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George Eliot NHS Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 July 2014

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

Inspection areas

Safe

Requires improvement

Updated 16 July 2014

Effective

Good

Updated 16 July 2014

Caring

Good

Updated 16 July 2014

Responsive

Good

Updated 16 July 2014

Well-led

Requires improvement

Updated 16 July 2014

Checks on specific services

Maternity and gynaecology

Good

Updated 16 July 2014

There were effective procedures that supported safe and effective care for women. Staff were caring and compassionate and treated women with dignity and respect. National guidelines were adhered to and outcomes were good. Women had choices during birth and were involved in decisions about their care and treatment. There was additional support for vulnerable women and teenage mothers. The staff were loyal, committed and enthusiastic, and there was evidence of effective team work.

The gaps in the leadership staffing structure had creating some instability and concern within the service and governance arrangements had deteriorated. Service plans did not go beyond operational requirements and staff were not learning from incidents and complaints. Staff were positive overall and fully engaged, but staff were striving to cover the gaps and were reporting some fatigue and a lack of direction overall. Team work remained good and there were high levels of respect and support. Although there were some good examples of improvement, staff said overall that there was a reluctance to change and innovation.

Medical care (including older people’s care)

Good

Updated 16 July 2014

There were effective procedures for patients to receive safe and effective care. Both medical and nurse staffing levels had improved and there were safe staffing levels with lower numbers of agency and locum staff. Safety standards were followed for infection prevention and control and the use of equipment but medicines management needed to improve. National guidance was used to treat patients, and local care pathways and care bundles were ensuring consistency of treatment. Multidisciplinary working was widespread. There had been significant progress with the development of seven-day services.

Staff were caring and patients and relatives told us they were treated with dignity, compassion and respect. Patients were involved in planning their treatment and were always given an opportunity to speak with the consultants looking after them. Efforts were made to ensure patients stayed in contact with friends and relatives, and extended visiting hours had helped to improve communication between staff and relatives. The service was well-led. Staff felt supported, valued and proud to be part of the organisation. Quality and patient experience were seen as priorities and everyone’s responsibility, and there was a developing culture of innovation and learning.

Urgent and emergency services (A&E)

Requires improvement

Updated 16 July 2014

The trust had invested in developing the emergency medicine department and providing a dedicated children’s assessment unit and an adult clinical decision unit. Staffing levels in the department had improved but there was still reliance on agency staff and junior doctors identified the need for more senior staff support. Safety standards for infection prevention and control, equipment and medicines management, particularly controlled drugs, were not met. The department was a low reporter of patient safety incidents and staff described the reporting system as slow with limited feedback to staff. National guidance was used to treat patients, and local care pathways and care bundles were ensuring consistency of treatment.

Staff were passionate about the A&E department and the service offered to the public, and they treated patients with dignity and respect. Patient feedback was positive. The department was performing well against national waiting time targets for A&E, although some children could spend a long time under observation in the children’s assessment unit . It was supportive of vulnerable patients, such as those with mental health conditions, learning disabilities or dementia, but this support could be inconsistent. The department did not have good governance processes to monitor quality and risk, and there was no culture of learning and innovation.

Surgery

Requires improvement

Updated 16 July 2014

Patients were assessed before surgery and monitored so that their risks were managed. However, the use of the ‘Five steps to safer surgery’ checklist was completed but there had not been ongoing observational audit to ensure it was appropriately embedded into clinical practice. Safety standards were met for infection prevention and control and the use of equipment, but medicines management needed to improve. Staffing levels had improved and recruitment was ongoing. In the eight weeks leading up to the CQC visit, out of 2,013 shifts only one shift was escalated as a red shift in surgery. There was still a high use of agency staff, however, and staff reported they were often understaffed and worked longer hours and overtime to support colleagues.  Although. Patients were treated in line with national guidelines and received good pain relief.

Staff provided compassionate care and treated patients with dignity and respect. Patients we spoke with during our inspection were positive about the care and treatment they had received. They were complimentary about the staff in the service, and felt informed and involved in their care and treatment. Overall, national waiting times for surgery within 18 weeks were being met, although not in oral surgery, orthopaedics or colorectal surgery, and the trust was taking action to address this. Some patients had surgery cancelled at short notice because of staff shortages. There was some good leadership at ward levels and staff felt well supported by their managers; however, this was not the case for the operating department and there were plans to improve the management of this service. Governance arrangements did not provide assurance around risk and efficiency. There was a developing culture of innovation and learning.

Intensive/critical care

Good

Updated 16 July 2014

There were effective procedures to protect patients and support safe care. Visitors we spoke with were pleased with the care their relatives had received in the intensive therapy unit (ITU) and spoke highly of the staff. Clinical outcomes for patients in the unit were good. Staff worked well together as a team and were enthusiastic about their work. Patients we spoke with gave us examples of the good care they had received in the unit. Staff built up trusting relationships with patients and their relatives by working in an open, honest and supportive way.

The unit had an annual clinical audit programme to monitor how guidance was adhered to. Information was collected for the Intensive Care National Audit and Research Centre (ICNARC) database. There was good multidisciplinary team working although specific therapy support was not available over seven days. There was strong local leadership of the unit. Openness and honesty was encouraged at all levels, and staff were encouraged to learn new skills and develop the service.

Services for children & young people

Good

Updated 16 July 2014

There had been a review of the children’s service that had resulted in changes. The review had been undertaken to ensure that the needs of the local population were met in a safe and responsive way. There were no inpatient children’s services at the trust and children were cared for on the day procedure unit. They were cared for in a safe way in an environment that met their needs, and by staff with appropriate skills and experience. Children who were seriously ill were appropriately escalated for specialised care and this might involve transfer to a neighbouring trust. Staff provided compassionate care and treated children and their families with kindness, dignity and respect. The service was developing networks to ensure that care could be provided close to home when safe to do so. The service was well-led with a learning and innovative culture.

End of life care

Good

Updated 16 July 2014

There were effective procedures to support patients to have safe and effective end of life care. Staff were caring and compassionate and treated patients with dignity and respect. They were committed to providing person-centred care and ensuring that patients had choices, a good experience and their preferences met at the end of life. Patients spoke positively about the way they were being supported with their care requirements.

Staff in all the ward areas we visited were aware of the guidance for patients receiving end of life care and all knew how to contact the specialist palliative care team. Not all patients were appropriately referred to the specialist palliative care team, but there were nurses called ‘Transform Champions’ in the ward areas who were responsible for ensuring that end of life care training was cascaded within the ward areas.

The Liverpool Care Pathway was still in use for patients but it was being used appropriately according to interim national guidelines. The hospital had planned to phase it out, as expected nationally after a national review. The specialist palliative care team was working to develop an end of life care pathway that would be rolled out in June 2014. This team provided outstanding leadership. It was a small team that was passionate and dedicated to their role.

Outpatients

Good

Updated 16 July 2014

There were effective procedures to support a safe service for patients. Staff were caring and treated patients with dignity and respect. Most patients were seen within national waiting times although there were delays in orthopaedics and neurosurgery. Patients told us they were happy with the care they had received while attending their appointments within the outpatient department.

Most of the patients we spoke with felt they were seen promptly and were kept informed if clinics were running late. Each clinic had a board that displayed the length of time patients might expect to wait to be seen. The radiology department, however, was overcrowded and people were waiting a long time for x-rays. The service was part of a ‘transform’ programme to improve efficiency (for example, to reduce ‘did not attend’ rates and become more responsive). The leadership of the service was good except in radiology where the lack of strong leadership was having an impact on staff and the running of clinics.