Worcestershire Royal Hospital

Updated 29 November 2023

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.

Updated 6 April 2023

Updated 20 September 2019

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff and the majority of staff had completed it.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to relieve pain.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and knew how to support patients experiencing mental health issues and those who lacked capacity to make decisions about their care. Staff followed the trust policy and procedures when a patient could not give consent. Consent was consistently undertaken in line with the trust consent policy.
• Staff cared for patients with compassion and feedback from patients and parents confirmed staff treated them well and with kindness.
• The service took account of patients’ individual needs and the service had a person-centred care approach to meeting the needs of babies, children and young people.
• People could access the service when they needed it.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care and clinical leaders were visible across children’s services.
• The service had a systematic approach to continually monitor the quality of its services and monitored activity, performance and used data to identify areas for improvement.
• The service collected, analysed, managed and used information well to support all its activities through the use of secure electronic systems with security safeguards.
• The service engaged well with patient’s staff and the public and local organisations to plan and manage appropriate services and collaborated with partner organisations.

However,

• There was a lack of clarity around the numbers of medical staff eligible for mandatory training in the children’s service.
• Staff training for preventing radicalisation was below the trust targets for some staff.
• The delayed installation of electronic prescribing of chemotherapy and the possible delay of the diabetes information system could incur a lo(ss of income to the children’s service.
• Waiting times for patients attending PAU were not being monitored on Riverbank ward.
• The ‘Facing the Future’ standards were not fully implemented to ensure all children were reviewed within 14 hours of admission by a consultant. Although we saw no evidence of patients coming to any harm during our inspection.
• The Friends and Family Test (FFT) response rate was below the trust standard of 30% on Riverbank ward and the children’s outpatient department.
• There were delays in the Child and Adolescent Mental Health Service (CAMHS) pathway for patient assessments and transfer to specialist inpatient beds.
• There were some delays in the electronic discharge summaries (EDS) for patients on Riverbank ward.

Updated 20 June 2017

We rated critical care as requiring improvement because:

• We found that clinical incidents were not always categorised accurately or reported externally. We saw evidence that staff remained confused as to what constituted a near miss incident and reported incidents as a near miss when patients were placed at risk.
• Outside of critical care, staff felt pressurised and unsupported. Nursing staff felt that patient care was not a priority to the trust.
• The executive team were not visible across the organisation and staff felt that the lack of a permanent executive team affected progress.
• Nursing records within the high dependency units were not always contemporaneous, with data entries being completed at the end of clinical shifts and not when events occurred.
• The clinical environment for the critical care and high dependency units did not meet all the recommendations set out in the Health Building Note 04-02 Critical care units’ standards. This included limited washing and toileting facilities for mobile patients on the critical care and high dependency units.
• Staff did not always adhere to infection control and prevention practices.
• Consultants were responsible for the management of children admitted as an emergency until transfer to a children’s specialist hospital was arranged.
• Patients on the high dependency units who were categorised as level two due to arterial line being in situ were not provided with additional screens or privacy when placed in beds opposite a member of the opposite sex.
• We saw that venous thromboembolism assessments were not always completed in line with recommendations, with the repeat assessment after 24 hours of admission missing.
• Mandatory training compliance did not always meet the trust target. High dependency staff had not completed critical care handbooks at the time of inspection, although these were in progress.
• Medical consultants were not always allocated to the care of patients following discharge from critical care, which affected patient follow up after discharge.
• There was a limited follow up service for patients discharged from critical care with no provision of a formal medical lead clinic.

However:

• Critical care staff completed a daily safety brief where they discussed any incidents or complaints and identified learning. Learning was also shared across the service at team meetings.
• Appropriate staff regularly reviewed patients. Medical teams reviewed patients a minimum of twice daily. The critical care outreach service assisted with the monitoring and treatment planning of sick patients across the trust, providing local support for teaching and monitoring of compliance in trust wide deteriorating patient audits.
• Critical care 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.
• The service had implemented a weekly multidisciplinary team meeting to review patient’s rehabilitation needs.
• Critical care used evidence based patient pathways, policies and protocols to provide care.
• Trust data published by the Intensive Care National Audit and Research Centre detailed that the service performed in line with similar sized organisations and as expected.
• The service provided a seven-day service with access to specialists, such as dietetics and pain specialists, for additional treatments or advice. Specialist were involved with the planning of treatments and participated in multidisciplinary team meetings.
• The service had a robust training programme for staff that included the use of a competency handbook, local training support from the practice development nurses and scenario based training.
• Patients and their relatives were treated in a compassionate, respectful manner. Staff provided privacy for relatives and patients. Patients and their relatives were supported during their stay within critical care with staff offering opportunities to discuss care and treatment.
• There were additional facilities within the critical care unit, which enabled patient’s relatives or loved ones to stay on site. There were also facilities for those requiring additional support for aspects such as learning disabilities, translation services.
• Staff and relatives used patient diaries to record events. These helped patients understand what had happened whilst they were sedated.
• There were systems in place to address formal and non-formal complaints. The most relevant persons completed investigations and responses and learning shared amongst the team though open discussion and team meetings.
• Critical care had a vision of the service, which reflected the trust core values. This included the plans to centralise critical care services and build a high dependency unit.
• The service had a robust governance structure and cascaded service performance data to the trust board and to staff on the units.
• Local leaders were reported as being supportive, accessible and approachable.

Updated 20 September 2019

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

• The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it, with attendance at some courses such as information governance and infection, prevention and control being significantly lower than the trust target.
• Compliance rates for all levels of children’s and adults safeguarding training was below the trust target for medical staff.
• Systems and processes were generally in place to prevent and control infection. Staff kept themselves clean and the service monitored staff adherence to most infection prevention and control procedures through audits, however there were inconsistences with keeping equipment and premises clean.
• The service had suitable premises, and equipment was generally looked after well, however some equipment was old and overdue for replacement, such as the CT scanners.
• Safe systems and procedures were in place to assess, monitor and manage risks to patients, however these were not always followed.
• Compliance rates for all levels of Mental Capacity Act and Deprivation of Liberty Safeguarding training was below the trust target for nursing and medical staff.
• While the service generally took into consideration the patients’ individual needs, there was limited provision for separate male and female changing and waiting areas.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. However, there was limited visibility and engagement of senior leaders.
• The service had a draft vision and strategy for what it wanted to achieve. However, further progress had paused to ensure it was linked to and supported delivery of the core elements within the recently developed trust strategy.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, while staff recognised that the service needed to develop the culture of the teams across all sites, they did not feel supported by senior leaders to address immediate concerns.
• Not all staff had completed information governance training.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
• The service had 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 service had a safety monitoring system in place to monitor their performance against targets. Staff completed and kept clear records of risk assessments and safety checklists for patients.
• Although there was a high number of vacancies for medical and qualified allied health professionals staff the service ensured enough medical 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 were on each shift.
• The service administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Care and treatment were delivered in line with legislation, standards and evidence based guidance.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• The service made sure patients had access to the main diagnostic services seven days a week.
• Staff took opportunities to promote healthy lifestyle options for patients.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA). They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• 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. Patients and those close to them were able to receive support to help them cope emotionally with their care and treatment.
• Most patients could access the service when they needed it. Waiting times to treat patients were generally in line with good practice. Most patients received diagnostic imaging within the six week target. The backlog of unreported images and delays in reporting had significantly improved. From July 2016 to May 2019, the trust had reduced its unreported plain film x ray backlog from over 11,000 to under 500, and 79% of scans were reported within the trusts target depending on modality.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. A local risk register was in place which was regularly reviewed at local and divisional level.
• The service collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards.
• The service was committed to improving services by learning from when things go well and when they go wrong, promoting training and innovation.

Updated 20 June 2017

We rated end of life care as good because:

• Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care.
• There was good identification of patients at risk of deterioration and identification of patients in the last days of life.
• The trust had taken action to improve the facilities in the mortuary since a previous inspection. This included replacing fridges, flooring and improving the hot water facilities.
• There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. A comprehensive programme of end of life care training was available for the full range of staff within the trust.
• There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
• People were supported, treated with dignity and respect and told us they felt involved in their care. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
• Patients and relatives told us that the staff were caring, kind and respected their wishes. People we spoke with were complimentary about the staff and told us they felt appropriately supported.
• The specialist palliative care team responded quickly to referrals and typically would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer and non-cancer referrals.
• The specialist palliative care team worked proactively with the emergency department to identify patients who may benefit from palliative care input.
• The trust had begun to record and audit preferred place of care at the end of life and there were clear systems in place to make improvements in this area.
• The specialist palliative care team had audited complaints that had an end of life care component, identified trends and had taken action to address improvements.
• There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.
• There was consistent promotion of the delivery of high quality person centred care and strong leadership for end of life care. Staff were consistently passionate about end of life care, positive about their roles and consistent in their belief that the quality of end of life care was good.
• Innovations included close working between the specialist palliative care team and emergency department 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.

However:

• Discussions around DNACPR (do not attempt cardiopulmonary resuscitation) decisions were not always sufficiently recorded within patient’s medical records.
• Feedback from relatives and staff showed there had been some delays in obtaining death certificates, although we saw that this had been discussed at the meeting of the bereavement group and we were told the lead nurse was taking the lead on addressing this issue.

Updated 29 November 2023

Updated 20 September 2019

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

• Not all staff were up to date for safeguarding training on how to recognise and report abuse.
• Whilst World Health Organisation safe surgery checklists were not used for all invasive procedures in ophthalmology, the trust took urgent actions to address this.
• People could not always access the service when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
• Performance against the national cancer standards for patients on two week waits and patients waiting less than 62 days for treatment were not in line with national standards.
• Local leadership in some outpatient departments required support.
• Whilst the service generally provided care and treatment based on national guidance and evidence-based practice, local safety standards for invasive procedures were not yet fully in use.

However,

• The service generally had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Outpatient services were generally provided from 8am to 6pm, Monday to Friday. Clinics in the main outpatient department did not routinely provide a seven day a week service.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
• The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
• The service generally had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Staff and managers across the service promoted a positive culture that supported and valued one and other.

Updated 20 September 2019

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

• Although the service had improved since our last inspection, we found some areas of concern/areas where the service still did not meet legal requirements, so we could not rate this above requires improvement.
• Mandatory training rates for medical staff, including training on safeguarding adults and children, although improved, did not meet trust targets.
• Audit data showed hand hygiene compliance in theatres was low but improving.
• There were inconsistencies in completion of patient risk assessments and some delays occurred in response to requests for medical review of patients at times. Not all the required pre-operative and peri-operative safety checks for patients receiving surgery were recorded.
• The prescription of antibiotics did not always meet national standards. Staff did not always state the indication for the use of antibiotics or when they should be reviewed.
• Patients access to the service was affected by longer than average referral to treatment times and when surgery was cancelled, patients were not always re-booked within 28 days of cancellation.
• Capacity issues resulted in some patients being cared for in a clinical room on two wards. Staff told us there were occasions when patients were cared for on trolleys in the corridor of the surgical clinical decisions’ unit for a few hours until a bed became available. Until approximately a month prior to the inspection, some patients stayed in the theatre recovery area for an extended period, due to bed capacity issues. The trust reported three breaches of same sex accommodation requirements in the vascular high care unit.
• The service did not have fully effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However,

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Managers provided mandatory training in key skills to staff. The percentage of nursing staff completing mandatory training mostly met trust targets.
• The service mostly controlled infection risk well. Staff kept themselves, equipment and the premises clean. They mostly used control measures to prevent the spread of infection. The service generally had suitable premises and equipment and looked after them well.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff mostly completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Staff kept detailed records of patients’ care and treatment. Records were mostly clear, up-to-date and easily available to all staff providing care.
• Medicines were mostly stored and managed safely and processes for this had improved since the last inspection. Patients received the right medication at the right dose at the right time.
• Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Audits were completed to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Performance in national audits such as the national bowel cancer audit, was mostly in line with other trusts or better. Risk of re-admission was slightly higher than the national average in general surgery; however, it was lower than the national average in other surgical specialties.
• Managers made sure staff were competent for their roles. Multidisciplinary team working was generally effective. Staff worked together as a team to benefit patients. The service was working towards seven day services.
• Consent was obtained in line with legislation and when patients did not have the capacity to make specific decisions, the principles of the Mental Capacity Act were followed. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients praised staff for their professional approach and the reassurance and consideration given to patients who were vulnerable. Staff involved patients and those close to them in decisions about their care and treatment.
• The service took account of patients’ individual needs. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• There were managers at all levels of the service, with the right skills and abilities to run a service providing high-quality sustainable care. Managers had a vision for what they wanted to achieve and workable plans to turn it into action.
• There was a clearly defined governance structure in place and a systematic approach was used to continually improve the quality of surgical services and safeguard high standards of care.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation. Action had been taken to address most of the concerns we identified at our inspection published in June 2018, although further improvement was needed.

Updated 6 April 2023