Royal Shrewsbury Hospital

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

We looked for evidence that people were always treated with kindness, empathy and compassion. We checked that people’s privacy and dignity was respected, that they understood that they and their experience of how they were treated and supported mattered. We also looked for evidence that every effort was made to take people’s wishes into account and respect their choices, to achieve the best possible outcomes for them.

At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to privacy and dignity. At this assessment the rating has remained requires improvement. Staff could not maintain the privacy and dignity of all patients.

We have not awarded this service a score for Caring.

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

People were mostly treated with kindness, empathy and compassion by everyone in the service. However, due to crowding, in the ED patient’s privacy and dignity was not consistently respected. Staff mostly treated colleagues from other organisations with kindness and respect.

There was a breakdown in patient care, dignity, and communication in some parts of the department. Not all patients and relatives said staff treated them well and behaved appropriately towards them. For example, when a patient in ARA had a soiled continence pad their relatives asked staff to change this. They were told by staff they would need to wait due to the volume of other patients also requiring their personal care needs being met. The family felt they had no option other than to change the pad themselves and began doing this with the agreement of staff. When the task became more difficult than expected they asked for urgent help from a member of staff who the relative said, “snapped at me, and said it is not our fault the ED is so busy”.

All the patients and relatives we spoke to said it was clear there were not enough staff in the department, but they “were trying their best”. Despite being busy most patients said staff were kind and helpful. For example, one patient in majors said, “They're always asking if I'm okay and always asking if I want anything.” However, the experience of patients differed greatly based on which part of the department they were in. A patient who had been in the waiting room for 6 hours told us, “I don't feel valued here. Staff are abrupt when you ask them questions.”

Not all patients were able to access basic needs, such as food, and sleep. For example, patients in fit to sit and the main waiting room overnight could not sleep. There were vending machines in the main waiting room but food and drinks could only be purchased using a bank card. We spoke to a patient and their relative who had been in the waiting room overnight. They were not offered anything to eat or drink for 10 hours.

Staff introduced themselves to patients. We saw staff being friendly and kind to patients and to each other.

The triage room in the ED was private so confidential conversations could not be overheard. Triage in PED took place in an appropriate area. However, as the only desk with a computer and phone was located there staff told us there were frequently other members of staff trying to access the area which could impact on privacy. We saw staff in majors protecting patients’ privacy and dignity. However, in ARA and ambulatory majors (fit to sit) it was not possible for staff to consistently maintain patients’ privacy and dignity. Patients in ARA had curtains that could be drawn around their trolley to provide some privacy, but conversations could be overheard by other patients and their relatives. Patients told us their assessment with a doctor took place in a private room. However, patients were given medication and other treatment and had observations taken in front of other patients.

We heard staff in ARA talking to patients with kindness. We heard them explain what they were going to do, for example, help reposition somebody to make them more comfortable. We heard staff offering patients and their relatives drinks and getting extra pillows and blankets for patients. We also head staff asking patients how they wanted to be addressed.

Patients we spoke to were in fit to sit for up to 34 hours. They told us they had been offered food and drinks and that staff were mostly friendly and approachable

Most, but not all ambulance trust staff told us ED staff treated them with kindness and respect.

We did not look at Treating people as individuals during this assessment. The score for this quality statement is based on the previous rating for Caring.

We did not look at Independence, choice and control during this assessment. The score for this quality statement is based on the previous rating for Caring.

The service listened to and understood people’s needs, views and wishes. However, staff could not consistently respond to people’s needs in the moment and act to minimise any discomfort, concern or distress.

Staff could not consistently respond to people’s individual needs because of the level of demand on the service. This was highlighted above by the example of a patient who could not have their continence pad changed by staff because they were too busy.

We saw patients in fit to sit who required support from staff having to wait because there were no available staff. We also saw other patients trying to get the attention of staff to help other patients. We saw patients who had been sitting in a chair in fit to sit for more than 24 hours. These patients told us they had been unable to sleep because they could not lie down and because of the bright overhead lights.

Most of the patients we spoke with told us they had been asked about pain and were given analgesia when required. Most of the patients we asked told us staff responded within a reasonable timeframe to answer their call bells.

Staff did not feel positive or proud about working for the trust. Staff told us they were going home from work feeling, “emotionally overwhelmed”. They told us it was very difficult to return to work the following day and see the same patients were still in the department. All the staff we spoke with told us there was not enough staff, especially nursing staff. They told us this impacted on patient safety and on the morale of the whole staff group. Although staff said their immediate managers were supportive and understanding of the difficulties they were experiencing, they were unable to make changes as the senior hospital leaders did not support them. Some staff told us they did not feel valued by the trust because of a perceived lack of interest from hospital leaders about staffing levels and patient safety concerns.

Low morale, staff burnout, staff not feeling listened to, along with bullying and poor communication were long standing cultural problems within the department. An independent review of culture that had taken place in June 2023 had demonstrated:

• staff feeling unsupported with the burden of level of risk and unrealistic demands placed on them
• feeling there was a lack of support from leadership within the department and the wider organisation
• a lack of shared ownership of risk
• pressure to get patients off ambulance instead of a focus on patient care
• the department operating as a ward: leading to loss of skills and inappropriate use of time
• patients being nursed in unsuitable areas
• errors occurring because of the high workload

Despite the introduction of initiatives to improve culture within the department these were also the key themes that arose when we spoke with staff. This demonstrated a continuation of a poor culture, fed by a lack of meaningful change in staff working conditions.

Staff reported that some patients and members of the public had been abusive towards them due to delays in treatment. The 2024 staff survey found that 42% of respondents had experienced harassment, bullying or abuse at work from patients, relatives or members of the public. The lowest-scoring survey metric was ‘We are safe and healthy’, indicating that abuse towards staff was a longstanding and significant issue within the Emergency Department (ED). In response to these findings, the trust introduced a zero-tolerance approach to unacceptable behaviour, aimed at protecting staff and ensuring they felt supported and respected in the workplace. The trust also planned to provide additional training focused on civility, respect and professional challenge for ED staff.

Some staff told us they were sometimes unable to get support from the security team when patients had been aggressive towards them. They gave us examples of incidents when the security team had been unable to respond to incidents.

Staff had access to support for their own physical and emotional health needs through an occupational health service. This included fast track access to physiotherapy and counselling.

Staff told us they had access to the hospital’s wellbeing room where they could access support, for example financial advice or counselling.

Staff in the PED told us they could access the support of a clinical psychologist following the death of a child in the department, or other traumatic events.

Staff told us the service made reasonable adjustments to support individual needs and circumstances. For example, a member of staff with a disability who had increased symptoms overnight and no longer felt able to work over night, was removed from the nightshift rota.

The trust had a workforce disability network, a diverse inclusion network, and a lesbian, gay, bisexual, transgender, and queer (LGBTQ+) network. The role of these networks included visible ensuring representation and acceptance of difference within the workforce. As well as providing a safe space where people could access advice and information.

Staff could nominate colleagues to receive an “above and beyond” award. There was a “positives board” in the staffroom. This board was used to display thank you cards from patients and relatives as well as photos of staff engaging in fun activities.

The matron was the wellbeing lead for the department and was also a trained mental health first aider. Mental health first aiders are trained to provide immediate support and signposting for colleagues experiencing poor mental health or emotional distress.

Nursing staff told us they felt well supported by the consultant team.