Royal Stoke University Hospital

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• 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 reviewed the safe systems, pathways and transitions, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control as part of the quality statements from the safe key question. Staff carried out daily safety checks of specialist equipment to ensure they were in good working order. The service did not always have suitable facilities and equipment to safely meet the needs of patients and their families; However, since our inspection the department have made some improvements. The service had enough nursing and support staff to keep patients safe and to provide the right care and treatment. Managers mitigated risks of short staffing by using supernumerary staff and bank staff to support the teams.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People could access the service when they needed it however, they did not always receive care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. Patients said staff treated them well and with kindness. We spoke with patients receiving care on the corridor, some patient voiced their dissatisfaction about the amount of time they had been waiting, however, many patients spoke highly of the staff and the care they provided. Patient records showed long waits for consultant review, during inspection, consultant review waits were up to 23hours, 10 patient records reviewed, 7 patients not reviewed by consultant longest wait being between 11 and 23 hours.

We were aware of challenges staff faced when working with staff from other specialities. Staff told us they had a good relationship with the medicine directorate and had a smoother referral process for them. Patients awaiting a bed within a medicine ward or department, were reviewed by the medicine team in the department. This had meant there were some delays for some patients who were waiting to be seen by a consultant. However, staff told us there were some considerable challenges when trying to refer patients to other specialties. This meant there was a risk of patients remaining in the department for longer and delaying other patients from being seen. We observed a positive relationship between staff from the department and staff from the ambulance trust. Staff were working cohesively towards providing safe and effective care for patients and had adapted to the increase demands and pressures. Managers tried to plan and organise services, so they met the needs of the local population, however there were significant challenges within the wider system. All staff we spoke with, with no exception told us they had concerns around the number of patients who attended the service who did not need to be seen at an emergency department. To reduce the activity at the department, processes had been implemented to direct patients with minor injuries and ailments to other services including a local minor injuries unit as well as the other emergency department at the County location. Although this had improved the provision to manage the more serious concerns and sicker patients, this was now no longer the case due to an increase in the number of patients attending this department each day. The service was unable to relieve pressure on other departments due to the significant pressure they faced

A meeting was held on 11 April 2024, with the systemwide colleagues, the discussion was around the ongoing pressures within the system. We shared our concerns that we saw during the inspection, this gave all colleagues opportunities to discuss the systemwide pressures faced on the local services, promoting communication and shared actions each service were taking to alleviate systemwide pressures and how as a system they could improve patient care. The service planned and provided care in a way that tried to meet the needs of local people and the communities served. However, they were challenged in delivering their plans due to issues with the wider system and local organisations. The department had received several external reviews to identify what, if any potential improvements could be made. Despite identifying the challenges around the wider system, at the time of our inspection, staff told us plans were in place in response to these reviews to improve the responsiveness of the department but at times it was extremely challenging . Site meetings were held periodically through the day to look at flow. Capacity concerns were discussed across the trust including predicted end of day figures. Meeting demonstrated hospital was gridlocked, with deficit of 61 medical and surgical beds, having a negative impact on ED where patients were being held. Discussion were held about how they can increase capacity plan, and open more beds on wards at other site.

Staff shared key information to keep patients safe when handing over their care to others. When handing patients over to other departments or wards. Shift changes and handovers included all necessary key information to keep patients safe. Staff completed, or arranged, psychosocial assessments and risk assessments for patients thought to be at risk of self-harm or suicide, staff worked closely with the local mental health trust. Staff worked across health care disciplines and with other agencies when required to care for patients. Staff referred patients for mental health assessments when they showed signs of mental ill health or depression. Staff told us the relationship between the local mental health trust had significantly improved and this had enabled patients experiencing mental ill health to go directly to the mental health facility for review and assessment. When patients attended the department, there was swift review by Mental Health Liaison Team (MHLT) once the patient had been referred and a plan implemented for patients to keep them safe. Staff held regular and effective multidisciplinary meetings to discuss patients and improve their care. Safety huddles were held throughout the day to discuss the patients within the department and plans in place for their care and treatment. They were also an opportunity to review the demands on the department and flex staff around to hot spot areas of activity.

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

Royal Stoke University Hospital had a considerable increase in ambulance handover delays of over 60 minutes from April 2023 to January 2024. There was a considerable increase in the number of the trust’s patients waiting more than 12 hours from the decision to admit to admission from April 2023 to January 2024. There was approximately 12 thousand and 14.5 thousand type 1 A&E attendances per month at the trust over the last twelve months. Trust collated patient feedback through patient questionnaires. As part of our assessment, we reviewed the patient questionnaires for the last 3 months; we found the feedback was mostly positive, with highest satisfactory score of 80% in April 2023 with lowest score of 57% in November 2023. During the inspection, some patient feedback and told us they had been waiting a very long time, some were waiting on the back of an ambulance then brought in to have further waits in ED, some had been waiting over 24 hours. During our inspection, we were quite concerned with the problems created by the doors fixed to cubicles in the Majors’ department. We understood these were created during Covid; However, they were creating safety barriers to oversight of patients. We discussed a frail elderly woman in a side room and been in the department for 24 hours. We asked the nurses, given she was behind a closed door, how they would know if she was safe and her basic needs were met they were not able to answer but we observed staff were under increased pressure at the time with caring for 2 patients needing close care and a new junior member of staff. It was also not helped by the barrier the door was creating. We felt the visibility in Majors and shutting patients behind doors without good clinical decision put patient at unnecessary risk. Since our inspection the trust have made some improvements and continue to share these improvements with the CQC.

Staff knew about specific risk issues; however, they were not always dealt with promptly, staff told us they struggled to complete risk assessments and patient records due to the pressures in the department. We reviewed patient records, and saw 2 of 10 patients had developed pressure sores while waiting in ED, however we had no evidence to support if these pressure ulcers had occurred before they attended ED. Staff told us patients in corridor were not always able to have their pressure sore assessments examined on the corridor, staff told us there was a specific area within the department to assess patients skin. We saw during inspection 5 of 35 patients in majors were on trollies not beds, beds were available if suitable. We spoke with senior teams about pressure ulcers and the trust were working closely with ED and ambulance crews to improve comfort rounds and skin bundle checks. ED carried out regular audits and were continuously trying to improve. Staff told us only patients who were due to be admitted from ED were risk assessed for the risk of venous thromboembolism (VTE). However, we observed patients who were within the department for extended lengths of time who had not undergone a VTE assessment as they had not been admitted, despite being at potential risk, staff told us this was because of the pressures they were under. Patients being held on ambulances had observations completed by the staff from the rapid assessment and treatment (RAT) area. The nurse and doctor covering the RAT (of registrar grade or above) tried to review the patient together, however if this was not possible at the time, the nurse would do the initial assessment and then escalate to the doctor if there were concerns. On going monitoring of the patient was completed by the ambulance crew until there was a cubicle available for the patient. If the ambulance staff had concerns, they were required to escalate to the ED staff.

Managers carried out audits to check improvement over time. The service completed a weekly quality checks audit, this included pressure ulcers, nutrition and hydration, falls and documentation. There were processes in place for staff to follow to assess and meet the needs of patients. The trust used the electronic system which had all risk assessments embedded within this and staff were required to ensure these were completed on admission and through various stages of a patients admission. The assessments included, but were not limited to skin integrity assessments, Waterlow assessments, MUST (malnutrition risk assessment), bed rails assessment and manual handling assessments. Where concerns were indicated this was documented ready for patients to be transferred to wards, where further assessments for staff to complete or escalate for specialist nurse involvement, this included where patients required close supervision. Managers regularly completed audits on the completion of risk assessments. In addition to audits, the service also used a clinical dashboard which gave real time data on the performance against a set of indicators. Risk assessments (Waterlow, falls, MUST) were included as key indicators on the dashboard.

Staff told us the equipment was safe and they had access to suitable equipment to carry out their role. They told us they carried out daily safety checks and we saw these were not always completed. We saw some patients were waiting long periods of time on trolleys, and at times causing some concerns around pressure areas. Staff told us that site support can provide hospital beds but these can only be used if patients are being nursed in suitable space for example not the escalation corridor. The effect for the ED was increasing corridor care for patients, which we know from all the staff and patients/relatives we spoke with was entirely unwanted and of constant worry. Overflow waiting area in children's ED did not have clinical oversight; however, we were told only patients who were assessed as low risk were told to sit there. We saw evidence of patients being cared for on trolleys in the department for over 24hours. Staff we spoke with told us the biggest challenges they were facing was the flow in the department. During our inspection on day 1, we saw there were 31 patients waiting for admission to a ward, with 35 cubicles available; Staff told us this hampers flow in the department and one of the reason for ambulance offload problems. Many staff we spoke with said the biggest problem was the exit block and that the risks were held in ED. We observed some patient being cared for on the corridor were high risk of falls, we reviewed the ED Standard Operating Procedure (SOP). All patients nursed in the corridor were identified by a clinical decision following discussion between the EPIC (emergency physician in charge) and the nurse in charge. Patients over the age of 65 years were automatically be determined as a falls risk via the risk assessment in line with NICE guidance.

The effect for people using the Emergency Department (ED) was seeing an increase in corridor care for patients, which we know from all the staff and patients/relatives we spoke with was entirely unwanted and of a constant worry. The pressure on the limited number of staff trying to care for patients while endlessly running around to deal with their needs was extremely challenging. Those patients we met during the inspection, majority were at high risk of falls, which, given the nature of the corridor, would be largely unpreventable at times. Those patients were not clinically unstable, but a number were fearful of why they were in a corridor and had no concept of what would happen next. Staff were, nonetheless, understanding and apologetic to the patients and relatives. Some patients told us they understood that the hospital were under constant pressure, many patient were grateful of being inside the hospital and not in the back of a vehicle. Some patients had been sat in vehicles waiting to enter the emergency department. Despite all the delays patients were complementary of staff, but told us 'staff are rushed off their feet'.

The service had enough nursing and medical staff to keep patients safe from avoidable harm and to provide the right care and treatment. Some staff we spoke with told us the department fell short on healthcare assistance (HCA) and felt the department would benefit if they had more HCA support in the department. Staffing was discussed throughout the day at management meetings and staffing moves were made to ensure safe staffing across the department. Managers used an acuity tool to calculate the number of staff needed per shift, this was utilised and the planned number of nurses on shift majority of the time remained the same; We saw evidence of this when we reviewed staff rota. Managers could adjust the staffing levels according to the needs of the patients. Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients. Managers gave all new staff a full induction tailored to their role before they started work.

During our inspection we saw there were 26 registered nurses (RN) and 4 triage nurses and were staggered to cover busier times, this was an increase of 2 RNs since corridor reopened and 16 Health Care Assistance (HCA). Recruitment plans were underway, we saw there were 33.15 whole time equivalent vacancy for HCA. Corridor care were normally staffed by agency staff with ED or acute medicine experience. We also saw that staff rota provided information for different staffing divisions, taking responsibility each day for the corridor, staff felt like the corridor was a trust area and not ED on its own, This was encouraged through the Executive teams, labelled ‘Trust corridor’ with trust support in place for staffing rather than just Medicine and urgent care. Medical staffing were planned using the Royal College Emergency Medicine (RCEM) tiering system, 3 consultants in the morning and 4 in the evening. 1:6 at weekends. 3 registrars at night, and 18 Advance Clinical practitioners. Staff said they could always access a member of the medical team when required even during out of hours and would access doctor in resus if needed. Nurses said there were not enough HCAs in the department. Staff were concerned about staffing of the escalation corridor as nurses who were not familiar with the ED were used, they felt these nurses required additional support and so could be a hindrance rather than a help. We saw senior nurses work alongside other staff. We spoke to nurses from a medical ward who was not happy about working on the corridor, she said she had never worked within ED before and she did not feel comfortable working there as she did not know what processes to follow and she did not know who was who. We were concerned about the lack of oversight of patients in the post-triage area, where there were no staff able to see the patients. The children’s waiting area was obscured by the L-shape, the receptionist could see people who chose to sit around the corner via CCTV.

There were processes in place for bank and agency staff to undergo a local induction. A standard operating procedure was provided to support managers in ensuring staffing within the department areas was safe. There was a process in place to ensure ED were adequately and safely staffed majority of the time. Authority was given to managers in each area within ED to take action when staffing had not reached or exceeded minimum staffing levels. When mitigation was not completed and all options exhausted such as the trust’s own bank, managers submitted requests for further support from external agency staff.

Staff followed infection control principles including the use of personal protective equipment (PPE). We saw examples of staff following correct processes during our inspection, one patient required isolation and we saw correct signage was on display on cubical door. However, in the children ED Isolation area, we saw a child with measles, we found there were breaches within isolation as children's waiting area toilets was also in the isolation area and was used by non-infected patients. Staff adhered to the World Health Organisations (WHO) five moments for hand hygiene. We observed staff completing hand hygiene at the point of care and followed the correct process of IPC. All areas of the hospital were clean, all surfaces were secure, no ripped seats or chipped surfaces. We saw staff cleaning equipment in between patients. We saw evidence of cleaning, cleaning staff were visible in the department and they used appropriate signage to show when areas (floors) were wet.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.