

Overall, we rated this trust as ‘good’. The trust was good for providing effective, caring and responsive services and was well led. The safety of some services ‘requires improvement’.

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'.

Key findings related to the following:

• We recognised that the trust had worked hard and had made significant progress since entering special measures in July 2013. Ten urgent priority actions had been identified within 55 recommendations for the trust, to improve the quality of their services. As of April 2014, all 10 key Keogh actions identified had been delivered with work ongoing with regards to Board development and the implementation of an electronic incident reporting system.
• Special measures status was designed to provide intensive support to challenged trusts: The trust was partnered with University Hospitals Birmingham NHS Foundation Trust. The relationship was described as supportive and flexible, and had developed depending on the needs of the George Eliot Hospital NHS Trust. The trust had benefited from support to develop governance processes, and support to the leadership, in particular, around challenged services. Both trusts described the relationship as extremely positive.
• The trust had a clear vision and a five-year strategy was in development to adapt and change services, and develop sustainable quality care. There were comprehensive governance processes to monitor quality, performance and patient experience. The leadership team were proactive in taking action on identified risks, and open and transparent about challenges and successes. They had made credible and significant progress against their action plan under special measures, and there had been an impact on reducing mortality, developing the quality of care, the progress of seven-day services, and the use of recognised pathways of care. The monitoring and approach to deliver harm free care was reducing avoidable harms, such as falls and pressure ulcers.
• Overall, we found that staff were caring and compassionate, and treated patients with dignity and respect. Patient’s experiences of care was good, and the NHS Friends and Family Test rating was higher than the national average for inpatient wards and for A&E.
• The trust had identified significant risks around managing patient flow, staffing levels and discharge planning. The number of patient bed moves had significantly reduced, with a change in the model of care and consultant responsibilities, and staffing levels had been reviewed and more staff had been recruited. The management of patient discharge remained a challenge, but was being managed through early discharge planning and co-ordination by the discharge team.
• The hospital had worked to improve emergency care, and had introduced the modified early warning system tool, care pathways and care bundles, to escalate and standardise care for patients who were acutely ill. In March 2014, the trust mortality rates were within the expected range.
• In December 2013, the trust had opened a new acute medical admissions unit and an ambulatory care unit. The A&E department had been reconfigured during 2013 to improve the flow of emergency patients through the hospital, and speed their assessment, treatment and discharge. The trust was seventh in a list of top 10 NHS trusts in the country for seeing A&E patients within four hours, in the 20-week period up to 23 March 2014, and the ambulatory care unit was successful in avoiding patient admissions.
• Seven-day working was developing across all services, and was significantly developed for emergency care. Staff worked in multidisciplinary teams to co-ordinate care around the patient, although clinical support, for example, in therapy, pathology and radiology services, were not as well developed across seven days.
• Nursing staffing levels were assessed using the national Safer Nursing Care Tool and minimum staffing levels had been set. Additional nurses had been recruited, and wards and patient areas were staffed appropriately. There had also been a change in the skill mix of nursing staff on night shifts. There was still a reliance on agency staff, particularly in A&E and the operating department, but where possible, the same staff were being used. Shifts were being monitored using a rating system, where green was staffing levels as required, and red was a safety concern. The trust had a system to escalate concerns when staffing levels fell below the minimum. They reported that there had not been any ‘red flags’ in the last 2,013 shifts in the last eight weeks leading up to the CQC inspection.
• Medical staffing levels had increased, but there was still concern in A&E, general medicine and paediatrics. Locum staff were being used, but this was costly. Overall, the trust spend on agency and locum staff was 15% of the total staffing budget The trust had a financial imperative to reduce the number of agency and locum posts to substantive posts in the coming year.
• Staff followed good infection prevention and 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 in an acceptable 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 and the lessons learnt were not widely shared. The trust was investing in a new electronic incident reporting system.
• Pharmacy services and medicines management were not receiving adequate attention. Pharmacy needed to increase its joint working and responsibility for prescribing, administration and medicines management. 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. The trust was taking action to improve this.
• Radiology services had been without appropriate leadership for two years. The service had antiquated procedures and these were not responding well to increasing service demands and there were long waiting times for services. The trust needed a new CT scanner and there were currently delays for urgent CTs due to the capacity of the single scanner. The service had unfilled consultant posts and difficulties in recruiting. There was external remote reporting but this was not monitored effectively. The governance arrangements in radiology were a concern and risk management, incident reporting and audit were underdeveloped; infection control standards were not being met. The trust was now working to identify leadership support for this service.
• Staff told us that special measures had been difficult, but wanted us to be aware of the positive changes. They felt that the culture was open and transparent, and staff were encouraged to learn and innovative. Learning across the trust, however, was not shared effectively. Some staff groups, such as cleaners, and administrative and clerical staff, said they were still under pressure and wanted their concerns to be heard. There were also particular services where there were leadership concerns, such as in theatres and maternity, and morale was low in radiology. This could affect patient care if they remained unresolved. The Trust had engaged with staff in these areas and was taking taking action to strengthen leadership arrangements and to build effective team working and resilience in these services.
• Complaints management was improving in response to patient feedback about delays, and defensive and jargonistic replies. A new format was being introduced to standardised responses and ensure information was being communicated in a way that patients could understand. There were still excessive delays however, with only 20% of complaints in February 2014 being responded to within 25 days.

We saw several areas of outstanding practice including:

• The ambulatory care unit (ACU), opened in December 2013, had had a positive impact on preventing patient admissions. The ACU was helping to meet the needs of patients in the community who required medical intervention without the need to be admitted to the 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 where named relatives could offer their help by coming into the ward and providing care for their loved one, such as help to eat meals or personal care. The hospital offered the named relative free parking or 10% off meals purchased 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 physiotherapist input. The team worked closely with the respiratory ward to ensure longer term management. A discharge bundle had been introduced, which included follow-up within 72 hours.
• The Oasis Project identified patients during their pre-operative assessment who may be anxious about surgery. The project comprised of a team of volunteer therapists who had a professional relaxation qualification. Therapists would talk through any anxieties at the pre-operative assessment, to provide reassurance to the patient, and also note any issues for the patient’s admission 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 in the intensive therapy unit (ITU), which depicted, for example, pictures of 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, providing information and positive parenting support to vulnerable and teenage mums. Midwives developed a close relationship with women, and offered additional support, continuity of care and co-ordinated multi-agency case conferences, involving social services.
• Multidisciplinary networks in paediatrics were being developed to deliver care closer to children’s homes.
• The AMBER care bundle is a simple approach used in hospitals when doctors are uncertain whether a patient may recover, or are concerned that a patient may be in the final stages of life (months or days), and the package supports advanced care planning. Trained team members act as champions, to drive high quality care at the end of life. It encourages staff, patients and families to continue with treatment in the hope of a recovery, while talking openly about people's wishes, and putting plans in place should the person die.
• The end of life care team had rolled out end of life 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.
• The Patient Advice and Liaison Service (PALS) responded to 95% of patient concerns on the same day.
• The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients; for example, details of the patient’s current medication.

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.
• Children did not 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.
• The trust needs to continue 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.
• Continue to develop services across seven days.
• Medical staff communicate with patients in a way that they can understand.
• Complaints are responded to within 25 days and responses address all concerns and are written in a way patients and the public can understand.

Staff engagement continues and develops and staff at all levels feel involved and listened to.

Professor Sir Mike Richards

Chief Inspector of Hospitals

16 July 2014