Blackpool Teaching Hospitals NHS Foundation Trust was established in December 2007 and serves a population of around 440,000 residents and around 11 million tourists and transient visitors seasonally. The trust has an acute hospital, Blackpool Victoria Hospital, two community hospitals, three elderly rehabilitation hospitals, a national eye treatment centre and a child development centre. The trust employs over 7000 staff, has an annual turnover of over £410 million and has 830 beds across all sites. The trust sees over 250,000 outpatients, 56,000 day cases and 91,000 emergency admissions annually.

This was an unannounced, focused inspection to review the safety of the emergency department as part of a focussed winter inspection programme. It took place between 1pm and 10pm on Monday 7 January 2019.

We did not inspect the whole core service therefore there are no ratings associated with this inspection. Our key findings were:

Our key findings were:

• The emergency department (ED) did not have space and capacity to cope with the number of patients and their relatives who presented there. We observed patients sitting on the floor of the waiting room and trolleys, beds and equipment blocking corridors and exit routes, which limited the standard of care.
• The paediatric ED was not compliant with staffing levels set by the Royal College of Paediatrics and Child Health (RCPCH).
• There were significant delays in most aspects of the service, including triage delays of over three hours. We found delays in transferring patients awaiting a mental health bed of over 17 hours whilst awaiting review by the mental health provider, which was separate to the trust.
• Flow to the rest of the hospital did not meet demand and there was very limited input from acute medical physicians. This reflected our discussions with nine members of medical staff, during which they said there was a culture in which specialty teams did not work well together for the improvement of patient experience.
• Patients were accommodated in corridors for extensive periods during our inspection. This included elderly patients and those with severe dementia and staff did not always meet their individual needs. Use of corridors was part of the trust’s surge plans during periods of exceptional demand.
• Overnight medical cover was restricted to one doctor with higher specialist training at grade ST4 (specialist trainee) with one or two doctors at basic specialty trainee level (ST3). This caused lengthy delays to assessment and all staff we spoke with told us it resulted in additional pressure.
• Provision for mental health patients was lacking and the trust had limited influence to improve the service provided to their patients.
• We saw isolated examples of very poor, unkind care in the acute medical unit during a violent incident.
• Staff described increasing levels of threatening behaviour, aggression and violence towards them from patients and relatives.
• There were senior decision-makers present in the resuscitation area and in the rapid assessment and treatment (RAT) area who managed patients appropriately.
• There was effective clinical collaboration between the consultant in charge and the nurse in charge and it was notable that staff systematically did their best in challenging circumstances.
• Staff demonstrated resilience and compassion when trying to help patients who had waited significant periods of time in the ED for a mental health review. This included when they faced aggression and verbal abuse.
• The patient and staff safety team had wide-ranging responsibilities and provided considerable support, including in safeguarding and child protection circumstances.
• The trust had a range of developing strategies to improve access, flow and capacity. These were in the early stages of development at the time of our inspection and we saw limited impact of them to date. Staff provided evidence the improvement works had resulted in faster treatment and an improved experience for some patients, particularly those who arrived by ambulance.

We told the trust they must:

• Further improve performance in the national 15-minute triage recommendation.
• Improve standards of care, including triage, time to assessment and time to mental health review, for patients with mental health needs.
• Ensure the paediatric ED is compliant with RCPCH staffing level standards.
• Review the availability of medical staffing in ED overnight.

In addition, the trust should:

• Improve governance processes and clinical governance oversight of the number of refused referrals to the urgent care centre through the streaming process.
• Improve the management of the waiting area in the main ED to ensure patients who are vulnerable are not put at risk by patients who pose a threat to their safety.
• Continue to work in partnership with the mental health provider and other providers to review the tools used to assess and improve the mental health pathway.
• Ensure staff working in the acute medical unit have the training and supervision to provide a caring and compassionate service.
• Effectively manage crowding in all areas of the ED.
• Review the flow of patients through the paediatric ED to reduce the time children spend waiting with adults.
• Ensure there is a clear, defined and ratified standard operating procedure for the ambulatory emergency care unit and ensure that staff understand this and adhere to it.
• Ensure patients have access to food and fluids during their time in the department.

There were also areas of outstanding practice:

• Senior ED staff had introduced more consistent support for staff following an incident, including a ‘support basket’ with items to encourage staff to come together and debrief for 15 minutes. Staff spoke highly of this initiative and said it helped them to focus again on patient care after a stressful period or incident.
• The trust had facilitated the implementation of a ‘synergy car’ service for patients who called 999 with urgent mental health needs. The service was staffed by a police officer, mental health crisis worker and a paramedic. In its first week of operation the synergy service had prevented seven unnecessary ED attendances and 17 attendances for patients detained under section 136 of the Mental Health Act.
• Although ED nurses lacked formal training in the management of mental health conditions, they demonstrated exceptional resilience and compassion when faced with patients who were clearly deteriorating. This included an ED nurse who remained kind and compassionate despite a patient screaming in their face after being in the department for 17 hours.

Professor Edward Baker

Chief Inspector of Hospitals

This inspection was carried out to follow up on compliance actions made at the previous inspection in June 2013. These related to systems in place to manage and respond to complaints and concerns. During the previous inspection we found that complaints were not always dealt with in the trusts own timescales. People did not always feel their concerns or complaints were managed satisfactorily.

The Trust provided the Care Quality Commission with an action plan to address the non- compliance issues. They told us they were reviewing the trusts operation procedures for complaints. This included timescales and communication with people raising complaints.

Two inspectors, a specialist advisor (a professional with specialist experience in hospital governance) and an expert by experience (a person who has personal experience of the services being provided), visited Victoria Hospital unannounced on 26th November 2013.

We looked at what systems had been put in place to improve the management of complaints. We visited three departments within the hospital to speak with staff and look at what information was available to patients to raise concerns or complaints, we also carried out a random selection of telephone interviews with people who had raised concerns and complaints with the Trust in order to determine what that experience was like for those people. Most people told us they had been informed of timescales in the response to their complaints. Some people told us the timescales were not always met. One person told us, “They did let me know about the timescales, they didn’t meet them but they did let me know this would be the case and why”.

Staff members we spoke with told us they were aware of the hospitals complaints processes and some gave examples of how they had directed people to the appropriate contact. This included P.A.L.S (Patients and Liaison Service) who provide confidential advice and support in health related matters.

We carried out this review in response to concerns centred on issues we had been made aware of from the Trust and also members of the public. The concerns centred around three areas inlcuding, consent to care and treatment, communication and complaints. This responsive inspection took account of the three areas and the content reflects the evidence found in respect of the Trusts compliance with those regulations.

As part of the inspection process we spoke with a number of patients on the wards. We also spoke with relatives in order to gain the views of people who experienced services including planned, emergency surgery and treatment.

Patients we spoke with told us they were given the opportunity to make informed choices about their care and treatment. They told us staff respected their preferences and decisions. One person told us, “I had everything explained to me including the benefits and risks. I had the time to discuss this with my wife. The nurse also spent time with us. It gave me more confidence to make a decision”. Another person told us, “I had all the information I needed to be able to give my consent to my operation”. Two other patients we spoke with told us they had been provided with the information they required to make an informed choice to consent to care and treatment.

Patients told us they had been looked after well and had confidence in the service offered. One person said "everyone is very kind and caring"; "nothing is too much trouble for them". One person said the "staff know what they are doing". Another added that the various staff had "explained everything" and all "knew what each other were doing".

The staff told us they enjoyed working in their particular departments, and they felt supported, both by their colleagues and the senior management team.

We saw the trust had made changes to the way complaints and concerns were being handled and managed. Patients we spoke with in the cardiology centre were satisfied with information they had been provided with and told us they felt comfortable in raising issues with senior staff if they were not satisfied with their care or treatment. Information received by the Care Quality Commission highlighted a number of concerns regarding the way the trust managed complaints and concerns. This included complaints not being responded to in the trusts own timescales. People felt they did not know what action had been taken to improve areas within the context of their individual concerns.

We saw that the trust had a number of internal and external audit systems in place to monitor the quality of the service provided. We were reassured that they responded appropriately when they were given information of concern. They reviewed their own processes as a result of concerns raised and made amendments to their systems if required.

We carried out this inspection to follow up areas of non compliance found during a Dignity and Nutrition Inspection (DANI) on 1st August 2012. In addition we looked at how hospital discharges were being managed and how patients privacy and dignity was being respected.

People we spoke with told us they were satisfied with the care and treatment they had received. They told us they were supported and staff were respectful. Comments included, “I had everything explained to me, staff were very supportive”. Also, “I was anxious about going home as I live alone. They have got carers coming in for the first few weeks. I am happy with what they have done for me”.

We saw there were systems in place for patients to receive a planned discharge. Records we looked at had been completed and other professionals and external agencies had been involved in the planning for patient discharge.

Patients requiring clinical assessment and intervention for nutrition had records in place to manage this process. Where patients were ‘nil by mouth’, there was evidence of clinical decision making as to how this would be managed. In one instance we saw a patient had been assessed for ‘nil by mouth’, on admission. Improvements had been made to record nutritional assessment for patients. The Malnutrition Universal Screening Tool (MUST) had been completed in all instances where there had been a need for the patient

People told us what it was like to be a patient in Blackpool Victoria Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older patients’ in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by two Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

To carry out the inspection, we identified two wards, where there were a percentage of

older patients, in order to focus the dignity and nutrition inspection (DANI). As part of the inspection process we spoke with a number of patients and visitors on both wards. We also spoke with members of the executive management board for Blackpool Teaching Hospital Trust. A range of staff members were spoken with on both wards throughout the site inspection. We did this to gain the views of patients who received care and treatment and people who visited the hospital or worked there.

Patients we spoke with were positive about the care and treatment they were receiving. They told us they liked the food in hospital and told us there was “plenty of choice,” available to them. Comments included, “It’s a busy ward all the staff seem to be involved in meal times, it’s really organised.” Also, “I can’t always manage my food, but the staff are around to help.” A visitor told us, “My wife never had a good appetite, but they go out of their way to try and encourage her with food.”

Patients told us they liked the way staff made them feel at ease if they were receiving treatment, or were talking to the doctor. They told us they felt staff respected their privacy and dignity. Comments included, “Nurse speaks ever so softly when she is asking if I want the bathroom, it’s nice because you don’t want everyone to hear.” Also, “When I need some treatment or the doctor comes to talk to me they always pull the curtains around the bed,” and, “I like my own room it’s more private, the nurses always knock even though I always have the door open, I like to see what’s going on.” We saw evidence of these practices occurring during the observations we made on both wards.

In addition to gaining the views of patients who used the hospital services, we asked other agencies including Local Involvement Network (LINkS) about Blackpool Victoria Hospital. They told us they had been involved in a recent patient experience meeting, which included visiting a ward. They told us comments received from patients had been positive. Patients spoken with were very satisfied with the choice of food and the quality of meals available to them.

We did not visit the provider as part of our inspection and there were no comments received from people in receipt of their service. We looked at all the information we hold about the provider and asked them to send us information confirming how they had achieved compliance with consent to care and treatment. They sent us comprehensive evidence of the action they had taken in ensuring staff have undertaken training in Mental Capacity Act (MCA). This evidence demonstrated staff at all levels have received training to gain the necessary knowledge and skills to act in peoples best interests and to act in accordance with the consent of people, in relation to their care and treatment. Action taken to gain compliance included, identification of a dedicated lead in Mental Capacity Act (MCA) training. Evidence of a comprehensive training programme, evidence of access to e-learning, regular reviews on the impact of training and regular board updates.

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.

Patients we spoke with during our inspection were very positive about the information they had received prior to under going surgery. All confirmed they had received information about what to expect during their stay in hospital and about the treatment they were to receive.

Patients told us that they felt fully informed about their care and treatment and that all

doctors had taken the time to answer any questions they had. Patients said that their pre-operative assessment and physical examinations were carried out in private and helped them understand the surgical procedure they were being admitted to hospital for and were positive about their experiences.

Patients said that the new building was relaxing and clean but some did not like the lay out of the four bedded bays. However patients told us there was insufficient natural light in the bay and the lighting provided was insufficient that in the for the bathroom there were no electric shaver points.

Patients said that staff were available when needed and had a relaxed and professional

approach to their jobs which put them at ease. They told us that they were supported by staff who were helpful and recognised if they had anxieties about their treatment. They confirmed that staff helped them understand their treatment and allay their anxieties.

Patients said that staff were attentive and were readily available to provide care and

support when needed.

"Everybody has been brilliant; they have told me everything I wanted to know"

"I thought the information I had was good".

"The leaflets were helpful, but then the staff explained everything I needed to know".

"They went through all the forms again so I understood what was happening and I had

already agreed to have the operation. They treat you really well in that way and I knew what to expect"

"The wards are new and clean – it's very comfortable in here."

"The staff are excellent; they do speak to people in a respectful way".

"Night staff are friendlier, the day staff seem to be a bit rushed to spend too long a time with you"

"The nurses have explained everything and carried out the procedure very well, they are all very caring".

Our rating of services stayed the same. We rated them as requires improvement because:

• Although surgical and medical services had improved, urgent and emergency care services required improvement.
• The emergency department had consistently failed to meet the Royal College of Emergency Medicine recommendation that the time patients should wait from time of arrival to being triaged (having an initial assessment undertaken) is no more than 15 minutes. This is important as it is a system that emergency departments use to make sure that the patients who may need immediate treatment are prioritised.
• The emergency department and medical care services did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. This was because the planned establishment for nursing and medical staffing had not always been met.
• The service had not always planned services in a way that met the needs of local people. The emergency department faced challenges to make sure that that the environment matched the needs of patients. We observed some patients were cared for in corridors.
• People could not always access the service when they needed it. The emergency department had consistently failed to meet the four hour standard for admission, transfer or discharge.
• Patient outcomes for urgent and emergency care continued to be poor and information submitted to the Royal College of Emergency Medicine showed that results were worse than the national average in most areas.
• The service did not provide a suitable environment for high risk mental health patients within the emergency department. This was because the department did not have a designated area, which for example, was free of ligature points.
• The service did not always ensure that each mandatory training area was completed to the trust target for the identified staff within the emergency department. Information provided indicated compliance with training was lower for medical staff.
• Staff within the emergency department did not always have the correct level of training to prevent patients from abuse. Safeguarding training was not always provided in line with the Intercollegiate Document, 2014.
• The service did not always manage medicines well. Controlled drugs were not always checked appropriately and patients’ own medicines were not reconciled in line with trust policy within the emergency department. The review dates for medicines were not consistently documented and there was a lack of adherence to the medicines self-administration policy within the medical wards.
• The service had not always made sure that staff were competent in their roles and up to date competency records were not always available. This was because not all new staff within the emergency department had completed mandatory training before taking on the role and only 55% of nursing staff were up to date with annual appraisals.
• The emergency department had a vision for what it wanted to achieve. However, not all of the aims had workable plans in place.

However,

• Staff of different kinds worked together as a team to benefit patients. We observed positive examples of collaborative working.
• Staff understood their role and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff continued to care for patients with compassion.
• The service took account of patients’ individual needs.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.