Posted: Wed 29th Mar 2023

Ysbyty Glan Clwyd A&E still requires ‘significant improvement’ amid high patient numbers and staff shortages

News and Info from Deeside, Flintshire, North Wales
This article is old - Published: Wednesday, Mar 29th, 2023


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Betsi Cadwaladr University Health Board must take “strong and decisive action” to resolve the ongoing problems at Ysbyty Glan Clwyd. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Health Inspectorate Wales (HIW) have today released their findings of an unannounced, follow-up inspection at the hospital’s emergency department on the 28, 29 and 30 November 2022. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

They include inspectors having to support one patient who was unwell and needed help – but no staff could be located ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

The department in Bodelwyddan was designated a ‘Service Requiring Significant Improvement’ in May 2022 following an initial inspection. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Targeted intervention measures were put in place in June 2022 following concerns about some of the services at Ysbyty Glan Clwyd. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

This included vascular services and the emergency department after a series of damning findings around patient safety and infection prevention and control procedures. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

The targeted intervention measures included:​‌​‌​​​ ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

  • Support cultural change and promote leadership at Ysbyty Glan Clwyd
  • Continue to monitor centralised vascular services
  • Deploy national clinical leads to the Emergency Department at Ysbyty Glan Clwyd to address the concerns identified by Healthcare Inspectorate Wales.
  • Commission an independent assessment of the progress that has been made against recent mental health reviews.

A report released today found that whilst there were some improvements in November, compared to earlier in the year, these were minimal and did not provide HIW with enough evidence to be able to remove the SRSI designation. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Over the three days the inspectorate found that there were significant challenges with patient flow through the department. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

This was largely due to delays in discharging patients from other areas of the hospital which meant there were insufficient numbers of spaces to move patients into. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

As a result some patients were spending in excess of 48 hours in the department. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

On day two of the inspection in November, the department was short of both nurses and healthcare assistants (HCAs), meaning staff were moved to support the busiest areas of the unit. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

However this meant the corridor area accommodating unwell patients was left unsupervised. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

During this time HIW inspectors had to support one patient who was unwell and needed help, but no staff could be located. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Despite the significant demand being experienced by the emergency department, the inspectorate found that staff were “working tirelessly in this challenging environment to provide the best care that they could.” ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Although initial waiting times to see a doctor had improved since the visit in May 2022, but these were still in the region of three hours. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Where input from a specialty doctor was requested by ED, the inspection found that there were varying response times. HIW state that on some occasions, specialty doctors refused to review patients waiting within the emergency department. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

This led to blocks in the department and worsened waiting times. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

The provision of timely care to patients within the department was again highlighted by inspectors as an area for improvement. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

HIW found that there were significant delays in patients being triaged and this placed patients at significant risk of harm. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

At times these delays exceeded two hours and included patients with time critical conditions such as stroke and chest pain. This meant that treatments could not be offered within recognised critical intervention timescales. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

According to HIW There was evidence that observations such as blood pressure checks, records of pulse and breathing rate on patients at risk of deterioration were not repeated at a frequency in line with national guidelines. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

There were also instances where screening for sepsis was not undertaken and delays in patients being given antibiotics or pain relief. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

The report states: “There was an absence of sepsis screening despite patients being in the ED for over 24 hours. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“This meant that key interventions recommended by NICE, which are required to minimise risk of harm and death, were not implemented in a timely way. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“In some cases, patients waited 12 hours for their first dose of antibiotics despite being diagnosed with sepsis. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“In other cases, required blood tests were not taken and oxygen was not administered as needed.” ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Issues also remained in relation to management of environmental risks within the department. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

There were medicines left unattended, out of date medication, unlocked cupboards containing sharp instruments easily accessible and doors between different areas of the department not secured. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Inspectors also found empty food trays, used urine bottles and other clinical equipment not cleared away for long lengths of time. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

One cupboard left unlocked contained scalpels. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

However there were also improvements to the overall standard of recording within patient notes, with staff recording interventions and actions in a clear and improved way. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

But concerns were raised by some staff who said they often felt unhappy, struggled with the workload and did not feel supported by health board senior leaders. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

The inspection also identified that the staffing rota for the department was challenging to maintain, with a heavy reliance on using bank and agency staff to cover absences, alongside a difficulty in recruiting and retaining staff. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

It found that there “were frequent gaps in rotas due to both long and short-term absence”, which was having an significant impact on staff’s ability to deliver safe and effective care. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Staff also raised concerns about the varied levels of staff experience available on shifts, including times when most staff were junior. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Inspectors found that efforts had been made to improve the arrangements for oversight and care provided to patients in the waiting room, including a registered nurse now allocated to cover patient arrival and waiting areas. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

When there was no nurse available, an health care assistant was assigned to this role. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Chief Executive of HIW, Alun Jones said: “This inspection found evidence of a department struggling to cope with the day-to-day demand of providing a safe service to patients. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“It has highlighted areas such as poor team working between the ED and other departments within the hospital which in turn is compounding nationally recognised challenges around patient flow. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“The health board will need to take strong and decisive action to tackle the issues identified in our inspection. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“We will continue to engage with the health board to ensure sustained action is taken in relation to our findings.” ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

A plan has been produced by Betsi Cadwaladr University Health Board which contains a comprehensive set of actions to address the wide range of improvements needed. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

As a service that remains under HIWs highest level of scrutiny, HIW will continue to monitor the response of the health board very closely. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

Dr Nick Lyons, executive medical director and interim deputy chief executive of Betsi Cadwaladr University Health Board, has apologised to the patients who did not receive the level of the care they deserved. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

He said: “I note the inspection team’s comments surrounding improvements since the last report but it is clear we still have some way to go in providing a service in our emergency department which is consistently good for every patient. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“It is true staff within the ED at Glan Clwyd Hospital have been under enormous strain for the past three years and this has increased since restrictions eased. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“Attempts to attract permanent members of staff to support the ED’s work continues and another recruitment open day is planned within the next few weeks. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“However, the fragility in staffing and the volume of acutely unwell people we receive each day means we remain a service requiring significant improvement. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“The vast majority of our colleagues are a credit to our organisation and we value their hard work and professionalism. We will continue to strive to make sure they feel supported by colleagues in other specialties and their hospital management teams. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“I note with pride the inspection team’s comments about how hard our staff work and their commitment. I’m also pleased the majority of patients they spoke to are happy with the care they receive within the department. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“Record keeping has improved and the inspection team noted the commitment of our staff to give the level of care we would all want to see. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“Despite the issues raised in the report inspectors acknowledged progress has been made but we know this needs to accelerate. ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

“Our colleagues within ED, and in other areas of the hospital, are fully focused on driving this change forward and we are pleased to see the proportion of patients moving through the department within four hours continuing to rise.” ‌​‌​‌​​​‍‌​‌​​‌‌‌‍‌​‌‌​​‌​‍‌​‌‌‌​‌‌‍‌​‌‌‌‌​​

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