Stamford & Rutland Hospital

⚠ Within some services the trust did not ensure sufficient numbers of staff completed mandatory training in key skills. Nursing and medical staff did not always meet the trust’s compliance target.

⚠ Within some services the trust did not ensure sufficient numbers of staff completed mandatory training in key skills. Nursing and medical staff did not always meet the trust’s compliance target.

⚠ Governance processes were not always fully effective. Staff did not always have regular opportunities to meet, discuss and learn from the performance of the service.

⚠ Risks and issues were not always escalated promptly. Action was not always taken quickly to reduce their impact.

⚠ The trust did not collect, analyse, manage or use information well to support all of its activities. There was a lack of governance and monitoring around areas of key risk within the trust, for example the risks associated with the storage of medicines and risks associated with the grading and …

⚠ Medicines were not always managed consistently and safely. Medicines on the Peterborough City Hospital site were not stored in line with national guidance. Medicines could be accessed by staff who were not authorised to access them.

⚠ Staff did not always complete risk assessments for each patient swiftly and did not always remove or minimise risks and update the assessments. Staff did not always identify or quickly act upon patients at risk of deterioration.

⚠ Staff did not always keep detailed records of patients’ care and treatment. Records were not always clear and up-to-date.

⚠ Not all staff were aware of appropriate isolation procedures should they treat an infectious patient.

⚠ The service did not have enough medical staff with the right qualifications, skills, training and experience. There were several vacant posts and rota gaps were filled by staff at short notice. Managers did not regularly review staffing levels to ensure an appropriate skill mix of medical staff.

⚠ It was unclear if people could access the service when they needed it. The service did not always admit, treat and discharge patients in line with national standards. For example, waiting times to be admitted were not monitored, and patients stayed in the department for longer than they needed to.

⚠ It was unclear if people could access the service when they needed it. The service did not always admit, treat and discharge patients in line with national standards. For example, waiting times to be admitted were not monitored, and patients stayed in the department for longer than they needed to.

⚠ Leaders did not operate a consistent governance process, throughout the service and with due to lack of senior staff and time constraints of leaders. Not all staff at all levels were clear about their roles and accountabilities. Staff did not have regular opportunities to meet, discuss, understand and learn from …

⚠ Not all staff were committed to continually learning and improving services. They did not have an understanding of quality improvement methods and had not been equipped with the skills to improve quality. Leaders did not encourage innovation and participation in research.

⚠ Not all staff felt respected, supported or valued. The service had an open culture where patients, and their families could raise concerns however not all staff felt they could do so without fear of retribution.

⚠ Not all leaders had the capacity to run the service. They did not understand and manage all the priorities and issues the service faced.

⚠ Leaders did not operate a consistent governance process, throughout the service and with due to lack of senior staff and time constraints of leaders. Not all staff at all levels were clear about their roles and accountabilities. Staff did not have regular opportunities to meet, discuss, understand and learn from …

⚠ The service did not collect reliable data and data was not always analysed. Staff were able to find the data they needed, in easily accessible formats, but not all staff understood performance, made decisions or improvements.

⚠ The ward did not have a secured exit door to monitor who was leaving the area. Which meant that there was a risk that babies could be abducted. The service had not performed any baby abduction drills.

⚠ Not all equipment was safety tested. Not all equipment was safety checked and tested in line with safety standards.

⚠ Women who attended the triage unit were not seen immediately by a member of staff. We were concerned that women were not having a timely risk assessment when presenting with complications. We raised our concerns with the trust who took action to address our concerns. Staff did not always fully …

⚠ Staff did not always deal with specific risk issues. For example, we found that carbon monoxide screening which is part of the ‘saving babies lives 2016’ initiative was not always performed in line with trust guidance.

⚠ Staff did not always complete the nationally recognised tool to identify deteriorating women correctly.

⚠ Staff had training in key skills, required by the trust.

⚠ Audit demonstrated that staff did not always fully complete the World Health Organisation and five steps to safer surgery checklist.

⚠ There were a number of guidelines that were out of date. There were a number of guidelines, five out of ten were viewed were out of date.

⚠ The service did not control infection risk well, not all equipment and premises were visibly clean.

⚠ The service did not always store intravenous medicines and oxygens safely.

⚠ The expressed breast milk fridge was not locked, which meant milk could be taken or tampered with which was not in accordance with the Royal College of Nursing 2015.

⚠ The service did not control infection risk well, not all equipment and premises were visibly clean.

⚠ Paper records and were not always stored securely on the delivery suite. The service did not ensure all identifiable information was kept confidential. Women’s details could be observed in corridors within the delivery suite.

⚠ Staff documentation around cardiopulmonary resuscitation was poorly completed and not in line with national guidance. The trust used a recommended summary plan for emergency care and treatment (ReSPECT) to document discussions around cardiopulmonary resuscitation. ReSPECT documentation was poorly completed. Of the 14 ReSPECT forms we reviewed, six forms showed no …

⚠ Assurance was not provided that there was a member of staff trained in advanced life support and paediatric immediate life support on every shift.

⚠ Staff knowledge of the Mental Health Act 1983, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was inconsistent.

⚠ Annual prescribing updates and staff competencies could not be assured for non-medical prescribers.

⚠ Not all staff supported patients to make informed decisions about their care and treatment or followed national guidance to gain patients’ consent.

⚠ Governance, risk and quality performance processes were not embedded or aligned across the division, with the majority of focus given to Peterborough City hospital. Local audit was not utilised to monitor and improve services.

⚠ There was a lack of transition services and support in place. Staff did not have access to transition plans used to support young people moving on to adult services.