Nuffield Health Brentwood 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

This means we looked for evidence that people were protected from abuse and avoidable harm. 

At our last inspection we rated this key question outstanding. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been no serious incidents reported in the 12 months prior to our assessment.

Nursing staff for children and young people(CYP) knew how to report incidents and could explain how learning from incidents was shared within the service to improve patient experience. Staff were able to provide examples of the types of incidents that would be logged for investigation and discussed near misses, including other opportunities to improve patient experience. Staff were aware of a medication error in pharmacy that had resulted in all take home medication being checked with the CYP lead nurse, including logging discussion with parents about scheduling dosages and the course of medication.

Incidents from other provider locations were shared for learning and discussed at the service.

Key risks were dealt with as an opportunity to put things right, learn and improve. We reviewed CYP newsletters that showed operational oversight of operational risk.

The CYP lead communicated key messages relating to staff across the service through newsletters and service updates.

All staff understood their responsibility to be open and honest with patients and their families when things went wrong. Staff were able to explain and give examples of instances where duty of candour had been applied. They knew this involved an apology to those affected as well as an investigation into certain adverse events.

Managers encouraged staff to raise concerns when things went wrong.

All necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment. Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.

Children’s nurses accompanied patients for surgical procedures so there was sufficient competency within the multidisciplinary team.

The hospital shared discharge information with other health services such as GPs and other hospitals when required. The service had recently reviewed the process in place for the transportation of acutely unwell patients to a local NHS emergency department – this included an emergency transportation requirement.

Children and young people’s (CYP) services were overseen by a CYP nurse and a named consultant paediatrician. They ensured that there was a named registered children’s nurse assigned to the patient through the patient pathway.

Staff carried out observational checks on patients in the timeframes set out in national guidance.

There was clear documentation across the CYP pathway that helped guide safe treatment. Nurses completed pre-assessment checklists, which documented patient pathways through the hospital. We reviewed 5 patient records, which showed that records had been completed appropriately.

The hospital had processes in place to ensure anaesthetists stayed with the patient after surgery. They ensured patients were well enough to return to the ward.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The children’s named safeguarding lead for the hospital was trained to level 4.

Safeguarding processes followed best practice. We reviewed the safeguarding policy that set out roles and responsibilities for staff.

Staff had knowledge and awareness of specific safeguarding concerns such as modern slavery and an awareness of domestic violence. We saw evidence of staff training on PREVENT. Staff were able to direct safeguarding concerns to the provider’s safeguarding lead. The safeguarding lead had direct links with the CYP service.

Staff followed safe procedures for children visiting the service. Staff were aware of procedures for arranging chaperones and posters were displayed throughout the hospital about requesting a chaperone.

Safeguarding updates were embedded into the CYP service governance framework. Staff had links with a local NHS trust and shared updates and learning about emerging safeguarding risks such as the ‘hydrant programme’. The hydrant programme is aimed at improving the response to child protection and abuse investigations, particularly focusing on child sexual exploitation.

Managers monitored the numbers of children and young people who were not brought to medical appointments by their parents or carers. Managers reported how these had been investigated and the outcomes in governance reports.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed the provider’s children in hospital policy (CL20). This identified the hospital as a type A location in respect of CYP services. Type A hospitals treated children ages 3-18. The CYP nurses processed booking forms and completed medical questionnaires prior to each procedure. There was dedicated time set aside to listen to parents, children and young people throughout the treatment process. We saw an example where a patient was readmitted for a procedure due to anxiety – more time was dedicated to help reassure the patient.

At the time of the assessment, all CYP nurses had completed Paediatric Basic Life Support (PBLS) or Paediatric Immediate Life Support (PILS) training. This meant that staff were trained to respond to any sudden deterioration in the health of a child or young person using the service.

Children and young people had their vital signs completed and recorded on a Paediatric Early Warning System (PEWS) chart. The PEWS is a clinical system to recognised, monitor and track deterioration in children.

Children aged between 16 and 17 years admitted on the adult pathway had their vital signs recorded and monitored on a National Early Warning Score (NEWS2) chart.

We reviewed records that demonstrated risks were managed by thinking holisticaly. There was opportunity for patients and their families to raise concerns so that care was provided in a supportive way.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff had access to visual aids and resources to help communicate with patients.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There was no designated waiting area for children and young people in line with national guidelines: NICE NG204. This meant that children and young people were not always segregated from adults and other patients.

There were no ward rooms designed and decorated specifically for children and young people. The CYP lead had flagged this as a risk on the risk register. The ward rooms, recovery and anaesthetic rooms were dual purpose for adult and children. Access to the first floor was through a secure door that required buzz access from reception. It was not possible to leave the ward area without staff assistance.

Security within the hospital was assisted with close circuit television (CCTV) cameras; all arrivals went to the main reception desk at the main entrance to the hospital and announced their arrival. Access to the children's and young people (CYP) assessment room was accessible on the first floor. There were some play equipment and activity boxes available for small children. CYP patients and their families spent their time post-surgery in an individual ward room.

Resuscitation equipment throughout the hospital was in date with separate children and adult trollies containing size appropriate equipment. Resuscitation equipment was available in both theatre and ward areas.

Staff had access to paediatric resuscitation equipment, anaphylaxis equipment difficult airway kit and anaesthetic equipment in the hospital.

We checked equipment throughout the service and saw stickers with dates, which confirmed maintenance checks had taken place. The service audited the equipment maintenance every three months as part of the medical devices audit.

Desk based emergency scenarios took place to ensure staff responded appropriately to situations that required coordinated action, such as baby abduction.

The service had enough nursing and support staff to keep children and young people safe. The hospital had a lead registered children’s nurse (RCN), 2 permanent RCNs and 3 bank RCNs. The service did not use agency RCNs and utilised its own bank staff. This enabled the same staff to consistently work at the site. These staff received comprehensive inductions and training. There was always an RCN assigned to the whole patient pathway.

On inspection we saw that some consultants did not have sufficient mandatory training completed in line with the service’s policy. The service was aware of this risk. However, we saw evidence that consultants were providing clinics without appropriate safeguarding training and without evidence of appropriate paediatric life support training. There was a risk that staff would not have appropriate competency to identify and act on safeguarding concerns and respond appropriately to a deteriorating patient within children’s services. We escalated these concerns following our onsite inspection. Leaders told us that these consultants had completed the respective training however the hospital did not document this, nonetheless the consultants had been suspended until appropriate assurance was provided.

The hospital employed a registered children and young people’s (CYP) nurse who was accountable for all the children’s services at the hospital. This met the Royal College of Nursing guidance on defining staffing levels for children and young people’s services.

We saw evidence that the number registered children and young people’s (CYP) nurses matched the number of planned numbers on shifts.

Mandatory training was comprehensive and met the needs of children and young people. All services at the hospital were planned rather than emergency procedures so the service could plan staffing for the procedures and outpatient appointments being carried out every day. During surgery, a children and young people’s nurse was always at the hospital.

Staff had clear roles and responsibilities. These were set out in the Nuffield governance documents (CL-20). Recruitment processes included Disclosure and Barring Service (DBS) checks and an induction that was role appropriate.

Consultants who requested practising privileges completed a provider Nuffield Health application. The process outlined the role of the hospital director to meet with the doctor to discuss their suitability to practice independently. Following completion of the relevant paperwork, the application was taken to the medical advisory committee (MAC) for approval. The CYP lead nurse was also empowered to provide challenge regarding consultant practicing privileges approval.

All relevant CYP staff had completed a CYP medicines management competency.

All staff completed Oliver McGowan training to better recognise and respond to the needs of people with a learning disability or autism.

Staff adhered to infection control principles, including handwashing. We observed the use of personal protective equipment and hand sanitiser by staff. Hand sanitiser was located on entry to each clinical area and within clinical areas. On the assessment we saw that staff maintained equipment well and kept it visibly clean. All ward areas were visibly clean, had required furnishings and were well-maintained.

Staff received infection prevention and control training as part of their induction and mandatory training. Staff confirmed completion of the yearly mandatory online infection control training.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

We reviewed infection prevention and control audits for children and young people services and they were all above 90% and within Nuffield targets.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Children and young people’s medicines were mostly prescribed safely by clinicians. The service had a process in place to ensure the safe administration of medicines, which included nurses completing a double-check before administration.

Pre-operative assessments were completed face-to-face for most children, with pharmacy input to review medicines and ensure safe prescribing.

We saw parents or guardians were given clear information about medicines, including preparation instructions, dosage and post-operative guidance. Staff supported families with medicine schedules and safety advice, including a contact number for escalating concerns.

We reviewed patient records that did not always record the rationale for the use of medication as a reversal agent and there was no policy to guide the use and administration of the drug.

Emergency medicines and reversal agents were available and checked regularly. Staff were aware of which medicines required consultant authorisation.