Worcestershire Royal Hospital

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

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