The Dudley Group NHS Foundation Trust operates acute hospital services from three hospital sites:

• Russells Hall Hospital

• Corbett Outpatient Centre

• Guest Outpatient Centre.

In addition, the trust provides community services in a range of community facilities.

Core services provided at Russells Hall include urgent care, medical care, surgery, children and young people, maternity, outpatients, diagnostics, end of life and critical care. The trust has approximately 669 inpatient beds, 31 escalation beds and 152-day case beds. The trust employs around 4,147 whole time equivalent staff (WTE). These included 482 medical staff, 1,225 nursing staff and 2,440 other staff.

The emergency department (ED) includes a paediatric ED and both provide care for the population of Dudley, Stourbridge and the surrounding towns and villages, 24 hours a day, seven days a week.

Our inspection of the trust covered only the Emergency and Urgent Care core service of Russells Hall hospital.

In January and February 2018, we took enforcement action against this provider under Section 31 of the Health and Social Care Act 2008 by imposing urgent conditions upon their registration. We are continuing to monitor progress against these. We took this action as we believed people will or may be exposed to the risk of harm if we do not do so. After this inspection in June 2018 we took further enforcement action by varying the conditions upon their registration.

We carried out an out of hours, unannounced, focussed inspection on the morning of 28 June 2018 starting before 6am. We specifically looked at the safe and well-led aspects of our key lines of enquiry within the emergency department at Russells Hall. We further focussed on the areas of assessing and responding to patient risk, nurse staffing, medical staffing, leadership, governance and risk management. This was based on our findings of previous inspections and to monitor compliance of the conditions that we had previously imposed on the trust’s registration.

Our Key findings were:

• Patients presenting to the emergency department did not always receive a robust assessment of their clinical presentation and condition during the triage process.

• We found the waiting time for triage assessment to routinely exceed one hour for patients who presented by other modes aside from ambulance presentations. This was particularly evident in the category of adult majors.

• We found that staff were unclear on what the triage categories meant for patients who were in the ambulance assessment areas.

• There was a lack of accountability for the safety of patients pre and post triage who were located within the waiting room.

• Staff were unable to describe what ‘fit to sit’ meant or any criteria for this assessment.

• The electronic tracking system did not allow for patients to be easily located within the department.

• We remained concerned about how quickly and appropriately staff were responding to patients with serious and deteriorating conditions.

• Some patients with suspected sepsis were not identified or managed appropriately.

• There was a disconnect between leader’s impression of key areas such as sepsis management in the department and what was happening in practice.

• Doctors appeared frustrated at the focus on sepsis and did not fully engage with the need to assess for sepsis.

• Local audits being completed for sepsis patients were providing false assurance on the management of this condition within the department.

• There was no clear accountability of which team was responsible for the patient once they had been referred to a medical speciality.

• Staff were not always using clinical judgement alongside NEWS scoring criteria.

• Care records were not always written and managed in a way that kept patients safe.

• Some staff raised concerns regarding incidences of poor leadership style from some of the executive team. They told us that this had led to a poor culture and working environment where some staff told us that they felt fearful and disempowered.

• There were no clear criteria for patients that could be put into the fit to sit areas of the department.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust MUST:

• The trust MUST ensure that all systems and processes in place to identify and manage patients with deterioration effectively are followed.

• The trust MUST ensure that staff record an accurate, complete and contemporaneous record of the care provided to patients.

• The trust MUST ensure there is sufficient numbers of staff, who are suitably trained and competent, to care for the number and acuity of patients.

• The trust MUST ensure that deaths in the service are reviewed robustly and where appropriate lessons from these are learned and shared.

Following the inspection, we told the provider that it must take some action to comply with the regulations and that it should make other improvements, even where a regulation had not been breached, to help the service improve.

We imposed a number of urgent conditions to safeguard patient’s safety immediately following the inspection. These conditions related to the management of patients at risk of deterioration and the arrangements for assessing and triaging patients.

Ted Baker

Chief Inspector of Hospitals

The trust runs services at Russells Hall Hospital, Corbett Hospital and the Guest Hospital.

Russells Hall Hospital provides urgent care, medical care, surgery, children and young people services, maternity services, outpatients, diagnostics, end of life and critical care services.

Outpatient services are also provided at the Corbett and Guest hospitals. Corbett hospital provides day case treatment alongside a range of outpatient services which include radiology, pharmacy, gynaecology, physiotherapy, rehabilitation and a wheelchair supply and maintenance service. Guest hospital is a satellite hospital which offers additional outpatient facilities.

The Trust also provides community services for adults (including sexual health) and End of Life Care. There are no community services for inpatients or children and young people. The community services provide clinical care to patients who are acutely, chronically or terminally ill in their own homes or from GP practices or health centres. The services are multidisciplinary and include nursing staff and allied health professionals. The Dudley Group was the first trust in the area to be awarded Foundation Trust status in 2008.

In January and February 2018, we took enforcement action against this provider under Section 31 of the Health and Social Care Act 2008 by imposing urgent conditions upon their registration. We are continuing to monitor progress against these. We took this action as we believe a person will or may be exposed to the risk of harm if we do not do so.

Our inspection of the trust covered only this hospital and only Emergency Department, IMAA and Medical ward A2 based at Russells Hall hospital.

We carried out an out of hours, unannounced, focussed inspection. We specifically looked at the safety aspects of our key lines of enquiry domain on the evening of 15 March 2018 at Russells Hall Hospital. This was based on information of concern we received relating to the management of patient flow and notice of concern relating to a death at the hospital.

We attended the emergency department (ED), the Immediate Medical Assessment Area (IMAA) and the A2 ward (a short stay ward).

Our key findings were as follows:

• Clinical observations were not undertaken in a consistent manner. We saw two patients whose clinical deterioration had gone unnoticed by staff, this had to be alerted to staff by the inspection team who then acted on this immediately.

• The medical and nursing cover across all areas was not sufficient to meet the needs of the patients.

• Agency or bank staff predominantly staffed each area we inspected. These were staff who may not fully understand the hospital processes and systems to keep patients safe.The staff we spoke with could not always locate clinical presentation information or history of the patients that could result in poor quality and unsafe care and treatment.

• We spoke with staff on A2 ward and the IMAA who described the teams as stressed and not coping as a result of the high number of agency staff. Staff also told us that the environment was unsafe and that they were concerned about the safety of patients.

• Patients admitted to these wards could stay for extended periods and we saw that on some occasions their specific health and dignity need were not met because of this. Some patients told us that they were uncomfortable staying in these areas for longer periods due to the design of the areas and the number of temporary staff who worked in the areas.

• Patients were not wearing allergy wristbands, allergies were not easily identified unless records were consulted or reviewed.

• Staff documented oxygen saturation (SpO2) scores in National Early Warning Scores (NEWS) and recording of patients’ vital signs in majors had improved since the December 2017 and January 2018 inspection.

• Staff on the emergency department demonstrated a good understanding of the triage system and felt they had enough support and information on the triage process and system through-out our inspection.

Professor Ted Baker

Chief Inspector of Hospitals

Our inspection of the trust covered only this hospital and community services. What we found is summarised within the overall summary.

A pharmacist inspector inspected the hospital following some information of concern that we received around the management of medicines. We looked at the medicine management systems on the Emergency Admission Unit (EAU) and ward C8. We also visited the pharmacy department.

We found that arrangements were in place to ensure that medicines were managed safely.

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.

We planned this review to check that improvements had been made following our visit to the trust in February 2011. We had also been told about concerns with an increase in the number of people who had Clostridium difficile. This is an infection which may cause people to experience diarrhoea.

There has been a delay in producing this report as we were waiting for additional information from the trust on infection control. The trust have worked with us and have kept us informed of developments and changes.

We spoke with 44 people who were using the service or their relatives. We spoke with 22 members of staff of various roles and grades. We visited the accident and emergency department, the emergency assessment unit, the isolation ward and the trauma and orthopaedic ward.

People told us that staff had told them what was happening, so they were fully aware of what investigations or treatments they were waiting for and what their treatment would be. Information was available for people to read if they chose to.

People told us that they were happy with the care that they had received at the hospital. They said “I could not have been treated any better anywhere, its all first class” and “I have been treated above and beyond the call of duty”.

We saw that a number of improvements had been made to the diet and fluids that people received. People told us that they were given choices about meals and drinks so that they received things they liked. Some people told us they would like more variety.

The environment was clean and people we spoke to confirmed that this was what they had experienced when they used the services available.

We saw that new mattresses had been purchased in the emergency assessment areas and one person told us “It is really comfortable”.

People told us that they knew how to make a complaint if they needed to; however people we spoke to told us that they did not have any complaints. One person said “If I wanted to complain I would go to the chief executive, but I have no complaints here”.

During our visit on 25 January 2011, we spoke to people receiving a service at Russells Hall Hospital. People were mostly positive about their experiences of care and treatment. They told us that they felt they were treated with dignity and respect. The majority of people we spoke to told us that staff explained things to them and that they were kept informed and were involved in decisions. Some people in the accident and emergency department said that they had not been told what was happening and this could be improved. People told us that consent had been sought and different care and treatment options had been explained to them. People told us that the staff were caring and friendly and that the hospital was clean and tidy.

People told us:

“I’ve not been told what is happening but it’s really busy”

“I’ve been in and out a lot recently, can’t fault them”

“Treatment very good here”

“Staff very friendly”

“Staff are always washing their hands”

“My care was discussed and information was clear”

“The most positive thing is that I know that when there are hiccups they will be sorted out and I will be listened to”

The Trust also asks patients for their views and experiences of care on a regular basis, and we looked at the analysis of these surveys. Between October and December 2010, 507 surveys had been completed. One of the questions was about peoples experience of the service, 382 said ‘great’, 108 people said ‘satisfactory’ and 13 people commented ‘poor’.

The Dudley Group NHS Foundation Trust operates acute hospital services from three hospital sites:

• Russells Hall Hospital

• Corbett Outpatient Centre

• Guest Outpatient Centre.

In addition, the trust provides community services in a range of community facilities.

Core services provided at Russells Hall include urgent care, medical care, surgery, children and young people, maternity, outpatients, diagnostics, end of life and critical care. The trust has approximately 669 inpatient beds, 31 escalation beds and 152-day case beds. The trust employs around 4,147 whole time equivalent staff (WTE). These included 482 medical staff, 1,225 nursing staff and 2,440 other staff.

The emergency department (ED) includes a paediatric ED and both provide care for the population of Dudley, Stourbridge and the surrounding towns and villages, 24 hours a day, seven days a week.

Our inspection of the trust covered only the Emergency and Urgent Care core service of Russells Hall hospital.

We carried out an unannounced, focussed inspection starting on the morning of 08 August 2018 starting before 6am. We specifically looked at the safe aspects of our key lines of enquiry within the emergency department at Russells Hall. We further focussed on the areas of assessing and responding to patient risk, nurse staffing, medical staffing, leadership, governance and risk management. This was based on our findings of previous inspections and to monitor compliance of the conditions that we had previously imposed on the trust’s registration.

Our Key findings were:

• Patients presenting to the emergency department still did not always receive a robust assessment of their clinical presentation and condition during the triage process.

• There was still a lack of accountability for the safety of patients pre and post triage who were located within the waiting room.

• Staff were still unable to describe what ‘fit to sit’ meant or any criteria for this assessment and patients were left unattended in this area.

• The electronic tracking system did now allow for patients to be assigned correctly within the department but staff did not monitor this effectively.

• We remained concerned about how quickly and appropriately staff were responding to patients with serious and deteriorating conditions.

• Some patients with suspected sepsis were still not being identified or managed appropriately.

• Staff continued to be frustrated at the focus on sepsis and did not fully engage with the need to assess for sepsis.

• Staff were still not always using clinical judgement alongside NEWS scoring criteria.

• Care records were still not always written and managed in a way that kept patients safe.

• There was insufficient senior medical and specialist oversight and in reach to the department. This affected the safety and management of patients.

However

• Some staff could recognise signs of sepsis and deterioration and acted on this appropriately.

• The ambulance triage area was functioning more effectively with clear and appropriate medical input and leadership.

• Some improvement in patient flow through the ambulance triage assessment area were seen.

• AEC was well run and escalated patients that they couldn’t manage.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust MUST:

• The trust MUST ensure that all systems and processes in place to identify and manage patients with deterioration effectively are followed.

• The trust MUST ensure that staff record an accurate, complete and contemporaneous record of the care provided to patients.

• The trust MUST ensure all service users are safeguarded and protected from abuse and improper treatment.

• The trust MUST ensure that specialist clinical expertise is secured to ensure expertise across the emergency department. The clinicians should provide the oversight of care provision, ensuring all patients receive care from senior clinicians that is safe, effective, timely and in line with best practice.

Following the inspection, we told the provider that it must take some action to comply with the regulations and that it should make other improvements, even where a regulation had not been breached, to help the service improve.

Following this inspection, we imposed an urgent condition to safeguard patient’s safety immediately following the inspection. This condition related to the provision of specialist medical in reach and support into the emergency department.

Ted Baker

Chief Inspector of Hospitals