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We are carrying out checks at Alexandra Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 1 Nov to 8 Nov 2017

During a routine inspection

  • Staff had not all received training in key skills to undertake their roles. This included resuscitation and safeguarding vulnerable adults and children.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, staff did not always have training on how to recognise and report abuse and how to apply the learning.
  • Medical staffing in the department was not always sufficient to maintain patient safety. Recommendations by the Royal College of Emergency Medicine (RCEM) were not met. Medical cover overnight consisted of one registrar who was responsible for all inpatient areas.
  • Learning from mortality, incidents and complaints was not always effectively identified, implemented, reviewed or shared.
  • Hand hygiene best practice was not always followed to prevent the spread of infection.
  • There was variable performance in a number of national audits relating to patient safety and treatment.
  • Departmental risks were recorded on the urgent care divisional risk register, which was not comprehensive and did not include control measures.
  • Patients’ views and experiences were not routinely gathered or acted upon to improve services.
  • We found progress had been made in assessments and responses to patient risk within each of the medical wards we visited. Initial venous thromboembolism assessments were completed on a patient’s admission to hospital. The assessments were not always repeated within 24 hours of admission.
  • Data showed that wards were regularly working with reduced numbers of qualified nursing staff.
  • Appraisal rates did not meet the trust target of 90%.
  • The service did not always treat complaints in line with trust policy.
  • There were a high number of patient bed moves out of hours (10pm to 7am).
  • The trust’s vision and strategy remained under development at the time of the inspection. There was no documented local strategy for the service however, and some staff were uncertain about the trust’s vision and strategy regarding the Alexandra Hospital.

However, we also found;

  • Patients had their needs assessed and their care was planned and delivered in line with evidence-based guidance, standards and best practice.
  • Staff provided care that was kind and compassionate. Patients’ individual needs were met.
  • Staff worked with the mental health liaison service to provide high quality care for patients with mental health conditions.
  • The trust planned and provided services in a way that met the needs of local people.
  • The ambulatory care and frailty pathways were operating effectively in the ED and contributing to improved patient flow. Patients spent less time waiting for hospital beds.
  • The trust recognised there were issues with leadership and governance arrangements in the ED. A new, smaller urgent care division had been set up and there were plans to provide executive support to improve governance and performance management.
  • The service prescribed, gave, recorded and stored medicines well.
  • Most patient safety incidents were managed well.
  • Medical notes contained comprehensive and detailed patient reviews, referrals to other clinicians, and clear treatment plans.
  • Staff from different disciplines worked together as a team to benefit patients.
  • Patients’ pain was assessed on admission to hospital and repeated at intervals throughout their stay.

Inspection carried out on 12, 12 and 25 April 2017

During an inspection to make sure that the improvements required had been made

The Care Quality Commission (CQC) previously carried out a comprehensive inspection in November 2016, which found that overall; the trust had a rating of 'inadequate'.

We carried out a focused inspection on 11 and 12 April 2017. We also visited on 25 April 2017, specifically to interview key members of the trust’s senior management team. This was in response to concerns found during our previous comprehensive inspection on Worcestershire Royal Hospital, the Alexandra Hospital and Kidderminster Hospital and Treatment Centre whereby the trust was served with a Section 29a Warning Notice. The 29a Warning Notice required the service to complete a number of actions to ensure compliance with the Health and Social Care Act 2008 Regulations and the trust had produced a comprehensive action, which reflected these requirements as well as additional aims and objectives for the service.

Focused inspections do not look at all five key questions; is it safe, is it effective, is it caring, is it responsive to people’s needs and is it well-led, they focus on the areas indicated by the information that triggered the focused inspection.

The inspection focused on the following services; adult emergency department (ED), medical care, surgery, and maternity and gynaecology. We inspected parts of the five key questions for these services but did not rate them.

Areas where significant improvements included in the Section 29a Warning Notice had not been made were:

  • There was inadequate investigation of, and learning from, serious incidents and inadequate mortality and morbidity reviews in the emergency department (ED).
  • There was minimal reporting of patient safety incidents relating to patients waiting on trolleys in corridors and when the department was over capacity.
  • There was very little response from the hospital as a whole when the ED safety matrix showed that the department was overwhelmed.
  • This was not sufficient medical cover to provide a consultant presence in the department for 16 hours a day as recommended by the Royal College of Emergency Medicine.
  • The trust had told us that a new full capacity protocol had been developed describing the actions to be taken when the hospital and ED were full. This had not been completed and the trust appeared to take very little action on the many occasions when the ED was full and unable to treat any more patients.
  • There remained long delays for patients at every stage of their assessment and treatment. There had been no improvement in the ability to meet the national standard to admit or discharge 95% of patients within four hours. In February and March 2017, this had been achieved for only 80% of patients which was similar to our previous inspection. We observed six patients who spent between eight and 12 hours in the department.
  • There was very little privacy and confidentiality for patients waiting on trolleys in the corridor in ED.
  • There had been no clinical governance or performance management meetings since our last inspection. High levels of clinical activity in the ED meant there was little time for governance and risk management.
  • There was little understanding of the processes for escalating significant risks to divisional or board level. Doubt remained regarding the degree of oversight of ED risks by senior leaders within the trust.
  • There was significant concern about the lack of effective leadership in the ED and at trust level to tackle the ongoing risks to patient safety.
  • During this inspection, we still observed that most staff did not generally wash their hands before and after patient contact on ward 12 and the medical assessment unit (MAU). In surgery, some staff were not compliant with infection control precautions including hand hygiene and appropriate use of personal protective equipment.
  • Time critical medicines were not always given when required in some medical care wards.
  • In surgery, medications were not administered as prescribed. Medications were stored in temperatures above manufactures recommended guidelines.
  • Venous thromboembolism (VTE) assessments were not carried out on all patients in line with trust and national guidance in medical and surgical wards.
  • Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst countywide perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
  • The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

Additional areas of concern, that were not included in the Section 29a Warning Notice, that we found during this inspection were:

  • There was a lack of advanced training in child safeguarding for doctors and nurses.
  • Safeguarding adults training for doctors and nurses in the ED was inadequate.
  • There was a lack of immediately accessible equipment for the care and treatment for patients being cared for in the corridor area of ED.
  • There was a risk that there would be no appropriately qualified doctors on duty if a child needed resuscitating in the ED.
  • Only 78% of patients were assessed by a member of ED staff within 15 minutes of arrival: this had not improved since the last inspection.
  • There were fewer nurses than required for the numbers of patients in the department, particularly at night.
  • The trust had told us that a frailty team was to be implemented in order to improve response for frail patients with complex health needs. This had not happened.
  • Only twenty-four per cent of staff were up-to-date on medicines’ management training and this was below the trust target of 90% in medical care wards.
  • Patient weights were not routinely recorded on drug charts we looked at. Patients declining to take prescribed medication were not always escalated to or reviewed by medical staff. Doctors prescribed medication but did not always review drug charts to ensure patients were either taking their medication as prescribed or declining to take them. This meant that effective treatment was not provided.
  • Patient’s medical notes were not stored securely as they were left in unlocked trolleys that could be easily accessed by unauthorised individuals. Visitors to medical and surgical wards could see patient identification details on electronic white boards.
  • All wards displayed the actual number of staff on duty. However, some surgical wards did not display the planned number of staff and therefore patients and visitors could not identify any staff shortages.
  • Staff compliance with Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training was very low.
  • In response to high capacity demands for medical beds, the hospital had converted a surgical ward to a medical ward: however, nurses said they did not always have the required skills to care for medical patients.
  • Some surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.
  • The medical service leadership team had not addressed all issues identified as areas for improvement in our last inspection. This meant that there were still potential risks to the safety and quality of care and treatment of patients’ care.
  • Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and compliance with hand hygiene. However, we saw examples throughout surgery where national guidance had not been followed. When risks had been escalated, there was a lack of follow up and resolution.

Areas where we found improvements included in the Section 29a Warning Notice had been made were:

  • We observed good infection control precautions performed by all staff in ED clinical areas.
  • Staff were now confident in the use of paediatric early warning scores in ED.
  • Improvements were noted in completed of National Early Warning Score (NEWS) records in the medical care wards visited.
  • Staffing levels in the discharge lounge met patients’ needs.
  • The service had taken steps to improve the management of medical patients cared for on non-medical speciality wards with evidence that patients were reviewed regularly by medical doctors.
  • All staff had ‘arms bare below the elbows’ in surgical clinical areas.
  • We saw fewer medical outliers on most surgical wards. However, one surgical ward had nine medical outliers at the time of our inspection.
  • Patients undergoing surgery had the correct consent form.
  • Patients who lacked capacity had evidence of a mental capacity assessment.
  • The trust had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

Areas of improvement, that were not included in the Section 29a Warning Notice, found from the last inspection were:

  • There were improved processes for the recording of medication that had been given to patients by ambulance crews.
  • Staff felt that increased availability of ambulatory emergency care had improved some aspects of patient flow through the department.
  • The lead consultant and matron were highly visible within the ED and led clinical activity. The matron had recently implemented new clinical audits.
  • Staff had documented competencies to work in the non-invasive ventilation (NIV) unit. This was identified as an issue during our inspection in November 2016 and had improved during this inspection.
  • Adequate staffing levels were observed on all surgical wards during our inspection. Staff explained their new staffing application (an electronic tool which measured how many staff were on duty against how many should have been on duty), which helped escalate any shortages rapidly.
  • Patients undergoing surgery had the correct consent form. Patients who lacked capacity had evidence of a mental capacity assessment.
  • All clinical areas we visited in the maternity and gynaecology service were clean and there was good adherence to infection control policies and the use of personal protective equipment.
  • There had been an improvement in compliance with safeguarding children level three training in maternity and gynaecology service.
  • Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training in maternity and gynaecology service had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.
  • The trust had implemented a new quality dashboard, known as the safety and quality information dashboard (SQuID). This was used as a drive for improvement and had improved staff’s understanding of safety and quality in the service.

However, there were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that the privacy and dignity of all patients in the ED is supported at all times, including when care is provided in corridor areas.
  • Ensure that systems or processes are fully established and operated effectively to assess, monitor and improve the quality and safety of the services provided within the ED.
  • Ensure that systems or processes are fully established and operated effectively to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients while using the ED.
  • Ensure that medicine’s management training compliance meets trust target of 90%.
  • Ensure all staff have completed their Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
  • Ensure the completion of VTE assessments and re-assessments is in line with national guidance.
  • Ensure drug charts have patient weights recorded.
  • Ensure all anticoagulation medication is administered as prescribed. All non-administrations must have a valid reason code.
  • Ensure all medicines are stored at the correct temperature. Systems must be in place to ensure medication, which has been stored outside of manufactures recommended ranges, remains safe or is discarded.
  • Ensure there are processes in place to ensure that any medicine omissions are escalated to the medical team for review.
  • Ensure when patients refuse to take prescribed medication, this is escalated to the medical team for a review.
  • Ensure patient identifiable information is stored securely and not kept on display.
  • Ensure all staff comply with hand hygiene and the use of personal protective equipment policies.
  • Ensure all staff have completed the required level of safeguarding training.
  • Ensure all staff comply with hand hygiene and the use of personal protective equipment policies.
  • Ensure all staff have completed their Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
  • Ensure all staff have completed the required level of safeguarding training for vulnerable adults and children.

In addition the trust should:

  • Achieve the required numbers of consultants in the ED on duty to meet national guidelines.
  • Review its processes to confirm that all ED consultants and middle grade doctors hold a current advanced paediatric life support qualification and that they would lead resuscitation of children. Including those from temporary staffing agencies.
  • Consider displaying actual and planned staff numbers in all clinical areas.
  • Review nurse staff competence for the management of medical patient outliers.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 22 to 25 November, 8 and 15 December 2016

During an inspection to make sure that the improvements required had been made

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire, with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire, as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust, we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection from 7 to 15 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

Overall, we rated Alexandra Hospital as inadequate, with two of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

  • The flow of patients in the emergency department (ED) was often blocked by internal capacity issues, for example, a lack of available beds in the hospital. This resulted in ED becoming over crowded, and with patients waiting on trolleys in a corridor.
  • In November 2016, only 50% of ambulance patients were handed over to ED staff within 15 minutes. There were not enough nurses to ensure that all patients were assessed within 15 minutes of arrival in the department, or to safely care for patients in the major treatment area and resuscitation room.
  • There were not enough consultants to provide 16 hours of consultant cover within the ED each day, in line with national guidance.
  • There was no privacy and little confidentiality for patients waiting on trolleys in the corridor of the ED. Staff did not always have line of sight of these patients.
  • The department could not ensure that there was always as a senior doctor available who was qualified to resuscitate children. Staff had not been trained to use a new system to help staff recognise when a child’s condition was deteriorating. The system had been introduced two days before our inspection.
  • Staff did not complete venous thromboembolism assessments on patients in line with trust policy and national guidance.
  • Appropriate systems were not always in place for the storage, administration and recording of medicines. Intravenous fluids for emergency use were stored unsecured in resuscitation trolleys on corridors in the ward areas. The trolleys were accessible to staff, patients and relatives which meant there was a risk of medicines being tampered with which could cause harm to patients.
  • Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
  • Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
  • There was a lack of radiation protection infrastructure.
  • Medical notes were not always locked away safely.
  • The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) results were worse than expected.
  • There was no policy in place regarding the management of medical outliers. Medical outliers are patients who are admitted to a non-medical ward. Doctors and nurses told us these patients were at greater risk because they were not cared for on a designated medical ward.
  • Not all staff had completed mandatory training or received an annual appraisal.
  • Not all staff cleaned their hands before and after contact with patients and some staff did not change their gloves or aprons after each task. This meant that infection prevention and control practices were not in line with trust policy or national guidance throughout the hospital.
  • There was a high number of medical and nursing vacancies and unfilled shifts.
  • The strategy for countywide management of emergency surgery was not fully implemented and some staff were unaware of the surgical plan.
  • There was a culture of incident reporting and most staff said they received feedback and learning from serious incidents.
  • Feedback from patients and those who were close to them was positive about the way staff treated them. We observed patients being treated with dignity, respect and kindness.
  • Relatives of patients in critical care had access to facilities to enhance their stay on the unit; this included overnight accommodation, refreshments and information leaflets.
  • Patients with a mental health condition who attended the ED were cared for by a responsive and effective psychiatric liaison service and specialist alcohol liaison nurse services were available.

There were areas of poor practice where the trust needs to make improvements:

Action the hospital MUST take to improve

  • Ensure patients privacy, dignity and confidentiality is maintained at all times, particularly during handover.
  • Ensure patients are always assessed and treated in line with the Mental Capacity Act 2005.
  • Ensure that patient documentation, including risk assessments, are completed accurately and routinely to assess the health and safety of patients. This must include pain assessments, venous thromboembolism assessments and fluid balance charts.
  • Ensure that patient weights are recorded on their drug charts.
  • Ensure that there is clear oversight of all deteriorating patients and that the National Early Warning Score chart is completed accurately.
  • Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
  • Establish a female genital mutilation training programme for all staff working in children and young people’s services.
  • Ensure staff are aware of the Mental Capacity Act 2005.
  • Ensure operating team brief is attended by all required members of staff, as per national guidance.
  • A robust system must be in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
  • Ensure that all equipment is checked as per policy, particularly in midwifery services.
  • Ensure that patients are cared for in a safe environment that has the appropriate equipment to facilitate care to a deteriorating patient.
  • Ensure that medicines are stored within the recommended temperature ranges to ensure their efficacy and safety.
  • Review arrangements for the storage of intravenous fluids for emergency use to ensure patient safety.
  • Ensure that medicines are always administered to patients as prescribed.
  • Ensure that there is a system in place in the emergency department to record medicines (including intravenous morphine) administered to patients by ambulance crews.
  • Ensure infection prevention and control procedures are always carried out as per trust policy and national guidelines.
  • Ensure theatres and anaesthetic rooms are compliant with national guidance, Health Technical Memorandum 03-01: Specialised Ventilation for Healthcare Premises.
  • Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
  • Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
  • Ensure patient harm reviews are carried out on patients who breach the referral to treatment times and cancer waits in order to mitigate any risks.
  • Ensure that incidents are accurately reported and investigated.
  • Ensure all mortality and morbidity meetings are recorded and lessons are learnt.
  • Ensure there are systems and processes established in surgical service to address identified risks, such as cancelled operations, bed capacity and access to emergency theatres.
  • Ensure divisional management teams are aware of patient harm reviews.
  • Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
  • Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
  • Ensure children’s and young people’s service carry out clinical audits to identify effectiveness and areas for improvement.
  • Ensure staff are aware of the strategy for diagnostic and imaging services.
  • Ensure patient notes are stored securely and safely.
  • Ensure staff complete the required level of safeguarding training, including safeguarding children.
  • Ensure staff compliance with mandatory training meets the trust target of 90%.
  • Ensure all staff receive an annual appraisal and that there is appropriate supervision for staff.
  • Ensure that there are sufficient registered children’s nurses in post so that the emergency department always has at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in emergency departments.
  • Ensure only appropriately trained staff members are left in charge of a ward to care for patients.
  • Ensure all patients are clinically assessed by a competent member of staff within fifteen minutes of arrival in the emergency department.

In addition, the trust should:

  • Ensure there are consistent mortality review group meetings in order to review the Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) across the service.
  • Ensure that clinical audits in the emergency department are reviewed to enable the findings to improve practice. Accurate performance data should be collected and discussed at relevant governance meetings.
  • Ensure robust risk management processes are in place with defined action plans and regular reviews.
  • Ensure governance meetings reflect their terms of reference.
  • Ensure all staff use appropriate personal protective equipment and decontaminate their hands appropriately at all times, especially before and after every patient contact and when moving between clinical areas.
  • Review the arrangements for the storage of intravenous fluids for emergency use.
  • Ensure trust policies are up to date and reflect current national guidance.
  • Develop documents that clearly identify where specific information should be recorded.
  • Ensure record keeping systems are coordinated to enable staff access to all relevant patient information.
  • Ensure there is an effective escalation process when the hospital is approaching full capacity.
  • Ensure there are sufficient consultant emergency medicine doctors to keep patients safe.
  • Ensure all new bank and agency staff receive thorough inductions and ward orientations before starting work.
  • Document and record all meetings where performance in the children’s clinic is discussed.
  • The provision of children’s services should be clarified with external providers to ensure the safe care of children in the emergency department.
  • Ensure all women are asked about domestic violence during their pregnancy in line with national guidance.
  • Share results from national audits and action plans with all levels of staff to improve patient outcomes.
  • The trust should improve its local audit schedule and consider more regular audits in documentation, the environment, equipment, surgical site infections and hand hygiene audits. Audit results should be followed up with improvement action plans where indicated.
  • Ensure staff have knowledge of the key objectives within their service.
  • Ensure all cancelled clinics and outpatient appointments are rescheduled in a timely manner.
  • Review the high levels of unplanned medical admissions onto the surgical wards and implement steps to reduce the number of cancelled operations.
  • Ensure all treatment areas where children and young people are provided with care and treatment, including adult services, are appropriate and child friendly environments.
  • Ensure appropriate waiting areas are available for children and young people when sharing adult services.
  • Take action to address the ‘did not attend’ appointment rate for new children and young people’s services appointments.
  • Ensure patients are discharged from the critical care unit within four hours of the decision to discharge, in order to improve the access and flow of patients within critical care.
  • Investigate complaints within the timescales stated in the trust’s complaints policy.
  • Review the choices offered to patients about where they are discharged to for continuing care.
  • Ensure information from the children’s clinic flows to the board via effective governance processes.
  • Engage and consult with all staff when considering any service reconfiguration and involve staff in the strategic plans to develop the surgical services across the three hospital sites.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the

section

29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14-17th July 2015

During a routine inspection

Worcestershire Acute Hospitals NHS Trust (WAHNHST) was established on 1 April 2000 to cover all acute services in Worcestershire with approximately 900 beds. It provides a wide range of services to a population of around 570,000 people in Worcestershire as well as caring for patients from surrounding counties and further afield.

The Trust includes four hospital sites, Worcestershire Royal Hospital (WRH), Alexandra Hospital in Redditch (AHR) Kidderminster Treatment Centre (KTC) and one day ward and a theatre at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust

We carried out this inspection between 14th and 17th July 2015 as part of our comprehensive inspection programme, and undertook an unannounced inspection on the 26th July 2015.

Overall, we rated Alexandra Hospital, Redditch as inadequate, with 2 of the 5 key questions we always ask being inadequate (safe and well-led)

Two of the 8 core services (Maternity and gynaecology and children's and young peoples services) were rated as inadequate, and four required improvement (Medicine, surgery, urgent and emergency care and outpatients and diagnostics). Only critical care and end of life care services were rated as good overall.

We have judged the service ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support. However, improvements were needed to ensure services were safe, effective, responsive and well-led

Our key findings were as follows:

  • All clinical areas were seen to be tidy and visibly clean
  • Staff followed the trusts infection control policy. Staff were ‘bare below the elbow’, used sanitising hand gel between patients and used personal protect equipment
  • Rates for methicillin resistant staphylococcus aureus (MRSA) and Clostridium Difficile for the trust were within acceptable range nationally.
  • There were challenges in recruiting doctors to the hospital. Surgical services, children’s and young people’s services and maternity and gynaecology especially had high vacancies for middle grade doctors and relied heavily on locum staff. There were not enough consultants in the Emergency Department to meet College of Emergency Medicine’s (CEMs) emergency medicine consultants’ workforce recommendations to provide consultant presence in all EDs for 16 hours a day, 7 days a week as a minimum
  • Nursing and allied professional staffing was good in critical care, however midwifery staffing did not meet national recommendations, minimum staffing levels were not always met in children’s and young people’s services, and the outpatients and radiography department had significant vacancies for health care assistants and radiographers
  • The Hospital Standardised Mortality Ratio (HSMR) is an indicator of trust-wide mortality that measures whether the number of in-hospital deaths is higher or lower than would be expected. The trust’s HSMR for the 12 month period July 2013 to June 2014 was significantly higher than expected, with a value of 109. Previous publications of this indicator have shown a steady rise in mortality since 2013.
  • There was good feedback from patients about the availability and quality of food and drinks across the hospital. Multiple faith foods were available on request, and choice was supported particularly for children and young people, and patients at the end of life
  • The hospital promoted breastfeeding and was awarded the UNICEF full accreditation in July 2015. Statistics for breastfeeding initiation were consistently better than the trusts own targets
  • An interim plan was in place for some patients requiring emergency surgery to be assessed at the Alexandra Hospital and transferred to Worcestershire Royal Hospital. The trust’s Risk and Options Impact Assessment assessment for this change identified that there was an ongoing risk of a potential delay in care due to the additional ambulance transfer. There was no evidence of actual harm occurring since the change was implemented, however the risk remained
  • The room provided by the hospital for the Early Pregnancy Unit was not considered to be fit for purpose, and there was no separate waiting room for women attending antenatal clinic.
  • The Malnutrition Universal Scoring Tool (MUST) was used to assess and record patients’ nutrition and hydration status. This was well used in critical care and medical services; however this was not consistently completed for surgical patients. There was also no process in place to review patients nil by mouth status to ensure their starvation times reflected national guidance when operations were delayed

We saw several areas of outstanding practice including:

  • There was an outstanding patient observation chart used within the critical care unit. This chart was regularly reviewed and updated with any new developments or patient safety, care quality and outcome measures. The detail within the chart meant few if any crucial measures or indicators were not recorded, regularly reviewed, and deterioration or improvements acted upon.
  • The critical care team provided an outstanding example of compassion to a patient with a learning disability.
  • The critical care had shown an outstanding example of responsiveness with obtaining and using noise monitoring devices. Patients need peace and quiet for their recovery in critical care, and this had been recognised by the provision of devices that reminded staff when noise levels were increasing to disruptive levels.
  • The response time to new referrals to the palliative care team is very fast. An audit of the team’s response times over 70 days showed that over 92% of patients were seen for the first time on the same day the referral is made. No patient waited more than two days for a first clinical assessment.
  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
  • In Maternity and gynaecology services, overwhelmingly we received feedback that staff were excellent and compassionate. Women reported being treated with respect and dignity and having their privacy respected at all times. Outstanding practice was noted with staff having thought about the caring needs of women and devising innovative solutions to support them. This was demonstrated by staff facilitating a teenage buddying system and developing bereavement care pathway for women who suffer pregnancy losses at any gestation. The patient experience midwife was available to support women who were anxious or fearful about pregnancy and childbirth. We observed staff demonstrating a strong, visible person centred culture throughout the service.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Review the existing incident reporting process to ensure that incidents are reported, investigated, patient harm graded in line with national guidance, actions correlate to the concerns identified, lessons learnt are disseminated trust wide, and reports are closed appropriately.
  • Ensure there is a sustainable system in place to ensure all surgical patients receive safe and timely care
  • Review the existing arrangements with regards to the management of referrals into the organisation in order that the backlog of patients on an 18 week pathway are seen in accordance with national standards.
  • Ensure that risk registers are reviewed regularly in a timely fashion
  • Develop a suitable process to ensure children and young people who present with mental health needs are suitably risk assessed when admitted to the department to ensure care and support provided meets their needs.
  • Review consultant cover in ED in line with the College of Emergency Medicine’s (CEMs) emergency medicine consultant’s workforce recommendations to provide consultant presence in the ED 16 hours a day, 7 days a week as a minimum.
  • Improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards; reduce the unacceptable number of discharges at night; reduce the risks of this situation not enabling patients to be admitted when they needed to be or discharged too early in their care; reduce occupancy to recommended levels; and improve outcomes for patients.
  • Complete risk assessments and use effectively to prevent avoidable harm such as the development of pressure ulcers.
  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the requirements of the service including the provision of daily ward rounds.
  • Ensure that patient records are accurate, complete and fit for purpose.
  • Ensure that patient’s nutrition and hydration status is fully assessed recorded and acted upon in a timely manner.
  • Evaluate and improve their practice in response to results from the hip fracture audit for 2014
  • Respond to patient complaints in a timely manner and in accordance with the trusts complaints policy.
  • Ensure that there is sufficient levels of medical staff cover throughout the week to ensure patient reviews are carried out in a timely manner.
  • Ensure that all staff are compliant with the trust mandatory training target of 95%, including safeguarding children as a priority.
  • Ensure all medicines are prescribed and stored in accordance with trust procedures.
  • Review the management of medical outliers and devise a trust wide policy to improve their management
  • Take steps to ensure that all staff are included in lessons learnt from incidents and near misses, including lessons learned from mortality reviews, with effective ward based risk registers and safety dashboards being in place and understood by all staff.
  • Ensure there are the appropriate number of qualified paediatric staff in the ED to meet national guidelines
  • Ensure the facilities in the Early Pregnancy Unit are fit for purpose

In addition the trust should:

  • Ensure staff at ward level have access to information and agreed outcomes from governance meetings to continually improve their practice.
  • Ensure an action plan is developed to improve NNAP compliance.
  • Ensure staff are aware of the trust’s strategy and vision for the future.
  • Ensure all staff in the maternity and gynaecology service understand their role and responsibilities regarding the Deprivation of Liberty Safeguards.
  • Ensure cardiotocogragh (CTG) documentation is clear, to identify that staff are following current local and national guidance.
  • Ensure that women having procedures for fetal abnormalities are cared for in a side room.
  • Ensure that the delivery suite facilitate home from home rooms for low risk women.
  • Undertake a review of staffing in maternity in line with the acuity tool results.
  • Ensure that antenatal screening KPI data can be reported.
  • Consider providing a separate waiting room for women attending antenatal clinic
  • The security of confidential patient records should be reviewed to ensure they are safe from removal or the sight of unauthorised people.
  • Develop a policy on restraint and / or supportive holding and staff should receive training to ensure they understand how to apply the policy.
  • Consider developing an early warning tool for neonates.
  • Ensure that staffing records relating to medical staff accurately record who has worked each shift and that sickness absence is accurately recorded in order to monitor the shortfalls in shift and take necessary action to fill shifts to the required number.
  • Approve the audit plan for children and young people and ensure audits are completed in line with the plan including regular updates on audits outstanding with revised completion dates.
  • Ensure pain assessments for children should be consistently completed.
  • Ensure the dashboard for children and young people is reviewed and updated to include all pertinent information.
  • Develop a suitable business plan for children and young people which identifies the needs of patients and adequately plans services for the year ahead. This should identify areas for improvement or expansion and ensure that patient demand can be met safely with the resources available.
  • Respond to complaints within agreed timeframes and summary data should be explicit as to which location the complaint relates to. Meeting minutes should clarify which area of women’s and children’s complaints relate to and where performance times need to be improved.
  • Ensure governance arrangements are improved to ensure meeting minutes accurately reflect discussions held and /or that discussion takes place in accordance with the terms of the committee and that actions agreed are followed up at subsequent meetings.
  • Ensure the morbidity and mortality meeting minutes clearly document discussions.
  • Ensure that there is a systematic screening to identify patients with alcohol misuse to facilitate all patients who attend the ED for alcohol consumption receiving a brief intervention and signposting.
  • Ensure a county-wide consultant on call rota is achieved as part of the ED transformation programme.
  • Ensure medicine facilities are adequate to assist staff with the collection and preparation of medication.
  • Continue to liaise with other organisations to improve the mental health service provision.
  • Ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for E.Ds.
  • Ensure unplanned re-attendance to ED within seven days meets the target of 5%.
  • Continue to engage with local organisations to improve patient flow to ensure that patient waiting for hospital beds in ED can be transferred in a timely manner to prevent breaches.
  • Reduce the speciality referral time to less than 60 minutes to meet the trust target.
  • Ensure delays in ambulance handover times are reduced to meet the trust target of 80% of patients admitted via an ambulance having handovers carried out within 15 minutes and 95% of patient handovers being carried out within 30 minutes of arrival by ambulance.
  • Ensure the vision of the ED is understood by all staff.
  • Ensure effective governance and performance management of ED to make significant improvements in the quality measures.
  • Ensure audit action plans are always in place and provide assurance, evidence or progress updates to show how improvements had been achieved.
  • Ensure all senior staff are visible enough for staff to recognise them and feel supported.
  • Ensure the changes to manage overcrowding and patient safety in the ED are sustainable.
  • Ensure that there is a lead staff member for ED audits in place.
  • Support staff in Critical Care with training and guidance to investigate and report upon serious incidents.
  • Ensure adherence to the Duty of Candour regulation is recorded in incident reports in line with requirements.
  • Ensure trolleys for resuscitation equipment in critical care are secured in such a way to highlight to staff if they had been opened, used or tampered with between daily checks.
  • Review and risk-assess the provision of the critical care Outreach team service which was not being provided for 24 hours a day.
  • Review the provision of care to patients in CCU as this currently does not meet the National Institute for Health and Care Excellence (NICE) guidance 83 in relation to some parts of patient rehabilitation, including discharge advice and guidance and follow-up clinics.
  • Review the role of the clinical nurse educator in CCU to ensure adequate time and resources are given to this essential post in line with best practice and FICM Core Standards.
  • Ensure that critical care have supernumerary cover from a sister at all times.
  • Ensure patient notes in CCU have clear records of assessments and best interest decisions for patients who lack the mental capacity to make their own decisions.
  • Revisit the use of patient diaries in order to use them more creatively to the benefit of patients and their loved ones.
  • Review CCU’s access to a Regional Home Ventilation and weaning service in line with the Faculty of Intensive Care Medicine Core Standards.
  • Ensure leaflets and information it provides contains the most up-to-date information for people to contact services. Information about getting leaflets in other formats should be included in all printed literature.
  • Critical care should review the use of care plans for patients living with a dementia in line with national guidance and best practice.
  • Ensure critical care strategies and future plans are part of the overarching vision of the division in which it sat.
  • Ensure critical care services are represented in all clinical governance meetings.
  • Ensure high-level risks on the local risk register in the CCU are incorporated into the corporate risk register and have board oversight.
  • Implement a risk register for end of life care services in order to ensure that risk is adequately assessed and monitored.
  • Develop an end of life strategy with well–defined objectives that are aligned to the ‘five priorities for care of the dying person’ as recommended by the Leadership Alliance (2014).
  • Routinely audit the numbers of patients who achieve their preferred place of dying.
  • Ensure all patients have person centred care plans that reflect their current needs and provide clear guidance for staff to follow.
  • Ensure that staff at all levels are supported effectively via supervision and appraisal systems.
  • Ensure all temporary staff have an effective ward induction.
  • Ensure that any chemicals are stored appropriately, and ‘out of bounds’ areas are appropriately secured.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 24 March 2015

During an inspection to make sure that the improvements required had been made

We inspected Worcestershire Acute Hospitals NHS Trust on the evening of the 24th March 2015 as a part of a responsive inspection. The purpose of the unannounced inspection was to look at the emergency departments (ED) at Worcestershire Royal Hospital and Alexandra Hospital. The services were selected as examples of a high risk services according to our intelligent monitoring model. This looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations.

We did not inspect any other services provided at the trust.

The inspection focused on the safety of patients. We found that improvements were needed to ensure that the EDs were safe.

We also looked to ensure each ED was effective, caring, responsive and well led. However, we did not have sufficient evidence to rate domains.

Our key findings were as follows:

Incidents

  • Systems were in place for reporting incidents. However, incidents were not always reported. This meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.

Safeguarding

  • Children were not routinely screened for safeguarding concerns. At Alexandra Hospital we found one child who had received an injury, did not have a safeguarding assessment completed.
  • We found paediatric patients were at risk because there were inadequate measures in place in relation to their security.

Medicines management

  • The medicines in the resuscitation room were stored in a lockable cupboard, which was in constant use during our visit.
  • The register for the controlled medications were completed and tallied with the actual medications in the controlled drug cupboard.

Staffing

  • There was a shortfall in nursing staff numbers. There was no evidence shifts were being planned to reflect the patients’ acuity and therefore the planned staffing did not always meet the needs of the patients in the department.
  • Senior staff told us they had escalated concerns about staffing and capacity in the department to senior managers as they considered the department was “not safe” at times due to the high volume of patients.
  • We saw evidence of the department being “Overwhelmed”. However the escalation process could not always been carried out because there were no more staff available. This meant that the department was not able to manage the situation safely.

Medical staffing

  • Forty percent of the senior staff were locum.
  • There was one consultant on site after 5pm covering both the Worcestershire Royal Hospital and the Alexandra Hospital site, including trauma calls. This was raised as a concern during a peer review from NHS England. If two trauma patients were admitted at the same time on each site, the protocol was that one of the trauma calls would be led by the orthopaedic doctor.

Environment and equipment

  • All of the cubicles had nurse call bells available.

Ambulance Handovers

  • There were delays in handover time from ambulance crew to the emergency department team. This meant that patients, including clinical unstable patients, remained under the care of the ambulance crew longer than expected which delayed initiation of treatment.
  • In the past 12 months the trust had not consistently met its 15 minute triage target or its target for patient handovers being carried out within 30 minutes of arrival by ambulance.

There were areas of poor practice where the trust needs to make improvements.

We found breaches with the following regulations:

  • Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Regulation 15 (1) and (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].

Importantly, the trust must:

  • The trust must ensure that service users are protected against the risks associated with unsafe or unsuitable premises, by means of appropriate measures in relation to the security of the EDs.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 6 March 2014

During a routine inspection

This inspection looked at how the provider dealt with and responded to hospital acquired infections. In particular we looked closely at how outbreaks of Norovirus were managed. Norovirus causes sickness and diarrhoea and can cause complications for people that are vulnerable due to illness. This infection has been known to be a recurrent problem for hospitals throughout the winter months.

We were unable to carry out any observations in ward areas. However, we met with the registered manager, the chief executive and with a range of staff which included doctors, nurses, housekeepers and care assistants. We held a special forum with staff to enable them to discuss with us their feelings on how infection prevention and control was managed. We also looked at the policies, procedures and risk assessments for infection control.

During our inspection we found that the provider had systems in place to prevent, detect and control the spread of infection. For example, we read the policies and procedures around the management of Norovirus. We found that these policies provided robust guidelines for the monitoring, reporting and management of this infection.

We saw that the provider had risk assessments and action plans for how to manage the risk if infections were present in the hospital. These included guidance for staff on isolating patients if they had any infection that could be contracted by other patients, this included Norovirus. The policy stated that this prevented the further spread of infection and also protected patients that were at increased risk of acquiring an infection from other patients. Staff we spoke with confirmed that wards were closed and staff movements to other wards restricted when Norovirus was present. This meant that the provider had appropriate measures in place to reduce the risk of the spread of infection.

Inspection carried out on 7 March 2013

During a routine inspection

We carried out observations on wards 9, 10, 12, and 16. We also spent time in the Accident and Emergency department and the Discharge Lounge and spoke with some of the staff who worked in the areas we visited. We also took the opportunity to formally meet with groups of staff who worked in other areas such as physiotherapy, occupational therapy, pharmacy and portering services.

We observed how care was delivered and spoke to 26 patients about the care they had received. Most people told us they were happy with the care provided and the level of information they had been given about their care and treatment.

One person told us: “The staff here are brilliant, whichever part of the hospital I’ve been on. Despite staff always being busy, you never see them stood”. Another person said: “They always ask if I need anything and explain before they start and say what they are doing it for”.

Overall we found that there were arrangements in place to ensure that people’s needs would be met when they were discharged or were transferred to other care providers .

There were appropriate arrangements for staff training and staff told us they received training which was appropriate to their roles and responsibilities.

There were arrangements for monitoring the quality of care delivered at ward and departmental level and for reporting the information to the trust board. Information from audits or checks completed was used to improve practice where necessary.

Inspection carried out on 20 March and 24 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 15 June 2011

During an inspection to make sure that the improvements required had been made

We spoke to a total of nine patients, one relative and two visitors at the Alexandra Hospital and three patients at the Worcestershire Royal Hospital.

People we spoke to were positive about the care provided and made a number of very positive comments ‘Yes, very happy, the staff are lovely’, ‘Brilliant can’t fault it’, ‘The staff are really nice and provide good care’.

People told us they were kept informed about their care and treatment and that staff explained things to them. Patient information was not widely available at the Alexandra Hospital but we were told that this was being addressed.

All of the people we spoke to felt that staff responded to their needs promptly although not everyone we saw at the Alexandra Hospital had call bells accessible to them.

People we spoke to were very complimentary about the meals served to them and we saw that food was made available to people who may have missed food while investigations were being carried out.

The environment was quiet and conducive to eating, people appeared relaxed and reported they enjoyed their meal. Three of the nine people we spoke with were not aware that snacks outside mealtimes were available if they wished.

Inspection carried out on 22 March 2011

During a themed inspection looking at Dignity and Nutrition

During our observations on both wards we spoke with a total of five patients and one visitor. People we spoke to were generally complimentary of the care they had received from staff in the hospital. However, some people told us that that they were not given any information on their arrival to hospital and that they were not always kept informed of what was happening to them. When we spoke to people about how staff respond to their individual needs some people told us that they often experienced delays in getting help from staff when they pressed their call bell for help.

People we spoke to were very complimentary of the meals provided to them and most people were able to choose what they wanted to eat from a menu. However, none of the people we spoke to said that snacks were available to them between meals.