Royal Preston A&E staff praised for their care - but more of them may be needed to keep patients safe, inspectors say

There are not always enough doctors and nurses to care for the ballooning number of people attending the accident and emergency unit at the Royal Preston Hospital.

That was one of the main conclusions of an inspection report which heaped praise on staff at the under-pressure facility for how they look after those in need of help - but also warned that staffing levels must always be “safe for the numbers of patients in the department”.

Inspectors from the Care Quality Commission (CQC) spent two days at the hospital’s A&E in April as part of a broader assessment of urgent and emergency care services across Lancashire and South Cumbria.

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The accident and emergency department at the Royal Preston has been rated as "requires improvement" after an inspection by the regulator

In their report about the Royal Preston, they concluded that there were occasions when there were insufficient nursing and medical staff “with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment” - in spite of significant increases in staffing levels in the emergency department since the onset of the pandemic.

The report also highlighted concerns over the length of time that patients sometimes waited for treatment and how long they might continue to spend in A&E following a decision to admit them to a ward.

Those findings contributed towards an overall rating for the A&E at the Sharoe Green Lane site of “requires improvement” - unchanged from the grading given to the service in 2019 during a routine inspection of the entire Lancashire Teaching Hospitals NHS Foundation Trust (LTH), which also runs Chorley and South Ribble Hospital.

Across both of those sites, attendances at urgent and emergency care facilities leapt by 22 percent between December 2020 and November 2021 compared to the previous 12 months - to stand at just over 160,000 in total. While some of that increase may have been accounted for by the fact that the comparable period incorporated the early months of the pandemic, it continued an upward trend for A&E visits that had begun prior to the emergence of Covid.

Kevin McGee, chief executive of the Royal Preston and Chorley and South Ribble Hospital

The rise in the number of children seeking urgent and emergency care over the same period was sharper still - up 40 percent to just under 35,000.

Against that tough backdrop, staff were lauded by inspectors for the way in which they treated their patients, with the A&E at the Royal Preston being rated as “good” in the “caring”, “effective” and “well-led” categories - just as it was in 2019.

The CQC noted that there was a “zero tolerance” approach to caring for patients in corridors, meaning that they were always looked after in private areas - even if not always in places originally intended for that purpose.

Staff were found to remove or minimise risks by quickly identifying and acting upon any signs that a patient might be about to deteriorate. They also provided timely pain relief soon after it was requested or when it became clear that it was required.

Like most hospitals, the Royal Preston is under pressure

The inspection report added: “Staff treated patients with compassion and kindness, respected their privacy and dignity and took account of their individual needs.

“[They] were discreet and responsive when caring for patients [and] took time to interact with patients and those close to them in a respectful and considerate way.

“Staff understood and respected the individual needs of each patient and showed understanding and a non-judgemental attitude when caring for or discussing patients with physical or mental health needs.”

The CQC said that there had been a 76 percent increase in the nurse “staffing establishment” - the required level of staff - for urgent and emergency care services at the Royal Preston since Covid struck.

However, inspectors concluded that, due to the large numbers of patients attending A&E, it was "not clear" whether even this heightened level was sufficient.

Managers were found to regularly review staffing levels and the skill mix available, while there was also “unlimited” access to agency and bank staff, with individuals who were familiar with the hospital sought to cover shifts.

There was also seven-day-a-week support from matrons - and healthcare assistants were integrated into teams to provide back up in the event of any reduction in the numbers of registered nurses available.

There was an 11 percent uplift in the number of nursing staff working across the whole trust in the 12 months to November 2021, when the tally reached 2,063.

However, as with nurses, the CQC was similarly uncertain over whether pandemic-era increases in medical staff were adequate to meet the needs of an emergency department experiencing such high demand.

Their report revealed that consultants were sometimes having to work long beyond the end of their shifts - with those clinicians due to clock off at midnight sometimes still being at the hospital as late as 4am so that they could oversee any seriously ill patients.

While the funded establishment for medical posts at the trust had jumped by more than two thirds to 108 compared to July 2019, 12 of those posts were vacant at the time of the inspection.

Doctors spoken to by inspectors suggested that medical staffing numbers were based on patient numbers prior to the pandemic and also did not take into account the change in the layout of the department to ensure that Covid and non-Covid patients do not mix.

However, managers were able to book locum medics when necessary - all of whom were said to be given full inductions to the department when they arrived.

An LTH board meeting last month heard that the trust’s international recruitment campaign was continuing in an attempt to close some of its “larger vacancy gaps” - with 70 new healthcare support worker roles having been filled in the preceding two months and 150 further offers having been made.

An assessment of staffing levels on the hospital’s wards - away from A&E - found that not all of them had a “full complement” of nursing staff as a result of national shortages of nurses and support workers. On the occasions that a ward did have a full rota, its staff were often obliged to provide cover elsewhere, the report said.

As of April, the trust’s overall vacancy rate stood at 10.4 percent, which board members were last month told was “within normal expected limits”.

The safety and responsiveness of the Royal Preston’s emergency department was rated by inspectors as requiring improvement - two further categories which were unchanged from the last full inspection three years ago.

However, executive leaders were recognised for being available to support staff and being well-informed of any concerns. Staff were also said to feel “respected, supported and valued by their managers”.

The Post approached Lancashire Teaching Hospitals for comment on the details of the report about the Royal Preston’s A&E.

LTH chief executive Kevin McGee issued a statement on behalf of all of the NHS trusts in Lancashire and South Cumbria which, along with LTH, also had some of their urgent and emergency services assessed.

He said: “The CQC’s reports for the wider system and individual NHS trusts highlight some of the excellent partnership work that we do as well as ongoing challenges across the region.

“The reports are very timely, coming soon after the formation of Lancashire and South Cumbria’s Integrated Care Board. Working collaboratively across the region will be key to addressing the challenges and areas for improvement which the reports have highlighted, including demand for emergency and urgent care, staffing, and patient flow.

“As ever, I would like to pay tribute to NHS colleagues throughout Lancashire and South Cumbria who continue to do incredible work on a daily basis,” Mr. McGee added.

WAITING WOES

The CQC said that patients at the Royal Preston's A&E sometimes had to "wait long periods for treatment due to high demand and lack of a capacity in the hospital".

The regulator's inspection was carried out - coincidentally - just days after a leaked letter from senior managers and medics described how some experienced staff had been left “crying with frustration and anger” at having to resuscitate patients in waiting areas.

It also referred to occasions earlier in the year on which waits for a bed for people being admitted to hospital from A&E had exceeded two days. Such a situation was replicated during the inspection, when the longest wait was 61 hours for a patient who required a side room.

The CQC report noted that in the 12 months to March 2022, the average time an adult patient spent in the department after a decision had been taken to admit them to a ward trebled from five to 15 hours. Children usually waited for between 50 and 100 minutes.

In February 2022, the trust was, according to inspectors “much worse” than others for the number of patients waiting longer than 12 hours in A&E in those circumstances. In the year to January, 722 patients remained in the department for more than 12 hours while they waited to be admitted.

However, as of January, the median time a patient spent waiting for an initial triage assessment after arrival met the expected standard of 15 minutes - although this was nevertheless up from nine minutes a year earlier.

Also in January this year, 63 percent of ambulance turnaround times were longer than 30 minutes, compared to 40 percent 12 months previously. An LTH board meeting last month heard that 199 handovers during April took more than an hour.

Inspectors said that patients in need of an ambulance “could experience delays in accessing [help] in a timely manner” as a result of handover delays, but acknowledged that there was “collaboration” with the North West Ambulance Service to tackle the problem.

LTH has fluctuated over the last 18 months between being better and worse than the England average for treating, discharging or admitting A&E patents within four hours - with the proportion standing at 77 percent as of the latest published figures for June, against a national target of 95 percent.

However, over the 12 months to the turn of the year, the trust’s monthly average total time spent in the emergency department for all patients was in line with the England average - standing at 166 minutes in December 2021.

COVID CAUTION

CQC inspectors recognised the Royal Preston had established segregated areas within its emergency department to keep Covid-positive and Covid-negative patients away from each other - resulting in the creation of two of each of the triage, resuscitation and “majors” areas.

All locations were found to be clean and had appropriate furnishings which were well-maintained, while cleaning schedules were in place to ensure all high-touch surfaces were attended to several times per day. The domestic team also deep cleaned Covid areas after each patient had left - and staff cleaned equipment after patient contact.

However, inspectors observed that staff dealing with patients suspected of having Covid-19 did not always wear the plastic aprons that were trust policy in such a scenario.

At the time of the inspection, patients were required to wear masks in the hospital - a measure which has since been reintroduced after being briefly dropped - but the CQC said it had spotted that this precaution was not always being adhered to, including in the waiting room areas.

Spot checks carried out on staff hand hygiene between October 2020 and February 2022 found 100 percent compliance in all bar one month, when it dipped to 96 percent. Compliance with use of personal protective equipment ranged from 82 to 100 percent - with the average being 89.percent.

HEALTH AND CARE STAFF 'TIRED AND UNDER PRESSURE'

The Lancashire and South Cumbria patch is amongst the first in the country to be inspected under the Care Quality Commission's new pilot regime of assessing multiple health and social care providers within an area in order to get a picture of the entire patient journey through the urgent and emergency care system.

The regulator also wants to judge how individual operators work together to address any challenges that need to be dealt with collectively across a wider geographical area.

In an overview of its findings for Lancashire and South Cumbria, the CQC said that some people were opting to access urgent care services instead of their GP, when the latter was a suitable option. Its report also concluded that the North West's NHS 111 service was facing a combination of high demand and staff shortages - leading to "significant delays" for those accessing it.

Delays in discharging patients from hospital were found to be exacerbated by a lack of social care capacity in the community - and the failure to plan for a patient's discharge from the moment they were admitted to hospital.

Meanwhile, staff across the more than 30 assessed services felt "tired and...under sustained pressure", the CQC said.

Ann Ford, the organisation's network director, said it was important for health and social care leaders to work together to ease the pressure on both staff and emergency services.

Kevin Lavery, chief executive of the newly-formed Lancashire and South Cumbria Integrated Care Board (ICB), welcomed that the CQC found that "many of our local services are providing good, safe care and effective treatment".

He added: The CQC’s review took place during a time of considerable and ongoing pressures within urgent and emergency care that were being experienced, both locally and nationally, resulting from seasonal pressures, the Covid-19 pandemic, and workforce challenges.

"We recognise as a system we need to make improvements and are working closely with the North West Ambulance Service and across the North West to improve NHS 111 performance and have been working across Lancashire and South Cumbria to reduce long waits in our emergency departments."