Bradford Royal Infirmary

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 assessed key questions within safe. We rated it as good. We found, a positive learning culture, evidence of safe systems pathways and transitions. However, we did not always find safe and effective staffing levels and safe management of the destruction of medicines.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

During the assessment we spoke to several patients and relatives on seven wards across the assessment service group within medicine including stroke and rehabilitation. No concerns were raised, and we observed compassionate care and treatment. Patients we spoke to told us they felt included in their care planning. Patients were positive about their experience and interactions with staff, they told us they felt confident and comfortable to raise concerns, though none of the patients we spoke with had needed to raise concerns during their stay. Friends and family feedback was reviewed which was positive overall and there was evidence of actions taken by the Trust to improve following feedback.

There is a culture of safety and learning from incidents within the organisation. This is based on openness, transparency and learning from events that have either put people and staff at risk of harm, or that have caused them harm. Incidents and complaints are investigated and reported. During inspection we saw examples of differing patient complaints and incidents with harm. Staff were able to explain the investigation process, actions taken and lessons learnt. Staff gave examples of honest conversations with patients and family members to support duty of candour both verbal and in written form. Staff were able to raise concerns to proactively identify and manage risks before safety events occurred.

During inspection we saw examples of differing patient complaints and incidents with harm. Staff were able to explain the investigation process, actions taken, and lessons learnt. Staff gave examples of honest conversations with patients and family members to support duty of candour both verbal and in written form. We reviewed 3 reported serious incident investigations provided by the trust following the assessment. We found examples where action plans did not always include all concerns raised within the report, timeliness of investigation completion and action planning timeframes and sign off. We escalated this with senior leaders at the time of the well led assessment. Staff had access to raise concerns to proactively identify and manage risks. There was a governance process in place where complaints, incidents and risk was reviewed. The Trust officially transitioned to the national Patient Safety Incident Response Framework (PSIRF) from 1st December 2023. The policy and plan was approved by the Trust board of directors, and Bradford District and Craven Health and Care Partnership in November 2023.

Patients we spoke to told us they had been fully involved in their care and were aware of next steps. They told us staff were attentive and provided quality care.

Staff told us there were clear pathways in place for transfer from the acute assessment units to the medicine wards. We heard that discharge planning started immediately on admission. We observed a discharge planning discussion. We saw that electronic records were used and staff could access information on patients who had moved between wards to provide continuous care. Risk assessments were completed and reviewed weekly or sooner if required. There were clear handover systems in place. Staff were able to tell us about pathways such as the respiratory pathway. We heard that wards had clear criteria and heard about recent changes to one ward to allow for a young frailty service to be provided – staff told us that before changes had been made to this ward it had felt like an unsafe place to work without clear criteria for admissions and without clear processes. Staff told us the ward now felt much more able to support patients safely. On the stroke wards we heard there was a shortage of Allied Health Professional staff which impacted on timely transitions to community from wards. Patients were not always ready from a therapy point of view for discharge and also had long waits in the community for the community therapy stroke services to be able to pick them up. Whilst there were appropriate pathways, we heard that therapy was not able to be provided as frequently and to the extent that it should be to support timely recovery and discharge home. This is referred to further in safe staffing.

We did not receive feedback from partners for this aspect of assessment. However, we saw evidence of partnership working with community agencies. For example, the local homeless housing team attended acute medical wards to support discharge processes.

We saw standard operating processes for completion of documentation by both nursing and allied health professional staff when discharging patients from care. The system allowed for discharge documentation to be sent directly to General Practitioners with copies to be printed and provided to patients.

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.

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

During the assessment we spoke to several patients on seven wards including stroke and rehabilitation. No concerns were raised, and we observed compassionate care and treatment. Patients we spoke to told us they felt included in their care planning. Patients we spoke with were positive about their experience and interactions with staff, they told us they felt confident and comfortable to raise concerns, though none of the patients we spoke with had needed to raise concerns during their stay. Some patients told us they felt there was not always enough staff on duty to care for patients requiring additional support. Friends and family feedback was reviewed which was positive overall and there was evidence of actions taken by the Trust to improve following feedback.

Managers regularly reviewed staffing levels and skill mix and efforts were made to increase staffing levels for each shift. However, this did not always provide established planned verses actual levels of staffing required to care for patients. The service did not always have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We inspected 7 wards at Bradford Royal infirmary 6 out of the seven wards did not meet planned verses actual staffing levels for registered nurses. Patients were placed at risk of deteriorating mental health, infections and de-conditioning as a result of longer stays in hospital due to limited therapy resource. We also heard that patients might be kept on the wards longer than usual because of a delay of 8 to12 weeks to access the community therapy stroke team. The trust reported a serious incident (April 2024) resulting in severe patient harm. Initial investigation highlighted an additional escalation request for 1:1 support staff to care for a patient at known risk of falls. The request was not supported which resulted in patient harm. During inspection staff told us escalation requests were often not supported due to the lack of staff available. The trust had successfully recruited a number of oversees nurses and newly registered nurses to cover vacancies; however, staff told us some recruits required ongoing support and mentorship throughout induction, Objective Structured Clinical Examination (OSCE) training and apprenticeship training. The trust had recruited additional clinical practice educators to facilitate additional learning needs for newly recruited staff. However, most staff we spoke to said it was difficult to offer consistent mentorship and training opportunities to junior staff due to patient numbers and patient acuity.

On inspection we observed staff working hard to complete tasks for patients; however, we were not assured that staff had the time to always provide person centred care that met individual patient needs and acuity. We assessed seven wards at Bradford Royal infirmary. Six of the seven wards did not meet planned versus actual staffing levels for registered nurses. Planned verses actual staffing boards evidenced this and managers corroborated there was often gaps in staffing rotas. This demonstrates a breach in Regulation 18 (1) staffing, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Therapy staff for the stroke and rehabilitation wards (6 and 9) were staffed to establishment, however, it was recognised that the establishment numbers were not sufficient to meet the needs of patients in order to achieve The National Institute for Health and Care Excellence (NICE) guidance and to achieve Sentinel Stroke National Audit Programme (SSNAP) outcomes. The trust had agreed a 5-year business case; however, the business case was nearing the end of year 1 and it had not been possible to recruit to the additional posts agreed within the 1st year. This meant therapy was not provided as frequently and to the extent that it should be to support timely recovery and discharge. Patients were placed at risk of deteriorating and de-conditioning as a result of longer stays in hospital due to limited therapy resource.

Managers regularly reviewed staffing levels and skill mix and efforts were made to increase staffing levels for each shift. However, this did not always provide established planned verses actual levels of staffing required to care for patients. Medicine wards inspected had differing levels of patient acuity, some requiring 1:1 support due to risk of falls, dementia, confusion etc. The service had a range of steps and processes to mitigate staffing risks. We assessed seven wards at Bradford Royal infirmary. Six of the seven wards did not meet planned verses actual staffing levels for registered nurses. There was a process in place to compare staff numbers and skill mix alongside actual patient demand in real-time, to base informed decisions. The trust had a clear process in place for additional staff escalation requests. There were registered nurse vacancies on all wards assessed. However, the trust had successfully recruited oversees nurses and newly registered nurses to cover some vacancies; however, some staff were inexperienced and required support and mentorship throughout induction, Objective Structured Clinical Examination (OSCE) training and apprenticeship training. Mandatory training compliance on all wards inspected met the trust target of 90%. The division provided data which evidenced compliance rates met the trust target rate. Staff appraisal compliance was well managed and was in line with the trust target of 90% on all wards we assessed. Staff at all levels had opportunities to learn, and poor performance was managed appropriately.

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

People were supported to access the medicines that they were prescribed in a timely manner. Medicines were reconciled for people we looked at within 24 hours of admission. Where interventions had been made during medicines reconciliation documented actions were not always reviewed in a timely manner to ensure people had everything prescribed they needed. The trust provided medicines reconciliation data however the data provided did not cover all medical wards and looked at a sample of patients. However, the Trust was working on building a report to extract medicines reconciliation data from the Electronic Patient Record (EPR) for all clinical service units throughout the Trust. All prescribers have access to the community view on EPR which has an interface with the primary care summary care record which facilitates the clinicians to document accurate drug history. The trust had completed a project called “Get it on time”. This project aimed to support people receiving time critical medicines on time. The project was led by the outstanding pharmacy services team, and only centred on medicines for Parkinson’s Disease. It was possible for staff to provide medicines information leaflets in other languages and for those who required medicines to be dispensed in multi compartment devices this was facilitated by the pharmacy. On one ward we saw how ward staff were working in collaboration with family to support a person with a learning disability to safely access their medicines in a way that met their individual needs. This had improved the patients experience and prevented missed doses of medicines as the medicines were administered by a familiar person.

Pharmacy staffing on the admission wards covered a seven-day clinical service. One ward had budgeted for a pharmacy technician and nursing staff on the ward stated they were integral to the ward team. Cover for other areas within medicine was sometimes limited due to staffing resource. No staffing capacity plan had been completed to evaluate how many pharmacy staff would be needed to provide a clinical service across all medical wards. We were told that the discharge process could be lengthy and ward staff felt that this impacted discharge. The dispensary had a two hour turn around once they received the authorised prescription and information provided to us showed that on average in February prescriptions had taken 1 hour 49 minutes. Once the ward wrote a prescription this then required pharmacy authorisation prior to dispensing and staff told us that this was where they felt the delays occurred. The trust was unable to provide figures on how long the authorisation process took.

Medicines were not always stored securely on the wards we visited. Room temperatures and fridge temperatures were recorded on most days. We observed that pre-labelled medicines were available for discharge on some wards to help speed up the discharge processes. However, we saw that some stock records were not accurate, and these were not regularly reviewed as part of an audit process. We saw that the process for destruction of stock controlled drugs was not in line with the trust policy or legal requirements. We brought this to the attention of the trusts Controlled Drug Accountable Officer during the inspection. This demonstrates a breach in Regulation 12(1)(2)(g) the proper and safe management of medicines the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We saw that one person had returned post discharge to an admissions ward to collect an antibiotic prescription. The medicine had not been dispensed by pharmacy. We were told that once the person is processed as discharged, the person is not active on the trusts electronic record system even if there are outstanding tasks such as awaiting prescriptions to be dispensed. We were told by staff that they encouraged wards to move the patient to a virtual chair so that prescriptions could be processed but this did not always happen and sometimes patients returned to collect medicines that had not been processed.

The trust used an electronic prescribing system to prescribe and administer medicines. There was a range of in date medicines policies in place to support staff in medicines management. There was a process in place to ensure that oxygen was prescribed and that VTE assessments were completed at the time of admission. The trust employed a pharmacist who worked alongside IPC and microbiology to review antimicrobial use. The pharmacist was integrated into all areas of the trust and supported ward and pharmacy staff with antimicrobial stewardship. The trust had been without a dedicated medicines safety officer for a period of time and staff were unable to tell us who was managing this in the interim.