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Weston General Hospital Inadequate

Reports


Inspection carried out on 6 - 8 June 2021

During a routine inspection

Weston General Hospital provides urgent and emergency services, medical care, surgery, critical care, maternity, services for children and young people, end of life care and outpatient core services.

On 1 April 2020, University Hospitals Bristol NHS Foundation Trust and Weston Area Health NHS Trust merged to form a new organisation, University Hospitals Bristol and Weston NHS Foundation Trust (UHBW).

Following the merger the previous ratings for Weston General Hospital do not apply.

When a trust acquires or merges with another service or trust in order to improve the quality and safety of care, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years. Therefore, we have rated services at Weston General Hospital as this inspection. However, these ratings do not form part of the Trust’s overall current rating.

Our rating of this location is inadequate. This rating is based on the inspection of two core services.

We rated medical care as inadequate overall and outpatient services as good overall:

  • The medical care service did not always have enough nursing and medical staff to care for patients and keep them safe. The service provided mandatory training in key skills but not all staff had completed it. The design, maintenance and use of facilities, premises and equipment did not always keep people safe, the areas used for outlier patients were not suitable for this use. Staff did not always keep people safe by following systems and processes when prescribing, administering, recording and storing medicines. The service did not always learn from incidents and accidents as they did not consistently make changes and improvements when they happened.
  • Medical care staff gave patients enough food and drink to meet their needs This service was not seen to be the same service provision for patients using escalation areas. Access to pharmacy support was not available in all escalation areas. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care but there was not always a clear record of how those capacity decisions had been made.
  • Medical care staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers.
  • The medical care service responded reactively to meet the needs of local people and the communities served, which meant care was sometimes delayed. Forward planning to meet demand was not used. Patients could not always access services when needed and not all received treatment in the right speciality ward or area.
  • Medical care leaders had not yet managed the priorities and issues the service faced. The trust vision and strategy were not known by staff. Staff all expressed that they loved working at the hospital but did not feel supported and valued and often felt isolated within the trust. Governance processes were not effective in developing the service. Learning from the performance of the service was not always maintained or used to make positive changes. The management of risks were reactive and not planned which sometimes left patients at risk.
  • People could not access the outpatient service when they needed it and had too long waits for treatment.

However:

  • The outpatient service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Outpatient staff provided good care and treatment, gave patients enough to eat and drink when remaining in the departments for lengthy periods, 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.
  • Outpatient 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 outpatient service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Outpatient leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. 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 well with patients and the community to plan and manage services and all staff were committed to improving services continually.
  • Medical care staff understood how to protect patients from abuse. The infection risk were controlled well and kept equipment and the premises visibly clean. Staff managed clinical waste well. Staff completed and updated risk assessments for each patient and removed or minimised risks when possible. Staff identified and quickly acted upon patients at risk of deterioration. Staff kept good care records. Staff collected safety information on each ward and used it to improve the service.
  • Medical care managers monitored the effectiveness of some aspects of the service. Staff worked well together using a multidisciplinary approach for the benefit of patients. Key services were available seven days a week. The patients were complementary about the meals and availability of food and drinks. Staff ensured patients had enough to eat and drink and gave them pain relief when they needed it.
  • The medical care service was inclusive and took account of patients’ individual needs and preferences. Staff were focused on the needs of patients receiving care. Staff felt pride in their role and work they undertook. The service promoted equality and diversity in daily work. Engagement was being developed by the trust with staff to improve morale.

Inspection carried out on 11 March 2021

During an inspection looking at part of the service

Inspection carried out on 28 Jul to 29 Jul 2020

During an inspection looking at part of the service

We inspected the urgent and emergency service to follow up on concerns identified in a Section 29A Warning Notice served in December 2019 following a comprehensive inspection of the service in February 2019. At that time, the hospital was run by Weston Area Health Trust, which is now part of University Hospitals Bristol and Weston NHS Foundation Trust. When a hospital changes management in this way, we would normally do a comprehensive inspection and give up-to-date ratings for all services. However, during the COVID-19 pandemic we have restricted our inspection activity, resulting in this focused inspection. We did not rate any aspect of the service. We were also concerned about safety in the emergency department, following some recent serious incidents, and a ‘never event’ (a serious patient safety incident that should not happen if healthcare providers follow national guidance on how to prevent them). We therefore extended the scope of this inspection to look at all key lines of enquiry in the safe domain, one area of the effective domain, and most of the well led domain.

Our inspection reports about this service under its previous management are available here: https://www.cqc.org.uk/location/RA301. We will inspect and rate the hospital as part of our normal regulatory processes in due course.

The warning notice (2019) set out the following areas of concern, where significant improvement was required by 31 March 2020:

  • Governance systems were still not operating effectively. We had limited assurance that the main governance forum in the emergency department provided good oversight of quality and risk at departmental, division or trust level, in order to support informed decision-making. The risk register was not up to date and was not an effective tool to manage risks or provide assurance that controls were effective. Incident management had improved, and serious incidents were investigated and acted upon within appropriate timescales. However, there remained a significant backlog of other incidents.
  • Although junior doctors were mainly positive about the support and supervision they received from senior medical staff, some still told us that the quality of supervision was variable depending on which consultant was in charge. Concerns were expressed about a lack of support and supervision at weekends.
  • There was limited assurance that the nursing workforce had the skills and experience to provide safe care and treatment. A training needs analysis was underway, but this still showed numerous training gaps. Training sessions were being provided but these were ad hoc and did not form part of a coordinated and structured training plan. There was still no structured or formal system of nurse supervision, although some progress had been made in identifying teams to be led by senior nurses.

During this inspection we found:

  • The quality of data available did not provide assurance that the trust could be confident in mandatory training compliance. The trust found it difficult to provide us with training data that showed nursing or medical staff were compliant with mandatory training.
  • At the time of our inspection 56% of nursing staff in the emergency department had completed level three safeguarding training for children.
  • The service did not have enough permanent nursing staff. There was a shortage of registered nurses and heavy reliance on bank and agency staff, although they had taken steps to mitigate the risks of short staffing created by effectively managing a pool of temporary staff and using the same agency and bank staff over an extended period of time.
  • The service did not always manage patient safety incidents well. Staff recognised incidents and near misses and reported them. Managers investigated incidents but did not always share lessons learned effectively with the whole team and the wider service.
  • There was not an effective process to disseminate actions required following a national patient safety alert to all staff in the emergency department. This meant there was a continued risk that patients may not receive care in line with recommendations in these national alerts.
  • The service held a central spreadsheet of all equipment in the emergency department which monitored maintenance and replacement dates. We reviewed this document and saw 40 pieces of equipment outside of their planned preventive maintenance dates, of which, seven pre-dated Covid-19.
  • Handover medical meetings did not have a formal structure. We witnessed one handover, and several patients were not discussed because the doctor treating them was not present. We noted and there was no specific teaching or learning included.
  • There was heavy reliance on the clinical lead of the emergency department. Whilst we heard of plans to recruit further staff to mitigate this risk, it remained the case that this created a huge vulnerability to all the strands of work currently undertaken by the clinical lead.
  • Registrars, junior doctors and nursing staff told us that attending governance meetings was difficult because of operational pressures in the emergency department. It was clear from discussions with these staff that information from the governance meetings was not effectively shared with all staff in the emergency department.

However:

  • Governance systems had improved. We had assurance that the main governance forum in the emergency department provided good oversight of quality and risk at departmental, division and trust level, in order to support informed decision-making. They were aware of the issues in the department and were putting actions in place to mitigate the concerns.
  • The risk register was up to date and was used to manage risks or provide assurance that controls were effective.
  • The backlog of incidents, which was a concern at our last inspection, had been reduced significantly.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. This was a significant improvement from our last inspection.
  • Junior doctors told us consultant presence in the emergency department had improved and consultants were visible and accessible.
  • A training needs analysis of nurse competencies had been completed and taken actions to ensure that nursing staff completed required competencies and put in place processes to support them to do so. A practice development nurse had been appointed to develop and oversee all aspects of nurse training, including mandatory training.
  • During a recent outbreak of Covid-19 at the hospital, all staff were tested. Of the 6% of hospital staff who tested positive for the virus, none of these worked in the emergency department. Managers told us staff had been using personal protective equipment (PPE) since January 2020, which they believed had greatly contributed to this result.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South), on behalf of the Chief Inspector of Hospitals