George Eliot Hospital NHS Trust was opened in 1984 and provides a range of hospital and community-based services to more than 300,000 people across Nuneaton and Bedworth, North Warwickshire, South West Leicestershire and North Coventry.
We carried out this unannounced inspection on Monday 2 December 2019 as part of our winter pressure resilience programme. The decision to inspect was based on intelligence we held about the department and was associated to a potential increase in risk. During our inspection we spoke with 16 members of staff, six patients and three relatives. We looked at 10 sets of patient records. We also spoke with the leaders of the department, the trust medical director, director of nursing and director of operations.
The emergency department (ED) provides a 24-hour, seven day a week service. From June 2017 to July 2018 there were 81,661 attendances (an increase of 6% from the previous year). Of these, 19,000 were children of 17 years and under who were treated in a dedicated children's assessment unit. 6,724 adult patients arrived by ambulance (7% increase from the previous year). Between September 2018 October 2019, attendances to the emergency department had increased to 103,006 patients.
The ED consists of a major treatment area with 10 cubicles and a side room, a minor treatment area with six assessment/treatment rooms, and a resuscitation room with three trolley bays. A rapid assessment and treatment area had recently been built and consisted of four curtained trolley bays. The department had a seven-bed clinical decision unit and a seated observation area for a further seven patients.
We last inspected the emergency department in November 2018 and rated them as ‘Requires Improvement’.
Our key findings were as follows:
The design, maintenance and use of facilities, premises and equipment did not always keep people safe.
Staff did not always complete equipment checklists and limited space meant patients were cared for in non-clinical areas. Staff did not always complete risk assessments for each patient swiftly. However, staff used systems and processes to identify and act upon patients at risk of deterioration.
The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix to meet the demands of the service.
There were not enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The department had a high vacancy rate and was heavily reliant on temporary doctors. There had been little improvement in medical staffing since our last inspection.
Patients could not always access the service when they needed it. Although there had been some improvement in patient flow since our last inspection it was not enough to prevent patients being cared for in a corridor daily.
The vision for the department was poorly developed and there remained no agreed strategy.
There had been limited progress in governance processes since our last inspection in part because of the limited capacity within the medical workforce.
Whilst there was a system in place to support the improvement of quality of services, further work was required to ensure action plans were robustly implemented.
There had been some improvement within the culture of the senior leadership team; however, there remained a lack of common purpose and shared values within the clinical teams responsible for the day-to-day delivery of care.
We have told the provider they need to make improvements in a range of areas including:
The provider must ensure patients are assessed and identified risks are acted upon in a timely way to reduce the potential for avoidable harm.
Whilst there had been some improvements in the completion of documentation, staff did not always complete risk assessments for each patient swiftly.
Patient flow must be coordinated across the whole emergency care pathway to ensure patients receive care and treatment in a timely way. This should include, but is not limited to, addressing the challenges in both the stroke and mental health pathways.
The provider must ensure there are sufficient numbers of staff with the right skills deployed at all times to ensure the department remains safe.
The provider must address the cultural challenges in the department and ensure there is a cohesive and multi-disciplinary approach to the management of patients in the department.
The provide must ensure governance processes are sufficiently robust. Actions from action plans and other improvement initiatives should be verified to ensure they have been effectively implemented and where appropriate, change audits undertaken to demonstrate sufficient improvements have been made.
The provider should ensure equipment is checked and records of such checks are maintained.
The provider should ensure there is a robust and sustainable strategy for the emergency care service provided from George Eliot Hospital.
On the basis of this inspection findings, and due to the need to significantly improve the quality of health care services provided, we have issued the trust with a s29A warning notice. We will monitor the trust's progress closely to ensure all patients receive safe, high quality care.
Professor Edward Baker
Chief Inspector of Hospitals