Pilgrim Hospital

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• 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 requires improvement. We assessed 4 quality statements. At the time of the onsite assessment the evidence indicated that there was one breach of the legal regulations in relation to safe storage of medicines. Monitoring of room and fridge temperatures where medicines were stored was not done regularly, medicines were not always stored in locked cupboards, medicines with a limited shelf life were not always dated once opened and controlled drugs were not always accurately recorded.

There has been significant time since the assessment and the trust has taken some action in these areas, including increasing pharmacy led audits and support in the department and strengthened oversight of medicines storage and security. Therefore, at the time of publication, this is not an ongoing breach.

The service worked with partners to try to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They tried to ensure continuity of care, including when people moved between different services.

The service detected and controlled potential risks in the care environment. The service made sure that the equipment, facilities and technology support the delivery of safe care.

During the assessment we observed all areas within the department appeared clean.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service worked with partners to try to establish and maintain safe systems of care, in which safety was managed, monitored and assured. They tried to ensure continuity of care, including when people moved between different services.

Staff told us that the flow in to and out of the service was the main challenge they faced. Patients were staying in the department longer than necessary due to lack of bed capacity within the wider hospital.

Staff told us that they had medical input from other areas of the hospital as patients were starting medical care within the emergency department.

There were long waits for bed across the department in both the majors and seated majors areas. However, the percentage of patients receiving treatment within 60 minutes of arrival on ambulance had improved across the past 12 months, it had increased from 64% to 92%. The percentage of patients seen within 15 minutes who arrived by ambulance had remained mostly consistent and was always above 90%.

The service had made improvements on the average time for triage for walk in patients, however the wait for beds for walk in patients in the last 12 months had remained at a consistent level.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Whilst on assessment we observed that the service detected and controlled potential risks in the care environment. The service made sure that the equipment, facilities and technology supported the delivery of safe care. Whilst the department was busy the environment that staff and patients were operating in appeared safe throughout.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

Observation

During the assessment we observed all areas within the department appeared clean. The service assessed and managed the risk of infection throughout the assessment, regularly cleaning equipment and the area.

The service assessed and managed the risk of infection. The service detected and controlled the risk of it spreading and share any concerns with appropriate agencies promptly.

The service audited cleanliness and between September and November 2024 they scored over 90%. Where there was some room for improvement the service had actions in place to improve. Members of the IPC team regularly visited the department.

Staff did not always make sure that medicines and treatments were safe and met people’s needs.

Monitoring of room and fridge temperatures where medicines were stored was not done regularly, as per the providers local policy therefore we could not be assured medicines were stored safely and in appropriate conditions. The service carried out monthly audits of both fridge and room temperatures across the department. We were assured that results were positive, however this did not reflect what was seen on the day of the assessment.

Medicines used for resuscitation and other medical emergencies (e.g. anaphylaxis) were available, regularly checked and tamper proof. However, in resus, immediate access to emergency trolleys could be challenging due to space. The trust has since moved the Emergency Department to a new building which includes larger resuscitation bays.

Medicines were not always kept securely. A medicines cupboard in the one area was left unlocked and medicines were freely accessible, including to patients in the department. The service carried out monthly audits of medicine security. The evidence provided showed that improvement is still required to ensure that drug cupboards are locked when not in use within resus and majors.

Medicines with a limited shelf life were not always dated once opened so we could not be assured they were suitable for use.

The pharmacy clinical team was not involved in the service delivery on the department, therefore could not ensure the best use of medicines through interventions and regular department visits. ED staff told us that implementing this would be a welcomed and positive addition to the team and service delivery on the department actioned.

Records of Controlled Drugs handling were not always accurate and made in line with legislation, best practice and local policies. Medicines audits had demonstrated that the ward was not always compliant, and this had been fed back to the ward managers.

Antimicrobial agents were appropriately prescribed however not always reviewed at 48-72 hours after start of treatment.

There was a robust system in place to monitor the safe use and storage of prescriptions, high-risk medicines were identified and recorded upon admission to ensure appropriate monitoring. Patients’ allergies were accurately recorded on admission and coloured bracelets were in use to identify patients and medicines administration records including electronic Prescribing and Medicines Administration (ePMA) were updated accurately and in a timely way when medicines were started, changed or stopped.

Staff told us they were able to access pharmacy specialist advice, emergency medicines and critical medicines out of hours.

Staff told us that the pharmacy staff supported them with the management of medicines such as checking expiry dates, replenishing and adjusting the appropriate stock of medicines.