The County Hospital

Updated 28 February 2024

Urgent and emergency care was delivered by the emergency department (ED) based at County Hospital, Hereford. It provides consultant-led emergency care and treatment 24 hours a day, 7 days a week to people across Herefordshire and further.

The ED was split into different sections; ‘resus’, for patients who required immediate lifesaving treatment or resuscitation, ‘majors’, for patients with serious and life-threatening conditions; and ‘minors’, for patients who had minor injuries. There was a triage area or ‘pitstop’ where all patients were assessed and a ‘fit to sit’ area in majors for patients who were awaiting further tests or a bed in majors. There was a same-day emergency care unit which saw ambulatory patients who needed treatment or tests and could be discharged home after this.

There was a paediatric area used to treat children and young people, including a waiting area. There was a waiting room for patients who had made their own way to the department as well as a waiting area for patients waiting for treatment for minor injuries. In addition to these areas an internal corridor was used to hold and treat up to 4 patients when the department was at capacity.

We inspected this service on 5, 6 and 7 December 2023 (first visit) and did a follow up inspection on the 20 December 2023 (second visit). This was an unannounced full core service inspection looking at urgent and emergency care. We checked the quality of the services in response to being made aware of emerging risks within the department.

Updated 21 December 2022

Updated 17 October 2018

Our overall rating of this service has improved since our July 2016 inspection when we rated it requires improvement. At this inspection in June 2018, we rated the service good because:

• There was a strong, visible patient- and family-centred culture. Staff were highly motivated and inspired to provide care and treatment that was kind, compassionate and promoted patients’ dignity, and respected the totality of people’s needs.
• Patient’s emotional and social needs were seen as being as important as their physical needs. Staff were fully committed to working in partnership with patients and their families, and empowered them to have a voice.
• Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Staff were committed to providing the best possible care for children, young people and their families. Staff felt ownership for the service and were proud to be part of the children’s service.
• The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met. The vision and strategy was developed with involvement from staff, patients, and key groups within the local community.
• Staff understood their responsibilities to raise concerns and report patient safety incidents. There was an effective governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was shared with staff and changes were made to the delivery of care because of lessons learned.
• The service made sure staff were competent for their roles. Mandatory training in key skills was provided to all staff and the service made sure everyone completed it. Staff were encouraged to develop their knowledge, skills and practice. The number of staff who had received an annual appraisal exceeded the trust target.
• Service provision met the needs of local people. They worked closely with commissioners, clinical networks, stakeholders and service users to plan and improve the delivery of care and treatment for the local population.
• The service generally provided care and treatment based on national guidance and evidence of its effectiveness. Local and national audits were completed and actions were taken to improve care and treatment when indicated.
• The children’s unit was imaginatively decorated, and equipment and toys were used creatively to create a fun, warm and child-friendly environment. Play was seen as an essential part of children’s care. There was a wide range of age appropriate toys, games and books for children and young people, including a separate teenage room for adolescents and outside play area. Play therapists supported the care and treatment of children and young people and arranged special activities and days out for long-term patients.
• The service met and generally exceeded national standards in relation to paediatric consultant availability. Patients could generally access the service when they needed it and waiting times for treatment were similar to the England average.

However:

• We found that many policies and guidance had expired their review date. At the time of our inspection (June 2018), 39% of paediatric guidelines were under review. We found expired guidelines had not been included on the service’s risk register.
• We found multidisciplinary attendance at perinatal mortality and morbidity meetings was variable. We also found specialty meeting minutes often lacked detail.
• Nurse staffing levels did not always meet planned levels or national recommendations. However, we found there was generally enough staff to keep people safe from avoidable harm and to provide the right care and treatment.
• The service’s most recent audit results showed that sepsis screening tools were not always completed in line with trust guidance.

Updated 18 March 2020

• The service did not always ensure staff had completed mandatory training. Staff were not always aware of specific safeguarding arrangements and they did not always manage safety well. The service did not always control infection risk well. The design, layout and use of facilities was not always appropriate to care for patients safely. The service did not always maintain equipment well. The service did not have enough allied health professionals to care for patients and keep them safe. Staff did not always manage medicines well.
• Staff understanding around the Mental Capacity Act and Deprivation of Liberty Safeguards was mixed. Processes and understanding of delirium screening were not fully embedded.
• The service did not always meet the needs of local people. People could not always access the service when they needed it. They were delayed for prolonged periods of time in critical care when there was no longer a need for the service.
• Leaders did not always use reliable information systems. Staff were not clear about the leadership structure for their service. Staff were not clear if there was a service vision and strategy. Behaviour inconsistent with values and trust policy was not always addressed. Leaders did not always operate effective governance processes. Systems and processes used to identify and manage risks were not effective. Staff did not always submit notifications to external organisations as required. The service was not committed to improving continually.

However

• The service had enough nursing and medical staff to care for patients and keep them safe. Staff understood how to protect patients from abuse. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• 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 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 seven 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 worked with others to plan care, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders supported staff to develop their skills. 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 with patients and the community to plan and manage services.

Updated 3 November 2016

We rated end of life care services as good. The service was safe, effective, caring, responsive and well led because:

• Care records were maintained in line with trust policy.
• Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of their life.
• The trust had a replacement for the Liverpool Care Pathway (LCP) called the multidisciplinary care record for adults for the last days of life (MCR). The use of this document was embedded in practice on all of the wards. The MCR was also used in community based care homes in the area.
• Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed had been signed and dated by appropriate senior medical staff. There was a clear documented reason for the decision recorded. This included relevant clinical information.
• Policies and procedures were accessible and based on national guidance. We saw improvements since the September 2015 inspection, with regard to only one DNACPR policy being accessible to staff on the intranet.

• We found the trust had addressed maintenance issues affecting the mortuary body storage units (fridges), that we had identified on the September 2015 inspection. We also saw a new governance structure in place. The mortuary staff had a clear reporting structure.

• Patients were happy with the care they had received. Relatives were happy with the care their relatives had received.
• Patients were involved in making decisions about their care. Staff carried out care in a respectful and careful manner.
• Care and treatment was coordinated with other services and other providers. The specialist palliative care team (SPCT) had good working relationships with their community colleagues, which ensured when patients were discharged, their care was coordinated.
• 100% of patients were seen by the SPCT within 24 hours of referral.
• The trust had an executive and a non-executive director on the trust board with a responsibility for end of life care.
• The risks regarding the mortuary were identified on the support services risk register.
• Risk associated with SPCT were on the divisional risk register. The staff had taken action to mitigate against risks.

However:

• The acute SPCT were not collecting information on percentage of patients that had been discharged to their preferred place of death within 24 hours. Without this information, the service was unable to monitor if they were able to honour patients’ wishes and assess if they needed to improve on this. This had not improved since the inspection in 2015.
• We did not see evidence of a hand hygiene audit being completed in the mortuary.
• The mortuary team did not have oversight of the service arrangements for mortuary equipment so were unable to assure us that this was completed in a timely manner.
• The facilities management company provided staff training, while it did not specifically include safeguarding training. However, it identified the need to raise any concerns about the treatment or condition of deceased patients to the mortuary staff and their line manager.
• The service did not provide face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to Sunday. This did not meet the recommendation from the National Institute for Health and Care Excellence (NICE) guidelines for ‘End of life care for adults’.
• Medical staffing did not meet the NICE guidance for end of life care staffing, that recommends there is one whole time equivalent consultant/associate specialist in palliative medicine per 250 hospital beds. However, in addition to the hospital based medical cover, an out of hours consultant led palliative care advice service was available through the local hospice 24 hours a day, seven days per week.

Updated 4 October 2023

Updated 17 October 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

• From March 2017 to February 2018, the trust’s referral to treatment time (RTT) for non-admitted pathways had been worse than the England overall performance. Figures for February 2018, showed 83% of this group of patients were treated within 18 weeks versus the England average of 89%. In June 2018, the RTT on incomplete pathways within 18 weeks had dropped to 75% which was below England average of 87%.
• We saw 13 out of 17 specialties were below the England average for non-admitted RTT within 18 weeks. The hospital’s action plan for reducing their waiting lists included running additional clinics to meet the demand for outpatient services.
• The design and use of facilities and premises met patients’ needs. However, the maintenance and use of equipment did not always keep patients safe. Some equipment had not been serviced tested and out of date equipment was found in some areas. This meant that we could not be assured that all equipment was suitable for purpose. We raised this with senior staff who took immediate actions to get this equipment service tested.
• Although there were processes in place to recognise and care for patients who became unwell within the outpatient’s department, not all staff were aware of where emergency equipment was located. We could not be assured that in the event of an emergency, staff would be able to locate emergency equipment required to keep patients safe.
• Whilst systems were in place to manage the safe storage of medicines, there were intravenous fluids stored on resuscitation trolleys which were not secure. This contravened the Resuscitation Council November 2016 guidance. New tamper evident trolleys had been ordered.
• We found that vision tests including blood pressure checks were administered on the corridor in vision lanes with no screens and there was no means of protecting patient’s privacy because the corridor was accessible to staff, patients and their relatives or friends. This meant that privacy and dignity of patients was not maintained. This had been highlighted during our last inspection.

However:

• The service managed patient safety incidents well and staff were confident to report incidents.
• Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
• Medical staffing levels and skill mix was planned and reviewed so that patients received safe care and treatment in line with relevant tools and guidance.
• Staff kept appropriate records of patients’ care and treatment. Records were clear and entries were dated, timed and signed. However not all patient records were stored securely, some trolleys were not locked.
• Outpatient services delivered care and treatment in line with the National Institute for Health and Care Excellence (NICE) and national guidelines where appropriate.
• Staff had opportunities for development and received an annual appraisal. Competency assessment frameworks were developed to ensure staff had the skills necessary to undertake their job role.
• Staff received an annual appraisal that was constructive and provided a formal opportunity to review their progress and identify further training needs.
• Patients were treated with compassion, kindness, dignity and respect.
• Staff had good awareness of patients with specific needs and those patients who may require additional support should they display anxious or difficult behaviour during their visit to the service.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust performed better than the 93% operational standard for people being seen within two weeks of an urgent GP referral.
• Staff we spoke with said two-week waits were well managed and an increase in clinic capacity had made a big difference over the last few months.
• Staff reported that leadership within the department was strong, with visible, supportive and approachable managers. Staff felt there was a positive working culture and in all areas we visited staff felt there was a good sense of teamwork.
• Staff told us that local leadership was good and felt they could approach managers with concerns. Managers told us they had an ‘open door’ policy and they encouraged staff to share any issues, concerns or ideas they may have.

Updated 21 December 2022

Updated 28 February 2024