We carried out a focused inspection of The Royal United Hospital Bath urgent and emergency care service on 4 January 2021 as part of our winter pressures programme. As this was a focused inspection, we only inspected parts of our key questions: safe, responsive and well led. We did not inspect effective or caring. Urgent and emergency care was the only service we inspected. We took into account nationally available performance data and concerns we had received about the safety and quality of the service. We also reviewed concerns identified at our last inspection in September 2018 in relation to safe staffing, crowding and paediatric care.
Our inspection had a short announcement (a few hours) to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received. Due to the narrow focus of this inspection, we did not change the rating of the service at this inspection. Our rating of the service therefore stayed the same as requires improvement.
- The Royal United Hospital Bath emergency department did not always have enough staff with the right qualifications and updated training to keep patients safe from avoidable harm and to provide the right care and treatment at all times. There were concerns about the level of senior medical staff on duty at night due to the complex layout of the department and lack of visibility for some patients. The design of the environment meant social distancing in some areas was difficult and this could lead to overcrowding in the waiting area at busy times. Triaging and the ongoing care and treatment of children was not always undertaken by nurses with paediatric qualifications. Some patients’ medical records did not state the time the patient was reviewed by the doctor.
- Patients could access the service when they needed it but often had to wait longer than the national standard for a decision or treatment and a bed if they needed to be admitted. Demands on services throughout the hospital often resulted in patients in the emergency department or in ambulances waiting for beds. For a number of years, the emergency department's performance against national waiting time standards was worse than the NHS constitutional standards and the national average for England. However, no patient had waited for more than 12 hours during 2020 and fewer patients that the national average waited over four hours. As with most of the rest of the emergency departments in England, this performance was deteriorating in the last six months of 2020 and the winter months particularly. There was a need to resolve a difference in opinion around the responsibility for patients remaining in ambulances and oversight of their care and treatment.
- Service leaders had procedures and escalation plans to follow for managing periods of heavy demand. However, the action plan devised to improve service provision was in its early stages and had not had time to impact on improving performance.
- The service controlled infection risk well and dedicated areas had been established to protect staff and patients from cross infection during the COVID-19 pandemic. Staff knew how to keep patients safe from abuse and how to report this.
- Although the service did not always have enough nursing staff, particularly at night and not enough trained children’s nurses to ensure safe care was always provided managers regularly reviewed staffing levels and the skill mix where possible to increase numbers of nursing staff.
- The service liaised with other health care providers to help reduce the demand on the emergency department. This involved signposting patients to other appropriate health care settings which were able to meet their needs.
- A new leadership team had been appointed both at service and executive level. They were working on an action plan to improve the service provision and outcomes for patients. They had the skills, knowledge and abilities to run the service and felt strongly supported by the trust leadership team. The trust and the emergency department leaders understood the priorities and issues the service faced both internally and externally and from the additional pressures of the COVID-19 pandemic. The team were visible and approachable for patients and staff. Staff felt respected, supported and valued.