The Care Quality Commission (CQC) has told University Hospitals Bristol and Weston NHS Foundation Trust that improvements are needed at Bristol Royal Infirmary’s accident and emergency (A&E) service for adults.
CQC carried out a focused inspection of the A&E department in February as part of its winter pressures programme, which looks at whether a service is safe, responsive and well-led. Due to the narrow focus of the inspection, the overall rating of the service did not change, and remains Requires Improvement.
Amanda Williams, CQC’s head of hospital inspections, said:
“During our inspection, it was clear that staff within Bristol Royal Infirmary’s accident and emergency department valued and respected each other and supported one another to deliver patient focused care in incredibly challenging circumstances.
“We were however, particularly concerned to find high levels of violence and aggression against staff from patients in the department and to learn that staff did not feel adequately trained to deal with this. We have told the trust that it must take urgent action to protect both staff and patients. Staff need to be given the appropriate training and support to ensure they feel safe and to enable them to defuse tension and prevent violence from escalating.
“We also told the trust it must ensure it has sufficient numbers of consultants, and staff of all grades, to enable the service to run a fully operational same-day emergency service, thereby reducing demand for overnight beds. Flow through the emergency department also needs to be improved, as the unprecedented numbers caused by the COVID-19 pandemic meant that some patients were waiting on trolleys for more than 12 hours. In addition, hygiene and safety standards must be upheld in patient waiting areas.
“We have asked the trust to send us a report outlining what action they will take to meet these requirements and we will continue to monitor the service to ensure that these improvements are made.”
During the inspection, CQC found:
- Inspectors had serious concerns about the growth in violence and aggression to staff from patients and staff felt they were not adequately trained and protected.
- The service did not have enough medical staff to meet the recommended guidance for the size of the department.
- Although efforts had been made to protect patients and staff from infection during the COVID-19 pandemic, there were some lapses in infection prevention and control practices that needed addressing. For example, in one of the waiting areas, some seats were torn, so they could not be cleaned properly.
- Patients did not always receive care and treatment promptly in a time considered to be safe and responsive to their needs. This was due to pressure from high demand, COVID-19 restrictions, a lack of beds in the rest of the hospital and patients being more unwell.
- Patient handover from ambulance crews and waiting-time performance for onward admission to the hospital was worse than NHS national standards. However, staff were actively looking for improvements and short and long-term solutions, both internally and externally with system partners
- Although leaders and teams identified and escalated relevant risks and issues and identified actions to reduce their impact, these were not always revisited in times of crisis.
- There was a perception from staff in the emergency department of limited visibility from the trust executive team and their recognition, understanding and support.
However, there were many positive findings to report:
- Leaders in the emergency department demonstrated the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible, supportive, caring and approachable in the service for patients and staff.
- Staff understood how to protect patients from abuse and acted on any concerns. They recognised when abuse might be occurring and were trained in how to deal with their concerns to keep patients safe.
- Staff kept detailed and comprehensive records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care.
- Patients had an assessment of their infection risk and other clinical risks on arrival at the department. The department had a system for monitoring patients who were either at risk or found to be deteriorating. This included patients who were waiting on ambulances to be admitted to the department when demand was high or patient flow out of the department was blocked or slow.
- The pressures of COVID-19 meant the service struggled at times to have enough nursing staff, but measures were taken to ensure staff were brought in where possible to reach safe levels. This was addressed and reviewed on a regular basis by the senior nursing team.
- Staff in the department felt respected, supported and valued by their colleagues. They were focused on the needs of patients receiving care. There were strong examples of staff feeling able to speak up and raise concerns without fear.