george eliot nhs hospital - care quality commission · george eliot hospital nhs trust was opened...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this locationAre services safe?Are services responsive?Are services well-led?

Overall summary

George Eliot Hospital NHS Trust was opened in 1984 andprovides a range of hospital and community-basedservices to more than 300,000 people across Nuneatonand Bedworth, North Warwickshire, South WestLeicestershire and North Coventry.

We carried out this unannounced inspection on Monday2 December 2019 as part of our winter pressure resilienceprogramme. The decision to inspect was based onintelligence we held about the department and wasassociated to a potential increase in risk. During ourinspection we spoke with 16 members of staff, sixpatients and three relatives. We looked at 10 sets ofpatient records. We also spoke with the leaders of thedepartment, the trust medical director, director ofnursing and director of operations.

The emergency department (ED) provides a 24-hour,seven day a week service. From June 2017 to July 2018there were 81,661 attendances (an increase of 6% fromthe previous year). Of these, 19,000 were children of 17years and under who were treated in a dedicatedchildren's assessment unit. 6,724 adult patients arrivedby ambulance (7% increase from the previous year).Between September 2018 October 2019, attendances tothe emergency department had increased to 103,006patients.

The ED consists of a major treatment area with 10cubicles and a side room, a minor treatment area with sixassessment/treatment rooms, and a resuscitation roomwith three trolley bays. A rapid assessment and treatment

GeorGeorggee EliotEliot NHSNHS HospitHospitalalQuality Report

George Eliot HospitalCollege StreetNuneatonWarwickshireCV10 7DJTel:024 7635 1351Website: www.geh.nhs.uk

Date of inspection visit: 2 December 2019Date of publication: 16/01/2020

1 George Eliot NHS Hospital Quality Report 16/01/2020

area had recently been built and consisted of fourcurtained trolley bays. The department had a seven-bedclinical decision unit and a seated observation area for afurther seven patients.

We last inspected the emergency department inNovember 2018 and rated them as ‘RequiresImprovement’.

Our key findings were as follows:

The design, maintenance and use of facilities, premisesand equipment did not always keep people safe.

Staff did not always complete equipment checklists andlimited space meant patients were cared for innon-clinical areas. Staff did not always complete riskassessments for each patient swiftly. However, staff usedsystems and processes to identify and act upon patientsat risk of deterioration.

The service had enough nursing and support staff withthe right qualifications, skills, training and experience tokeep patients safe from avoidable harm and to providethe right care and treatment. Managers regularlyreviewed and adjusted staffing levels and skill mix tomeet the demands of the service.

There were not enough medical staff with the rightqualifications, skills, training and experience to keeppeople safe from avoidable harm and to provide the rightcare and treatment. The department had a high vacancyrate and was heavily reliant on temporary doctors. Therehad been little improvement in medical staffing since ourlast inspection.

Patients could not always access the service when theyneeded it. Although there had been some improvementin patient flow since our last inspection it was not enoughto prevent patients being cared for in a corridor daily.

The vision for the department was poorly developed andthere remained no agreed strategy.

There had been limited progress in governance processessince our last inspection in part because of the limitedcapacity within the medical workforce.

Whilst there was a system in place to support theimprovement of quality of services, further work wasrequired to ensure action plans were robustlyimplemented.

There had been some improvement within the culture ofthe senior leadership team; however, there remained alack of common purpose and shared values within theclinical teams responsible for the day-to-day delivery ofcare.

We have told the provider they need to makeimprovements in a range of areas including:

The provider must ensure patients are assessed andidentified risks are acted upon in a timely way to reducethe potential for avoidable harm. Whilst there had beensome improvements in the completion ofdocumentation, staff did not always complete riskassessments for each patient swiftly.

Patient flow must be coordinated across the wholeemergency care pathway to ensure patients receive careand treatment in a timely way. This should include, but isnot limited to, addressing the challenges in both thestroke and mental health pathways.

The provider must ensure there are sufficient numbers ofstaff with the right skills deployed at all times to ensurethe department remains safe.

The provider must address the cultural challenges in thedepartment and ensure there is a cohesive andmulti-disciplinary approach to the management ofpatients in the department.

The provide must ensure governance processes aresufficiently robust. Actions from action plans and otherimprovement initiatives should be verified to ensure theyhave been effectively implemented and whereappropriate, change audits undertaken to demonstratesufficient improvements have been made.

The provider should ensure equipment is checked andrecords of such checks are maintained.

The provider should ensure there is a robust andsustainable strategy for the emergency care serviceprovided from George Eliot Hospital.

On the basis of this inspection findings, and due to theneed to significantly improve the quality of health careservices provided, we have issued the trust with a s29Awarning notice. We will monitor the trust's progressclosely to ensure all patients receive safe, high qualitycare.

Summary of findings


Professor Edward Baker Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Urgent andemergencyservices

Requires improvement –––

The design, maintenance and use of facilities,premises and equipment did not always keeppeople safe. Staff did not always completeequipment checklists and limited space meantpatients were cared for in non-clinical areas.Whilst there had been some improvements in thecompletion of documentation, staff did not alwayscomplete risk assessments for each patient swiftly.However, staff used systems and processes toidentify and act upon patients at risk ofdeterioration.The service had enough nursing and support staffwith the right qualifications, skills, training andexperience to keep patients safe from avoidableharm and to provide the right care and treatment.Managers regularly reviewed and adjusted staffinglevels and skill mix to meet the demands of theservice.There were not enough medical staff with the rightqualifications, skills, training and experience tokeep people safe from avoidable harm and toprovide the right care and treatment. Thedepartment had a high vacancy rate and washeavily reliant on temporary doctors. There hadbeen little improvement in medical staffing sinceour last inspection.Patients could not always access the service whenthey needed it. Although there had been someimprovement in patient flow since our lastinspection it was not enough to prevent patientsbeing cared for in a corridor daily.The vision for the department was poorlydeveloped and there remained no agreed strategy.There had been limited progress in governanceprocesses since our last inspection in part becauseof the limited capacity within the medicalworkforce. Whilst there was a system in place tosupport the improvement of quality of services,further work was required to ensure action planswere robustly implemented.

Summary of findings


There had been some improvement within theculture of the senior leadership team howeverthere remained a lack of common purpose andshared values within the clinical teams responsiblefor the day-to-day delivery of care.

Summary of findings


Contents

PageSummary of this inspectionBackground to George Eliot NHS Hospital 8

Our inspection team 9

How we carried out this inspection 9

Detailed findings from this inspectionDetailed findings by main service 10

Outstanding practice 20

Areas for improvement 20

Summary of findings


George Eliot Hospital

Services we looked atUrgent and emergency services


Background to George Eliot NHS Hospital

George Eliot Hospital NHS Trust was opened in 1984 andprovides a range of hospital and community-basedservices to more than 300,000 people across Nuneatonand Bedworth, North Warwickshire, South WestLeicestershire and North Coventry.

Information from the last Census conducted in 2011,indicated that there are now around 2,800 fewer youngpeople (aged 5 to 15 years) in Nuneaton and Bedworththan there were 10 years ago. The largest percentageincreases in population have been seen in the older agecategories; over 85-year olds grew by 40% in the last 10years in Nuneaton and Bedworth. The ‘white British’ethnic group accounted for 88.9% of the population ofNuneaton and Bedworth in 2011, a fall from 93.5% in2001. This was roughly in line with the countrywide trend.The Census indicated that 6.3% of the population wasfrom minority ethnic groups. This was an increase of 43%from 3,977 to 5,705 people in 2011.

The main hospital site is George Eliot Hospital which isbased on the outskirts of Nuneaton.

Acute hospital sites at the trust:

George Eliot Hospital, College Street, Nuneaton,Warwickshire, CV10 7DJ

The trust provides a range of elective, non-elective,surgical, medical, women’s, children’s, diagnostic andtherapeutic services (Source: http://www.geh.nhs.uk).

The trust was last inspected by the CQC in November2018 and was rated as requires improvement overall. Weissued the trust three requirement notices in relation toregulations that were not being met, and where theyneeded to make significant improvements in thehealthcare provided.

Facts and data about the trustThere are approximately 286 beds, including eight criticalcare beds, 12 day case beds and a coronary care unit with11 beds. There are 14 inpatient wards. There are nochildren’s inpatient beds. The trust has eight operating

theatres providing planned and emergency surgicalfacilities for trauma and orthopaedics, general surgery(including breast and colorectal surgery), urology andgynaecology.

They also offer a wide range of day case procedures, foradults and children aged 2 to 16 years old. The trust alsoprovides a range of community services across Coventry,Warwickshire and Leicestershire. These include, sexualhealth and community dentistry services for the whole ofWarwickshire.

Urgent and emergency servicesDetails of emergency departments and other urgentand emergency care services

All urgent and emergency care services are located atGeorge Eliot Hospital. Within urgent and emergency careare the following departments and units:

• Emergency Department (ED).• Urgent Care Centre (UCC) for patients with

non-emergency illnesses and injuries.• Clinical Decisions Unit (CDU) for patients waiting for

the results of investigations (seven beds and a seatedobservation area for a further seven patients).

• Ambulatory Care Unit (ACU) providing urgent day casemedical treatment.

The emergency department (ED) provides a 24-hour,seven day a week service. From June 2017 to July 2018there were 81,661 attendances (an increase of 6% fromthe previous year). Of these, 19,000 were children of 17years and under who were treated in a dedicatedchildren's assessment unit. 6,724 adult patients arrivedby ambulance (7% increase from the previous year).Between September 2018 October 2019, attendances tothe emergency department had increased to 103,006patients.

The ED consists of a major treatment area with 10cubicles and a side room, a minor treatment area with sixassessment/treatment rooms, and a resuscitation roomwith three trolley bays. A rapid assessment and treatmentarea had recently been built and consisted of fourcurtained trolley bays.

Summaryofthisinspection

Summary of this inspection


The department had a seven-bed clinical decision unitand a seated observation area for a further sevenpatients.

We last inspected the emergency department inNovember 2018 and rated them as ‘RequiresImprovement’.

We carried out this unannounced inspection on Monday2 December 2019 as part of our winter pressure resilience

programme. The decision to inspect was based onintelligence we held about the department and wasassociated to a potential increase in risk. During ourinspection we spoke with 16 members of staff, sixpatients and three relatives. We looked at 10 sets ofpatient records. We also spoke with the leaders of thedepartment, the trust medical director, director ofnursing and director of operations.

Our inspection team

Our inspection team included a CQC inspector and twospecialist advisors consisting of an emergency careconsultant and an experienced emergency care nurse,who was the head of nursing for a large teaching hospital.

The inspection was overseen by Bernadette Hanney,Head of Hospital Inspection for Midlands region.

How we carried out this inspection

This was a focused unannounced inspection of theemergency department at George Eliot Hospital on 2December 2019.

We did not inspect the whole core service, therefore thereare no ratings associated with this inspection. We did notinspect any other core service or wards at this hospital orany other locations or services provided by George Eliot

NHS Hospital Trust. During this inspection, we inspectedusing our focused inspection methodology. We did notcover all key lines of enquiry; however, because we tookenforcement action, we opted to rate the safe, responsiveand well-led domains as detailed in the summary sectionof this report.

Summaryofthisinspection

Summary of this inspection


Safe Requires improvement –––

Responsive Requires improvement –––

Well-led Inadequate –––

Summary of findingsThe design, maintenance and use of facilities, premisesand equipment did not always keep people safe.

Staff did not always complete equipment checklists andlimited space meant patients were cared for innon-clinical areas. Staff did not always complete riskassessments for each patient swiftly. However, staffused systems and processes to identify and act uponpatients at risk of deterioration.

The service had enough nursing and support staff withthe right qualifications, skills, training and experience tokeep patients safe from avoidable harm and to providethe right care and treatment. Managers regularlyreviewed and adjusted staffing levels and skill mix tomeet the demands of the service.

There were not enough medical staff with the rightqualifications, skills, training and experience to keeppeople safe from avoidable harm and to provide theright care and treatment. The department had a highvacancy rate and was heavily reliant on temporarydoctors. There had been little improvement in medicalstaffing since our last inspection.

Patients could not always access the service when theyneeded it. Although there had been some improvementin patient flow since our last inspection it was notenough to prevent patients being cared for in a corridordaily.

The vision for the department was poorly developedand there remained no agreed strategy.

There had been limited progress in governanceprocesses since our last inspection in part because ofthe limited capacity within the medical workforce.

Whilst there was a system in place to support theimprovement of quality of services, further work wasrequired to ensure action plans were robustlyimplemented.

There had been some improvement within the cultureof the senior leadership team; however, there remaineda lack of common purpose and shared values within theclinical teams responsible for the day-to-day delivery ofcare.

Urgentandemergencyservices

Urgent and emergency services



Are urgent and emergency services safe?


Environment and equipmentThe design, maintenance and use of facilities,premises and equipment did not always keeppeople safe. Staff did not always completeequipment checklists and limited space meantpatients were cared for in non-clinical areas.

The emergency department had one triage room whichwas located at the main reception area. This was staffedby a registered nurse 24 hours a day, seven days a week.We had previously reported the adult emergencydepartment was not of sufficient size or design tocurrently treat the increasing number of patients whopresented to George Eliot Hospital; this remained thecase at this recent inspection. The adult emergencydepartment (ED) consisted of 10 major’s cubicles and onemajor's side room, a minor treatment area with sixassessment/treatment rooms and a resuscitation areawith three trolley bays. To supplement the spaceavailable in the adult ED, an additional four trolley areawas used to accommodate patients who were identifiedas being of lower acuity but still required a trolley andwhere the corridor was not an appropriate area forpatients to wait. This area had initially been intended tooperate as a rapid assessment area; however, following ashort trial period, the senior management teamdetermined that until challenges in medical staffing hadbeen resolved, rapid assessment could not be effectivelycarried out.

An urgent care centre was co-located next to the waitingroom and was used to see and treat patients whopresented with minor ailments and minor physicalinjuries. We noted that whilst the waiting room was cleanand tidy, the positioning of the chairs meant patientsfaced away from reception staff and the triage nurse. Thismeant patients who were perhaps showing signs ofdeterioration such as pallor, or who were showingnon-verbal signs of pain such as facial gestures may notbe immediately recognised, thus potentially delayingcare and treatment. To address this, the service hadintroduced a new navigator staff role, whose remit was toprovide clinical oversight to the waiting room, whilst also

assessing all new patients who presented to thedepartment and to navigate them to the mostappropriate clinical pathway. We have discussed thispilot role in more detail further on in the report.

A clinical decision unit was co-located in the emergencydepartment and was primarily used for patients whowere awaiting results of investigations. This consisted ofseven beds and a seated observation area for anadditional seven patients. During the inspection, theseven beds were occupied by six medical and onesurgical "outlier" patients (outliers is a common phraseused to describe patients who often require input frommedical or surgical specialties but due to a lack ofcapacity, cannot be admitted to the correct specialtyward).

A children's assessment unit was co-located next to themain emergency department but operated as anindependent unit, thus separating the children's andadult’s emergency care pathways as recommended bynational standards. The children's unit consisted of eightcubicles and one triage room. Five cubicles containedtrolleys, whilst three contained chairs for those childrenidentified as being of lower acuity. The service wassupported by qualified children's nurses, a consultantpaediatrician and a junior doctor Monday to Fridaybetween the hours of 8am and 10pm. A consultantpaediatrician and junior paediatric trainee doctorremained on site at George Eliot Hospital outside of thesehours to support the maternity and special care babyunit, and so were able to provide advice and support tothe emergency team out of hours. Children who requiredadmission were transferred to one of three local NHStrusts depending on their presenting complaint. Access tothe children's assessment area was by way of doorswhich were locked; access was controlled by thereception staff who were observed confirming theidentity of individuals before access was permitted. Wenoted the line of sight between the nurses’ station andthe children's waiting room was restricted because of thedesign of the partition wall. This meant nursing staff maynot have been able to identify or witness a childdeteriorating suddenly whilst in the waiting room.

The department had a dedicated ambulance entrance,which was located near to the major treatment andresuscitation areas. Two screens displaying impendingambulance arrivals and the associate clinical complaint





of the patient was viewable to the nurse in charge whowas responsible for receiving and assessing all patientswho arrived by ambulance. An adjacent imagingdepartment provided X-rays and scans for walkingpatients and those on trolleys.

We checked a range of specialist equipment, includingadult and children’s resuscitation equipment. Whilstequipment was clean and organised, a review ofequipment checklists showed that daily checks had notbeen completed for a range of the trolleys located in theemergency department. Clinical waste and specimenswere appropriately labelled and segregated. They werestored safely and disposed of according to hospitalpolicy. We had previously reported the design and layoutof the emergency department was no longer suitable tomeet the growing demands of the service.

During this inspection, we noted the department to beunder some operational pressure. We observed sixpatients being cared for along the main corridor of theemergency department and some patients being in thedepartment for extended periods due to a lack of bedsacross the hospital. We noted the bed position improvedduring the inspection resulting in patients beingdischarged across the hospital, allowing patients in theemergency department to be admitted to inpatient beds.We also noted that three clinical decision trolley spaceshad been reallocated back to the ED, to help improveflow through the emergency pathway and to reduce thenumber of patients required to wait in the corridor.

An area of the ED had been designated as a “Fit to Sit”area. Fit to sit areas are based on a concept which helpssupport patient flow and improve departmentalperformance against the standard set by the RoyalCollege of Emergency Medicine (RCEM), whichrecommends all patients should commence theirtreatment within one hour of arrival. However, during theinspection we noted this area was not always used to itsoptimum capacity. We noted two patients who had beenassessed and had received primary treatment; however,they had been relocated to chairs in the corridor whilstthey awaited investigation results rather than beingmoved to the fit to sit area which would have been moreappropriate. Where we observed patients being cared forin the main corridor, a nurse had been allocated to meetthe ongoing needs of patients. We spoke with threepatients who were receiving care whilst being

accommodated on the main corridor. Each patientreported nursing staff had been responsive to theirneeds; however, each patient reported they were not fullyaware of their treatment plan or next steps of care.

There was a designated room for seeing patients whorequired a mental health assessment. This had recentlybeen re-furbished so that it met the Psychiatric LiaisonAccreditation Network quality standard requirements.Patients identified as being at high risk of self-harmingwere allocated a nurse to provide one to one care. Staffreported patients would be located to a cubicle withinthe majors 2 area to help improve observation of thepatient.

Assessing and responding to patient riskStaff did not always complete risk assessmentsfor each patient swiftly. However, staff usedsystems and processes to identify and act uponpatients at risk of deterioration.

National standards require 95% of patients to have hadan initial clinical assessment within 15 minutes of arrivalto the department by ambulance. Data available to theCommission showed the average time from arrival byambulance to assessment was zero between thereporting period of October 2018 to September 2019.However, due to the limited capacity of thenurse-in-charge (whose responsibility it was to bothco-ordinate the major’s department and to also receiveall patients who arrived by ambulance), patients oftenexperienced some delay with being assessed. Atapproximately 16:50 on the day of the inspection, theaverage time for those patients who arrived byambulance was thirty minutes for one ambulance trustand 1 minute for another (the discrepancy is likelyexplained by the numbers of patients conveyed by eachambulance service respectively). The trust was able toclarify the dataset and reported as follows:

• Median time to initial assessment was reported as zerominutes between September 2018 and October 2019,except for:▪ November 2018 (2 minutes).▪ December 2018 (2 minutes).▪ January 2019 (4 minutes).▪ and September 2019 (3 minutes).

The average time to initial assessment ranged from fourminutes to 18 minutes during the above period. The





average time for the entire period was nine minutes. Thiswas better than the national recommended standardwhich states all patients arriving by ambulance should beassessed within 15 minutes of arrival.

We reviewed the process by which patients were initiallyreceived in to the department when conveyed byambulance. The department had previously established afour-trolley rapid assessment area. This area was newlybuilt and commissioned in 2018. Following a short trial, itwas recognised that due to limited medical oversight, inpart due to sustained medical workforce challenges, thedelivery of a rapid assessment and treatment service wasnot viable. Therefore, all patients conveyed to the ED viaambulance were reviewed and assessed by the nurse incharge who, based on their assessment, would allocatethe patient to a specific area within the majors’department. Where a patient was identified as being oflow risk or low acuity, the patient was queued along themain ambulance corridor. Patients who presented to theemergency department independently (walk-in) were firstrequired to book in with a receptionist.

The trust had recently commenced a new pilot in which anavigator nurse had been introduced. The role of thenavigator was to undertake a rapid assessment ofpatients to ascertain the most appropriate clinicalpathway, be it via the minor see and treat, urgent care,majors or resuscitation pathway. However, due to staffingchallenges on the day of the inspection, there was noallocated navigator and so the service reverted to theirstandard triage pathway. A senior nurse was attemptingto fulfill some element of the navigator role; however,other clinical and managerial responsibilities meant thisindividual could not be present to at the reception area tonavigate all patients who self-presented to the ED.

We spent time reviewing the triage process. Staff used anationally recognised triage system which helped toprioritise patients dependent on their clinical riskindicators. High risk patients were prioritised orfast-tracked to the most appropriate clinical area such asthe resuscitation area. During the inspection we observedthe triage process; seven patients waited longer than 15minutes before being assessed. One patient waited 27minutes before being seen by the triage nurse.

As part of their induction, all reception staff had receivedtraining on ‘red flag’ presenting complaints and the

deteriorating patient. Red flags are signs and symptomsthat indicate the possible or probable presence of seriousmedical conditions that can cause irreversible disabilityor untimely death unless managed promptly.

We reviewed 10 patient records during theinspection. National early warning scores (NEWS2) wereused to assess the seriousness of a patient’s condition.This was a quick and systematic way of identifyingpatients who were at risk of deteriorating. Clinicalobservations such as blood pressure, temperature, heartrate and respirations were recorded and contributed to atotal score. Once a certain score was reached a clearescalation of treatment was commenced. Theobservations were recorded on an electronic recordingsystem which automatically calculated the early warningscore and alerted staff if action needed to be taken.

Sepsis screening tools were completed in three of thefour relevant care records we reviewed. Where patientshad been identified as being at moderate or high risk ofsepsis, we noted good adherence to local and nationallyaligned treatment protocols including the earlyadministration of intravenous fluids, timelyadministration of antibiotics, strict fluid balancemonitoring and the use of oxygen. There was one case inwhich the sepsis screening protocol was not completedfor a patient who had arrived with a low temperature andwho had been found having collapsed and unresponsivefor approximately 10 minutes. Whilst it was clear from thetreatment plan that staff had considered both chest andurinary tract infections, staff had potentially missed theopportunity to instigate more timely treatment by nothaving completed the sepsis screening bundle. We alsonoted the patient safety checklist had not beencompleted past two hours, despite the patient havingbeen in the department for five hours. We further notedthe patient had not had a falls risk assessment completeddespite having been found in a collapsed state at home.The patient had not had a skin integrity assessmentcompleted; the department standard was that allpatients would have such an assessment within twohours of arrival. We fed this back to the trust whoacknowledged that whilst improvements had been madein the completion of documentation, more work wasrequired to ensure patients received timely assessmentsto help staff manage risks to patients.





A second patient had been in the department forapproximately 12 hours; however, their ED safetychecklist had only been completed for the first threehours. The matron reported that daily documentationchecks of patient safety checklists and associated nursingdocumentation was undertaken, which showedimproving compliance. They recognised that further workwas required to ensure staff consistently completed therelevant documentation for patients.

Nursing staffingThe service had enough nursing and support staffwith the right qualifications, skills, training andexperience to keep patients safe from avoidableharm and to provide the right care andtreatment. Managers regularly reviewed andadjusted staffing levels and skill mix to meet thedemands of the service.

At the time of the inspection, the trust reported a vacancyrate of 22.98 whole time equivalent nursing staff for theED. Of this, 15.19 whole time equivalent vacancies wereacross the band five ED nurse workforce. This was animproving position, in part due to sustained activerecruitment and retention strategies. Both band 4 andband 6 nursing workforce were over-established to helpoffset the band five vacancies. We had previouslyreported that nurse staffing levels had not been assessedor reviewed with the use of an evidence-based resourcingtool.

At this inspection, a comprehensive five-year review ofthe nursing workforce had been completed. The trustreported that following a nursing workforcetransformation review, the current seven shift patternused in the ED would be changing to a two-shift patternon 12/01/2020 to provide a consistent 16 staff on the longday and 14 on the night. Staff on flexible contracts wouldbe accommodated using their hours across the long dayor night and supplemented with regular temporaryworkforce, unused hours and roster balancing. The trustwas liaising with national agencies, including NHSImprovement, to quality assure the process and to seeksupport in developing a validated emergency departmentacuity tool.

Each shift was managed by an experienced senior bandsix or band seven nurse. Through the 24-hour period,staffing was assessed through a safety matrix two hourlywithin ED. The shift co-ordinator used the safety matrix

information to determine the most effective allocation ofthe available workforce to optimise safety within the ED.All staffing issues, shortfalls and staff movement wererecorded on the co-ordinator shift handover for record.Any compromise or patient safety issue arising fromstaffing was reported via the incident managementsystem.

At 8.15am each weekday, nursing huddles took placeduring which staffing was discussed. Resources betweenthe ED and the admissions unit were reviewed to ensurestaff were appropriately deployed to ensure each areahad the right skill mix and number of staff. Nurse staffingwas discussed three times a day at the site meetings.Shortfalls were escalated, and temporary staff weresourced where appropriate. A matron of the day wasavailable seven days a week with the responsibility forsafe staffing and a clinical site manager responsibleoutside of normal working hours.

Current NHS guidance ('Safe, sustainable and productivestaffing in urgent and emergency care', November 2017)states that there should be a minimum of one qualifiednurse for every two patients in the resuscitation room. Wehad previously reported that legacy rota allocationsmeant the three-trolley resuscitation area was notconsistently covered by a substantive nurse. Instead, anurse working in the major’s area was assigned to coverthe resuscitation area in the event the departmentreceived a pre-alert call, or where a patient requiredincreased observation or resuscitation whilst in the ED.This remained the same at this inspection despite thetrust having approved, in 2018, funding for a full-timeregistered nurse to be assigned to the resuscitation room.The trust reported that this supplementary funding hadbeen used to offset agency costs during periods of peakactivity. The trust reported that following our initialfeedback, the Director of Nursing was now reviewing thereasons as to why the post had not been substantivelyrecruited too.

Medical staffingThere were not enough medical staff with the rightqualifications, skills, training and experience tokeep people safe from avoidable harm and toprovide the right care and treatment. The





department had a high vacancy rate and was heavilyreliant on temporary doctors. There had been littleimprovement in medical staffing since our lastinspection.

There were not enough consultants to provide the daily16 hours of consultant presence as recommended by theRoyal College of Emergency Medicine (RCEM). During theweek there was a consultant in the department for 12hours a day and for four or five hours a day at weekends.The department directly employed 3.5 consultants inemergency medicine. The part time consultant did notparticipate in the on-call rota. The department wasbudgeted for five WTE consultants. The newly appointedclinical lead acknowledged further work was required toensure there were enough consultants employed tosupport the department. A range or recruitmentstrategies had been adopted by the trust to address theshortfall.

The clinical lead reported they were working towardsincreasing the establishment of consultants to six WTE, ifthey were to meet RCEM safer staffing recommendations.The executive team were able to describe a range ofmitigating strategies they could instigate in the event theconsultant workforce reduced further. The clinical leadfurther reported significant challenges in the recruitmentof experienced middle grade doctors to support the ED.As of 8 December 2019, the department had a budgetedestablishment of 22 whole time equivalent middle gradedoctors, however there were only 1.6 WTE in post.

The department was heavily reliant on locum doctors tosupport the rota. Whilst staff were complimentary of thelocum staff used, some of whom had adopted long-termtemporary contracts with the department and so werefamiliar with staff and working practices, the executiveteam acknowledged the position was not sustainablelong term.

The clinical lead reported their focus was to recruitinitially to the consultant body, in order highlyexperienced clinicians were available to support morejunior doctors, and thus improve retention of middlegrade doctors. Due to the clinical pathways and clinicalservices provided at George Eliot Hospital, thedepartment was not recognised as a training centre foremergency medicine specialty trainee doctors, whichfurther impeded the ability of the leadership team toback-fill the middle grade rota.

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)


Access and flowPatients could not always access the service whenthey needed it. Although there had been someimprovement in patient flow since our lastinspection, it was not enough to prevent patientsbeing cared for in a corridor daily.

At the time of our inspection, the hospital was onoperational pressure escalation level (OPEL) 3. This refersto the number of beds available in the hospital and thenumber of patients needing to be admitted. OPELprovides a nationally consistent set of escalation levels,triggers and protocols for hospitals and ensures anawareness of activity across local healthcare providers.Escalation levels run from OPEL 1; the local health andsocial care system capacity is such that organisations canmaintain patient flow and are able to meet demandwithin available resources through to OPEL 4; pressure inthe local health and social care system continues toescalate, leaving organisations unable to delivercomprehensive care.

Managers monitored waiting times and but didn't alwaysmake sure that patients could access emergency serviceswhen needed and received treatment within agreedtimeframes and national targets.

The Royal College of Emergency Medicine recommendsthat the time patients should wait from time of arrival toreceiving treatment should be no more than one hour.

From October 2018 to September 2019 performanceagainst this standard showed it was generally shorterthan the England average and the sixty minuterecommendation. However, the median time began toclimb in June 2019 and data was not reported for July2019.

Managers and staff worked to make sure patients did notstay longer than they needed to but were not alwayssuccessful.





The Department of Health’s standard for emergencydepartments is that 95% of patients should be admitted,transferred or discharged within four hours of arrival inthe emergency department. From November 2018 toOctober 2019, the trust failed to meet the standard andperformed worse than the England average.

From November 2018 to October 2019, the trust’smonthly percentage of patients waiting more than fourhours from the decision to admit until being admittedwas worse than the England average.

From November 2018 to October 2019, performanceagainst this metric showed unstable performance andperformance worse than the England average.

Over the 12 months from November 2018 to October2019, 74 patients waited more than 12 hours from thedecision to admit until being admitted. Senior clinicalstaff described a varied response from the site capacityteam when managing risk within the emergencydepartment (ED). We observed two site meetings duringthe inspection, which were led by the allocated sitecommander. There was representation from a range ofprofessionals including general managers and nurses.The medical director was also present as the executiverepresentative. At the 13:00 meeting, consideration wasgiven to those patients who already had a "decision toadmit". This is a phrase used when a clinician hasdetermined a patient requires admission to hospital. Thesite commander considered the potential beds tobecome available over the remainder of the day. At theend of the meeting, eight potential beds had beenidentified; the medical director prompted those presentto consider the additional requirements, considering theemergency department was already at full capacity.There were limited actions identified to ensure supplywas greater than demand for the full twenty-four-hourperiod. Critical care had been identified as being at fullcapacity with no remedial actions to consider anyadditional requirements from the emergency departmentthroughout the remainder of the day. Pre 12pm inpatientdischarges had been reported to be minimal and therehad been no robust discussion or action plans identifiedto try and relocate the surgical and medical outliersoccupying the clinical decision unit beds. The sitemeeting did not consider the risks associated with anovercrowded ED. There were no identified initiatives oractions to help decompress the ED. Staff reported the

discharge lounge remained empty at 13:00. Whilst werecognise that there may not always be patients suitablefor transfer to the discharge lounge, there had been nodiscussion as to whether there were any suitable patientswithin the hospital who could have been moved toenable in-patient beds to be made available. Followingthe inspection, the trust provided clarity on the dischargelounge in that it was a small area used predominantly torecover patients who were recovering from minorprocedures; the area was not a formalised or dedicateddischarge facility.

The Royal College of Emergency Medicine recommendsthat the time patients should wait from time of arrival toreceiving treatment should be no more than onehour. From October 2018 to September 2019,performance against this standard showed it wasgenerally shorter than the England average and thesixty-minute recommendation. However, the mediantime began to climb in June 2019 and data was notreported for July 2019.

The number of patients leaving the service before beingseen for treatments was low.

From October 2018 to September 2019, performanceagainst this metric showed performance was similar orbetter than the England performance. In July 2019, nodata was reported.

We explored the concept of escalation with seniorleaders. Whilst staff could describe the processes, it wasreported there was little in the way of system response,even when the ED was at a position of being"overwhelmed". A lack of community inpatient provisionhad been identified as one of the contributory factors topoor flow through the emergency care pathway. Further,clinical pathways had been poorly developed orinstigated across the hospital, in part due to legacyleadership decisions which had not been sufficientlychallenged previously. Limited capacity in theambulatory care unit meant insufficient numbers ofpatients could be appropriately referred instead ofreceiving care in the emergency department. Rigidreferral protocols and again limited capacity in thesurgical assessment unit further impeded the ability ofthe emergency unscheduled care pathway to operateeffectively. These were areas the clinical lead and localexecutive team had recognised these as areas whichrequired improvement and could describe the enabling





strategies and plans which were being instigated toimprove the pathways. However, at the time of theinspection, these strategies had not been fully instigatedand so we were not able to assess their effectiveness.

Staff reported challenges with ensuring stroke patientswere referred to the stroke specialty and transferred to adedicated stroke assessment bed within four hours ofarrival to the hospital. This had been identified as along-standing challenge for the hospital. We reviewedincidents which had been reported by staff between April2019 and October 2019 and noted there had been 39occasions when stroke patients had not been transferredwithin four hour and a further 13 occasions when patientshad not been referred to the stroke team within a timelymanner. An action plan had been introduced as a meansof improving the access for stroke patients, forassessment on the stroke unit. Whilst it was reported thatinitial performance had improved, this had not beensustained, in part because the assessment room used onthe stroke unit was used to accommodate inpatientsduring times of escalation, and thus reduced the abilityfor patients to be transferred to the unit. The stroke teamhad completed a range of quality improvement initiativesto further evidence the importance of having dedicatedassessment areas for the timely assessment of strokepatients, and a detailed report to the quality assurancecommittee detailed the further work required to ensure along-term solution was achieved.

The provision of mental health services was also raised asa concern during the inspection and appeared as atheme when we reviewed incident reports for the periodof 16 April 2019 through to 30 October 2019. Staffreported patients who required specialist mental healthbeds could experience significant delays and weretherefore required to stay in the emergency period forextended periods until such a bed became available.Staff recognised the ED was not the ideal location for thispatient cohort and was an issue we had previouslyreported on in 2018. We noted on one occasion a youngperson had spent an extended period on the acutemedical unit whilst a specialty bed was sourced. Whilstthe trust instigated their local policy regarding the safemanagement of the patient and could demonstrate theyhad escalated the matter to regional commissioners,there appeared to remain an on-going problem with theprovision of specialist mental health services in theregion. The trust was able to provide evidence of

on-going system-wide strategies to address the issues;however, we considered there to be limited pace ofchange regarding this matter. The trust continued toreport incidents where mental health patients remainedin the department for extended periods of time whilstwaiting for specialist beds to be available.

Are urgent and emergency serviceswell-led?

Inadequate –––

Leadership

Vision and strategy for the serviceThe vision for the department was poorly developedand there remained no agreed strategy.

At our last inspection in 2018, we reported there was noformal vision for the emergency service at George Eliothospital. Staff spoke positively about the future of theservice and recognised the investment that had beenmade in terms of developing the urgent care service andcreating new clinical spaces to enable improved clinicalpathways across the hospital. However, staff could notsignpost the inspection team to a formal strategy, norcould they provide us with a long-term plan which was tobe used to address longstanding issues within theemergency department (ED) aside from ED improvementplan meetings. These meetings appeared to beorientated towards action plans which addressed issuesregarding regulatory compliance and could detail theactions staff were taking to address these. The localWarwickshire North Health and Social Care DeliveryBoard discussed a range of enabling strategies to helpimprove access and flow through the emergency carepathway. We were provided with the minutes of the June2019 meeting in which challenges regarding performanceagainst constitutional access targets, frailty and mentalhealth provision were discussed. There appeared limitedoutputs and commitments from the wider system tosupport the acute service. Commentary within theminutes included the requirement for there to be furtherconversations about specific topics, as compared to thedelivery board being used as a driver for change. Theeffectiveness of the delivery board at the June 2019meeting may have been hampered by the lack ofattendance from key individuals from external parties





including the mental health trust and the local authority.This suggested a lack of grip and ownership of theemergency care pathway by the wider health economy,with responsibility placed with the local team based atGeorge Eliot Hospital.

The newly appointed clinical lead was present at the timeof the inspection. They had a clear understanding of thechallenges of the department, but also recognised theareas of good practice. There was an acknowledgment ofthe need to stabilise the team in the first instance, beforesignificant focus could be placed on developing a unitwide vision and strategy. The executive team were alsoacutely aware of the challenges of sustaining anddelivering an emergency care service at George EliotHospital which was impeded by the challenges ofrecruiting enough numbers of experienced doctors. Theexecutive team had developed a range on mitigatingstrategies in the event medical staffing numbers fellfurther then than the current establishment as a means ofbeing able to continue to deliver the emergency careservice.

There was an appetite among the leadership team toensure the emergency care service at George Eliothospital delivered consistently good outcomes for serviceusers, however the team were aware of the challengesthey faced in terms of delivering this.

Governance, risk management and qualitymeasurement

There had been limited progress in governance processessince our last inspection in part because of the limitedcapacity within the medical workforce. Whilst there was asystem in place to support the improvement of quality ofservices, further work was required to ensure action planswere robustly implemented.

Whilst there had been improvements in the developmentof governance processes within the ED, there was arecognition of the need for further work. All nursing staffhad been set standard objectives which included theattendance at governance and morbidity and mortalitymeetings. There was evidence that this was starting tooccur with three nurses reporting their attendance at themost recent mortality review meeting which had assistedtheir personal development. The ED clinical manager wasable to demonstrate improvements across a range ofmetrics including the completion of documentation

however they recognised further work was required. Theirapproach was to undertake daily audits and to providereal-time feedback to individual nurses to help improvetheir practice and to ensure compliance with both trustpolicies and the requirements set by the Nursing andMidwifery council.

The limited medical workforce meant there were gaps inthe completion of clinical audits. Further, the sparsesubstantive medical workforce meant responsibility forspecific areas rested with one or two individuals. Thispresented a risk for the department in that auditprogrammes and risk management strategies could notbe fully embedded because of this reliance on individualsto deliver. We noted shortfalls in the process by which thedepartment could demonstrate they adhered to andapplied national best practice standards. For example,we asked the local team to provide us with a copy of theprotocol for procedural sedation. Neither medical ornursing staff could provide such a protocol, despite thisbeing an area of gold standard practice set by the RoyalCollege of Emergency Medicine. One doctor was able tolocate a checklist which they reported was used as part ofjunior doctor teaching sessions, but confirmed this wasnot a checklist ordinarily used in day to day practice. Wewere also left confused as to who in the departmentundertook procedural sedation activities as we receivedconflicting answers from different doctors and nurses.The lack of robust governance processes meant thatwhilst the department could evidence some compliancewith national best practice standards, other elementswere left wanting.

The leadership team were aware of the risks and areas forimprovement in the department and we could see thesewere discussed at governance meetings. There lackedsome attention to detail with regards to the completionof identified actions. For example, we reported in 2018the requirement for the local major haemorrhageprotocol to be introduced. We noted a flow chart datingback to 2014 was on display in the major’s department.We raised this with the trust who confirmed the protocolhad been updated in October 2018, and was availableelectronically, and that the flowchart, whilst dated 2013/2014 remained the correct flowchart. The trust reportedthey would act to ensure the date of the flowchart hadbeen updated so staff were aware it was the latestversion. We had also previously reported challenges withstaff referring patients to specialty teams in a timely way.





A review of incidents both during and after the inspectionidentified a continued theme with stroke patients notbeing referred to the stroke specialty in a timely way.Whilst there was a trust wide action plan to address this,there was limited evidence to suggest there had beensustained improvements in what were long standingissues.

Culture within the serviceThere had been some improvement within theculture of the senior leadership team however thereremained a lack of common purpose and sharedvalues within the clinical teams responsible for theday-to-day delivery of care.

We had previously reported that on a day-to-day basis,there was little joint working between senior medical andnursing staff. Each team had a separate staff base andthere was little communication between the two.Although senior doctors and nurses discussed patients atthe thrice daily “board rounds” (patient handoversessions) we saw very few discussions at other times. Atthis most recent inspection, we still considered there tobe a lack of cohesive operational working between theconsultant in charge of the department on the day of theinspection, and the nurse in charge. There lacked anyform of command and control management, even whenthe department was bordering on a state of being

overwhelmed. We observed the responsible consultantspending most of their time in the minor’s area, whilst anexperienced middle grade doctor was left to oversee themajor’s area. Whilst we were not concerned with thecompetence of the middle grade doctor, we consideredthere had been little progress within the culture of thedepartment in terms of developing the workingrelationship between those responsible for the dailymanagement of the department. This was an arearecognised as in need of improvement by both theclinical lead and the executive team. The team were ableto discuss the strategies and approaches they intended totake but could not provide evidence of such actionhaving been taken at the time of the inspection.

Clinical and non-clinical staff told us that, overall, theyenjoyed working in the service and felt supported by theleadership team. They were able to express any concernsthey may have had but felt they were given littleopportunity to make changes in the department. Somestaff reported they had not yet met the new clinical leadbut were aware of their appointment. There was someconcern the new lead would not have enough time toaddress and sustainably bring about change to thechallenges of the department because they had onlybeen appointed on a part time basis.





Areas for improvement

Action the provider MUST take to improveThe provider must ensure patients are assessed andidentified risks are acted upon in a timely way to reducethe potential for avoidable harm. Regulation 12 (1)(2)(a)(b): Safe care and treatment.

Patient flow must be coordinated across the wholeemergency care pathway to ensure patients receive careand treatment in a timely way. This should include, but isnot limited to addressing the challenges in both thestroke and mental health pathways. Regulation 12(1)(2)(i): Safe care and treatment.

The provider must ensure there are sufficient numbers ofstaff with the right skills deployed at all times to ensurethe department remains safe. Regulation 18(1): Staffing.

The provider must address the cultural challenges in thedepartment and ensure there is a cohesive andmulti-disciplinary approach to the management ofpatients in the department. Regulation 17(1)(2)(e)(f):Good governance.

The provide must ensure governance processes aresufficiently robust. Actions from action plans and otherimprovement initiatives should be verified to ensure theyhave been effectively implemented and whereappropriate, change audits undertaken to demonstratesufficient improvements have been made. Regulation 17(1)(2)(a)(b): Good governance.

Action the provider SHOULD take to improveThe provider should ensure equipment is checked andrecords of such checks are maintained. Regulation12(1)(2)(e): Safe care and treatment.

The provider should ensure there is a robust andsustainable strategy to drive improvements in thefor theemergency care service provided from George EliotHospital. Regulation 17(1)(2)(e)(f): Good governance.

The provider should ensure all relevant patient riskassessments are documented in a timely manner.Regulation 17(1)(2)(c): Good governance.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Treatment of disease, disorder or injury Section 29A HSCA Warning notice: quality of health care

· The trust has not taken enough action to mitigatethe risks associated with the high levels of vacanciesacross the medical workforce.

· The trust has not taken enough action to addressflow challenges across the emergency care pathway inorder patients can access care and treatment in a timelyway, and in a way which demonstrated the privacy anddignity of patients was always respected.

· There remained ineffective governance systems tomonitor quality, safety and risk within the urgent caredivision.

Regulation

This section is primarily information for the provider

Enforcement actionsEnforcementactions


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