We carried out this inspection in response to information received raising concerns about staffing levels on ward D57, an emergency assessment ward at the Queen’s Medical Centre.

We had previously inspected ward D57 on 19 July 2013 and found that there were not always enough qualified, skilled and experienced staff to meet people’s needs. We set a compliance action and the trust provided us with an action plan setting out the actions they would take in response to our report. Most actions had been timetabled to have been completed at the time of our most recent inspection but not all.

We spoke with four patients who were on the ward during our inspection and asked about staffing levels on the ward. We were told by one patient, “It’s been fine, I think there are plenty of staff.” Another patient said, “The staff have been very caring and come to help when I’ve needed it.” A further patient said, “They’ve been good on this ward, kept my water topped up and kept checking I am alright.”

We spoke with four relatives of patients who were present during our inspection. One person said, “We have been seen to pretty quickly on this ward, I am quite happy with the staffing levels.” Another person said, “There seem to be plenty of staff around, they’ve been to talk with my relative and let us know what’s happening.”

We spoke with eight members of staff who gave us mixed information about the staffing levels on the ward.

We found there were enough qualified, skilled and experienced staff to meet people’s needs on ward D57. We also found that the trust was taking action to address the concerns being raised by staff on this ward.

We visited two wards during the inspection. We looked at staffing levels on ward D57 and consent processes on ward F22. We spoke with 14 patients, one relative and nine staff. We looked at five patient records.

Patients told us that they were asked for their consent before they received any care or treatment. All patients told us they signed a consent form. Three of the four patients told us they had not received a copy of the consent form. A patient said, “Yes, they sit and talk to me, they make sure I understand what is happening. They tell you properly and ask me if I have any questions. Yes, I have had to sign a few consent forms. They go through it on this ward, tell me any complications and ask if I have any questions then I sign it. I don’t get a copy.”

Nine of the ten patients we asked told us they felt there was enough staff to meet their needs. A patient said, “They have time to care.” Another patient said, “There are enough staff and they have been respectful and caring. The staff are spread evenly.” The patient who did not feel their needs were met said, “I think there are enough staff but they need to be better organised.”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. However, we also found that there were not always enough qualified, skilled and experienced staff to meet people’s needs on ward D57.

Most patients told us that they understood the care and treatment choices available to them. One patient said, "I’ve been given literature about my condition and treatment each step of the way to help me take it all in and help me reflect, I know I’m in the driving seat." However, one patient told us that they had not been given enough information to enable them to make an informed choice about treatment.

Patients told us that they could express their views and were involved in making decisions about their care and treatment. One patient said, "I’m in control, they give me the information I need and I make my own decisions." Patients told us their privacy and dignity was respected.

Patients told us that they were able to give consent to the care and treatment that they received. They also told us that they understood and knew how to change any decisions about care and treatment that had been previously agreed.

One patient told us they were very satisfied with the way their individual care needs had been assessed and managed. Another patient said, "I’ve had ultrasounds and x-rays, and other procedures in other departments and they’ve all been brilliant." Some patients had experienced delay in the implementation of their assessment and treatment plans. Two patients expressed their frustration that they had not been told about delays to their planned procedures. Neither patient had been told to anticipate delays nor were they given an explanation of the reason for the delay and what was being done to address the problems.

One patient told us that the food was fine but said, "Then again, I’d eat anything, it’s not always that hot but I don’t mind that." One patient said, "[The food was] absolutely diabolical, even the sandwiches are old, pre-packed, dry and awful." Another patient said, "The food is very poor, lukewarm at best."

One patient thought the liaison between services was, "excellent." Another patient told us that there had been very good communication between departments and that information had been shared with them so that they knew what was happening and planned for them. However, three patients we spoke with in the discharge lounge had experienced significant delays waiting for their prescriptions to be filled by the hospital pharmacy and for transport to take them home.

Patients told us that they felt safe and they knew who to speak to if they had any concerns. Patients told us that they were happy with the premises.

Patients told us that their needs were met by competent staff. They also told us that staff were well trained and worked hard. Most patients knew where their records were kept and were happy they were available for staff to use but kept secure enough so as to be safe and confidential.

Our rating of services went down. We rated it them as requires improvement because:

• Not all services had enough medical and nursing to keep people protected from avoidable harm and to provide the right care and treatment.
• Not all services controlled infection risk well. Staff did not always keep equipment and the premises clean.
• We were not assured of appropriate safety processes at service level for laser equipment in eye casualty. There were discrepancies between the services the trust believed were offered in the laser service and the services offered in practice. The most recent annual laser protection audit identified areas in need of significant improvement
• Arrangements to admit, treat and discharge patients were not in line with national standards.
• The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From October 2017 to September 2018 the trust failed to meet the standard and performed worse than the England average.
• The Royal College of Emergency Medicine (RCEM) recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. From September 2017 to August 2018, the trust did not meet the standard for 11 months over the 12-month period.
• In children’s services, outpatient appointments did not always run on time. Children and their families were not informed about delays in outpatients and the service did not monitor or analyse delays to outpatients. The outpatient environment could become very crowded for certain clinics
• Lack of out of hours access to paediatric interventional radiology meant that some babies needed to be transferred to other hospitals.
• In maternity, although the trust had made improvements to the leadership and governance structures, the changes had not yet been fully embedded and there was still a lack of oversight and assurance in some areas.
• In maternity there was not a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

• Staff understood how to protect patients from abuse and the services worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service provided care and treatment based on national guidance and monitored patient outcome to monitor for the effectiveness.
• Staff worked together as a team to benefit patients.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people.
• The services took account of patients’ individual needs.
• Most of the services had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff patients, and key groups representing the local community.
• The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.