Practice Plus Group Hospital - Emersons Green

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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 looked for evidence that safety was a priority for everyone. We checked people were safe and protected from bullying, harassment, neglect and discrimination. This means we also looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained 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.

The service had reported 1 serious incident in the 12 months prior to inspection. This was investigated and an action plan created to address areas of concern which needed improvement. Incidents were reported and all staff knew what was defined as an incident and how to report them. The service had a Patient Safety Incident Response Policy. Most staff we spoke with said they reported all incidents they should report and understood duty of candour. However, some staff told us there was sometimes a reluctance to report incidents and near misses due to concerns about repercussions on reporting staff from senior managers.

The service was transparent and gave patients and families a full explanation if and when things went wrong. Staff received feedback from investigation of incidents via email, safety briefings and team meetings where staff met to discuss feedback. Staff said they got feedback from incidents if they requested it. We saw evidence changes to practice had been made as a result of feedback. Following an incident whereby a patient had to be readmitted due to hydration issues, the service changed their practice to ensure patients with lower readings on their blood tests were sent to their GP within a week for repeat testing, even if results were in safe limits for discharge.

Staff reporting incidents had the option to choose to receive individual feedback if they wished. The service’s incident policy highlighted the benefit of staff seeking support following a patient safety incident. However, the policy did not detail a process for staff to be debriefed and receive support after a serious incident.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff held a Multi Disciplinary Team (MDT) meeting with all relevant staff ahead of patient admissions for any patients with complex or additional health or access needs identified at their pre-operative assessment.

Some staff said there had been concerns about staffing safety when nurses had to leave the ward to transition patients up to theatre. The service did not have a porter at the time of inspection. However, leaders showed us evidence of a business case to provide this service to improve patient flow and staffing levels through the service.

Staff involved the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. There was an Interprovider Transfer Pathway detailing the responsibilities of all staff during any transfer of care of patients to services outside of the service when necessary. In cases of any unexpected or emergency transfers the service held transfer packs to ensure safe handover of patients into the care of external services. All staff knew how to access these packs.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service 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 were trained in safeguarding adults and children, knew how to make a safeguarding alert, and did that when appropriate. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. There had been 2 safeguarding referrals made in the 12 months preceding the inspection. There was a pre-operative assessment which picked up any concerns around patients at risk and Multi Disciplinary Team meetings offered a platform for staff to discuss any concerns and take action to address any issues. Staff followed safe procedures for children visiting the service. There was a Safeguarding Children policy and staff knew where to access this information.

Safeguarding incidents were reviewed and learning both internally and externally from incidents across partner services was applied. Safeguarding leads were included in local safeguarding meetings which had improved information sharing and gave opportunities for collaborative learning. We saw posters in the services toilets with contact telephone numbers and emails for anyone who was concerned about abuse. There was also information displayed in patient rooms to help reduce their risk of falls.

The service had a process for assessing capacity and implementing Deprivation of Liberty Safeguards. However, the service did not provide evidence of a process for managing patients under the Mental Health Act (1983) (MHA). Staff told us patients detained under the MHA were unlikely to be admitted to the service for surgery and would be treated at the local acute trust.

The service had a restraint policy and staff understood what restraint and restrictive practice meant and where to find this policy. Staff received restraint training. There was a process to assess ligature risks in the hospital environment.

Compliance with the mandatory training requirement on learning disability and autism was at 100% for the service. There was a room for patients with dementia or additional needs on the ward and pre-operative assessments were thorough, considering any additional needs patients may have. Where these needs presented challenges, patients were discussed at a multidisciplinary team meeting to assess how best to meet people’s needs during their admission.

We scored the service as 3. The evidence showed a good standard. 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.

Staff communicated with patients so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. There was a translate line which was accessible to all staff and they knew how to use this. Staff ensured patients could access advocacy and translation services. Pre-operative assessments for surgery were thorough and patients were able to ask questions about risks. The service provided visits to clinical areas in the department before surgery for patients with any additional needs or concerns where appropriate. This helped reduce risk by ensuring patients felt safe.

Staff enabled patients to give feedback on the service they received via questionnaires and patient surveys. Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate. Patients with Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were discussed at multidisciplinary team meetings to ensure patient choices around risk were included in care plans.

We reviewed 7 sets of patient surgical records and found gaps in venous thromboembolism (VTE) risk assessments, sepsis monitoring, pressure ulcer risk assessments, nutritional assessments and falls risk assessments in all records. Only one set of records in theatre contained details of patient’s mental health needs, learning disability needs, autism needs or dementia needs alongside their physical requirements. There was a policy to manage the restraint of patients effectively and staff understood the meaning or restrictive practice.

The service had a policy for the prevention of VTE and there were monthly audits to provide assurance World Health Organisation (WHO) surgical checklists were completed which included VTE risk category was confirmed and prophylaxis were undertaken. Audits showed 100% of records contained this information. Sepsis monitoring was also audited as part of this process. Patient records on the ward showed consistent recording for all risk categories. However, patient record audits for the service showed a 91% completion rate on average. This was below the service target of 95%.

The major haemorrhage policy for how to respond in the event of a major bleed in a surgical patient was out of date and theatre staff did not always know what they would do if a major bleed happened. However, the service had recently held a clinical governance day to review the policy and carried out training including simulation practice scenarios.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had a process to check the safety of electrical equipment. All items we checked on wards and in theatres were in date and PAT tested (portable appliance testing to check electrical appliances for safety). All service checks were in date. The onsite engineer was named each day at the safety briefing.

The service had resuscitation trolleys in each area. However, each trolley was different and there were more items on trolleys than listed on checklists. This meant there was a risk resuscitation training for staff could not be applied consistently to each area. The service had recently employed a resuscitation lead for 1 day per week across the service and its partner site to address some of these concerns.

Staff disposed of clinical waste safely. The service carried out environmental risk assessments and audits for each clinical area. Sharps (medical instruments with sharp points such as blades and needles) bins were managed safely and were fully compliant. However, chemical or substances hazardous to health (COSHH) were not always stored safely. We found the COSHH cupboard in theatres was unlocked. The cleaners cupboard containing COSHH on the ward was unlocked in an area accessible to patients and we found a cupboard containing backstock including needles was left unlocked and unattended next to a patient room on the ward. These were risks to patient safety.

We observed a controlled drugs cupboard in the spinal preparation area which required access by external staff during procedures being conducted in the room. One member of staff told us they had been interrupted 5 times for other staff to access the controlled drugs cupboard whilst they performed spinal block procedures. The patient area was blocked off by a screen to protect patient dignity. However, the clinical area was not soundproof and staff told us there was a risk to procedures for patients due to the distractions of other staff entering the room.

Risk assessments were carried out to check water systems for legionella bacteria and we saw evidence daily logs recorded all water outlets had been flushed to prevent bacteria from developing. Storage for the estate was a challenge and we found boxes stored on floors which meant cleaning in these areas did not happen effectively. However, all clinical stock was in date.

Fire exits were free from obstruction. We observed fire procedure notices, fire alarms and fire extinguishers which were all in date. There was a nominated fire officer each day. Patient rooms, theatre areas and equipment appeared to be well maintained, free from clutter and visibly clean.

The service achieved the joint advisory group (JAG) accreditation for its endoscopy service. The JAG accreditation is the formal recognition an endoscopy service has demonstrated competence to deliver its service against endoscopy standards.

Environmental audits were conducted in theatres and wards with recommendations for improvements, for example, to replace the flooring in the staff rest room. There were comprehensive cleaning schedules and tasks for each department, ensuring deep cleaning on a regular basis at weekends. Theatre cleaning audits showed mainly 100% compliance.

Patients we spoke with said the environment appeared clean and well-maintained.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most staff said there were enough staff to meet patients’ needs. However, some staff said there were sometimes challenges with staffing if there were patients with higher needs, or when staff had to assist with transferring patients between the ward and theatres. A business case for a hospital porter had been successfully created and accepted to help address these concerns. There was a safer staffing tool used to calculate safe staff numbers and data showed theatre and ward staff levels were safely managed. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Staffing was discussed at a daily safety briefing. Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix. Rotas for anaesthetist cover for the service were not available to view.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the area. There was adequate 24-hour medical cover.

Staff had received and were up to date with mandatory training . Venous thromboembolism (VTE) training compliance was low for theatre practitioners at 75%. However, all other training was close to target compliance or above. Training was appropriate for the patient group using the service. There was a capability policy which helped staff to achieve and maintain safe working standards of care and supported line managers to address any performance issues in a timely manner.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Patients told us the environment looked clean. There was an infection prevention and control (IPC) policy which was accessible to staff. There was a decontamination policy and an IPC lead responsible for actioning this process. The service was compliant with the decontamination process for flexible endoscopes. Staff completed training in IPC management and management of sharps. We saw staff following IPC policy for decontamination including cleaning of shoes before leaving theatre, hand washing, the use of personal protective equipment (PPE) and cleaning down of theatres and equipment between patients. PPE audits were conducted. Hand gel was available in ward corridors and hand hygiene audits were carried out every 6 months which showed consistently high compliance. However, we observed staff did not always follow IPC policy in theatres and were wearing earrings which did not comply. This was raised with staff at the time and managers highlighted this to staff at safety briefings. There were actions recorded and followed up from hand hygiene audits where staff had been found not to be complying with IPC policy. 

There was a blood spill kit available. However, some items in the blood box were out of date. We reported this to leaders at the time of inspection. Staff maintained equipment and kept it clean. Any ‘I am clean’ stickers were visible and in date on disinfected equipment. All ward areas were clean, had required furnishings and were well-maintained. Deep cleans of ward rooms were carried out following patient discharge. However, cleaning records of daily cleaning schedules were not always up to date. There were some gaps where areas had been missed for sign off. The service carried out IPC audits and targets for cleanliness were consistently met. The service discussed IPC at Environmental Safety Meetings and environmental action logs were recorded to ensure the estate was well maintained. Curtains were audited for cleanliness and changed in line with IPC policy. All curtain changes were dated and documented.

The service monitored surgical site infection (SSI) rates and had an action plan to manage any SSI occurrences. The service had an SSI policy and a post infection review policy to support and SSI. At the time of inspection, there had been no SSI cases.

If endoscopy patients with a known infection were expected at the service, lists were planned accordingly ahead of time to ensure no cross contamination between patients. Air exchange rates for endoscopy procedures (the rate at which the air in the room was filtered for infection prevention and control) were adequate and there were no themes of incidents relating to hospital acquired infection for endoscopy. Endoscopy staff were observed to be compliant with IPC policy.

We scored the service as 3. The evidence showed a good standard. 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.

The service had safe systems for the appropriate and safe handling of medicines. Processes were in place to ensure people received the medicines that they needed.

There were processes to support people with their medicines when they attended for surgery. Staff followed national practice to ensure they had a complete medical history and list of current medicines the patient was taking prior to any surgical procedures taking place. In the pre-operative clinic a risk assessment was completed in relation to people’s regular medicines. Written and verbal advice was given to people about medicines to stop or hold prior to surgery.

Medicines were stored safely and securely on the wards. Temperature monitoring was completed regularly and all medicines checked were within their expiry dates. Controlled drugs (CDs) were kept securely, and appropriate record keeping was in place. During our visit there was an issue with the provider’s Home Office Controlled Drugs Licence. However, the provider worked to resolve this and it had no impact on patient care.

The surgical wards received support with medicines reconciliation and discharge from the pharmacy team. Take home medicines were prepared in advance of people’s discharge to prevent delays in them going home. To facilitate discharge when the pharmacy was closed To Take Away (TTA) Packs were available on the ward and in recovery. Staff were aware of the processes to be followed for the use of TTA packs and received additional training prior to being involved in this process.

Venous thromboembolism (VTE) risk assessments were completed for all the people we reviewed, and prophylaxis was prescribed where necessary. Staff could access Practice Plus guidance in relation to VTE prophylaxis to support decision making and prescribing.

Staff followed Practice Plus guidance in relation to antimicrobial prophylaxis in surgery. For the treatment of infections, staff were able to access guidance from the local NHS Trust. Staff told us that antimicrobial audits took place however they did not provide us with results of these audits. A sepsis box was available in the medicines room on the surgical ward containing antibiotics. However, staff were not able to tell us who managed this box and ensured the stock was in date. Staff told us that the Medicines Management Committee (MMC) provided oversight for medicines at the hospital. Results of audits and subsequent action plans were reviewed and approved at this committee. Recent controlled drugs audits had identified poor compliance with documentation requirements. An improvement program, led by pharmacy, was underway in relation to this. The MMC also ensured compliance with medicines related safety alerts.