Hospital of St Cross

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

We rated safe as requires improvement. We assessed 8 quality statements. Significant concerns were raised around the reliability of the new electronic prescribing system. There were gaps in anaesthetic check logs. Some intravenous medicines and equipment were not in date and some flooring was worn and non-compliant with the standards for operating theatres.

However, there was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's Experience

People were confident about raising concerns. Staff involved patients and their relatives in investigations if they wanted to be, and reports of the event were shared with them. People or those who represented them were given an apology and an explanation of the event, and people were given a timely response.

Feedback from staff and leaders

Staff knew what incidents to report and how to report them. Staff understood their responsibilities to raise concerns, to record safety incidents and to report them internally and externally. The service had no ‘never events’ in the last 12 months. These are events that should never happen if all safety processes are followed. The staff used an electronic online system for reporting incidents. Staff throughout theatres and the wards we visited described the process for reporting incidents and were confident in using the system. Staff gave examples of changes implemented following incidents to improve patient care. We saw evidence of learning from a specific incident where a patient’s own medication was not administered. When things went wrong, staff apologised and gave patients honest information and suitable support. We saw reports from investigations of incidents which showed managers investigated incidents thoroughly. Managers shared feedback from incidents with staff and learning was used to improve the service. There was a positive culture for incident reporting and learning, and staff were able to give examples of changes made within the theatres following incidents.

Processes

There were policies and processes for staff to follow when reporting incidents. They explained how to report, categorise, and investigate incidents. Incidents were discussed within governance meetings and team meetings. Incidents and complaints were appropriately investigated and reported. Staff reviewed the incidents to determine if national guidance had been followed and acted if not. Staff identified and shared learning outcomes from incidents and ensured any required actions were implemented to promote effective learning and prevent similar incidents happening again. Staff reported serious incidents clearly and in line with trust policy. The trust reported no serious incidents (SIs) in surgery which met the reporting criteria set by NHS England in the 12 months prior to our assessment. They reported 181 patient safety incidents for trauma and neuro services at the Hospital of St Cross. We reviewed 2 action plans and found necessary steps had been taken to review these incidents. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff said they were open and honest with patients and applied this to all their interactions.

People's Experience

A patient said they knew who to contact if they had concerns things were going wrong. Another patient said, "I have been fully informed about my procedure and do know about plans for what happens following my procedure."

Feedback from staff and leaders

We observed staff including physiotherapists and occupational therapists and worked closely with ward and theatre staff to provide treatment and support. Staff met to discuss feedback and looked at improvements to patient care. Leaders shared feedback following any improvements during safety huddles.

Feedback from Partners

Staff worked across healthcare disciplines and with other agencies when required to care for patients.

Processes

Staff referred patients for mental health assessments when they showed signs of mental ill health, for example depression. Staff were able to refer patients for mental health assessments and for psychological support where necessary. However, systems did not support staff to meet the full range of potential needs of patients with a learning disability and those who were autistic. Staff said the loss of electronic patient record (EPR) flag system and lack of tools available to support them meant they had no way of knowing about a person's needs before meeting them and so making adjustments was difficult. A process to record reasonable adjustments was available but sat in an open text field of the EPR and relied on the user inputting and reading information as no flag was in use at the time (although we understood it was planned). This had the potential to adversely affect the experience of this patient group because staff were unable to work in a proactive way to meet their needs. However, staff made full use of what was available when possible.

Mandatory training was up to date for almost all staff for people with learning disabilities and with autism. Data provided by the trust following our assessment showed 95% of staff across all surgical wards had attended mandatory training on learning disability and autism.

There was a good system for checking patient safety prior to commencement of surgery. The surgeon, scrub nurse and circulator conducted a visual check prior to opening a prosthesis during a check we observed. This was in line with standard practice. The service had introduced an enhanced checklist to avoid mistakes. We observed a thorough swab count prior to surgical site closure. A day surgery patient pathway allowed patients having general anaesthetic to have a pre-assessment prior to their operation.

Staff were fully aware of the risk of sepsis. They followed the trust's `screening and management of sepsis in adults' policy which provided staff with the tools to assist in identifying a deteriorating patient. This enabled them to take appropriate action for the patient's safety. A sepsis September month display was in the corridor on the day surgery unit. Staff had put together a `sepsis box' for future use and knew how to manage sepsis.

There were concerns from staff about the new EPR system. Staff raised a concern about the reliability of the system the trust had recently introduced. For example, a patient had been lost to follow up due to the introduction of the EPR system. They went on to develop a complication as a result of this missed appointment request. During the transition period comprehensive support to all staff members was available including training resources and dedicated assistance. The trust had approved the employment of 10 new data correction staff to support the EPR team by providing themes and narratives of where issues occurred.

People’s experience

People knew how to raise concerns and were comfortable about raising safeguarding concerns. A relative told us they felt listened to and staff took action to make their relative feel safe.

Feedback from staff and leaders

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff escalated safeguarding concerns to the ward manager. They could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff in all areas had access to safeguarding information about how to refer and escalate concerns.

Processes

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. An up-to-date safeguarding vulnerable adults’ policy, with flow charts for the escalation of concerns was available. There was good compliance with safeguarding training being updated. The service had a process to monitor staff training to ensure they were in compliance with the hospital’s target. Information provided following our assessment demonstrated 97% of staff were trained in level 1 and 2 safeguarding for both children and adults, and all staff who required level 3 safeguarding training for children and adults had completed this.

People's Experience

People were aware of risks related to their care and felt risks were managed in a safe way. A patient told us pre-procedure risks had been explained by an anaesthetist and a surgeon. They were able to ask questions and were provided with information regarding risks and benefits of their surgery. We observed an anaesthetist ask a patient in recovery if they were in pain and provided post arm surgery advice.

Feedback from staff and leaders

Staff used the National Early Warning Score (NEWS2) to identify deteriorating patients and escalated them appropriately. Any patients with a NEWS2 of 4 or more would need a review from the doctor. We found NEWS2 charts were calculated and escalated correctly. From January to June 2024, the NEWS2 audit had 93.9% compliance. Staff knew about patients with a medical history which represented an increased risk. The service used the ‘5 steps to safer surgery’, World Health Organisation (WHO) surgical safety checklist, in line with National Patient Safety Agency guidelines. We looked at 3 sets of notes on the ward and these were all completed. Staff knew in advance when most patients with additional needs were attending and planned to meet these needs and reduce risks posed to them. This included patients with reduced mobility that may need more assistance.

Processes

All pre-operative clinical tests were completed in line with National Institute for Health and Care Excellence guidelines. Risk assessments of a patient’s risk of developing blood clots or venous thromboembolism (VTE) while in hospital and after surgery were always completed in records we looked at. The VTE assessments were completed, and advanced preventative treatment given where required in all patients’ records we looked at. VTE risk assessments were also checked the day after surgery in all 9 records; this was in line with best practice. We requested for data relating to VTE audits following our assessment. We were told updates were pending to the dashboard and this information was unavailable due to the implementation of a new EPR system in June 2024. However, VTE assessments and prescriptions were available on the EPR system and as mandatory field for staff to complete.

There was a policy for how to manage a deteriorating patient within the service. Staff completed risk assessments for each patient during clinic appointments when needed. We saw patients being assessed for risks of general anaesthetic, venous thromboembolism, and allergic reactions to medicines. We looked at patient records which when needed had risk assessments completed. There was a theatre huddle at the beginning of each shift with all of theatre staff and then at the beginning of each surgical list. We observed a huddle and saw they discussed each patient on the list, risks, allergies, medication and equipment needed.

People's Experience

A patient we spoke with during our assessment told us they had received a stairs’ assessment from a physiotherapist and felt safer to move around as a result.

Feedback from staff and leaders

The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. Staff had access to all the equipment they needed and guidance or instructions for using them. Staff used their training in moving and handling to support their safety and that of patients. There was good availability of equipment within the theatres. Staff were able to request loan equipment if they did not have it in stock. Staff said there was advanced planning of schedules which meant they could ensure equipment was available.

Observation

The surgery service had suitable facilities to meet the needs of patients for the type of care delivered. The service had 6 theatres and 1 treatment room. A recovery room with 4 bays was available and covered 4 of the 6 theatres. The other two theatres had their own recovery areas.Each of the bays had the required equipment as recommended by the Association of Anaesthetists of Great Britain and Ireland. Cedar ward was used for pre- and post-operative patient care as an inpatient ward with 27 elective beds and 14 trauma beds.

In theatres 1 to 5, staff carried out daily checks of anaesthetic equipment prior to the start of the surgery list in line with evidence-based practice. However, anaesthetic check logs in theatres 6 and 7 were not being routinely completed. From August 2024 to the time of our inspection in September 2024, we identified 8 gaps in the checks including days when the theatre was in use, but no routine checks had been done. This did not provide staff with assurance that equipment was ready for use and fully compliant. We raised this with senior staff in theatres at the time of our assessment for follow up. Pressure relieving pads and equipment were used in theatres to protect patients from pressure injuries. Body warming equipment was also used to maintain patient’s body temperature during lengthy procedures. All beds had emergency oxygen and suction points which were checked daily and recorded as checked. Five theatres were equipped with laminar airflow for patients receiving arthroplasty (joint) surgery. However, the anaesthetic room including 3 theatres did not have an alarm bell. Staff said in the event of an emergency they would shout for help from recovery staff. This was on the trust’s risk register.

Staff did not always monitor expiry dates of all equipment. For example, we found 4 out of date blood bottles and 2 out of date sodium chloride in 100 millilitres on the resuscitation trolleys in theatres despite regular checks. We raised this with senior staff at the time of our assessment and these were removed.

Not all equipment or premises were clean or free from wear and tear. We saw dust visible on the suction machine on the corridor in theatres. We raised this with staff at the time of our assessment. We found wear and tear to the flooring, such as visibly marked stains, defects to the skirting, walls and protective door covering on the corridor adjacent to one of the theatres.

Processes

Staff understood their responsibility to ensure they segregated and disposed of clinical waste according to the hospital’s waste management policy. We saw the correct management of containers for sharps and the use of coloured bags to correctly segregate hazardous and non-hazardous waste. Staff removed clinical waste from the clinical areas at regular intervals to reduce infection control risks. We saw evidence of electrical safety testing of equipment used including airflow systems in theatres and surgical wards and servicing of these items were in date. The service had an effective system to manage waste disposal. Across the service sharps bins were correctly assembled and labelled to ensure traceability.

People's experience

A patient said although staff were always busy, they were always available and were always ready to support when they needed assistance.

Feedback from staff and leaders

Managers ensured the ward and theatres had enough staff to provide appropriate care and treatment on site. The service knew patient admissions in advance and managers determined staffing levels to ensure they were safe for the number of patients. Each theatre was staffed with 1 operating department officer (ODP), 1 healthcare assistant (HCA) and 2 scrub staff. However, theatres had 9 band 5 vacancies, but 32 staff had been shortlisted for an interview. The service sponsored 2 HCAs with ODP training, and 2 nurses attended an anaesthetic course in a neighbouring university.

Theatre staff attended morning safety briefings (huddles) and covered issues such as incidents, safety and availability of equipment.

The service ran routine theatre lists 7 days a week from 8am to 8pm, Monday to Friday, and from 8am to 6pm on Saturdays and Sundays.

Staff were given training for their safety and that of patients, and to provide effective support. Violence and aggression management was incorporated into dementia training. All staff in theatres had completed a multidisciplinary team emergency scenario training called a major haemorrhage simulation training which involved the blood bank. The simulation focused on a patient who had a potential cardiac arrest in a prone position. A number of staff education sessions had been implemented on the traffic light system for fluid balance monitoring, catheterising patients, communicating with families on admissions and recording of fluid status in ward rounds.There was a daily coordinator in theatres. A student nurse told us they had been allocated a mentor, had received cardiopulmonary resuscitation training and had learning opportunities through shadowing various staff members.

Not all staff were able to receive as much formal and informal education in practise as they would like as there was no education facilitator in theatres. However, they received reminders relating to mandatory training needs from senior staff.

There was a link tissue viability staff in theatres. Information about pressure ulcer risk assessment (PURPOSE T) was available to staff. PURPOSE T steps involved the screening process, a full assessment and an assessment decision. Staff said they could clearly follow this process.

The service used regular bank and agency staff. From April to September 2024, the total bank and agency use across surgical wards and theatres was 13%. A recruitment event was planned in November to recruit to 4 healthcare assistant vacancies. The vacancy rate across the surgical specialties in August 2024 was 12% against a key performance indicator target of 10%. Senior staff ensured safe staffing ratios were maintained with the use of daily safe staffing reviews which considered gaps and mitigations. It included temporary deployment across areas and the use of bank and agency if required and in accordance with trust approval processes.

The service set a sickness rates target of 4% but reported high sickness rates of 8.5% across surgical specialties in August 2024. There was a comprehensive wellbeing programme across the trust providing extensive support including self-help, occupational health, psychological support, fast track services, lifestyle and prevention resources and health kiosks.

The service reported turnover rates of 6.7% in August 2024 against the trust’s target of 10%. Ongoing actions and future developments included stay interview pilots and the ways to stay task group focusing on the national “Ways to Stay” high impact action plan.

Observation

We reviewed staffing rotas during our onsite assessment and found the number of staff in theatres and ward areas matched the planned numbers. We observed a team brief led by a team leader in theatres. Staff discussed the patients on the list, the procedures required, anaesthetics, X-ray requirements and team members had the opportunity to raise issues. A clinical placement folder and orientation was available for students.

Processes

The service mostly 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. Staff received and kept up to date with their mandatory training. Across all subjects and staffing groups training completion figures were 96.7% and this was above the trust target of 90%. Each staff member in recovery was allocated to a theatre. The service ensured 2 staff were always available in theatres. The service did not have recovery staff trained to advanced life support (ALS) which was not in line with the Association of Anaesthetists 2018 safety guidelines. However, an anaesthetist who had been trained in immediate life support (ILS) was always available as supernumerary on call. We found 2 ODPs had received immediate life support training, and all other staff had received basic life support training. During our assessment, we requested ALS and ILS training figures. Figures provided showed a compliance of 94.7% for ILS and 100% for ALS training. A robust management of resuscitation policy was in place. Senior staff allocated either a nurse and an HCA for each bay or a nurse to care for 8 patients on the ward during day and night shifts. Staff also carried out twilight shifts, and senior staff were in the process of putting in a business case to allow for more twilight shifts to support additional patient discharges.

Managers supported staff to develop through yearly, constructive appraisals of their work. Data showed 85.3% of staff had an appraisal within the last 12 months. Post the introduction of the electronic patient record system, all staff groups had a 3-month improvement plan for compliance with appraisal. Senior staff tracked compliance through governance and oversight mechanisms. Matrons held safe staffing meetings twice a day and discussed staffing levels. They moved staff to cover various areas as required. Managers ensured staff had necessary competences such as intravenous fluid competencies to safely move them to cover other areas. Nursing staff also received orthopaedic competencies to enable them safely mobilise patients.

A ‘production board’ occurred every Thursday where senior staff reviewed staffing for two weeks and made decisions relating to staffing requirements.

Prior to commencing the same day discharge service, an anaesthetist carried out teaching sessions for consultants. The same day discharge service was reviewed as a multidisciplinary team and all staff went to a neighbouring trust for shared learning. Ward managers attended accountability meetings where they discussed the governance around the rostering system.

People's experience

Patients told us they felt supported and understood how to manage any infection risks. For example, they knew who to contact if they had any concerns. A patient told us they needed to go to the GP for stitches to be removed and had been given sufficient information to help with any risk of infection.

Feedback from staff and leaders

The service had an infection prevention and control (IPC) and sepsis practitioner who carried out weekly walk arounds and also covered topics such as IPC and sepsis with staff. Cedar ward had sepsis link workers and staff attended sepsis awareness training. A weekly IPC dashboard gave information about various topics and compliance. Where compliance was found to have dropped, IPC leads liaised with ward managers. The IPC team carried out catheter and cannula audits and offered staff feedback. Audit results reviewed showed good compliance. They also prompted staff to remove catheters and cannulas as soon as they were no longer required to reduce the risk of infection.

Observation

An infection prevention and control link carried out hand hygiene audits in theatres. Results were displayed on a board in theatres, and we saw compliance for August 2024 was 100%.However, we observed ODPs leaving the anaesthetic room, removing personal protective equipment and going for lunch without washing or cleaning their hands. We observed good hand hygiene compliance in all other areas we assessed.

All areas of the surgery service we assessed, including the theatres and wards, were visibly clean and tidy. Staff mostly followed infection control principles including the use of personal protective equipment (PPE). All staff we saw during the assessment were ‘bare below the elbows’ and dressed in line with the service’s policy. The service had washable curtains around bays in recovery and other areas. Staff changed them every 3 months or when they appeared visibly soiled. Housekeepers kept a record of when curtains were last changed. We saw a log which showed they had been changed regularly. Staff cleaned equipment after patient contact and labelled them to show when it was last cleaned. We found equipment to be visibly clean. Staff used “I am clean” stickers to indicate they had cleaned the equipment recently and it was ready for use with another patient. Figures of cleaning audits conducted in theatres and Cedar ward from July to September 2024 showed an overall compliance rate of 98%. An IPC action tracker was used within theatres and reported on actions IPC link staff needed to take.

Processes

The trust had infection control policies and procedures to help control infection risk. These and other related policies covered the actions required by staff to minimise the risk of infection and cross infection in the hospital and the surgery service. Staff received training in infection prevention and control. Compliance with this training was 95% for staff across surgical areas. This was higher than the trust’s target of 90%. Staff had access to PPE including aprons, masks and gloves in a variety of sizes. We saw staff used PPE in line with the service’s policy. The policy was in line with national guidance at the time of our assessment. Patients who were electively booked for theatres had a MRSA negative swab result available prior to the operation taking place. No patients were admitted to the elective wards without a negative MRSA status.

Outcomes

There was an effective system to ensure water testing for legionella and pseudomonas bacteria. We saw records of water testing in areas we visited. These had been completed regularly and included actions. The service conducted several audits including hand hygiene and surgical site infections (SSI) audits. SSIs were considered as serious incidents and were discussed at divisional level. Mandatory surveillance of SSI required the trust to conduct surveillance for at least 1 orthopaedic category (hip replacements, knee replacements, repair of neck of femur or reduction of long bone fracture) for 1 period each year. Trust data from June 2023 to June 2024 showed no reported SSIs. There had been 4 elective trauma and orthopaedics patients needing to return to theatres in the same reporting period, and these included a total hip dislocation, and post-surgical complications. This was a low return to theatre rate.

People's experience

A patient told us staff reviewed their medicines regularly and gave them clear instructions on how to take them.

Feedback from staff and leaders

Staff told us the service introduced anaesthetic block trays following a medicine error which occurred a year ago. The change was to reduce risk, to ensure safety, and ensure the right site/side surgery. Staff completed medicines records accurately and kept them up to date. All qualified staff attended a medicine safety e-learning on safe use of insulin.

Observation

We observed staff collecting medicines for patients to take home from a secure medicines cupboard. They checked the patients’ details and explained how to take the medicines at home. Patient records showed good documentation of patients’ allergies including positive documentation of no known allergies. We observed a medicines round and staff wore ‘do not disturb’ red tabards to prevent distractions, reduce errors and increase safety. In theatres, controlled drugs were kept securely and staff checked them twice a day. Similarly, drugs that needed to be kept cool were kept in a locked fridge and were in date. Fridge temperatures were recorded daily, and no concerns were noted by the inspection team. We checked a selection of medicines in the surgery service and found all were in date and kept in line with guidance. Stock matched the records. Medicines prescribed on the medicine chart were dated and signed by the prescriber. Prescriptions included the dose and the time the medicine needed to be administered. Nurses signed to record they had administered the medicine to the patient.

Nursing staff told us pharmacy staff provided a good service and were available and accessible when needed. Staff followed current national practice to check patients had the correct medicines.

Processes

There were effective processes for the supply of medicines. Staff followed the hospital’s policies and procedures when prescribing, administering, recording, and storing medicines. The service had systems to ensure staff knew about safety alerts and incidents, so patients received their medicines safely. There was a system through the pharmacy to distribute and action national alerts. Local incidents were managed through the trust’s incident reporting systems with pharmacy input as needed. We saw evidence of an electronic incident raised as a result of the prescription of a blood thinning medication prior to surgery. Staff held a debrief and the medicine was omitted as it was not required pre-operation. The hospital had its own pharmacy with their staff being responsible for the supply and top-up of medicines used in the theatre area and inpatient wards and take-home medicines for patients. The trust conducted medicines management audits of controlled drugs in May 2024. The audit showed 95% overall compliance in theatres which met the target. The audit team provided recommendations, feedback to nursing staff, and presented the audit report to the medicines management committee.