We inspected the emergency department as an unannounced responsive inspection on 7 March 2018 in response to concerns regarding patient safety and how responsive the department were to people’s needs. We had previously inspected the urgent and emergency care service in November 2017, when we rated the service overall as requires improvement and inadequate in terms of patient safety. At this inspection we looked at specific areas of concern including: patient safety, medicines, staffing levels, the environment, infection prevention and control, record keeping, mandatory training of staff, how services were planned, whether services met patients’ individual needs and how the flow of patient through the department was managed. We wanted to make sure patients were receiving safe care that was responsive to their needs.

We did not re-rate urgent and emergency care at the time of this inspection. We found the following areas for improvement:

• We had concerns about the safety of patients in the department. This was for a number of reasons. The department did not have enough capacity to accommodate all the patients requiring treatment.

• Patients waited a long time to receive medicines such as pain relief. Handover, initial assessment and responsibility for patients was not happening in a timely manner. Ambulance staff were waiting with patients for excessively long times in the department.

• Records were not completed in a comprehensive way and risk assessments were not documented as being carried out.

• Infection prevention and control practices were not following national guidance: staff were not always washing their hands, using gloves appropriately or arms bare below the elbow. The department was not always as clean as it should be with dirty rooms and smears of bodily fluids on walls.

• There were insufficient staff deployed to the department and from the evidence we looked at, this had been a long-term issue.

• Staff were not up to date with their mandatory training.

• We had concerns about the responsiveness of the department. It was not able to meet the demand from the number of patients attending. The department had severe problems with capacity.

• The hospital was also full to capacity and as a result, emergency department patients were waiting for long periods of time in corridors before being admitted to wards. There was poor flow through the department on to wards and from wards to home. From what we saw and what staff told us, the whole flow of the system did not appear to be working well.

• The department was performing poorly against national government performance indicators such as waiting time targets. This meant patients did not have access to treatment and care in a timely manner.

• There was no system of data validation in place to ensure waiting time information was accurately reflecting the time patients spent in the department.

• Escalation processes in place were not effective and patients were waiting excessive time in the department as a result.

However:

• Staff were working extremely hard to deliver care that was caring and compassionate under very difficult circumstances.

• We observed staff helping patients and supporting them as best they could.

• Nursing and medical staff worked well together and were doing the best they could for patients.

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

Importantly, the trust must:

• Ensure sufficient medical and nursing staff are deployed in the department to meet the need of patients.

• Prescribe and administer pain relief in a timely way to ensure patients are not left in pain for long periods of time.

• Improve the triage process and take responsibility for patients brought to the department by ambulance and as soon as handover has been carried out, administer their medicines and manage their needs.

• Improve the quality of record keeping and storage of paper records to ensure no information is lost or misfiled. This includes completion of risk assessments, safeguarding, mental capacity assessments and National Early Warning Scores (NEWS).

• Adhere to infection prevention and control standards including cleaning of rooms, and following hand hygiene and other infection control processes.

• Improve data validation oversight.

• Improve the escalation process to ensure senior decision makers are involved in the process as soon as possible.

• Make sure processes for the management of medicines is robust; that expired drugs are removed and replaced and oral medicines are dated and disposed of once expired.

• Ensure all staff follow the same triage process and assess patients in order of urgency and not chronology.

• Ensure patients receiving treatment have privacy and their dignity respected.

• Work towards improving performance against national standards such as the time from arrival to treatment and median total time in the department.

• Work collaboratively with other departments around the hospital to improve the length of time patients wait to see specialist medical staff and reduce the length of time before a decision whether to admit or not is made.

In addition, the trust should:

• Work towards a system, such as a patient group direction, that allows simple medicines such as pain relief to be given by nurses without the need for a doctor’s prescription.

• Continue the work being carried out to ensure staff attend their mandatory training in a timely manner.

• Consider having a robust process in place to ensure cannulas are checked for early signs of infection.

• Have a robust system in place to support patients who are self-medicating in the department whilst waiting for treatment.

• Monitor ambient temperature in clinic rooms to ensure medicines are stored within their recommended temperature ranges.

• Have a process for monitoring the compliance of staff against the hospital policy of prescribing all oxygen.

• Have a robust process for making sure all appropriate sepsis patients are started on the sepsis pathway.

• Have a robust process to make sure controlled drugs are routinely checked in line with trust policy.

• Ensure ‘corridor’ nurses are fully aware of the ‘tag’ process should they need to leave their designated corridor area.

• Consider raising the profile of patients living with dementia or a learning disability, or others with additional needs to improve the support they receive in the department.

• Explore alternative ways of discharging patients waiting for social care packages to improve flow through the emergency department.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

• Across the hospital patients’ records were not securely stored. In spinal injuries, surgery and medical wards we found nursing, medical and notes from teams who supported patients were kept in different places. This presented a risk that staff did not have access to all a patient’s records when making decisions. We escalated this issue to the trust at the time of our inspection and immediate action was taken.
• In urgent and emergency care, surgical wards and the spinal injuries unit, patients’ risk assessments were not consistently completed. This meant the hospital’s staff were not assessing all the risks to health and safety for patients and doing all that was reasonably practicable to minimise these risks. We escalated this issue to the trust at the time of our inspection.
• Across the hospital staff did not follow the trust’s infection control policy in relation to nursing patients with communicable diseases. Patients were not barrier nursed, side room doors where isolated patients were located were open and appropriate signage was not consistently used. This represented an infection control risk, which we escalated at the time of our inspection.
• At the time of our inspection areas within the hospital were not visibly clean. This included areas within spinal injuries, urgent and emergency care, surgery and medical wards.
• In urgent and emergency care and surgery, care provided was not always person centred. Areas used by the hospital’s staff to provide care for patients did not consistently allow staff to make reasonable adjustments to meet people’s needs or ensure their privacy and dignity was maintained. We escalated this to the trust at the time of our inspection and immediate action was taken.
• In the emergency department and some surgical wards resuscitation equipment was not all in date including medicines.
• Investigation of incidents and learning from them was not consistent and comprehensive. This meant that opportunities to improve services were missed.
• Staff in medicine and surgery told us that although they were aware what constituted an incident, they did not consistently report them. This issue was also identified at our last inspection.
• In urgent and emergency care and surgery, staff did not manage medicines consistently and safely at all times. We found medicines were not consistently stored, oxygen was not consistently prescribed and there were omissions in procedures for checking and signing for controlled drugs. We escalated this to the trust at the time of our inspection.
• Staff in some areas where mandatory training completion was low reported that they had not been able to attend training. Across medicine and surgery not all staff had received an annual personal development review. We identified similar issues at our last inspection.
• Across the hospital staff did not consistently apply the principles outlined in the Mental Capacity Act 2005. We found delays in assessment of patients’ mental capacity. There was a lack of consistency in how people’s mental capacity was assessed and not all decision-making was informed or in line with guidance and legislation.
• In spinal injuries there was open access to the unit including wards where high risk patients were nursed. We escalated this at the time of our inspection and the trust took immediate action.
• In some areas of the hospital outcomes for people who used services were below expectations compared with similar services.
• In urgent and emergency care there were times when people did not feel well supported or cared for and their dignity was not consistently maintained.
• The hospital continued to experience challenges in relation to patient flow. Bed occupancy, length of stay, and delayed transfers of care had an impact on the flow of patients throughout the hospital due to the demand for medical services. This impacted on urgent and emergency care where patients were still experiencing long and unacceptable waits for treatment.
• There was limited personalisation of care plans in the records we reviewed. Plans were largely in the form of standardised templates, which identified risks, but lacked clarity relating to the specific needs and wishes of the patient.
• Across surgery and medicine we found risks that had previously been identified at the last inspection. There was insufficient progress to improve these areas and/or improvement was not sustained.
• Across the hospital we found a range of concerns relating to the systems and processes that should be in place to ensure the hospital runs effectively and efficiently. New systems and processes had recently been introduced to address this, but were not fully embedded to ensure all risks were identified and addressed.
• The trust did not have a current strategy. As a result staff did not understand how their role contributed to achieving the organisation’s strategic goals.
• The absence of a strategy meant services did not have meaningful and measurable plans in place in order to achieve strategic goals.
• There was no credible statement of vision and staff were not aware of or did not understand the organisation’s values.

However:

• Safeguarding adults, children and young people at risk was given sufficient priority. Staff took a proactive approach to safeguarding and focused on early identification. They took steps to prevent abuse or discrimination that might cause avoidable harm, responded appropriately to any signs or allegations of abuse and worked effectively with others, including people using the service, to agree and implement protection plans. There was active and appropriate engagement in local safeguarding procedures and effective work with other relevant organisations, including when people experienced harassment or abuse in the community.
• Since out last inspection mandatory training levels had improved across the hospital. Whilst they were still below the trust’s target of 90%, they had significantly improved to average 78% across all areas.
• Across most areas of the hospital staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Where relevant, there were effective handovers and shift changes to ensure that staff can manage risks to people who use services.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and technologies.
• People received coordinated care from a range of different staff, teams or services. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
• Across most areas of the hospital, people were supported, treated with dignity and respect, and were involved as partners in their care.
• The majority of the hospital was easily accessible for patients who required assistance with mobility, including patients who required the use of a wheelchair.

During our inspection we visited five inpatient wards. We spent time with 15 patients and invited them to share with us their experience and views of care and treatment at the hospital. Some of their comments included:

“In general staff do their best but they are under pressure. They have got too much to do”, “Usually buzzers are answered quickly. It takes a bit longer in the middle of the night”, “Most of the staff are pleasant”, “I get my medication on time. Some (staff) watch you take it, others just leave it on the table”, “There are plenty of staff and they are good. They work hard” and “I have no complaints. Staff are kind. They struggle because there are not enough of them."

Patients we spoke with said they were treated with dignity and respect and that staff came promptly when they needed them. We observed staff draw curtains around patients’ beds when attending to them and they lowered their voices when they spoke to patients, to observe their privacy. However, on one ward the staff handover was held in a bay on the ward.

The health care records we looked at were not consistently completed in a timely manner on admission to the hospital or reviewed by medical staff on some of the wards we visited. Some patients did not have care plans or risk assessments. We found regular observations were made and recorded.

We found there were staff vacancies on all of the wards we visited. Staff were in the process of being recruited. We were told of the process for finding staff to cover for absences on the wards. However we found staff shortages on the day of our inspection on one ward because an absence had not been covered.

Patients told us staff were responsive and attentive to their requests, with nurse call bells responded to in a timely way. We heard one patient say “They [the staff] always close your curtains to try and keep things as private as they can.” A relative told us the staff had been “kind and considerate.”

Patients said they were provided with enough information about their medicines and treatment. One patient said “Medicines are given to me correctly.” Another patient told us “I get pain relief medicines when I need them.”

Overall, patients were aware of their plan of care and felt they had received adequate information to understand their condition and treatment. The health care records we looked at showed that care and treatment was planned and delivered in a way that ensured patient safety and welfare. Some patients told us the discharge process had not been efficient. Senior managers were aware of this concern and explained that plans were in place to improve the discharge process.

The trust had reviewed and revised its quality and risk management systems. For example, the trust had invested in new storage facilities, including the provision of lockable doors to all medicine storage areas, new lockable fridges, new medicine trolleys and secure medicine disposal bins. These developments had assisted in ensuring medicines were safely stored to help prevent misuse and mishandling.

As part of our visit to the hospital we spent time with patients listening to their experience of care and treatment at the hospital. The majority of patients who talked with us had been admitted via the accident and emergency department. Patients said they were pleased with the treatment and care they received. One patient told us, “It was a very positive experience”. Patients told us that staff kept them informed about what was happening, including explanations about tests, investigations and treatment plans.

We heard from a patient say that, “The hospital is brilliant and the care excellent”. All the patients we talked with said the majority of staff were pleasant, caring and had a nice attitude. They said staff were respectful of their privacy and dignity. We heard that staff were responsive and attentive to requests, and nurse call bells were generally responded to in a timely way.

Patients were aware of how to make a complaint but were not sure about how to provide formal feedback on the quality of the service.

A number of patient relatives contacted us to report concerns that their family member had not experienced safe and effective care at this Trust. Patient interviews on the day of our visit told us they felt safe and they considered staff treated them with dignity and respect. When asked about their individual care plans patients were not aware that these were in place.

Before this inspection visit we were told by a number of patient relatives that staffing levels at the Trust was "poor" and for some concerns were raised about staff competence. We asked patients we interviewed about the care they received specifically around the numbers of staff available to provide this. We were told by all patients there were not enough staff available to meet their needs. They said staff were well trained and highly skilled, but they did not have the time to meet thier needs in full. Patient comments included "Staff were on the go all the time, I see them flying about and sometimes it’s hard to catch their attention". One patient said "Bells were left ringing for a long period of time and if you ask for anything it takes a long time before you get it".

We asked patients their views on how well staff knew them and their needs and we got mixed comments. One patient reported that staff knew her needs well but mostly patients responded by telling us staff did not have enough time to get to know them.

We rated the hospital as requires improvement overall which is no change from the last inspection in November 2015. The same four of the five domains were judged to be requiring improvement with the caring domain rated as good. Urgent care services had a worse rating in safety being rated as inadequate from requires improvement last inspection and surgery had changed to an inadequate from requires improvement in safety and being well led.

However the regional spinal injuries service had improved from inadequate ratings in safety and being well-led to good across all domains. Medicine remained in the same ratings for all domains. Critical care services had improved in safe effective and well led to a good rating but continued to require improvement in responsiveness. Outpatient services remained at a rating of requires improvement in safety but had improved to good in all other domains. End of life services continued with good ratings in all domains.

Our key findings since our last inspection were as follows:

Urgent care

• We found evidence of significant flow issues and significant delays for patients during our inspection. Higher (worse) than average numbers of patients were waiting between four and 12 hours to be admitted into the hospital following a decision being made. The department was not meeting the Department of Health target to admit, treat or discharge 95% of patients within four hours. We saw patients waiting in corridors in public areas which we were concerned impacted negatively on their privacy and dignity. We saw some elements of sepsis care which were worse than the regional average. Re-attendance rates for patients were consistently higher (worse than) than the national average. We also saw an example of poor management of a patient suffering with sepsis. National audits were undertaken which highlighted poor performance in a number of areas but action to improve care in these areas was not sufficient.

• Staff did not have a focused approach to reviewing mortality. Although most areas were visibly clean, the floor of a storeroom was not, with debris and dust on the floor and around equipment. Some major incident equipment was stored in a disorganised way with items piled high and unlabelled.

• Patient records were not audited the records we reviewed showed that tools to manage risks to patients such as observations, risk assessments and early warning scores were not always recorded. Although national and local guidelines and care pathways were in place, they also were not always evidenced in records.

• Compliance with mandatory training did not meet the trust target of 90%. We shared staff concerns that medical staffing levels were low and at times appeared unsafe. Although nurse staffing levels were adequate, sickness levels were higher than the NHS national average.

• Staff were open to risk because of a lack of security arrangements on site. Staff felt leaders from the executive team were not supportive and that the culture was reactive with action taken ‘too little, too late’, rather than having a proactive approach.

North West Spinal Injuries Unit

• Following a rating of inadequate during the inspection in November 2014, the service is now rated as good overall because the trust had invested significantly in nurse staffing and we saw that the staffing ratios had increased to adequate levels. The centre had a dedicated spinal medical team with on-site medical cover between the hours of 9am and 9pm Monday to Friday. Out of hours the centre was supported via spinal on-call including a consultant and the trust out of hours hospital at night team.

• They had renamed the former intensive care and high dependency units as it was revealed that intensive care was not delivered at the centre. The centre demonstrated a clear admission policy with strong individual assessment for admission in accordance with the national clinical reference group classification for clinical priority. There was also a focus on discharge planning and there was good multidisciplinary working to support this. A case manager facilitated the discharge process. The consultants reviewed their patients six monthly or annually to ensure patients were reaching their goals.

• In March 2016 the safety thermometer showed harm free care had been provided for pressure ulcers, catheter acquired urinary tract infections and VTE assessments. There had only been one fall with harm. Since the last inspection staff had been supported to manage patients with challenging behaviour. The partnership working document was discussed with all patients on admission and an explanation given regarding expected behaviour in line with the trust’s violence and aggression policy.

Medicine

• We found that not all wards appeared clean and well maintained. Equipment was left on wards and outside in corridors, and not all staff followed staff hygiene practices as they did not always wear suitable protective equipment between providing care and treatment to patients. There had been no formal process since July 2015 to April 2016, to ensure that the quality of care on the medical wards was maintained by senior managers and that all trust policies and procedures were being adhered to. Nurse staffing establishment levels across all wards was variable. All wards we visited had vacancies that were being filled by either staff working extra hours or agency workers. Consultant vacancy rates across medical services in March 2016 were high at 30%, and had been deemed as a high risk on the risk register. There was limited consultant cover on medical wards at weekends, and no ward rounds took place.

• Mandatory training statistics showed that only one medical ward had achieved the trust target of 90% in mandatory training in the period of October 2015 to February 2016. Staff training in some core areas was below the trust targets and staff reported that they had to cancel training due to low staffing levels. Not all staff had received an annual personal development review.

• Initial patient risk assessments were not consistently completed for example VTE assessments. Access and flow throughout medical services was poor and so patients were being cared for and treated on wards that were not appropriate to their needs. Due to a high demand for beds throughout the Hospital, some areas of the hospital were being used inappropriately to care and treat patients. For example the GPAU and the discharge lounge were being used as bedded areas. Escalation wards did not provide all the necessary amenities to ensure a high quality service was experienced by all patients, and call bells were not always in reach of patients.

• There was inadequate storage for staff belongings on the ward which posed a security issue for staff. There was no security team on site to ensure the safety of staff and visitors in the event of violence and aggression from patients or visitors. There had been 76 police call outs to the trust, with the main reason being due to physical abuse/violence from patients to staff.

Surgery

• Safety did not have a sufficient priority across surgical services. Systems and processes were not always reliable to keep people safe. Incidents were not always properly identified and we saw evidence of previous incidents being repeated. Risk assessments were not always completed and mitigation of identified risk did not always take place. Medically deteriorating patients were not always identified promptly, nor did they always receive the prompt medical attention the required, once they were identified. The mortality and morbidity of surgical specialties are not reviewed by the trust board.

• Staffing levels on wards were frequently insufficient and these were not addressed quickly. Staff were distressed at the low staffing levels and the heavy workload. We observed the impact that the low staffing levels had on patient safety and patients’ needs being met.

• In addition to the above issues, matters identified during the previous inspection remained evident. There were problems with the replacement of theatre equipment and there was still no pager system in place which had connectivity across the entire hospital.

• There was no clear vision about the future of surgical services across the trust. However, decisions about the future of surgical services could only be made as part of a decision in the wider healthcare economy. Significant issues that threatened the delivery of safe and effective care were not identified and adequate action to manage them was not always taken. There was also a combative approach to dealing with disciplinary matters across the division for both nursing and medical staff.

• There were poor patient outcomes as indicated by high elective readmission rates and poor performance in national audit programmes. We found that nutrition and hydration needs were not always addressed. In addition staff were not implementing trust policy for fasting guidelines prior to surgery, meaning that people were being left longer than recommended without fluids.

• They experienced significant difficulties with patient flow. Services were not organised efficiently. This further exacerbated patient flow issues. Surgical services did not always meet the individual needs of patients who had complex requirements. Complaints were not used as a means of improving services.

Critical Care

• The critical care services were previously rated as ‘requires improvement’ for responsive following our last inspection because we had concerns around delayed discharges and the provision of single sex accommodation. During this inspection, we found that significant improvements had been made to reduce the number of delayed discharges. However, further improvements were still needed to ensure patients received appropriate care.

• The services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with expected levels for most performance measures in the Intensive Care National Audit and Research Centre (ICNARC) audit. Patient’s relatives spoke positively about the care and treatment they received.

• Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. There were systems in place to manage resource and capacity risks and to manage patients whose condition was deteriorating. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks. The consultants covering the unit during out of hours were also responsible for other areas, such as providing anaesthetic cover for the surgical and maternity services however, there was a second on-call consultant to provide additional cover and support. There was one speech and language therapist across the hospital during weekdays. This meant staff on the unit occasionally experienced a delayed response after referring patients for this service.

• There was effective teamwork and clearly visible leadership within the services. Most staff were positive about the culture within the critical care services and the level of support they received from their managers. Key risks to the services, audit findings and quality and performance was monitored though routine departmental and divisional quality and governance meetings.

End of Life

• Conversations between district nurses and GPs around the commencement of the IPOC to support patients at the end of life were not always documented. The service should ensure that all GP involvement is documented in the IPOC when the decision is made for this to be commenced.
• Completion of mental capacity assessments was not consistent, even when indicated on the DNACPR. The trust was not using the unified DNACPR process and hospital DNACPR forms did not travel with the patient when they left hospital. There was no audit of DNACPR forms or decisions despite the system for reviewing these forms being identified as an area for improvement in the last CQC inspection in 2014.
• The complaints process and governance processes around monitoring incidents required improvement. The trust should ensure the new incident monitoring system includes dissemination of feedback and lessons learned to all relevant areas, including the mortuary.
• Syringe drivers were not being checked four hourly in line with hospital standards. The service should continue to educate and audit this process.
• Prior to our inspection there had been no-one actively taking the part of executive lead for EOLC and there was no non-executive director with responsibility for EOLC.
• Anticipatory EOL care medication was prescribed appropriately in hospital and in the community. Hospital staff were knowledgeable about responding to deteriorating patients and hospital care records reflected this with appropriate evidence or establishment of ceilings of care documented. There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) of those thought likely to be dying which was well embedded in community services. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a Transform team which promoted advance care planning, the amber care bundle and provided EOLC training.
• The delivery of EOLC was planned in accordance with the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People including the introduction of the IPOC. Actions were being taken to meet the national framework, Ambitions for Palliative and End of Life Care, including cross boundary working to coordinate care and the generation of data via national and local audits to review and improve services. Patients had comprehensive assessments of their needs which included pain assessments and in hospital, nutrition and hydration assessments. There was good evidence of multidisciplinary team working and seven day services were in place. There was a rapid transfer process in place which the team were working to improve.

OPD

• The previous ‘requires improvement’ rating was due to safety incidents not being communicated with the trust board. This has since been addressed, however other issues of concern were found.

• We raised a control of infection issue in the eye clinic that was raised during the inspection. The trust responded quickly and an action plan to improve was put in place; however, some issues were not addressed.

• The hospital performed well against national targets. Waiting times for appointments were better than average with 50% of patients receiving an appointment within five weeks of referral. Radiology figures were excellent for both receiving appointments and results. In the last 12 months, less than 1% of patients waited six weeks for a radiology appointment.

• There were a large number of appointment cancellations that had a variety of causes including IT issues and patients receiving multiple appointments in error. However, managers were gathering evidence and had set improvement targets

• Some areas of mandatory training showed poor results and managers acknowledged that work was needed.

• The outpatient improvement project was still progressing from 2014; changes had been made to the environment, clinical coding and staffing ratios. Phase four had been suspended due to staffing issues, which was to address the high cancellation numbers.

However, there were areas of poor practice where the trust needs to make improvements.

In Urgent and Emergency Services

• The service must ensure mortality is discussed monthly and minutes taken to evidence discussion.

• The service must ensure mandatory training compliance reaches and consistently achieves the trust target.

• The service must ensure appropriate signage is displayed in areas where close circuit television cameras are used.

• The service must ensure the actions identified following our concerns about the death of a patient during our inspection, are implemented in accordance with planned timescales

• The service must ensure all patients receive timely (particularly initial) observations whilst in the department

• The service must ensure staff use and evidence use of the sepsis care pathway for patients suffering sepsis.

• The service must increase middle grade staffing to ensure rotas can be planned without the routine use of consultants or junior doctors to back fill vacant middle grade shifts. Where it is not possible to recruit staff, ensure suitable alternative and sustainable solutions are identified and implemented.

• The service must ensure action plans following CEM audits target areas of poor performance and improve practice.

• The service must ensure staff make use of the trust capacity assessment documents when required and properly evidence that where a patient lacks capacity best interests have been adequately considered.

• The service must improve performance, particularly in relation to the department of health four hour target, wait times following a decision to admit, ambulance handovers.

• The service must ensure robust processes are in place to mitigate risks to staff in relation to violence in the work place.

• The service must improve the organisation of major incident equipment in the store room.

• The service must develop and embed a clear escalation process with identified actions for managers and executives.

In surgery

• The service must take action to ensure that there are adequate staffing levels present on all wards to provide safe level of care and treatment for the acuity and dependency of the patients on the wards.

• The service must take action to ensure that Oxygen is prescribed to patients, in line with recommended guidelines, prior to administration.

• The service must take action to ensure that all patients, particularly those who are very confused and able to wander off a ward, are cared for in a secure environment.

• The service must take action to ensure that a system of feedback is in place for staff who have reported incidents.

• The service must take action to ensure that medically deteriorating patients are always identified as they deteriorate and are medically reviewed in line with trust policy.

• The service must take action to ensure that mortality and morbidity events in surgical services are reported to the trust board.

• Surgical services must take action to ensure that the plan for the replacement of old theatre equipment is implemented.

• Surgical services must take action to ensure that all risk assessments are appropriately completed for patients.

• Surgical services must take action to ensure that a system is in place to identify trends and reasons for the high readmissions rates in elective surgery.

• Surgical services must take action to develop an action plan to reduce the high readmission rate in elective surgery.

• Surgical services must take action to improve performance in relation to the indicators in the following national audits,

-The national emergency laparotomy audit

-The national bowel audit

-The national lung cancer audit

-The national hip fracture audit

• Surgical services must take action to ensure that patients are being fasted for surgery in accordance with national guidelines and trust policy.

• Surgical services must take action to ensure that the surgical admissions process is designed to facilitate a timely flow through the surgical process.

• Surgical services must take action to ensure that patients are cared for in treatment areas with full access to toilet facilities and meals.

• Surgical services must take action to ensure that care is provided to patients with complex needs in a manner that is responsive to the needs that they have.

• Surgical services must take action to ensure that patients with dementia and other cognitive impairments are cared for on wards that take account of these needs in terms of physical environment.

• Surgical services should use service user complaints about to drive service improvements.

In End of Life Care

• The service must improve the consistent use and completion of formal pain assessment; assessment of nutritional and hydration status in the community; mental capacity assessments when indicated on the DNACPR.

In Medicine

• The service must take action to ensure that all staff have the up to date training they require to be able to safely care and treat patients and performance development reviews are in line with trust policy.

• The service must take action to ensure that all wards and corridors are clean and well maintained, and equipment is stored appropriately.

• The service must ensure that all records relating to patients are kept securely and computers are locked when left unattended to prevent breaches in data protection.

• The service must take action to ensure that all Initial patient risk assessments are consistently completed for all patients.

• The service must ensure that there are sufficient numbers of qualified, competent staff across all medical wards.

• The service must take action to improve the access and flow throughout the medical wards, to reduce bed occupancy and prevent patients being cared for on wards that are outside their specialty.

Professor Sir Mike Richards

Chief Inspector of Hospitals