Alexandra Hospital

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 a 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 on Worcestershire Royal Hospital, the Alexandra Hospital and Kidderminster Hospital and Treatment Centre whereby the trust was served with a Section 29a Warning Notice. The 29a Warning Notice required the service to complete a number of actions to ensure compliance with the Health and Social Care Act 2008 Regulations and the trust had produced a comprehensive action, which reflected these requirements as well as additional aims and objectives for the service.

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, and maternity and gynaecology. 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:

• There was inadequate investigation of, and learning from, serious incidents and inadequate mortality and morbidity reviews in the emergency department (ED).
• There was minimal reporting of patient safety incidents relating to patients waiting on trolleys in corridors and when the department was over capacity.
• There was very little response from the hospital as a whole when the ED safety matrix showed that the department was overwhelmed.
• This was not sufficient medical cover to provide a consultant presence in the department for 16 hours a day as recommended by the Royal College of Emergency Medicine.
• The trust had told us that a new full capacity protocol had been developed describing the actions to be taken when the hospital and ED were full. This had not been completed and the trust appeared to take very little action on the many occasions when the ED was full and unable to treat any more patients.
• There remained long delays for patients at every stage of their assessment and treatment. There had been no improvement in the ability to meet the national standard to admit or discharge 95% of patients within four hours. In February and March 2017, this had been achieved for only 80% of patients which was similar to our previous inspection. We observed six patients who spent between eight and 12 hours in the department.
• There was very little privacy and confidentiality for patients waiting on trolleys in the corridor in ED.
• There had been no clinical governance or performance management meetings since our last inspection. High levels of clinical activity in the ED meant there was little time for governance and risk management.
• There was little understanding of the processes for escalating significant risks to divisional or board level. Doubt remained regarding the degree of oversight of ED risks by senior leaders within the trust.
• There was significant concern about the lack of effective leadership in the ED and at trust level to tackle the ongoing risks to patient safety.
• During this inspection, we still observed that most staff did not generally wash their hands before and after patient contact on ward 12 and the medical assessment unit (MAU). In surgery, some staff were not compliant with infection control precautions including hand hygiene and appropriate use of personal protective equipment.
• Time critical medicines were not always given when required in some medical care wards.
• In surgery, medications were not administered as prescribed. Medications were stored in temperatures above manufactures recommended guidelines.
• Venous thromboembolism (VTE) assessments were not carried out on all patients in line with trust and national guidance in medical and surgical wards.
• Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst countywide perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
• The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

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

• There was a lack of advanced training in child safeguarding for doctors and nurses.
• Safeguarding adults training for doctors and nurses in the ED was inadequate.
• There was a lack of immediately accessible equipment for the care and treatment for patients being cared for in the corridor area of ED.
• There was a risk that there would be no appropriately qualified doctors on duty if a child needed resuscitating in the ED.
• Only 78% of patients were assessed by a member of ED staff within 15 minutes of arrival: this had not improved since the last inspection.
• There were fewer nurses than required for the numbers of patients in the department, particularly at night.
• The trust had told us that a frailty team was to be implemented in order to improve response for frail patients with complex health needs. This had not happened.
• Only twenty-four per cent of staff were up-to-date on medicines’ management training and this was below the trust target of 90% in medical care wards.
• Patient weights were not routinely recorded on drug charts we looked at. Patients declining to take prescribed medication were not always escalated to or reviewed by medical staff. Doctors prescribed medication but did not always review drug charts to ensure patients were either taking their medication as prescribed or declining to take them. This meant that effective treatment was not provided.
• Patient’s medical notes were not stored securely as they were left in unlocked trolleys that could be easily accessed by unauthorised individuals. Visitors to medical and surgical wards could see patient identification details on electronic white boards.
• All wards displayed the actual number of staff on duty. However, some surgical wards did not display the planned number of staff and therefore patients and visitors could not identify any staff shortages.
• Staff compliance with Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training was very low.
• In response to high capacity demands for medical beds, the hospital had converted a surgical ward to a medical ward: however, nurses said they did not always have the required skills to care for medical patients.
• Some surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.
• The medical service leadership team had not addressed all issues identified as areas for improvement in our last inspection. This meant that there were still potential risks to the safety and quality of care and treatment of patients’ care.
• Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments (VTE) and compliance with hand hygiene. However, we saw examples throughout surgery where national guidance had not been followed. When risks had been escalated, there was a lack of follow up and resolution.

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

• We observed good infection control precautions performed by all staff in ED clinical areas.
• Staff were now confident in the use of paediatric early warning scores in ED.
• Improvements were noted in completed of National Early Warning Score (NEWS) records in the medical care wards visited.
• Staffing levels in the discharge lounge met patients’ needs.
• The service had taken steps to improve the management of medical patients cared for on non-medical speciality wards with evidence that patients were reviewed regularly by medical doctors.
• All staff had ‘arms bare below the elbows’ in surgical clinical areas.
• We saw fewer medical outliers on most surgical wards. However, one surgical ward had nine medical outliers at the time of our inspection.
• Patients undergoing surgery had the correct consent form.
• Patients who lacked capacity had evidence of a mental capacity assessment.
• The trust had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

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

• There were improved processes for the recording of medication that had been given to patients by ambulance crews.
• Staff felt that increased availability of ambulatory emergency care had improved some aspects of patient flow through the department.
• The lead consultant and matron were highly visible within the ED and led clinical activity. The matron had recently implemented new clinical audits.
• Staff had documented competencies to work in the non-invasive ventilation (NIV) unit. This was identified as an issue during our inspection in November 2016 and had improved during this inspection.
• Adequate staffing levels were observed on all surgical wards during our inspection. Staff explained their new staffing application (an electronic tool which measured how many staff were on duty against how many should have been on duty), which helped escalate any shortages rapidly.
• Patients undergoing surgery had the correct consent form. Patients who lacked capacity had evidence of a mental capacity assessment.
• All clinical areas we visited in the maternity and gynaecology service were clean and there was good adherence to infection control policies and the use of personal protective equipment.
• There had been an improvement in compliance with safeguarding children level three training in maternity and gynaecology service.
• Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training in maternity and gynaecology service had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.
• The trust had implemented a new quality dashboard, known as the safety and quality information dashboard (SQuID). This was used as a drive for improvement and had improved staff’s understanding of safety and quality in the service.

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

Importantly, the trust must:

• Ensure that the privacy and dignity of all patients in the ED 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 improve the quality and safety of the services provided within the ED.
• 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 ED.
• Ensure that medicine’s management training compliance meets trust target of 90%.
• Ensure all staff have completed their Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
• Ensure the completion of VTE assessments and re-assessments is in line with national guidance.
• Ensure drug charts have patient weights recorded.
• 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 there are processes in place to ensure that any medicine omissions are escalated to the medical team for review.
• Ensure when patients refuse to take prescribed medication, this is escalated to the medical team for a review.
• 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 have completed the required level of safeguarding training.
• Ensure all staff comply with hand hygiene and the use of personal protective equipment policies.
• Ensure all staff have completed their Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training.
• Ensure all staff have completed the required level of safeguarding training for vulnerable adults and children.

In addition the trust should:

• Achieve the required numbers of consultants in the ED on duty to meet national guidelines.
• Review its processes to confirm that all ED consultants and middle grade doctors hold a current advanced paediatric life support qualification and that they would lead resuscitation of children. Including those from temporary staffing agencies.
• Consider displaying actual and planned staff numbers in all clinical areas.
• Review nurse staff competence for the management of medical patient outliers.

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, Redditch, Kidderminster Hospital and Treatment Centre and surgical services at Evesham Community Hospital, which is run by Worcestershire Health and Care NHS Trust.

The trust was rated overall as inadequate and entered the “special measures” regime based on the initial inspection from 14 to 17 July 2015. Special measures apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing management cannot make the necessary improvements without support. Kidderminster Hospital was rated as requires improvement overall during this period.

As part of a scheduled re-inspection of the trust, we carried out a further comprehensive inspection of Worcestershire Acute Hospitals NHS Trust from 22 to 25 November 2016, as well as an unannounced inspection from 7 to 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.

Overall, we rated Alexandra Hospital as inadequate, with two of the five key questions we always ask being judged as inadequate.

Our key findings were as follows:

• The flow of patients in the emergency department (ED) was often blocked by internal capacity issues, for example, a lack of available beds in the hospital. This resulted in ED becoming over crowded, and with patients waiting on trolleys in a corridor.
• In November 2016, only 50% of ambulance patients were handed over to ED staff within 15 minutes. There were not enough nurses to ensure that all patients were assessed within 15 minutes of arrival in the department, or to safely care for patients in the major treatment area and resuscitation room.
• There were not enough consultants to provide 16 hours of consultant cover within the ED each day, in line with national guidance.
• There was no privacy and little confidentiality for patients waiting on trolleys in the corridor of the ED. Staff did not always have line of sight of these patients.
• The department could not ensure that there was always as 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. The system had been introduced two days before our inspection.
• Staff did not complete venous thromboembolism assessments on patients in line with trust policy and national guidance.
• Appropriate systems were not always in place for the storage, administration and recording of medicines. Intravenous fluids for emergency use were stored unsecured in resuscitation trolleys on corridors in the ward areas. The trolleys were accessible to staff, patients and relatives which meant there was a risk of medicines being tampered with which could cause harm to patients.
• Safeguarding children training compliance was low throughout the hospital and not in line with national guidance.
• Staff were unaware of female genital mutilation and child sexual abuse. There was a risk that staff would not recognise when a child was being abused or exploited.
• There was a lack of radiation protection infrastructure.
• Medical notes were not always locked away safely.
• The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) results were worse than expected.
• There was no policy in place regarding the management of medical outliers. Medical outliers are patients who are admitted to a non-medical ward. Doctors and nurses told us these patients were at greater risk because they were not cared for on a designated medical ward.
• Not all staff had completed mandatory training or received an annual appraisal.
• Not all staff cleaned their hands before and after contact with patients and some staff did not change their gloves or aprons after each task. This meant that infection prevention and control practices were not in line with trust policy or national guidance throughout the hospital.
• There was a high number of medical and nursing vacancies and unfilled shifts.
• The strategy for countywide management of emergency surgery was not fully implemented and some staff were unaware of the surgical plan.
• There was a culture of incident reporting and most staff said they received feedback and learning from serious incidents.
• Feedback from patients and those who were close to them was positive about the way staff treated them. We observed patients being treated with dignity, respect and kindness.
• Relatives of patients in critical care had access to facilities to enhance their stay on the unit; this included overnight accommodation, refreshments and information leaflets.
• Patients with a mental health condition who attended the ED were cared for by a responsive and effective psychiatric liaison service and specialist alcohol liaison nurse services were available.

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

Action the hospital MUST take to improve

• Ensure patients privacy, dignity and confidentiality is maintained at all times, particularly during handover.
• Ensure patients are always assessed and treated in line with the Mental Capacity Act 2005.
• Ensure that patient documentation, including risk assessments, are completed accurately and routinely to assess the health and safety of patients. This must include pain assessments, venous thromboembolism assessments and fluid balance charts.
• Ensure that patient weights are recorded on their drug charts.
• Ensure that there is clear oversight of all deteriorating patients and that the National Early Warning Score chart is completed accurately.
• Ensure there is an embedded risk assessment process to determine the criteria for patient moves to non-medical wards.
• Establish a female genital mutilation training programme for all staff working in children and young people’s services.
• Ensure staff are aware of the Mental Capacity Act 2005.
• Ensure operating team brief is attended by all required members of staff, as per national guidance.
• A robust system must be in place to ensure that all electrical equipment has safety checks as recommended by the manufacturer.
• Ensure that all equipment is checked as per policy, particularly in midwifery services.
• 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 stored within the recommended temperature ranges to ensure their efficacy and safety.
• Review arrangements for the storage of intravenous fluids for emergency use to ensure patient safety.
• Ensure that medicines are always administered to patients as prescribed.
• 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 infection prevention and control procedures are always carried out as per trust policy and national guidelines.
• Ensure theatres and anaesthetic rooms are compliant with national guidance, Health Technical Memorandum 03-01: Specialised Ventilation for Healthcare Premises.
• 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 patient harm reviews are carried out on patients who breach the referral to treatment times and cancer waits in order to mitigate any risks.
• Ensure that incidents are accurately reported and investigated.
• 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.
• 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.
• Ensure children’s and young people’s service carry out clinical audits to identify effectiveness and areas for improvement.
• Ensure staff are aware of the strategy for diagnostic and imaging services.
• 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 the trust target of 90%.
• Ensure all staff receive an annual appraisal and that there is appropriate supervision for staff.
• Ensure that there are sufficient registered children’s nurses in post so that the emergency department always 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 only appropriately trained staff members are left in charge of a ward to care for patients.
• Ensure all patients are clinically assessed by a competent member of staff within fifteen minutes of arrival in the emergency department.

In addition, the trust should:

• Ensure there are consistent mortality review group meetings in order to review the Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) across the service.
• Ensure that clinical audits in the emergency department are reviewed to enable the findings to improve practice. Accurate performance data should be collected and discussed at relevant governance meetings.
• Ensure robust risk management processes are in place with defined action plans and regular reviews.
• Ensure governance meetings reflect their terms of reference.
• Ensure all staff use appropriate personal protective equipment and decontaminate their hands appropriately at all times, especially before and after every patient contact and when moving between clinical areas.
• Review the arrangements for the storage of intravenous fluids for emergency use.
• Ensure trust policies are up to date and reflect current national guidance.
• Develop documents that clearly identify where specific information should be recorded.
• Ensure record keeping systems are coordinated to enable staff access to all relevant patient information.
• Ensure there is an effective escalation process when the hospital is approaching full capacity.
• Ensure there are sufficient consultant emergency medicine doctors to keep patients safe.
• Ensure all new bank and agency staff receive thorough inductions and ward orientations before starting work.
• Document and record all meetings where performance in the children’s clinic is discussed.
• The provision of children’s services should be clarified with external providers to ensure the safe care of children in the emergency department.
• Ensure all women are asked about domestic violence during their pregnancy in line with national guidance.
• Share results from national audits and action plans with all levels of staff to improve patient outcomes.
• The trust should improve its local audit schedule and consider more regular audits in documentation, the environment, equipment, surgical site infections and hand hygiene audits. Audit results should be followed up with improvement action plans where indicated.
• Ensure staff have knowledge of the key objectives within their service.
• Ensure all cancelled clinics and outpatient appointments are rescheduled in a timely manner.
• Review the high levels of unplanned medical admissions onto the surgical wards and implement steps to reduce the number of cancelled operations.
• Ensure all treatment areas where children and young people are provided with care and treatment, including adult services, are appropriate and child friendly environments.
• Ensure appropriate waiting areas are available for children and young people when sharing adult services.
• Take action to address the ‘did not attend’ appointment rate for new children and young people’s services appointments.
• Ensure patients are discharged from the critical care unit within four hours of the decision to discharge, in order to improve the access and flow of patients within critical care.
• Investigate complaints within the timescales stated in the trust’s complaints policy.
• Review the choices offered to patients about where they are discharged to for continuing care.
• Ensure information from the children’s clinic flows to the board via effective governance processes.
• Engage and consult with all staff when considering any service reconfiguration and involve staff in the strategic plans to develop the surgical services across the three hospital sites.

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