• Hospital
  • NHS hospital

Worcestershire Royal Hospital

Overall: Requires improvement read more about inspection ratings

Charles Hastings Way, Worcester, WR5 1DD (01562) 513240

Provided and run by:
Worcestershire Acute Hospitals NHS Trust

All Inspections

18th of December 2023

During an inspection looking at part of the service

Worcestershire Royal Hospital provides acute hospital services to a population of 580,000.

We inspected Worcestershire Royal Hospital critical care services only during this inspection. We used our comprehensive inspection methodology as this service had not been inspected since 2017 when we rated critical care at this location requires improvement. We carried out an unannounced visit to critical care services at Worcestershire Royal Hospital on 18 December 2023.

The trust has a countywide approach to critical care; and therefore, overall management of the critical care service is the,same across the 2 sites that deliver this; the Worcestershire Royal Hospital and the Alexandra Hospital in Redditch. There are a total of 23 beds countywide with 8 beds at the Alexandra Hospital and 15 at the Worcestershire Royal Hospital. The service is funded for up to 15 level 3 beds across both sites and work with 4 at the Alexandra Hospital and 11 at Worcestershire Royal Hospital. Beds can be used or ‘flexed’ between level three and level 2 depending on patient need (level 3 beds require 1 nurse to each patient and level 2 beds 1 nurse between 2 patients). In addition, the trust has 8 high dependency (level 2) beds on the acute respiratory unit which is situated within the acute respiratory ward and 8 level 2 beds on the hyperacute stroke unit (HASU, within the acute stroke unit). We visited the HASU but as it did not have any high dependency patients at the time of our inspection, we have not included these findings in this report.
To get to the heart of patients’ experiences of care and treatment, we ask the same 5 questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’
performance against each key question as outstanding, good, requires improvement or inadequate.
Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.
with support from an offsite inspection manager, carried out the inspection on 18 December 2023.
During the inspection we reviewed a range of documents related to running of the service including, staffing rotas,performance data, risk assessments and emergency equipment checks, policies and procedures, an independent website browser platform and servicing records of equipment. We spoke with 11 members of staff including service leaders and 3 patients and 2 relatives who had used the service. We reviewed 5 sets of patient records.

11 October 2023

During an inspection looking at part of the service

Pages 1 and 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Worcestershire Royal Hospital.

We inspected the maternity service at Worcestershire Royal Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level. We did not inspect services at the Alexandra Hospital as services provided at this location were outside of the scope of the national maternity inspection programme.

Worcestershire Royal Hospital provides maternity services to the population of 580,000.

Maternity services include an early pregnancy unit, outpatient department, maternity assessment unit, antenatal ward, delivery suite / labour ward, midwifery led birthing centre (The Meadow Birth Centre), two maternity theatres, postnatal ward, High dependency area / enhanced care. Between April 2021 and March 2022 4,785 babies were born at Worcestershire Royal Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of Good for maternity services did not change ratings for the hospital overall. We rated safe as Requires Improvement and well-led as Good.

Worcestershire Royal Hospital is rated Requires Improvement.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited Maternity assessment (Triage), day assessment unit, Labour ward / Delivery Suite, maternity theatres, the antenatal and postnatal wards.

We spoke with 2 obstetric consultants, 15 midwives, 1 support workers. We received 709 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 6 patient care records, 6 Observation and escalation charts and 10 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

21-23 November 2022

During a routine inspection

Medical care (including older people's care)

Our rating of this location stayed the same. We rated it as requires improvement because:

  • Although the service generally had enough staff to care for patients and keep them safe, the vacancy rate for medical staff was high. The service had high rates of bank and agency staff. Medical staff did not always keep up to date with training in key skills, including safeguarding training. ‘Pods’ on Laurel 2 ward were not well maintained and posed an infection control risk. Staff did not always have all the equipment they needed to care for patients. Patients were regularly admitted onto discharge units against standard operating procedure criteria, and we could not be assured that risks were fully assessed and mitigated. Staff did not always manage medicines well. Though the service generally investigated safety incidents well and learned lessons from them, this was not the case on all units.
  • Outcomes for patients were mixed. People could not always access parts of the service when they needed it, particularly stroke services. Outliers in national audits were not always addressed. Medical staff did not keep up to date with training in the Mental Capacity Act and Deprivation of Liberty Safeguards.
  • Staff did not always feel respected, supported and valued. Morale was low amongst some staff, who felt that their concerns were not always listened to by leaders.

However:

  • The service generally controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service through comprehensive repeat audits, and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available 7 days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

How we carried out the inspection  

We inspected this service on the evening of 21 November, and 22 and 23 November 2022. This was an unannounced full core service inspection looking at medical care. We visited the following medical wards and speciality services:

  • Acute Stroke Unit
  • Acute Respiratory Unit
  • Medical Assessment Unit
  • Avon 2 ward
  • Avon 3 ward
  • Avon 4 ward
  • Endoscopy
  • Laurel 2 (oncology) ward
  • Laurel 3 (haematology) ward
  • Pathway Discharge Unit
  • Evergreen Discharge Lounge

The team that inspected the service comprised of 1 CQC inspector, 2 CQC inspection managers, a specialist advisor with expertise in medical care for 2 days, and another specialist advisor with expertise in medical care for 1 day.

During our inspection we spoke with approximately 30 staff members. This consisted of nursing staff, including ward managers and healthcare assistants, medical staff, students and a pharmacist. We spoke to 11 patients and we reviewed 10 patient records.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.   

Urgent and Emergency Care

Our rating of this location ​improved​. We rated it as ​requires improvement​ because:

  • Staff did not always have training in key skills. Mandatory training levels for medical staff did not meet the trust target of 90%. Staff did not always store medicines safely.
  • Staff provided good care and treatment, gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available 7 days a week.
  • Staff treated patients with compassion and kindness and as individuals. They took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • While people could access the service when they needed it, they had to wait far too long for assessment and treatment. There were delays in moving patients off ambulances into the department. This resulted in delays in assessment and treatment for some patients.
  • Systems to manage risk, issues and performance were not effective due to capacity and flow issues.

However:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
  • Pain relief was not always given to some patients when they needed it.
  • Although staff respected patient’s privacy and dignity, corridor care meant they could not provide private and dignified care to all patients.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services.

How we carried out the inspection  

We carried out an unannounced inspection of the urgent and emergency care services over 3 days. We went to the unit on the late evening of the first day and then spent 2 further days on site.

The team comprised a CQC lead inspector, a CQC team inspector, a CQC inspection manager and a CQC medicines inspector. We were accompanied by 2 specialist advisors who were a senior emergency department nurse and a consultant in emergency care.

During our inspection we spoke to 10 patients and 4 relatives and looked at 8 sets of patient records.

We interviewed 28 members of staff including nurses, doctors, healthcare assistants, senior managers, staff from the professions allied to medicine and ancillary workers.

The inspection team was overseen by Charlotte Rudge, Interim Deputy Director for Operations.  

9 December 2020

During an inspection looking at part of the service

Our rating of the location stayed the same. We rated it requires improvement.

Summary of services at Worcestershire Royal Hospital

Worcestershire Acute Hospitals NHS Trust was established in April 2000 and provides a service across five sites: Worcestershire Royal Hospital (WRH); Alexandra Hospital (AH); Kidderminster Hospital and Treatment Centre (KHTC); Evesham Hospital (EH); and Malvern Community Hospital.

Worcestershire Acute Hospitals NHS Trust provides acute healthcare services to a population of around 580,000 in Worcestershire and the surrounding counties. The trust provides maternity services to women living across the county of Worcestershire. Outpatient maternity services are provided on the WRH, AH and KHTC sites. There are also six community midwifery teams and five continuity of carer teams based at various locations across the county.

The maternity service is managed through the trust’s women and children’s division. The current leadership structure includes a clinical director, a directorate manager, and a director of midwifery. Obstetricians, matrons, and senior midwives also support the senior leadership team.

The maternity service provides consultant and midwife-led antenatal, intrapartum and postnatal care. There are 62 inpatient beds, spread across the delivery suite, the Meadow Birth Centre, and antenatal and postnatal wards, transitional care unit and neonatal unit. Outpatient services include antenatal clinics, a maternity day assessment unit, a triage unit and screening services. Community midwifery services are provided at local children’s centres, GP practices or at the patients’ home address.

The consultant led delivery suite has nine delivery rooms plus a pool room, two dedicated obstetric theatres and a two-bedded recovery bay for post-operative women. The Meadow Birth Centre is the midwife-led birthing unit and consists of three low-risk birthing rooms each with birthing pools and the dedicated bereavement suite which had a garden area attached.

There is a 14-bedded antenatal ward with six beds for elective gynaecology patients, and a 35-bedded postnatal ward which includes a nine-bedded transitional care unit. The maternity service has an antenatal outpatient department and includes screening services, the early pregnancy assessment clinic and antenatal clinics.

Community midwives provide care for women and their babies both during the antenatal and postnatal period. They also provide a home birth service. The total number of home deliveries for 2020 (January to December inclusive) was 121, 2.5% of all deliveries for the period.

Due to the COVID-19 pandemic there had been changes in the way services were delivered. The Meadow Birth Centre had been reallocated as a specific COVID-19 area for women. There had been no community-based parent education or breast-feeding support sessions in line with social distancing advice. Women were directed to access reputable websites for guidance, or phone the community midwife for advice. The service had also temporarily suspended their tongue tie service.

From July 2019 to June 2020 the service reported 4,961 deliveries. This was a 4.5% decrease from the previous 12 months, where 5,195 deliveries were reported.

Activity:

  • Caesarean sections rate was 29.9%
  • Instrumental delivery rate was 10.7%
  • Non-interventional delivery rate was 59.3% (-1.28% compared to the previous year).
  • Midwives numbers 203.8 (in post) whole time equivalents (WTE) September 2020. Funded is 213 WTE midwives.
  • Consultant obstetricians/gynaecologists numbers: 20.9 WTE September 2020
  • There were no never events between December 2019 and November 2020 in maternity or gynaecology (NHS England and NHS Improvement)
  • There were no current CQC maternity alerts under consideration by the CQC outliers panel.
  • Ratio of births to midwifery staff: 22.4 July 2019 to June 2020.
  • Ratio of senior midwives to midwives: 0.21 September 2020
  • Four maternal deaths were reported to the Healthcare Service Investigation Branch (HSIB) since the start of 2018 (2 in 2019; 2 in 2020). [July 19, Nov 19, Mar 20, Dec 20]

We last inspected maternity services in June 2018. We rated the service as requires improvement for safe, and good for effective, caring, responsive and well-led. The service was rated as good overall.

During the 2018 inspection, we identified some concerns in the safe domain for the maternity service. These included poor compliance with safeguarding adults and children training for medical staff, maternity specific training compliance that did not meet trust targets; prescription charts were not always completed with patient’s weight or allergy status, which was not in line with national standards; poor compliance with cardiotocography trace peer reviews; and not all staff had received an annual appraisal.

We were concerned about maternity services at the trust following four whistle-blower enquiries we received between July and September 2020, and information we received from the trust. Therefore, we carried out an unannounced focused maternity inspection at Worcestershire Royal Hospital on 9 December 2020.

We inspected clinical areas in the service, including the delivery suite, Meadow Birth Centre, ante natal and post-natal wards, the antenatal clinic, and the maternity day assessment unit. We spoke with 19 staff, including service leads, midwives, medical staff, and student midwives. We reviewed 11 sets of patient records and 11 prescription charts and observed staff providing care and treatment to women.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activities. We carried out a focused inspection related to the concerns raised, this did not include all our key lines of enquiry. As a result of this inspection, we rated safe and well-led as requires improvement, and effective as good.

Overall the service was rated as requires improvement.

Following this inspection, we issued two requirement notices to the trust as we found improvement was required in several areas. We will make sure that the trust takes the necessary action to improve its services. We will continue to monitor the safety and quality of services through our continuing relationship with the trust and our regular inspections.

16 December 2019

During an inspection looking at part of the service

We carried out an unannounced focused inspection of the emergency department at Worcestershire Royal Hospital on 16 December 2019, in response to concerning information we had received about the care of patients in this department. At the time of our inspection the department was under adverse pressure.We did not inspect any other core service or wards at this hospital. During this inspection we inspected using our focused inspection methodology.We found that:

Ambulance handover delays remained a challenge, with some patients experiencing delays of more than 3 hours from arrival by ambulance to being handed over to trust staff for commencement of care and treatment. Whilst the trust had procedures in place for assessing patients who experienced delays of 60 minutes or more from arrival to handover, staff were not consistently following these procedures; further, the trust had a lack of robust assurance and oversight for ensuring such procedures were consistently followed. National standards require trusts to ensure that 95% of patients arriving by ambulance are clinically assessed within 15 minutes of arrival. The trust had not met this target in any month between January 2019 and December 2019. The trust could not demonstrate any sustained improvement in this metric.

The trust monitored patients who arrived by ambulance who did not receive a clinical assessment within 15 minutes but had received a clinical assessment within 60 minutes. This metric also demonstrated consistent poor performance without any marked improvement between January 2019 and December 2019.

As a result of this inspection, and due to the level of concern we had, CQC opted to use their urgent enforcement powers to ensure the provider took swift action to protect service users from harm. We imposed a range of conditions on the provider's registration including, but not limited to requiring the trust to ensure that all patients who arrived by ambulance were clinically assessed within 15 minutes, in order the trust could determine the sickest patients or those patients who required time critical care or treatment.

Patient's continued to be nursed along the corridor for extended periods of time. The total number of hours patient's spent on the corridor was reported as 9,530 hours in January 2019 and 7,952 hours in December 2019. A review of data for each month in 2019 suggested limited overall improvement, suggesting staff had normalised the use of the corridor. as compared to the use of the corridor only being reserved for times of significant surge.

The trust had recognised an increase in the number of patients who sustained pressure damage whilst waiting in the emergency department (specifically, there had been an increase in grade two pressure ulcers being attributed to the emergency department). The trust had taken action to deploy a tissue viability nurse to support ED nursing staff, as well as ensuring there was sufficient pressure relieving devices for staff to use. However, patients remained on trolleys for extended periods of time due to a lack of space in the department for patients to be transferred on to a more appropriate hospital bed. We therefore imposed a second condition on the provider's registration requiring them to ensure staff undertook dynamic risk assessments of all patients in the ED to ensure patients were managed in the most appropriate clinical area.

Patient's referred to medical and surgical specialties could expect to wait extended periods of time before being reviewed. Staff were not effectively using the trust escalation protocol. There had been some marginal improvement in the average time to specialty review between February 2019 (104 minutes (compared to 146 minutes in January 2019) and July 2019 (109 minutes). However, performance started to deteriorate thereafter, increasing to 130 minutes in December 2019. We therefore imposed a third condition on the provider's registration which required them to ensure they operated an effective professional standards protocol so patients received a timely review by specialty teams.

There was a general poor understanding and use of the national operational pressures escalation levels (OPEL) protocol issued by NHS Improvement and NHS England. Front-line staff assumed they were at the highest level of escalation (OPEL 4) on the day of the inspection however the trust executive team reported the trust was at OPEL 2. This was despite there being 18 patients being nursed on the corridor, three or more ambulances experiencing delays of one hour or more in handing over their patients, and 19 patients waiting for an inpatient bed to become available.

There were insufficient numbers of nursing staff deployed to support the children's area of the emergency department, in line with national recommendations. During the inspection, six children and their carer/parents were left in the department with only a student nurse present for a period of at least ten minutes. The trust executive team considered this not to be a risk and referred CQC to the trust standard operating procedure which required parents or carers to contact a member of staff should they be concerned about their child. We considered this to be inappropriate in that parents/carers may not be sufficiently trained to recognise an infant, child or young person whose clinical condition was deteriorating. The trust subsequently amended the standard operating procedure for the children's area of the emergency department and provided assurances that two members of staff were rostered at all times to support the area.

As a result of this inspection, we have identified areas which the trust make take to ensure they comply with relevant elements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 fundamental standards.

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

Importantly, the trust must:

  • The trust must ensure that ambulance handovers are timely and effective.
  • The trust must ensure that all patients are assessed in a timely manner and ensure that patients receive assessment and treatment in appropriate environments.
  • The trust must ensure that patients receive medical and specialty reviews in a timely manner.
  • The trust must ensure that consultant and nurse cover in the department meets national guidelines. Trainee consultants must not be classed as ‘consultants’ on the staffing rota.
  • Fully implement the trust wide actions to reduce overcrowding in the department.
  • The trust must ensure that the privacy and dignity of patients receiving care and treatment in the emergency department is maintained at all times.

Following this inspection, we have taken urgent enforcement action, to impose conditions on the trust's registration to make urgent improvements in the quality and safety of care for patients.

Professor Edward Baker

Chief Inspector of Hospitals

14 May to 29 May 2019

During a routine inspection

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

  • The safe key question was rated as requires improvement overall at this hospital.
  • The responsive key question was rated as requires improvement overall.
  • The well led key question was rated as requires improvement overall.
  • We found regulatory breaches of the Health and Social care Act 2008 in urgent and emergency care, medical care, surgery, outpatients and diagnostic imaging.

However,

  • The effective key question was rated as good overall.
  • The caring key question was rated as good overall.

14 January 2019

During an inspection looking at part of the service

We carried out an unannounced focused inspection of the emergency department (ED) at Worcestershire Royal Hospital on 14 January 2019, in response to concerning information we had received in relation to care of patients in this department.

We did not inspect any other core service or wards at this hospital, however we did visit the admissions areas to discuss patient flow from the ED. During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry and we did not rate this service at this inspection.

This was a focused inspection to review concerns relating to the department. It took place between 1pm and 9.30pm on Monday 14 January 2019. We found that:

  • Patients could not access the service when they needed to due to overcrowding. The time of arrival by ambulance to the initial assessment had increased. The time to treatment had increased and was worse than the previous year.
  • Due to overcrowding in the ED seen on the inspection, there were significant delays in handing over patients from ambulances to the ED.
  • Whilst the service mostly had suitable premises, there was insufficient space to accommodate all the patients in the department at the time of the inspection. The department was overcrowded with many patients being cared for in corridors.
  • Whilst risks to patients were generally assessed and their safety monitored and managed, not all patients received assessment and treatment in a timely manner due to overcrowding. We were not assured that all patients received treatment in a timely manner at the time of the inspection. The trust and these patients were reviewed and the trust reported no harm had been experienced.
  • There were delays in some patients being assessed by speciality doctors.
  • There was not always sufficient staff in the children’s ED during the inspection. We raised this as a concern and the trust took action to address this.
  • It was not clear that there were sufficient medical staff to manage the increased demand or activity of the ED at the time of inspection. Some doctors told us that they did not feel the department was safe due to overcrowding.

However:

  • Staff cared for patients with compassion at all times during the inspection. Staff were friendly, professional and caring at all times even when under extreme pressure due to overcrowding in the department. Staff did everything within their capacity to maintain patient privacy and dignity in times of overcrowding.
  • Feedback from parents and relatives confirmed staff treated them well and with kindness. Staff involved patients and those close to them in decisions about their care and treatment.
  • Patients received a comprehensive assessment in line with clinical pathways and protocols. Risk assessments were completed accurately, and actions taken to address any concerns. The service had introduced a tool for recognising patients at risk which promoted actions to be taken to prevent deterioration.
  • The service generally had suitable equipment which was easy to access and ready for use.
  • There were enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care in the adult ED.
  • There were processes in place to escalate concerns regarding patients’ safety/care or treatment. The trust had policies in place for responding when demand exceeded capacity in the ED.
  • Staff worked collaboratively at all times during the inspection to provide patient care and treatment.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a documented vision for what it wanted to achieve. Plans were being implemented to ease overcrowding in the department were in development with involvement from staff, patients, and key groups representing the local community.
  • The service had a systematic approach to continually monitor the quality of its services. The service monitored activity and performance and used data to identify areas for improvement.
  • Staff and managers across the service promoted a positive culture that supported and valued one and other. Staff were respectful of each other and demonstrated an understanding of the pressures and a common goal.

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

Importantly, the trust must:

  • Reduce the number of ambulance handover delays.
  • Ensure all patients receive timely initial clinical assessments.
  • Ensure all patients are seen by emergency department doctors and speciality doctors when needed.
  • Reduce the number of patients cared for in corridor areas.

In addition, the trust should:

  • Fully implement the trust wide actions to reduce overcrowding in the department.
  • Monitor that children using the service are not left unattended for periods of time.
  • Implement additional training of staff who support the ED in times of surges in demand to complete the Global Risk Assessment Tool.
  • Ensure that there is sufficient medical staff to ensure timely assessments and treatment.

Following this inspection, we considered enforcement action, however, we were not assured that conditions applied would benefit or improve the situation or manage the risks. The trust were therefore issued with a requirement notice.

Professor Edward Baker

Chief Inspector of Hospitals

23 January to 22 March 2018

During a routine inspection

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.

1 Nov to 8 Nov 2017

During a routine inspection

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

  • Not all issues highlighted in the section 29A warning notices and previous inspections had been addressed in the emergency department (ED).
  • The department remained severely crowded and measures previously identified to prevent this had produced little significant improvement. The patient safety matrix did not contain guidance about what to do in these circumstances.
  • Routine use of the corridor to care for patients over long periods of time was previously highlighted as a major patient safety concern.
  • There were delays of up to six hours for specialist doctors to respond to patients who had been referred to them for treatment.
  • Compliance with mandatory training did not meet the trust target of 90% in the majority of modules. Not all nursing staff had received basic or intermediate life support training.
  • Staff compliance with safeguarding children’s training did not meet national recommendations.
  • There was no privacy and little confidentiality for patients waiting on trolleys in the corridor. ED staff were frustrated about this situation and were as discrete and considerate as possible. Patients were moved to a more private cubicle when intimate care was needed.
  • Many patients could not access the service when they needed it.
  • Patients spent longer in this ED than at other trusts in England. The monthly total time spent in ED for all patients was consistently worse than the England average from November 2016 to September 2017. During our inspection patients who needed to be admitted to a ward were spending up to 20 hours in the department.
  • Emergency departments in England are expected to ensure that 95% of their patients are admitted, transferred or discharged within four hours of arrival. The standard had not been met in any month at the Worcestershire Royal Hospital since November 2013. From November 2016 to October 2017, 62.8% of patients were admitted, transferred or discharged within four hours of arrival.
  • There was no documented local strategy for the emergency department.
  • Risk management processes remained an area of concern. The ED did not have its own risk register. It was unclear how staff used all risk documents effectively to manage and mitigate risks.
  • Medicine ward nurse staffing levels were frequently below the nurse establishment particularly at night. Ward managers escalated any concerns with patient acuity and staffing to arrange additional support where possible.
  • Escalation areas, such as the trauma assessment unit, were not always fully equipped to meet the demands of inpatient care.
  • The stroke service did not provide a seven day transient ischaemic attack clinic in line with national guidance.
  • There was a high number of patient bed moves between 10pm and 8am.
  • Patient complaints were not responded to within the 25 days outlined in trust policy.

However:

  • Staff cared for patients with compassion.
  • Adult nurse staffing levels within the department meet national guidance. Since November 2017, there were sufficient registered children’s nurses in post to ensure that the ED had at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in EDs.
  • Staff kept appropriate records of patients’ care and treatment.
  • Equipment, clinical waste and specimens were stored, labelled and handled appropriately throughout the ED.
  • Patient risk assessments had been completed correctly and in a timely manner.
  • The ED provided care and treatment that was based on national guidance.
  • Reasonable adjustments had been made for patients with dementia, a learning disability, gender and cultural needs.
  • Medicines were stored appropriately with processes in place for monitoring usage and safe storage. Medicines were prescribed and administered in line with guidance and patients received the right dose at the right time.
  • There were robust processes in place for the recording, escalation and sharing of learning from incidents.
  • Patient’s pain was assessed and monitored with processes in place to offer appropriate pain control and refer for additional support when necessary.
  • Capacity and flow had been reviewed with ward managers taking the responsibility for pulling patients to speciality wards to ensure that patients were located in the correct environment for their clinical condition.
  • Staff felt supported, able to challenge, and felt listened too.
  • The service used divisional dashboards to review and monitor performance. This was discussed locally within the division and escalated to the trust board for oversight of performance.

12, 12 and 25 April 2017

During an inspection looking at part of the service

The Care Quality Commission (CQC) previously carried out a comprehensive inspection in November 2016, which found that overall; the trust had a rating of 'inadequate'.

We carried out an unannounced focused inspection on 11 and 12 April 2017. We also visited on 25 April 2017, specifically to interview key members of the trust’s senior management team. This was in response to concerns found during our previous comprehensive inspection in November 2016 at Worcestershire Royal Hospital, the Alexandra Hospital Redditch and Kidderminster Hospital and Treatment Centre whereby the trust was served with a Section 29a Warning Notice. The Section 29a Warning Notice required the service to complete a number of actions to ensure compliance with the Health and Social Care Act 2008 Regulations. The trust had produced an action plan, which reflected these requirements as well as additional aims and objectives for the service. This inspection looked specifically at the issues identified in the warning notice and therefore no services were rated as a result of this inspection.

Focused inspections do not look at all five key questions; is it safe, is it effective, is it caring, is it responsive to people’s needs and is it well-led, they focus on the areas indicated by the information that triggered the focused inspection.

The inspection focused on the following services: adult emergency department (ED), medical care, surgery, maternity and gynaecology and children and young people. We inspected parts of the five key questions for these services but did not rate them.

Areas where significant improvements included in the Section 29a Warning Notice had not been made were:

  • In the emergency department (ED), essential risk assessments were not completed when required to keep patients safe from avoidable harm. There were not effective systems in place to assess and manage risks to patients in the ED. Staff did not always identify and respond appropriately to changing risks to patients, including deteriorating health and wellbeing.
  • There was no appropriate mental health room available in the ED within which to safely care for patients.
  • The children’s ED area was not consistently attended by staff except via CCTV surveillance to the nurses/doctors station in the major’s area. Patients and their parents/carers were left alone after assessment and while they waited to see a doctor.
  • There were insufficient numbers of consultants in the ED on duty to meet national guidelines.
  • Staff were not using privacy screens to respect patients’ privacy and dignity whilst being cared for in the ED corridor area. Patients were given meals in their hands by the staff but there was nowhere to rest plates and cups so they could eat their food with dignity. Routine nursing observations, conversations about care and eating of meals were undertaken in a public space with other patients and relatives passing by.
  • There was no effective plan in place to effectively manage the overcrowding in the ED. Actions already identified by the trust as necessary to mitigate patient care being compromised from overcrowding in the ED were either yet to be implemented or were not effective in reducing the risk. There was no tangible improvement in performance. The ED’s patient safety matrix showed ‘critical’ or ‘overwhelmed’ for much of the two days we visited the trust. Patients were being cared for on trollies in the ED corridor. This action had become an institutionalised means of managing the ‘flow’ through the ED, including on occasions when ED cubicles were empty. The number of patients waiting between four and twelve hours to be admitted or discharged was consistently higher than the national average. The trust senior leaders were not effectively addressing these risks through a whole hospital approach.
  • In medical care and surgical wards visited, venous thromboembolism assessments and 24-hour reassessments were not always carried out for all patients in line with trust and national guidance.
  • We observed that staff did not always wash their hands before and after patient contact in ED, medical care and surgical wards in line with national guidance.
  • In the ED, time critical medications were not always administered to patients who had been assessed as needing them on time.
  • Patients declining to take prescribed medication on Evergreen 1 ward and Beech ward were not always referred to medical staff for a review and were not always reviewed by medical staff. We raised this as an urgent concern with senior staff.
  • In the surgery service, anticoagulation medicine had not always been administered as prescribed.
  • Fridge temperatures for the storage of medicines in exceeded recommended ranges in two surgical areas visited and in the maternity and gynaecology service, staff did not consistently follow trust processes for storing medicines at the recommended temperatures, despite there being policies in place.
  • Although perinatal mortality and morbidity meetings were minuted, there was no evidence that action was taken to address learning from case reviews. We were not assured an effective system was in place to ensure learning from these meetings was shared, and actions were taken to improve the safety and quality of patient care. In addition were not multidisciplinary and only attended by medical staff in the children and young people’s service.
  • Whilst some improvements were observed in completion of Patient Early Warning Scores charts, not all charts had been completed in accordance with trust policy. We also found there was not always evidence of appropriate escalation for medical review when required.
  • In the paediatric ward, one to one care for patients with mental health needs was not consistently provided by a member of staff with appropriate training and reliance was, on occasion, placed on parents or carers.

Additional areas of concern, that were not included in the Section 29a Warning Notice, that we found during this inspection were:

  • There was an inconsistent approach to following both the ED’s child and adult safeguarding processes. Staff training compliance for both adult and children’s safeguarding was a significant concern and very low, significantly worse than the trust target.
  • Pain relief given to children in the ED was not evaluated for its effectiveness for all patients.
  • There was no significant change in streaming for self-presenting patients with an operating model based on urgent care GP streaming.
  • On the haematology ward staff handled food with their hands without the use of gloves; this was not in line with national and trust guidelines.
  • The recording of patients’ weights on drug charts on some medical care wards had not improved.
  • In medical care wards, only 31% of staff were up-to-date on medicines’ management training and this was below the trust target of 90%.
  • Patient records were left unsecured on a number of medical care wards we visited and there was a risk that personal information was available to members of the public. This was raised as a concern during the last inspection in November 2016.
  • Some risk assessment records in medical care wards were not routinely completed in their entirety, including elderly patient risk assessments and sepsis bundle assessments. We were not assured that inpatient wards were effectively following the trust’s sepsis pathway when required.
  • In the surgery service, some patients were prescribed inappropriate doses of anticoagulation medication without regard to their weight.
  • Some surgical wards did not display their planned staff on duty only their actual staff on duty.
  • Visitors to surgical wards could see patient identification details on electronic white boards.
  • Senior leaders in surgery were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and hand hygiene. However, we saw examples throughout the service where compliance with trust and national guidance had not significantly improved. When risks had been escalated, there was a lack of follow up and resolution. Effective action following the reporting of high fridge temperatures for storage of medicines was not evident.
  • There was no system in place to ensure medicines stored in the emergency gynaecology assessment unit were safe for patient use. Immediate action was taken by the trust once we raised this as a concern.
  • In the maternity and gynaecology service, training data showed that 86% of midwifery staff and 53% of medical staff had completed safeguarding children level three training. This was an improvement from our previous inspection. However, compliance was still below the trust target of 90%, particularly with medical staff.
  • The waiting room and toilet facilities for patients attending the emergency gynaecology assessment unit were mixed sex, as these were shared with the respiratory outpatient clinic. Furthermore, this assessment unit did not have appropriate facilities such as bathrooms, to facilitate personal care for patients who had to stay overnight at times of increased bed pressures.
  • In the children and young people’s service, safeguarding children’s level three training was below the trust’s target of 85% and future training sessions had been cancelled. Compliance rates for this essential training were no better or worse in April 2017 in some staff teams compared to November 2016.
  • The children and young people’s service became busy at times and staff said activity had increased since the service reconfiguration. However, there was limited monitoring of assessment and admission to inpatient areas. This meant that service leaders were not in a position to understand current and future performance and to be able to drive improvements for better patient outcomes.
  • The risk register for the children and young people’s service had been updated to include two additional risks identified during the November 2016 inspection, but not all risks found on this inspection had been identified, assessed, and recorded. For example, the increased activity in the service following the transformation process.

Areas where we found improvements included in the Section 29a Warning Notice had been made were:

  • Staff felt supported to report incidents including occasions when they judged patients unsafe because the emergency department (ED) was ‘overwhelmed’. An electronic patient safety matrix and ED occupancy tool was in place showing real time data about ED capacity, which gave oversight of the pressures in ED.
  • The trust had implemented a ‘Full Capacity Protocol’ that was activated when the emergency department safety matrix status showed critical or overwhelmed status.
  • Most patients were assessed within 15 minutes of arriving to the ED by senior nurses.
  • Nurse breaks in the clinical decision unit were now covered by other nurses. Most ED staff were attentive, discrete as possible and considerate to patients.
  • During this inspection, all 21 records looked on the acute stroke unit, Avon 3, Evergreen 1 and 2 wards showed NEWS charts were completed fully and patients were escalated for medical review appropriately when required.
  • There had been improvements in the monitoring of medicines’ fridge temperatures in medical care wards visited.
  • All staff we saw in surgical clinical areas had ‘arms bare below elbows’.
  • Infection control protocols were followed in the children and young people’s service.
  • There were appropriate arrangements in place for management of medicines in the children and young people’s service, which included their safe storage.
  • All patients admitted to the paediatric ward because of an episode of self-harm or attempted suicide had a risk assessment on file.

Areas of improvement, that were not included in the Section 29a Warning Notice, found from the last inspection were:

  • There was a senior initial assessment nursing system in place for patients arriving by ambulance to the ED. Staff told us the flow had improved since two ‘ambulance access’ cubicles were specifically allocated in the department.
  • Health care assistants were undertaking comfort rounds for patients’ cared for in the corridor area of ED, completing documentation and giving patients a leaflet explaining why they were waiting in a corridor.
  • The ED was managed locally by the matron and senior ED consultant. Staff were very committed to their work and doing the best they could for their patients even under regular and consistent heavy pressure.
  • The medical care service had taken steps to improve the management of medical patients on non-medical speciality wards.
  • The medical care service had improved patient flow in the hospital to minimise patient moves.
  • The trust had implemented a new quality dashboard, known as the safety and quality information dashboard (SQuID). This was being used as to drive improvement and had improved staff’s understanding of safety and quality in the service.
  • There were fewer reported surgical staff shortages and shortfalls were escalated and risk assessed so patients’ needs were met.
  • Effective systems had been introduced to ensure emergency equipment was checked daily in the maternity and gynaecology service. Equipment was well maintained and had been safety tested to ensure it was fit for purpose.
  • The hospital did not have a dedicated gynaecology inpatient ward. This meant some patients stayed overnight in the outpatient emergency gynaecology assessment unit and were nursed in medical wards. However, the trust had put processes in place to ensure patients were cared for in environments that were suitable for their needs.
  • Daily ward rounds by a gynaecology consultant and nurse were carried out to ensure gynaecology patients were appropriately reviewed and managed, regardless of location within the trust.
  • Staff caring for gynaecology patients on Beech B1 ward had received training on bereavement care, including early pregnancy loss and the management of miscarriage.
  • Risks identified in the maternity and gynaecology service were reviewed regularly with mitigation and assurances in place. Staff were aware of the risks and the trust board had oversight of the main risks within the service.
  • The majority of staff in the children and young people’s service had been competency assessed in medical devices used to help patients breathe more easily.

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

Importantly, the trust must:

  • Ensure that patients in the ED receive medication prescribed for them at the correct time and interval.
  • Ensure that all patients’ conditions are monitored effectively to enable any deterioration to be quickly identified and care and treatment is provided in a timely way.
  • Ensure that staff complete all of the risk assessments and documentation required to assess the condition of patients and record their care and treatment.
  • Ensure all patients have a venous thromboembolism (VTE) assessment and are reassessed 24 hours after admission in accordance with national guidance.
  • Ensure that the privacy and dignity of all patients in the ED is supported at all times, including when care is provided in corridor areas.
  • Ensure that systems or processes are fully established and operated effectively to assess, monitor and improve the quality and safety of the services provided within the ED.
  • Ensure that systems or processes are fully established and operated effectively to assess, monitor and mitigate the risks relating to the health, safety, and welfare of patients while using the ED.
  • Ensure mental health assessment room in the emergency department is appropriate to meet needs of patients.
  • Ensure the children’s ED area is consistently monitored by staff via appropriate CCTV surveillance at the nurses/doctors station in the major’s area.
  • Ensure patient weights are recorded on drug charts.
  • Ensure there are processes in place to ensure that any medicine omissions are escalated appropriately to the medical team.
  • Where patients refuse to take prescribed medication, ensure it is escalated to the medical team for a review.
  • Ensure all anticoagulation medication is administered as prescribed. All non-administrations must have a valid reason code.
  • Ensure all medicines are stored at the correct temperature. Systems must be in place to ensure medication, which has been stored outside of manufactures recommended ranges, remains safe or is discarded.
  • Ensure patient identifiable information is stored securely and not kept on display
  • Ensure all staff comply with hand hygiene and the use of personal protective equipment policies.
  • Ensure all staff are up-to-date on medicines’ management training.
  • Ensure all staff have completed their Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) training.
  • Ensure all staff have completed the required level of safeguarding training.
  • Ensure all patients in the children and young people’s service with mental health needs have the appropriate level of staff one to one care in accordance with their risk assessments.
  • Ensure paediatric assessment area activity is monitored effectively so the service can drive improvements in patient flow.
  • Ensure the risk registers reflects all significant risks in the service and effective mitigating actions are in place to reduce potential risks to patients.
  • Ensure safeguarding referrals are made when required for patients seen in the ED.
  • Ensure the sepsis pathway is fully embedded in inpatient wards.

In addition the trust should:

  • Achieve the required numbers of consultants in the ED on duty to meet national guidelines.
  • Continue to monitor the effectiveness of the sepsis pathway in the ED.
  • Review systems in place so food is served using either gloves or tong in accordance with trust policy.
  • Review processes for maintaining patient confidentiality during nursing handovers.
  • Review systems in place to manage the safe and effective use of controlled drugs within the discharge lounge.
  • Consider displaying actual and planned staff numbers in all clinical areas.
  • Consider using a standard risk assessment to assess and identify the needs of patients admitted to the paediatric ward with mental health needs. All forms should be kept updated as required for the duration of the patient’s stay.
  • Review how pain relief given to children in the emergency department is evaluated for its effectiveness for all patients.
  • Consider possible changes in streaming for self-presenting patients with an operating model based on urgent care GP streaming.
  • Review the waiting room, bathroom and toilet facilities for patients attending the emergency gynaecology assessment unit as these were mixed sex being shared with the respiratory outpatient clinic.
  • Review systems in place for the monitoring of assessment and admission to inpatient areas in the children and young people’s service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

22 to 25 November and 8 December 2016

During an inspection looking at part of the service

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire, with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire, as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust, we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection from 7 to 15 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

Overall, we rated Worcestershire Royal Hospital as inadequate, with three of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

  • Crowding and poor flow were having a significant impact on patient care and experience. The flow of patients in the emergency department (ED) was often blocked by internal capacity issues in the hospital. The trust was consistently not achieving the national target to admit or discharge 95% of patients within four hours of arrival.
  • Due to patient care being carried out in corridors and small cubicles in the ED there was a lack of privacy and dignity for patients in these areas.
  • There were not enough consultants to provide 16 hours of consultant cover within the ED each day, in line with national guidance.
  • Not all staff cleaned their hands before and after contact with patients and some staff did not change their gloves or aprons after each task. This meant that infection prevention and control practices were not in line with trust policy or national guidance throughout the hospital.
  • Staff did not feel valued or listened to by divisional and executive teams. This led to low morale and frustration amongst staff.
  • Robust and appropriate systems were not in place for carrying out and monitoring venous thromboembolism (VTE) assessments, which contravened National Institute for Health and Care Excellence guidance.
  • Medical notes were not always locked away safely.
  • The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) results were worse than expected.
  • Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
  • Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
  • Assessments for paediatric patients’ requirement of 1:1 care from a mental health nurse were not always undertaken and care was not consistently provided by a member of staff with appropriate training.
  • Not all equipment had been safety tested and the emergency neonatal trolley in the delivery suite was not always checked daily.
  • Medicines management was poor with medicines that required cool storage being stored in fridges which were either below or above the manufacturers recommended temperature. Emergency medicines were not protected from tampering
  • There was inadequate review and document control of protocols for standard x-ray examinations. Some protocols were in a handwritten format with alterations made by various members of staff without apparent ratification.
  • Patient feedback during our inspection was very positive about the nursing and medical staff that provided their care. Patients were treated with compassion and respect by staff
  • There was a positive culture of incident reporting and incidents were reported appropriately and in-line with trust policy. Staff said they received feedback after reporting an incident. However we found in the ED department some senior staff discouraged the reporting of incidents relating to overcrowding.
  • The critical care team were able to ensure safety across the county wide service by transferring skilled staff to assist with the management of patient care according to need.
  • We observed close working between the specialist palliative care team and ED staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

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

Action the hospital MUST take to improve

  • Ensure patients’ privacy, dignity and confidentiality is maintained at all times. For example, patients staying overnight in the gynaecology assessment unit.
  • Ensure that patient documentation, including risk assessments, are always completed accurately and routinely to assess the health and safety of patients. This should include elderly patient risk assessments, dementia assessments, venous thromboembolism assessments, sepsis bundle assessments and fluid balance charts.
  • Use a standard risk assessment to assess and identify the needs of patients admitted to wards with mental health needs. This must include details of whether the patient requires 1:1 or 2:1 care from a specialist mental health nurse, and the level of care provided.
  • Ensure nursing documentation on high dependency units is contemporaneous with detailed accounts of the day’s activities completed.
  • Ensure that patient weights are recorded on their drug charts.
  • Ensure that there is clear oversight of the deterioration of patients and the National Early Warning Score chart is completed accurately.
  • Ensure that the Paediatric Early Warning Score charts are consistently completed in a timely manner and accurately.
  • Ensure that patients are escalated as a result of the Paediatric Early Warning Score where they trigger a deteriorating patient.
  • Ensure that the eligibility criteria for the clinical decisions unit is followed to ensure appropriate patients are admitted.
  • Ensure there is access to 24-hour interventional radiology services.
  • Ensure staff are aware of ligature points.
  • Establish identification of female genital mutilation training that is to be completed by all staff working in children and young people’s services.
  • Ensure that patients under child and adolescent mental health services receive care from appropriately trained staff at all times.
  • Ensure that staff providing care for children requiring continuous positive air pressure or AIRvlo have appropriate training or up to date competencies to use this equipment safely.
  • Ensure that there is an appropriate mental health room in the emergency department to care for patients presenting with mental health conditions that complies with national guidance.
  • Ensure that flow in the hospital is maintained to prevent patients being treated in the emergency department corridors for extended periods of time.
  • Ensure that children are not left unattended in the emergency department paediatric area.
  • Ensure that there is a robust system in place to make sure that all electrical equipment has safety checks as recommended by the manufacturer.
  • Ensure that equipment is checked as per policy, particularly in midwifery services.
  • Ensure that patients are cared for in a safe environment that has the appropriate equipment to facilitate care to a deteriorating patient.
  • Ensure that medicines are always stored within the recommended temperature ranges to ensure their efficacy or safety.
  • Ensure prompt investigation of any medicines which are unaccounted for.
  • Review arrangements around storage of intravenous fluids for emergency use to ensure patient safety.
  • Ensure that medicines are always administered to patients as prescribed.
  • Ensure infection prevention and control procedures are always carried out as per trust policy and national guidelines.
  • Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
  • Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
  • Ensure they are carrying out patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
  • Ensure safeguarding checks are made consistently.
  • Ensure information relating to the children at risk register is accessible.
  • Ensure that incidents are accurately reported and investigated.
  • Ensure that staff receive appropriate training to enable the correct categorising of incidents.
  • Ensure that staff are not discouraged from reporting incidents relating to capacity and corridor care.
  • Ensure that incidents that need reporting to external authorities are completed.
  • Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
  • Ensure all mortality and morbidity meetings are recorded and lessons are learnt.
  • Ensure there are systems and processes established in surgical service to address identified risks, such as cancelled operations, bed capacity and access to emergency theatres.
  • Ensure divisional management teams are aware of patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
  • Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
  • Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
  • Develop a clearly defined business plan for paediatrics, which considers the risks to the service and incorporates a vision and plans for service improvement. The plan must have clear objectives and milestones, supported by actions to ensure objectives are realised.
  • Ensure the risk register identifies and mitigates all risks.
  • Ensure there is a review of the paediatric assessment area and subsequent admissions to identify and resolve potential issues with flow and capacity.
  • Ensure the bed management plans for children and young people, devised to deal with escalation issues for staffing shortages or high bed occupancy, is up to date.
  • Ensure there is a strategy is in place for diagnostic and imaging services that staff are aware of.
  • Ensure patient notes are stored securely and safely.
  • Ensure staff complete the required level of safeguarding training, including safeguarding children.
  • Ensure staff compliance with mandatory training meets the trust target of 90%.
  • Ensure all staff receive an annual appraisal.
  • Ensure there are sufficient registered children’s nurses in post to make certain that the emergency department has at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in emergency departments.
  • Ensure that only an appropriately trained staff member is left in charge of a ward to care for patients.

In addition, the trust should:

  • Ensure lessons learned from incidents are shared.
  • Ensure all equipment is in date and fit for purpose.
  • Ensure that staff follow the policy on the use of the ‘I am clean stickers’, particularly in the emergency department.
  • Ensure that all needles and cleaning chemicals are kept securely.
  • All departmental policies and procedures, including safeguarding policies, should be reviewed and revised to ensure they are reflective of up to date guidance.
  • Ensure that standard operating procedures are in place and are correctly followed, including care of patients within the clinical decisions unit and care of patients within the emergency department corridor.
  • Ensure staff are familiar with the major incident policy and undertake specific training or complete exercises.
  • Ensure that staff are aware of the escalation policies in the trust and were clear on what steps should or be taken during times of increased demand in the emergency department.
  • Ensure that staff are aware of how to use panic buttons or what response would be received.
  • Ensure that the emergency department door which ambulance patients are bought in by is not used as a shortcut for other staff.
  • Ensure there is evidence of mitigating actions taken at trust wide and divisional level to significantly improve the care and environment in the emergency department to ensure patients are safe.
  • Review the agency induction proforma.
  • Ensure NHS Safety Thermometer data is displayed.
  • Ensure that all medical patients have a nominated medical consultant allocated prior to discharge.
  • Review the staffing levels within diagnostic and imagining ensuring adequate cover for the demands for the service, supervision of staff and suitable radiation protection supervisor cover across all sites.
  • Improve the process of review and document control of protocols for standard x-ray examinations.
  • Develop a clinical audit plan that includes local priorities and audits completed on a timely basis. This should include clinical audits that meet the requirements of Ionising Radiation (Medical Exposure) Regulations 2000.
  • Ensure action plans include sufficient detail to address identified concerns.
  • Share results and action plans from national audits with all levels of staff to improve patient outcomes.
  • The maternity service should conduct audits of the care of women with termination of pregnancies and the completion of their maternal early warning score; Worcestershire Obstetric Warning score.
  • Ensure that all cardiotocograph traces have evidence of fresh eye reviews every two hours.
  • Ensure that patients receive pain relief in a timely way.
  • Ensure that patients are appropriately assessed to have a Deprivation of Liberty Safeguard implemented, where required.
  • Ensure that additional steps are taken to maintain patients’ privacy and dignity when nursed in mixed sex areas and during nursing handovers.
  • Provide a follow up service for patients discharged from critical care with access to consultant and nurses.
  • Review the choices offered to patients about where they are discharged to for continuing care.
  • Reduce the number of cancelled of operations in line with the national average of 6%.
  • Review the high levels of unplanned medical admission onto surgical wards, resulting in some cancelled operations.
  • Put arrangements in place to limit the number of gynaecology patients being nursed on general wards.
  • Review the capacity in emergency theatres.
  • Ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for emergency departments.
  • Ensure delays in ambulance handover times are reduced to meet the national targets.
  • Ensure initial patient treatment times are reduced to meet the national target for 95% of patients attending the emergency department to be admitted, discharged or transferred within four hours.
  • Ensure paediatric patients are directed to the paediatric waiting area in the emergency department.
  • Ensure there are appropriate waiting room and toilet facilities for patients using the gynaecology assessment unit.
  • Ensure there are clear pathways in place to support patients with complex needs, such as a learning disability and patients living with dementia, particularly within the emergency department, gynaecology and maternity.
  • Ensure that staff are aware of how to access full patient information leaflets in an alternate language other than English.
  • Ensure that all complaints are responded to in line with the trust policy.
  • Ensure that health and wellbeing of staff is promoted, including encouragement to take their allocated breaks, particularly in the emergency department.
  • Ensure that staff have an awareness of the trust's strategy.
  • Ensure that senior trust wide leaders have an accurate overview of the care and environment in the emergency department.
  • Ensure there is radiology representation at divisional level.
  • Review the radiation protection governance and infrastructure to ensure compliance with statutory radiation regulations.
  • Consider involving staff in strategic plans and developments within surgical services.
  • Ensure visibility of the executive team.
  • Develop a strategy to monitor the implementation of the gynaecology vision.
  • Undertake a ligature audit in the paediatric department.
  • Improve the process of risk rating and replacement of diagnostic and imaging equipment.
  • Ensure there are consistent mortality review group meetings in order to review the Hospital Standardised Mortality Ratio and Summary Hospital-level Mortality Indicator across the service.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the section 29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

14-17th July 2015

During a routine inspection

Worcestershire Acute Hospitals NHS Trust (WAHNHST) was established on 1 April 2000 to cover all acute services in Worcestershire with approximately 900 beds. It provides a wide range of services to a population of around 570,000 people in Worcestershire as well as caring for patients from surrounding counties and further afield.

The Trust includes four hospital sites, Worcestershire Royal Hospital (WRH), Alexandra Hospital in Redditch (AHR) Kidderminster Treatment Centre (KTC) and one day ward and a theatre at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust

Worcestershire Royal Hospital is the newest and largest of the three sites. It was built under the private finance Initiative (PFI) and opened in 2002. It has 500 beds and serves a local population of more than 550,000, and provides specialist services for the whole of Worcestershire including stroke services and cardiac stenting. It has nine operating theatre including four laminar theatres, a level 2 neonatal unit and a cardiac catheterization laboratory

We carried out this inspection between14th and 17th July 2015 as part of our comprehensive inspection programme, and undertook unannounced inspections at Worcestershire Royal Hospital on 26th and 27th July 2015

Overall, we rated Worcestershire Royal Hospital as inadequate, with 2 of the 5 key questions we always ask being inadequate (safe and well-led)

Two of the 8 core services (Maternity and gynaecology, and children's and young peoples services) were rated as inadequate, and four required improvement (Surgery, urgent and emergency care, children's and young peoples services and outpatients and diagnostics). Critical care and end of life care services were rated as good overall.

We have judged the service ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support. We judged that maternity and gynaecology services were outstanding for caring. However, improvements were needed to ensure services were safe, effective, responsive and well-led.

Our Key findings were as follows:

  • Staff we spoke to were friendly and welcoming.
  • Staff were caring, compassionate and kind.
  • Patients did not always receive timely care and treatment. The Emergency Department was consistently failing to meet the national treatment standards. Actions taken to improve access and flow through the ED and the hospital had reduced the time patients waited for initial assessment. Although they still did not meet RCEM guidance, waiting times had reduced since our unannounced inspection in March 2015.
  • Mandatory training compliance was consistently below the trusts target of 95% across all areas.
  • All clinical areas were seen to be tidy and visibly clean.
  • Staff followed the trusts infection control policy. Staff were ‘bare below the elbow’, used sanitising hand gel between patients and used personal protect equipment.
  • Rates for methicillin resistant staphylococcus aureus (MRSA) and Clostridium Difficile for the trust were within acceptable range nationally.
  • There were challenges in recruiting doctors to the hospital. Surgical services, medical care, children’s and young people’s services and maternity and gynaecology especially had high vacancies for middle grade doctors and relied heavily on locum staff. There were not enough consultants in the Emergency Department to meet College of Emergency Medicine’s (CEMs) emergency medicine consultants’ workforce recommendations to provide consultant presence in all EDs for 16 hours a day, 7 days a week as a minimum.
  • Nursing and allied professional staffing was good in critical care. However, midwifery staffing did not meet national recommendations, minimum staffing levels were not always met in children’s and young people’s services, and the outpatients and radiography department had significant vacancies for health care assistants and radiographer’s.
  • There was good feedback from patients about the availability and quality of food and drinks across the hospital. Multiple faith foods were available on request, and choice was supported particularly for children’s and young people, and patients at the end of life.
  • The hospital promoted breastfeeding and was awarded the UNICEF full accreditation in July 2015. Statistics for breastfeeding initiation were consistently better than the trusts own targets.
  • The Malnutrition Universal Scoring Tool (MUST) was used to assess and record patient’s nutrition and hydration status. This was well used in critical care and medical services. However this was not consistently completed for surgical patients where there had been poor nutritional management of some patients, and this was reported as a contributing factor to the development of Grade 3 pressure ulcers.
  • Governance systems were not always effective; incidents were not always reported or investigated in a timely way. Lessons learnt from incidents were not always shared.

We saw several areas of outstanding practice including:

  • There was an exceptional patient observation chart used within the critical care unit. This chart was regularly reviewed and updated with any new developments or patient safety, care quality and outcome measures. The detail within the chart meant few if any crucial measures or indicators were not recorded, regularly reviewed, and deterioration or improvements acted upon.
  • The critical care unit had shown an outstanding example of responsiveness with obtaining and using noise monitoring devices. Patients need peace and quiet for their recovery in critical care, and this had been recognised by the provision of devices that reminded staff when noise levels were increasing to disruptive levels.
  • The pharmacy department operate an innovative seven day clinical service in the ED. This had shown a reduction in some direct admissions to hospital, patient’s treatment had been optimised, patients had been counselled about their medicines to prevent readmission and a significant amount of patients (25%) benefitted from an intervention from the clinical pharmacist to prevent a future admission. The pharmacist told us that they often lectured at healthcare events and had other pharmacists visit the service to share the good practice. The service was planning to roll this practice out to other parts of the trust.
  • We observed outstanding care in the early morning whilst visiting Avon 4 ward and found the staff approach to patients was extremely respectful, compassionate and caring. The atmosphere on the ward at this early hour was relaxed and calm with appropriate low levels of lighting, and staff spoke with each other in low tones to ensure patients were not disturbed whilst asleep.
  • In Maternity and gynaecology services, overwhelmingly we received feedback that staff were excellent and compassionate. Women reported being treated with respect and dignity and having their privacy respected at all times. Outstanding practice was noted with staff having thought about the caring needs of women and devising innovative solutions to support them. This was demonstrated by staff facilitating a teenage buddying system and developing bereavement care pathway for women who suffer pregnancy losses at any gestation. The patient experience midwife was available to support women who were anxious or fearful about pregnancy and childbirth. We observed staff demonstrating a strong, visible person centred culture throughout the service.

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

Importantly, the trust must:

  • Improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards; reduce the unacceptable number of discharges at night; reduce the risks of this situation not enabling patients to be admitted when they needed to be or discharged too early in their care; reduce occupancy to recommended levels; and improve outcomes for patients.
  • Ensure all staff meet the trust wide mandatory training target of 95% compliance
  • Review the HDUs to bring their data collection and provision of care and treatment up to all Faculty of Intensive Care Medicine Core Standards.
  • Ensure there is a timely and appropriate response from the medical teams to the CCU requests for support, follow-up and patient discharge.
  • Risk assessments must be completed and used effectively to prevent avoidable harm such as the development of pressure ulcers.
  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the requirements of the service including the provision of daily ward rounds.
  • Ensure that patient records are accurate, complete and fit for purpose, and ensure they are safe from removal or the sight of unauthorised people.
  • Ensure patients nutrition and hydration status is fully assessed recorded and acted upon in a timely manner.
  • Evaluate and improve their practice in response to the results from the hip fracture audit for 2014.
  • Ensure patients receive appropriate training and information about self-medication such as self-administration of heparin prior to discharge home.
  • Ensure that staff providing care or treatment to patients receive appropriate support, and training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
  • Take steps to ensure that all staff are included in lessons learnt from incidents and near misses, including lessons learned from mortality reviews, with effective ward based risk registers and safety dashboards being in place and understood by all staff.
  • Ensure that suitably qualified staff in accordance with the agreed numbers set by the trust and taking into account national policy are employed to cover each shift.
  • Review the environment within outpatients to ensure that the seating is fit for purpose
  • Review the existing arrangements with regards to the management of referrals in to the organisation in order that the backlog of patients on an 18 week pathway are seen in accordance with national standards.
  • Develop a robust system to ensure children and young people who present with mental health needs are suitably risk assessed when admitted to the department to ensure care and support provided meets their needs.
  • Ensure all medicines are prescribed and stored in accordance with trust procedures.
  • Ensure there are effective systems in place for the ongoing management of outlying patients.
  • Ensure that the risk matrix in MAU is completed to the frequency required by the trust policy.
  • Review consultant cover in the ED in line with the Royal College of Emergency Medicine’s (RCEMs) emergency medicine consultants workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum
  • Ensure there are the appropriate number of qualified paediatric staff in the ED to meet national guidelines.
  • Respond to complaints within agreed timeframes and summary data and meeting minutes should be explicit as to which location the complaint relates to and where performance times need to be improved.

In addition the trust should:

  • Ensure that staff in critical care are supported with training and guidance to investigate and report upon serious incidents.
  • Ensure that adherence to the Duty of Candour regulation should be recorded in incident reports in line with requirements.
  • Record mortality and morbidity reviews in order to demonstrate lessons from any reviews are learned and these can be shared throughout the trust.
  • Ensure trolleys for resuscitation equipment in critical care are secured in such a way to highlight to staff if they had been opened, used or tampered with between daily checks.
  • Review and risk-assess the provision of the critical care Outreach team service which was not being provided for 24 hours a day.
  • Review the cover and continuity of presence from specialist registrar doctors in the CCU to ensure this meets recommended safe levels at all times.
  • Review the provision of care for CCU patients as this currently does not meet the National Institute for Health and Care Excellence (NICE) guidance 83 in relation to some parts of patient rehabilitation, including discharge advice and guidance and follow-up clinics.
  • Review the role of the clinical nurse educator in the CCU to ensure adequate time and resources are given to this essential post in line with best practice and FICM Core Standards.
  • Ensure patient notes in CCU have clear records of assessments and best interest decisions for patients who lack the mental capacity to make their own decisions.
  • Revisit the use of patient diaries in order to use them more creatively to the benefit of patients and their loved ones.
  • Review CCU access to a Regional Home Ventilation and weaning service in line with the Faculty of Intensive Care Medicine Core Standards.
  • Ensure leaflets and information they provide contain the most up-to-date information for people to contact services. Information about getting leaflets in other formats should be included in all printed literature.
  • Review the use of care plans in Critical Care for patients living with a dementia in line with national guidance and best practice.
  • Ensure critical care strategies and future plans are part of the overarching vision of the division in which it sat.
  • Ensure that the critical care team are represented in all clinical governance meetings.
  • Ensure high-level risks on the local risk register in the CCU are incorporated into the corporate risk register and have board oversight.
  • Address non-compliances identified by the 2014 National Emergency laparotomy audit-compliance including the provision of a sustained 24-hour Interventional radiology service.
  • Ensure staff at ward level have access to information and agreed outcomes from governance meetings to continually improve their practice.
  • Evaluate the effectiveness of the Patient Flow service to ensure it meets patient needs and improves access and flow of services.
  • Review the management of medical outliers and devise a trust wide policy to improve their management.
  • Develop an action plan to improve NNAP compliance.
  • Ensure staff are aware of the trust’s strategy and vision for the future.
  • Improve the visibility of all senior staff in all of the areas of the maternity and gynaecology service.
  • Ensure all staff in the maternity and gynaecology service understand their role and responsibilities regarding the Deprivation of Liberty Safeguards.
  • Ensure cardiotocogragh (CTG) documentation is clear, in order to be assured that staff are following current local and national guidance.
  • Review the system in the triage area on the delivery suite to develop a pathway to prioritise women attending by clinical need.
  • Ensure that women are assessed in the emergency department before being transferred to the gynaecology ward.
  • Ensure that antenatal screening KPI data can be reported.
  • Develop a policy on restraint and / or supportive holding and provide training for staff to ensure they understand how to apply the policy.
  • Consider developing/ adopting an early warning tool for neonates.
  • Ensure that staffing records relating to medical staff accurately record who has worked each shift and that sickness absence is accurately recorded in order to monitor the shortfalls in shift and take necessary action to fill shifts to the required number.
  • Approve the audit plan for children and young people and ensure audits completed in line with the plan with regular updates on audits outstanding with revised completion dates.
  • Ensure that pain assessments for children are consistently completed.
  • Review the dashboard for children and young people and update it to include all pertinent information.
  • Develop a business plan for children and young people which identifies the needs of patients and adequately plans services for the year ahead. This should identify areas for improvement or expansion and ensure that patient demand can be met safely with the resources available.
  • Make available a communication tool for children who are unable to explain their needs and may require assistance from picture books for example.
  • Improve governance arrangements to ensure meeting minutes accurately reflect discussions held and /or that discussion takes place in accordance with the terms of the committee and that actions agreed are followed up at subsequent meetings.
  • Implement a risk register for end of life care services in order to ensure that risk is adequately assessed and monitored.
  • Resolve the issues relating to the faulty refrigerated storage units and inadequate water system in the mortuary.
  • Develop an end of life strategy with well–defined objectives that are aligned to the ‘five priorities for care of the dying person’ as recommended by the Leadership Alliance (2014).
  • Routinely audit the numbers of patients who achieve their preferred place of dying.
  • Ensure all patients can reach their call bell, to facilitate alerting staff for help if needed.
  • Ensure the ED door for entrance of patients brought in by ambulance is used appropriately.
  • Ensure the child protection register is stored safely and securely to prevent theft, damage or misuse.
  • Ensure that there is a systematic screening to identify patients with alcohol misuse to facilitate all patients who attend the ED for alcohol consumption receiving a brief intervention and signposting.
  • Ensure all nursing and medical vacancies are recruited to.
  • Ensure all appropriate patients have a drink within their reach.
  • Continue to liaise with other organisations to improve the mental health service provisions.
  • Ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for E.Ds.
  • Continue to engage with local organisations to improve patient flow to ensure that patient waiting for hospital beds in ED can be transferred in a timely manner to prevent breaches.
  • Reduce the speciality referral time to less than 60 minutes to meet the trust target.
  • Ensure that the whiteboard behind the reception in ED that displayed the waiting time is regularly updated to keep patients informed.
  • Ensure delays in ambulance handover times are reduced to meet the trust target of 80% of patients admitted via an ambulance having handovers carried out within 15 minutes and 95% of patient handovers being carried out within 30 minutes of arrival by ambulance.
  • Ensure the vision of the ED is understood by all staff.
  • Ensure effective governance and performance management of ED to make significant improvements in the quality measures.
  • Ensure audit action plans are always in place and provide assurance, evidence or progress updates to show how improvements had been achieved.
  • Ensure all senior staff are visible enough for staff to recognise them and feel supported.
  • Ensure the changes to manage overcrowding and patient safety in ED are sustainable.
  • Review the audit process relating to the management of FP10 prescription pads to ensure that there is a robust audit trail for all pads used within the organisation.
  • Ensure all patients have person centred care plans that reflect their current needs and provide clear guidance for staff to follow.
  • Ensure all temporary staff have an effective ward induction.
  • Ensure that any chemicals are stored appropriately, and ‘out of bounds’ areas are appropriately secured.

Professor Sir Mike RichardsChief Inspector of Hospitals

24 March 2015

During an inspection looking at part of the service

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

6 March 2014

During a routine inspection

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.

8 March 2013

During a routine inspection

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.

20 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

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.

15 June 2011

During an inspection looking at part of the service

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.