Worcestershire Royal Hospital

Updated 17 May 2024

Worcestershire Royal Hospital provides acute hospital services to a population of 580,000.

We inspected Worcestershire Royal Hospital critical care services only during this inspection. We used our comprehensive inspection methodology as this service had not been inspected since 2017 when we rated critical care at this location requires improvement. We carried out an unannounced visit to critical care services at Worcestershire Royal Hospital on 18 December 2023.

The trust has a countywide approach to critical care; and therefore, overall management of the critical care service is the,same across the 2 sites that deliver this; the Worcestershire Royal Hospital and the Alexandra Hospital in Redditch. There are a total of 23 beds countywide with 8 beds at the Alexandra Hospital and 15 at the Worcestershire Royal Hospital. The service is funded for up to 15 level 3 beds across both sites and work with 4 at the Alexandra Hospital and 11 at Worcestershire Royal Hospital. Beds can be used or ‘flexed’ between level three and level 2 depending on patient need (level 3 beds require 1 nurse to each patient and level 2 beds 1 nurse between 2 patients). In addition, the trust has 8 high dependency (level 2) beds on the acute respiratory unit which is situated within the acute respiratory ward and 8 level 2 beds on the hyperacute stroke unit (HASU, within the acute stroke unit). We visited the HASU but as it did not have any high dependency patients at the time of our inspection, we have not included these findings in this report.
To get to the heart of patients’ experiences of care and treatment, we ask the same 5 questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’
performance against each key question as outstanding, good, requires improvement or inadequate.
Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.
with support from an offsite inspection manager, carried out the inspection on 18 December 2023.
During the inspection we reviewed a range of documents related to running of the service including, staffing rotas,performance data, risk assessments and emergency equipment checks, policies and procedures, an independent website browser platform and servicing records of equipment. We spoke with 11 members of staff including service leaders and 3 patients and 2 relatives who had used the service. We reviewed 5 sets of patient records.

Updated 6 April 2023

Updated 20 September 2019

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff and the majority of staff had completed it.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to relieve pain.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and knew how to support patients experiencing mental health issues and those who lacked capacity to make decisions about their care. Staff followed the trust policy and procedures when a patient could not give consent. Consent was consistently undertaken in line with the trust consent policy.
• Staff cared for patients with compassion and feedback from patients and parents confirmed staff treated them well and with kindness.
• The service took account of patients’ individual needs and the service had a person-centred care approach to meeting the needs of babies, children and young people.
• People could access the service when they needed it.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care and clinical leaders were visible across children’s services.
• The service had a systematic approach to continually monitor the quality of its services and monitored activity, performance and used data to identify areas for improvement.
• The service collected, analysed, managed and used information well to support all its activities through the use of secure electronic systems with security safeguards.
• The service engaged well with patient’s staff and the public and local organisations to plan and manage appropriate services and collaborated with partner organisations.

However,

• There was a lack of clarity around the numbers of medical staff eligible for mandatory training in the children’s service.
• Staff training for preventing radicalisation was below the trust targets for some staff.
• The delayed installation of electronic prescribing of chemotherapy and the possible delay of the diabetes information system could incur a lo(ss of income to the children’s service.
• Waiting times for patients attending PAU were not being monitored on Riverbank ward.
• The ‘Facing the Future’ standards were not fully implemented to ensure all children were reviewed within 14 hours of admission by a consultant. Although we saw no evidence of patients coming to any harm during our inspection.
• The Friends and Family Test (FFT) response rate was below the trust standard of 30% on Riverbank ward and the children’s outpatient department.
• There were delays in the Child and Adolescent Mental Health Service (CAMHS) pathway for patient assessments and transfer to specialist inpatient beds.
• There were some delays in the electronic discharge summaries (EDS) for patients on Riverbank ward.

Updated 17 May 2024

Updated 20 September 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it, with attendance at some courses such as information governance and infection, prevention and control being significantly lower than the trust target.
• Compliance rates for all levels of children’s and adults safeguarding training was below the trust target for medical staff.
• Systems and processes were generally in place to prevent and control infection. Staff kept themselves clean and the service monitored staff adherence to most infection prevention and control procedures through audits, however there were inconsistences with keeping equipment and premises clean.
• The service had suitable premises, and equipment was generally looked after well, however some equipment was old and overdue for replacement, such as the CT scanners.
• Safe systems and procedures were in place to assess, monitor and manage risks to patients, however these were not always followed.
• Compliance rates for all levels of Mental Capacity Act and Deprivation of Liberty Safeguarding training was below the trust target for nursing and medical staff.
• While the service generally took into consideration the patients’ individual needs, there was limited provision for separate male and female changing and waiting areas.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. However, there was limited visibility and engagement of senior leaders.
• The service had a draft vision and strategy for what it wanted to achieve. However, further progress had paused to ensure it was linked to and supported delivery of the core elements within the recently developed trust strategy.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, while staff recognised that the service needed to develop the culture of the teams across all sites, they did not feel supported by senior leaders to address immediate concerns.
• Not all staff had completed information governance training.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew how to apply it.
• The service had enough nursing 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.
• The service had a safety monitoring system in place to monitor their performance against targets. Staff completed and kept clear records of risk assessments and safety checklists for patients.
• Although there was a high number of vacancies for medical and qualified allied health professionals staff the service ensured enough medical 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 were on each shift.
• The service administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Care and treatment were delivered in line with legislation, standards and evidence based guidance.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• The service made sure patients had access to the main diagnostic services seven days a week.
• Staff took opportunities to promote healthy lifestyle options for patients.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA). They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff provided emotional support to patients to minimise their distress. Patients and those close to them were able to receive support to help them cope emotionally with their care and treatment.
• Most patients could access the service when they needed it. Waiting times to treat patients were generally in line with good practice. Most patients received diagnostic imaging within the six week target. The backlog of unreported images and delays in reporting had significantly improved. From July 2016 to May 2019, the trust had reduced its unreported plain film x ray backlog from over 11,000 to under 500, and 79% of scans were reported within the trusts target depending on modality.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. A local risk register was in place which was regularly reviewed at local and divisional level.
• The service collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards.
• The service was committed to improving services by learning from when things go well and when they go wrong, promoting training and innovation.

Updated 20 June 2017

We rated end of life care as good because:

• Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care.
• There was good identification of patients at risk of deterioration and identification of patients in the last days of life.
• The trust had taken action to improve the facilities in the mortuary since a previous inspection. This included replacing fridges, flooring and improving the hot water facilities.
• There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. A comprehensive programme of end of life care training was available for the full range of staff within the trust.
• There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
• People were supported, treated with dignity and respect and told us they felt involved in their care. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
• Patients and relatives told us that the staff were caring, kind and respected their wishes. People we spoke with were complimentary about the staff and told us they felt appropriately supported.
• The specialist palliative care team responded quickly to referrals and typically would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer and non-cancer referrals.
• The specialist palliative care team worked proactively with the emergency department to identify patients who may benefit from palliative care input.
• The trust had begun to record and audit preferred place of care at the end of life and there were clear systems in place to make improvements in this area.
• The specialist palliative care team had audited complaints that had an end of life care component, identified trends and had taken action to address improvements.
• There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.
• There was consistent promotion of the delivery of high quality person centred care and strong leadership for end of life care. Staff were consistently passionate about end of life care, positive about their roles and consistent in their belief that the quality of end of life care was good.
• Innovations included close working between the specialist palliative care team and emergency department staff to identify patients at the end of life and provide specialist support. The trust was one of ten that had been chosen to participate in a quality improvement partnership with The National Council for Palliative Care and Macmillan Cancer Support.

However:

• Discussions around DNACPR (do not attempt cardiopulmonary resuscitation) decisions were not always sufficiently recorded within patient’s medical records.
• Feedback from relatives and staff showed there had been some delays in obtaining death certificates, although we saw that this had been discussed at the meeting of the bereavement group and we were told the lead nurse was taking the lead on addressing this issue.

Updated 29 November 2023

Updated 20 September 2019

Our rating of this service improved. We rated it as requires improvement because:

• Not all staff were up to date for safeguarding training on how to recognise and report abuse.
• Whilst World Health Organisation safe surgery checklists were not used for all invasive procedures in ophthalmology, the trust took urgent actions to address this.
• People could not always access the service when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
• Performance against the national cancer standards for patients on two week waits and patients waiting less than 62 days for treatment were not in line with national standards.
• Local leadership in some outpatient departments required support.
• Whilst the service generally provided care and treatment based on national guidance and evidence-based practice, local safety standards for invasive procedures were not yet fully in use.

However,

• The service generally had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Outpatient services were generally provided from 8am to 6pm, Monday to Friday. Clinics in the main outpatient department did not routinely provide a seven day a week service.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
• The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
• The service generally had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Staff and managers across the service promoted a positive culture that supported and valued one and other.

Updated 20 September 2019

Our rating of this service improved. We rated it as requires improvement because:

• Although the service had improved since our last inspection, we found some areas of concern/areas where the service still did not meet legal requirements, so we could not rate this above requires improvement.
• Mandatory training rates for medical staff, including training on safeguarding adults and children, although improved, did not meet trust targets.
• Audit data showed hand hygiene compliance in theatres was low but improving.
• There were inconsistencies in completion of patient risk assessments and some delays occurred in response to requests for medical review of patients at times. Not all the required pre-operative and peri-operative safety checks for patients receiving surgery were recorded.
• The prescription of antibiotics did not always meet national standards. Staff did not always state the indication for the use of antibiotics or when they should be reviewed.
• Patients access to the service was affected by longer than average referral to treatment times and when surgery was cancelled, patients were not always re-booked within 28 days of cancellation.
• Capacity issues resulted in some patients being cared for in a clinical room on two wards. Staff told us there were occasions when patients were cared for on trolleys in the corridor of the surgical clinical decisions’ unit for a few hours until a bed became available. Until approximately a month prior to the inspection, some patients stayed in the theatre recovery area for an extended period, due to bed capacity issues. The trust reported three breaches of same sex accommodation requirements in the vascular high care unit.
• The service did not have fully effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However,

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Managers provided mandatory training in key skills to staff. The percentage of nursing staff completing mandatory training mostly met trust targets.
• The service mostly controlled infection risk well. Staff kept themselves, equipment and the premises clean. They mostly used control measures to prevent the spread of infection. The service generally had suitable premises and equipment and looked after them well.
• The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff mostly completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Staff kept detailed records of patients’ care and treatment. Records were mostly clear, up-to-date and easily available to all staff providing care.
• Medicines were mostly stored and managed safely and processes for this had improved since the last inspection. Patients received the right medication at the right dose at the right time.
• Patient safety incidents were managed well. Staff recognised incidents and reported them appropriately.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Audits were completed to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Performance in national audits such as the national bowel cancer audit, was mostly in line with other trusts or better. Risk of re-admission was slightly higher than the national average in general surgery; however, it was lower than the national average in other surgical specialties.
• Managers made sure staff were competent for their roles. Multidisciplinary team working was generally effective. Staff worked together as a team to benefit patients. The service was working towards seven day services.
• Consent was obtained in line with legislation and when patients did not have the capacity to make specific decisions, the principles of the Mental Capacity Act were followed. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients praised staff for their professional approach and the reassurance and consideration given to patients who were vulnerable. Staff involved patients and those close to them in decisions about their care and treatment.
• The service took account of patients’ individual needs. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• There were managers at all levels of the service, with the right skills and abilities to run a service providing high-quality sustainable care. Managers had a vision for what they wanted to achieve and workable plans to turn it into action.
• There was a clearly defined governance structure in place and a systematic approach was used to continually improve the quality of surgical services and safeguard high standards of care.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation. Action had been taken to address most of the concerns we identified at our inspection published in June 2018, although further improvement was needed.

Updated 6 April 2023