Worcestershire Acute Hospitals NHS Trust

The Care Quality Commission (CQC) previously carried out a comprehensive inspection in November 2016, which found that overall; the trust had a rating of 'inadequate'.

We carried out an unannounced focused inspection on 11 and 12 April 2017. We also visited on 25 April 2017, specifically to interview key members of the trust’s senior management team. This was in response to concerns found during our previous comprehensive inspection in November 2016 at Worcestershire Royal Hospital (WRH), the Alexandra Hospital (AH) and Kidderminster Hospital and Treatment Centre (KHTC) whereby the trust was served with a Section 29a Warning Notice. The Section 29a Warning Notice required the service to complete a number of actions to ensure compliance with the Health and Social Care Act 2008 Regulations. The trust had produced an action plan, which reflected these requirements as well as additional aims and objectives for the service. This inspection looked specifically at the issues identified in the warning notice and therefore no services were rated as a result of this inspection.

Focused inspections do not look at all five key questions; is it safe, is it effective, is it caring, is it responsive to people’s needs and is it well-led, they focus on the areas indicated by the information that triggered the focused inspection.

The inspection focused on the following services: adult emergency department (ED), medical care, surgery, maternity and gynaecology and children and young people and the minor injuries unit at KHTC. We inspected parts of the five key questions for these services but did not rate them.

Areas where significant improvements included in the Section 29a Warning Notice had not been made were:

• The leadership and governance arrangements of the trust were not effective in identifying and mitigating risks or in providing assurance that actions were resulting in improvements to the safety and quality of patient care.
• Leaders did not act on known concerns at the pace required and were dependant on other organisations escalating areas of concern. There was not effective ownership of the need to establish effective systems to recognise, assess and mitigate risks to patient safety.
• Actions to address urgent concerns were either yet to be implemented or were not effective in reducing the risk as the data reported nationally and provided by the trust demonstrated there was subsequently no tangible improvement in performance.
• The trust had identified, and our review found, that the corporate risk register required significant review. Work had started on ensuring that it contains risks and not issues, however we found that there was a lack of consistency in how things were recorded.
• Actions already identified by the trust as necessary to mitigate patient care being compromised from overcrowding in the ED at WRH and AH were either yet to be implemented or were not effective in reducing the risk.
• There was no tangible improvement in performance, caring for patients in the corridors in the ED had become institutionalised and we found patient’s privacy, dignity and effective care remained compromised. The trust senior leaders were not effectively addressing these risks through a whole hospital approach.
• The number of patients waiting between four and twelve hours to be admitted or discharged was consistently higher than the national average.
• In the emergency departments (ED) at WRH and AH, essential risk assessments were not always completed when required to keep patients safe from avoidable harm. There were not effective systems in place to assess and manage risks to patients in the ED at both hospitals. Staff did not always identify and respond appropriately to changing risks to patients, including deteriorating health and wellbeing.
• There was no appropriate mental health room available in the ED at WRH within which to safely care for patients.
• The children’s ED area at WRH was not consistently attended by staff except via CCTV surveillance to the nurses/doctors station in the major’s area. Patients and their parents/carers were left alone after assessment and while they waited to see a doctor.
• There were insufficient numbers of consultants in the ED at WRH and AH on duty to meet national guidelines.
• Staff were not using privacy screens to respect patients’ privacy and dignity whilst being cared for in the ED corridor area at WRH and AH. Patients were given meals in their hands by the staff but there was nowhere to rest plates and cups so they could eat their food with dignity. Routine nursing observations, conversations about care and eating of meals were undertaken in a public space with other patients and relatives passing by.
• In medical care and surgical wards visited at WRH and AH, venous thromboembolism assessments and 24-hour reassessments were not always carried out for all patients in line with trust and national guidance.
• We observed that staff did not always wash their hands before and after patient contact in ED, medical care and surgical wards in line with national guidance at WRH and AH.
• In the ED at WRH, time critical medications were not always administered to patients who had been assessed as needing them on time. In the surgery service at WRH, anticoagulation medicine had not always been administered as prescribed.
• Patients declining to take prescribed medication on Evergreen 1 ward and Beech ward at WRH were not always referred to medical staff for a review and were not always reviewed by medical staff. We raised this as an urgent concern with senior staff on the day of our inspection.
• Fridge temperatures for the storage of medicines in exceeded recommended ranges in some surgical areas visited and in the maternity and gynaecology service at WRH and AH, staff did not consistently follow trust processes for storing medicines at the recommended temperatures, despite there being policies in place.
• Although the trust's county wide perinatal mortality and morbidity meetings were minuted, there was no evidence that action was taken to address learning from case reviews. We were not assured an effective system was in place to ensure learning from these meetings was shared, and actions were taken to improve the safety and quality of patient care. In addition, these were not multidisciplinary and only attended by medical staff in the children and young people’s service at WRH.
• Whilst some improvements were observed in completion of Paediatric Early Warning Scores charts, not all charts at WRH had been completed in accordance with trust policy. We also found there was not always evidence of appropriate escalation for medical review when required.
• In the paediatric ward at WRH, one to one care for patients with mental health needs was not consistently provided by a member of staff with appropriate training and reliance was, on occasion, placed on parents or carers.
• Senior leaders in surgery and medical care were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and hand hygiene. However, we saw examples throughout the service where compliance with trust and national guidance had not significantly improved.
• When risks had been escalated, there was a lack of follow up and resolution. Effective action following the reporting of high fridge temperatures for storage of medicines was not evident.

Additional areas of concern, that were not included in the Section 29a Warning Notice, that we found during this inspection were:

• Some risk assessment records in medical care wards at WRH were not routinely completed in their entirety, including elderly patient risk assessments and sepsis bundle assessments. We were not assured that inpatient wards were effectively following the trust’s sepsis pathway when required.
• There was an inconsistent approach to following the ED’s child and adult safeguarding processes. Staff training compliance for both adult and children’s safeguarding was significantly worse than the trust target at both hospitals.
• Pain relief given to children in the ED was not evaluated for its effectiveness for all patients. There was no system in place to ensure medicines stored in the emergency gynaecology assessment unit were safe for patient use. Immediate action was taken by the trust once we raised this as a concern.
• The recording of patients’ weights on drug charts on some medical care wards at WRH had not improved. In the surgical service at WRH, some patients were prescribed inappropriate doses of anticoagulation medication without regard to their weight.
• Not all staff were up to date with the trust’s medicines’ management training.
• Resuscitation equipment was not fit for purpose in an emergency situation at the minor injuries unit at Kidderminster Hospital and Treatment Centre (KHTC). The defibrillator was not ready for use as the electronic pads had expired at midnight on the night previous to our inspection.
• On the haematology ward at WRH staff handled food with their hands without the use of
• In the maternity and gynaecology service, training data showed that 86% of midwifery staff and 53% of medical staff had completed safeguarding children level three training. This was an improvement from our previous inspection. However, compliance was still below the trust target of 90%, particularly with medical staff. In the children and young people’s service, safeguarding children’s level three training was below the trust’s target of 90% and future training sessions had been cancelled. Compliance rates for this essential training were no better or worse in April 2017 in some staff teams compared to November 2016.
• In the surgery service at WRH, less than 10% of nursing staff and 30% of surgical staff had received training in Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Less than 20% of nursing and surgical staff had received this training. Staff compliance in the medical care service at WRH was 45% and AH was 42%, which was below the trust target of 90%. At KHTC only 33% of staff were up-to-date on this training.
• Patient records were left unsecured on a number of medical care wards we visited and there was a risk that personal information was available to members of the public. Visitors to surgical wards could see patient identification details on electronic white boards.
• Some surgical wards did not display their planned staff on duty only their actual staff on duty.
• The waiting room and toilet facilities for patients attending the emergency gynaecology assessment unit were mixed sex, as these were shared with the respiratory outpatient clinic. Furthermore, this assessment unit did not have appropriate facilities such as bathrooms, to facilitate personal care for patients who had to stay overnight at times of increased bed pressures.
• The children and young people’s service became busy at times and staff said activity had increased since the service reconfiguration. However, there was limited monitoring of assessment and admission to inpatient areas. This meant that service leaders were not in a position to understand current and future performance and to be able to drive improvements for better patient outcomes.
• The risk register for the children and young people’s service had been updated to include two additional risks identified during the November 2016 inspection, but not all risks found on this inspection had been identified, assessed, and recorded. For example, the increased activity in the service following the transformation process.

Areas where we found improvements included in the Section 29a Warning Notice had been made were:

• Staff felt supported to report incidents including occasions when they judged patients unsafe because the emergency department (ED) was ‘overwhelmed’. An electronic patient safety matrix and ED occupancy tool was in place showing real time data about ED capacity, which gave oversight of the pressures in ED.
• The trust had implemented a ‘Full Capacity Protocol’ that was activated when the emergency department safety matrix status showed critical or overwhelmed status.
• Most patients were assessed within 15 minutes of arriving to the ED by senior nurses.
• Nurse breaks in the clinical decision unit were now covered by other nurses. Most ED staff were attentive, discrete as possible and considerate to patients.
• During this inspection, all 21 records looked on the acute stroke unit, Avon 3, Evergreen 1 and 2 wards showed NEWS charts were completed fully and patients were escalated for medical review appropriately when required.
• There had been improvements in the monitoring of medicines’ fridge temperatures in medical care wards visited.
• All staff we saw in surgical clinical areas had ‘arms bare below elbows’.
• Infection control protocols were followed in the children and young people’s service.
• There were appropriate arrangements in place for management of medicines in the children and young people’s service, which included their safe storage.
• All patients admitted to the paediatric ward because of an episode of self-harm or attempted suicide had a risk assessment on file.

Areas of improvement, that were not included in the Section 29a Warning Notice, found from the last inspection were:

• The trust had implemented a new quality dashboard, known as the safety and quality information dashboard (SQuID). This was being used as to drive improvement and had improved staff’s understanding of safety and quality in the service.
• There was a senior initial assessment nursing system in place for patients arriving by ambulance to the ED. Staff told us the flow had improved since two ‘ambulance access’ cubicles were specifically allocated in the department.
• Health care assistants were undertaking comfort rounds for patients’ cared for in the corridor area of ED, completing documentation and giving patients a leaflet explaining why they were waiting in a corridor.
• The ED was managed locally by the matron and senior ED consultant. Staff were very committed to their work and doing the best they could for their patients even under regular and consistent heavy pressure.
• The medical care service had taken steps to improve the management of medical patients on non-medical speciality wards.
• The medical care service had improved patient flow in WRH and AH to minimise patient moves.
• There were fewer reported surgical staff shortages and shortfalls were escalated and risk assessed so patients’ needs were met.
• Effective systems had been introduced to ensure emergency equipment was checked daily in the maternity and gynaecology service. Equipment was well maintained and had been safety tested to ensure it was fit for purpose.
• The hospital did not have a dedicated gynaecology inpatient ward. This meant some patients stayed overnight in the outpatient emergency gynaecology assessment unit and were nursed in medical wards. However, the trust had put processes in place to ensure patients were cared for in environments that were suitable for their needs.
• Daily ward rounds by a gynaecology consultant and nurse were carried out to ensure gynaecology patients were appropriately reviewed and managed, regardless of location within the trust.
• Staff caring for gynaecology patients on Beech B1 ward had received training on bereavement care, including early pregnancy loss and the management of miscarriage.
• Risks identified in the maternity and gynaecology service were reviewed regularly with mitigation and assurances in place. Staff were aware of the risks and the trust board had oversight of the main risks within the service.
• The majority of staff in the children and young people’s service had been competency assessed in medical devices used to help patients breathe more easily.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure the governance systems allow full oversight at board level of the potential risk to patients. This must include the recognition, assessment, monitoring and mitigation of risk.

• Ensure the processes to check that the trust only employs ‘fit and proper’ staff are in place and effective.

• Ensure that patients in the EDs receive medication prescribed for them at the correct time and interval.
• Ensure that all patients’ conditions are monitored effectively to enable any deterioration to be quickly identified and care and treatment is provided in a timely way.
• Ensure that staff complete all of the risk assessments and documentation required to assess the condition of patients and record their care and treatment.
• Ensure all patients have a venous thromboembolism (VTE) assessment and are reassessed 24 hours after admission in accordance with national guidance.
• Ensure that the privacy and dignity of all patients in the EDs is supported at all times, including when care is provided in corridor areas.
• Ensure that systems or processes are fully established and operated effectively to assess, monitor and mitigate the risks relating to the health, safety, and welfare of patients while using the EDs.
• Ensure mental health assessment room in the emergency department (WRH) is appropriate to meet needs of patients.
• Ensure the children’s ED (WRH) area is consistently monitored by staff.
• Ensure patient weights are recorded on drug charts.
• Ensure there are processes in place to ensure that any medicine omissions are escalated appropriately to the medical team, including when patients refuse to take prescribed medication.
• Ensure all anticoagulation medication is administered as prescribed. All non-administrations must have a valid reason code.
• Ensure all medicines are stored at the correct temperature. Systems must be in place to ensure medication, which has been stored outside of manufactures recommended ranges, remains safe or is discarded.
• Ensure patient identifiable information is stored securely and not kept on display
• Ensure all staff comply with hand hygiene and the use of personal protective equipment policies.
• Ensure all staff are up-to-date on medicines’ management training.
• Ensure all staff have completed their Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) training.
• Ensure all staff have completed the required level of safeguarding training.
• Ensure all patients in the children and young people’s service with mental health needs have the appropriate level of staff one to one care in accordance with their risk assessments.
• Ensure paediatric assessment area activity is monitored effectively so the service can drive improvements in patient flow.
• Ensure the risk registers reflects all significant risks in the service and effective mitigating actions are in place to reduce potential risks to patients.
• Ensure safeguarding referrals are made when required for patients seen in the ED at WRH.
• Ensure equipment is safe for use in the minor injuries unit at KHTC.
• Ensure the sepsis pathway is fully embedded in inpatient wards.

Please refer to the location reports for details of areas where the trust SHOULD make improvements.

Due to level of concerns found across a number of services and because the quality of health care provided required significant improvement, we served the trust with a new Warning Notice under Section 29A of the Health and Social Care Act 2008.

The trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Worcestershire Acute Hospitals NHS Trust was established on 1 April 2000 to cover all acute services in Worcestershire with approximately 885 beds spread across various core services. It provides a wide range of services to a population of around 580,000 people in Worcestershire as well as caring for patients from surrounding counties and further afield.

Worcestershire Acute Hospital NHS Trust provides services from four sites: Worcestershire Royal Hospital, Alexandra Hospital in Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

We inspected the trust from 22 to 25 November 2016, with unannounced inspections at Worcestershire Royal Hospital, the Alexandra Hospital and Kidderminster Hospital and Treatment Centre on 7, 8 and 15 December 2016.

On 27 January 2017 we issued a section 29A warning notice to the trust requiring significant improvements in the trusts governance arrangements for identifying and mitigating risks to patients.

We rated Worcestershire Acute Hospitals NHS Trust as inadequate overall. Three of the five key questions we always ask (is the trust safe, responsive to people’s needs and well-led) were rated as being inadequate. The trust was judged to require improvement to be effective.

We rated the trust as good for caring. We found that services were provided by dedicated, caring staff. Patients were treated with kindness, dignity and respect and were provided with the appropriate emotional support.

Our key findings were as follows:

Safety

• There was a culture of reporting, investigating and learning from incidents throughout the trust. However, not all incidents that were required to be reported externally as “serious” were correctly classified and externally reported.
• The emergency department at the Alexandra Hospital could not ensure that there was always a senior doctor available who was qualified to resuscitate children. Staff had not been trained to use a new system to help staff recognise when a child’s condition was deteriorating.
• Staffing levels within the emergency department were not planned and reviewed in line with national guidance. There were not enough consultants in the emergency departments to meet the Royal College of Emergency Medicine’s emergency medicine consultant workforce recommendations. However, most other areas had adequate staff to ensure patients received safe care and treatment.
• The level of safeguarding children’s training that staff in certain roles undertook was not compliant with the intercollegiate document “Safeguarding Children and Young People: Roles and competencies for Health Care Staff (March 2014) or the Royal College of Paediatric and Child Health guidelines. Therefore, we could not be sure that staff had sufficient knowledge and skills to safeguard children.
• Medicines management was poor with medicines that required cool storage being stored in fridges which were either below or above the manufacturers’ recommended temperature. Emergency medicines were not protected from tampering, and we saw poor practice relating to staff signing for controlled drugs in the endoscopy department at Kidderminster Hospital and Treatment Centre.
• Mandatory training was, across most areas, below the trust target of 90%. This meant that we could not be assured that staff had sufficient knowledge to manage the care and welfare of patients.

• There was no privacy and little confidentiality for patients being cared for on trolleys in the corridors of the emergency departments at Worcestershire Royal Hospital and the Alexandra Hospital. They were sometimes waiting by external doors in cold conditions or out of the line of staffs’ sight.
• Wards and clinical areas were visibly clean and most staff had access to personal protective equipment. We did observe some poor adherence to the trust’s infection prevention and control procedures on some wards providing medical care. However, overall infection rates were low.

• Patient risk assessments were not fully completed on admission and generally not reviewed at regular intervals throughout the patient’s stay in hospital.
• Patient records were not always stored securely.
• Aging and unsafe equipment was used in the radiology departments across the trust that was being inadequately risk rated. There was a lack of capital rolling replacement programmes in place.
• Medical patients on non-medical wards were not always effectively managed. Patients moved to non-medical wards, such as surgical wards were not always reviewed to check the move was appropriate and the risk of patients deteriorating was not always appropriately managed.

Effective

• The trust performed worse than expected for two mortality indicators (SHMI and HSMR respectively). The Hospital Standardised Mortality Ratio (HSMR) (January 2016) was 105 against the England figure of 100. The trust’s Summary Hospital-level Mortality Indicator (SHMI) for year-end figures (rolling 12 months to December 2015) was 113 against an England average of 100.
• Performance in national audits was, in some areas significantly worse than the England average. However, we found limited evidence of action plans to address all these areas for improvement.
• Most staff understood the effectiveness of completing localised audits. However, we found no standardised approach to the completion of audit. This was also identified in our previous inspection in July 2015.
• Between April 2015 and August 2016, 75% of staff within the trust had received an appraisal compared to a trust target of 85%.
• Not all staff had a good understanding of their obligations under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). As at August 2016 MCA training has been completed by 37% of staff trust wide against a target of 90%. DoLS training compliance was just below the trust target at 85%.
• Care was mostly delivered in line with legislation, standards and evidence-based guidance, however, some local and trust guidelines needed updating.

Caring

• Staff provided kind and compassionate care that was delivered in a respectful way.
• Patients and those close to them were involved in the planning of their care.
• The need for emotional and spiritual support was recognised and provided.
• The trust’s Friends and Family Test performance was generally about the same as the England average between August 2015 and July 2016.
• Patient’s privacy and dignity was often compromised when receiving care in the corridors in the emergency departments

Responsive

• The amount of time patients spent in the emergency department waiting for treatment was consistently worse than the expected standards.
• The trust had consistently failed to achieve the Department of Health emergency department national target to admit or discharge 95% of patients within four hours of arrival since October 2014.
• The percentage of emergency admissions of patients to the emergency department waiting four to 12 hours from the decision to admit until being admitted has been consistently higher than the England average. This meant that patients could not access services in a timely way.
• There were delays when patients in the emergency department were referred to specialist teams. Only 47% of specialist doctors arrived within an hour. There was a lack of plans or strategies to correct this.
• The admitted referral to treatment time was consistently below the trust standard of 90%.
• From January to November 2016 the cancer 62 day wait standard of 85% had only been met once.
• The flow of patients into and through the trust was not well-managed.
• There was a high volume of patients moving medical wards at night from 10pm to 6am. This contravened with the trust’s patient transfer policy, which states that internal transfers between wards should occur between 7am and 9pm. At Worcestershire Royal Hospital, 57% of patients moved medical ward at least once.
• Mixed sex accommodation breaches had not been reported.
• Complaints were not always managed within the timelines set out in the trust complaints policy.

Well-Led

• The executive team was made up of mainly interim executive directors who were not recognisable or visible to staff through the trust
• Although the trust had recently appointed a new substantive chairman, there remained significant concerns relating to the interim positions and future stability of the board and the impact that had on an organisation trying to make substantial improvements in the quality of care it provided for its’ patients. The stability of the board was a concern raised in our last inspection in 2015.
• The executive team did not have effective processes to ensure communication was embedded from ward to board.
• Although we saw many examples of good local leadership, many junior managers felt frustrated that they were not able to effect change due to poor communication between ward, divisional and executive levels.
• Although a revised framework for governance and assurance was in place, it was not operating effectively and the board did not have clear oversight of the risks affecting the quality and safety of care for patients.
• The trust had a poor performance in the 2015 NHS staff survey. It performed better than other trusts in one question, about the same as other trusts in 11 questions and worse than other trusts in 22 questions.
• There was not an appropriate system in place to support the fit and proper person’s requirements.
• The rates of bullying for both black and minority ethnic and white staff from patients, relatives and the public along with other staff were high and represented a significant risk to patient care.
• There was not a Freedom to Speak Up Guardian in place.

• The trust had a proactive view of public engagement, using social media and newspapers in order communicate changes and celebrate successes.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure patients privacy, dignity and confidentiality is maintained at all times. For example, patients staying overnight in the gynaecology assessment unit.
• Ensure that patient documentation, including risk assessments, are always completed accurately and routinely to assess the health and safety of patients. Including elderly patient risk assessments, dementia assessments, venous thromboembolism assessments, sepsis bundle assessments and fluid balance charts.
• Use a standard risk assessment to assess and identify the needs of patients admitted to wards with mental health needs. This must include details of whether the patient requires 1:1 or 2:1 care from a specialist mental health nurse, and the level of care provided.
• Ensure nursing documentation on high dependency units is contemporaneous with detailed accounts of the day’s activities completed.
• Ensure that patient weights are recorded on their drug charts.
• Ensure that there is clear oversight of the deterioration of patients and the National Early Warning Score chart is completed in accurately.
• Ensure that the Paediatric Early Warning Score charts are consistently completed in a timely manner and accurately.
• Ensure that patients are escalated as a result of the Paediatric Early Warning Score where they trigger a deteriorating patient.
• Ensure that the eligibility criteria for the clinical decision unit is followed to ensure appropriate patients are admitted.
• Ensure there is access to 24-hour interventional radiology services.
• Ensure staff are aware of ligature points.
• Establish identification of female genital mutilation and child sexual exploitation training that is to be completed by all staff working in children and young people’s services.
• Ensure that patients under child and adolescent mental health services receive care from appropriately trained staff at all times.
• Ensure that staff providing care for children requiring continuous positive air pressure or AIRvlo have appropriate training or up to date competencies to use this equipment safely.
• Ensure that there is an appropriate mental health room in the emergency department to care for patients presenting with mental health conditions that complies with national guidance.
• Ensure that flow in the trust is maintained to prevent patients being treated in the emergency department corridors for extended periods of time.
• Ensure that children are not left unattended in the emergency department paediatric area.
• Ensure that there is a robust system in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
• Ensure all equipment is in date and used, stored and maintained in line with manufacturers’ instructions.
• Ensure that patients are cared for in a safe environment that has the appropriate equipment to facilitate care to a deteriorating patient.
• Ensure that medicines are always stored within the recommended temperature ranges to ensure their efficacy or safety.
• Ensure prompt investigation of any medicines which are unaccounted for and notify the relevant authority and organisations.
• Review arrangements around storage of intravenous fluids for emergency use to ensure patient safety.
• Ensure that medicines are always administered to patients as prescribed.
• Ensure infection prevention and control procedures are always carried out as per trust policy and national guidelines.
• Improve performance against the 18 week referral to treatment time, with the aim of meeting the trust target.
• Improve performance against the national standard for cancer waiting times. This includes patients with suspected cancer being seen within two weeks and a two-week wait for symptomatic breast patients.
• Ensure they are carrying out patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
• Ensure safeguarding checks are made consistently.
• Ensure information relating to the children at risk register is accessible.
• Ensure that incidents are accurately reported and investigated.
• Ensure that staff receive appropriate training to enable the correct categorising of incidents.
• Ensure that staff are not discouraged from reporting incidents relating to capacity and corridor care.
• Ensure that incidents that need reporting to external authorities are completed.
• Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
• Ensure all mortality and morbidity meetings are recorded and lessons are learnt.
• Ensure there are systems and processes established in surgical service to address identified risks, such as cancelled operations, bed capacity and access to emergency theatres.
• Ensure divisional management teams are aware of patient harm reviews to mitigate risks to patients who breach the referral to treatment times and cancer waits.
• Ensure divisional management teams have oversight of the patient waiting lists and of initiatives and actions taken to address referral to treatment times and cancer waits.
• Develop a clear strategy for surgical services which includes a review of arrangements for county wide management of emergency surgery.
• Develop a clearly defined business plan for paediatrics, which considers the risks to the service and incorporates a vision and plans for service improvement. The plan must have clear objectives and milestones, supported by actions to ensure objectives are realised.
• Ensure the risk register identifies and mitigates all risks.
• Ensure there is a review of the paediatric assessment area and subsequent admissions to identify and resolve potential issues with flow and capacity.
• Ensure the bed management plans for children and young people devised to deal with escalation issues for staffing shortages or high bed occupancy is up to date.
• Ensure there is a strategy is in place for diagnostic and imaging services that staff are aware of.
• Ensure patient notes are stored securely and safely.
• Ensure staff complete the required level of safeguarding training, including safeguarding children.
• Ensure staff compliance with mandatory training meets trust target of 90%.
• Ensure all staff receive an annual appraisal.
• Ensure that there are sufficient registered children’s nurse in post to make certain that the emergency department has at least one registered children’s nurse on duty per shift in line with national guidelines for safer staffing for children in emergency departments.
• Ensure that only an appropriately trained staff member is left in charge of a ward to care for patients.
• Ensure administration of controlled drugs are always documented contemporaneously with signature as appropriate.
• Ensure that resuscitation equipment is readily available for use when required without posing a risk.
• Ensure there is a process for collecting data regarding the effectiveness of the children’s outpatients department to recognise and plan where improvements can be made.
• Ensure mixed sex breaches are reported as required.
• Increase staff awareness of the trust’s incident reporting procedures and risk matrix tool.
• Ensure staff receive appropriate clinical supervision.
• Ensure patients are always assessed and treated in line with the Mental Capacity Act 2005 to gain consent.
• Ensure staff are aware of the Mental Capacity Act 2005.
• Ensure all required members of staff are present at operating team brief as per guidance.
• Ensure that there is a system in place in the emergency department to record medicines (including intravenous morphine) administered to patients by ambulance crews.
• Ensure theatres and anaesthetic rooms are compliant with national guidance, Health Technical Memorandum 03-01: Specialised Ventilation for Healthcare Premises.
• Ensure children’s and young people’s service carrying out clinical audits of the service to establish its effectiveness and identify and complete improvements to the service.
• Ensure there is appropriate supervision for staff.
• Ensure all patients are clinically assessed by a competent member of staff within fifteen minutes of arrival in the emergency department.

Since this inspection in November 2016 CQC has undertaken a further inspection to follow up on the matters set out in the section 29A Warning Notice mentioned above, where the trust was required to make significant improvement in the quality of the health care provided. I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

​Chief Inspector of Hospitals

The Care Quality Commission (CQC) carried out an unannounced inspection at Worcestershire Royal Hospital on 27 July 2016. The purpose was to look at specific aspects of the care provided by radiology services at Worcestershire Acute Hospitals NHS Trust.

Concerns were initially raised by a member of the public, and the trust was given the opportunity to respond to these, however when satisfactory assurances were not received, the local inspection team decided to conduct an unannounced inspection.

In particular we looked at the time that it took to report on routine and urgent plain film x-ray examinations, and the governance processes in place to ensure that any backlog in reporting was managed escalated and resolved. We also looked at staffing within the department.

Worcestershire Acute Hospitals NHS Trust provides radiology services at Worcestershire Royal Hospital, Alexandra Hospital, Redditch, and Kidderminster Hospital and Treatment Centre. The service is managed by one management team based at Worcestershire Royal Hospital where Information technology systems (IT) that support the radiology services across all three sites are also based.

Worcestershire Acute Hospitals NHS Trust was rated inadequate overall at our last inspection in 2015. The outpatients and diagnostic imaging departments were rated requires improvement for all three sites, with leadership at Worcestershire Royal Hospital and Kidderminster Hospital and Treatment Centre rated as inadequate. A comprehensive inspection of all services across three sites is planned for November 2016.

A rating is not provided for this inspection. The reason for not providing a rating is because this was a very focused inspection, focusing on specific key questions and key lines of enquiry. It was carried out to assess whether there was significant risk of patient harm arising from the concerns raised.

In radiology services our key findings were:

• There was a significant backlog in the reporting of plain film x-rays dating back to 2013 which the trust could not provide us with evidence of board oversight or knowledge of. This meant we were not assured that there were suitable governance and escalation processes in place to protect patients from actual or potential harm and trust could not provide evidence to demonstrate that the board were aware of the reporting backlog.
• Lessons were not being learnt from incidents and safety goals had not been set. An audit of 4160 films, which was one months’ volume of unreported plain films from the backlog, was conducted in July 2013. This audit demonstrated that 46 films required follow up imaging, alternative imaging or clinical follow up by the patients’ specialist consultant. ln the course of the audit 16 patients were identified where some delay in providing a radiology report may have resulted in avoidable harm to the patient. There had been some limited follow up of these patients, but no record of the definitive outcome or conclusion of any harm review.
• The length of time for the reporting of diagnostic imaging tests had been on the trust risk register since 2003 and we saw no evidence of a review of the situation and clear actions to reduce the backlog
• During our inspection, we found that from 1 January 2016 to 26 July 2016, 10,442 plain film x-ray examinations remained unreported. The number of potentially unreported diagnostic imaging tests prior to January 2016 was undeterminable on the day of inspection. Subsequent to our inspection, the trust submitted data demonstrating that the total number of unreported images from 2013 to 2015 was 25,622.
• There were no procedures in place to trigger the escalation of risk caused by lengthy delays in reporting.
• Reports for patients referred into the departments for urgent images were not always prioritised, meaning there was a significant delay with some reports taking up to 21 days from when the image was taken before they were reported to GP referrers.
• There were 11 whole time equivalent radiographer vacancies within the department at the time of our inspection and reporting radiographers were not being released from clinical duties to undertake reporting sessions due to these vacancies. There had been six radiologist vacancies within the department since 2014. Workforce capacity therefore was not meeting the demands of the service and the clinical director told us that job plans were not reviewed regularly.
• The department was fragmented with radiologists and radiographers working separately. Radiologists were attending multidisciplinary meetings; however reporting radiographers said they would like to attend these meetings as a learning opportunity, but were not able to do so due to their clinical workload. Discrepancy meetings were being held separately which meant that there was not a cohesive approach to patient care. A discrepancy meeting is a meeting whereby results of an audit of a locally agreed number of x-ray examinations (as laid down in the Royal College of Radiologists guidelines), are presented and discussed. The audit is used to discuss cases where two radiologists have disagreed over the interpretation of an image. There is a general acceptance of a 2-5% discrepancy rate for all radiologists
• There was a comprehensive policy to support non-medical referrers requesting examinations and radiographers were following this policy and checking the database when they did not recognise the referrer’s name.

Action the hospital MUST take to improve

• Take appropriate steps to resolve the backlog of radiology reporting. This must include a clinical review and prioritisation of the current backlog of unreported images, (including those taken before January 2016); assess impact of harm to patients, and apply Duty of Candour to any patient adversely affected
• Ensure that they have robust processes to ensure any images taken are reported and risk assessed in line with trust policy

Based on the findings of this inspection I authorised conditions to be imposed on the trust’s registration as a service provider as I believed that patients may have been exposed to the risk of harm if I did not impose these conditions urgently.

Professor Sir Mike Richards

Chief Inspector of Hospitals