HEREFORD'S accident and emergency department has been told it must improve after an unannounced Care Quality Commission inspection.

Inspectors said Hereford County Hospital's urgent and emergency care service delivered by the emergency department, 'requires improvement' after an unannounced full core service inspection in December, in a report published today (February 27).

The hospital is run by Wye Valley NHS Trust, which has spoken out in the wake of the inspection.

READ MORE: Hereford hospital speaks out after heavy criticism from inspectors

The inspection rated five key areas of the service, rating it as 'good' in the 'caring' category, 'requires improvement' for the 'responsive', 'well led' and 'effective' categories, and 'inadequate' in the 'safe' category.

What needs to change

Inspectors found a slew of issues in the department, including the layout of the department, which meant some patients were not visible to staff responsible for them, while crowding led to patients being cared for in corridors and staying in ambulances, and the mental health environment was "poor" for patient safety.

The report highlighted issues with the department being cluttered, while staff could not always access equipment for emergency situations quickly. In one example, inspectors said there were no haemorrhage or trauma packs within the resuscitation room, while a chest drain drawer contained mostly dressings.

"Staff told us equipment had been removed when the area was ‘decluttered’ and not replaced," the report said.

Some staff working in the children's department had not completed paediatric life support training, paediatric competencies, and children’s safeguarding training, while non-clinical staff were expected to navigate patients to the minor injuries waiting area when they were not trained in clinical decision-making. Overall training completion figures for nursing staff in the department were 80.3 per cent, the report said.

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There were also insufficient medical staff at consultant level and nursing staff to care for patients and keep them safe without using high numbers of bank, agency, and locum staff, the report said. Consultant numbers were significantly below the recommendations of the Royal College of Emergency Medicine and there was not a paediatric emergency consultant, in line with the requirements of the Royal College of Paediatric and Child Health.

Further problems were found with record-keeping and medicines management, with staff failing to identify or quickly act upon patients at risk of deterioration, to keep good care records, or to consistently take regular patient observations in line with their local guidelines, while staff also did not ensure all patients had their medicines on time and this included time critical medicines, and patients were not always offered regular food and drink.

Three out of 12 patient records inspected did not have a completed triage, while all 12 showed hourly observations had not been carried out as required, while some staff did not have a good awareness of the assessment and treatment of sepsis and did not always act promptly to reduce the risks.

"Staff told us they did not have time to complete observations and management recognised this," the report said.

Poor flow in the hospital due to capacity issues and delays in discharging patients discharged safely meant many patients remained in accident and emergency for long periods of time, and overstretched capacity meant patients could not always access the service when they needed it, the report said.

Staff were increased to help manage these issues by their second visit, later in the month, inspectors said.

A lack of regular and consistent audit, risk management and learning from incidents was also criticised, while, when audits occurred, actions were not implemented to drive improvement.

"There was no formal learning from incidents that happened in the department which meant staff could miss out on key learning and improvements required from incidents. Staff we asked were not able to tell us about any changes which had been made in the department following an incident," the report said, with inspectors told that learning was shared in shift 'safety huddles' and in an encrypted social messaging group.

"There was no mechanism for informing staff who did not attend the huddle or use the messaging group, so it was not clear all staff were included, updated or involved," inspectors said.

The good bits

Despite the issues found, there were several positives also found during the inspection, with inspectors saying staff, who worked as a team to benefit patients and supported each other, mostly treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

There were pressures in the department due to high numbers of patients and a department that was no longer able to cope with demand and capacity, and staff worked their hardest to care compassionately for these patients in a difficult environment, the report said.

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Infection risks were mostly controlled well, and equipment and the premises were visibly clean, although hand-washing was not always carried out when required, the report said.

Leaders were visible and approachable for patients and staff, while staff, who were clear about their roles and accountabilities and committed to improving services, felt respected, supported and valued, and there was a good teamwork-based culture in the department.

"Following feedback to the senior leadership team after our first visit on site, improvements were underway to address in earnest many of the concerns we raised," the report said.

What the trust must do

Risks to health and safety must be assessed through documented regular observations, clinically-led navigation of patients through the department provided by trained and experienced staff, managing patients medicines on time, assessing and responding to deteriorating patients and responding to any risks such as sepsis, pressure ulcers, falls or patients in pain.

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The trust was also told it must ensure it has sufficient suitably qualified, competent, skilled and experienced staff with appropriate training to carry out their duties and ensure staff are trained to the right competency in safeguarding and life support, and must have sufficient medical staff to run the department safely and effectively including a paediatric emergency medicine consultant.

It must also ensure it does all that is reasonably practicable to mitigate risks through effective and safe care to patients needing ongoing treatment but unable to have timely access to a hospital bed.

Finally, inspectors said, it must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be at risk which arise from the carrying on of the regulated activity, and must have an effective governance system, risk profile and audit programme to be assured it is providing safe quality care and knows and addresses where it should improve.