We inspected Worcestershire Acute Hospitals NHS Trust on the evening of the 24th March 2015 as a part of a responsive inspection. The purpose of the unannounced inspection was to look at the emergency departments (ED) at Worcestershire Royal Hospital and Alexandra Hospital. The services were selected as examples of a high risk services according to our intelligent monitoring model. This looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations.

We did not inspect any other services provided at the trust.

The inspection focused on the safety of patients. We found that improvements were needed to ensure that the EDs were safe.

We also looked to ensure each ED was effective, caring, responsive and well led. However, we did not have sufficient evidence to rate domains.

Our key findings were as follows:

Incidents

• Systems were in place for reporting incidents. However, incidents were not always reported. This meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.

Safeguarding

• Children were not routinely screened for safeguarding concerns.
• We found paediatric patients were at risk because there were inadequate measures in place in relation to their security.

Medicines management

• The systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, were not robust or in line with requirements.
• Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.

Staffing

• There was a shortfall in nursing staff numbers. There was no evidence shifts were being planned to reflect the patients’ acuity and therefore the planned staffing did not always meet the needs of the patients in the department.
• Senior staff told us they had escalated concerns about staffing and capacity in the department to senior managers as they considered the department was “not safe” at times due to the high volume of patients.
• We saw evidence of the department being “Overwhelmed”. However the escalation process could not always been carried out because there were no more staff available. This meant that the department was not able to manage the situation safely.

Medical staffing

• Forty percent of the senior staff were locum.
• There was one consultant on site after 5pm covering both the Worcestershire Royal Hospital and the Alexandra Hospital site, including trauma calls. This was raised as a concern during a peer review from NHS England. If two trauma patients were admitted at the same time on each site, the protocol was that one of the trauma calls would be led by the orthopaedic doctor.

Environment and equipment

• We found that staff had not documented daily equipment testing for the resuscitation trolley at Worcestershire Royal Hospital to ensure equipment was fit-for-purpose.
• We found single use items on the resuscitation trolley and in the resuscitation room that had expired. Staff told us they did not always have time to check equipment.
• There was insufficient space within the department to assess patients. When all the cubicles and bays were full, patients were cared for in the corridor. This put patient safety at risk because of reduced visibility of patients when in the corridor.

Ambulance Handovers

• There were delays in handover time from ambulance crew to the emergency department team. This meant that patients, including clinical unstable patients, remained under the care of the ambulance crew longer than expected which delayed initiation of treatment.
• In the past 12 months the trust had not consistently met its 15 minute triage target or its target for patient handovers being carried out within 30 minutes of arrival by ambulance.

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

We found breaches with the following regulations:

• Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Regulation 18(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].
• Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Regulation 15 (1) and (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].
• Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Regulation 15 (1) and (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].

Importantly, the trust must:

• Ensure that at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff mix in the EDs to ensure people who use the service are safe and their health and welfare needs are met.
• Ensure that all equipment is in date and is checked consistently.
• The trust must ensure that service users are protected against the risks associated with unsafe or unsuitable premises, by means of appropriate measures in relation to the security of the EDs.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This inspection looked at how the provider dealt with and responded to hospital acquired infections. In particular we looked closely at how outbreaks of Norovirus were managed. Norovirus causes sickness and diarrhoea and can cause complications for people that are vulnerable due to illness. This infection has been known to be a recurrent problem for hospitals throughout the winter months.

We were unable to carry out any observations in ward areas. However, we met with the registered manager, the chief executive and with a range of staff which included doctors, nurses, housekeepers and care assistants. We held a special forum with staff to enable them to discuss with us their feelings on how infection prevention and control was managed. We also looked at the policies, procedures and risk assessments for infection control.

During our inspection we found that the provider had systems in place to prevent, detect and control the spread of infection. For example, we read the policies and procedures around the management of Norovirus. We found that these policies provided robust guidelines for the monitoring and reporting and management of this infection.

We saw that the provider had risk assessments and action plans for how to manage the risk if infections were present in the hospital. These included guidance for staff on isolating patients if they had any infection that could be contracted by other patients, this included Norovirus. The policy stated that this prevented the further spread of infection and also protected patients that were at increased risk of acquiring an infection from other patients. Staff we spoke with confirmed that wards were closed and staff movements to other wards restricted when Norovirus was present. This meant that the provider had appropriate measures in place to reduce the risk of the spread of infection.

We carried out observations on three wards, Chestnut Ward, Avon 2 and the Highfield unit. We also spent time in the Accident and Emergency department, AMU (the acute medical unit) and the Discharge Lounge. We spoke with some staff that worked in the areas we visited and took the opportunity to formally meet with groups of staff who worked in other areas. These included staff from physiotherapy, occupational therapy, pharmacy and portering services.

We observed how care was being delivered and spoke to 21 people about the care they or their relatives had received. Most of the people we spoke with told us that they were happy with the care they had received and the level of information they had been given.One person told us: “ I’ve got no complaints whatsoever. I always get treated absolutely brilliant”. Another person said they: “ Couldn’t wish for better”.

Overall we found that there were arrangements in place to ensure that people’s needs would be met when they were discharged or were transferred to other care providers.

There were appropriate arrangements for staff training and staff told us that they received training which was appropriate to their roles and responsibilities.

There were arrangements for monitoring the quality of care being delivered at ward and departmental level and for reporting the information to the trust board. Information from audits or checks completed was used to improve practice where necessary.

We spoke to a total of nine patients, one relative and two visitors at the Alexandra Hospital and three patients at the Worcestershire Royal Hospital.

People we spoke to were positive about the care provided and made a number of very positive comments ‘Yes, very happy, the staff are lovely’, ‘Brilliant can’t fault it’, ‘The staff are really nice and provide good care’.

People told us they were kept informed about their care and treatment and that staff explained things to them. Patient information was not widely available at the Alexandra Hospital but we were told that this was being addressed.

All of the people we spoke to felt that staff responded to their needs promptly although not everyone we saw at the Alexandra Hospital had call bells accessible to them.

People we spoke to were very complimentary about the meals served to them and we saw that food was made available to people who may have missed food while investigations were being carried out.

The environment was quiet and conducive to eating, people appeared relaxed and reported they enjoyed their meal. Three of the nine people we spoke with were not aware that snacks outside mealtimes were available if they wished.

Our rating of services stayed the same. We rated it them as inadequate because:

• Patients could not access services when they needed them. Waiting times for treatment were not in line with good practice. The percentage of patients whose operation was cancelled and were not treated within 28 days was worse than the national average.
• Not all systems in place were effective in recognising and responding to deteriorating patients’ needs. This included harm reviews of patients waiting for a procedure.
• The trust was performing worse than the England average for patients waiting over 60 minutes before being handed over to emergency department staff. Not all patients were recorded as being seen by a specialist doctor despite being referred.
• The trust did not ensure everyone completed mandatory training.
• While staff understood the need to protect patients from abuse, not all staff had completed training at the required level to ensure they had the appropriate level of knowledge to do so.

• There were inconsistencies in staff being able to recognise and report incidents. Mixed sex breaches were not always reported.
• Not all staff had received an appraisal. Not all staff received supervision to provide support and monitor the effectiveness of the service.
• Some areas did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The hospital had medical staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. However, there was insufficient medical cover to provide consultant presence in the department for 16 hours a day, as recommended by Royal College of Emergency Medicine.
• The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Not all risks identified during the inspection were documented on risk registers.
• The trust planned but did not provide services in a way that met the needs of local people.
• Services did not always have a documented vision or strategy.
• Information was not always collected, analysed, managed and used well to support activity.
• There were inconsistencies with infection control and prevention techniques, particularly hand hygiene.
• Processes to monitor the safe storage of medicines were not always followed.
• There was no privacy and very little confidentiality for patients waiting on trolleys in the emergency department corridor. Staff did not use privacy screens.

However:

• Managers investigated reported incidents and shared lessons learned with the whole team. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The hospital had suitable premises in most areas and systems were in place to ensure most equipment was well looked after.
• The hospital prescribed, gave, and recorded medicines well. Patients generally received the right medication of the right dose at the right time.
• Staff ensured that patients’ individual care records were well managed and stored appropriately.
• Generally, the hospital provided care and treatment based on national guidance and evidence of its effectiveness.
• The hospital managed patients’ pain effectively and provided or offered pain relief regularly.
• Staff generally gave patients enough food and drink to meet their needs and improve their health.
• Multidisciplinary 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 provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Most managers, but not all, across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.