Hospital of St Cross

Hospital of St Cross, Rugby is part of University Hospitals Coventry and Warwickshire NHS Trust. It provides a small range of hospital services, including urgent care, general medicine including elderly care and rehabilitation, elective surgery including a surgical day unit, and a range of outpatient services.

University Hospitals Coventry and Warwickshire NHS Trust serves a population of about 1,000,000 across Coventry, Warwickshire and beyond. Inpatient services are provided from two hospital sites, University Hospital Coventry (the main site) and Hospital of St Cross, Rugby. In total, the trust has 1,250 beds.

We carried out this inspection as part of our comprehensive inspection programme between 10 and 13 March 2015.

Overall, we rated Hospital of St Cross, Rugby as good, although improvements were required to ensure that urgent and emergency care and medical services were safe, responsive and well-led. All services were judged to provide caring and effective care. We found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support.

Our key findings were as follows:

Cleanliness and infection control

• Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene, with nursing staff regularly cleaning their hands with the disinfectant gel that was provided in dispensers in multiple locations. A large poster was displayed in the reception waiting area about the hand-cleansing charter and a board displaying information and instructions on effective hand decontamination were displayed along the corridor to the staff room.
• Adherence to ‘Bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care was observed in all clinical areas.
• Although the trust had seven cases of MRSA recorded from April 2013 to November 2014, none of these involved Hospital of St Cross. The records we reviewed showed that patients had been fully screened for hospital-acquired infections before being transferred to the hospital.
• In the urgent and emergency care centre there was an isolation room prepared and ready for use, with the appropriate personal protective clothing illustrated on the door. A copy of the trust’s infection control policy was available. We saw stocks of high-level personal protection equipment and clothing in a cupboard nearby.
• In the outpatients department we saw that, although the consulting rooms had hard floors, the carpets in the corridors were stained and worn in some places. We moved a portable computer table and found accumulated dust underneath it, because it had not been moved when the department was cleaned. We saw ground-in dirt on the edges of some of the desks and on the doors where they were pushed open.

Records

• The standard of record completion varied across the services. In surgical services we found that medical and nursing notes were concise, legible, complete and up to date. However, in medical services, three out of 12 sets of records checked had the patient’s surname recorded with no hospital number or date of birth.
• Both paper and electronic records were available in all departments.
• In medical services we found that ‘comfort rounds’ (checks on hydration, nutrition, continence, equipment, positioning, mobility and skin survey), which were meant to be completed two-hourly, were not always documented.
• We also found within the medical services that the daily fluids balance records were not totalled up in the records we read. This meant that staff caring for these patients could not identify adequate hydration and report any abnormalities in patients’ fluid documented recordings.
• In outpatients we were told that sometimes patients’ records were not available for their outpatient appointments, particularly if patients with complex conditions were visiting both hospital sites within a short time. Clerical staff created a temporary set of notes; the electronic patient records system meant that the referral letter and any previous clinic letters and blood test and x-ray results were available.

Staffing levels

• The trust used the nationally recognised ‘Safer Nursing Care Tool’ along with National Institute for Health and Care Excellence (NICE) guidance to assess required nursing staff levels.

• High nursing vacancy rates were seen in the medical and surgery wards (13%), with the shortfall being filled by trust bank or agency nurses, who all received a ward-specific induction.

• On both our planned and unplanned inspections, staffing levels on the medical wards were below optimum levels, and staff raised concerns about the effect this had on patients’ safety.

• It was recognised by ward-based staff that nursing recruitment was a major safety risk to the service and this was on the directorate risk register. Open recruitment days and overseas recruitment initiatives had been put in place and staff were aware of these initiatives and supported them. There was general agreement that recruitment and retention of nursing staff was seen as a priority by the trust.

• Overall, medical treatment was delivered by sufficient numbers of skilled and committed medical staff.

• Although they had no training in paediatrics, there was a ‘good Samaritan’ arrangement agreed for junior medical staff at Hospital of St Cross to assist with any paediatric emergency in the urgent care centre until the ambulance service arrived to transfer the child to the emergency department at University Hospital Coventry.

Incidents

• Systems were in place for reporting and managing incidents. However, these were not followed consistently across all services; for example, not all staff who reported incidents felt that they received feedback after investigation.
• Staff on the medical wards said they knew how to report an incident. However, staff said they did not always report incidents of challenging behaviour or physical abuse by patients, such as kicks and bites. Staff said that it would make little difference and felt they were discouraged by the clinical leaders.
• Incidents reviewed demonstrated that investigations and root cause analysis took place and action plans were developed to reduce the risk of a similar incident reoccurring. For example, in response to a high number of incidents relating to pressure ulcers, the trust had introduced intentional rounding (where nursing and healthcare assistants check on patients every two hours) on all the medical and care of elderly wards.
• Staff in outpatients told us that learning from incidents was discussed at the daily team brief and regular departmental meetings. We saw various examples of minutes that showed learning was being discussed at meetings.

Nutrition and hydration

• Patients received a malnutrition universal screening tool (MUST) assessment on admission, and any patients with complex dietary needs were referred to and seen by dieticians. On the surgical wards, we saw evidence of the MUST assessments and dieticians’ notes within the patient notes, but on the medical wards referrals to the dietician were seen not to have been actioned.
• On weekdays we saw that people were able to make choices regarding their meals and drinks and were able to select from a range of items. At weekends there were no catering facilities and patients were provided with snack boxes, which meant that only cold meals were available.
• On the medical wards, although there were protected meal times when visitors were not allowed, we observed visitors on wards during these times who told us they came during lunchtime to support their relative to eat. The visitors told us that they were concerned about how much assistance with drinking was provided for patients.

Medicines management

• During our unannounced visit we found the temperature in treatment rooms on the medical wards, where medicines including antibiotics, controlled drugs and intravenous fluids were stored, were in excess of 24°C. This meant staff could not ensure medicines had been stored safely, which could put patients at risk. All the medicines stored in these areas had to be replaced and air-conditioning units were installed and daily temperature monitoring implemented.
• On the medical wards we found a bag of intravenous fluid and nutritional supplements that were past their ‘use by’ date, which if used could put patients at risk.
• We noted that drugs, including controlled drugs, were safely and appropriately stored in all others areas. The controlled drugs protocol was followed.
• There was a pharmacist on site from Monday to Friday.
• We saw that medication in one theatre had been drawn up for all patients on that day’s list. The drugs had been placed in the anaesthetic room in separate piles corresponding to the patients on the list. This meant that incorrect medication could be used. Best practice would be to draw medication for each patient individually, thereby removing any possibility of error.

We saw several areas of outstanding practice including:

• University Hospital Coventry and Hospital of St Cross were working to improve the experience of older patients. Initiatives included blue pillowcases for patients with dementia, screening all patients aged 75 and over for dementia and the development of a ‘care bundle’.
• The trust was adopting the VERA technique as a means of communicating with a person with later stage dementia. VERA stands for: valuing what the person says, emotional which looks at the feelings behind the person’s words, reassurance and an activity that is helpful for the person. Staff were rolling out this technique across the trust.
• The trust was using the ‘M’ technique as a means of holistic communication through a system of touch on hands and feet for older adults. This included the repetition of stroking and conventional massage through slow, constant and rhythmical pressure.
• The endoscopy department responded to the needs of its patients by having separate lists for men and women so that each group had their dignity maintained.
• However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust MUST:

• Ensure that its systems to review equipment and audit compliance are effective so far as they relate to checking resuscitation equipment.
• Ensure that medicines are stored safely across the hospital.

Action the hospital SHOULD take to improve

• Nurse staffing levels comply with NICE’s 'Safe staffing for nursing in adult inpatient wards in acute hospitals'.
• The trust should consider improving GP support within the RUCC.
• The trust should review the frequency of senior leader presence at the RUCC and assess its effectiveness in the monitoring of risk.
• The trust should define its vision and strategy for the RUCC, and more effectively inform the local public about the limitations of the service.
• The trust should ensure that all ENP staff at the RUCC undertake child safeguarding training at level three.
• Local people receive a clear message about what the RUCC offered.
• Fluid scores are completed and recorded appropriately so that patients who are at risk of dehydration are correctly escalated.
• Information leaflets and signs are available in other languages and easy read formats.
• The access and flow of medical patients is improved and delayed patient discharges are managed appropriately, including robust processes in place to meet the estimated discharge dates.
• They have robust arrangements in place to meet referral to treatment times.
• Learning from incidents is shared across all staff groups.
• The trust should ensure that patients accommodated over weekend periods have access to a choice of suitable and nutritious food and hydration. This should include the provision of hot meals where this is the patients preferred choice. This is something which is required as part of regulation 14(1)(a, b & c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Protecting patients from the risk of inadequate nutrition. However it was considered that it would not be proportionate for the finding to result in a judgement of a breach of the Regulation overall at the location.
• Review and reduce the number of patients who have their appointments cancelled for non-clinical reasons.
• Review the anomalous reporting structure within the radiology department, so that reporting lines are clear.
• Review the arrangements for communication within the radiology department to ensure that staff receive essential information in a more methodical and regular manner.
• Review the radiography arrangements for regular late operating lists, so that the on-call radiographer is not restricted or delayed in undertaking urgent x-rays.  Review and update the environment in both outpatients and radiology.
• Consider the use of wasted space in the outpatients department, currently containing obsolete x-ray equipment.
• Review the anomalous reporting structure within the radiology department, so that reporting lines are clear.
• Review the arrangements for communication within the radiology department to ensure that staff receive essential information in a more methodical and regular manner.

Professor Sir Mike Richards

Chief Inspector of Hospitals