We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served in March 2017, following an inspection of the trust. The warning notice set out the following areas of concern, where significant improvement was required:

• Systems or processes to manage patient flow through the hospital did not operate effectively to ensure care and treatment was being provided in a safe way for patients and to reduce crowding in the emergency department.
• There was inadequate hospital-wide support for the emergency department when in escalation. The escalation process was not responsive, and the bed management function was not operating effectively.
• The emergency department was the single point of entry to the hospital for both emergency and expected patients, contributing to crowding. There were no direct admission pathways. This meant all GP referrals were seen in the emergency department. The emergency department did not make optimum use of the ambulatory care unit to help to improve flow and reduce crowding.
• Patients spent too long in the emergency department. There were delays in specialist review of patients, particularly at night, and admission delays from decision to admit.
• Crowding in the emergency department was a frequent occurrence. Patients queued in the corridor when there were no cubicles available. This was not an appropriate or safe place for care and treatment. Patients had no access to supplied oxygen and suction, call bells or facilities to store their belongings keep their records secure.

We conducted our first follow-up inspection in December 2017. Although the trust had achieved progress in addressing our concerns, we judged that the requirements of the warning notice had not been fully met.

We conducted this second follow-up inspection on 13 August 2018. The inspection was unannounced. The inspection focused solely on the issues identified in the warning notice, as described above.

The trust had achieved good progress in addressing our concerns. We judged that the requirements of the warning notice had been met.

We found:

• A number of improvements had taken place since the comprehensive inspection published in March 2017. These included new systems, staff changes and reconfiguration of premises. Changes appeared to have yielded benefits, seen, for example, in improved emergency department performance. However, this improvement must be viewed in the context of an emergency department which was currently closed at night and systems had yet to be tested when the department was open 24 hours a day.

• There was a protocol for the management of accident and emergency patients waiting in the adjacent corridor which was understood by staff.

• For patients being treated in the corridor, records could be safely stored in lockable cupboards.

• Systems and processes to manage patient flow through the hospital had been reviewed and strengthened. Senior staff were driving change and improvement.

• There was evidence of regular dialogue between the patient flow team and the emergency department. There was a clear escalation process and action cards for individuals, teams and departments if demand outstripped capacity.

• A primary care practitioner streaming unit were established to support the emergency department, allowing low acuity patients to be diverted from the emergency department.

• The trust had improved its performance against the standard which requires that 95% of patients are discharged, admitted or transferred within four hours.

• There had been a continual improvement from February 2018 in delayed specialist review of patients.

• Use of the corridor in the emergency department to accommodate patients at times of crowding had reduced, and curtains were available for use in the corridor to preserve the dignity of patients.

• The trust had employed ‘progress trackers’: administrative staff who were responsible for escalating any patients in the department who were at risk of breaching targets.

However:

• Nurse staffing at the time of our inspection was below establishment and recruitment and retention remained a challenge for the department.

• The capacity of the ambulatory emergency care unit was affected by vacancies within the unit.

• A recent upgrade to the IT systems within the department made it difficult for staff in the ambulatory emergency care and primary care practitioner streaming unit to take appropriate patients from the emergency department’s waiting area.

• Staff in the emergency department and the ambulatory emergency care unit did not work together to resolve common issues.

• The communication device for discussing GP referrals was held by a non-clinical member of the patient flow team. Staff in the emergency department told us that this was inefficient as the non-clinical staff were not able to make clinical decisions about the most appropriate pathway for a patient.

The trust should:

• Ensure executive staff are aware when the corridor is in use, as per the trust’s policy.
• Improve systems to allow ambulatory emergency care staff to effectively take appropriate patients from the waiting area.
• Improve communication between the emergency department and ambulatory emergency care unit.
• Ensure the communication device for discussing GP referrals is held by a clinical member of staff to make appropriate decisions regarding pathways for patients.

Edward Baker

Chief Inspector of Hospitals

We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served in March 2017, following an inspection of the trust. The warning notice set out the following areas of concern, where significant improvement was required:

• Systems or processes to manage patient flow through the hospital did not operate effectively to ensure care and treatment was being provided in a safe way for patients and to reduce crowding in the emergency department.

• There was inadequate hospital-wide support for the emergency department when in escalation. The escalation process was not responsive and the bed management function was not operating effectively.

• The emergency department was the single point of entry to the hospital for both emergency and expected patients, contributing to crowding. There were no direct admission pathways. This meant all GP referrals were seen in the emergency department. The emergency department did not make optimum use of the ambulatory care unit to help to improve flow and reduce crowding.

• Patients spent too long in the emergency department. There were delays in specialist review of patients, particularly at night, and admission delays from decision to admit.

• Crowding in the emergency department was a frequent occurrence. Patients queued in the corridor when there were no cubicles available. This was not an appropriate or safe place for care and treatment. Patients had no access to supplied oxygen and suction, call bells or facilities to store their belongings keep their records secure.

We conducted this follow-up inspection on 12 December 2017. The inspection was unannounced. The inspection focused solely on the issues identified in the warning notice, as described above.

The trust had achieved significant progress in addressing our concerns; however, there was still work to do. We judged that the requirements of the warning notice had not been fully met.

We found:

• Many positive changes had taken place since our last visit; new systems, staff changes and reconfiguration of premises. Further changes were in the pipeline. Some changes were very recent, not fully embedded and, in some cases not fully understood by staff. Changes appeared to have yielded benefits, seen, for example, in improved emergency department performance. However, this improvement must be viewed in the context of an emergency department which was closed at night and systems had yet to be tested when the department was fully operational.

• There was a lack of clarity and understanding amongst clinicians with regard to admission pathways. New processes had not been formalised or tested.

• The capacity and effectiveness of the ambulatory emergency care (AEC) unit was limited due to space and staffing. At the time of our inspection it operated during the day, Monday to Friday only. We were not able to obtain any data with regard to the effectiveness of the AEC and its impact in reducing crowding in the emergency department.

• On the day of our inspection patients experienced lengthy delays for admission. On arrival in the emergency department at 8am we found there were 17 patients who had attended the department the day before and were awaiting admission. We requested data and analysis in respect of these delays and historical data to show how long patients waited in the emergency department for admission, following the decision to admit. The trust did not currently capture this data.

• We were unable to obtain data in respect of the time patients waited for specialist review; we were told this had improved but surgical reviews were delayed at night.

• The corridor in the emergency department continued to be used to accommodate patients when all cubicles were full. Although senior staff told us this area was used in exceptional circumstances only, data provided by the trust showed that use was increasing. In October and November 2017, 59 and 73 patients respectively spent time in the corridor.

• On the day of our inspection the corridor was in use. The physical constraints we described at our last inspection remained. Temporary curtains were in place and were used to preserve patients’ privacy and dignity when being examined. However, use of curtains created a confined space in which staff examined and treated patients.  Patients’ records were not stored securely.

• We were concerned that unsuitable patients were placed in the corridor on arrival in the emergency department. This included a patient who was living with dementia, who was confused and combatant and a patient who, on the advice of paramedics, required cardiac monitoring. Following our inspection the trust investigated our concerns in relation to the placement of these patients in the corridor. They assured us that the nurse in charge had full oversight of the acuity of all of the patients in the department and there were no other suitable patients who could be moved to free up a cubicle space. 

• The nurse in charge on the day of our inspection was not appropriately supported to manage patient flow in the emergency department.

However,

• There had been a thorough review of systems and processes to improve capacity management and patient flow, to reduce crowding in the emergency department.

• The patient flow team had been reconfigured and the bed management process had been re-designed. Staff were embracing new ways of working and were clear about their individual and team responsibilities.

• Bed meetings were structured and focused on creating capacity. Meetings were well led and well attended. There was senior presence and staff told us this was the norm.

• The trust had taken a number of steps to reduce length of inpatient stay. This included education campaigns and promotion of management tools to increase focus on patient flow.

• The trust had established an integrated discharge team and an acute frailty assessment service to support complex discharges.

• The discharge lounge had been reconfigured to become more effective and there were plans to increase its capacity and utilization.

• There had been a lot of work undertaken to develop alternative admission pathways to reduce congestion in the emergency department.

• Primary care streaming had very recently been introduced. Appropriate patients (with minor illness) were directed on arrival in the emergency department, to see an advanced nurse practitioner in the adjacent ambulatory care unit.

• The ambulatory emergency care Unit was re-modelling pathways and developing direct access pathways for GPs and the ambulance service. There were plans to increase its capacity to assess a greater proportion of expected and emergency patients.

• The trust’s performance against the national standard which requires that patients are admitted, transferred or discharged within four hours had improved.

• Senior clinicians told us that specialist review of patients in the emergency department was subject to fewer delays. There was a registrar physician based in the emergency department to facilitate early review of patients. There was positive feedback about the introduction of a common clerking documentation, which reduced duplication and saved time. Clerking is the recording of a patient’s history, including initial investigations.

• We were pleased to note that use of the corridor for patients in ED had significantly reduced although this was now beginning to increase again. Staff told us this area was only used in exceptional circumstances. Staff were required to seek permission from senior managers to use the corridor and permission was only granted if safe levels of staffing were in place.

• We observed the corridor being used to accommodate patients on the day of our visit. The area was staffed at all times, to mitigate the environmental risks associated with this area.

The trust must:

• Continue to drive change to improve patient flow and reduce crowding in the emergency department.

• Formalise new systems and processes and ensure the engagement of staff in the change process so that new ways of working are understood.

• Embed and test effectiveness of new systems and processes through audit.

• Capture information and monitor delays in respect the time patients wait for admission following the decision to admit and any delays in specialist review of patients in the emergency department.

• Ensure that patients’ records are secured to ensure confidentiality is maintained.

In addition the trust should:

• Ensure the nurse in charge in the emergency department is appropriately supported to enable efficient coordination of patient flow in the department.

Edward Baker

Chief Inspector of Hospitals

We last carried out a review of this essential standard in March 2012 and issued a compliance action requiring the trust to make improvements. This inspection was a follow up to check that improvements had been made.

We discussed progress with the trust management and with representatives from external health and social care organisations. We found that improvements had been made in cooperation and coordination of care between the hospital, community services and other providers. We reviewed patient records and had discussions with patients and hospital staff. At this inspection we found that suitable hospital discharge arrangements were in place.

People waiting in the hospital’s discharge lounge told us they were happy with the care provided and the arrangements for their discharge from hospital. One patient said “I have been waiting for a couple of hours for my tablets and paperwork but I don’t mind. I’ve been seen by two doctors and the nurses and they all said I was OK to go”. Another patient said “They’ve all been very good. They offered me a hospital bed for the night but I preferred to go home and come back again today for tests”. A relative told us “I can’t fault it here. Staff were very good at explaining everything to us”. People told us that checks had been made to ensure that hospital prescribed medication did not react with their own medication. In other cases special equipment had been ordered to enable people to be discharged home.

We visited Weston General Hospital on 20 August 2012. On all of the wards we visited we heard conversations that were tailored to the individual needs of patients. Staff were compassionate, considerate and respectful in their delivery of care, providing care in a patient and calm manner.

One person told us that they had received treatment from a “wonderful nurse” and she also said that on the previous day she had been given an “outstanding” level of care.

All patients spoken with during our inspection said they felt safe and well looked after.

We saw that peoples privacy and dignity was not always maintained for example ward rounds and cleaning were still continuing throughout lunchtime. We saw that people were sometimes given tissue instead of hand wipes to wipe their hands prior to eating. We saw empty urine bottles on peoples bed side tables on two of the wards we visited. Following the inspection we were told that the urine bottles were clean and it was patient choice to keep them where they were.

On Harptree West we were told that staff raised their voices at night and were not always respectful of the need for sleep.

On all of the wards we visited we saw that the male and female patients were accommodated in different areas of the ward and there were separate male and female toilets and bathrooms.

People told us that the meals were generally good with drinks and snacks available at all times. However one patient said he was usually hungry around 10pm each night but was unwilling to ask for food as the staff were usually very busy caring for other patients.

We saw people being appropriately supported with their meals if necessary.

Patients and staff we spoke with told us that they felt there often were not enough staff. Patient comments included; staff were "hard pressed" and the staff “work hard” but are often "slow to answer the bell". Staff comments included; “not enough staff to meet needs of patients”, too much to do”, “too stretched” and “very rushed – not good for patients or staff”.

People spoken with on two wards said they believed their records were kept up to date. One person knew he could see his care plan/patient record.

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 treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

We had concerns raised with us in respect of the way information is relayed to health and social care providers who are providing ongoing care to people after discharged from hospital. The specific concerns related to the following:

¿ A lack of sufficient information provided by nurses to care homes about the person’s hospital stay

¿ Unclear instructions about medication regimes on doctors discharge summaries

¿ A lack of communication regarding the status of a person’s skin upon discharge from hospital, and

For this reason we did a spot check on some patient’s notes, with a focus on the discharge summaries completed by the medical staff, and transfer letters completed by the nursing staff. We also checked the information supplied about people’s medicines.

We met with hospital managers to find out what they are doing about these issues and their plans for improvement.

When we visited the hospital we spoke with patients who were waiting in the discharge lounge prior to going home. They told us “I am waiting for my tablets and letters”, “I have been given a letter for my doctor and my medicines. I know what to take and when” and “I think the nurse said there were some things for me to take with me. I think they have put them in my bag. I am waiting for an ambulance to take me back to the nursing home”.

We spoke to staff working in the discharge lounge and they told us that patients may be waiting for their medicines or for transport to collect them. We were told that ambulance transport would not be arranged for patients until their medicines were ready.

People told us that they were happy with the care and treatment they received. They were very complimentary about the staff saying that they were kept informed about their progress and what was happening. “The standards of care and the carers are brilliant”, “my husband has problems with his speech and the nurses are so patient with him” and “I can’t fault the way the nurses are looking after my wife. They are always cheerful”.

People were generally very complimentary about the meals they were served. They are able to choose what they would like to eat as a range of different meals are offered.

People told us that they were well looked after, their care needs were met and the staff were kind to them. “I feel safe”, “I am very satisfied” and “the doctors and nurses are all very respectful and take time to explain things to me even though they are always very busy”.

People told us that the ward was cleaned regularly, and they made particular reference to the toilets and the bathrooms. They told us that the domestic staff worked hard and did a thorough job.

People told us that the wards were comfortable. “The toilets are clean but there are not enough bathrooms. This means I sometimes have to wait until 11am to have a bath”, “The ward is calm” and “Generally the ward is quiet at night but sometimes I have to use ear plugs so I can sleep”.

People told us that they knew how to make a complaint about their care and treatment, and felt able to voice their concerns. They told us “I can not fault the way I have been looked after “, “I have no complaints about my care but I have a number of observations. My wife has told me about an exit card I can complete when I go home” and “I would ask to see the ward sister if I had reason to complain”.

We rated Weston General Hospital as requires improvement overall with the urgent and emergency care services rated as inadequate, medicine and older people as requires improvement and surgery and critical care as good.

There had been some progress since our previous inspection with surgery and critical care moving from requires improvement to good overall. Medical care also demonstrated improvement with safety and well led now rated requires improvement from inadequate. However, the ongoing pressures on the emergency department continued to be reflected in the ratings with safety remaining as inadequate and responsive and well led failing to improve also being rated inadequate. Patient flow had not been sufficiently improved since our last inspection and responsive in medical care was rated as inadequate.

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health care delivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has not contributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is not contributing to the ratings, we have reported on our findings in the report.

We had serious concerns that systems or processes to manage patient flow through the hospital were not operating effectively and did not ensure care and treatment was being provided in a safe way for service users. We served the trust with a Section 29A warning notice on 24 March 2017. The notice required the trust to make the significant improvements by 15 May 2017 in the following areas:

• Systems or processes to manage patient flow through the hospital must operate effectively to ensure care and treatment is being provided in a safe way for patients and to reduce crowding in the emergency department.

• Review the emergency department as the single point of entry to the hospital for both emergency and expected patients to reduce crowding.

• Ensure access to a specialist senior doctor to review patients overnight in the emergency department is timely and does not delay patient admission to wards.
• Ensure the use of the corridor in the emergency department is an appropriate and safe area for patients to receive care and treatment.

Our key findings were as follows:

• We found the trust had been under increasing pressure to manage flow in the hospital for several months and the emergency department was under sustained pressure from an increase in attendances.
• There was a lack of support for the emergency department from the wider hospital services and a lack of trust wide ownership around patient flow. This meant patients were frequently and consistently not able to access services in a timely way and some patients experienced unacceptable waits for some services.
• There was a fragile medical infrastructure in the emergency department with a crucial reliance on locum medical staff at consultant and middle grade positions. However, shortly after our on-site inspection a recent partnership with another local acute trust had secured some input for clinical leadership one day a week.
• The corridor area in the emergency department was frequently used when there were more patients than cubicles available. This was not a suitable or safe environment for patients to receive emergency care and treatment and was not fit for purpose.
• The trust mortality rate had been higher than the expected level for the recent reporting periods of July 2015 to June 2016. A review of mortality and an associated action plan were in place; however the lack of recorded minutes and actions in speciality mortality review meetings was of concern. It was unclear if learning was shared or action taken as a result of reviews of patient deaths.
• Since our previous inspection there had been some changes to the executive team with some people now in permanent roles and others being interim positions. More changes were due in April 2017 with a new medical director and director of operations starting in post. While the current executives worked well together they had been drawn into managing operational pressures in the emergency department on a regular basis. The new executives could lead to further change and approach to a team already under pressure and ‘wearing many hats’ due to the small trust and less senior roles.
• A review of governance had begun to implement change but was immature and lacking in clinical leadership at directorate level to provide robust assurance.

Safe

• We rated safety as requires improvement overall with safety in urgent and emergency care rated as inadequate, in medicine it was requires improvement and good in surgery and critical care.
• Medical staffing levels and skill mix did not ensure safe care at all times in the emergency department and medical wards. There was a fragile medical infrastructure with a critical reliance on locum medical staff at consultant and middle grade positions.
• In the emergency department there was no clinical lead consultant medical leadership to focus direction and ensure safety was a high priority.
• There were risks to children that medical staff did not have the appropriate skills and capability due to the lower numbers seen of emergency cases of paediatric cardiac arrest or deteriorating child.
• The facilities in the emergency department did not all meet patients’ needs and were inappropriate. The corridor area was not a suitable or safe environment for patients to receive emergency care and treatment and was not fit for purpose. This area posed environmental risks and was a poor patient experience.
• There had been little progress in reducing mortality at the trust. While an action plan was in place, progress with some areas was limited and there was a lack of attendance and accountability at the mortality meetings and learning points and actions were not evident in all specialities.
• Trust policy for the management of medicines was not always adhered to, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors.
• Pharmacy staffing levels did not meet service, clinical and medicines governance demands and achieve medicines related Commissioning for Quality and innovation (CQUINS) and Carter model hospital indicators and therefore protect patient safety.
• Mandatory training compliance required improvement, particularly in basic life support and dementia awareness. With doctors not reaching compliance targets more often than nursing staff.
• We found a fire exit in the stroke unit was blocked and could cause delay of evacuation in the event of a fire. The trust took action when we raised the issue but it continued to be poorly managed and had not been fully rectified on our unannounced visit. This was included on the risk register but not being managed effectively.

However:

• There had been no cases of methicillin-susceptible Staphylococcus aureus (MRSA) in the previous year.
• There were systems and processes in place to reduce the risk of cross infection and clinical areas and wards we visited were visibly clean.
• Sepsis screening and pathways were in place with early treatment seen to be improving. Within nine months, the number of patients with identified sepsis receiving antibiotics within one hour had increased from 11% to 78%.
• Staff took a proactive approach to safeguarding and were aware of local safeguarding procedures for both adults and children. Although there were some delays in investigations due to staffing pressures.
• A substantial amount of work had been carried out on National Safety Standards for Invasive Procedures (NatSSIPs). The changes were being embedded in to practice across all surgical departments.
• A prevention and reduction for pressure ulcers action plan had been created in November 2016, the action plan was in its infancy, however, processes were being put in place to improve awareness and ensure safe management of pressure ulcers.
• Staff understood their responsibility to report concerns and incidents. The duty of candour was mostly understood by staff and staff openness and transparency about safety was encouraged.

Effective

• We rated effective as requires improvement overall with urgent and emergency care and medicine and older people rated as requires improvement and surgery and critical care as good.
• The hospital did not have an orthopaedic-geriatric service in line with national guidance due to recruitment problems.
• Not all patients with fractured neck of femurs were operated on within 48 hours of admission, or admitted to an orthopaedic ward within four hours in line with national guidelines.
• When benchmarked against other hospitals the trust performed worse than the England average in a number of national audit programmes including: the 2015 Bowel Cancer Audit where the hospital had a mixed performance compared to other hospitals. The trust scored ‘E’ for patients being directly admitted to the stroke unit. The heart failure audit for 2015 showed the trust was worse than the England and Wales average for three of the four standards relating to in-hospital care and four of the seven standards relating to discharge. The 2015 National Diabetes Inpatient Audit (NaDIA) scored better than the England average in five metrics and worse than the England average in 12 metrics. Quality improvements were not always sustained and audit findings were not shared and used effectively to improve quality and patient outcomes.
• The inability to recruit senior medical staff led to a lack of clinical leadership and did not provide sufficient support to junior doctors and ensure optimum patient safety at times of increased capacity.
• Multidisciplinary working was not all coordinated to provide effective care for patients. In the emergency department there were professional working relationship breakdowns between doctors and established routines which had not been effectively addressed. These impacted on patients as early speciality review was delayed and patients had to wait in the emergency department.
• A dietician audit identified poor performance for the completion of the malnutrition universal screening tool (MUST) assessments within 24 hours of admission, where the MUST was not always completed accurately.

However:

• Care and treatment was planned in line with current evidence based guidance. Clinical care pathways and toolkits were developed in accordance with national guidelines.
• Patients received effective care in the critical care unit with practices and protocols in line with guidance and patients had the outcomes that should be expected.
• There was an effective stroke pathway in place through the emergency department.
• Patients’ consent to care and treatment was sought in line with legislation and guidance. Most staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
• Patients had their pain assessed regularly and managed promptly to ensure they remained as comfortable as possible.
• Since the last inspection, the hospital had employed a dedicated acute pain nurse in line with the Royal College of Anaesthetists Accreditation Standards.
• There was strong multidisciplinary working across wards and departments.
• The Patient Reporting Outcomes Measures (PROMS) and the National Joint Registry for the period of April 2015 to March 2016 showed that more patients who had groin hernia operations felt better and fewer patients felt worse after their treatment than the England average.
• The hospital performed well in the 2016 National Emergency Laparotomy Audit (NELA). The hospital achieved a green (>80%) rating for high-risk cases with a consultant surgeon and anaesthetist present in the theatre and of highest-risk cases admitted to critical care post-operatively.

Caring

• Caring was rated as good overall and good for each core service.
• Staff in the emergency department remained professional and capable while under considerable pressure in a full to capacity and pressured environment. They were seen to take the time to speak with patients and those close to them in a respectful and considerate way. We saw staff delivering compassionate care and treating patients with kindness, dignity and respect. Privacy and confidentiality was respected as much as was possible considering the constraints of the environment.
• Patients who were delayed in the emergency department received nursing care and support, and were transferred to beds for their comfort and food and drink provided.
• Patients on surgical wards commented on how the care from the nursing staff and allied health professionals was ‘superb’, ‘exemplary ’and staff had a ‘great sense of humour’
• In critical care we observed staff treating patients with kindness, warmth and emotional intelligence.

However:

• In critical care the patients’ diaries were not being seen as belonging to the patient and were not being given to all patients or their relatives when they left the unit.

Responsive

• Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. It was rated inadequate in urgent and emergency care and medical care, and requires improvement in surgery and critical care.
• There was no sense of urgency to respond and promote discharge to initiate flow through the emergency department to the rest of the hospital to reduce crowding in the emergency department. The bed management meetings were not dynamic in ensuring flow of discharges and admissions were acted on by the wider trust and not all required staff attended.
• The emergency department was the single point of entry to the hospital for GP expected patients. There were no direct GP admission pathways in place and this further impacted on crowding in the emergency department on a regular basis.
• Lack of timely access to a specialist senior doctor to review patients overnight in the emergency department was at times leading to delays in patient admission to wards.
• Patients were not able to responsively access the care they needed. The trust did not consistently admit patients within 4 to 12 hours. This meant patients were in the emergency department longer, up to 20 hours and the department was much busier as a result.

• Patient flow within the hospital affected theatre utilisation and cancellation rates. The ambulatory emergency care unit and discharge lounge were underutilised and the medical assessment unit was ineffectively used.
• Medical patients were being cared for on surgical wards. The trust seemed unable to rectify this position and ensure patients received care on the appropriate ward for their speciality.
• The trust does not separately measure the time to initial assessment for ambulance cases; this was included in the overall time to initial assessment in the emergency department. The trust consistently performed within the target for the latest 12 months. There had been a recent increase in patients leaving the department without being seen.
• The hospital performed worse than the England average for length of stay in general medicine and surgery. The average length of stay for the trust was 10.1 days compared to the England average 3.6 days for medical patients and for surgery it was 3 days for elective patients, compared to 3.3 days for the England average. For surgical non-elective patients, the average length of stay was 6.3 days, compared to 5.1 days for the England average.
• Too many patients were delayed in their discharge from critical care to a ward. These delays were worse than the national average. Some patients were discharged onto wards at night as a bed had become available, when night time discharge was recognised as less than optimal for patient’s wellbeing and mortality

However:

• Despite the pressures and capacity issues the emergency department took account of patients’ specific needs. Individual care needs and adjustments were put in place.
• Dementia was well considered across wards and units and patients were identified using a ‘forget me not’ magnet. There was an older people’s mental health liaison nurse who provided support for patients living with dementia. Staff were positive about this role and felt staff and patients were well supported.
• The trust also employed a complex needs sister and a strategic lead for learning disability services. Staff notified these staff when a person with a learning disability was admitted and the strategic lead would then follow up the patient either in hospital or through discharge.
• The management of meals and support provided to patients during a meal time on Kewstoke ward (care of the elderly) was responsive, where patient individual needs were central.
• The dietetic department had expanded menu choices for those patients on a textured diet and had provided patients with their own specific modified menu so they could specify their own meal choices.

Well led

• Well led was rated as requires improvement overall. It was rated as inadequate in urgent and emergency care, requires improvement in medicine and older people and good in surgery and critical care.
• There was no visible strategy for securing permanent clinical leadership for medical staff within the emergency department.
• The governance and management systems in place to review the risks, quality and safety of the service were reviewed regularly but have not effected any changes to the circumstances of the emergency department.
• Staff in the emergency department told us their views were not considered and they did not feel involved in how decisions about their department were made. There was poor cooperation between levels and conflict between medical teams on the wards.
• Arrangements were not robust for managing risks with lack of assurance these were managed timely and effectively. Audit processes had limited follow through of actions and findings were not widely shared at directorate level or at ward level.
• In critical care we found a lack of multidisciplinary approach to leadership with medical staff not in regular attendance at governance meetings.
• Leadership engagement with speciality mortality reviews did not support learning to improve patient outcomes in some services.

However:

• In the critical care unit there were good assurance frameworks to demonstrate how the quality and safety of care was reviewed and understood, with a good culture of staff and patient involvement.
• There was strong visible leadership within the surgical directorate and a good culture of team working. All the staff worked together to assess and plan ongoing care and treatment in a timely way.
• There was a positive culture amongst staff within medical wards and units. Staff felt a sense of team work and worked hard together with a priority to provide safe and compassionate care to patients.
• A crowding dashboard plus action cards had developed and was available in the department for staff to know if the level of escalation due to crowding had been reached. This tool had no link to the OPEL tool to escalate for wider action.
• Leadership in the theatre departments was recognised by staff as strong leading to changes to the safety and the culture of theatres.

We saw several areas of good practice including:

• The oncology and haematology department demonstrated outstanding practice with the way they assessed patient risk. Patients with a risk of neutropenic sepsis were easily identifiable through the use of a yellow jacket placed on patient notes.
• Patients living with dementia were situated in the bays or side rooms that were most visible to the nursing station. Staff who provided enhanced supervision to these patients were wearing yellow tabards and were easily identifiable. Staff were allocated to a patient or a group of patients in a bay and were not to be removed unless another staff member had taken over from them. We saw the hospitals own ‘This is me’ booklet in the notes of a patient living with dementia. This booklet had been completed by a relative of the patient and explained the patient in detail, what they liked to be called what they liked to do, what was their favourite food.

Importantly, the trust must:

• Ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced doctors deployed within the hospital. This includes sufficient medical leadership within the emergency department and suitable levels of staff to ensure the corridor is safely staffed.
• Take action to ensure that there are sufficient medical staff with sufficient skills in advanced paediatric life support in the emergency department.
• Take action to ensure that medicine systems in the emergency department are safe for controlled drugs including signature list for agency nursing staff and locum doctors, to cross reference who had prescribed and administered medicines.
• Take action to ensure that systems are in place to ensure patient flow through the hospital was responsive.
• Ensure patients are being admitted promptly once the decision to admit has been made. Take action to ensure that safety checks in the emergency department are completed.
• Take action to ensure that patients are cared for in a safe environment in the emergency department.
• Review the medical staffing and ensure safe levels of medical cover and support to juniors on the medical wards in evenings and weekends.
• Review the use of locum consultants and take action to ensure medical staffing is not vulnerable through recruitment of permanent consultant staff.
• Be assured junior medical staff are being provided with appropriate support and are competent in their roles.
• Ensure safe nursing cover is provided on Cheddar ward and agency usage is kept to a minimum.
• Take action to mitigate risks included on the risk registers effectively, reviewing regularly and managing those risks identified on a timely basis to ensure safety to staff or patients is not compromised.
• Manage quality and performance and ensure sustained learning and improvements from audits.
• Take action to continually maintain a clear path for evacuation in the event of a fire within the stroke unit by ensuring fire exits are not blocked.
• Take action to ensure patient flow from the emergency department through the medical wards to timely discharge is effective and timely in meeting the needs of patents and ensuring good quality care and treatment.
• Take action to address areas of concern and demonstrate patient outcomes monitored by the Summary Hospital – level Mortality Indicator (SHMI) are improved.
• Improve the quality, attendance, accountability learning points and actions from mortality and morbidity reviews in all specialities.
• Make sure the surgical directorate has an orthopaedic-geriatric service for pre and post-operative care.
• Ensure all patients that had fractured neck of femurs were operated on in line with national guidelines and admitted to an orthopaedic ward within four hours.
• Follow trust policy for the management of medicines, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors. (Accident and Emergency).
• Review pharmacy staffing levels in order to meet service, clinical and medicines governance demands and achieve medicines related CQUINS and Carter model hospital indicators and therefore protect patient safety.
• Ensure multidisciplinary input and a collective approach to the running of the critical care unit. The medical team leaders must ensure they meet regularly with the senior nursing leadership to provide a multi-professional approach and contribution to all aspects of running the unit, including governance and provision of quality care.
• Address the poor access and flow of patients in critical care in order to reduce the delays to patients who are fit to leave the unit, reduce the risks of patients not having timely admittance, eliminate breaches in same-sex rules, stop the relocation to or delay of patients in the operating theatre recovery area, and reduce the number of patients who are transferred to a ward bed at night.
• Produce mortality and morbidity reviews for critical care where there is accountability for learning and change, and a demonstration as to how this has improved practice and safety.
• Review the provision for and quality of life support training in the trust to ensure there are a satisfactory number of staff with the right experience and training on duty at all times.

In addition the trust should:

• Consider a clearer approach to reflect incident trends and ensure use of the hazard line identifies trends and is supported by consistent processes.
• Ensure there is sufficient overview of the children’s waiting area in the emergency department to ensure children’s safety at all times.
• Review the storage arrangements for patients own medicines and possessions when they were receiving care and treatment in the corridor of the emergency department.
• Produce care pathways through the emergency department to support patient care. These should include frailty pathways for older people to ensure they receive timely care and treatment.
• Consider actions to address professional working relationship breakdowns between doctors and established routines which had not been effectively addressed. These impacted on patients as early speciality review was delayed and patients had to wait in the emergency department.
• Ensure national audit programmes and local audits effect change in practice.
• Ensure emergency department staff are aware of the vision and strategy for the emergency department or the strategic development of the service.
• Ensure the governance and management systems in place to review the risks, quality and safety of the emergency department service were reviewed regularly and effect changes to the department.
• Ensure the risk registers for the hospital were accessible so staff can be aware of what was included on the risk register or how to raise issues for the risk register. This will enable risks to be addressed.
• Reduce the in-use expiry date when glucagon injection is removed from refrigerated storage and record the date of opening of liquid medicines to ensure that these medicines are suitable for use. Ensure there is a robust system for checking expiry dates of medicines.
• Review the storage arrangements for patients own medicines when they were receiving care and treatment in the corridor in accident and emergency.
• Complete the medicines safety thermometer on all in-patient units on a monthly basis.
• Audit the pharmacy service against the Royal Pharmaceutical Society standards for hospital pharmacy.
• Review the medicines reconciliation service provided such that medicines are reconciled for patients in line with the NICE quality statement 120 and benchmarked requirements.
• Ensure stroke patients are provided with optimum care in an environment which is conducive to improve their outcomes and meet their individual needs.
• Review length of stay data and act to reduce this in line with national recommendations.
• Review the environment regularly to ensure safety is not compromised for patients. During our inspection we identified broken window restrictors and fire extinguishers which were not secured to walls.
• Review provision of seven day services to improve access to support at weekends and overnight.
• Educate staff on the duty of candour so it is used consistently across the medical service.
• Provide regular appraisals and clinical supervision to all staff to ensure they are appropriately supported and competent in their job role in medicine and the emergency department.
• Remind staff of the procedures to follow in the event of a major incident and schedule regular practice.
• Ensure the discharge lounge has appropriate arrangements for nursing support within escalation extended hours when the day case unit is not open.
• Review the ward clerk staffing arrangements and extra resources available to ensure wards are appropriately supported for non-clinical duties.
• Maintain a record through minutes of weekly medical meetings in the stroke and care of the elderly specialisms to discuss best practice for patients.
• Remind staff of the importance to find the previous weight of a patient to enable them to identify weight changes at admission and comply with the malnutrition universal screening tool (MUST) guidelines.
• Improve mandatory training attendance rates across the surgical directorate.
• Improve compliance with completing the venous thromboembolism or blood clots (VTE) assessment tool.
• Review the storage of equipment in the day case unit clean utility room.
• Review length of stay for emergency and elective surgery patients so it is in line with the England average.
• Make sure complaints are documented at senior level as being handled in line with policy.
• Consider adding sepsis screening to the performance assurance framework, to continually audit sepsis recognition and treatment and monitor sepsis training.
• Review supernumerary nursing cover in critical care to address the Faculty of Intensive Care Medicine core standard for safe supernumerary levels.
• Make sure medical staff working in critical care have completed the update of their mandatory training.
• Ensure medical records in critical care clearly state who has created the record and who has attended ward rounds.
• Ensure all staff in critical care are aware of the difficult airways trolley.
• Ensure all equipment checks in critical care are performed and recorded when required.
• Review patient records to ensure the time a decision is taken to admit a patient to critical care is recorded and captured for audit work.
• Make sure any medicines not given to a patient in critical care have the reasons recorded on the prescription charts.
• Review the time taken with ward rounds in critical care and ensure this does not delay any requests for tests or procedures for patients while the round continues.
• Be assured that nursing staff in critical care providing direct patient care are at the right level of qualification.
• Review the provision of physiotherapy in critical care, which was not meeting best practice guidance. Also, review NICE guidance around rehabilitation and physiotherapy prescriptions.
• Develop a valid programme of audit for the medical teams in critical care in accordance with an audit calendar and suitable programme for critical care.
• Review how to address the lack of a clinical nurse educator role in critical care.
• Review the critical care risk register at a multidisciplinary critical care meeting.
• Ensure all staff in critical care have appropriate knowledge of Deprivation of Liberty Safeguards.
• Ensure the reports of the Intensive Care National Audit and Research Centre are received when they are available, and discussed at clinical governance reviews.
• Ensure any patient diary used with longer-stay patients is recognised as the property of the patient and returned to them or their relative when the patient is discharged from the critical care unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals