North West Anglia NHS Foundation Trust provides acute hospital services across three sites. At the time of our inspection, urgent and emergency care services were being provided across two sites from Peterborough City Hospital and Hinchingbrooke Hospital. The trust employs approximately 7,073 members of staff and is supported by approximately 452 volunteers.
We undertook an unannounced focused inspection of Peterborough City Hospital urgent and emergency care services and medical care services (including older people’s care) on 28 February. We also had an additional focus on the urgent and emergency care pathways across Cambridgeshire and Peterborough and carried out a number of inspections of services across a few weeks. This was to assess how patient risks were being managed across the health and care services during increased and extreme capacity pressures.
As this was a focused inspection at North West Anglia NHS Foundation Trust, we only inspected parts of our five key questions. For both core services, we inspected parts of safe, responsive, caring and well led. We included parts of effective in medical care. We did not inspect effective in urgent and emergency care at this inspection but would have reported any areas of concern.
The emergency department at Peterborough City Hospital was previously rated as requires improvement overall with safe, responsive and well led being rated as requires improvement and effective and caring being rated as good. Medical care was previously rated as good overall with all key questions rated as good.
For this inspection, we considered information and data about performance for the emergency department and medical care. This inspection was partly undertaken due to the concerns this raised over how the trust was responding to patient need and risk in the emergency department and the wider trust in times of high demand and pressure on capacity. We were concerned with waiting times for patients, delays in their onward care, treatment and delayed discharges, as well as delayed and lengthy turnaround times for ambulance crews.
We looked at the experience of patients using urgent and emergency care and medical care services in Peterborough City Hospital. This included the emergency department, medical wards and areas where patients in that pathway were cared for while waiting for treatment or admission. We visited services and departments that patients may encounter or use during their stay. We also went to medical wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.
System wide summary
A summary of CQC findings on urgent and emergency care services in Cambridgeshire and Peterborough.
Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Cambridgeshire and Peterborough below:
Cambridgeshire and Peterborough
Provision of urgent and emergency care in Cambridgeshire and Peterborough was supported by services, stakeholders, commissioners and the local authority.
We spoke with staff in services across primary care, urgent care, acute, mental health, ambulance services and in care homes and domiciliary care agencies (social care). Staff had worked very hard under sustained pressure across health and social care services. Staff reported feeling tired and frustrated due to the sustained pressure and the impact this had on their wellbeing and on the delivery of training.
We identified a need for more capacity in primary care to meet people’s needs in Cambridgeshire and Peterborough. We found some concerns in relation to access for patients trying to see or speak to a GP; however, other services proactively reviewed patients’ attendance at emergency departments and took action to reduce avoidable attendances and improve access to appointments.
We visited a primary care unit run by an acute trust; whilst this was working well, we were told it was addressing an issue in access to primary care and was a short-term solution. We were told of a GP liaison service which enabled GPs and Consultants to work together to discuss individual patient needs. This service had successfully supported a significant number of people to stay at home or to access an alternative pathway and avoid going to an Emergency Department.
Access to NHS111 services for people in Cambridgeshire and Peterborough was generally in line with or better than elsewhere in England. Performance was closely monitored and there were plans in place to address staff shortages, particularly for health advisors, and there was a successful on-going recruitment campaign.
System partners in Cambridgeshire and Peterborough had been part of a collaborative project to launch a Virtual Waiting Room within the Cambridge and Peterborough region. The initiative aimed to help patients who call NHS 111 receive the care they need while alleviating the pressure on Emergency Departments (EDs).
Staff working in ambulance services reported a significant volume of calls which were inappropriate for a 999 response and could have been dealt with in primary care or urgent care services. Staff also reported a high number of elderly people seeking support through emergency services because they felt their care packages were insufficient and did not meet their needs.
Ambulance crews also highlighted their frustrations with the variation in pathways at different hospitals across Cambridgeshire and Peterborough and that ambulance crews were not prioritised for accessing alternative pathways. By streamlining pathways and handover arrangements, ambulance crews felt they could be more efficient.
For many complex reasons, including ambulance handover delays and staffing shortages, there were not enough crewed ambulances to respond to 999 calls within national targets. This posed a risk to people in the community waiting for a 999 response.
Staffing shortages in some Emergency Departments impacted on the delivery of safe and effective care. Staff were not all up to date with mandatory training and did not always assess risks appropriately.
We visited a mental health service and found it met the needs of people who presented in the Emergency Department or transferred between acute and mental health services. However, staff within Emergency Departments reported problems in accessing mental health services and were not able to make referrals 24 hours, seven days a week. This impacted on the ability to provide appropriate care and treatment and moving patients to the appropriate service.
Whilst we found some examples of collaborative working focused on developing system wide resilience, we found Emergency Departments remained under significant pressure. Patients experienced significant waiting times in these departments and staff reported the challenges of caring for patients within the department for such long periods of time. Some staff felt too much risk was accepted and held within emergency departments and didn’t always feel supported by system leaders.
Same Day Emergency Care pathways aimed to relieve the pressure from Emergency departments. However, these services also experienced staff shortages, and some were only available during set times. Opportunities were lost to use admission avoidance pathways for the frail and elderly and increasing the risk of patient harm such as falls and skin pressure damage’
Delays in discharge for patients in hospital were significant and impacted on their health and wellbeing. Staffing issues were also impacting on the social care provision in Cambridgeshire and Peterborough; although there were beds available in care homes, there was not always enough staff to enable admissions. The staffing issues were also present in domiciliary care agencies which reduced the availability of care at home.
Staff working across health and social care reported poor discharge processes. Staff working in care homes and domiciliary care services reported that patients were often discharged late at night and with insufficient information to ensure a safe transfer of care.
Staff working in these services also reported significant delays in ambulance responses, however they gave very positive feedback in relation to welfare calls received by GPs or 111 and 999 call handlers.
We found a lack of knowledge across social care services in relation to managing deteriorating patients. By increasing staff awareness, services may be able to meet people’s needs without needing to request emergency services.
We observed some local and system escalation meetings and found there was limited, if any action taken in response to issues and risks escalated.
Summary of North West Anglia NHS Foundation Trust – Peterborough City Hospital
We found:
- The services provided mandatory training in key skills in relation to patient risk but not everyone had completed it.
- The design, maintenance and use of facilities and premises in the emergency department did not always keep people safe. Staff did not complete risk assessments for each patient comprehensively to remove or minimise risks or update the assessments. Staff did not always keep detailed records of patient care and treatment. The emergency department did not have systems and processes in place to safely prescribe, administer, record and store medicines.
- Within the emergency department, staff were not always discreet or attentive when caring for patients.
- People could not always access the emergency care service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. Staff described a culture of acceptance given the capacity and lack of movement of patients through and out of the hospital. This led to extended patient waits and patients staying for longer than necessary in the emergency and urgent care environment.
- Within medical care, shortages of staff meant the service did not always have enough medical, nursing and support staff to keep patients safe from the risk of avoidable harm and to provide the right care and treatment in a timely way. Managers regularly reviewed staffing levels and skill mix and efforts were made to increase staffing levels for each shift.
- Although people could access the medical care services when they needed it, they did not always receive the right care promptly due to pressures on bed capacity. Arrangements to admit, treat and discharge patients were impacted due to significant numbers of patients that no longer met the criteria to reside in the hospital but were waiting for access to onward care packages. Patients were being moved, sometimes at night, in order to admit them to the right place once a bed became available. Some patients were needing longer stays while they awaited treatment.
However:
- Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
- Within the emergency care service there was enough nursing, medical staff and support staff to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix. The services managed infection risk well. Staff used personal protective equipment and control measures to protect patients, themselves and others from infection. Equipment and the environment were visibly clean.
- Within medical care, doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Key services were available seven days a week to support timely patient care.
- Within medical care, staff treated patients with compassion and kindness, they respected their privacy and dignity, and took account of their individual needs. Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.
- Care was planned and provided in a way that met the needs of local people and the communities served. The services also worked with others in the wider system and local organisations to plan care.
- Leaders had the skills and abilities to run the services. Services had a vision for what they wanted to achieve and a strategy to turn it into action. Leaders operated effective governance processes throughout the service.
How we carried out the inspection
During the inspection we observed care, spoke with 37 members of staff and carried off site interviews with the senior leadership team. We spoke with 12 patients and/or their carers. We observed care provided; attended site meetings, reviewed relevant policies and documents and reviewed 22 sets of patient records.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection