Hull Royal Infirmary

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

This means we looked for evidence that people were protected from abuse and avoidable harm

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service enabled people to raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff involved people in planning any changes. The service did not always manage medicines or the risk of infection. The training provided was comprehensive, but the service did not ensure that all staff completed it.

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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents as the department promoted a no blame culture and told us incidents were essential for learning.

Incidents would be shared in staff meetings, and any themes or trends would be shared in the daily huddles that were held throughout each day.

We reviewed all incidents and saw a wide range of issues being reported, and that there were not any repeated themes or trends that would give cause for concern.

We saw examples of learning from incidents. We saw that work had been undertaken to ensure better oversight of care provided in the waiting areas of the department.

All staff we spoke with were able to articulate the complaints process and how they would facilitate patients making a complaint. We noted that staff would proactively request feedback and that equal importance was given to both positive and negative issues. We noted multiple examples of information regarding the complaints process distributed across the department.

We reviewed five complaints received by the department prior to inspection and found that all were managed appropriately and were investigated, actions were identified and responded to within the appropriate timescale. Where learning was identified, actions were shared with staff.

All staff were aware of their responsibilities under duty of candour and were able to give examples of when they had applied these principles. There was an up to date policy covering duty of candour.

Risks were managed by senior leaders within the department, and all senior leaders could articulate the highest risks in the department. The highest risk at time of the inspection was overcrowding in the department and a lack of escalation space. We saw the introduction of new streaming pathways to relieve the pressure on the department but at the time of inspection these were not fully embedded.

We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff learnt from incidents and complaints as all information was shared by senior leaders. We saw examples of service users being listened to and their views being considered.

The evidence showed improvement following the previous inspection. The service worked well with people and healthcare partners to establish and maintain safe systems of care. They did always manage and monitor people’s safety. They always made sure there was continuity of care, including when people moved between different services.

On arrival to the emergency department, patients who self-attended were booked into the department by a receptionist who passed the details to a senior nurse for review and allocated patients to the most appropriate area.

Patients streamed to the emergency department were triaged by trained staff using the Manchester triage system (MTS). There was support from a senior doctor or clinician who could assess patients and refer directly to clinical specialties. Staff told us there were pathways to stream patients directly to speciality assessment areas but there were inconsistencies when the specialities would accept the patients.

We noted significant improvements to the streaming and triage process since the last inspection, including enhanced waiting areas that allowed better oversight and patient management.

Senior staff were allocated to all clinical areas to maintain oversight. There were board rounds and safety huddles undertaken throughout the day. All board rounds and huddles were led by senior clinicians and recorded as being completed. We observed that all huddles and board rounds contained all pertinent information to enable effective oversight.

The service had 24-hour access to specialist mental health support. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions.

We were told about a new initiative from the local NHS ambulance trust that detailed that crews would wait a maximum of 45 minutes to handover a patient so that the crews would be able to react to emergency calls. This had been introduced within the department and staff were able to manage these patients. We noted that additional staff were employed to mitigate any staffing issues when caring for patients in temporary escalation areas.

We saw examples of electronic discharge summaries being completed which contained all relevant information about the patients stay in the department if they were discharged home.

Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialities. We noted the emergency department staff retained medical oversight and nursing care for those patients. This caused increased demand on the staff and space available for patients.

Bed management meetings were held throughout the day. The purpose of these meetings was to maintain oversight and grip of patient flow across the hospital.

We observed that overnight bed delays were promptly resolved the following morning.

The evidence showed an inconsistent standard as there was no assurance that all medical staff understood their role in safeguarding. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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. Training was provided but not all staff completed it to the required level

We saw that all nursing staff were trained to the appropriate safeguarding role for their level but only 68% of medical staff had completed safeguarding training for children.

Training was provided but medical staff training compliance was beneath the trust target of 85%. Dementia training had only been completed by 78% of medical staff and only 70% of medical staff had completed deprivation of liberty safeguards (DOLS) and mental capacity act (MCA) training.

All staff knew how to make a safeguarding referral and would do so when appropriate. We also noted that feedback from safeguarding was included in staff meetings and daily staff huddles. Feedback was also shared by email to ensure all staff received it.

All staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. We saw multiple examples of patient notes being updated regarding their status and that the electronic record included any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment.

We did not observe any interactions that required restraint or restrictive practice, but we observed junior medical staff requesting advice and support from senior colleagues.

The evidence showed a good standard. The service 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. The service was previously in breach of the legal regulation in relation to the assessment of patient risk. Improvements were found at this assessment and the service was no longer in breach of this regulation.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We saw that staff had access to a full range of interpretation services.

We saw examples of staff proactively encouraging patients to provide feedback on the service. Staff completed risk assessments for each patient on admission / arrival, using a recognised tool and reviewed this regularly, including after any incident.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being used within the emergency department to enable awareness to staff of specific patient need.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them. Observations of vital signs were recorded by staff and the national early warning score (NEWS2) was calculated. These were recorded electronically. The service had a clear escalation policy for the deteriorating patient. We reviewed 10 sets of patient records and found appropriate recognition and escalation in all 10 examples.

Staff knew about and dealt with any specific risk issues such as possible sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. Following review of departmental audits, we saw that sepsis recognition and treatment was 100%.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The service was previously in breach of the legal regulation in relation to safe environments. Improvements were not found at this assessment, and the service remained in breach of this regulation.

Patients felt the waiting area was busy and lacked space to accommodate the amount of people attending the emergency department. We observed patients waiting for long periods of time on trolleys without any pressure relieving equipment.

During our assessment we observed patients on trolleys situated in temporary escalation spaces. This meant patients were waiting in areas close to external doors or with high footfall. We also noted these areas did not have adequate facilities for personal care.

The service participated in clinical environmental audits. We requested previous audits covering the last six months and all showed repeated issues such as cleanliness and areas of damage with the environment. We were not assured that the pace of change was sufficient in addressing the highlighted issues.

Not all areas of the emergency department were clean. Cleaning was undertaken inconsistently; we observed cubicles being cleaned between patients within three minutes which provided no assurance that cleaning was effective.

Damage noted at the previous inspection remained unaddressed, with staff citing high demand for the clinical area and no opportunity to close the area for repairs.

The designated mental health assessment room was fully Psychiatric Liaison Accreditation Network (PLAN) compliant. We also noted that there were two allocated cubicles that could be made ligature free if required. We reviewed the risk assessments and found them complete and without omission.

All clinical and non-clinical waste was managed appropriately.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not consistently make sure staff received effective support, supervision and development. They did work together well to provide safe care that met people’s individual needs. The service was previously in breach of the legal regulation in relation to safe and effective staffing. Improvements were not found at this assessment, and the service remained in breach of this regulation.

Most nursing staff kept up to date with their mandatory training. At the time of our assessment,mandatory training compliance for nursing staff was 87%. This was above the trust target of 85%. The mandatory training compliance for medical staff was 78% and below the trust target.

We raised concerns after the previous inspection regarding resuscitation training for medical staff which was below the trust target at 76%. At this inspection this had worsened to 69%. We noted that paediatric resuscitation training for the senior nurses was at 58%.

All nursing staff we spoke with had undertaken core competencies when first employed within the emergency department. All newly appointed staff were able to describe a period of being supernumerary when first in the emergency department. We did note that compliance for staff to provide training (preceptorship) for newly qualified staff was only 44% which did not provide assurance that training was provided or was effective.

Managers did not consistently support all staff to develop through yearly, constructive appraisals of their work. The data provided showed that medical staff appraisal completion was only 68%. The nursing staff appraisal completion rate was 88% in the last 12 months.

The mandatory training for staff was comprehensive and when completed met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance.

Senior leaders calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift using a safer staffing tool. This assessed acuity and dependency twice a year to provide evidence-based decision making on workforce requirements. We noted that additional staff required for nursing patients in temporary escalation spaces were included in the establishment which meant that nurses were not required to move from other areas.

There was ongoing work to identify gaps in medical staffing rotas. Medical vacancies were only at consultant level. Staffing meetings took place regularly to address gaps in the medical rota. If these shifts could not be filled by department staff they were covered with locum or agency cover .

All non-permanent staff we spoke with told us that they had a full orientation on their first shift in the emergency department.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The service was previously in breach of the legal regulation in relation to infection prevention and control. Improvements were not found at this assessment, and the service remained in breach of this regulation

The department was not consistently clean and we only saw limited completed cleaning charts detailing when the cleaning had been undertaken.

We noted an inconsistent use of ‘I am clean’ stickers which showed when a piece of equipment was last cleaned. The stickers were either missing or incomplete.

We did not observe any staff cleaning equipment between use which meant there was an increased possibility of cross contamination.

We also noted that whilst the department used disposable curtains, these were inconsistently dated so it was not always possible to see how long they had been in place.

We saw staff failing to use PPE correctly, and saw staff coming out of cubicles and not removing their PPE before commencing additional tasks. We also noted a lack of hand washing from all grades of staff within the department.

We reviewed audit results following inspection and found that all environmental audits provided had highlighted repeated issues with hand hygiene, incorrect use of personal, protective equipment (PPE) and infection prevention and control.

The service did not consistently follow safe systems and processes for prescribing and administering medicines. We found ongoing issues with the administration and recording of time-critical medicines. The service had previously breached regulations relating to medicines optimisation, and no improvements were identified at this assessment. The service therefore remained in breach of this regulation.

Training compliance for emergency department prescribing was beneath the trust target of 85%; 78% for medical staff and 83% for nursing. Medication administration for nursing staff was 98%, which was above the trust target of 85%.

We reviewed departmental audits from the past six months and found ongoing issues with the timely prescribing and administration of time-critical medicines. Local audits also identified concerns with pain management and the omission of essential information from prescription documentation.

People’s regular medicines and allergies were recorded upon arrival to the department and Summary Care Records were used to support this process.

We saw improvements with the assessment, escalation and management of sepsis including the management of sepsis in children and in pregnancy.

Controlled stationary such as, paper prescriptions were stored securely and monitored to ensure they were handled in line with trust policy.

Governance structures were in place for the management and review of patient group directions (PGDs). PGDs are written instructions to facilitate the supply or administration of medicines to patients, without a prescription.

The service had systems in place to support learning from safety alerts and incidents.

Decision making processes were in place to ensure people’s behaviour was not controlled by excessive and inappropriate use of medicines.