University Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Due to demand and capacity pressures on the emergency departments, staff did not consistently provide evidence-based treatment in a timely way to ensure the care and treatment provided met patients’ needs. However, assessments included both patients’ mental and physical health, and any personal circumstances that needed to be considered. Staff worked in a culture of evidence-based practice. Staff mostly worked together and with others when assessing people’s needs and shared information to maintain continuity of care.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

People’s experience

Staff in majors discussed people’s needs with them, and they were involved in how care and treatment was planned. Staff asked them for any updates, such as whether pain was being controlled, or if they had any additional needs. Patients in majors said they were confident they had been listened to and understood and staff considered their wellbeing to give the best possible outcomes.

However, patients in the waiting room who had been waiting overnight said they did not consistently think their care needs were assessed and addressed. The 10-minute waiting time for an electrocardiogram (ECG) for patients presenting with chest pain was regularly breached. The relative of one patient told us after their partner’s suspected heart attack, they had to repeatedly ask for aspirin to reduce the chance of further damage to his heart. The delay in this patient being reviewed by a doctor meant they were unaware aspirin was not appropriate as the chest pain was non-cardiac chest pain.

Patients in the waiting room told us their pain was monitored, and they received pain relief when they requested it.

All patients told us they received a triage assessment at the start of their treatment journey. This included being asked a range of questions about their illness or injury as well as their medical and social history.

Feedback from staff and leaders

Staff completed a triage risk assessment for each patient on arrival, using a recognised tool to categorise each patient’s clinical risk score. Higher risk patients were seen by medical staff sooner. Between October 2023 and May 2024 the average wait for triage was below 15 minutes. However, during our inspection the provider did not ensure patients arriving on foot received a triage within 15 minutes of arriving at ED in line with national guidance by the Royal College of Emergency Medicine. We saw waits for triage of up to 74 minutes for adults and up to 55 minutes for children. Staff told us if queues for triage became very lengthy sometimes a third triage nurse was deployed.

The triage risk assessment process included gathering social information, for example, about people’s protected characteristics, other services that might be involved in their care, and if there were any domestic problems staff needed to be aware of.

Staff used tools to support clinical practice with people who had difficulties with communication. This included tools for people who had cognitive impairment, and tools for understanding pain experienced by children.

When possible, staff worked with other specially trained professionals to support people with additional needs. They referred patients with mental health problems to the relevant teams. However, the response of speciality teams for children and young people was slower than for adults. Staff told us they were sometimes not confident to discharge children or young people presenting with mental health concerns without them having a psychiatric assessment. They told us this resulted in longer stays in the children’s department at times.

Staff could refer patients with a learning disability to a specialist team for support. However, this team was only available during office hours and were not based within the hospital. This meant they were not always available to work with people who would benefit from their specialist support. There was no specialist support for people with autism for staff to ask for guidance.

Staff told us they understood what they needed to do to make reasonable adjustments for people and they told us about some of the ways they had supported people with a learning disability. However, they said sometimes, due to the sheer pressure they were under and the pace of work they were expected to deliver, they did not have the time or other resources to make reasonable adjustments for patients who needed them.

Observation

Records were up to date and showed comprehensive assessments of patients in majors were undertaken leading to effective ongoing care. This included commencing patients on their treatment pathway in majors rather than waiting for specialist treatment to start once patients were admitted to a ward.

However, as well as longer than expected waits for triage we saw some patients in the waiting room during our first visit had to wait for over 13 hours before they saw a doctor, or before they got the tests they needed. For example, records we reviewed for patients who attended with chest pain showed they waited between 4 and 147 minutes after arriving at the department before they received an electrocardiogram (ECG). On our second visit we saw patients who had arrived the previous evening who waited up to 175 minutes for an ECG. National guidance from the Royal College of Emergency Medicine (RCEM) states ECGs should be carried out within 10 minutes of a patient with chest pain arriving at hospital. During our second visit we also saw patients who waited over 14 hours to see a doctor before they were able to have a computerised tomography (CT) head scan to rule out brain injury.

Processes

Not all care and treatment was being provided in line with evidence-based practice, due at times to pressure on the department from demand and capacity. There was a process for staff to follow for patients presenting with conditions that required a time critical response like a suspected stroke or chest pain. The delays to triage further compounded this. There was a dedicated member of staff located in the reception area to carry out ECGs for patients with chest pain arriving during the day. ECGs were carried out by healthcare assistants overnight. However, the process of a rapid referral for an ECG was not being followed for patients arriving overnight. This meant there was also a potential delay for ECGs being reviewed by a clinician leading to a risk of increased heart damage occurring before treatment was started.

There was a process for staff to follow if triage waits went over the expected time frame set by the department. This included increasing the number of triage nurses in the adult department from 2 to 3 if 8 patients were waiting to be seen, or if 1 patient was waiting for triage over 30 minutes. However, we did not see this process being followed in response to the number of patients waiting to be seen or the length of time patients were waiting for triage.

The learning disability team was provided by an external provider. They did not have a remit to support patients who were under 18 years old or to provide overnight support for adult patients with a learning disability. The was no process to get support for patients with autism. The provision of support for patients under the age of 18 with a learning disability was recognised as a system wide risk.

The process for supporting children or young people presenting with a mental health need was protracted and access to a psychiatric assessment by an external mental health provider for this cohort of patients could take 48 hours. Patients who required psychiatric assessment were admitted to the paediatric ward. The challenge in children and young people accessing mental health services was recognised as a system wide risk.

There was a process to identify patients at high risk of falling. These patients had a yellow blanket and wore yellow slip resistant socks. Data from July and August 2024 showed there were a total of 7 falls resulting in no harm in July and 2 falls resulting in low harm, in August there were 4 no harm falls and two resulting in low harm to patients. The implementation of yellow blankets and socks in 2022 had made a reduction in average monthly number of falls in the department by 33% in the first 6 weeks.

Feedback from staff and leaders

Staff followed up-to-date policies to plan and deliver high quality care based on best practice and national guidance. Staff told us they used a range of monitoring tools to ensure the right care was being delivered to patients. Including tools to monitor fluid balance, glucose, falls, and pressure sores for patients with identified risks. They used tools to monitor all patients for early warning signs of deterioration.

Staff knew about and understood how and why patients can decondition while waiting for specialist intervention. They told us they regularly repositioned patients, checked on their wellbeing and ensured they had enough to eat and drink to reduce the chances of deconditioning.

When delays in patient transfer occurred, staff followed treatment pathways so that patients in the emergency department received appropriate care before their transfer to a specialist ward.

Processes

Audits showed not all care was delivered consistently in line with evidence-based practice. The provider’s systems monitored if staff were delivering care that was up to date with national legislation, evidence-based good practice, and required standards through a series of audits. Audits included falls, sepsis, and monitoring if time critical medication for example, for Parkinson’s disease or dementia, had been given on time. When audits were undertaken action plans were introduced to improve compliance.

The outcome of audits showed care was not always delivered consistently. For example, staff completed an audit to understand if patients’ pain levels were being assessed and if pain relief was being given in line with trust policy and best practice. The audit, which looked at the experience of 50 patients from the adult emergency department in March 2024, showed reassessments of pain were not done within agreed timescales in 82% of cases and pain relief was not always given in a timely way. A larger audit (119 patients) was undertaken in the children’s department from October to December 2023 to understand if pain was assessed at triage and if analgesia was given within a 30-minute timeframe. The outcome showed in 95% of cases this aim was achieved. There was a plan to include repeated pain assessments in a follow up audit. The fluid balance audit for the emergency medicine directorate for March to May 2024 showed that staff were not consistently accurately completing fluid balance charts. Compliance for March was 80%, this rose to 100% in April, and dropped to 90% in May. Fluid balance charts are an important tool used to ensure poorly patients stay hydrated.

However, trust policies were based on up-to-date clinical guidelines. For example, the policy for treating acute ischemic stroke and transient ischemic attack used information from, among others, the Royal College of Physicians and the National Institute for Health and Care Excellence (NICE). Policies were regularly reviewed in line with the trust’s processes.

People’s experience

Patients in majors and their relatives told us staff worked together well to provide a high standard of care and treatment.

Feedback from staff and leaders

Staff worked as part of a wider multidisciplinary team. The clinical team worked alongside allied health professionals such as physiotherapists and pharmacists. They also worked closely with the frailty team to provide specialist input for older people.

Staff made referrals to the mental health team and the learning disabilities team to seek guidance and support for providing effective care and treatment.

Doctors from the medical and surgical teams attended the adult and children’s departments to assess and care for those patients who were being considered for transfer for ongoing care in surgery or medical services. Staff had regular multidisciplinary meetings, both formal and informal, to discuss patients and ensure they had the most effective care.

Feedback from partners

Staff ensured all those involved in patient care were able to support patients being diverted to the best service for their needs, The hospital ambulance liaison officer told us they were included in multidisciplinary meetings to ensure patients arriving by ambulance were taken to the most appropriate part of the hospital to meet their needs. This meant a shorter time in hospital for some patients who did not have to go through the emergency department before they were transferred to a more appropriate setting.

Processes

The trust had internal professional standards designed to ensure staff worked together for the benefit of patients. This included clear directions for speciality teams to take responsibility for their patient during time spent in the emergency department.

Information was shared between teams and services to ensure continuity of care, for example when patients were discharged to a ward, or when people were referred between services.

Staff attended handover meetings to share important patient information. There were staff information boards to show the latest performance data and guide staff to see where there were emerging risks, or areas managing well. For example, in the children’s department, the staff focus board contained a reminder for staff to complete a patient safety checklist for each patient as this was not being done consistently.

There was a standard operating procedure for staff to refer to when pressure on the department inhibited normal daily functioning. It recognised the department did not have the option to stop demand once all patient cubicles and bays were occupied, and there was a potential risk of a serious incident occurring with every additional patient arriving over and above the department’s capacity. The SOP recognised high quality and safe healthcare could be impacted by high levels of demand. The SOP contained 12 actions for emergency medicine staff to follow which included making partnership agencies, for example the ambulances service, aware of the situation, and expediting discharges. The SOP contained clear actions for other hospital departments to follow to ensure staff across the hospital worked together to generate flow and maintain high quality and safe care for patients.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Feedback from staff and leaders

The time that patients waited for triage, waited on ambulances, waited to be seen by a doctor, and the total time patients spent in the department was collected and reviewed. Despite the pressure on the department, the entire staff team was invested in reducing these waits and improving the experience of patients.

Staff told us the medical team completed board rounds to oversee the clinical risk held within the department including in the waiting rooms. A board round is when patients’ key clinical markers are reviewed to see if their clinical risk has increased so their priority level can be amended. This allows staff to focus on the most poorly patients.

Because the health and social care system was under pressure due to demand outstripping capacity some patients had to stay in the department for longer than they otherwise would. Senior leaders told us they understood patients who spent prolonged periods of time in the department had a higher risk of death, from any reason, in the 30 days following their admission. They endeavoured to ensure patients did not spend longer than needed in the department and discharged them home or to a suitable setting as soon as possible.

Processes

Regular meetings were held throughout the day with internal and external partners to identify ways to improve flow in the hospital to reduce the amount of time patients waited to be transferred to wards, and to improve capacity in the department.

Outcomes

The service participated in relevant national clinical audits. They completed the RCEM annual audits to ensure they were effectively driving improvements and demonstrating good patient outcomes. The RCEM audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care given against 3 treatment criteria each year.

We saw evidence that managers and staff carried out a programme of repeated local audits to check improvement over time. For example, sepsis, falls and pressure ulcers. Managers used information from the audits to improve care and treatment by sharing outcomes with staff and introducing training and making other changes to improve performance. However, some things were not audited, for example the National Early Warning Score version 2.

Senior leaders captured information about the number of patients reattending the department within 7 days of their original visit. In the 12 months before our inspection 820, patients represented for treatment within 7 days, 450 in the children’s and 370 in the adult department. Reasons for reattendance included patients’ clinical condition not improving and patients not waiting to be seen due to long waits, especially in the evening and overnight. From April to June 2024, the total percentage of patients leaving prior to being seen was 5%. This was similar to the national average. However, since July 2024 reattendance had fallen and were below (better than) the national average.

The risk to the health and well-being of patients in the waiting room was recorded as a risk on the department's risk register. It was acknowledged that patients who were acutely unwell and being cared for in an unconventional area, for example the waiting room, could deteriorate and were likely to receive a delayed clinical intervention. The outcome of which could result in increased morbidity and mortality.

People’s experience

We saw consent to treatment had been requested when required and that if people lacked capacity to make decisions about their treatment options a best interest decision had been made. This involved appropriate staff and other key decision makers.

People told us they had been asked about consent to treatment. We spoke to a young person in the children’s department who refused to have her blood taken. Staff respected her decision and later gave her more information about why they wanted to perform this test at which point she consented.

Feedback from staff and leaders

Staff understood the basis for consent and delivering person-centred care. They understood they did not need to obtain consent if it could not be obtained from a seriously injured or unwell patient, and as soon as was possible, the reason for any treatment should be fully explained to the patient. For patients who were able to give valid informed consent, staff understood the importance of ensuring people fully understood the risks, knew their rights and gave valid consent to treatment before it was delivered.

Where necessary, decisions about care and treatment were made within the requirements of the Mental Capacity Act 2005. This included consulting others as part of best interest decision-making and ensuring that people with legal authority were involved in making any relevant decisions.

Processes

There was clear guidance for staff to follow if patients did not have capacity to consent to their care or treatment.

There was a process for staff to follow if patients over the age of 16 required additional levels of observation while in the department, including for patients who lacked capacity to make decisions about their healthcare. It included information on which members of staff were responsible for making decisions about the care for this cohort of patients, if an application for a deprivation of liberty safeguard should be considered, and directions of how to obtain support from the enhanced care team who were experienced in working with patients experiencing extreme distress.