The Norfolk and Norwich University Hospital is an established 1237 bedded NHS Foundation Trust which provides acute hospital care for a tertiary catchment area of up to 1,016,000 people. The trust provides a full range of acute clinical services and operates from a large purpose built site on the edge of Norwich and from a smaller satellite at Cromer in North Norfolk. The emergency department at the Norfolk and Norwich University Hospital is a type one major injuries unit, which had 133,073 attendances between July 2017 and June 2018.

We last inspected the urgent and emergency service in October 2017. The service was rated inadequate overall; safe and well-led were rated inadequate, effective and responsive were rated requires improvement, and caring was rated good. During the 2017 inspection, we identified significant concerns regarding staff understanding and application of the Mental Capacity Act (2005), the systems and processes for preventing and controlling the spread of infections, the healthcare records of service users, and the emergency department premises. Concerns regarding the premises included the layout and size of the department, the size of the children’s emergency department and the lack of safe environments for those living with mental health concerns. As a result, we issued a Section 29A warning notice to the trust in October 2017. The warning notice informed the trust that significant improvements were required by 1 January 2018, and we requested an action plan from the trust, outlining steps that had been taken to address the concerns raised in the warning notice.

We carried out a focussed inspection on 6 November 2018 to follow up on the concerns raised in the Section 29A warning notice.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We carried out a focused inspection which did not include all key lines of enquiry (KLOEs). We did not rate the service as a result of this inspection.

During this inspection we visited the emergency department (ED), children’s ED, older people’s emergency department (OPED), clinical decisions unit (CDU) and the urgent care centre (UCC). During the inspection visit, the inspection team spoke to 24 members of staff, including nurses, doctors, support workers and senior managers. We reviewed 10 paper healthcare records and seven electronic healthcare records.

Before and after the inspection visit, we reviewed information that we held about these services and information requested from the trust.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We found the following issues that the service provider needs to improve:

• Patients at high risk of deliberate self-harm continued to be cared for in the CDU, which remained an unsafe and inappropriate environment for these patients.
• Risk assessments for patients with mental health concerns had not always been completed appropriately. Mental capacity assessments had not always been completed when required, despite concerns raised at the time of our last inspection.

• We were not assured that staff understanding of isolation procedures was consistent or that implementation and monitoring of compliance was fully effective. Results from cannula insertion, commode and bed pan audits showed mixed compliance.
• There was a lack of evidence that progress against concerns raised at our last inspection were being regularly monitored at a local level. There was a lack of progress in developing and implementing effective governance systems within the department.
• The level of scrutiny and oversight that the mental health board was providing could be improved.
• Information was not always collected, analysed, managed and used well to support all the service’s activities.
• The emergency department strategy had not been reviewed or developed since our inspection in 2017.

However, we also found the following areas where improvement had been made:

• Environmental changes had positively impacted on infection prevention and control. We observed staff using personal protective equipment appropriately and adhering to bare below the elbows standards. Area specific cleaning records had been implemented.
• The emergency department premises had been re-configured to increase the number of patients that could be accommodated at any one time. The service had increased the environments which were safe, and secure where necessary, for those living with mental health concerns.
• There had been a reduction in the number of areas that were inappropriately being used as an extension to the majors area due to a lack of capacity. Whilst patients were still being cared for in the corridor at times of peak pressure, the trust had improved their processes to ensure that all patients were clinically assessed before a decision was made about whether their condition was appropriate for them to be cared for in the corridor.
• Staff had become more aware of the need to carry out a risk assessment to review whether patients could pose a risk of harm to themselves or others. Staff understanding of the Mental Capacity Act (MCA) and compliance rates for MCA and Deprivation of Liberty Safeguards (DoLS) training had significantly improved.
• Significant progress had been made in the development of the urgent and emergency service and senior staff were able to describe plans to further develop the service.
• The establishment of the mental health board had improved the focus on mental health care within the organisation.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected urgent and emergency services. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

• Diagnostic imaging staff were not always trained to the appropriate level for safeguarding children and there was low compliance in some areas of mandatory training.
• Equipment was ageing and there was no capital replacement programme in place. Specialised personal protective equipment was not always being checked on a regular basis. Resuscitation trolleys were not always being checked on a regular basis.
• Security and access to controlled areas was not consistent.
• Contrast media was not stored appropriately, in a temperature monitored and secure area, within the diagnostic imaging service areas.
• The emergency call bell system within nuclear medicine had not been fit for purpose since 2015.
• The diagnostic imaging service was not always meeting NHS England Seven Day Services Clinical Standards.

• Recommended changes to practice as a result of audit findings did not always identify the individual responsible for implementing changes or the date by which the change should have been implemented.
• Written consent for radiological procedures was not consistently undertaken in line with the trust’s standard operating procedure.
• The diagnostic imaging environment did not always afford patients with privacy and dignity.
• Friends and Family Test scores were below the national average, and there were low response rates.
• Reporting times were not meeting targets in the majority of diagnostic imaging areas.
• Managers had not identified or put in place actions to address a number of the concerns that were identified during our inspection and action had not been taken to address some of the concerns identified at our previous inspection. Risks were not always resolved or acted upon in a timely manner and the risk register did not reflect all of the risks identified during this inspection.

However:

• There had been improvements in staff understanding of the incident process and training provided for those undertaking incident investigation and root cause analysis..
• Progress had been made in the recruitment of new staff to address previously high vacancy levels.
• Appraisal rates were in line with trust targets and the service offered staff the opportunity for development and progression in their roles.
• The service was regularly reviewing the effectiveness of care and treatment through a comprehensive range of audits.
• Staff cared for patients with compassion, involved patients in decisions and provided emotional support to minimise distress. Feedback from patients confirmed that staff treated them well and with kindness.
• The service took account of patients’ individual needs and offered out of hours, walk-in and one stop services to provide flexibility and choice. The service gathered the views of patients to ensure that services were being provided in a way that met their needs.
• Staff said that they felt proud to work in the organisation and described supportive relationships with colleagues. Staff said that their managers were approachable and supportive. None of the staff spoken to on this inspection raised concerns about bullying or harassment.

During this inspection visit we spoke with 14 people who were able to answer our questions on the care, treatment and support provided to them during there stay in hospital. We looked at care plans that showed us individual records of consent to treatment signed by the person and care plans that were personalised for the individuals. These records included assessed potential risks and the action required to minimise those risks.

Those people we spoke with who used the service and visitors said they were very impressed with the cleanliness and hygiene standards they had witnessed. People said staff always cleaned their hands before and after they attended to anyone.

The areas we saw had been cleaned regularly, and a cleaning schedule was available at the entrance to the ward which demonstrated to visitors the frequency and type of cleaning.

We were told staff were quick to answer call bells so that people were attended to when required. The only time there may be a delay was when an emergency arose.

People who were attending the hospital through the accident and emergency department (A&E) and were kept waiting were supported by staff who regularly attended and assessed those waiting, ensuring people with high level needs were prioritised.

During mealtimes, staff were allocated to serving and assisting with meals. This ensured that there were sufficient staff to provide people who required assistance with a relaxed and comfortable mealtime.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

During this visit we only spoke with people admitted to the wards about their care plan records and how they were involved in completing their records.

The people we spoke with told us they had been asked about the amount of food and drink they had consumed and that staff had explained to them why it was important to keep accurate records of what they had consumed.

We did not ask direct questions about other records during this visit.

During our visit on 07 October 2011 people told us that staff were good at promoting their privacy and dignity. They told us that they had been kept well informed about their health and had been involved in any decisions made about their treatment. They told us that they had been given good information about what will happen when they leave hospital.

We were told by people on the maternity ward that they could not fault the support the hospital had given them during their stay. They told us that they knew exactly what was happening, why it was happening and what the plans were for their stay and then their discharge home. They said “I feel fully involved and not at all awkward when asking questions.”

People on one ward with whom we spoke told us that staff were very good and responded to their needs well. They said that “staff can’t do enough for you”. They also told us that staff were very busy and they had to sometimes wait for up to ten minutes for a response to a call bell. Yet another person accommodated in a side room told us “I can ring the bell at anytime and get the help I need. I never have to wait long.”

People we spoke with after the lunch meal had been served told us “The food is alright most of the time but sometimes it is not very good” and “The food is pretty fair, we get a choice from the menu and it is hot.” People told us that they got enough to eat and one person stated “When my food got cold because I was called away for a treatment my meal was replaced with a hot meal.” On the maternity ward we were told how pleasantly surprised people were by the quality and choice of the food provided which was hot and tasty.

We were told that although staff were very busy they were very caring. One person told us, from their own observations, how staff spent time with people who were very poorly and could not communicate. She said that staff would spend time sitting with people, perhaps stroking their hand or cheek to offer reassurance and try to connect with them.

New mothers on the maternity ward had nothing but praise for the staff. They gave us good examples of how staff had spent time guiding and explaining how to care for their baby. We were told, “I was anxious but am now reassured.” One mother said that she had been offered an extended stay to ensure she was confident in managing breast feeding before she was discharged.

People staying in the hospital told us that they were asked if they were satisfied with the nursing care and support they received. They also said “I have been given a questionnaire to fill in mostly about the food but also about the care I have received.”

The people with whom we spoke told us that they were listened to and were given the opportunity to express their views about their care, support and treatment. Some people were complimentary about the medical staff, they said that staff were always kind and made comments such as ‘I am very happy with the care I am given’ and ‘I have no complaints at all’. One person told us that staff called them by their first name, which they preferred and that they had been fully informed of any care, treatment or action that was to take place.

When we asked people using the service about the food they were provided with during their stay they told us that there was a choice of food and that the meals were served hot. One person told us ‘I am so well known by the ward staff that all my meal requirements are met without question.’ and ‘The mealtimes are pleasant and there is plenty of choice’. However, we were also told by one person they required a soft diet but were given hard carrots. Two other people said that ‘too much mince is used’ and ‘not enough fish offered’.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

• Records were not always stored securely and medicines were not always stored appropriately in outpatient areas, which were both raised at our previous inspection.
• Data on waiting times was not formally recorded and therefore efficiency and areas for improvement could not be monitored and identified. This was raised at our previous inspection.
• People could not always access the service when they needed it. Waiting times from referral to treatment were not in line with national guidance.
• Clinics continued to run behind time. We observed, and patients told us, that clinics frequently ran late, however the trust did not monitor clinic waiting times formally to enable oversight and improvement.
• An average of 18.8% of clinics were cancelled at short notice (under six weeks).
• The service was not always managing information effectively. Staffing related information held by the trust, such as training, appraisals and vacancy numbers, did not always clearly identify compliance for outpatient medical staff. Therefore, we were not assured there was sufficient oversight of medical staffing of the service.

However:

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
• There was an appropriate process for responding to risk for patients that were waiting for appointments.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion, involved them in decisions about their care and treatment and provided them with emotional support to minimise their distress.
• Outpatient specialties offered some out-of-hours appointments, one-stop clinics, community based appointments, and telephone appointments, which provided patients with flexibility and choice.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service engaged well with patients and staff to plan and manage appropriate services.