Peterborough 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

At out last assessment we rated this key question requires improvement. At this assessment, the rating remained the same. The service was in breach of the legal regulations relating to safe care and treatment and staffing.

There was a culture of safety and learning. Risks were dealt with willingly as an opportunity to put things right, learn and improve. Staff felt confident to raise concerns, however, they did not always feel listened to. Incidents were appropriately investigated.

Safety and continuity of care was a priority throughout people’s care journey. There were systems and processes in place to ensure safety, although staff did not always complete all processes, and sometimes patients were not reviewed as needed.



People using the service were informed about any risks and how to keep themselves safe. Risks were assessed, and people and staff understood them. Risk assessments about care were person-centred, proportionate, and regularly reviewed.

Most people were cared for in a safe environment that was designed to meet their needs. However, the care of patients in boarding beds (cared for in corridors) and escalation areas did not always follow the trust’s policies and procedures to ensure this was safe.

Recruitment practices were safe. Compliance with training mostly met the recommended target, although there were some shortfalls. Staffing levels did not always meet planned levels. However, three times a day staffing reviews and the use of an acuity tool ensured staffing concerns were escalated and mitigations put in place to reduce risk. Staff received training that was relevant to their roles and responsibilities, and support they needed to deliver safe care.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with during our assessment told us risks were explained by staff and they mostly felt involved in decision making, although there were sometimes differing views on explanations being given sufficiently ahead of procedures. They told us they knew who to contact during their care journey. Patient comments included “The procedure was not explained on the ward, but now I have asked questions and now come to a more informed decision”, and “I was informed of the care and treatment I would receive on arrival to the unit. A leaflet came in the post of what to expect but this was in English and I am unable to read it”.

One patient felt their plan of care could be improved due to difficulty in discussing whilst in a boarding bed.

People were confident about raising concerns and they said staff responded quickly.



As part of the assessment, we reviewed 3 complaints the trust had received. The service had recognised themes from complaints, including, but not limited to, clinical decision making and poor care.

A system was in place to investigate incidents and identify learning. Incidents were reviewed daily and involved a collaborative approach, between management and ward teams. Incidents requiring immediate attention were investigated as a priority, to ensure potential safety concerns were addressed and mitigated.



Monthly governance meetings were held to discuss incidents, identify themes and learning, and action to reduce future occurrence.



Staff we spoke with during the assessment felt confident to report incidents in line with trust policy. Most staff were able to discuss how incidents were reported and how they were fed back to staff. They were able to give examples of a variety of methods used by leaders to share feedback from incidents and identified shared learning such as safety alerts, team meetings, emails and posters. However, not all staff were confident their concerns were listened to or acted on, nor did they always receive feedback.

Staff told us they were able to raise concerns through a variety of avenues, including freedom to speak up guardian (FTSUG) and knew how to contact them.

Staff had systems to raise concerns both formally and informally. A Patient Safety Incident Response Framework (PSIRF) policy was in place, which set out the trust’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety. A Patient Safety Incident Response Plan was also in place, which set out how the trust sought to learn from patient safety incidents reported by staff, patients, their families and carers as part of their work to continually improve the quality and safety of care provided.



Reports were analysed and urgent actions taken by leaders to manage or remove risks. Incidents were appropriately investigated. We reviewed the last 3 completed investigations relating to a safety incident within medical care. We saw that the service undertook thorough investigations and identified opportunities for learning with an aim to minimise similar incidents recurring in the future.



A Duty of Candour Policy was in place, which set out staff roles and responsibilities regarding openness, honesty and transparency if something went wrong with a patient’s care or treatment.

A Complaints Policy was in place and complaints were appropriately investigated, although there were sometimes a delay in responding to complaints in line with the trust’s guidance. We reviewed 3 complaint responses within medical care, which all identified opportunities for learning. Learning from complaints was shared with staff through a number of different methods, including a quarterly newsletter. The main themes from complaints in the latest quarter related to communication and medical/clinical care.

Not all patients or relatives we spoke with told us they were informed of their planned care and treatment. We heard comments, such as, “We get mixed messages regarding which scans have been carried out and whether he needs a drip or not”, and “I felt a bit rushed to sign the consent form, but have managed to speak to a consultant now who has explained it all to me”.

Patients knew who to contact if they required support, and follow up arrangements were made prior to discharge. One patient told us the results of their investigation and follow up review was communicated to them before leaving with a discharge letter. Another patient on the ward said, “I see the doctors regularly and I know what the plan is".

Some patients told us that they had discussed their wishes regarding how much care they wanted, should they deteriorate during their admission, and this was documented in their notes to reflect their decision.

Safety and continuity of care was a priority, and there was a strong awareness of risks to people. Risk assessments were completed by staff, including but not limited to, falls, pressure ulcers and safeguarding. We reviewed care records for 10 patients. There was evidence of evaluation of risk at each contact through their care journey, with clear documentation of risk that was acted upon.



Staff identified deteriorating patients through the use of tools such as the national early warning score (NEWS). Staff confirmed there was a process for escalating deteriorating patients to the critical care outreach team (CCOT) through an adverse NEWS score, which could be seen hospital-wide on the electronic system. Patients could also be placed on ‘Amber’ care, which was a way of alerting the palliative care and CCOT to unwell patients. The service had developed an overnight ‘hospital at night’ team that pro-actively oversaw the electronic system and contacted ward staff to check on patients’ condition if they felt there was any deterioration.



Staff attended a daily MDT handover where all patients' care and treatment was discussed. Staff took part in meetings that were proactive in identifying when patients were to be discharged, although not all areas made the most of this opportunity to plan for discharge as early as possible. Ward-based therapists did not attend the MDT meetings we observed and there were numerous nursing actions that had not been completed.



Staff used a ‘situation, background, assessment and recommendation (SBAR) format to provide updates during staff handover and when transferring patients to other areas and shifts.

Senior leaders had developed a set of Internal Professional Standards to ensure patient flow, timely decision making and safe patient care. These provided guidance about the optimum discharge of patients. However, audits for these standards were not completed.

Audits to monitor compliance and performance of systems and process for patient assessment were completed. Overall compliance was good or improving. For example, staff had completed over 95% of venous thromboembolism (VTE) risk assessments and training in falls prevention was above 96%. The number of falls and hospital acquired pressure ulcers had also fallen. Completion of national early warning score (NEWS2) records was lower at 78% in July 2024. However, the audits had shown a consistent improvement since the NEWS2 audit in July 2023, which was 59%. The trust had undertaken a quality improvement project to drive improvement in the completion of NEWS2, which had identified reasons for the low completion rate and identified actions to improve completion.

Policies were in place to support staff plan and deliver appropriate care, according to best practice and national guidance. We reviewed policies for deteriorating patients, those with possible sepsis and the opening of non-inpatient escalation areas.



However, although there was an in-date policy for the opening of escalation areas, staff did not always adhere to the inclusion/exclusion criteria. Incident reports for the endoscopy escalation area indicated patients transferred to this area did not always have their discharge arranged, were not always the same sex, more patients accommodated in the escalation area than agreed in the policy, patients in the area for multiple days, and patients with conditions that were in the exclusion criteria for non in-patient escalation. Incidents for in-patient boarding also identified that staff did not always follow boarding criteria when transferring patients.

Policies were in place for the safe use of oxygen administered from a cylinder, which was mostly adhered to. However, we did see oxygen cylinders that were not properly secured. Not all patients who received oxygen from a cylinder had individual risk assessments completed for this use.

All patients we spoke with during assessment told us they felt safe and comfortable to raise concerns.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had a safeguarding team that staff could access when they had concerns. We reviewed care records and saw evidence of safeguarding concerns being raised by staff with appropriate escalation and action taken to safeguard vulnerable adults.

Staff reported completing safeguarding training and were alerted to updates by email. They told us they could refer and review safeguarding referrals on the trust’s electronic system.

Safeguarding policies and procedures were in place. We saw how the service’s safeguarding process worked in practice on one ward where there were concerns about a patient’s care in the community. This was completed in line with the trust’s process and staff confirmed the safeguarding lead had been made aware of the referral.

Overall safeguarding training compliance for nursing staff was 94%, against a trust target of 90%. Overall safeguarding training compliance for medical staff was 83%, against a Trust target of 90%. Compliance with Safeguarding Training level 3 for medical staff was particularly low at 69%.

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.

Patients reported feeling supported and cared for by both the nursing and medical teams. They also acknowledged that staff were not happy that they were caring for patients in the corridor. Two patients cared for in corridor beds told us their needs were not always being met by being in these beds. One patient in a fit to sit chair in a 4-chair area said they felt very isolated. Patients reported being moved from the corridor into a treatment room overnight because of noisy equipment they were using, or not being able to sleep in the corridor due to the lights and noise.

Policies and procedures were in place for patients cared for in the corridor.

Staff told us who was responsible for flushing little used water outlets each week and the action they took if this was not carried out to help reduce the risk of bacteria build up.

There was variable understanding of ligature risks amongst staff, with one staff member unaware of any ward risk assessments. Another staff member confirmed that patient risk assessments were completed as part of the falls risk assessment. This staff member also confirmed that call bells were not easy release, but staff had been alerted to a ligature incident due to the persistent call bell ringing. However, reliance on this to alert staff was not without risk, particularly in a busy area as it may not ensure staff are able to attend the patient in sufficient time to prevent injury.

The design of the environment in specialist areas, such as endoscopy, followed national guidance.

Staff completed safety checks of specialist and emergency equipment and we saw adult resuscitation equipment was checked daily. Staff also completed safety checklists in specialist areas, such as endoscopy, to ensure that equipment and areas were clean and safe for patients and staff.



Call bells were accessible to patients if they needed support. Patients cared for in the corridors had a portable call bell which alerted staff with a doorbell sound. However, staff did not always respond quickly when call bells were used; we saw a call bell not answered for 6 minutes. We saw occasions where in-patient boarding beds obstructed access for portering staff and a lack of space on wards led to medical staff having private and sensitive conversations with patients in corridors, which could be overheard. There were no storage facilities for in-patient boarding patients to safely store their belongings or own medicines. We saw corridor care was not always in line with policy, for example for patients that were on oxygen and a lack of signage. The area in endoscopy where patients were boarded overnight did not always have same sex bed or toilet areas.

There were 14 ‘fit to sit’ chairs used in the 24-hour stay medical admissions unit, but staff told us at the time of our visit the longest patient stay in a fit to sit chair was 48 hours due to the inability to move to a bed.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

During our previous inspection in 2022, we found that the service had not ensured the National Patient Safety Alerts were actioned specific to airflow meters. During this assessment we found that this had been actioned and no air flow meters were on wards.

During our onsite assessment, we checked 10 pieces of equipment for service dates and found all were in date for testing. We saw staff had identified and clearly labelled faulty equipment and arranged for this to be collected from wards.

We reviewed emergency trolleys for compliance with daily/weekly checks in line with trust policy. We found a good compliance across the wards with accurate records of checks with no gaps in daily check list records for the emergency trolley.

Staff told us they could access trust policies and standard operating procedures online to ensure they were delivering safe care in line with policy and were made aware of updates policies via email and at team meetings.

Most patients we spoke with felt there were enough staff and they received care and support when this was needed. Patients reported, “There is always someone at the nursing station if I need them”, “I sometimes have to wait a while to get help” and “All staff are very caring and sympathetic.”.

Staffing levels did not always meet planned levels in all areas. Staff told us that sometimes there were not enough staff to support at meals times and they were not given extra staff to manage additional boarded patients. We were told patients had to wait until staff were available for meal support and, although understaffing was escalated, routinely there was no replacement or increase in resources or bank staff availability. Staff felt that at times the acuity of patients meant that they could not always meet the demands placed on them in a timely manner. Although, they had volunteers that visited the ward to support patients during their admission.



Staff told us they received training that was relevant to their roles and responsibilities. As well as mandatory training, staff received speciality specific training as well as learning identified through incidents. Staff were rostered according to the competency/training they required which they felt worked well. We saw packs that staff received detailing the training they were required to complete with oversight from managers and practice development nurses. They knew when to complete required training and received reminders from their managers. Staff told us they received appraisals annually and were encouraged to identify additional learning and development.



Both medical and nursing staff from overseas said they were happy and felt supported. They were able to raise concerns with educational supervisors and clinical leads and felt supported in dealing with issues.

During our visit, we saw that nursing staffing numbers were lower than planned in some areas. Managers looked at the acuity in each area and moved staff to where they were most needed to ensure staffing was safe.

The mandatory training programme was in line with Skills for Health’s Core Skills Training Framework (England). Most nursing and medical staff were up to date overall on mandatory training, with 89% completion against a trust target of 90%. However, completion rates for some elements, such as advanced life support, had particularly low completion rates below 66%. Systems were in place to support staff through supervision and annual appraisals. Overall, 87% of nursing staff and 95% of medical staff had received an appraisal within the 12 months to 30 June 2024. A practice development team and specialist nurses were also available for staff support. Staff used a recognised tool to assess patients’ acuity and dependency, where each patient’s care hours were calculated to support the need for additional staff if required. The policy also provided guidance for safe staffing of escalation areas and boarding patients. Monthly and bi-annual analysis of staffing levels, sickness, recruitment and retention, and turnover rates were completed, and compared against ICB and national provider information. When compared to other Trusts within the Integrated Care Service, the trust consistently recorded a lower turnover rate. Overall, the service had enough nursing and medical staff to keep patients safe, although some specific areas did not have a full complement of permanently employed staff. Senior staff were guided by the trust’s recruitment, safer staffing and capacity escalation policies, which ensured additional staff could be sought when there were not enough permanently employed staff available. The service showed consistent use of bank and agency staff, although data provided showed in July 2024, there were an average of 6.5 nursing shifts not covered each day. Vacancy rates for nursing and medical staff were low at 3% and 2%, absence rates for medical staff were also low at 3%, which was below the trust target of 3.5%. Nursing absence was slightly higher than the trust target at 4%.

Most patients we spoke with told us the ward areas were clean. All patients we spoke with told us that they saw staff washing their hands and using aprons and gloves.

There were clear process and systems in place to manage the risk of infection. Staff explained the approach to assessing and managing the risk of known infection, such as Hepatitis B. Clear signage indicating infection was used with machine decontamination protocols in place. Staff told us processes were in place for checking patient lists for known infection and checking recent blood test results. We saw documentation to support the daily checks had taken place.

Staff told us they knew who was responsible for cleaning different areas within the wards and units, and which pieces of equipment. All areas of the service we visited were visibly clean, cleaning staff explained their schedules, which included the areas they were allocated to clean daily. They told us there were cleaning staff present every day and evening and an on-call cleaner was available overnight.

All ward and department areas were visibly clean with suitable furnishings that were clean and well maintained. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.



Staff followed infection prevention and control principles such as, bare below the elbows, and we observed staff don and doff aprons and gloves before and after entering side rooms isolating infectious patients. Hand gel was available for staff and visitors within ward areas. Patients with potentially infectious illnesses were isolated in single rooms which were clearly signposted to staff and other patients.

Quality Balanced Scorecard results with performance relating to infection, prevention and control audits, such as the number of MRSA infections and hand gel compliance were displayed for each ward area for staff, patients and visitors to see. We saw green RAG ratings for performance in the last 3 months indicating good compliance against trust targets. Cleaning scores displayed in ward areas showed most areas consistently performed well for cleanliness. Where there were exceptions, the service implemented a cleaning action plan to address identified concerns.

Data showed hand hygiene audits were completed monthly in most areas, although there were some areas that routinely did not complete this audit. Most areas regularly achieved scores of 100% compliance each month. Where staff had identified issues, these had improved on the following audit. Infection, prevention and control audits similarly identified where there were issues, although not all audits recorded specific information or any immediate actions that had been taken to improve.

Leaders monitored the rates of hospital-based infections, such as common transmissible bacteria, such as E Coli, MRSA or Clostridium Difficile. Audits and monitoring systems showed there had been an overall improvement in actions, such as hand hygiene and dress code, to reduce the risk of cross infection. Actions, such as MRSA suppression therapy and monitoring of catheters and intravenous cannulas meant low or no hospital acquired infections in the 3 months before our visit. However, incidents of other infections, such as clostridium difficile, remained above the trust target.

The trust had a policy to guide staff in the management of infectious respiratory infections. There were clear instructions for cohorting patients and when this should be considered, which did not include patients that did not have the same infectious agent.

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