Nottingham City 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 rated safe as requires improvement.

We assessed 8 quality statements. We identified 4 breaches in safe care and treatment. These related to infection control procedures, equipment safety, medicines and expressed milk storage.

There was a learning safety culture where events were investigated. However, staff we spoke with told us learning was not fully embedded or shared consistently to promote good practice.

Staff were open and honest when things went wrong or could be a risk.

Staff mostly provided safe care and treatment.

The environment was not always safe. Staff checks on emergency equipment were not always complete. Despite some increases in staffing there were still gaps in rotas, not expected to be filled before the autumn. Leaders had increased staffing levels when needed to keep the department and people safe. Staff training had increased. However, there was a delay in providing some types of essential training.

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.

People told us they were not always confident about raising concerns. They did not always feel taken seriously. However, when concerns were raised, reports of the event were shared with them. People or those who represented them were given an apology. However, people were not always given a response within the time limits the trust agreed.

Staff we spoke with were not always confident reporting incidents. They told us they didn't feel supported when things went wrong. However, staff knew what should be reported and when.

The trust’s formal reporting system was easy to use.

Staff we spoke with saw incidents as an opportunity to learn and improve. However, they did not feel the trust shared learning effectively.

Staff had systems in place to raise concerns both formally and informally. However, staff we spoke with did not always feel confident raising concerns .

We found that the majority of people using Nottingham University Hospitals found the systems and pathways were safe. A number of people told us that they found the neonatal transitional nurses particularly helpful and that they knew the process and felt safe when on the wards and in the labour suite. However, a number of people told us that there were inconsistencies and delays with induction processes. There were some examples of people telling us they were called in to the hospital to be inducted but were waiting up to 24 hours for staff to be available for bed space on labour ward. One person was transferred to City Hospital in order to be closer to facilities that would be able to support their child postpartum.

Information provided post onsite assessment highlighted that delays did not cause harm to women and birthing people. Delays occured potentially due to a number of concerns due to demand and capacity of the service. The service had a process for these eventualities which included the need for communication with mothers and birthing people.

We found that staff and leaders had a good understanding of safe systems, pathways, and transitions. All wards had a good mix of staffing levels at the time of the assessment. However, all staff told us this was not normally the case. Staff also outlined that skill mix was sometimes an issue, with a large number of inexperienced midwives. Staff reported these concerns, however, staff told us they did not feel listened to.

Information provided by the trust post onsite assessment identified processes to manage daily operational and strategic staffing which was in line with national standard. However, staff we spoke with onsite did not feel staffing was always safe.

When asked what could be improved during these times, the vast majority of staff told us that staffing levels could sometimes delay women from getting into the labour suite.

Staff praised the Maternity Advice line which was used to support all women and birthing people throughout pregnancy and post-partum.

We were provided with mixed feedback from partners which identified concerns specifically related to staffing and skill mix. However, the trust were aware of these concerns and were working towards improving them.

There were sufficient processes in place to support people in labour and after delivery. Staff were trained and up to date with mandatory training and took part in scenario training which included emergency procedures. Staff were aware of where to find policy documents. However, when staff printed these out they did not have the most up to date policy available. This had the potential to lead to harm if a member of staff relied on an out of date document.

Women and birthing people we spoke with told us staff supported them throughout their time in the unit. They were given the opportunity to raise any concerns,

confidentially with the midwife when on the ward, during clinic appointments or by contacting them by telephone.

Staff understood how to protect women and birthing people from abuse and the service worked well with other agencies to do so. Staff we spoke with gave examples of joint working with the local safeguarding authority. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff we spoke with understood how to identify any concerns about harassment and discrimination and were able to describe the process of escalation. Equality, diversity, and human rights was part of the core mandatory training programme. Staff we spoke with told us how they supported someone with a physical disability with the help of multiple agencies working together to support care throughout the pregnancy and subsequent birth.

There were up-to-date safeguarding policies and procedures, which were accessible to staff through the trust’s intranet site.

Safeguarding training was part of the trust’s mandatory training programme. All staff we spoke to had received safeguarding training.

The trust had a baby abduction policy and undertook baby abduction drills to ensure staff knew what actions to take.

We were told that people felt they were involved in their care and mostly felt safe to question staff. People we spoke with felt their birth plans were adhered to within reason and that they could challenge staff when talking about their care.

One person told us that they mentioned a genetic condition within their family to the midwives. We were told that staff took extra steps to diagnose the condition, taught the family how to support the baby and ensured they were aware of how to perform emergency first aid should it be required.

Staff we spoke with told us that they would incorporate birth plans within a person's care plan when in maternity. However, staff acknowledged that this was not always possible due to medical complications.

There were processes in place for staff to follow that supported them when making decisions with people about their care.

Most people we spoke with told us they generally felt the environment was safe and had no concerns regarding their surroundings. However, we found a breach of regulation in relation to safe care and treatment. Safe storage of expressed breast milk was not consistent as it had been misplaced .

Staff reported they did not always have access to all the equipment they needed . Staff told us that when equiptment was missing from specific emergency trolleys they would often struggle to find replacements.

People were kept safe while waiting to be seen or receive treatment. The facilities were well maintained, and any equipment used with patients was in working order and used safely. Staff wore personal protective equipment in line with regulations. However, we found a breach of regulation in relation to safe care and treatment. Emergency equipment trolleys had not been checked over a number of days . We could not be assured the correct equipment was present.

Hazardous and clinical waste was responsibly managed. The department’s fire safety and other emergency systems were tested and maintained. However, processes for checking emergency trolleys and some equipment were not robust. Information provided by the Trust during the course of the assessment process, provided some assurance that processes had been introduced to improve checking of emergency trolleys.

People told us they felt there were enough staff with the right skills and experience to look after people safely. They said the staff were well trained and competent with the care and treatment they were providing. However, all people told us that staff were extremely busy and were not always available when they were needed.

Leaders told us they kept staffing numbers at a safe level with a suitable skill mix increasing numbers as much as possible when the department had higher numbers of people attending for maternity care. They had recently reduced the use of agency and bank staff. Staff we spoke with told us that ward areas were led by band 6 staff instead of band 7 and that staff were often moved to other areas leaving patients less supported. Information provided by the trust identified band 7 ward managers worked clinically 40% of the time.

Staff we spoke with told us there were skill mix concerns due to high numbers of band 6 staff leaving the department. Information provided by the trust post on site assessment did not support staff perception of the numbers of band 6 staff leaving.

Staff at the Nottingham City Hospital site did not report staffing concerns as regularly as the Queens Medical Centre staff.

Leaders provided us with information after the onsite assessment which identified mitigations and improvements to staffing and recruitment.

Staff were noticeably busy and worked under pressure when the department had higher numbers of patients or when people required close supervision. There were gaps identified within areas which were not accounted for in staff rosters. There appeared to be a good degree of support and mutual respect amongst staff working in the unit.

Records showed there were not always enough medical staff to meet the recommendations of the Royal College of Obstetricians and Gynaecologists. There were consultant vacancies of 20.91% at the time of our assessment and midwifery vacancies were at 13%. There was a plan to fill the midwifery vacancies, however this would not take place until the Autumn as they were all newly qualified or overseas staff. Staff we spoke with were concerned support for newly qualified midwives would affect patient care. During the assessment process the trust provided information to outline plans to manage skill mix and ability of the service to support newly qualified staff. However, these plans would not be implemented until new staff joined the service. We were unable to take full assurance from these plans as a result.

People we spoke with expressed that the hospital was mostly clean and that they had witnessed staff using hand sanitiser and personal protective equipment during episodes of care.

All staff that we spoke with identified specific training they had undertaken in order to maintain safe infection prevention and control procedures.

We observed staff appropriately using hand sanitiser when working on ward areas. Staff were wearing correct uniform and were bare below the elbows. Cleaning schedules were available and completed daily. However, we observed a breach of the regulations in relation to safe care and treatment. The curtains around beds were not consistently disposable or dated for changing. Staff were unaware of when curtains required changing. This was highlighted to the trust at a previous inspection in June 2023.

Whilst there were processes in place, staff were not always aware how to follow them. For example, appropriate use of curtains within a ward /unit area.

Mothers and birthing people did not raise any concerns with the assessment team in respect of medicines.

We did not have any concerns raised by staff in relation to medicines. However, audits provided after the assessment identified concerns related to temperature reviews,

medicine storage rooms and refrigerators for storing medicines. These were also identified during the June 2023 inspection of maternity services.

We observed a breach of the legal regulations in relation to safe care and treatment. On all 3 wards medicine refrigerator temperatures were recorded inconsistently with different methods dependant on the ward. We observed medicine room temperatures, where they were also inconsistently monitored.

We observed patient group directives for medicines printed on ward areas. These were mostly out of date. However, staff were aware of how to access them on the staff intranet site.

There were processes in place for managing medicines and safe storage. However, staff were not consistently following procedures implemented at the trust.