The Robert Jones & Agnes Hunt 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

Training and regular updates on systems and processes which helped to keep people safe were available to all staff. Safeguarding systems, processes and practices were effective, and staff demonstrated good understanding of their responsibilities. Cleanliness and hygiene were well maintained and there were reliable systems to prevent and protect people from healthcare-associated infections. Staff kept detailed records of patient care and treatment. The service followed best practice when prescribing, giving, recording and storing medicines. The service managed patient safety incidents well. The trust had made significant improvements since the 2019 inspection; they now had a highly motivated and respectful intensivist lead in place. Safeguarding policies were in place and staff gave us examples of when they would raise a safeguarding concern. Risk assessments were completed consistently in patient records including sepsis risk assessments. The service audited documentation and key risks were discussed in various meetings. The service employed 1 full time professional development nurses.

However,

The service did not have enough intensivists to provide continuous cover as per the GPICS standards.

Not all staff had completed their safeguarding training against trust target.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty.Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report and how to report them. Staff informed us they were confident in reporting incidents. They were also encouraged to report incidents and received feedback on them. Staff were aware of the incidents that had been reported on the unit as they were displayed on a notice board and discussed at their team meetings.

All incidents are reported through the trusts incident management system. If a level of harm is reported as moderate or above then these incidents are discussed at the Patient Safety Incident Review Group, chaired by the Assistant Chief Nurse and Patient Safety Officer. Any patient safety reviews are investigated by a staff member outside of the unit to maintain a fresh eyes approach.

Investigations into any themes or trends were carried out and shared with staff at their daily safety briefings. All commissioned patient safety reviews, including never events were escalated by a senior member of the unit, who was advised and supported by the Unit Governance Lead. Between 1 April 2024 and 29 April 2025, there were no Patient Safety Incident Investigations reported via the Strategic Executive Information System (StEIS) at the trust.

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. The unit had applied the duty of candour in applicable situations we were made aware of. Staff were aware of their responsibilities and when the duty applied. The duty of candour policy was easily accessible for staff and was in date.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.Staff made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. All patients attending the trust were elective patients and consultants booked patients during their pre-operative clinic. If a patient was required to stay at the unit for post operative care this was booked in advance.

There was an outreach team within the hospital, who provided a 24-hour cover 7 days a week. The band 7 high dependency unit manager managed the team. The staffing of the team comprised of dedicated band 6 high dependency unit nurses, who worked on a monthly rota. If the nursing cover was short on the high dependency unit or across the hospital wards, the outreach nurse would be pulled on to the unit or ward to provide support. The nurses on the outreach team also provided a hospital cover role at night. This required them to respond to hospital wide issues.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.There was a standard operating procedure for the safe inter and intra hospital transfer of adults receiving critical caresupport. Leaders were working to introduce a critical care informational system with their partnering trust.

The hospital was part of a pilot for Martha’s rule, staff told us they had awareness through posters and support from the outreach team.

Not all staff had completed their safeguarding mandatory training.

Safeguarding policies were in place for children and adults, these were in date and version controlled; they contained links to legal, professional and national guidelines.

Not all staff had completed their safeguarding mandatory training; The lowest compliance level for level 3 adult safeguarding as of March 2025 was72% of which only 59% of medical staff had completed this, against trust target of 92%. However, staff were able to demonstrate how to make a safeguarding alert when appropriate.

Within the trust, there were 2 named nurses for safeguarding and 2 safeguarding practitioners. The named nurses provided staff with expert advice and support regarding safeguarding children issues when required. The unit had a link nurse with experience in safeguarding and staff could approach them for advice and guidance. The link nurse was responsible for sharing learning with staff and linked with the safeguarding lead within the trust

Staff could give examples of how to protect patients from harassmentand discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

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 7 samples of patient records and found risk assessments including sepsis risk assessments and subsequent planning were consistently completed. Risk assessments included but were not limited to the prevention of venous thromboembolism, pressure ulcers, malnutrition and falls. Where risks were Identified, actions from the assessments were noted and implemented. It was clear within the records we reviewed, that patients were assessed by a consultant anesthetist within their first 12 hours of admission on the unit.

Handover documentation from the high dependency unit to the wards was safe. There was a formal handover document for people being stepped down from the high dependency unit. When patients were transferred from the unit to a ward, the nurses completed a formal handover clinical transfer to ward form.

Patients were typically managed on the unit until transfer; long-term ventilation was not standard practice, but there were discussions about potentially providing 24-hour cover in the future. Staff with anesthetic backgrounds were generally comfortable with ventilator management. Some staff identified as anesthetists with intensive care skills, highlighting the distinction between intensivists and anesthetists. The unit did not routinely have ventilated patients for extended periods; transfers were arranged as soon as possible, though delays could occur due to bed availability at receiving units, some examples were shared with us and staff told us the unit managed challenges extremely well.

Patients were increasingly frail, with requirements for longer hospital stays, presenting additional management challenges.

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 high dependency unit (HDU) was secure. Access to HDU was restricted by an intercom, the entrance to the unit could only be granted to those who were allowed in by staff. Once access to the unit was granted, visitors could enter the clinical areas of the unit without any further restrictions. There was a waiting area which visitors could use before accessing the unit.

HDU was designated for up to 6 patients, with 1 spare bed; occasionally, capacity stretched to 7. At maximum capacity, decisions were made about which patient could be moved to accommodate new admissions, often based on clinical stability.

Staff consistently carried out daily and weekly checks of emergency equipment including resuscitation trolleys.The unit had 4 ventilators and considered to be of good quality.

Staff told us there was a need for more space and resources to accommodate increasing patient numbers and complexity. Staff told us that lack of space was a limiting factor for further expansion.

Each bed space was specifically built with negative air pressure, ensuring compliance with Health Building Notes (HBN) standards. There was a HDU emergency evacuation plan which included actions to be taken upon hearing the fire alarm and evacuation procedures.

The service made sure staff were qualified, skilled and experienced. Staff received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. However,there was no consultant available on-site overnight; consultant response time was 30 minutes, with on-call duty from 6pm to 8am. The trust had 1 intensivist for the whole trust.

Staff on shift included 3 registered nurses, a unit manager, consultant anesthetist and 2 healthcare assistants. Staff told us how staffing on the inspection day was at full capacity. At the time of inspection, 3 patients were staying in the unit with 3 patients due to be transferred out. The unit had a direct connection to the operating theaters, with proximity facilitating transfers, this allowed additional staffing support if required.

We saw the unit’s April 2025 figures around effective staffing: sickness absence was 6.11% against target 5.04%. The vacancy rate of 7.15% of which nursing vacancy was 6.81%. Senior leaders told us the unit required a further 20%- 25% to support rotation skills for staff; 53% of staff had critical care qualifications and inductions and 6 weeks supernumerary was given. Staff were required to complete a monthly simulation session to ensure they were kept up to date with their clinical skills and any changes or updates were managed during simulation training (SIM).

The service employed 1 full time professional development nurse. They told us they facilitated learning events including monthly simulation sessions for nursing staff, bi-monthly simulations for the whole critical care team, as well as study days.

Staff told us that staffing concerns were mainly an issue after 6pm, with only one intensivist and reliance on the on-call anesthetists after 6pm. This was known to the senior leadership and a recruitment drive was underway, 18 specialties of doctors were being interviewed in June 2025.

The anaesthetic on-call team consisted of 16 anesthetists, resulting in each being on-call for one weekend (Friday to Monday morning) every 16 weeks. The on-call duty required staff to be available by phone and to come in as needed for patient care; staying on-site was not mandatory unless necessary. Staff who lived further away utilised free accommodation during their on-call period. Some staff told us that there was a perception that those living closer may be asked to cover more frequently, potentially affecting the fairness of on-call duty distribution.

Staff we spoke with told us there had been an increase in emergency spinal procedures, particularly out of hours, over the past 2 to 3 months. Typical emergencies include cauda equina syndrome, infections, and bleeding. On-call responsibilities focussed more on managing the patients on the high dependancy unit in particular those on organ support. Airway management was handled initially by medics and the outreach team with the support of the on-call anaesthetist. There was an on-call anesthetist support available if there was an emergency.

We saw the unit’s latest figures for April 2025 for staff personal development review was at 88% against the trust target of 93%.

The unit had skilled nursing staff, with regular input from medical and surgical registrars, who were described as capable of making appropriate decisions. Some staff told us that having an anesthetist on-site 24 hours would be beneficial, especially as the unit aspired to become a national spinal unit. Some senior leaders we spoke with told us that there could be a cost implication of sourcing a 24-hour anesthetist coverage.

The outreach team provided 24-7 coverage and acted as site managers overnight, with a team of 6 members. However, there is no consultant available on-site for the outreach team overnight; consultant response time was 30 minutes, with on-call duty from 6pm to 8am. The external review 12 months ago noted sufficient oversight by a senior nurse at night but highlighted the absence of on-site consultant cover.

Staff told us that the presence of fellows and trainees was beneficial to the unit and there were more fellows expected to be interviewed early 2026. Junior medics were present with varying levels of experience and engagement; some were highly capable and contributed significantly. Ongoing discussions were held about the need for more junior staff to support the unit, with recruitment efforts underway. We saw that the unit valued the contribution of junior staff and were actively seeking to expand the team to support increasing workload and complexity.

There was no dedicated critical care pharmacy service, although a pharmacist visited the unit daily. Similar gaps existed with dedicated services for occupational therapists, physiotherapists, psychologists, and microbiologists, which were recognised as areas needing further workforce development in the workforce plan. However, staff told us they could access these services if required.

We observed a physiotherapist attending a patient post operatively, patients told us they were visited daily. When we spoke with the physiotherapist, they told us they were informed of patients requiring a visit through the trust daily huddles and the operating theatre scheduling list.

Some staff were up to date with appropriate mandatory training, 89% had completed statutory and mandatory training against trust target of 92%. The lowest compliance of training was within immediate life support at 68%; However, 100% of staff had completed advance life support (ALS) and European paediatric advance life support (EPALS). Other mandatory training was within target or near target. The unit had action plans in place to ensure mandatory training was completed.

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.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. All ward areas appeared to be clean, had required furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. April 2025 unit cleanliness audit was 99.49% against trust target of 98%.

The equipment storage room was small but functional for its use. We found some critical machines and non-invasive mask and suction catheters were stored here and if required urgently could make access time difficult.

Infection prevention and control (IPC) practices were consistently followed. All high dependency unit staff were bare below the elbow to enable effective handwashing. Hand hygiene audits results as of April was 98.50% with bare below the elbow at 98.50% against trust target of 95%

Adequate personal protective equipment was available at the end of each bed space, which included disposable gloves and aprons. We observed staff using equipment appropriately during each patient interaction.

Signage and guidance reminding staff and visitors to wash their hands and use the hand sanitising gel that was present on the unit.

Staff adhered to infection control principles, including handwashing. There were reliable systems, processes and practices to prevent and protect people from healthcare-associated infections.

Performance relating to IPC was regularly monitored. The unit manager received a monthly performance report of their areas with a view to implementing any action plans for areas that did not achieve the 92% target. A copy of the audit results was also sent to the infection control link nurses. We saw92.3% of staff were compliant as of April 2025.

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.

Staff followed good practice in medicines management and did it in line with national guidance. All appropriate medicines and fluids were stored securely in locked cupboards.

Prescription charts used on the unit were complete and included all the relevant information. Prescription charts we reviewed; were all clear on who prescribed a medication. Patients with a known drug allergy were wearing a red wristband as required.

The trust had recently introduced a new system for the prescribing and administration of medicines (EPMA). Staff were still familiarising with this new system.

The medication trolley had recently been fitted with digital secure lock. Medication main keys were always held by the nurse in charge.