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George Eliot NHS Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 January 2018

Our rating of services went down. We rated it them as requires improvement because:

  • Safe, effective, and responsive were requires improvement, caring was good and well-led was inadequate because end of life services and urgent and emergency care were rated as inadequate, however leadership at the trust level overall was rated as requires improvement.
  • Urgent and emergency overall was rated as requires improvement. Safety remained requires improvement, caring remained good. Effective was rated as requires improvement. Responsive went down from good to requires improvement. Well-led went down from requires improvement to inadequate. Staff did not have the appropriate level of children’s safeguarding training, staffs did not follow the trust policy on safeguarding and mandatory training for all staff were below (worse than) the trusts targets in a majority of topics. The senior leaders were not visible within the department, leaders were not aware of the risks to patients in the department. There was a significant disconnect between the CAU, the emergency department and the UCC.
  • Surgery overall was rated as requires improvement. Safe remained requires improvement, effective, caring and responsive remained good and well led remained requires improvement. Patients did not always receive their medicines as prescribed, mandatory training was low and did not meet the trusts target of 85%. Leaders did not ensure effective action was taken to improve aspects of compliance, risk and performance. Staff did not always document risk assessments regarding patients’ risk of falls or malnutrition. The leaders had not ensured that changes to services had been planned to use inpatient beds effectively. However, patients and their relatives were happy with care and treatment they received. Staff were competent for their roles. Managers appraised staff’s work performance. Patients could access care and treatment in a timely way with referral to treatment times in line with the England average.
  • End of life overall was rated as inadequate. Safe went down to requires improvement, effectiveness went down from good to inadequate, caring remained good. Responsive went down from good to requires improvement and well led went down from outstanding to inadequate. The trust did not always ensure there were sufficient quantities of equipment to maintain the safety of patients. The service did not ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced persons in end of life care services. Staff did not always have the appropriate skills and experience for their roles. The delivery of end of life care training was not sufficient throughout the hospital and ward staff were had not been kept up to date with new processes and procedures. The trust did not have managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The end of life care strategy and vision for the trust remained under development. There was no governance framework for reviewing patient harm incidents within end of life care services. There was a lack of any systematic audit programme relating to end of life care, few measures to review risk and quality, and no governance framework to support the delivery of care. The trust had not always engaged well with patients, staff, the public and local organisations to plan and manage appropriate services. However, we observed good infection control practices. Staff kept appropriate records of patients’ care and treatment. Staff ensured that relatives were supported, involved and treated with compassion as best they could. Staff involved patients and those close to them in decisions about their care and treatment.
  • Previously in May 2014, we rated outpatients and diagnostic imaging together. On this inspection, we rated each service separately therefore, we are unable to compare with the previous ratings.
  • Outpatient services were rated as required improvement overall. Safe and responsive and well led was rated as requires improvement. Care was rated as good. Effective is not currently rated. Mandatory training for all staff was below (worse than) the trusts target in a majority of topics. Staff did not have the appropriate level of children’s safeguarding training. The trust did not complete regular audits of infection prevention and control practices. Patients were unable to access services for assessment, diagnosis and treatment in a timely way due to waiting times, delays and cancellations.
  • Previously in May 2014, we rated outpatients and diagnostic imaging together. On this inspection, we rated each service separately therefore, we are unable to compare with the previous ratings. Diagnostics imaging overall was rated as good overall. Caring, responsive and well led were rated as good. Safe was rated as requires improvement. Effective is not currently rated. The service managed patient safety incidents well. Staff across different disciplines worked well together to deliver effective care and treatment. The service provided care and treatment based on national guidance and evidence of its effectiveness. The service had managers at all levels with the right skills and abilities to run a service, Managers were visible. There was a positive culture of support, teamwork and focus on patient care. However mandatory training for all staff was below (worse than) the trusts target in a majority of topics. Staff did not have the appropriate level of children’s safeguarding training. The department was not consistently using the computerised reporting system to check that paediatric scans had been reported on appropriately.
  • On this inspection we did not inspect medicine (including older people’s care), critical care, maternity, and services for children and young people. The ratings we gave to these services on the previous inspection in May 2014 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
Inspection areas

Safe

Requires improvement

Updated 25 January 2018

Effective

Requires improvement

Updated 25 January 2018

Caring

Good

Updated 25 January 2018

Responsive

Requires improvement

Updated 25 January 2018

Well-led

Requires improvement

Updated 25 January 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 25 January 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • We rated safe, responsive and well led as requires improvement and rated caring as good. We do not currently rate effective for outpatients.
  • Mandatory training was low and did not meet the trusts target of 85%.
  • Staff did not have the appropriate level of children’s safeguarding training.
  • The trust did not complete regular audits of infection prevention and control practices.
  • Patients were unable to access services for assessment, diagnosis and treatment in a timely way due to waiting times, delays and cancellations. Action to address this was not robustly managed and timescales were unclear. Overbooking of fracture clinics resulted in long waiting times for patients.
  • The service did not take full account of people’s individual needs. Facilities for children and adjustments for people living with dementia or a learning disability were not in place.
  • Governance and management processes did not function effectively. Roles and processes for managing issues and performance were unclear. The flow of information from the departments within the directorate to the directorate governance committees and vice versa was limited and there was no evidence of cross directorate learning. Data and information was not collected and managed effectively to inform improvement initiatives and challenge practice.

However:

  • Patients were treated with kindness, dignity and respect and staff were attentive to their needs. They were involved in decision making about their care and treatment and were supported in this.
  • Staff and teams worked well together to deliver effective care and treatment and overcome operational issues. We saw examples of good multi-disciplinary working and staff had opportunities to develop their skills and roles to improve patient experience.

Maternity and gynaecology

Good

Updated 16 July 2014

There were effective procedures that supported safe and effective care for women. Staff were caring and compassionate and treated women with dignity and respect. National guidelines were adhered to and outcomes were good. Women had choices during birth and were involved in decisions about their care and treatment. There was additional support for vulnerable women and teenage mothers. The staff were loyal, committed and enthusiastic, and there was evidence of effective team work.

The gaps in the leadership staffing structure had creating some instability and concern within the service and governance arrangements had deteriorated. Service plans did not go beyond operational requirements and staff were not learning from incidents and complaints. Staff were positive overall and fully engaged, but staff were striving to cover the gaps and were reporting some fatigue and a lack of direction overall. Team work remained good and there were high levels of respect and support. Although there were some good examples of improvement, staff said overall that there was a reluctance to change and innovation.

Medical care (including older people’s care)

Good

Updated 16 July 2014

There were effective procedures for patients to receive safe and effective care. Both medical and nurse staffing levels had improved and there were safe staffing levels with lower numbers of agency and locum staff. Safety standards were followed for infection prevention and control and the use of equipment but medicines management needed to improve. National guidance was used to treat patients, and local care pathways and care bundles were ensuring consistency of treatment. Multidisciplinary working was widespread. There had been significant progress with the development of seven-day services.

Staff were caring and patients and relatives told us they were treated with dignity, compassion and respect. Patients were involved in planning their treatment and were always given an opportunity to speak with the consultants looking after them. Efforts were made to ensure patients stayed in contact with friends and relatives, and extended visiting hours had helped to improve communication between staff and relatives. The service was well-led. Staff felt supported, valued and proud to be part of the organisation. Quality and patient experience were seen as priorities and everyone’s responsibility, and there was a developing culture of innovation and learning.

Diagnostic imaging

Good

Updated 25 January 2018

We rated it as good because:

  • The service managed patient safety incidents well. Staff knew their responsibilities around reporting incidents and shared learning from incidents related to diagnostic imaging. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff across different disciplines worked well together to deliver effective care and treatment.
  • Staff were patient focused and patients and carers spoke positively about the care and respect shown by the diagnostic imaging staff.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. For example, we reviewed ten x-ray patient referral forms and saw each were signed and documented appropriately.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers were visible to their staff and provided opportunity for regular appraisals, support and professional development.
  • There was a positive culture of support, teamwork and focus on patient care.
  • New equipment had been and was in the process of being installed. Staff showed a willingness to change and make improvements to support a better patient experience.

However:

  • The department was not consistently using the computerised reporting system to check that paediatric plain film scans (x-rays) had been reported on appropriately.
  • The trust records showed a variance of compliance rates for mandatory safety training. There were some areas of poor compliance with mandatory training including safeguarding adult training and basic life support.

Urgent and emergency services (A&E)

Requires improvement

Updated 25 January 2018

Our rating of this service went down. We rated it as requires improvement because:

  • Safeguarding was not given sufficient priority at all times. Systems were not fully embedded and staff knowledge of safeguarding children was variable.
  • Not all staff, including senior staff, had received appropriate training to care for patients. Not all staff were trained in the correct level of life support training, safeguarding adults and children, and mandatory training.
  • Safety systems were in place but were not monitored. Care rounds and risk assessments were not always formally documented in patient records.
  • Environmental risk assessments were not robust and did not address nor mitigate potential risks in the department during temporary changes and building work.
  • Quality monitoring and improvement was not a priority. There was no local audit plan and there were no action plans in place following national audits. Monthly matron checks were not completed routinely in the department and there were no plans in place to address poor practice such as hand hygiene audit results.
  • Incidents and complaints were rarely shared with staff in the adult’s emergency department and lessons learnt were not always identified.
  • Senior nursing leaders were not always visible in the department due to demand and their individual responsibilities in other areas of the hospital. Leaders were not aware of the risks to patients in the department. There was a significant disconnect between the CAU, the emergency department and the UCC. Staff morale amongst medical staff was negative and historical issues between emergency department consultants and consultant paediatricians had not been resolved.

However:

  • The trust took actions to address inconsistent safeguarding knowledge of staff and improve safeguarding training compliance.
  • Patients were cared for with compassion. Feedback from patient’s parents about care in the CAU was extremely positive.
  • Sepsis management was appropriate and staff had access to age-specific pathways for children with suspected sepsis.
  • Senior managers in the emergency department planned and provided services in a way that met the needs of local people.
  • Nursing staff spoke highly of their nursing leaders.

Surgery

Requires improvement

Updated 25 January 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Patients did not always receive their medicines as prescribed. There were errors or omissions within prescription charts.
  • Staff did not always report incidents in a timely manner.
  • The service did not make sure all staff completed all required training, including mandatory topics such as safeguarding and safe use of medical devices.
  • Leaders did not ensure effective action was taken to improve aspects of compliance, risk and performance. Information was available, recognised and documented by leaders.
  • Staff did not always document risk assessments regarding patients’ risk of falls or malnutrition.
  • The leaders had not ensured that changes to services had been planned to use inpatient beds effectively.
  • However:
  • Patients and their relatives were happy with care and treatment they received. This was reflected in the friend and family test results for surgery services.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance.
  • Patients could access care and treatment in a timely way with referral to treatment times in line with the England average.
  • Staff across different disciplines worked well together to deliver effective care and treatment.

Intensive/critical care

Good

Updated 16 July 2014

There were effective procedures to protect patients and support safe care. Visitors we spoke with were pleased with the care their relatives had received in the intensive therapy unit (ITU) and spoke highly of the staff. Clinical outcomes for patients in the unit were good. Staff worked well together as a team and were enthusiastic about their work. Patients we spoke with gave us examples of the good care they had received in the unit. Staff built up trusting relationships with patients and their relatives by working in an open, honest and supportive way.

The unit had an annual clinical audit programme to monitor how guidance was adhered to. Information was collected for the Intensive Care National Audit and Research Centre (ICNARC) database. There was good multidisciplinary team working although specific therapy support was not available over seven days. There was strong local leadership of the unit. Openness and honesty was encouraged at all levels, and staff were encouraged to learn new skills and develop the service.

Services for children & young people

Good

Updated 16 July 2014

There had been a review of the children’s service that had resulted in changes. The review had been undertaken to ensure that the needs of the local population were met in a safe and responsive way. There were no inpatient children’s services at the trust and children were cared for on the day procedure unit. They were cared for in a safe way in an environment that met their needs, and by staff with appropriate skills and experience. Children who were seriously ill were appropriately escalated for specialised care and this might involve transfer to a neighbouring trust. Staff provided compassionate care and treated children and their families with kindness, dignity and respect. The service was developing networks to ensure that care could be provided close to home when safe to do so. The service was well-led with a learning and innovative culture.

End of life care

Inadequate

Updated 25 January 2018

Our rating of this service went down. We rated it as inadequate because:

  • The trust did not always ensure there were sufficient quantities of equipment to maintain the safety of patients. Incidents concerning delays in patient care had been reported on six occasions in a 12-month period due to the lack of availability of syringe drivers.
  • The service did not ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced persons in end of life care services. We found there were no palliative care consultants in post within the specialist palliative care team (SPCT) at the time of our inspection. However, specialist nursing advice was available always available to ward staff some of this was provided from the local hospice.
  • Staff did not always have the appropriate skills and experience for their roles. The delivery of end of life care training was not sufficient throughout the hospital and ward staff had not been kept up to date with new processes and procedures.
  • The trust did not consistently assess, monitor and improve the quality and safety of the services it provided. A small number of audits had been completed to identify if evidence-based, end of life documentation was consistently completed and reviewed. No data had been collected from bereaved relatives to drive forward service improvements, and no monitoring or review had been completed of patients who had achieved their preferred place of death.

However:

  • We found medical staff were competent at prescribing anticipatory medicines for patients who required prompt symptom relief. Medical staff sought specialist advice from the SPCT or consultant at a local hospice for complex palliative care needs.
  • Comprehensive, patient assessments were completed which identified physical, mental and social needs. Patient records were clearly written and patients and those close to them were involved in their care.
  • Staff were caring and compassionate and end of life care services provided a flexible service to meet the needs of local people.