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George Eliot NHS Hospital Requires improvement

Reports


Inspection carried out on 04/10/2017

During a routine inspection

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 carried out on 30 April and 1 May 2014

During a routine inspection

The George Eliot Hospital is part of George Eliot Hospital NHS Trust. It is an acute hospital and provides accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’s services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

The George Eliot Hospital is a 352-bed district general hospital, based on the outskirts of Nuneaton. The hospital employs approximately 1,676 staff. It provides a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&E department, maternity and outpatient services.

We carried out this comprehensive inspection because the George Eliot NHS Trust had been flagged as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system due to being in special measures as a result of the trust inspection as part of the Keogh review.

The team of 31 included CQC inspectors and analysts, doctors, nurses, patients and public representatives, experts by experience and senior NHS managers. The inspection took place on 30 April and 1 May 2014 with an unannounced visit on 10 May between 4pm and 8pm.

Overall, we rated this hospital as ‘requires improvement’. We rated it ‘good’ for providing effective, caring and responsive care, but it required improvement for safety and well led care in some services

We rated medical, critical care, maternity, children and young people’s services, end of life care and outpatient services as ‘good’ and A&E and surgery services as ‘requires improvement’.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • Staff followed good infection control practices except in A&E where poor practices were observed. The hospital was clean and well maintained and infection control rates in the hospital were within an acceptable range.
  • Patients’ experiences of care were good and the NHS Friends and Family Test results were higher than the national average for most inpatient wards and A&E.
  • A review of nurse staffing levels had been undertaken and staffing levels had been increased. Safe staffing levels were being monitored and maintained but there was a heavy reliance on nurse bank and agency staff in some areas. Staff recruitment was continuing.
  • The trust had opened a new acute medical admissions unit (AMU), which, along with the ambulatory care unit (ACU), was intended to improve the flow of emergency patients through the hospital by speeding up their assessment, treatment and discharge.
  • The hospital had worked to improve emergency care and had introduced the modified early warning system, care pathways and care bundles to standardise care for patients who were acutely ill. Seven-day services had been developed and mortality rates were now within the expected range.
  • The number of pressure ulcers, falls and catheter related infections was higher than the England average. The hospital monitored harm-free care in all patient areas and had taken action that was reducing these avoidable harms.
  • Incidents were reported but staff did not always receive feedback; nor were lessons learned widely shared. A&E and maternity services were under-reporting incidents. The trust was investing in a new electronic incident reporting system.
  • Medicines were not always being safely stored and managed. This was particularly evident in the A&E department and the operating department. In both departments there were concerns relating to the storage and stock control of medicines, including controlled drugs, where legal requirements not been met.
  • Radiology services had been without appropriate leadership for many years. The service had antiquated procedures and these were not responding well to increasing service demands and there were long waiting times for services.
  • Discharge arrangements were improving and there was early supported discharge coordinated by a discharge team.
  • Staff were positive about the changes in the trust and they felt that the culture was open, transparent, educative and innovative.

We saw several areas of outstanding practice including:

  • The ambulatory care unit (ACU) opened in December 2013 and had a positive impact on preventing patient admissions. It was helping to meet the needs of patients in the community who required medical intervention without the need for admission to hospital.
  • There were physician associates, who were staff trained to support medical staff with assessment, investigation and diagnosis.  One physician associates was trained to complete comprehensive assessments for frail elderly patients.
  • The trust had developed initiatives to encourage people living with dementia to eat. They used coloured plates and adapted cutlery, and warmed plates to keep food warm.
  • The trust had a ‘carer’s passport’, which was a scheme whereby named relatives could offer their help by coming onto the ward and providing care for their loved one, such as help with eating meals or personal care. The hospital offered named relatives free parking or 10% off meals bought at the hospital.
  • Discharge booklets were introduced in all medical wards. These were kept by every patient’s bed and were completed by members of the multidisciplinary team (including intermediate care and social services) to record specific outcomes leading towards safe patient discharge.
  • A nurse-led early discharge support team was provided for patients with chronic obstructive pulmonary disease. This included home visits and physiotherapy input. The team worked closely with the respiratory ward to ensure longer term management. A discharge bundle had been introduced that included follow-up within 72 hours.
  • The Oasis Project identified patients during their pre-operative assessment who may be anxious about surgery. The project consisted of a team of volunteer therapists who had a professional qualification in relaxation. Therapists would talk through any anxieties at that time to provide reassurance to the patient and would make a note in the patient’s file to prompt action for when they were admitted for surgery
  • The trust had produced a leaflet for relatives and friends inviting them to contact the critical care outreach team directly if they had concerns about their relative.
  • The hospital had made significant strides in the recognition and management of sepsis and the delivery of the 'Sepsis Six' care bundle. They had a critical care outreach nurse seconded as a Sepsis Nurse who monitored compliance and had introduced a sepsis recognition tool, sepsis boxes for the wards and stickers to improve fluid balance completion.
  • Picture screens were used on the intensive therapy unit (ITU) that depicted, for example, a soothing flower blossom scene. Staff and relatives commented that these were calming and relaxing and gave the patients lovely visual images.
  • A special service called ‘Providing information and positive parenting support’ (PIPPs) was available to give information and positive parenting support to teenage mothers and others who were vulnerable. Midwives developed close relationships with the women and offered additional support, continuity of care and coordinated multi-agency cases conferences involving social services.
  • Multidisciplinary networks in children’s and young people’s services were being developed to deliver care closer to their homes.
  • The hospital used the AMBER care bundle, which is a national approach to support advanced care planning when doctors are uncertain whether a patient may recover or be in the final stages of life (months or days). Trained team members acted as champions to drive high-quality care at these times. They encouraged staff, patients and families to continue with treatment in the hope of a recovery, while talking openly about everyone’s wishes and putting plans in place should the person die.
  • The end of life care team had rolled out care standards to ward areas using a strategy called ‘Transform’. Staff were trained to ensure that patients in the hospital had a good experience of end of life care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

  • Medicines are managed at all times in line with legal requirements.
  • There is effective leadership and governance arrangements in the A&E, operating department, maternity and radiology.

In addition the trust should ensure:

  • Safety standards in the A&E department are improved to be in line with current national guidance.
  • Parents and Children have information if they have to have long waiting times in the Rose Goodwin observation unit in A&E.
  • Care pathways and care bundles continue to be embedded into everyday practice and monitored.
  • It continues to reduce the avoidable harms of pressure ulcers, falls, and catheter urinary tract infections.
  • People living with dementia continue to have consistent care and support in all areas of the trust.
  • The Five Steps to Safer Surgery checklist is audited to ensure appropriate and consistent use.
  • Patients being ‘checked in’ for theatre have their privacy and dignity maintained.
  • Staffing levels continue to improve (especially in A&E and surgery), and patient care is appropriately delivered by trained, experienced and skilled staff.
  • The use of linen drapes in theatres is avoided.
  • That all staff use the incident reporting system to report incidents, and that learning from incidents is cascaded and shared.
  • Do Not Attempt Cardio Pulmonary Resuscitation orders are appropriately completed so that there is timely documentation of the decision by the appropriate person, and this decision is reviewed if there is a change in a patient’s condition, and mental capacity is assessed.
  • Radiology services improve so that patients do not experience delays and long waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

16 July 2014

Inspection carried out on 12 February 2014

During a routine inspection

Our focus during this inspection was to look at whether the hospital met the care and welfare needs of patients, met patient nutritional needs and look at the staffing arrangements on the wards and units we visited.

We visited the accident and emergency department (A&E), the acute medical unit (AMU), clinical decisions unit (CDU), coronary care unit (CCU), Felix Holt, Bob Jakin and Nason Wards. We spoke with 22 patients and five relatives during the inspection. We reviewed the clinical care records of nine patients across the units and wards. We spoke with consultants, doctors, matrons, ward managers, ward sisters, nurses, healthcare assistants and health professionals. We also had discussions with the Director and Deputy Director of Nursing.

We observed many interventions from medical and nursing staff throughout the inspection. We saw that staff in each department and ward we visited were responsive, professional and appropriate in their interactions with patients.

Patient feedback on the care received was positive. Patients felt they had been kept informed by doctors, consultants and the nursing staff regarding their treatment. They felt that staff caring for them were skilled to do so appropriately.

Comments received included, "I can't find any fault,” "The staff are excellent," “They’re marvellous in here, always caring,” and “My dad couldn’t be in a better place.”

We found that records were very well completed and provided comprehensive evidence that patients had care delivered according to their preferences and needs. The individual care pathways seen had been completed appropriately and individual risk assessments were updated as necessary. This meant that the multidisciplinary team worked together to meet the needs of patients.

Patients chose what they wanted to eat and were generally satisfied with the food. One patient told us, “The meals are on time, there is a good choice and the food is hot”. Another patient said, “The food here is very good, much better than I expected.”

There were enough qualified, skilled and experienced staff to meet patient's needs. The trust had management structures, systems and procedures which were followed, monitored and reviewed to ensure appropriate staffing levels were maintained. Patients told us that there were enough staff to meet their care needs in a timely way. One person who had recently had treatment in AMU said, “I was very impressed. I was taken straight in there from A&E. The staff were very attentive, not just to me, but to all the patients on the unit.”

Inspection carried out on 26, 28 November 2012

During a routine inspection

At the inspection we visited a number of wards and departments including a surgical ward, three medical wards, accident and emergency department and the clinical decisions unit (CDU). The CDU is part of the accident and emergency department. It is where patients wait for a clinical decision to admit them to a ward or discharge them.

We spoke with patients, visitors, volunteers, ward staff and clinical lead specialists. We also spoke with the chairman for the trust, chief executive, director of quality and nursing, medical director and department managers. All spoken with demonstrated a commitment to providing positive outcomes for patients and making improvements where necessary.

Patients and visiting relatives were positive about the staff and treatment that they had received. Patients said that staff were “incredibly hard working.” They said staff took time to assess and meet their needs. Patients were confident that they knew the nature of their treatment. Some of the comments we received included;

“It’s a marvellous hospital,”

“I don’t think anyone can complain about the care here,”

“You always know if you are sent here, you are going to be looked after.”

Patients spoken with told us their privacy was protected and that they felt staff were respectful during their stay at the hospital.

We looked at patient records, which were clear, accurate and up to date. They included care and treatment plans, risk assessments and plans for safe discharge.

Inspection carried out on 20 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 19 July 2011

During a routine inspection

The inspection team included an ‘expert by experience’ – a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective. We visited a number of wards and departments including, two surgical wards, medical ward, children’s ward, accident and emergency department, emergency medical unit, clinical decisions unit and some outpatients departments.

During the course of the two day visit we spoke with patients using the service and received a lot of positive comments about the care and treatment provided by George Eliot Hospital. One patient said, “The treatment and care that I have received has definitely met my expectations, staff have been so helpful and obliging. I have not met a rude one yet.” Another patient told us that staff were ”very caring.” A relative commented, "We cannot fault the care and attention my (family member) has received here at this hospital.”

We were told that patients thought their privacy was protected and that they felt staff were respectful during their visit or stay at the hospital. Patients also told us that they had felt involved in planning their care or treatment. We were told that patients were very satisfied with the information given, either verbally or in leaflets, and the majority were confident that they knew exactly the nature of their treatment. One person told us, “They have informed me about everything, I understand about my treatment,” however another patient said, “I’d like to know more about my medical condition.”

Patients thought that the hospital was kept clean. We were told, “The cleaning is very good I have no concerns.” and “I can't fault the cleanliness of my ward.”

Patients said that they felt safe and there were usually enough staff on the wards. However, they thought that staff were often busy, which meant that patients might have to wait longer than they wanted to. One patient told us, “Sometimes you have to wait for them to come, but they are so busy I understand the wait.”

Inspection carried out on 19 April 2011 and 20 September 2012

During a themed inspection looking at Dignity and Nutrition

Patients we spoke with confirmed that they were listened to and were given the opportunity to express their views about their care, support and treatment. They said they were given clear information and had been involved in decisions about their care. Some patients told us that they often experienced delays in getting help from staff when they pressed their call bell for help, whilst others said staff responded promptly.

Patients said that the staff always asked permission before carrying out any examinations or care and also regularly asked if they had any concerns. They said staff asked them how they wanted to be addressed, were respectful and always maintained their privacy. All said they had never been embarrassed or felt uncomfortable while care was being carried out.

Most of the patients we spoke with said there was a choice of meals and the food was good. They said that they were given help to eat if they needed it and they had never missed a meal.