Worthing Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as requires improvement. We found a breaches of regulation relating to the safe management of medicines and staffing. We assessed seven quality statements. Staff gave us both negative and positive feedback about the departments learning culture. The trust did have an embedded improvement strategy and had recently made the transition to the new national system for the recording and analysis of patient safety events. Staff were open and honest when things went wrong or could be a risk, however felt they were not always listened to when they did raise concerns. Staffing levels at the time of our assessment were not in line with national standards and staff were concerned that they could not keep patients safe at all times. Pathways and systems did not always support timely and safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were involved in investigations if they wanted to be, and reports of the event were shared with them. We looked at the Patient Safety Incident Response Policy, which showed that people or those that represent them were included in response to incidents. People or those who represented them were given an apology and an explanation of the event, and people were given a timely response, and could expect to receive a copy of the incident investigation report and local learning reviews.

Staff knew how to report incidents and could describe the type of incidents to report in line with policies, however staff from the local mental health trust could not access the trusts internal reporting or notes systems. This meant that there was no shared understanding of patient care and assessments, and no shared incidents or learning. Staff gave mixed feedback regarding learning and support following incidents. In serious incidents or incidents where staff could have been exposed to traumatic events, some staff told us there were hot debriefs at the time of the incident to support staff, and cold de-briefs held at a later stage with the senior clinician. A bereavement nurse was sometimes included in these debriefs to provide support. However, staff also told us after a recent significant incident, they were only de-briefed three weeks later. Some staff told us that they did not feel supported after traumatic incidents and that the support following on from these had been poor, with little face to face support. There was a clinical governance bi-monthly meeting which nurses had protected time for if they wished to attend. However some nurses told us they did not feel able to attend these as it would leave the areas short staffed.

The trust formally adopted the Patient Safety Incident Response Framework in December 2023, as directed by NHS England. The trust’s Patient Safety Incident Response Policy (PSIRP) gave examples to staff of types of patient safety incidents and their response, and the processes involved. The trust shared some after action reviews (AAR)s from recent incidents which showed learning and actions identified, however some were in a draft format with completion/target dates not included. This meant the trust may not have oversight of all actions that were due.The trust provided an example of a change following regular audits of the National Paediatric Early Warning Scores (NPEWS). These scores were recorded electronically and could be reviewed and audited through the electronic system. Staff realised that one of the metrics required to accurately calculate NPEWS was often not completed and therefore the electronic system was altered to make this a mandatory requirement. Following this change, the trust reported that timely observation audits had increased from 40% in May 2023 to 78%, which was just below the trust target of 80%.

Pathways and systems, did not always support timely and safe care and treatment. CAHMS patients (those displaying emotional, behavioural or mental health difficulties) without additional medical/physical needs were kept in the paediatric emergency department (ED) for longer than was appropriate for their needs. Examples had been given where patients could wait for days when awaiting social input. Staff told us patients sometimes left the department prior to their CAHMS assessment which meant they were still at risk when leaving the hospital. The trust told us there were 6 incidents where patients self-discharged prior to a CAHMS assessment from November 2023 to April 2024. There was a flowchart advising staff of what to do if a patient chose to discharge prior to their assessment which included giving a patient safety leaflet.The trust told us that it was the responsibility of the local NHS mental health trust to monitor the outcomes for these patients and that staff at Worthing Hospital followed their internal processes for when CYP left without being seen.The Royal College of Emergency Medicine (RCEM) guidance states that patients should be triaged within 15 minutes or less. The percentage of patients triaged within 15 minutes or less in June 2024 was 56%, and 73% of patients waited less than 60 minutes to be seen by a clinician. Of those patients admitted, 47% were done so in less than 4 hours. Of those not admitted or discharged, 83% were done so in less then 4 hours. Data provided by the trust showed the average length of time in ED for children and young people was 165 minutes. Some patients waited considerably longer, with the maximum wait in July 2024 was 84 hours. The trust told us that in each of the past twelve months the longest wait in ED was a mental health patient. The trust said that wider social and care issues had led to these long waits.

Some staff in the paediatric ED expressed concern there was no process or policy to support them to provide safe care and treatment to patients when the department was at full capacity. Staff told us that they did not have a policy for when the department was full despite staff members drafting a process for approval and expressed their concern about approaching winter, where attendance in the paediatric ED can increase. Staff told us it felt like ‘waiting for a disaster to happen’. Staff on the ward had received training and support for caring for patients with mental health needs, however the training was limited in availability and some senior staff were unaware of crucial policies for mental health patients such as rapid tranquilisation.Following the assessment the trust told us that the rapid tranquilisation protocol for CYP in ED was overdue for review since 2021. The trust told us that they have now adopted the Paediatric Innovation, Education and Research Network (PIER) guidance for rapid tranquilisation which staff have access to in the department.There had been a change of policy and patients for the ward had to have a physical issue to be admitted for care. Staff on the ward felt there were processes and systems in place to support them with patient pathways and care.

The local mental health trust had not been made aware of the clinical decision to stop admitting patients without physical needs onto the paediatric ward. This had been in place since January 2024.

Staff working in the ED had felt unsupported and anxious about the risk to their patients. They had collectively trialled a collaborative walkaround which happened every 4 hours, but at the time of our assessment did not feel supported to complete this. Following our assessment this was fully implemented and welcomed by staff who told us the benefits of walking round to each area and checking in on the status of the staff and patients. In addition to this, staff had been asked by the senior leadership team to complete a 2 hourly situation report in the emergency department. However, staff in the department had not been told why this had been initiated, and to their knowledge the data was not being reviewed, audited or used to support improvement. They told us that It was difficult to release a doctor and nurse every 2 hours, particularly during the night when cover was stretched, especially when they felt the data collected was not being used.Following the assessment the trust confirmed the two hourly huddles were still occurring, but there was no formal data collection from these.The trust told us that for mental health patients, the four-hour performance has worsened from 69.2% in Jul-23 to just 8.3% in Jul-24. This decline in performance followed a clinical decision to stop admitting mental health patients with no physical health need to Bluefin ward. There was no action plan in place to address this decline in performance, and the majority of staff we spoke to on paediatric ED felt overwhelmed by the additional work this had created.

We did not collect evidence to score this category.

During the assessment staff described how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff we spoke with felt the safeguarding systems and processes in place worked well and gave examples of where they had raised issues and concerns. We spoke to staff who told us they worked with the trust safeguarding team when they had concerns about a child or young person. Examples given included a youth worker working with the safeguarding team to ensure patients remained safe.

Safeguarding training was available for all staff to attend however compliance with this was variable across the departments with some of the lowest scoring compliance in paediatric ED, where only 26% of health care assistants had received their level 3 training. We were not provided with any rationale for this poor compliance however the trust told us that there was an improvement plan in place to increase compliance to 85% by August 2024. Compliance with safeguarding training on Bluefin ward was better, ranging between 66% and 100%.

Safeguarding leads at the trust had received level 4 safeguarding training in line with national guidance.

We spoke with parents of children on the departments about if they felt involved in their care plans going forwards. There were mixed views from parents about their involvement in managing their children’s conditions and risks with some parents not feeling involved. On the paediatric emergency department, we observed that initial triage of patients took up to 45 minutes due to the insufficient number of staff, and children with abnormal vital signs at their first triage did not always have their observations within 60 minutes. This was not in line with standard 16 and 17 of RCPCH Facing the Future - standards for children and young people in emergency care settings (2018).

There was no formal standard operating procedure for staff in the ED since the change to not admitting patients to Bluefin ward. The trust told us that the staff instead followed the CAHMS referral flowchart and used the Paediatric Safeguarding and Management Tool (PSMART) tool. Many staff we spoke with were frustrated at the lack of information given about this change and were frustrated that they had to manage challenging patients for a longer amount of time in an unsuitable environment. The service used the National Paediatric Early Warning Score (NPEWS) to assess illness severity and risks of deterioration in patients. There was a dashboard used to monitor the number of observations, and those that were given late or missed. The trust had a key performance indicator of 80% for timely observations which was reviewed monthly. Overall compliance with timeliness of NPEWS had improved as at July 2024 to be just shy of the 80%. However, timeliness compliance for the NPEWS at escalation levels 3 4 was at less than 50%.

Staff were trained in either Paediatric Immediate Life Support or Paediatric Advanced Life Support training depending on their role. Records provided to us by the trust showed that 83% of staff had completed this training. The emergency department used a PSMART for any patients presenting with mental health concerns or suicidal ideation. The tool asked a variety of questions which allowed the staff member to risk assess the patient as ‘red’, amber’ or ‘green’ and whether they had been referred to the CAHMS team. The emergency department and ward had been stripped of as many ligature points as possible however it was not possible to remove all of them. There was one cubicle which was kept as a mental health cubicle with minimal ligature points however staff told us there were often times when more than one patient with mental health needs were in the department. At the time of our assessment there was no ligature risk assessment policy in place, however we were told that one was being written. Ligature cutters were kept on the emergency trolleys and at the nursing stations. Only registered mental health nurses (RMN) employed by Sussex Partnership NHS trust or through an agency were trained to restraint and this would only be as a last resort. Patients who were likely to need restraint were risk assessed and assigned to trained mental health nurses on a one to one basis. Senior nursing staff within the paediatric emergency department were not aware of the Rapid Tranquilization Policy for Children and Young People. Children and young people attending the emergency department may need rapid tranquilization as part of their treatment. The risk is that staff involved may not have the competence and skills to do this safely.

The waiting room in the paediatric ED was crowded, noisy with very limited opportunities for distraction such as toys, or television. There was no specific area for the care and management of children presenting with acute mental health problems, particularly those who exhibited distress through violent behaviours. This meant there was insufficient assurance about the safety of the environment for these children as there was ready access to the essential equipment for physically unwell children that may include potentially harmful items or items that can be used to harm themselves. The environment was hot, noisy, cramped and stressful and not conducive to calming children who were agitated.

People were not always cared for in safe environments that are designed to meet their needs .

There had been a change to the process for CAHMS patients (those displaying emotional, behavioural or mental health difficulties) attending the hospital. CAMHS patients that displayed no medical/physical concerns, could not be admitted to the paediatric (Bluefin) ward. Instead the patient remained in ED, to be referred to the CAMHS team (provided by another NHS trust) who would aim to contact the patient within 1 hour of referral . However staff told us that often this would not be the case and patients presenting in the afternoon would often be waiting until the next day to be seen.

Staff from the paediatric ED told us they felt children and young people with mental health needs often stayed in paediatric ED for long periods of time, which was not an appropriate place for them to stay as they don’t have access to a play area or kitchen. Examples were given including a young child with additional needs that was not admitted to the ward and had to stay in the ED area . Staff described incidents like this as ‘heartbreaking’. We saw from data provided by the trust that this incident was reported via the electronic reporting system, however no actions taken following this.

The trust told us there were 6 incidents where a patient self discharged prior to a CAHMS assessment from November 2023 to April 2024. There was currently no action plan or standard operating procedure in place to address this, however there was a flowchart that documented if a patient wanted to leave prior to their assessment, they should be given a safety plan leaflet, ensure social care and CAHMS referrals completed, and if urgent concerns to contact duty social worker or the police. We saw from incident reports provided that staff did follow the flowchart.

The paediatric ward environment was suitable for the patients and family members who used it. The ward was secure and access to staff was via a swipe card, and visitors had to use a call bell with a camera for staff to check who was entering. There were single bedded cubicles and also a critical care room. There were separate areas for different aged young people including a play area for younger patients and a room with a pool table and games consoles for older children. Parents had access to a kitchen where they could make drinks and refreshments. However we noted one of the bedrooms had a high drop from the first floor and a window that appeared could be opened easily which we raised with the ward manager.

We observed a child with mental health needs in the paediatric ED becoming distressed but could not be admitted to the ward. They remained on ED until they could be reviewed by the CAMHS team. Staff could access a play specialist to help distract and provide enrichment whilst in the ED, however as they were ward-based, they were often not able to attend the ED.

We asked the trust to provide evidence of how they keep children and young people displaying mental health concerns safe in the paediatric ED if they are faced with a long wait. We were provided with a CAMHS guideline which was a first version and dated 20 September 2024. This suggested there was no formal guidance for supporting CYP in the department prior to this.

During the site visit the inspection team could not find evidence of a policy for patient flow between the paediatric emergency department or a decision making / risk assessment tool to ensure each child was assessed and treated in the correct area – with the emergency department, the assessment unit or the paediatric ward. Staff could not be assured the patient was being assessed and treated in the most appropriate area of the unit and this could lead to a delay in treatment or discharge.

There were not enough staff with the right skills and experience to look after people safely. Children and young people waited for long periods of time when waiting for mental health input. There were delays in triaging children and young people due to insufficient numbers of staff available. Children and young people waiting for a mental health assessment would be assigned a registered mental health nurse to provide one to one care. However, there was often a delay in the mental health nurse attending and therefore on some occasions security staff were used, which is not in line with best practice.

Staff told us they were coming to work when unwell and were not taking allocated breaks as they felt the risk to patients and their colleagues was too high. Staff were concerned that they had missed safety tasks during their shifts and would ring in during days off to ensure the department and service users were kept safe. This impacted on the health and well-being of the staff. Staff felt it was only a matter of time before a patient suffered actual harm in the department because of the current staffing levels. The matron post for Bluefin ward had been vacant for over a year and staff told us the nurse in charge was supposed to be supernumerary to be able to help and supervise staff but rarely was due to staffing pressures.Following our assessment, the trust confirmed that the matron post had been filled, following the changes made to the clinical operating model that was ongoing at the time of our assessment. In addition, the trust confirmed that the nurse in charge role was not a supernumerary role.Staff told us that there was no parity between the Worthing staffing model and others across the trust. Examples were given that the numbers and acuity of patients was higher at the Worthing site than other sites, but the staffing template at Worthing was significantly lower. Other examples included no patient flow co-ordinator at the Worthing site and a difference in banding for ED reception staff between sites. Data provided by the trust showed us that whilst overall attendance numbers were higher at the Royal Alexander Hospital, the acuity of patients attending was higher at Worthing. This meant that staff at the Worthing site were regularly dealing with sicker patients presenting to the ED. Staff told us that emergency care support workers (ECSW) had been recruited to support with mental health patients, which were valuable to the department once they had been fully trained. However, nursing staff told us they had to organise and arrange suitable training to meet their needs and to ensure their competence. This was on top of their everyday duties. Staff said once the ECSWs were in post they were asked by a senior leader if they could now remove the registered mental health nurse (RMN) cover, which staff told us they felt would be unsafe.The trust confirmed following the assessment that ECSWs were trained to specialise in mental health observation and one to one interaction. An ECSW may replace an RMN where it has been risk assessed in a care plan, but a baseline of 2 RMN’s per shift would remain and there has never been an agreement to remove this.

During the site visit inspectors observed time crucial tasks, such as patient triage, patient observations and cleaning of patient areas were delayed due to the low number of staff on duty and number of patients attending the emergency department. We observed delayed patient triage, delayed patient observations and patient flow delayed as the nurse did not have time to clean the empty assessment cubicle to review the next patient. Staff told us if they had support staff such as administrators and health care assistants the registered children’s nurses could focus on completing critical safety tasks. They told us that similar services within the trust had support from administrators and healthcare assistants. On the paediatric ward we observed that there were enough staff to keep patients safe. We saw nurses, clinical support workers, administrators, medical staff and allied healthcare professionals working well together. Staff felt well supported in their roles and with the ward leadership team. We heard from staff the positive impact of having a paediatric emergency medicine (PEM) doctor in the department. This is a trainee doctor who is training to specialise in paediatric emergency medicine. Both medical and nursing staff told us of how supportive this role had been since it had begun and how the PEM doctors advocate for the paediatric department.

Overnight, staff told us there was only one clinical decision maker for both adult and paediatric ED. Staff told us that the clinical decision maker would prioritise the paediatric patients over the adults, which had knock on effects for the adult ED. The trust told us that there was always level 4 senior trainee doctor and a doctor allocated to the whole of the emergency department (adults and paediatrics) overnight with a consultant on call to support. Between July 2023 and June 2024, the average vacancy rate for non-medical staff on Bluefin ward was 23%. There had been an improvement over the last 12 months to 26.5% There were currently controls around the recruitment of any further administrative or clerical support which staff we spoke with expressed disappointment with. The vacancy rates for Bluefin medical staff in June 2024 was 29.1%. From June 2024 onwards, the rate varied between 25% and 32%.Between September 2023 and June 2024 there were 24 incidents reported by the trust related to staffing in the paediatric ED. Of these, all were listed as ‘no harm’. However several of these incidents reported that one nurse was on shift to care for up to 17 patients with no additional support, which if happened repeatedly could lead to staff burnout.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not collect the evidence to score this evidence category.

Staff told us there had been an increase in the number of children and adolescents presenting to the emergency department with mental health conditions. Prescribers were able to talk to the duty CAMHS (child and adolescent mental health service) consultant for additional support if needed. People’s care and treatment was discussed in multi-disciplinary team meetings (MDT), this sometimes supported the use of least restrictive practice when managing anxiety and agitation in the emergency department. Staff had received some training to support children and adolescents in mental health crisis. Staff felt the level of pharmacy support to the children and young people’s services was lower than what was needed.

The trust had systems and processes in place to safely administer and record medicines use. However, medicines and controlled stationary were not always stored safely and securely or in line with national guidance. Access to medicines wasn’t limited to authorised staff only. Stock levels of medicines were sometimes incorrect, this included drugs liable to misuse (DLMs). We could not be assured the trust had robust auditing processes in place for the safe use and storage of medicines.