Newark Hospital

On this page

• 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

At our last inspection we rated this key question good. At this inspection 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.

Leaders promoted a culture of safety and learning within the trust.

Leaders and staff were fully aware of their responsibilities for reporting incidents and accidents.

Staff reported incidents through the electronic reporting system which all staff had access to. Staff reported in line with the trust policy.

Managers reviewed all incidents within the department and escalated incidents in line with the trust incident management framework.

Managers shared learning from incidents, and this was used to identify and embed good practice.

There was a standard operating procedure that provided guidance about the requirements of duty of candour, and all staff were knowledgeable about this.

Staff worked in partnership with external providers of end of life care in assessing, planning and delivering care and treatment. This included GP's, primary care nursing teams, allied health professionals, social care providers, secondary care and other voluntary sector workers.

Palliative and end of life care patients were referred from Kings Mill Hospital by the specialist palliative care team, (SPCT) however if the patient was not known to them, they were referred through the end of life care team on admission.

Staff kept detailed records of patients’ care and treatment. Records were clear, comprehensive up to date, stored securely and easily available to all staff providing care.

The service worked with patients and those close to them to establish and maintain safe treatment and care to eliminate risks and ensure continuity of care.

Discharge summaries including anticipatory medications were shared electronically if on the trusts’ system or if not by post with GPs.

We reviewed 3 discharge summaries and found they were completed correctly .For example, they included all the relevant clinical information, the DNACPR status and medication.

There were daily meetings to discuss the waiting list, bed availability, and patients awaiting discharge.

Staff worked collaboratively, and we saw examples of positive cross-team working to provide joined up care for patients. There were particularly strong links between those working in the community and inpatient staff, meaning that patients received a seamless service.

With the patients’ consent, staff shared electronic records and images could be shared with other healthcare providers.

The service provided care and treatment based on national guidance and evidence of its effectiveness. The service completed a range of audits, including audits of Medicines Management, whether relatives have been given the “What to expect in the final days of life booklet” and audits of the ReSPECT forms.

The trust had a comprehensive safeguarding policy with clear guidance for identifying and reporting concerns. Staff knew how to access the safeguarding team for advice and guidance when required. They knew how to make a safeguarding referral, had a good understanding of when they would need to report safeguarding issues and who to inform if they had concerns.

Staff received training specific for their role on how to recognise and report abuse and understood how to apply it and to protect people from abuse. The service worked well with other agencies to do so.

The trust had a safeguarding team; staff knew the names of the safeguarding leads and told us they could approach them for advice if they needed to.

Staff were able to describe situations which would prompt a safeguarding concern and lead to a referral being made. For example, one staff member told us of how a patient had disclosed some very concerning information which they reported to the local authority using the trust processes. The local authority took immediate action to safeguard the person concerned.

The end of life care team (EOLC) team were trained to level three Safeguarding children and adults which was in line with the trusts mandatory training schedule.

Staff understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They know how to support patients experiencing mental ill health and those who lack capacity to make decisions about their care.

Mental capacity assessments were undertaken by both the nursing and medical staff to identify if patients had the capacity to consent to routine care and treatment. Deprivation of Liberty Safeguards applications (DoLS) were completed by the nursing staff.

A mental capacity assessment is a legal test used to determine if a person over the age of 16 can make a specific, important decision at a particular time. Based on the Mental Capacity Act 2005, it evaluates if an individual can understand, retain, weigh, and communicate information regarding their health, finances, or welfare.

DoLS is a legal framework in England and Wales designed to protect individuals lacking mental capacity who are confined in hospitals or care homes. These safeguards ensure that care arrangements restricting a person's freedom are necessary, proportionate, and in their best interests,

Managers described how the service promoted inclusion and worked with staff who had protected characteristics and were able to give examples of how they did this.

Patient needs were escalated appropriately, within the context of the service. Staff completed risk assessments for each patient on admission, using an appropriate tool.

Nursing staff were trained in the identification of Sepsis. There was a lead nurse for Sepsis within the trust and staff knew how to contact them.

End-of-life (EOL) care patients did not receive routine 4-hourly observations (blood pressure, temperature, heart rate), but instead received 1 to 4 hourly "comfort observations" to monitor for pain, distress, and symptom management

Staff knew the process for making a referral to the mental health team should a patient present with mental health symptoms. In addition to access to the mental health team, staff could refer palliative and end of life care patients to additional psychological support by the specialist palliative care team.

During our inspection, we found Sconce Ward clean and well maintained. Staff identified and controlled potential risks in the care environment. Leaders made sure that equipment, facilities and technology supported the delivery of safe care and treatment.

We observed that facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

The design, maintenance and use of facilities, premises and equipment kept people safe. Hazardous items were out of reach, and there were no sharp corners. Equipment was visibly clean. We saw labels on equipment with the last service

There were enough syringe drivers and the size, setting and design of the ward aligned with best practice.

Access to all wards was through a swipe card system. This meant the area was secure and minimised the risk of unauthorised access.

There was a side room on the ward for end of life care patients named ‘The butterfly room’. The butterfly room had the main area with a bed for the patient and a sofa bed where relatives could stay, a separate kitchenette and a wet room which included a shower and toilet.

Staff had taken action to support the safety of patients with specific vulnerabilities such as those living with dementia. For example, colour coding was used so that patients would be able to recognise the facilities they could use. This meant patients could easily identify which bay they were in. For example, patients in a blue bay used toilets and showers that had doors painted in the same colour. There were also large illustrations on doors to denote what they were. We observed a nurse redirecting a patient to their bay with reference to the colour. The wards also provided single sex accommodation with designated male and female facilities close to the single sex bays.

Equipment used to deliver care was suitable for the intended purpose. Staff stored equipment securely and used properly and appropriately. For example, the resuscitation equipment was clean, well maintained and ready for use in an emergency.

Daily checks took place on the resuscitation trolley to ensure the safety seal had not been broken. Logbooks showed staff had signed to indicate the resuscitation equipment had been checked and was safe and ready for use in an emergency.

Some patients required continuous medication administration through a syringe driver to control their symptoms. At the time of our inspection, 1 patient required a syringe driver. Staff were knowledgeable about syringe drivers and the medicines that were administered through them. Staff told us some patients required more than one syringe driver due to incompatibilities between some medicines. All staff were required to undergo specific competency training for managing a syringe driver with a duration of supervised practice prior to being able to lead on this.

Administration of medicines and intravenous fluids to patients was managed safely. All intravenous fluids, medicines and syringe drivers were checked and administered by two registered nurses.

Oxygen was readily available and accessible throughout the ward.

There was an end of life care education trolley for staff which contained information concerning all aspects of palliative and end of life care, including training opportunities for staff.

Managers made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development. Staff worked together effectively to provide safe care that meets people’s individual needs.

All new members of staff underwent a structured and comprehensive induction training programme appropriate to their role. For example, one staff member told us about infection, prevention and control teaching, which was part of mandatory training, and how they put that training into practice when caring for patients and in their general work on the ward.

The service had 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. Managers regularly reviewed and adjusted staffing levels and skill mix.

On the ward, staffing levels were observed to be adequate with a good skill mix comprising nurses, occupational therapists, doctors, health care assistants and physiotherapists.

During handover we observed that arrangements were made for patient safety during these periods and adequate numbers of staff were observed to be left on the ward to care for patients. Staff attending handover would advise the ward staff of all updates once handover was completed.

There were no dedicated end of life care beds at the trust. Patients requiring end of life care were nursed on Sconce ward however, if there were no beds on Sconce ward, they were nursed on the general wards throughout the hospital. Nursing staff told us they were able to provide end of life care and would always prioritise those patients in the last hours or days of life.

Staff told us they received adequate training for their role.

End of life care champions based on the wards also provided training and regularly updated staff on important updates. End of life care champions based on the wards receive a higher level of training, and cascaded information to ward staff from the EOLC team.

There was dedicated end of life care (EOLC) team based at the trust. The team consisted of 2 consultants, 2 clinical nurse specialists a lead nurse and an administrator.

The end of life care team were supported by the Specialist Palliative Care Team (SPCT) who were based at the local hospice and external to the trust, who provided a service between 9am and 5pm, Monday to Friday.

End of life care patients had access to a palliative care consultant care 3 times per week. In addition, a dedicated hospice advice line operated 24 hours a day, seven days a week. This ensured that healthcare professionals could access expert guidance during evenings, nights, and weekends.

The National Institute of Health Care and Excellence (NICE) guidelines state the minimum service level for patient access to specialist palliative care should be 9am to 5pm, seven days per week. Whilst the trust did not provide a consultant led daily ward round seven days per week patients had access to specialist care as required at any time. The local hospice provided an out of hours non-patient facing advice service through a dedicated telephone advice line as part of an on-call rota. The advice was for all aspects of palliative and end of life care. Patients had access to specialist input through a clearly defined escalation route. A triage clinical nurse specialist (CNS) was on duty 9am to 5pm, 365 days a year. If ward staff requested an urgent face‑to‑face assessment, a CNS attended the ward.

At the time of our inspection 100% of the End of Life Care Team had completed their yearly appraisal against the trust target of 90%

We observed that staff were visible in all areas and did not appear to be rushed. Staff communicated well with each other to respond promptly to patients’ needs.

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment visibly clean.

During our inspection, we observed a number of pieces of equipment with green ‘I am clean stickers’

All areas of the ward were observed to be visibly clean and tidy.

Staff were observed to be following the service’s ‘bare below the elbows’ protocol. Hand gels were readily available in all areas of the hospital.

Staff followed infection control principles including the use of personal protective equipment (PPE), appropriately.

We saw staff regularly utilise the alcohol hand rubs and washing their hands in accordance with the World Health Organisation’s (WHO) ‘5 Moments for Hand Hygiene’. These guidelines are for all staff working within healthcare environments and define the key moments when staff should be performing hand hygiene to reduce risk of cross contamination between patients.

We saw the use of hand sanitising gel was standard practice across the hospital. The hand gel was available at all exit and entry points and signs encouraged visitors to make use of it.

Staff made sure that medicines and treatments were safe and met patients' needs, capacities and preferences. Staff made sure patients were involved in planning for their medicine needs, including when changes happen.

The trust had a 'last days of life individualised care plan' which included and was based on ‘The five priorities for care of the dying person.’ The plan was for the last 48 hours of life and provided guidelines for staff on actions to take such as anticipatory prescribing. Anticipatory medicines are medicines which are prescribed for key symptoms associated with last days of life (for example, pain, agitation, excessive respiratory secretions, nausea and vomiting and breathlessness) and are prescribed in advance for rapid symptom relief.

The service followed best practice and local policy when prescribing, dispensing, delivering and monitoring medicines given to end of life care patients which included medications used in anticipatory prescribing.

The service used anticipatory prescribing, also known as "just in case" medicine. This is the pre-emptive prescribing of medication for palliative or end-of-life patients to treat potential, predictable symptoms before they become severe.

Anticipatory prescribing was evidenced during our inspection. Doctors and nurses showed us how instructions and flow charts had been set up on the trust’s electronic system, so they had immediate guidance as to what pain relief was appropriate. The nurses we talked with were clear about the medicines used for pain relief.

We observed where pain relief had been changed following input from one of the SPCT. Patients told us that they had received prompt pain relief and their pain was dealt with effectively.

At the time of our inspection, data showed that 100% of end of life care patients on Sconce ward at Newark hospital had been prescribed anticipatory medicines, with a 100% of end of life care patients also having a syringe driver prescribed if there was a clinical need. We saw medicines prepared in a syringe driver for patients had been checked and records signed by 2 nurses to show the correct amount of medicine were given.

Controlled drugs (CDs) were stored and administered in line with National Institute for Health and Care Excellence (NICE) guidance, including the double locking of cupboards and the practice of two nurses checking-in CDs. A record of the signatures of staff authorised to give out CDs was maintained and had been updated monthly.

We observed 2 nurses checking controlled drugs. These were undertaken appropriately and signed by both nurses. We reviewed the controlled drugs book and found all medication was signed and dated by 2 nurses.

Stock levels and medications were checked twice daily and signed for. Patients own medication was checked and kept in a locked cupboard alongside the controlled drugs.

All the medication we checked as part of our inspection, were found to be in date and correctly stored. Medication was stored and disposed of securely with access only to authorised clinical staff. Accurate records were kept of medicines prescribed for and dispensed to patients.