Good Hope 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

We rated safe as required improvement which was an improvement from the previous rating of inadequate. We reviewed 8 quality statements during this assessment.

People were not always cared for staff who were compliant with their mandatory training. People’s risk factors were not always fully understood or managed. People were not always protected from the risk of infection and medicines were not always managed in a safe way which met people’s needs. People were not always cared for in a safe environment.

However, there was a positive and proactive culture around safety, patients were protected from the risk of bullying, harassment, abuse, discrimination and avoidable harm and neglect. Staffing levels had increased since the previous inspection to ensure there were enough staff members to meet the needs of people.

This service scored 59 (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.

All staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with trust policy. Staff spoke confidently around the incident reporting policy and what incidents to report. Staff told us since the previous inspections, there had been a positive improvement in the culture around incident reporting. Staff were actively encouraged to report all types of incidents, which included concerning staffing levels. Staff mostly received feedback relating to the incidents reported.

Data from the service showed there were 280 incidents reported by the medical wards and departments between 1 August 2024 and 31 January 2025. The majority of these incidents were graded no harm (137 incidents) and low harm (132 incidents). There were 5 common themes identified amongst the incidents reported, these were pressure ulcers, staffing levels, discharge planning, patient falls and self-harming patients.

Staff understood the duty of candour. Staff were generally open and transparent in their approach to incidents. Where things went wrong, staff apologised and provided a full explanation.

The trust as a whole implemented a new approach to reporting and investigating patient safety incidents in 2024 called Patient Safety Incident Response Framework (PSIRF). Staff were aware of the new process, but their responsibilities for raising incidents had not changed. Some senior staff told us the investigation process for patient safety incidents had changed for the better and captured all potential contributory factors including human factors. However, other staff were still finding it challenging adapting to the new way of investigating incidents.

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.

Staff spoke positively about the partnership working within the region to support patients transitions between services when further care was required after patients were deemed medically fit for discharge. Wards we assessed had flow co-ordinators who managed the transfer of patients who required ongoing care to ensure the transition between services was smooth and patients were fully informed.

Within the acute setting, patients were transferred between wards and services to ensure they received the right care and treatment which they required. Staff were required to complete transfer documents to ensure the receiving staff were aware of the patient's care requirements.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was a strong understanding of safeguarding and how to take appropriate action. All staff knew how to identify adults and children at risk of, or suffering significant harm and worked with other agencies to protect them. Staff were aware of relevant safeguarding policies which were based on national guidance and legislation and followed them if they had concerns. The trust had a safeguarding team which provided direct support to all hospital locations where concerns were raised about patients.

Staff received training specific for their role on how to recognise and report abuse. In accordance with national requirements, all staff completed PREVENT training during induction and non-clinical staff completed a safeguarding level 1 and PREVENT training package. Clinical staff completed PREVENT level 3 training and a combined safeguarding adults and children level 3 training which included the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Information provided showed the service had met the trust target of 90% for PREVENT and non-clinical level 1 Safeguarding training. However, the target had not been met for level 3 PREVENT or safeguarding adults and children training with compliance for updating training being recorded at 84% and 89%, respectively. Although the training was recorded below the trust's own training target, this did not appear to impact staff knowledge on what constituted as abuse and neglect and how to act on these concerns.

People were supported to understand their rights, including their human rights, under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff were aware of the Mental Capacity Act 2005 and completed patient assessments when concerns were identified about their capacity to make decisions about their care.

There was an understanding of the DoLS, and staff only used this in the best interests of their patients. We observed staff applying for a DoLS authorisation for patients in appropriate circumstances. Where patients had a DoLS order applied for, the safeguarding team reviewed them and provided a prompt for staff to follow up with the local authority after 2 weeks if the patient was still admitted.

There were effective systems, processes and practices to ensure patients were protected from abuse and neglect. Managers contributed to the site safeguarding report which detailed all the safeguarding activity. Although this was not medical services specific, there had been no missed safeguarding opportunities at the hospital within the last 6 months.

The service mostly 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. However, we found there were continued challenges in relation to sepsis management.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The hospital used the National Early Warning Score 2 (NEWS2) for the detection and response of deteriorating patients. We reviewed 22 records for patients admitted within the medical wards or under the care of medical specialties and found observations were completed according to the frequency required for the patient. Staff inputted the observations into the electronic system and this calculated the NEWS2. When patients scored outside of the acceptable parameters, an alert was placed on the system which staff accessing that patients record would see. Critical care outreach teams were also notified of any high scores for patients and would follow up with ward staff by telephone or directly by visiting the ward, dependent on the severity of the deterioration of the patient.

Risks were assessed and people and staff understood them. Staff completed risk assessments for each patient on admission, using recognised tools, and reviewed these regularly, including after any incidents. These risk assessments included but were not limited to a patient's risk of skin damage, malnutrition risks, manual handling, venous thromboembolism (VTE - blood clots) risk, and falls risk. We reviewed the risk assessments completed for 22 patients and found risk assessments were completed within the expected time frame and where action was required, staff had taken this. An example of this was where a patient was high risk for a fall, staff had implemented actions to mitigate the risk by providing close supervision of the patient. Staff told us VTE risk assessments were completed by medical staff and where indicated, appropriate action was taken. All 22 patient records reviewed by the assessment team and 18 medication records reviewed by pharmacy colleagues showed patients had been risk assessed and those who were at risk of developing blood clots received appropriate medication.

Staff were aware of sepsis and told us they completed sepsis screening for patients when concerns were raised. Sepsis awareness training became compulsory for all clinical staff at the end of 2024, and staff we spoke with told us about the positive value of this training. Compliance with sepsis training at the time of our assessment was 84% for all medical care wards, with compliance ranging from 71% on Ward 28 to 100% on Ward 24. At the time of our onsite assessment, we did not identify any patients who were showing signs of potential sepsis.

The service completed sepsis audits. However, there were areas which had low numbers of patients with sepsis which meant it was difficult to interpret compliance within some wards. Information showed overall there were challenges with administering antibiotics within 1 hour of confirmed sepsis, as well as taking blood cultures within 1 hour of confirmed sepsis. In February 2025, the information showed 11.6% of confirmed sepsis cases were not administered antibiotics within 1 hour of confirmation. This was a decline from 12% in January 2025. In February 2025, 55% of confirmed sepsis cases did not have blood cultures taken within 1 hour of diagnosis which was a decline in performance from 57% overall in January 2025. Following an assessment of surgical services at this location in June 2024, we formally wrote to the trust to raise our concerns about the management of sepsis and requested a formal review of the governance and management of sepsis. The results of the audits shared after the onsite assessment indicated there were still areas of improvement which the service, the hospital and trust as a whole had not entirely addressed.

Where staff identified patients were at risk due to mental ill health, staff escalated patients to the mental health liaison team who provided 24-hour support to patients within the trust. Staff also had access to therapeutic observation and engagement tools to establish what additional support patients with mental health needs required. Where patients required restraint, staff ensured the least restrictive method was applied and for the shortest duration. When patients were restrained, staff completed incident reports to record this. We reviewed the notes of a patient who had been restrained and found staff followed hospital policies and procedures and recorded the incident report reference in the patient records.

Patients who were acutely unwell due to respiratory problems were assessed for non-invasive ventilation (NIV). If this was required they were then admitted to the respiratory acute care unit (RACU) which was part of the main respiratory ward (Ward 24). The RACU continued to provide a more specialist and supervised service for 6 acutely unwell patients and this was staffed in accordance with British Thoracic Society guidelines. Staff told us there had been continued increase in the need for NIV and this had meant at times patients needing to be admitted to the intensive care unit so they could be cared for safely if RACU was full. Due to the increasing demand on the service, leaders told us they were in the process of submitting a further business case to increase the beds in the RACU.

Safety thermometer was reintroduced to the service in December 2024. This was a snapshot of audit to assess harm free care in relation to pressure ulcers, inpatient falls, urinary tract infections, risk for VTE and swallowing difficulty risk. Results between December 2024 and March 2025, showed most ward areas were ensuring the correct signage was in place for patients who had swallowing difficulties although there was variable compliance with other elements of the audit. The management of patients with a urinary catheter had identified ongoing concerns with most ward areas (except Medical Assessment Unit (MAU), and Ward 23) recording performance below 95%.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were processes to ensure most equipment and the environment were well maintained and safely met the needs of the patients admitted to the area. However, the building was known to be ageing and with this came some concerns over the safety of the environment. On Ward 10, we observed tears in the flooring of a bay which staff had attempted to cover with hazard tape. However, this was wearing away and was now a trip hazard. Staff were aware of this and had raised concerns about this with hospital maintenance services.

The process was ineffective for ensuring emergency equipment, including the resuscitation trolleys and hypoglycaemic kits, were well maintained and ready to use. We found resuscitation trolleys did not have any tamperproof mechanisms and the checks for ensuring the hypoglycaemia kits were not consistently completed in all areas. Information received after the assessment showed the trust were in the process of rolling out tamper evident seals to all resuscitation trolleys. No timeframes were provided for when trolleys at this hospital would be fitted with tamper evident seals. The service completed audits on the resuscitation trolleys to ensure there were not out of date items or missing items. Results showed the majority of the trolleys were compliant and no concerns were identified.

We reviewed a selection of clinical consumable items including cannulas, dressings, airways, suction tubing, syringes and blood sample bottles and found all items were in date. We also reviewed 9 items of equipment and found their electrical testing and services had been completed.

Staff disposed of clinical waste safely. We observed staff correctly segregating clinical and domestic waste. Waste bins were enclosed and foot operated. Sharps bins were correctly assembled and below the fill line. The management and disposal of sharps and waste was completed in accordance with the trust policy.

The service did not always make sure staff received effective training and development. However, the service had improved their staffing and now had enough staff who worked together well to provide safe care that met people’s individual needs.

The service had improved it’s nurse staffing levels since the last inspection to ensure there were enough nursing and support staff to keep patients safe. However, the service had medical staffing vacancies which was impacting on the delivery of services within some specialties. Staff told us there were vacancies within diabetes and Ward 9 (healthcare of the older person) which the leadership were trying to recruit into. Information from the hospital showed there was a 20% vacancy amongst the medical care consultants.

The highest vacancies were noted within healthcare of the older people (32% vacancy), acute and short stay medicine (21% vacancy), diabetes and endocrinology (19% vacancy) and respiratory medicine (18% vacancy). There was a high reliance in temporary cover within these medical care specialties to ensure safe care and treatment was being delivered. In relation to other grades for medical staffing, there was a vacancy of 25% within medical same day emergency care (SDEC) and 7% vacancy amongst the foundation year 2 (FY2) doctors who covered the general medicine areas.

Staff told us there were few nursing staff vacancies within medical wards and observations of staffing levels during our time on site identified that actual staffing mainly met the planned staffing levels on all wards we assessed. Staff told us there were occasions when staffing levels did not quite meet the planned levels, but this was a rarity now compared to the circumstances during our last inspection. At that time the actual levels never met the planned staffing and where staff felt the actual levels were dangerous at times. Vacancies had significantly reduced since the last inspection. There were still vacancies within the Acute Medicine Unit (AMU), MAU and medical SDEC which had an 8% vacancy, Ward 15 which had a 19% vacancy rate and Ward 24 which had a 10% vacancy rate for nursing staff.

There were concerns raised about the number of support staff within some areas. Staff told us this was specifically noticeable when there were patients admitted to wards who required close observation and supervision, which within some areas was a common occurrence. Leaders told us reviews of support staffing levels was being completed and there was likely to be an uplift in the number of support staff that each ward would need. This would specifically look to cover the wards where frequent requests for additional staff to cover enhanced supervision for patients were made.

Information provided by the hospital showed there were a number of wards where support staff vacancies were recorded. Vacancy rates were recorded of 8% for AMU, MAU and SDEC and 20% for Ward 10. Observations of ward staffing during the onsite assessment showed some differences between planned and actual staffing for support staff. However, staff told us this was not impacting on patient care.

Managers and leaders told us sickness levels and turnover had reduced in most ward areas. Data showed most medical specialties were better than the trust target of 9% for turnover of staff with the exception of healthcare for the older people which recorded a turnover of staff of 10% in January 2025. However, sickness rates within the medical specialties showed most specialties were worse than the trust target of 4% with the exception of endoscopy, gastroenterology and respiratory. Sickness within the stroke specialty recorded the highest sickness rate of 12% in January 2025.

Staff were required to complete and update mandatory training which was comprehensive and met the needs of the patients and staff. Staff we spoke with told us they had completed the training and managers told us there were processes for monitoring staff compliance with mandatory training. Data showed the overall mandatory training compliance was 92% for the service.

However, there were aspects of training which fell below the trust target of 90%, this included information governance, fire safety, prevent level 3 training, safeguarding training level 3 and clinical life support. Clinical life support training had the lowest compliance overall at 61% with Ward 3 only demonstrating 33% of the staff had completed this training. Additional information around the compliance for all levels of resuscitation training for staff was requested due to the importance of this training in ensuring patients received the appropriate care in an emergency situation. However, the information provided did not show staff had undertaken any additional training.

There was a process to ensure all medical patients who were not admitted on a medical ward (medical outliers) had regular medical reviews while they were admitted. There was a ward-based medical doctor assigned to each non-medical ward where patients who were medical outliers were admitted until 4pm. This doctor was responsible for immediate needs of patients and were the first to be contacted in the event of a patient deteriorating. After 4pm, the on-call medical doctors were responsible for any escalations or concerns.

Staff from non-medical wards were complimentary about this process as it ensured medical patients received the appropriate care and treatment they required. Staff told us on weekends there could be some challenges getting patients reviewed if required. However, the new process that was implemented was much improved to the previous process. The service had implemented audits of the care which medical outlier patients received. Leaders told us these audits were relatively new but had already showed patients who were not on the ward specialising in their care and treatment were receiving the same level of care from medical staff as those admitted on a medical ward.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff mostly protected patients from the risk of infection by maintaining the environment and equipment to ensure they remained visibly clean and tidy. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. However, we found dust on items of equipment which had not been used recently, for example resuscitation trolleys and suction equipment. This was previously identified during the last inspection where we identified a continued failure to implement an effective system to ensure equipment remained clean and ready for use.

Staff did not always follow infection control principles when it came to the use of personal protective equipment (PPE). All wards had an adequate supply of PPE for staff, patients and visitors to use. However, we observed some staff leaving side rooms still wearing gloves and staff generally walking around the ward wearing gloves. We also observed some staff wearing masks in ward areas. We requested an update on the policy regarding mask wearing in the clinical environments and were informed this was staff preference.

The hospital policy stipulated when masks should be worn, and we observed areas within the hospital which required staff to wear masks due to respiratory infections. The policy did not provide staff with the direction to wear masks in areas when there was no risk of infection based on their preference. The practice of staff wearing masks due to their own preference appeared confusing for patients and visitors on the ward areas and unsure over what the level of risk was.

We requested information in relation to the numbers of MRSA bacteraemia's, Meticillin sensitive Staphylococcus aureus (MSSA) bacteraemia's, Escherichia coli (E. coli) bacteraemia's and Clostridioides difficile (C. difficile) infections within the medical service at this location. Between February 2024 and January 2025 there had been 2 cases of MRSA bacteraemias, 14 MSSA bacteraemias, 36 E.coli bacteraemias and 35 C. difficile infections. Staff continued to take all infections seriously. However, there continued to be issues raised about the challenges which the wards at this location faced.

The trust had an approach for assessing and managing the risk of infection. However, staff told us about examples where the management of patients with a known infection had not always been effective. There were situations reported of where patients with highly infectious organisms had been admitted into bed spaces which led to a spread of infection. Staff had worked hard on 1 ward following a significant outbreak to reduce the ongoing risk to patients. This included regular screening and a rigorous cleaning regime.

Staff completed infection, prevention and control risk assessments for all patients on admission. The trust's electronic patient records system had an alert to highlight any previously known infections which patients had tested positive for. This enabled staff to manage bed allocation and ensure they were admitted into a bed space which did not place other patients at risk.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff told us there was a good pharmacy presence and the pharmacy department was available to support them with managing medicine processes such as ordering and receiving medicines. There was good access to pharmacy advice, emergency medicines and critical medicines out of hours. However, the discharge lounge routinely had patients for longer than 24 hours with no pharmacist cover. Although there was a designated pharmacy technician, the post was not fully funded to cover when the technician was not available. When the technician was absent, we were told there were issues in obtaining medicines which had sometimes caused delays in treating patients.

Medicines storage was locked and secure with access only to authorised staff in most areas. However, medicine storage in the discharge lounge was not locked at the time of the assessment and medicines were not stored neatly or tidily. This increased the potential for a medicine error or missed medicine administration.

Emergency medicines were stored in tamper evident sealed boxes with the expiry date visible on the outer box. All oxygen cylinders seen were within date. Daily safety checks on emergency medicines and equipment were undertaken by staff to ensure the medicines were safe to use. However, we observed inconsistencies where the emergency medicine boxes were stored. For example, on 1 ward we saw 2 emergency medicine boxes stored on an open trolley and not stored within the dedicated medicine drawer in the resuscitation trolley. We were told these inconsistencies had been highlighted as an issue across the site. However, this was a potential risk in the event of a patient emergency.

Medicine room storage and refrigerator temperatures were monitored. Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely. Staff informed pharmacy if there were any issues so that appropriate action would be taken to ensure the safe storage of medicines.

Controlled drugs (CDs are medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by two staff twice a day.

The service had good systems and processes to safely support people with their medicines. Pharmacy staff were actively involved in reviewing people’s care and treatment with medicines. They would support with prescribing, de-prescribing, side effect monitoring, medication reviews, and medicines advice. Pharmacist recommendations were recorded into patients’ electronic records to ensure prescribers and nursing staff had access to their advice.

We observed members of the pharmacy team having discussions with patients to check their medicine history was accurate and up to date. We observed clinical checks being undertaken by clinical pharmacists and updating patient medicine records as part of medicines reconciliation (the process of gathering a complete list of people’s prescribed medicines) to ensure people did not go without medicines when admitted to the ward. Any discrepancies or medicine issues were successfully resolved and recorded to ensure the effective continuation of treatment. Medicines for discharge were screened and checked by the pharmacy team for accuracy.

We reviewed 18 medicine administration records on the electronic prescribing medicine administration system. Staff documented the route and time of medicine administration. It was easy to track a patient’s medicine administration timeline which helped to ensure medicines were being given as prescribed. Any missed doses were flagged as a reminder until the medicine was administered. Nursing and pharmacy staff had access to a missed dose dashboard to look at any emerging themes where action could be taken. Where a ‘PRN’ (when required) medicine was administered staff recorded why it was needed. The information we looked at showed people were receiving their medicines as prescribed.

Allergy status of patients was routinely recorded on all medicine records seen. This meant that allergies were highlighted, and medicines could be prescribed safely. Weights of patients were recorded, which was needed to help support calculating weight-based medicines prescribing. Venous thromboembolism (VTE) assessments were mandatory and had been completed by the medical team.

There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice.

There was a process for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. Medicine incidents would be discussed within the team at team huddles.

Staff told us they had access to relevant medicine policies, procedures and guidelines.

Medicines management and medicines optimisation audits were undertaken to monitor the quality and safety of the service. For example, a biannual audit was undertaken for the safe and secure handling of medicines. Recommendations were given to wards where actions and improvements were needed to ensure the safe management of medicines.