St Peter's 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

The scores for our assessment have been combined with scores based on the key question ratings from the last inspection. Though the assessment of these quality statements indicated some areas of concern, our rating for Safe remains good. The care we saw being delivered was safe and patients were positive about their experiences. We found safety was a priority among the clinical teams and staff took concerns seriously. People were supported to receive their prescribed medicines in a way which met their individual needs. Staff interacted kindly with people whilst conducting medicine rounds and timely access to pain relief was available. However, we found a breach of the regulations in relation to safe care and treatment. Planned nursing staffing did not match the actual number of people on duty, due to short notice sickness absence. We noted indications in patient records of harms that could be attributed to low nursing staffing and skill mix, such as unwitnessed falls and medicine administration errors. There was a delay in informing the Trust of the breaches until March 2025 and we have asked the Trust for an action plan.

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

The care we saw being delivered was safe and patients along with their relatives were overwhelmingly positive about their experiences. People we spoke with had been in the hospital for periods ranging from new admissions to 3 weeks. None had concerns over safety while using the service and patients and relatives felt they could raise concerns if necessary and had been listened to by staff.

We spoke with a variety of clinical and support staff from the areas we visited along with divisional leaders. Responses we received about the culture of safety and learning were mixed. Staff knew how to record incidents or accidents, and how to escalate safety concerns. Likewise, divisional leaders gave examples of how they have learned from incidents. However, some staff told us that concerns arising from incidents were not always dealt with willingly by senior managers or used as an opportunity to put things right, learn and improve. Staff confirmed that staff meetings helped ensure their teams discussed and learnt from clinical issues. However, safety was not always a top priority. Some staff told us they did not feel confident to raise concerns with senior staff.

There were processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The trust was in the process of transferring over to this framework.There was evidence that learning reviews were undertaken from rapid review documents. However, it was not evident if actions following incidents were always reviewed and actioned in a timely way: the medical division had 4 serious incident actions (SI) which were more than 1 month overdue and 2 SI actions overdue in August 2023. There were 191 open incidents in the division, of which 98 were overdue. The trust was actively improving their overdue open incidents and this metric had significantly improved compared to previous years.

Patients and relatives described being admitted to the ward via the Accident and Emergency department, having been referred by their GP or NHS 111 service. While some described delays experienced in the Emergency Department, others described the process as seamless and all were positive about the way they were treated by staff. People told us that if staff needed equipment to carry out their tasks, this was readily available.

Clinical staff expressed concerns about delays that occurred when patients were moved between services, which they attributed to staff constraints and skill mix. Almost all staff we spoke with were concerned with the care being given to patients due to the low staffing levels and lack of visible trust leadership.Staff told us senior divisional leaders were visible and approachable.

Although we were aware of a recent Healthwatch report which had highlighted poor discharge planning within the trust, we found that multidisciplinary reviews were completed and patients with extra discharge needs were supported by the complex discharge team

Clinical staff expressed concerns about delays that occurred when patients were moved between services, which they attributed to staff constraints and skill mix. Almost all staff we spoke with were concerned with the care being given to patients due to the low staffing levels and lack of visible leadership.

Patients we spoke with confirmed that they felt safe. They said staff always sought their consent for any procedures and they felt able to ask questions about the care provided. Relatives said they were made to feel welcome when they visited, although acknowledged staff were “often busy.” Relatives also said they knew how to complain or raise concerns. Advice posters seeking feedback from patients and visitors were displayed in public areas.

Clinical staff received safeguarding training at levels specific for their role on how to recognise and report abuse. This was included in induction and annual mandatory training. Staff we spoke with could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew to raise any concerns initially with their manager, who could obtain advice and support from the trust’s safeguarding team or on-call senior nursing managers.

The service had safeguarding policies and processes, and staff were aware of how to follow these. Training compliance with safeguarding within the medical division was below the trust standard for adults’ level 2 and level 3 safeguarding. Dementia training was available via e-learning which included tier 1 dementia awareness training and tier 2 enhanced dementia care training. Low compliance training rates had been identified at governance meetings.

The service had an older peoples’ advice and liaison service which provided easy access on matters about the care of older patients living with dementia or delirium.

Patients and relatives we spoke with were positive about the care and support they received either during the day or at night time. People told us that staff checked on them regularly; explained treatment or medicines to them and answered call bells without undue delay.

Although the care we saw being delivered on the day was safe, Staff and managers described the challenges they faced with high rates of bed occupancy, which exceeded 98%.

Staff used patient screening tools to help identify those at risk of falls, venous thromboembolism and malnutrition. Trust compliance data showed that not all risk assessments were completed on admission or updated. We saw evidence that this had been identified as an ongoing risk and senior leaders were developing new processes to improve completion rates.

Falls risk assessments were completed and patients at risk of falling were cared for in bays where they could be overseen by a staff member. We were told by some staff that allocated staff were sometimes moved to other areas to work due to staff shortages. After reviewing nursing dashboards, we identified a match of increased falls at times of less staff within the medical ward areas. Senior staff said these risks were managed by making sure safety huddles discussed high risk patients. Anti-slip yellow socks and blankets for those patients who were identified as a high falls risk were also provided. Staff told us safety huddles were not always completed during shifts and sometimes yellow socks and blankets were not available.

The trust had a post fall process, which included the completion of neurological observations and a medical escalation referral. However, we identified from governance meetings notes that these processes were not always followed. Senior managers were in the process of completing action plans to ensure this was addressed.

Patients and relatives were positive about the care and support they received either during the day or night. They felt the ward environment was clean and well maintained.

Staff told us the facilities, equipment and technology had been provided to support them deliver safe and effective care. There were effective arrangements to monitor the safety and upkeep of the premises.

We saw the facilities were suitably arranged and the equipment and technology provided supported staff deliver safe and effective care. In all areas we visited, there was a distinction in colours on the walls and floors to assist people living with dementia. Corridors and rooms were well lit and we observed that signage used throughout the site was clear and suitable for people with impaired vision. Equipment used to deliver care and treatment was appropriate for intended purposes and used properly.

Public entryways were served by curb-free access with automatic doors which were wide enough to accommodate wheelchairs. Secure access was afforded to clinical areas and store rooms using keycode or keypad access. These room were kept locked when not in use. Overall, the wards and units appeared clean and tidy. Cupboards we checked were organised and stocked. Piped oxygen and suction was provided in designated care areas. Resuscitation, firefighting and evacuation equipment was available. We saw emergency and clinical equipment had identification and servicing labels. These were in date, indicating the items were being calibrated and maintained as appropriate.

The trust had created a dementia friendly environment, ensuring patients were admitted to a more calming environment to reduce additional anxiety and agitation. Following an environmental audit of the medical wards, it was found that in some areas, there was equipment stored within corridors, lack of signage for patients, lack of bed area space and lights were bright. These aspects had been addressed by the trust.

People were satisfied with the care provided and told us staff checked on them to ensure they were comfortable. They confirmed staff introduced themselves and responded to call bells without undue delay. Overall, patients and their relatives felt there were sufficient staff, including night times and weekends, to ensure they got the care they needed when they wanted it. Patients and relatives were aware staff were under pressure and expressed concern for them and the “long shifts they worked.” One person told us some staff “looked weary.” Complaints reviewed by us showed staffing levels were not always as expected.

Clinical and operational staff expressed concerns about staffing levels within the medical division. The number of nursing staff we saw on the day was close to planned levels in some areas, but overall the number of staff present did not meet planned levels. Managers stated they regularly reviewed and adjusted staffing levels and skill mix.

Staff confirmed they had received training as appropriate and relevant to their role. Staff and leaders told us they had supervision, appraisal and support to develop, improve services and where needed, professional revalidation. We learned of examples where staff had been given opportunities to learn and development that resulted in promotion.

During our assessment, we visited a ward where a bank Band 5 nurse was in charge of a team of nursing staff and health care assistants. However, managers explained that the skill mix would have been reviewed on the day and been deemed safe. Senior managers told us the staff member was a trust employee with the relevant competence and experience to be in charge but was working a bank shift on Cherry Ward with the support of the Clinical Matron. The nurse worked with 3 Cherry Ward substantive nurses and 2 healthcare support workers (HCSW) plus an additional HCSW on the early shift, all of whom were substantive to Cherry Ward.

Mandatory training within the medical division was below the trust compliance standard. Training modules identified as poor compliance included resuscitation; basic life support; safeguarding (level 2 and level 3), mental capacity act and deprivation of liberty, infection control, hand hygiene and dementia training. We saw evidence that senior leaders had identified the areas of lower compliance and were acting upon these concerns.

Following a trust review of staffing allocation, low staffing levels was shown to have an impact on pressure ulcers, falls and completion of risk assessments. In some cases, nurses and care assistants in post were higher than establishments, however we found that increased sickness levels and other factors such as opening escalation wards, reduced the number of staff available.

Medical staffing levels in the division had improved. The trust had increased the establishment number of stroke consultants and senior managers told us that a locum agency had been approached to source another consultant.

Patients and relatives told us they saw cleaners at work during their stays and generally recalled staff cleaning their hands when approaching them. They had no concerns about general cleanliness in their wards or units.

Staff kept equipment and the premises visibly clean. Hand sanitising stations were placed at entry points throughout the hospital, and we saw people using these. Best practice infection prevention and control (IPC) guidelines were followed, and electronic systems were used to help identify patients at greater infection risks (such as people on chemotherapy). Staff explained the arrangements for segregating people with Coronavirus symptoms and accessing rapid COVID-19 testing. Staff followed infection control principles including the wearing of short-sleeved clinical uniforms or medical scrubs.

Cleaning records were up-to-date and demonstrated areas were cleaned regularly. The trust had suitable furnishings which were clean and well-maintained. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Staff disposed of clinical waste safely and the bins were labelled and stored correctly.

There was an effective approach to assessing and managing the risk of infection, which was in line with national guidance. People were protected from the risk of infection, and the trust had regular infection prevention control (IPC) audits completed by specialist teams. For example, an environmental audit on the medical wards revealed that curtain rails had been secured with surgical tape. Actions had been implemented to rectify this aspect and the trust’s estates department had been contacted to ensure necessary works were completed. However, bed spacing did not comply with the required environmental and IPC standards. This was a trust-wide issue that had been identified as a risk which was included on the divisional risk register. The trust had recently suggested an ‘IPC reset week’ to address issues identified in the audits about IPC in the hospital. Trends identified included: poor hand hygiene audits, non-compliance with bare below the elbows, clutter and tidiness of the hospitals, indiscriminate use of scrubs outside of theatres and hand gel unavailability.

The medical division had acknowledged 5 cases of Meticillin-resistant Staphylococcus aureus (MRSA) over the past year, although 3 cases were identified as coming from the same person. The other 2 cases were due to infected cannula sites. As a result, the medical division had reviewed the intravenous therapy policy and cannula care audits were carried out by ward staff in line with Saving Lives standards. The medical division had also noted 10 meticillin-sensitive staphylococcus aureus (MSSA) cases of varying origins. The service had identified areas of learning and were actively training clinical professional educators to take on the task of increasing staff awareness about the infection.

People were supported to receive their prescribed medicines in a way which met their individual needs. Staff interacted kindly with people whilst conducting medicine rounds and provided people with information about their medicines. Timely access to pain relief was available and supported with assessment tools if a person was unable to communicate their needs directly. People told us the care and support with medicines they received was “first class.” One person we spoke to told us “They’re quick to respond if I’m in pain.”

Staff were trained to give medicines to patients and underwent a period of shadowing when first learning to administer medicines. Once signed off as competent this was followed by annual required learning.

Staff used an electronic prescribing system to manage patient medicines. Staff told us they could seek medicines advice from the pharmacy department when needed. Staff knew who the ward pharmacist and technicians were. Staff worked with speciality teams in the trust to ensure they met people’s needs. However, said there were not always enough staff on duty which could lead to interruptions in the administration of medicines.

Staff stated that the pharmacy department was available for advice at all hours through a rota system. Wards had access to a medicines management pharmacy technician. They completed a medicines reconciliation (the process of gathering a complete list of people’s prescribed medicines) to ensure people didn’t go without medicines when admitted to the ward.

Staff described different techniques used to distract and de-escalate a distressed person without resorting to the use of medicines where possible. We were told by staff that rapid tranquilisation was sometimes used on the wards, but this was very rare and always as a last resort.

Staff told us there was no formal process for ensuring that people on time sensitive medicines, such as those to treat Parkinson’s disease, were given at the correct time every time. Staff told us they usually would have a good idea of who’s on these medicines and would give them either first on the administration round or would set alarms to remind themselves to go and administer the medicines.

There was a clear 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. This included following the duty of candour and being open and honest with people and their families about when things did go wrong.

We observed staff giving medicines to people in a kind and person-centred way. Staff ensured there was a second check for medicines that required these, such as controlled drugs. We saw staff following the trust’s procedure for ensuring any controlled drug, injection or intravenous fluid was witnessed and confirmed as correct by 2 members of staff before the medicine was given to the patient.

Most medicines were stored safely and securely either in a clinic room or in lockers next to the person’s bed. Access to these was limited to authorised staff only. While there was a process for the safe storage of oxygen cylinders, this was not in use in the Cherry Ward clinic room. This put staff at increased risk of harm if they were to fall over as well as increasing the risk of harm in the event of a fire.

There were processes to ensure patients were receiving their medicines as prescribed. Ward staff were required to scan each medicine on administration. This provided an extra layer of safety when giving medicines. However, this did not work for some medicines and staff had to override the system. The electronic prescribing system team were aware of this and were addressing the issues.

We reviewed medicines administration records across several wards. On most wards, the information was accurate and people were receiving their medicines as prescribed. Where doses were omitted, there was usually a reason recorded. Where a ‘PRN’ (when required) medicine was administered, staff recorded why it was needed.

On Cherry Ward, we found gaps in administration records where doses of prescribed medicines had either been missed or omitted with no clear explanation as to why. There was no process in place to follow up on missed doses and ensure people were receiving their treatments as intended. We were not assured people were always getting their medicines as prescribed on this ward.

The pharmacy department conducted medicines management and optimisation audits including controlled drugs and safe and secure handling of medicines. However, learning from these audits was not shared with the wards so they could improve their practice.

The pharmacy team had integrated their electronic prescribing system with the discharge medicines service (DMS). This ensured better communication of changes to a person’s medicines when they left hospital and reduced incidences of avoidable harm caused by medicines.

There were several prescribing support tools built into the electronic system, which supported prescribers to follow the trust’s formulary and treatment plans. These helped ensure accurate prescribing. Patients prescribed medicines were reviewed daily at the ward round. This involved a multidisciplinary team including prescribers, nurses, and pharmacy staff when possible.