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Emergency department staff at Midlands trust under 'regular and consistent heavy pressure'

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A troubled trust in the Midlands has been given yet another official warning for failing to address ongoing safety issues, including patients routinely being cared for in corridors.

Troubled Worcestershire Acute Hospitals NHS Trust is in special measures and rated “inadequate” overall by the Care Quality Commission.

“I remain concerned that the trust has not taken sufficient action to address the requirements of our previous inspections”

Ted Baker

It has now been told by the CQC to make further urgent improvements after an unannounced inspection in April to check on previously raised concerns. Inspectors issued a warning notice after finding “no tangible difference in performance” since the last inspection in late 2016.

They visited Worcestershire Royal Hospital, Alexandra Hospital in Redditch, and Kidderminster Hospital and Treatment Centre and looked at areas of previous concern in accident and emergency, and other departments.

As revealed in Nursing Times last month, one of the key issues identified by inspectors was the fact adult patients were regularly cared for in A&E corridors at both the Worcestershire Royal and Alexandra hospitals and were often there “for a long time” before being admitted or discharged.

Patients who had arrived at the Worcestershire Royal by ambulance and had been assessed by senior nursing staff were placed in queue alongside the nurses’ desk when they needed to wait for a cubicle in the majors area, said the CQC in its latest report.

“We saw this consistently over two days of our visit at Worcestershire Royal Hospital and heard staff speak about it as part of a natural process within the department,” said the report.

“This meant routine nursing observations, conversations about care and eating of meals were undertaken in a public space with other patients and relatives passing by to the X ray area,” it said.

“The trust’s new chief nurse had met with ED staff and displayed commitment to addressing immediate as well as medium term problems”

CQC report

When the emergency department at the Alexandra was very busy, patients arriving by ambulance “often had to wait on trolleys in the corridor”.

“Staff told us that this happened several times a week and trust data showed it had happened over several hours on seven different days during March 2017,” said the report.

Trolleys in the emergency department corridors at both hospitals “had no space between them” and there was no room to use screen to maintain patients’ privacy, said the CQC report, adding that “confidential conversations relating to patients clinical care could be overheard”.

“Doctors described having to take blood and taking clinical histories while patients were in the corridor,” noted the report.

Meanwhile, there were ongoing issues with staffing levels. Inspectors found there were not always enough nurses in the major treatment area or resuscitation room in the emergency department at the Alexandra.

At night, there was no nurse allocated to look after patients in the corridor and so the nurse in charge was the only person available to do this.

Ted Baker

edward ted baker

Ted Baker

On the night that inspectors visited, there were up to six patients in the corridor between midnight and 8am.

“This meant that the nurse in charge of the department was trying to look after six patients in the corridor, assess new patients arriving by ambulance, and run the department as a whole,” said the report.

Nurse staffing levels in surgery at the Worcestershire Royal and Alexandra seemed to have got worse since the previous inspection visit, with large numbers of unfilled shifts. However, staff reported there were adequate numbers to meet patients’ needs.

Other issues found included that children and parents were often left alone in the children’s area of A&E at the Worcestershire Royal, while they waited to see a doctor – with the only monitoring done via CCTV at the nurses’ and doctors’ station in the majors area.

Inspectors also identified a lack of safeguarding training among doctors and nurses in the emergency department at the Alexandra.

They did find some improvements since the trust’s last warning notice, including the fact most patients were assessed by a senior nurse within 15 minutes of arriving at the emergency department.

Meanwhile, new measures to try and identify and act on pressures in A&E had been introduced. These included an electronic patient safety matrix and occupancy tool to give real-time information, plus a “full capacity protocol” to be activated when the department was “overwhelmed” or capacity was at critical levels.

Worcestershire Acute Hospitals NHS Trust

Nursing staff at troubled trust under ‘consistent heavy pressure’

Vicky Morris

Inspectors said staff “felt supported to report incidents, including occasions when they judged patients unsafe because the emergency department was ‘overwhelmed’.”

However, they found “minimal reporting” of patient safety incidents relating to patients waiting on trolleys in corridors when the emergency department at Alexandra Hospital was over capacity. And “very little response from the hospital as a whole” when the safety measures showed the department was “overwhelmed”.

During the unannounced inspection in December 2016, inspectors raised concerns about untrained staff being left alone to care for patients in the discharge lounge at Alexandra Hospital. But “appropriate staffing levels” were now in place.

A similar issue at Worcestershire Royal – where one healthcare assistant was left caring for eight patients in the clinical decision unit while the registered nurse went on a break – had also been resolved with all breaks now covered by another nurse.

Inspectors were positive about the role played by senior nurses including emergency department matrons and the trust’s new chief nurse Vicky Morris.

“The trust’s new chief nurse had met with ED staff and displayed commitment to addressing immediate as well as medium term problems,” said the CQC report.

Inspectors also noted the fact “staff were very committed to their work and doing the best they could for their patients even under regular and consistent heavy pressure”.

“We are determined to move forward with pace and focus”

Michelle McKay

The CQC’s warning notice identified nine areas that require urgent improvement including management of bed capacity and patient flow, safeguarding, assessing and responding to patient risks, infection prevention and control and learning from incidents.

Professor Ted Baker, the CQC’s chief inspector of hospitals, said the regulator was concerned by the lack of progress given the heightened scrutiny the trust has been under.

“Over the last two years Worcestershire Acute Hospitals NHS Trust has been subject to rigorous and frequent regulatory action,” he said. “I remain concerned that the trust has not taken sufficient action to address the requirements of our previous inspections.”

Trust chief executive Michelle McKay said managers were “disappointed with, but fully accepted” the CQC’s findings including the fact the organisation had not made all the necessary improvements in the timeframe set by the regulator.

Worcestershire Acute Hospitals NHS Trust

Nursing staff at troubled trust under ‘consistent heavy pressure’

Michelle McKay

“I am sorry the trust did not make all the necessary improvements in that period and have continued to let down our patients, their families and carers by not meeting the quality standards they rightly expect,” she said. “We want all our patients to get the best care possible and regret that this isn’t always happening but we’re determined to put things right.”

She said the trust had continued to make improvements since the latest inspection in April, including introducing “safety huddles” to address safety issues.

The trust’s rating for infection control had moved from red to amber and a new system of clinical audits by matrons ensured risks were being monitored and swift action was taken when a patient’s condition deteriorated.

Meanwhile, plans to expand ambulatory emergency care and the medical assessment unit at Worcestershire Royal and buy extra monitoring and diagnostic equipment – all of which should be in place by the winter – should help lift pressure on the hospital’s A&E.

“We are determined to move forward with pace and focus so we can deliver high quality standards for patients across all our services all of the time,” said Ms McKay. “Whilst we have improvements to make we are working hard to urgently address them.”

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