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George Eliot NHS Hospital Requires improvement

We are carrying out a review of quality at George Eliot NHS Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 26 February 2019

At this inspection, we inspected urgent and emergency services, medical care, surgery, maternity, children and young people and end of life services. We did not inspect critical care, end of life, outpatients or diagnostics services at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

Our rating of services stayed the same. We rated them as requires improvement because:

  • Our rating for safe remained requires improvement because not all services ensured mandatory training was completed. Risk assessments were not always documented and medicines management was not always manged safely.
  • Our rating for effective remained requires improvement because there was variable performance in some national audits and not all services had action plans to drive improvements. Not all staff had competencies to carry out their roles.
  • Our rating for caring remained good because staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.
  • Our rating for responsive remained requires improvement because not all patients could access the services when they needed them, patient transfers occurred during the night and there were delays in patients discharges.
  • Our rating for well-led improved from inadequate to requires improvement because there was insufficient resource in the leadership for the medical and urgent and emergency care services for them to consistently run a service providing high-quality sustainable care. Governance processes were not consistently embedded across the service, there was poor compliance with training and Mortality review meetings had not been held which meant the sharing of learning from death reviews was not consistent. Urgent and emergency care did not always collect, analyse, or use information to support all its activities, although it did use secure electronic systems with security safeguards. Although there had been a number of improvements since our last inspection, further actions were still required.
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

Medical care (including older people’s care)

Requires improvement

Updated 26 February 2019

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

  • Whilst the service provided mandatory training in key skills to all staff, not all staff had completed it in accordance with the service’s targets. During this inspection, we found deterioration in that the trust compliance target was not met in 50% of subjects, as at July 2018.
  • Whilst staff assessed risks to patients and monitored their safety, they were not always completed for every patient when required. Although assessments were in place to alert staff when a patient’s condition deteriorated, reviews were not always completed within recommended timescales.
  • The service did not collectively monitor the percentage of staff that had completed sepsis training, or set a target for compliance.
  • The service made sure most, but not all staff, were competent for their roles. Not all eligible staff had completed blood transfusion training. Training compliance was significantly below the trust target for eligible staff on six out of eight wards and units. Furthermore, a TACO (transfusion associated circulatory overload) audit completed in April 2018, found that 28% of patients had not received a TACO assessment to support the minimisation of risks for those patients who required a blood transfusion.
  • Malnutrition and Screening Tool (MUST) assessments were not always completed within 12 hours of admission, or reassessments completed in line with a patient’s care plan or policy.
  • Most, but not all people, could not always access the service when they needed to; there were delays at times in admitting patients from the acute areas to appropriate inpatient medical wards.
  • There was insufficient resource in the leadership for it to consistently run a service providing high-quality sustainable care. A vacancy in the senior management team meant there was reduced support provided within the division.
  • Governance processes were not consistently embedded across the service.
  • Ward staff meetings were not held consistently across the service and agendas differed which did not support the cascading of information from board to ward level.

However;

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Most staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and used control measures to prevent the spread of infection.
  • Patients had their needs assessed and their care was planned and delivered in line with evidence-based guidance, standards and best practice.
  • The endoscopy department had their Joint Advisory Group (JAG) accreditation confirmed following a recent inspection.
  • Patients’ pain was assessed on admission to hospital and repeated at intervals throughout their stay.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs. The service identified and met the information and communication needs of people with a disability or sensory loss.

  • The service had a vision based on the trust’s overall vision for what it wanted to achieve.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were proud to work at the trust and felt valued for the contribution they made to patient care.

Services for children & young people

Good

Updated 26 February 2019

  • The service provided mandatory training in key skills to all staff and nursing staff were mainly compliant.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies. The trust target of 85% compliance was met for the majority of safeguarding training courses.
  • The service controlled infection risk well.
  • The service had suitable premises and equipment and looked after them well. Equipment was checked at regular intervals to ensure it was safe for use.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service had sufficient nursing staff with the right qualifications, skills, training and experience. Staffing levels were safe at the time of the inspection and we saw evidence of this in all the areas we visited.
  • At the time of the inspection there were sufficient medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept detailed records of patient’s care and treatment and individual records were managed in a way that mainly kept patient’s safe. Records were stored securely in all the areas we visited.
  • Staff prescribed gave and recorded medicines well. Patients received the right medication and the right dose at the right time.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Pain was assessed and managed well.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Outcomes were generally better than the national average. Action plans were in place to address any shortcomings.
  • The service made sure staff were competent in their roles.
  • Staff worked together as a team to benefit patients.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed trust policy and procedures when a child or young person could not give consent. The majority of staff in children’s services had undertaken training in the Mental Capacity Act (MCA).
  • Staff cared for babies, children and young people with compassion. Feedback from children and parents confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their treatment. Parents were encouraged to be actively involved in their children’s care.
  • The trust planned and delivered services to meet the needs of local people.
  • The service took account of children and young people’s needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results and shared these with staff.
  • Senior managers in children’s services had the right skills and abilities to address risks identified in sustaining paediatrics at the hospital. Performance issues across clinical teams in children’s and urgent care services continued to be addressed and we saw improvements in the local leadership and management of children’s services starting to emerge.
  • The service had a vision of what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients and key groups representing the local community.
  • Senior managers were continuing to promote a positive culture to help address the challenges raised at the previous inspection. Improvements in behaviours and staff morale were observed and a sense of common purpose across CAU and ED was starting to emerge.
  • The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellent care would flourish.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged with patient’s, staff and the public to plan and manage appropriate services for children, young people and their families.
  • The service was committed to improving services by learning from when things went well and when things went wrong in promoting training, research and innovation.

However

  • There were four patients who had been referred to the child and adolescent mental health service (CAMHS) that were in the CAU for over 12 hours awaiting admission to the nearby NHS acute trust for assessment. This then affected the flow of other patients through CAU. We raised this with the service at the time of the inspection who were taking the appropriate actions to address current concerns and a multi-agency action plan was in place with Coventry and Warwickshire.
  • Children’s services had identified paediatrics as a risk to the organisation due to the inability to recruit a substantive medical workforce and financial sustainability. However, the trust was taking the appropriate actions to address the service shortfalls.
  • Although the service prior to the inspection had not identified the risks associated with CYP waiting for an acute paediatric bed for mental health assessment, additional data demonstrated the service was working closely with Coventry and Warwickshire on a multi-agency action plan which included reviewing the risks posed to CYP.
  • Medical staff were not meeting the 85% trust standard for mandatory training.

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.

End of life care

Good

Updated 26 February 2019

Our rating of this service improved. We rated it it as good because:

  • The last inspection in 2017 identified the trust did not always ensure there were sufficient quantities of equipment to maintain the safety of patients. This had improved during this inspection. No incidents concerning delays in patient care due to the lack of availability of syringe drivers had been reported in a 12-month period.
  • The service now had sufficient numbers of suitably qualified, competent, skilled and experienced persons in end of life care services. There was palliative care consultant in post within the specialist palliative care team (SPCT) at the time of our inspection.
  • The trust did not consistently assess, monitor and improve the quality and safety of the services it provided during our last inspection. This had improved during this inspection. The service now completed audits to identify if evidence-based, end of life documentation was consistently completed and reviewed. For example, staff had carried out an audit on preferred place of death for patients known to SPCT and used the audit to evaluate the quality of the information collated in the care plans.
  • The trust had appointed end of life care champions in various ward areas and ensured the delivery of end of life care training was sufficient throughout the hospital.
  • Staff were caring and compassionate and end of life care services provided a flexible service to meet the needs of local people.

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.

Surgery

Good

Updated 26 February 2019

Our rating of this service improved. We rated it it as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff we spoke with had a good working knowledge of safeguarding issues and they could provide examples of safeguarding referrals or concerns they had reported.
  • The service controlled infection risk well. Staff generally kept themselves, equipment and the premises clean.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. All patient records were kept in locked trolleys to maintain confidentiality.
  • Medicines were prescribed, administered, recorded and stored in accordance with good practice. Systems were in place for the safe management of medicines. Staff gave, recorded and stored medicines well.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We observed staff to be caring and compassionate with patients and their relatives without exception during the inspection.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients said they felt involved in their care and had been asked for permission and agreement first which meant that the views and preferences of patients were considered. Patients and relatives had been given the opportunity to speak with the consultant looking after them.
  • The service planned and provided services in a way that met the needs of local people. The trust worked with commissioners, the local authority, and health services in Nuneaton to plan services for local people. Surgical divisions worked within strategic clinical networks in the region to ensure patients received effective care. These included the trauma and cancer networks.
  • Services were planned to consider the individual needs of patients. There were arrangements in place for patients with complex social health and social care needs. For example, information from pre-operative assessments were clearly recorded, which included patients individual care needs and their medical conditions.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The surgical services were managed as two separate divisions. The surgical wards and DPU were managed within the surgical division, and theatres was managed under the clinical support services.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and key groups representing the local community. The trust had a vision and values which were displayed throughout all areas of the surgical divisions. The vision was to ExCEL at patient care, providing high quality clinically and financially sustainable services.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Both theatre staff and nursing staff on surgical wards reported a good culture. Staff felt supported by their colleagues and matrons in their individual areas.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Managers, matrons and leaders of the service described the systems and processes of accountability within surgery.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The surgical divisions maintained a divisional risk register, which defined the severity and likelihood of risks causing harm to patients or staff. It documented the measures needed to be taken to reduce the risk.
  • The trust collected, analysed, managed and used most information well to support all its activities, using secure electronic systems with security safeguards. Leaders had a holistic understanding of performance. Information was used to measure improvements. There were clear and robust divisional performance measures in place, which were monitored at monthly governance meetings.

However:

  • Whilst staff generally kept themselves, equipment and the premises clean, we observed some theatre clogs covered in blood and some staff wore theatre attire outside the theatre environment.
  • Staff generally assessed risks to patients and monitored their safety. Assessments were in place to alert staff when a patient’s condition deteriorated. However not all patients had Venous thrombo-embolism (VTE) assessments completed in line with recommended national guidance and hospital policy.
  • Patients could not always access the service when they needed it. Waiting times for treatment were not in line with good practice. The referral to treatment times(RTT) were below the England average. In June 2018, the trust percentage rating was 57.4%, compared to the England average of 66.8%. RTT incomplete pathway performance for the trust was 78.41% which was lower than the National Standard of 92% and was lower than the locally agreed trajectory of 86.4%.
  • Although the service generally treated concerns and complaints seriously, investigated them and learnt lessons from the results, which were shared with staff, not all complaints were investigated in a timely manner.

Urgent and emergency services

Requires improvement

Updated 26 February 2019

  • There was insufficient resource in the leadership team for it to run a service providing high-quality sustainable care. There had been challenges recruiting and retaining staff in several senior posts. Although there had been several improvements in nursing leadership, there had been few improvements in the overall leadership of the service since our last inspection.
  • There was a lack of common purpose and shared values within the leadership team and mixed staff satisfaction within the department. Whilst there had been greater focus on the systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected, some risks remained unidentified and actions were not always implemented.
  • The service did not always collect, analyse, or use information to support all its activities, although it did use secure electronic systems with security safeguards. We were told that performance management meetings took place but no records of them were kept. The vision for the service was poorly developed and there was no agreed strategy.

  • Patients could not always access the service when they needed it. Although there had been some improvement in patient flow since our last inspection it was not enough to prevent patients being cared for in a corridor on a daily basis. There were sometimes long delays before specialist doctors came to see patients in the department.
  • Clinical leaders did not always monitor the effectiveness of care and treatment. Although the department compared local results with those of other services we could not find any changes in local practice since our last inspection. Results from national audits showed that compliance with national guidance was not as good as most other emergency departments.
  • The service did not always make sure staff were competent for their roles. Although there had been significant improvements in training and appraisals of nursing staff, records for medical staff were lacking in detail. The process for assessing medical knowledge and competency for all doctors was unclear.
  • Staff from different disciplines did not always work together as a team to benefit patients. There were very few meetings with other disciplines and clinical handovers lacked detail.
  • Although staff completed risk assessments for each patient they did not always communicate the results or update them when necessary. Staff did not always pay attention to early warning scores and triage priorities.
  • There were not always enough nursing or medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. There was a high vacancy rate for doctors and the emergency department was heavily reliant on temporary doctors. There had been little improvement in medical staffing since our last inspection.
  • Although staff recognised incidents and reported them appropriately, managers did not always share learning from them with relevant staff. Planned actions were not always implemented. There was no routine monitoring or review of deaths that occurred in the department and no mortality and morbidity reviews.

However,

  • There had been improvements in governance processes since our last inspection. There was a systematic approach to continually improving the quality of services although not all action plans were implemented.

  • Staff cared for patients with compassion and provided emotional support to minimise their distress. Feedback from patients mostly confirmed that staff treated them well and with kindness.
  • There had been significant improvements in the assessment of patient’s pain since our last inspection. Staff assessed and monitored patients regularly to see if they were in pain and administered effective pain relief.
  • The service took account of patients’ individual needs. Staff spend additional time with patients who had complex social needs and included families in planning their care.
  • The services had suitable premises and equipment and staff looked after them well. There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained. These had improved since our last inspection.

Maternity

Good

Updated 26 February 2019

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

  • The last inspection of this service in 2014 identified that the service did not have a vision or strategy. The service had developed a clear vision and strategy which focussed on providing optimum personal care for each woman and was embedded in practice.
  • The service now had a clear management structure with defined lines of responsibility and accountability.
  • The service did not have a systematic approach to sharing lessons learned from incidents at the previous inspection. This had improved during this inspection. The service had systems in place to share the learning from incidents at all levels.
  • Staff received their mandatory training through face-to-face sessions and e-learning modules. Staff within the maternity service understood their responsibility to complete mandatory training and managers had oversight of training compliance.
  • Safeguarding was given sufficient priority within the service. Safeguarding training compliance was monitored by the learning and development team who provided monthly compliance reports to managers.
  • Daily multidisciplinary safety meetings were held where staffing levels, patient dependency and any areas of concern were discussed and actions taken to reduce risks.
  • The service was piloting a “Juniper” team pathway which focused on facilitating normal births, increasing access to midwifery led continuity of care and reducing maternal and new born health inequalities.
  • Medicines were stored and prescribed safely. A new clinical ward based pharmacy service had been introduced and had made a significant improvement to communication and relationships with the maternity teams.
  • Women and babies care was consistently planned and delivered in line with evidenced based guidance. Staff followed National Institute for Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) and other professional guidelines regarding the treatment of women and babies.
  • The service introduced NHS England’s saving babies lives care bundle in May 2016 and was recognised as a leader in the project as one of the first trusts to embed all four elements: carbon monoxide monitoring for all pregnant women, use of customised growth charts in pregnancy for improved identification of small for gestational age babies, use of recommended checklists for improved management of reduced foetal movements and Improved interpretation of continuous foetal monitoring in labour.
  • The service had a range of specialist midwives. These included specialists in a range of areas including obesity, diabetes and infant feeding
  • Staff were caring and compassionate and maternity services provided a flexible service to meet the needs of local people
  • Staff understood the impact that a person’s care, treatment or condition could have on their wellbeing and those close to them. Staff demonstrated an awareness of women with complex needs and when to provide additional support to minimise the risk of them becoming anxious or distressed.
  • The service worked closely with local stakeholders and neighbouring trusts to establish the local maternity system (LMS) to improve the maternal and neonatal safety across the clinical network.
  • The service had a PIPPS team (providing information and positive parenting service) for vulnerable and young mothers. There were two PIPPS midwives who had a reduced caseload. They worked closely with mothers to build close relationships and provide additional care.
  • The maternity service had not closed the unit on any occasions from August 2017 to July 2018. There was an escalation guideline to support staff during peaks in activity, which gave staff clear and concise guidance. No antenatal clinics had been cancelled during this time.

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.