Worcestershire Royal Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as requires improvement. People were not always satisfied with the service they received and suitable adjustments for people with complex needs were not always provided. Medicines were not always dispensed appropriately. People were often cared for in the back of ambulances or on corridors whilst waiting for a cubicle within the department and ambulances were held often waiting to handover patients. The service worked well with local and system partners and stakeholders to address concerns such as crowding and measures to best support patients with timely care and treatment and to access other services. The service reviewed all deaths, incidents and complaints and when needed learning was implemented. There were sufficient numbers of staff, however, we saw a high reliance on agency staff. At the time of the inspection the service was actively recruiting to address this. Processes were in place to identify and manage patient risk including pressure wound and falls risk assessment and monitoring.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People knew how to raise concerns, information such as posters and leaflets were available in the department signposting people on where to go and what to do. People we spoke with said they would know how to raise a complaint. A poster with a digital link attached to a patient feedback form was visible within the department and written forms were also available.

Staff told us they were encouraged and supported to raise concerns. Staff felt confident that they would be treated with compassion and understanding, and not blamed, or treated negatively if they did so.   Between November 2023 and May 2024, 1013, incidents had been reported to the service. After action reviews had been undertaken for 4 incidents. Themes identified by the service included crowding within the department and quality of documentation and escalation. In response to this the service had started a mid-shift huddle, extra monitoring of patients with an early warning score more than 5 (are at risk of deterioration) and a waiting room proforma to closely monitor patients who have been in the area more than 6 hours.   Information provided by the service demonstrated that learning had been taken and shared with staff following incidents within the department.   Patient information leaflets were being relaunched to support awareness and expectations of patients and their loved ones.

A quarterly report provided by the service demonstrated between January and March 2024, 29 actions had been identified from incident reviews. At the time of the quarterly report, 19 actions were on schedule, and 10 actions were overdue and have since been completed. No falls with harm had occurred in the department.  All deaths within the service were reviewed. This meant that themes and trends could be identified. Length of stay (where patients had been in the department for more than 12 hours) had been identified by the service as a theme. Monthly divisional mortality meetings were held and opportunities for improvement were shared throughout the service.   A waiting room checklist had been implemented following patient and relative feedback. At the time of the inspection the service was carrying out a trial of digital tablets for patients and relatives in the waiting room to make it easier in getting help and support if needed.

People we spoke with during the inspection and those who had shared feedback with us outside of the inspection felt they waited very long periods of time for care and treatment within the department. One patient explained they had waited in the waiting room for 13 hours in pain whilst others said they were on trollies in corridors waiting to be transferred to other services.   We also spoke with patients who were waiting inside the back of ambulances as the department was too full for them to be moved.   A disabled patient shared with the commission they had spent 16 hours in a wheelchair as there was no bed available.   Patients did not always know what plan was in place for their care and treatment. One patient told us they were expecting blood results back in the early morning and by lunch time still had not heard anything whilst another said although staff had been wonderful, their management plan had been discussed with them early that morning, at least 5 hours ago and nothing since. Another patient said they had been waiting in a wheelchair between 8pm and 5am, they were unable to sleep and the information they received was “scarce”.  People also told us that key information such as discharge plans, recommended summary plan for emergency care and treatment forms and medicines were not always sent home with the patient at the point of discharge. One nursing home told us that these items were missing and not with the patient when they had been discharged home including their antibiotic medicine which was needed to help fight an infection.   People that we spoke with told us that they did know how to get help if they needed it, patients in cubicles mostly had call bells within reach and those in corridors were visible to staff working in those areas.

Staff told us discharge planning was a collaborative process throughout the wider trust and community. A pathway for planned discharges was started the day before discharge as part of a 'home for lunch' initiative throughout the wider trust. This included doctors writing up medicines to take home, accessing community pharmacy provision, a new pathway for equipment such as chair leg raisers, slide sheets and bed grab rails which has meant a reduction of delayed discharges due to lack of equipment meaning more patients could be admitted into hospital beds from the department. Specialty same day emergency care had been set up including cardiology and a streaming workforce action group chaired by the Divisional Director for Medicine met biweekly. We saw that general practitioners worked within the department and an internal care process set out to community practitioners a step wise approach in where to direct people with specific conditions and symptoms such as asthma, cellulitis and pneumonia. A situation, background, assessment and recommendation type handover was shared when patients were transferred to other areas either within the department or wider hospital.

Care and support was planned and organised together with partners to support safety and continuity of care despite the challenges faced.   Following our on site assessment a round table discussion with key stakeholders was undertaken. This was to establish how the service worked with partners and, how the system responded in support of the service dealing with unprecedented demand. Representatives from commissioners, local ambulance trusts, and the wider Worcestershire Hospital Acute NHS Trust were present. During the discussion partners told us how measures to support flow and provide alternative places of care for patients were being developed. This included emergency department consultants at the front door, pathways to outpatients and hot clinics (consultant led rapid access clinics). Identified gaps in the upskilling of ambulance staff in a call before conveyance initiative and a consistent presence of a hospital ambulance liaison officer were discussed.    Policies and pathways such as rapid ambulance triage and same day emergency care were aligned with other key partners to drive improvements for patient care and treatment. A relaunch of a framework with social care providers around tiered levels of funding was underway and commissioning staff told us that in November 2023 an upskilling of clinical knowledge programme across the care home network had begun.   Data produced by the clinical learning groups review of 29 patients found a lack of community catheterisation services for non housebound patients, safety netting services such as night sitting and next day same day emergency care appointments were rejected by some allied health professionals and there was no direct pathway gynaecology assessment. All resulted in people spending unnecessary lengths of time in the department; one case resulted in a patient spending 5 hours on an ambulance and 14 hours in the department.

We found although care had been planned with partners to support safety and continuity of care, in practice processes did not always enable this to happen. We observed a patient with a learning disability who had not received any of their usual medicines, staff told us regular prescription charts were written up at ‘certain’ times throughout the shift. The patient had been given an incorrect format of medicine (tablets not liquid) which posed a choking hazard, and their hospital passport had not been referred to despite being available with the patient. Medicines were also left on their side table. Staff caring for them did not know what a hospital passport was, despite a notice board in the department explaining about them. Information provided by the service following the inspection showed that an in-reach learning disability team supported the wider trust. A daily report was shared with the team notifying them of any patients with learning disabilities within the hospital. Staff within the department would contact the team via telephone given patients were not always admitted. No referral had been made for this patient. This meant patients with learning disabilities attending the service may not have been identified and supported appropriately. Between May 2023 and 2024 under 25% of the 534 patients with learning disabilities that attended the department were seen by a member of the learning disability team.  Information provided following our inspection identified the trust had reviewed arrangements for people with a learning disability and had identified this as a key area of risk.  The patient self-discharged because they could no longer tolerate the overwhelming sensory stimulation from lights and noise. The specialty team due to review the patient did not attend the department despite a referral being made 10 hours earlier. This was not in line with the internal professional standards of the trust.

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

People told us they were informed about any risk and how they could keep themselves safe. Children with head injuries were given specific guidance and patients who were self-discharging were given information they could understand on what the risks to them were and how to seek help if they needed to. Information relating to smoking cessation was available throughout the department and people could seek support if they were in pain or discomfort. The 2023 annual trust report demonstrated between April 2022 and February 2023 90% of the 21% respondents would recommend the service.

Risks were assessed and shared with staff, and staff we spoke with understood them. We saw the department risk register had a risk related to the management of trauma in older people. Teaching sessions and correspondence had been shared with staff. We also saw that information about fire safety had been included in the daily huddles.  Risk assessments about care were person-centred and regularly reviewed. We reviewed 5 sets of medical records and found that risk assessments included falls, nutrition, blood clotting and past medical history had all been completed in line with national requirements and service policies.

The service worked alongside partner organisations to identify and manage clinical risk and emergencies. This included the ambulance service who “ring ahead" to alert the department they were transporting a seriously ill patient, “see and treat” and other initiatives around supporting early discharges.

Processes were in place to manage clinical risk and emergencies which included a nationally recognised early warning score was used to identify patients at risk of deterioration.   When patients were kept waiting on ambulances because the service was full, the rapid assessment triage nurses completed a risk assessment too. Blood tests and other diagnostic tests were completed whilst on the ambulance so as not to delay care and treatment.   There was a corridor standard operating policy which set out the mandatory actions such as minimum staff to patient ratios. Specialist trolleys provided improved protection for patients from pressure skin damage, recognising patients remained in the department longer.   An operating procedure set out requirements for the paediatric area, this included which staff grade saw which category of patients and were streamed directly to the on-site general practitioner, emergency nurse practitioner and minimum staffing requirements.  Staff said trust wide escalation plans did not always align to the challenges seen within the department. We saw at 1 point during the inspection, 9 patients were waiting on ambulances, and a patient had waited 42 hours in the department. At this point the emergency department board representing all bed spaces were full including all resuscitation cubicles. At that time the trust operational pressure escalation level was 3 (the highest level is 4 which identifies increased potential for patient care and safety to be compromised). The trust told us the escalation level was increased shortly after this time which meant additional support measures were implemented. Information provided by the service following the inspection set out that the wider trust leadership held assurance telephone calls with the integrated care board lead 3 times a day. A weekly meeting was held with the Chief Operating Officer and primary and social care providers to reduce time spent in the department and improve hospital flow.

People's experience of the environment was not always positive due to where they waited and how long they waited in the department. Please refer to safe systems, pathways and transitions domain for further details.   Feedback from patients included the entrance sign was not lit very well, there was limited access to wheelchairs in the car park and no cover for the wheelchairs in the car park to protect them from the rain. Patients fed back there was difficulty in negotiating the door sensor in a wheelchair at the entrance of the service and difficulty in hearing staff calling out patient's names.

Computers were widely available throughout the department which meant that staff did not have to wait to access them.   The service had arrangements in place to monitor the safety and upkeep of the premises including Legionella and fire alarm testing. A risk had been identified and recorded upon the service risk register about the possibility of being unable to safely evacuate the department. This risk had been listed since 2022 and was due for review in September 2024 when it was anticipated it could be downgraded or removed now that there was a new service building. Several actions had been taken previously by the service to reduce the risk as much as possible. The service had made an application for funding to place a ‘pod’ into the waiting room so that the triage nurse was visible to and could see patients.

People were not always cared for in an environment to meet their needs and often had delays on ambulances, the waiting rooms and on corridors. During the inspection we saw a dedicated paediatric area of the department was secure and could not be accessed by non-staff members. Waiting room facilities contained a television, vending machines and telephone where people could arrange public transport.   A dedicated 24 hour 7 days a week rapid assessment triage area was in place for patients being brought in by ambulance, this was staffed by 2 registered nurses and had 6 cubicles. A resuscitation area had 7 cubicles where enhanced care could be provided, this included 2 isolation cubicles which could care for patients with infections or weak immune systems.   Although there was a dedicated room for patients experiencing mental health illness, we found this room was not ligature free and staff told us the room could not be used. This was a concern as vulnerable patients were at risk of potential harm. Following the inspection the trust advised they were aware of the risk and had carried out a risk assessment to support care and treatment of people experiencing mental health illness.

Equipment was serviced and maintained in line with national requirements and the service maintenance schedule. Oxygen, medical gases and clinical waste were stored appropriately. Risk assessments for oxygen cylinder usage rather than piped oxygen usage had been completed, this was relevant for patients who were waiting on trolleys in the corridors.   Stock was rotated appropriately, and daily checks had been carried out on emergency equipment such as resuscitation trolleys and defibrillators.   A patient trolley and resuscitation trolley were in the waiting area so that staff could respond as quickly as possible in the event on an emergency in the area.

Not all people we spoke with during the inspection told us they felt there were enough staff with the right knowledge and experience and did not receive timely care and treatment.

The service had appropriate staffing levels and skill mix to meet patients' needs. There were 20 registered general nurses and 8 health care assistants on each shift. This included 2 registered children’s nurses working in the paediatric area of the department.   The emergency department safe care staffing tool was used to determine the number of staff required. Staff that we spoke to told us that there had been a 6.3 whole time equivalent band 6 and 10.1 whole time equivalent band 5 uplift from the most recent review of the staffing tool. These positions had been advertised and were in the process of being recruited to at the time of the inspection. A 14.2 whole time equivalent band 3 uplift was also in progress. At the time of the inspection these posts were in the process of being filled, in the meantime the service had a high reliance on agency staff.   We reviewed staffing rotas across 5 days and nights. The actual staffing level was either the same or higher than the planned staffing level on all shifts and staff told us the service rarely did not have the planned number of staff. We did see however, that there was a strong reliance on agency staff members. On 1 day shift there were 7 agency staff. Out of 290 shifts across the 5 days and nights, 88 (30%) were covered by agency staff.   Since our inspection the trust have told us there had been an increase in funding to employ additional nurses to support the increasing numbers of patients being cared for in the corridor and the waiting room. The service had 12.5 whole time equivalent consultants within the department and a vacancy rate of 3.1 whole time equivalent consultants. Across all medical grades within the service there were 4.9 whole time equivalent vacancies. The service had recognised challenges which it had faced in recruiting to some of the positions and so had overfilled the middle grade doctor role. The service was attempting to recruit international staff into positions.

During the inspection we saw there was a play specialist working within the department across weekdays. Staff told us weekends, sickness absence and annual leave were not covered for play specialists. Following the inspection the trust said when a play specialist was not on duty within the service, they could access a play specialist from the inpatient children’s ward. The service did not have dedicated substantive allied health staff, instead staff such as physiotherapy were ‘allocated’ to the service on a daily basis.

There was a robust process for recruitment of trust staff to ensure they were suitably experienced and competent to carry out their role. This included a supernumerary period of induction and buddy system. We reviewed 2 staff files including recruitment files and found the process had followed statutory requirements. In addition, the service had a process to review data barring service checks every 3 years or when a person changed roles and professional registrations and revalidations which were reviewed. The service required agency staff however we saw a lack of knowledge around tools to support the care and treatment of a patient with a learning disabilities and incorrect practices around medicine management. This indicated that the local induction procedures and recruitment arrangements for temporary staff were not always as detailed as required and were not effective for agency staff. Staff received mandatory training appropriate and relevant to their role. Overall compliance for registered nursing staff was 85% and medical staff 78%.   A mandatory training module in mental capacity and deprivation of liberty had been completed by 68% of the 34 eligible medical staff and 82% of the 113 eligible nursing and allied health professionals. Modules in sepsis, and dementia awareness were also provided. The service had a process for carrying out effective appraisals and 82% of staff had received an appraisal.

People we spoke with did not raise any concerns about the cleanliness of the environment or equipment.     

Staff we spoke with during the inspection explained they had completed the level 2 infection, prevention and control mandatory training module. Information provided by the service demonstrated that of the 108 eligible registered nursing staff, 90%, 97, had completed the training. Medical staff infection control mandatory training module completion was not in line with the trust target. Of the 34 eligible medical staff members, 70%, 24, had completed the training.  

During the inspection we observed staff within the service maintain standards of hygiene and cleanliness. Staff washed hands in line with infection control policies and adhered to the uniform policy set out within the service. Aseptic non touch technique was observed when staff were undertaking invasive procedures such as cannulation (a plastic tube inserted into a vein so that medications and fluids could be administered). The cleaning schedule set out by the service was followed. The service was visibly clean to look at and labels were used to indicate when equipment had been cleaned. Items such as disposable cubicle curtains were clearly dated to show when they had been changed. Personal protective equipment and handwashing facilities were readily available. 

The service had an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. An infection prevention and control policy set out key information for staff to support maintaining infection, prevention and control standards.   Hand hygiene, local cleaning and infection prevention and control audits were undertaken by the service. Hand hygiene audits completed by the service between December 2023 and May 2024 demonstrated that hand hygiene practice was in line with service policy and national expectation.   A trust wide annual infection prevention and control report included information relating to the service included the number of hospital acquired infections. No cases of MRSA had been reported between April 2022 and February 2023.  All cubicles had been designed with doors to reduce infections, 2 isolations rooms were designated as part of the resuscitation area of the department and a large tent was available outside of the service for any incidents requiring decontamination. 

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