Cambridge University Hospitals NHS Foundation Trust is one of the largest trusts in the United Kingdom. The trust is a 1,100-bedded teaching hospital, which provides acute and specialist healthcare for the local people of Cambridge, together with specialist services, dealing with rare or complex conditions for a regional, national and international population.
Addenbrookes Hospital provides emergency, surgical and medical care for local people and is the Major Trauma Centre (MTC) for the East of England region. It is a regional centre providing specialist services such as organ transplantation, cancer, neurosciences, paediatrics and genetics.
The hospital campus opened in 1962 and became a foundation trust in July 2004. The trust serves an estimated population of around 578,264 and employs approximately 11,000 members of staff
We carried out an unannounced focused inspection of Addenbrookes Hospital urgent and emergency care and medical care services on 21 March 2022. We had an additional focus on the urgent and emergency care pathway across Cambridgeshire and Peterborough and carried out a number of inspections of services across a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme demand.
As this was a focused inspection of urgent and emergency care at Addenbrookes Hospital we only inspected parts of our key questions: safe, responsive and well led. The inspection framework focused on five key lines of enquiry relating to critical care, infection prevention and control, patient flow, workforce and leadership and culture.
At our last inspection in 2018, urgent and emergency services at Addenbrookes Hospital was rated overall as good. It was good for safe and effective, outstanding for caring and well led, and requires improvement for responsive. Medical Care services was rated as good overall.
For this inspection we considered information and data on urgent and emergency care performance. This inspection was partly undertaken due to the concerns raised over how the organisation was responding to patient need and risk in the wider trust in times of high demand and pressure on capacity. We were concerned with waiting times for patients and delays in ambulance handovers.
We looked at the experience of patients using urgent and emergency care and medical care services at Addenbrookes Hospital. This included the emergency department, medical wards and areas where patients in that pathway were cared for while waiting for treatment or admission. We visited services and departments that patients may encounter or use during their stay. We also went to medical wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.
Due to the nature of the service, we inspected and reported on EAU4, an emergency assessment unit within the medical care report. This ward was led by urgent and emergency care staff.
A summary of CQC findings on urgent and emergency care services in Cambridgeshire and Peterborough.
Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Cambridgeshire and Peterborough below:
Cambridgeshire and Peterborough
Provision of urgent and emergency care in Cambridgeshire and Peterborough was supported by services, stakeholders, commissioners and the local authority.
We spoke with staff in services across primary care, urgent care, acute, mental health, ambulance services and in care homes and domiciliary care agencies (social care). Staff had worked very hard under sustained pressure across health and social care services. Staff reported feeling tired and frustrated due to the sustained pressure and the impact this had on their wellbeing and on the delivery of training.
We identified a need for more capacity in primary care to meet people’s needs in Cambridgeshire and Peterborough. We found some concerns in relation to access for patients trying to see or speak to a GP; however, other services proactively reviewed patients’ attendance at emergency departments and took action to reduce avoidable attendances and improve access to appointments.
We visited a primary care unit run by an acute trust; whilst this was working well, we were told it was addressing an issue in access to primary care and was a short-term solution. We were told of a GP liaison service which enabled GPs and Consultants to work together to discuss individual patient needs. This service had successfully supported a significant number of people to stay at home or to access an alternative pathway and avoid going to an Emergency Department.
Access to NHS111 services for people in Cambridgeshire and Peterborough was generally in line with or better than elsewhere in England. Performance was closely monitored and there were plans in place to address staff shortages, particularly for health advisors, and there was a successful on-going recruitment campaign.
System partners in Cambridgeshire and Peterborough had been part of a collaborative project to launch a Virtual Waiting Room within the Cambridge and Peterborough region. The initiative aimed to help patients who call NHS 111 receive the care they need while alleviating the pressure on Emergency Departments (EDs).
Staff working in ambulance services reported a significant volume of calls which were inappropriate for a 999 response and could have been dealt with in primary care or urgent care services. Staff also reported a high number of elderly people seeking support through emergency services because they felt their care packages were insufficient and did not meet their needs.
Ambulance crews also highlighted their frustrations with the variation in pathways at different hospitals across Cambridgeshire and Peterborough and that ambulance crews were not prioritised for accessing alternative pathways. By streamlining pathways and handover arrangements, ambulance crews felt they could be more efficient.
For many complex reasons, including ambulance handover delays and staffing shortages, there were not enough crewed ambulances to respond to 999 calls within national targets. This posed a risk to people in the community waiting for a 999 response.
Staffing shortages in some Emergency Departments impacted on the delivery of safe and effective care. Staff were not all up to date with mandatory training and did not always assess risks appropriately.
We visited a mental health service and found it met the needs of people who presented in the Emergency Department or transferred between acute and mental health services. However, staff within Emergency Departments reported problems in accessing mental health services and were not able to make referrals 24 hours, seven days a week. This impacted on the ability to provide appropriate care and treatment and moving patients to the appropriate service.
Whilst we found some examples of collaborative working focused on developing system wide resilience, we found Emergency Departments remained under significant pressure. Patients experienced significant waiting times in these departments and staff reported the challenges of caring for patients within the department for such long periods of time. Some staff felt too much risk was accepted and held within emergency departments and didn’t always feel supported by system leaders.
Same Day Emergency Care pathways aimed to relieve the pressure from Emergency departments. However, these services also experienced staff shortages, and some were only available during set times. Opportunities were lost to use admission avoidance pathways for the frail and elderly and increasing the risk of patient harm such as falls and skin pressure damage’
Delays in discharge for patients in hospital were significant and impacted on their health and wellbeing. Staffing issues were also impacting on the social care provision in Cambridgeshire and Peterborough; although there were beds available in care homes, there was not always enough staff to enable admissions. The staffing issues were also present in domiciliary care agencies which reduced the availability of care at home.
Staff working across health and social care reported poor discharge processes. Staff working in care homes and domiciliary care services reported that patients were often discharged late at night and with insufficient information to ensure a safe transfer of care.
Staff working in these services also reported significant delays in ambulance responses, however they gave very positive feedback in relation to welfare calls received by GPs or 111 and 999 call handlers.
We found a lack of knowledge across social care services in relation to managing deteriorating patients. By increasing staff awareness, services may be able to meet people’s needs without needing to request emergency services.
We observed some local and system escalation meetings and found there was limited, if any action taken in response to issues and risks escalated.
How we carried out the inspection
We spoke with 74 members of staff including nursing staff, consultants, junior doctors, support staff and senior managers. We observed the environment and spoke with 14 patients and reviewed 30 sets of patient records. We also looked at a range of performance data and documents including policies, meeting minutes, audits and action plans.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.