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 reviewed learning culture, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control and medicines optimisation for the safe key question. We found safe stayed the same and was rated as requires improvement.

The service did not have enough staff to care for patients and keep them safe. The service did not always manage safety incidents well and did not always learn lessons from them.

However, most staff had training in key skills and understood how to protect patients from abuse. The service controlled infection risk well. They managed medicines well.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was mixed feedback from staff in relation to learning from incidents. Staff within theatres were aware of a serious incident which had occurred and learning which had taken place. However, staff from other areas and medical staff were not as positive about the learning from incidents with some staff telling us they do not always hear about serious incidents. Staff also raised concerns about the investigations into incidents not always covering all important aspects.

Staff told us they completed their mandatory training and appraisals. However, information received after the assessment showed not all modules of the mandatory training had been completed, with safeguarding level 3 and information governance being amongst the modules where compliance was below the 90% trust target.

Staff told us sepsis training was not part of the mandatory modules which meant uptake of the training was variable. Information provided after the assessment showed compliance amongst nursing staff was between 50 and 81% and medical staff compliance was between 0 and 68%. This therefore did not provide assurance there was a positive learning culture around sepsis.

There were processes for staff to follow when reporting incidents. Staff were aware of the incident reporting process. There were also processes to share learning from incidents. Incidents was a regular agenda item on each speciality’s governance meeting.

Where serious incidents had occurred, staff formally undertook the duty of candour. Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was introduced in November 2014. This regulation requires the organisation to be open and transparent with a patient when things go wrong in relation to their care and the patient suffers harm or could suffer harm, which falls into defined thresholds. The duty of candour regulation only applies to incidents where severe or moderate harm to a patient has occurred. In the last 12 months, the service had recorded 4 serious incidents, 3 of which were still under investigation. We reviewed the serious incident investigation report and found there were concerns about the initial report and discussed our concerns with senior leaders. As a result of our discussion, a review of the investigation report was to be conducted and further exploration of learning opportunities.

There was a process to ensure there was oversight of all the incidents reported within the service and reviewing for themes and trends. Within the last 6 months, there was a total of 1,157 incidents reported, of these the majority were recorded as no harm incidents (85.2% of incidents).

The service had reported a never event (wrong site surgery) which occurred outside of the 12-month period (February 2023). Due to the nature of the incident, the learning from this was important for all staff within the service. However, the investigation report which was completed over 12 months after the incident failed to address all aspects of learning from the incident.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The sample of staff we spoke with were able to explain about safeguarding and understood abuse and neglect. Staff told us they received mandatory training for vulnerable adults and children, although information received after the assessment identified gaps in the training. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff discussed examples of safeguarding concerns they had identified, and the actions taken to ensure patients were safe. Staff were clear about their responsibilities in relation to patients who were deprived of their liberties.

Staff were aware of the safeguarding policy and processes related to escalating concerns to the safeguarding team and local authority.

There were processes for staff to follow to ensure patients were safeguarded from the risk of harm and abuse. The trust had a process to identify where patients were at risk due to safeguarding concerns. The policies were in date and contained the most recent national guidance and legislation. The service had a process to monitor staff training to ensure they were in compliance with the trust’s target. Training information provided showed 84.4% of staff had completed the Prevent level 3 training, 79.3% of non-clinical staff had completed level 1 safeguarding and prevent training and 86% of clinical staff had completed level 3 adults and children safeguarding training. All safeguarding training for staff within the service was below the trust’s target of 90% which meant the process for monitoring training compliance was not effective.

The training matrix provided for additional evidence did not identify what training staff completed in relation to learning disability and autism.

There was a trust-wide process which the service was aware of for management and escalation of a deteriorating patient. This provided staff with the information they required to ensure the situation was managed well regardless of where the emergency occurred. The service completed risk assessments in line with trust policy which was patient centred and kept patients safe. The service had a dashboard which covered some key risk assessments such as falls, nutritional assessments, malnutrition universal screening tool (MUST) and pressure area assessment using a nationally recognised tool. This monitored completion compliance enabling managers to drive improvement where required.

There was a trust-wide sepsis policy which the service implemented. There were also plans to develop a sepsis dashboard which would provide real time data in relation to the identification/diagnosis and treatment of sepsis. At the time of our onsite assessment, the service completed an audit which focused on antibiotics being administered within 60 minutes of a sepsis diagnosis and blood cultures being taken within 60 minutes of diagnosis. Between 1 January and 26 June 2024, there were 13 patients who were identified with a diagnosis of sepsis. Of the 13 patients 13% had their intravenous antibiotics administered within 60 minutes and 31% had blood cultures taken. Actions identified to address this included sepsis education and support to the sepsis champions within the wards. Ongoing performance would be monitored through the sepsis group. The audit did not indicate that all cases of sepsis had been correctly identified and there was no additional information around how the service were assured all patients with sepsis were being correctly identified. In addition to this, processes to ensure fluid intake and outtake were strictly monitored from all patients who required this were not effective.

Not all staff we spoke with believed the environment they worked in was safe. Some staff within wards told us they did not all receive training on all items of equipment they used, this was especially related to new items of equipment.

Staff within recovery told us they had only completed basic life support training (BLS); however, the patients they cared for could be in altered states of consciousness and were therefore vulnerable and at risk of deterioration. No staff within the immediate surroundings had life support training to a level above this.

Staff told us they had concerns about access from the gynaecology ward to the main building. To access the main building, patients were taken along a long corridor underground was 102.5 meters long. Staff felt this was a concern if patients deteriorated along the way, but also because any staff members escorting patients were away from their designated areas for a long duration.

Information provided after the assessment showed the service had considered the risk this posed and completed a simulation of an emergency scenario for this, and we were told the total time from delivery suite be via the lifts and tunnel to main theatre operating table was 5 and a half minutes.

The wards were clean and well maintained. The rooms for holding equipment were well organised and set up to allow effective cleaning and manage stock on the wards. However, within theatres, storage was observed to be inadequate. This impacted the ability for effective cleaning in these areas and restricted access along corridors where equipment was kept. The clinical rooms and the sluice were clean within ward areas. The temperatures were monitored in the clinical rooms and the refrigerators in Wards 16 and 17 and they were reported in daily checks as safe for medicines storage.

We reviewed a random sample of equipment (both electrical and consumable) and found items were in date and where required had evidence of an electrical safety test.

We observed a number of patients who were not surgical patients admitted on the surgical wards. This meant patients were delayed returning from theatres or at times, cancelling patients due to no surgical beds being available.

There was a process to ensure most equipment, and the environment were well maintained and safely met the needs of the patients admitted to the area. Wards and theatres were in line with the relevant health building notes. However, at the time of our onsite assessment, we were concerned the process for ensuring the resuscitation trolleys were well maintained and ready to use was not effective. We found trolleys did not have any tamperproof mechanisms and audits conducted by the trust identified items went missing from the trolleys. Despite evidence identifying items were missing, no action was taken to ensure the trolleys were secured. We raised this as a concern with the trust at the time of the assessment and a review of this was to be completed.

There were concerns the service did not have the right skill and experience mix on a daily basis, with some staff only having done tasks once before. We heard staff were lost through retirement or moving elsewhere. Recruitment of experienced theatre nurses was difficult. Although there had been a recent major recruitment drive, the workforce was overall very junior, which meant numbers of staff were good, but their experience level was lower overall.

Theatres were staffed according to the Associations for Perioperative Practice (AFPP), Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendations. There were 3.5 whole time equivalent (WTE) band 7 theatre and day surgery team managers who each managed a smaller group of theatres within the overall group of 10 theatres. Band 5 staff were offered rotations through other specialties.

However, we heard staffing was generally poor, with a lot of sickness and annual leave. A lot of bank staff were used, and bank fill was good, so theatres were not often short staffed. We were told theatres would never be allowed to be short staffed, and multiskilled recovery staff would be moved to cover if needed. Sometimes emergency theatre staff were used in recovery (ODP), but this was usually resolved promptly and would not be allowed to compromise urgent surgery.

Medical staff working within gynaecology raised concerns about staff shortages and trainee concerns. Staff especially raised concerns over only 1 registrar being on call for both gynaecology and obstetrics, as there was meant to be a separate registrar for both services. Information reviewed after the assessment supported the concerns from the medical staff. In addition to this, other staff raised concerns over medical staffing within gynaecology at the weekends describing it as “terrible”, “overwhelming”, “really challenging” and “a whole different world” with many adding this was both physically and mentally stressful. Medical staff told us there were consultant ward rounds on the weekend and consultants were approachable and willing to help.

The service had processes to determine if there were enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service completed weekly reporting to escalate any areas of concern. There were also processes to escalate any staffing challenges which presented during the day. However, at the time of our assessment, gynaecology did not complete the same reporting processes as other surgical areas. There were still processes to ensure any staffing challenges were addressed.

Medical staffing was noted to be lower than expected within the gynaecology service, with staff stating during the onsite assessment at times this felt unsafe, especially over the weekend. Medical staffing was on the gynaecology risk register, graded at 9 after mitigation which included the use of locums and ongoing recruitment. Staffing for senior house officer level was recorded at 50% vacancy and registrar level medical staff 25% vacancy.

The service shared details around fill rates for each of the surgical wards, for the 6 months leading up to the onsite assessment. Most wards showed fill rates of 80% and over, there was some months, for example January 2024 on Ward 16 where fill rates for registered staff were within the 60%. However, improvements within all fill rates were observed. Information indicated trainee nurse associates were included in the fill rates of unregistered staff as well as being counted as supernumerary. This led to confusion about staffing levels on some of the shifts we reviewed.

There were processes to ensure staff kept patients safe from the risk of infection. There was a policy which was trust wide for staff to follow to ensure they adhered to correct infection prevention and control standards. There were isolation procedures for patients who had a known infection or were susceptible to infection. Most patients were admitted straight into a side room in line with the infection prevention and control policy, which had clear identification on appropriate action required when caring for these patients.

However, it was noted on the orthopaedic risk register that due to the number of outliers within the wards, this was an increased risk to elective orthopaedic patients from an infection perspective. Even with mitigation, the risk rating for this was still 12.

The trust monitored all infection rates across all locations and departments. Information reviewed showed Good Hope Hospital had varied outcomes in relation to their infection rates. Improvements had been observed in relation to Clostridium difficile rates however there had been an increase at this location in relation to Escherichia coli bacteraemia.

Local audits were completed in relation to performance against IPC related standards. Where areas of non-compliance were observed, actions were taken to address this.

Staff on wards were supported by pharmacy staff to manage medicines processes, such as ordering and receiving medicines. Ward staff were responsible for the practice of removing expired medicines and this practice needed reviewing to ensure expired medicines were removed at the appropriate time. Staff from the clinical pharmacy service supported staff on the wards with medicines optimisation. Staff on wards could access pharmacy advice, emergency medicines and critical medicines out of hours. Staff received medicines training and were assessed as competent to provide medicines support to people.

We observed medicines were administered safely and at the right time. Medicines were stored securely and at the expected temperature. However, Controlled Drugs were not always stored in line with current legislation. Medicines used for resuscitation and other medical emergencies were available, accessible for immediate use and tamperproof. However, the balance between accessibility and security of these medicines needed to be addressed.

Medication administration records were updated accurately and in a timely way when medicines were started, changed or stopped. Medicines administration was recorded accurately and contemporaneously. An accurate record was made when medicines were not administered, for example, if the person was asleep, medicine were out of stock or medicines were refused. Venous Thromboembolic Event (VTE) risk assessment, weight and allergy status of patients were appropriately documented. The outcome of the VTE assessments was actioned. Local and national guidance on Antimicrobial Stewardship was followed; staff ensured people received antimicrobials at the right time, their doses were spaced appropriately, and the course was completed. Within 48 hours of the first dose of the Intravenous (IV) antimicrobial being administered IV oral switching was considered. Audits of Controlled Drugs were not able to demonstrate the medicines were managed safely.